Breast Reduction Surgery and Gynecomastia Surgery

Number: 0017

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery.

1. Medical Necessity

   Reduction Mammoplasty

   Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 years or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met:

   1. Macromastia: all of the following criteria must be met:

      1. Member has persistent symptoms in at least two of the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least 1 year:

         1. Headaches;
         2. Pain in neck;
         3. Pain in shoulders;
         4. Pain in upper back;
         5. Painful kyphosis documented by X-rays;
         6. Pain/discomfort/ulceration from bra straps cutting into shoulders;
         7. Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue;
         8. Upper extremity paresthesia and

      2. All of the following criteria are met:

         1. Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs; and
            

            1. There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; and
            2. Reduction mammoplasty (also spelled mammaplasty) is likely to result in improvement of the chronic pain; and
            3. Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as:
               
               
               1. Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants
               2. Dermatologic therapy of ulcers, necrosis and refractory infection
               3. Physical therapy/exercises/posturing maneuvers
               4. Supportive devices (e.g., proper bra support, wide bra straps)
               5. Chiropractic care or osteopathic manipulative treatment
               6. Medically supervised weight loss program
               7. Orthopedic or spine surgeon evaluation of spinal pain; and
                  

         2. Women 50 years of age or older are required to have a mammogram that was negative for cancer performed within the two years prior to the date of the planned reduction mammoplasty; and

      3. The surgeon's preoperative evaluation must indicate that reduction mammaplasty is expected to provide meaningful improvement of the member's symptoms and that the anticipated amount of breast tissue to be removed from at least one breast meets the minimum resection weight corresponding to the member's body surface area (BSA), see Table 1 in the Appendix. Documentation submitted with the request must include:
         1. Member's height and weight
         2. Description of the size and configuration of the breast(s) contributing to symptoms; and
         3. Anticipated amount of breast tissue to be removed from each breast;

      Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast.

      Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated in section I above.

   2. Gigantomastia of Pregnancy:

      The member has gigantomastia of pregnancy accompanied by any of the following complications, and delivery is not imminent:

      1. Massive infection; or
      2. Significant hemorrhage; or
      3. Tissue necrosis with slough; or
      4. Ulceration of breast tissue; or

   3. Asymmetry:

      For medical necessity criteria for surgery to correct breast asymmetry, see CPB 0185 - Breast Reconstructive Surgery.

2. Experimental, Investigational, or Unproven

   The following procedures are considered experimental, investigational, or unproven because there is insufficient evidence of its effectiveness or its effectiveness has not been established:

   1. Air-assisted, nipple-areola-sparing mastectomy and liposuction
   2. Combined arthroscopic shaver and liposuction for the treatment of adolescent gynecomastia
   3. Liposuction and peri-areolar excision under tumescent local anesthesia
   4. Liposuction-only reduction mammoplasty
   5. Mastoscopic subcutaneous mastectomy
   6. Radiotherapy (for the prevention or management of gynecomastia recurrence)
   7. Vacuum-assisted breast biopsy system for treatment of gynecomastia.

3. Cosmetic

   1. Gynecomastia Surgery

      Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure.  Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance).  Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia.

   2. Breast reduction surgery is considered cosmetic for all indications not listed in the Medical Necessity section for Macromastia.
   3. Reduction mammoplasty for asymptomatic members is considered cosmetic.

4. Related Policies

   • CPB 0031 - Cosmetic Surgery
   • CPB 0185 - Breast Reconstructive Surgery
   • CPB 0227 - Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy
   • CPB 0615 - Gender Reassignment Surgery

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Table:

Applicable CPT / HCPCS / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
19318	Reduction mammaplasty
CPT codes not covered for indications listed in the CPB:
Vacuum-assisted breast biopsy system, Combined arthroscopic shaver and liposuction, Air assisted, nipple areole-sparing mastectomy and liposuction, Liposuction and peri-areolar excision under tumescent local anesthesia, Mastoscopic subcutaneous mastectomy - No specific code
15877	Suction assisted lipectomy; trunk
19300	Mastectomy for gynecomastia
19303	Mastectomy, simple, complete [not covered for Air assisted, nipple areole-sparing mastectomy]
77402-77417	Radiation Treatment Delivery
Other CPT codes related to the CPB:
17360	Chemical exfoliation for acne (eg, acne paste, acid)
19301	Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)
19316	Mastopexy
77065 - 77067	Diagnostic mammography, including computer-aided detection (CAD) when performed
96567	Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session
96573	Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day
98925 - 98929	Osteopathic manipulative treatment
98940 - 98943	Chiropractic manipulative treatment
99450	Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates
Other HCPCS codes related to the CPB:
S9449	Weight management classes, non-physician provider, per session
ICD-10 codes covered if selection criteria are met:
G56.00 - G56.93	Mononeuropathies of upper limb [upper extremity paresthesia]
I96	Gangrene, not elsewhere classified [tissue necrosis]
L98.491 - L98.494	Non-pressure chronic ulcer of skin of other sites
N62	Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration]
N64.89	Other specified disorders of breast [soft tissue infection]

