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Whilst tuberous female breasts are well described, the tuberous male breast is a very unusual variant of gynaecomastia. Two cases are presented, the development of the condition is considered and the surgical management is discussed.
Gynaecomastia is a common condition causing significant embarrassment. Although gynaecomastia can be associated with hormonal imbalances, tumours, hepatic, thyroid and renal disease and drug interactions, the majority of cases arise in adolescent and middle-aged males in the absence of an underlying pathology.
Lower-grade gynaecomastia can be managed with simple excision and/or liposuction of the abnormal tissue (Grade I–IIa), whilst higher-grade disease will usually require skin excision and, consequently, involves more extensive scarring (Grade IIb–III). The tuberous male breast is a rare variant of gynaecomastia where the skin excess is disproportionately great in comparison to the surplus bulk; a relatively constricted base (often seen in the female tuberous breast)
is also present. The clinical picture does not easily fit into the classification suggested by Simon et al. Some skin reduction is necessary even if there is a relatively minor degree of breast hypertrophy. There are problems, both of significant ptosis and of herniation of the breast tissue into the areolar area. We present two cases of this rare condition and describe the surgical management of each.
1. Case reports
1.1 Case 1
A 15-year-old male presented with a two year history of bilateral tuberous gynaecomastia (Fig. 1(A)) . The glandular and skin excess was excised using a Wise breast-reduction pattern, leaving vertical and horizontal scars, and the nipples were reapplied as free grafts (Fig. 1(B)). We excised 160 and 170 g of dermoglandular tissue from the right and left sides, respectively. The patient made an uneventful recovery and progressed satisfactorily. Mild hypertrophic scarring at the medial ends of the ‘inframammary’ scars was managed using silicone gel tape, and a degree of nipple hypopigmentation was noted on the right (Fig. 1(C)).
A 15-year-old male presented with a two year history of embarrassing gynaecomastia. A pronounced tuberous deformity was noted, with apparent ‘herniation’ of glandular tissue through the areola, a feature usually associated with more severe cases of female tuberous breasts (Fig. 2(A)) .
The skin excess was treated using a circumferential areola-reducing approach. The excess areola produced by the deformity was de-epithelialised, and the nipple was kept vascularised on four dermal pedicles at three, six, nine and twelve o'clock, respectively. Between these pedicles the dermis and the glandular tissue behind the nipple were removed (70 g on the left and 80 g on the right). The periphery of the glandular excision was ‘feathered’ using liposuction (Fig. 2(B)). No nipple loss was observed, and the patient made an uneventful recovery (Fig. 2(C)).
Figure 2Case 2. (A) Preoperative photographs. (B) Intraoperative photographs showing (top left) preoperative marking, (centre left) de-epithelialisation, (bottom) creation of multiple dermal bridges to nipple, (top right) excision of breast tissue and (centre right) eventual specimen. (C) Postoperative appearance at 30 months.
Indeed, Aegineta gives instructions for simple excision in mild disease and the excision of breast and skin in more advanced disease. The surgical management of the condition has changed little in principle since then. Where no skin excision is required, periareolar or intra-areolar incisions can be employed to good effect,
and in young patients minor skin redundancy will often settle with time. When excess skin is a problem, the unwanted skin can be easily removed, but repositioning of the nipple becomes necessary. In cases of minor skin excess, a crescent of skin above the nipple can be removed and the nipple advanced into the defect.
Circumareolar excision has also been advocated, preserving the nipple on a de-epithelialised dermal pedicle along one half of the circumareolar incision.
More recently, some authors have recommended liposuction as a treatment for mild gynaecomastia, an adjunct to surgical excision or a primary bulk-reducing manoeuvre prior to subsequent (less extensive) surgical correction.
The tuberous male breast requires relative skin redundancy to be addressed even when the tissue excess is minor, and, therefore, additional unattractive scarring is unavoidable. The cases we present show the application of current techniques and the resultant scarring. Nonetheless, patient satisfaction was high, and this reflects the greater social stigma of the female appearance of gynaecomastia in comparison with postoperative scarring.
Whilst specific figures for the incidence of tuberous female breasts are not available, the condition is clearly rare. It is only at the onset of breast development that the condition becomes apparent in affected women. An equivalent predisposition may exist (asymptomatically) in a similar proportion of males. Perhaps, therefore, the rarity of the male tuberous breast is related to the necessity for an underlying predisposition and, in addition, the development of gynaecomastia. Developmental anomalies have been proposed as a basis for the deformity in females,
but no clear evidence exists. Certainly, one might speculate that it is the conformation of the soft tissue and the pattern of breast-tissue growth that predispose to a tuberous appearance in affected women. We have not encountered tuberous male breasts in older patients, probably because of the typically slow progression of gynaecomastia in this age-group and the fatty consistency of the tissue, which do not truly parallel the situation in the adolescent male (or female) tuberous breast.
In summary, two cases of this rare variant of gynaecomastia are presented. It is clear that significant skin reduction may be necessary even in relatively minor cases, and the patient must be prepared to accept the resultant scarring if an adequate surgical correction is to be achieved.
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