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The treatment of larger types of gynecomastia is significantly different than that of less severe gynecomastias. Special concerns of the former include areola enlargement, nipple-areola ptosis, and redundant skin. Many procedures have been described to address these issues, none of which is completely satisfactory; these are reviewed here. Unsatisfactory results may be due to residual breast hypertrophy, skin redundancy, complications related to nipple-areola placement, form and viability, and cosmetically unacceptable scars. We describe a new technique that uses an inferior pedicle to reposition the nipple-areola complex and to maintain its neurovascular integrity and form. A superiorly based chest wall flap in conjunction with suction-assisted lipectomy maximizes chest wall contour. There are no breast mound scars, only a periareolar and inframammary scar.
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PMID:Inferior pedicle reduction technique for larger forms of gynecomastia. 141 58

In this paper we present anatomic parameters for nipple position and areolar diameter in males. Larger forms of gynecomastia with significant ptosis pose a challenge to the plastic surgeon with respect to relocation of the nipples on the chest wall. Selection of the appropriate areolar size is also of concern in gynecomastia correction. There is a paucity of information in the current literature pertaining to this problem. In order to establish guidelines for the placement of the nipple in gynecomastia correction and for the selection of the appropriate areolar size, we set out to determine these anatomic parameters. We believe use of these parameters will enhance the aesthetic results of gynecomastia correction. One hundred males between the ages of 17 to 30 years were chosen for this study. The males selected were of ideal body weight and without evidence of gynecomastia. The distances from the sternal notch to the nipple, the midclavicular line to the nipple, and the nipple-to-nipple distance were recorded. The areolar diameter was also measured in each subject. The average distances were determined for each category. The validity of these values was confirmed with statistical analysis. Equations were then derived, using this analysis, to determine nipple position in males. We have determined the nipple position in males to be approximately 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average areolar diameter is 2.8 cm.
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PMID:Anatomical parameters for nipple position and areolar diameter in males. 872 81

Driven by a persistent and unchangeable need to undo the discrepancy between reality of the body and gender of the mind, most male-to-female transsexuals seek physical feminization through hormonal and surgical treatment. The authors report some rare presenting conditions and exceptional results of augmentation mammaplasty in 11 male-to-female transsexuals treated between January 1979 and January 1998, as well as describe how to treat these conditions. In patients in whom gynecomastia was treated previously, the remaining subcutaneous fatty tissue may be insufficient to cover the implants safely, and subpectoral implantation should be considered. Augmentation after unilateral correction of gynecomastia requires different sizes of implants. Although exceptional in male-to-female transsexuals, mastopexy is the treatment of choice to correct any mammary ptosis, but the patient may request augmentation mammaplasty to fill out the breasts. Previous stacking mammaplasty may have been performed subglandularly, subpectorally, or both. Stacking may not have been noticed prior to corrective surgery. Extrusion of the implant may be associated with avascular necrosis or infection, but also with the use of high concentrations of steroid placed within the lumen of fluid-filled implants. The correction involves removal of the implant, with skin graft or flap reconstruction of the affected area. Replacement of the implant may have to be delayed. Symmastia results from overzealous medial dissection coupled with overaugmentation. Combined restoration of the presternal subcutaneous integrity, and medial closure of the pocket by subcutaneous approach only, leads to satisfactory reconstruction of the presternal median cleavage. Galactorrhea may be the result of hyperprolactemia but is more often caused by stimulation of the intercostal nerve by the implants.
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PMID:Exceptional presenting conditions and outcome of augmentation mammaplasty in male-to-female transsexuals. 1056 Aug 62

A case with 47,XXY, del(11)(q23) karyotype-coexistence of Jacobsen and Klinefelter syndromes: A two-year-old dysmorphic male child was found to have 47,XXY,del(11)(q23) karyotype. Domination of the clinical features of Jacobsen syndrome was observed: mild mental retardation, trigonocephaly, ptosis, downward slanting palpebral fissures, low set ears, carp-shape mouth and micrognathia. Transient thrombocytopenia and leukopenia were also present. Over the following five years gynecomastia and eunuchoid body proportions became evident as clinical features of Klinefelter syndrome. This is the first description of the coexistence of both syndromes.
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PMID:A case with 47,XXY,del(11)(q23) karotype-coexistence of Jacobsen and Klinefelter syndromes. 1104 35

Gynecomastia is a benign enlargement of the male breast due to a physiological or pathological factor that interferes with the balance between estrogens and androgens in the serum. Gynecomastia itself requires no treatment unless the persistent enlargement of the male breast is a source of embarrassment and/or distress for the adolescent or adult man. The indications for the surgical treatment of gynecomastia are founded on two main objectives: (1) the restoration of male chest shape and (2) diagnostic evaluation of suspected breast lesions. The diagnostic evaluation begins with an adequate history and a thorough breast examination helped by laboratory tests and instrumental research. Several approaches for surgical treatment have been described in the literature. Some problems arise in patients who have significant enlargement and ptosis of the breast that will require skin reduction and in some patients requiring nipple-areola complex reduction. The authors believe that the complete circumareolar technique with purse-string suture creates the best aesthetic results, with fewer complications, in patients with moderate and severe ptotic glandular breast enlargements that have skin redundancy combined with areolar enlargement. From 1995 through 1999, a total of 10 male patients with moderate to severe gynecomastia were treated surgically using a complete circumareolar approach. All patients achieved a good aesthetic contour of the chest. Only two patients required a revision of the circumareolar scar to correct postoperative enlargement.
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PMID:Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy. 1125 87