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Background

Reduction Mammoplasty

Reduction mammaplasty, also known as breast reduction surgery, is a surgical procedure that reduces breast size and weight through the removal of excess breast tissue, fat, and skin. The goals of the procedure include alleviating symptoms associated with macromastia, improving functional impairment, and achieving breast proportions that are appropriate for the individual's body habitus. Reduction mammaplasty may be performed using a variety of surgical techniques, including traditional excisional approaches and, in selected individuals, liposuction-assisted techniques.

Reduction mammaplasty is commonly performed for women with symptomatic macromastia who experience neck, shoulder, and upper back pain, bra strap grooving, intertriginous skin irritation, postural difficulties, and other functional limitations related to excessive breast size and weight. Published studies have consistently demonstrated improvements in symptoms, physical functioning, health-related quality of life, and patient satisfaction following reduction mammaplasty (Behmand et al., 2000; Blomqvist et al., 2000; Chadbourne et al., 2001; Glatt et al., 1999; Kerrigan et al., 2001).

The Breast Reduction Assessment of Value and Outcomes (BRAVO) study evaluated health status, symptoms, and quality-of-life outcomes following reduction mammaplasty and has been cited extensively in discussions regarding medical necessity criteria for breast reduction surgery. Investigators reported significant improvements in pain, physical functioning, health-related quality of life, and symptoms associated with macromastia following reduction mammaplasty (Collins et al., 2002; Kerrigan et al., 2001; Kerrigan et al., 2002). The BRAVO study and subsequent observational studies suggested that clinical improvement may occur across a broad range of tissue resection weights and did not identify a consistent relationship between the amount of tissue removed and the degree of postoperative symptom improvement (Behmand et al., 2000; Blomqvist et al., 2000; Chadbourne et al., 2001; Collins et al., 2002; Glatt et al., 1999; Kerrigan et al., 2001; Kerrigan et al., 2002).

Professional society guidance has similarly noted that breast volume or tissue resection weight alone should not be the sole determinant of functional benefit or medical necessity (ASPS, 2002; ASPS, 2011). However, because reduction mammaplasty may be performed for either reconstructive or cosmetic purposes, objective criteria are commonly incorporated into coverage policies to assist in distinguishing medically necessary procedures from those performed primarily for aesthetic indications. One of the most widely used approaches is the Schnur Sliding Scale.

The Schnur Sliding Scale, first described by Schnur et al. (1991), correlates body surface area (BSA) with anticipated breast tissue resection weight and remains one of the most commonly used tools for evaluating reduction mammaplasty requests. Developed from a survey of plastic surgeons, the scale provides a standardized method for relating anticipated tissue resection to an individual's body habitus (Schnur et al., 1991).

Although concerns have been raised regarding the use of the Schnur Sliding Scale as the sole determinant of medical necessity, it continues to be widely incorporated into payer coverage policies as an objective measure of anticipated tissue resection (Nguyen et al., 1999). Consistent with current clinical practice, the Schnur Sliding Scale should be considered in conjunction with the member's symptoms, functional impairment, physical findings, and the surgeon's preoperative assessment.

For purposes of this policy, the Schnur Sliding Scale is used as one component of the medical necessity evaluation for reduction mammaplasty. The Appendix provides the corresponding BSA values and minimum anticipated breast tissue resection weights.