Circumareolar dermo-glandular plication is the latest advancement of the periareolar dermopexy with a retromammary mastopexy technique I published in 1969. Rather than a technique, the new concept is a procedure which originates new techniques covering multiple indications, i.e. for all conditions combined with ptosis: for mastopexy in ptotic breasts, for hypertrophic or hypoplastic breasts with resection or implant augmentation, respectively; for subcutaneous mastectomy, gynecomastia, asymmetries, and tuberous breasts. It is useful for reoperations to correct secondary ptosis as well as to reduce the length of the scar in vertical techniques. The corresponding techniques are described. The procedure has proved to be safe and reliable in over 200 patients with the following advantages: no full thickness skin incision or excisions are performed; only the epidermis is excised. Except for hypertrophies, the skin is not dissected from the gland, nor the gland from the pectoralis fascia, which increases vascular safety and preserves NAC innervation; the dermoglandular unit of the breast through Cooper's ligaments is stabilized by a single or multiple plications. The scar is only circumareolar, reducing psychological stress and discomfort and achieving an early recovery and patient satisfaction. The inconveniences are puckering and some widening of the periareolar scar, which requires a secondary revision in approximately 50% of the cases, also frequently necessary in conventional techniques. There is a tendency to flattening of the NAC and periareolar bulging with tendency to a "tomato breast appearance." The prevention of the latter is described.
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PMID:Circumareolar dermo-glandular plication: a new concept for correction of breast ptosis. 1173 46

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.
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PMID:Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. 1466 66

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder with highly variable expression generally ascribed to random factors. However, evidence is presented for patterns suggesting non-stochastic processes as follows: (1) We have seen a MZ twin pair concordant for renal vascular hypertension, and another for unilateral ptosis. Other concordances have been reported, including both malformations and tumors, and combinations as well. (2) Four children were seen with a distinct ipsilateral association of glaucoma or iris anomaly, optic glioma, plexiform neurofibromas arising from the trigeminal nerve and its branches, and sphenoid dysplasia. Other cases in the literature support milder forms of this association. (3) We saw six children with apparent gynecomastia or premature thelarche without endocrine abnormalities. Tissue samples from four of these showed an unusual fibrous plexiform neurofibroma. Interestingly, five of the six cases were African Americans, and constitutional factors affecting fibrous reactions may also be involved here.A tentative hypothesis is presented suggesting vascular fields involving defined areas that can: (1) Support tumor growth. They would be the "soil" determining the ability and the extent of growth. There would, however, still be a need for a "second hit" tumor transformation. (2) Affect blood supply to organs, creating structural anomalies. NF1 involves a vasculopathy, and would predispose to vulnerabilities of such fields. Genetic factors could induce superimposed susceptibilities of specific fields, leading to twin concordances. "Hits" affecting specific fields would increase the likelihood of multiple abnormalities that could include both tumors and structural findings. Finally, tumors may follow the contours of existing fields. The breast is an area normally primed for growth, and the observation of clitoromegally secondary to tumor involvement suggests that such fields exist elsewhere.
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PMID:Non-random associations and vascular fields in neurofibromatosis 1: a pathogenetic hypothesis. 1677 Aug 9

Both hypergonadotropic hypogonadism and myasthenia gravis can be parts of type II autoimmune polyendocrine syndrome and association between the two disorders has been reported in few cases. A 14 year old male patient with a personal history of bilateral cryptorchidism and ptosis was referred for delayed puberty. Clinical examination revealed eunuchoid habitus, small, soft testes, gynecomastia, ptosis, a myasthenic deficit score of 22.5 points and an IQ of 84 points. Decreased testosterone (0.064 ng/mL) and elevated LH (64.5 mUI/mL) were consistent with hypergonadotropic hypogonadism and karyotype was normal: 46,XY. Thyroid function, haematologic evaluation, BUN, electrolytes, and glycemia were in the normal range. Therapy consisted of anticholinesterase inhibitors, immunosuppressants, corticotherapy, testosterone; thoracoscopic thymectomy was performed showing thymic lymphoid hyperplasia on histopathologic examination. Myasthenic score improved (12.5 points), progressive virilization occurred, and a year later the patient presented with cushingoid features and obesity.
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PMID:46,XY hypergonadotropic hypogonadism and myasthenia gravis. 1730 92

We describe a 34-year-old patient who was admitted with episodic diplopia, ptosis, and swallowing difficulties of 6 months duration. He also had some muscle cramps aggravated by exercise since the age of 20. Bilateral ptosis of the eyelids, normal gaze, rare fasciculations of the tongue, easy fatigability of ocular and bilateral proximal limb muscles, atrophy of the testes, and gynecomastia were found on neurologic examination. Repetitive nerve stimulation studies and jitter measurement disclosed the defect of neuromuscular junction transmission. Acetylcholine receptor binding antibody was not detected. Acetylcholine esterase inhibitors relieved these episodic symptoms. A genetic study that showed an expansion of cytosine-adenine-guanine (CAG) repeat in the first exon of the androgen receptor (AR) confirmed the diagnosis of X-linked recessive spinal and bulbar muscular atrophy (X-SBMA). Thus, this case shows a rare association of ocular myasthenia gravis with X-SBMA.
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PMID:Ocular myasthenia gravis associated with x-linked recessive spinal and bulbar muscular atrophy. 1907 30


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