Proposed Assessment Instruments and Scales

Sinno et al. (2014) reviewed outcome measurement tools in plastic surgery and described methods used to objectively evaluate treatment outcomes, outlining categories that included health perception, functional measures, preference-based measures and utility scores, patient satisfaction, and multidimensional tools. They indicated that many validated outcome instruments are available to measure endpoints such as symptoms, functional status, and patient satisfaction, with functional measures assessing the impact of healthcare on activities of daily living across physical, mental, psychological, social, and general health domains. In this context, the SF-36 was presented as a functional measure instrument that evaluates health status across eight domains, including physical activity limitations, social activity limitations, role limitations due to physical and emotional problems, mental health, bodily pain, vitality, and general health perception; it was noted to be self-administered, simple to use, and widely utilized in clinical practice and clinical trials. Additionally, the BREAST-Q was described as a breast surgery-specific, modular patient-reported outcome tool developed to measure the impact and effectiveness of breast surgery from the patient perspective, with modules for augmentation, reduction or mastopexy, reconstruction, and mastectomy-only patients, and domains that encompass satisfaction with breasts, satisfaction with overall outcome, psychosocial well-being, sexual well-being, physical well-being, and satisfaction with care. This tool quantifies patient satisfaction and health-related quality of life, allowing for perioperative measurement of patient-reported outcomes. Furthermore, it was noted that outcome measures could span multiple categories and that tools such as the BREAST-Q and SF-36 contribute to the objective assessment of clinical outcomes and patient experience. In conclusion, the authors emphasized that the selection of outcome tools should be based on defined endpoints, and the use of multiple validated instruments—generally at least three—could help address inherent bias and provide a more comprehensive evaluation of treatment outcomes in plastic surgery.

Lonie et al. (2019) conducted a systematic review to evaluate patient satisfaction and patient-reported outcome measures (PROMs) in women undergoing reduction mammaplasty, using databases including PubMed, Cochrane Library, Medline, and Scopus from 1966 to July 2018 following PRISMA guidelines. The review included 95 studies representing 9,716 patients, with extracted data on demographics, questionnaires, surgical techniques, and physical, psychological, and aesthetic outcomes. Overall satisfaction was reported in 58 studies including 5,867 patients, with a mean satisfaction rate of 90.3% (range, 67.6–100%), mean age 37.8 years, mean body mass index 28.0, and mean resection weight 1,402.9 g. Unvalidated questionnaires were used in 52.6% of studies, while validated instruments included the SF-36 (25.3%), Rosenberg Self-Esteem Scale (9.5%), and BREAST-Q (8.4%). Reported satisfaction with BREAST-Q ranged from 76.0% to 95.0%, physical quality of life improvement ranged from 48.15% to 90.61%, and psychological quality of life improvement ranged from 76.37% to 84.54%; RSES showed self-esteem improvement rates from 12.9% to 17.9%, and SF-36 demonstrated improvement in bodily pain from 22.34% to 83.33%, physical quality of life from 10.38% to 33.24%, and psychological quality of life from 3.33% to 33%. Surgical technique analysis showed inferior pedicle use in 1,418 cases with 87.4% satisfaction, vertical pedicle in 210 cases with 97.9% satisfaction, wise pattern excision in 899 patients with 85.5% satisfaction, and horizontal scar technique in 127 patients with 97% satisfaction. The review reported consistent improvement in physical and mental health outcomes after surgery and indicated that PROMs assessing multiple domains combined with breast-specific instruments were commonly used to evaluate outcomes. However, the authors acknowledged some limitations to their study, which included heterogeneous questionnaire use, variable outcomes, and loss to follow-up. The author  concluded that PROM questionnaires that address multiple aspects of health appear to be preferred by most authors. Additionally, when combined with breast-specific questions, validated PROMs may provide a more accurate assessment of pre- and post-operative quality of life.

BREAST-Q Reduction/Mastopexy Module and Physical Well-Being Scale

The BREAST‑Q Reduction/Mastopexy module is a validated disease‑specific patient‑reported outcome measure (PROM) designed to assess quality of life and satisfaction following breast reduction surgery across physical, psychosocial, and sexual well‑being domains (Pusic et al., 2009). It is widely used in clinical research and practice and is considered a standard instrument for evaluating outcomes in breast surgery (Arora et al., 2023). Evidence from a systematic review and meta‑analysis of 28 studies demonstrates that individuals undergoing reduction mammaplasty have significantly lower preoperative scores compared with normative populations, with substantial postoperative improvement across all domains to levels comparable with the general population, independent of resection weight or clinical factors (Wang et al., 2023).

Morley et al. (2019) highlight that the Breast-Q™ is a validated PROM that has been extensively used by researchers and clinicians to assess the impact and effectiveness of breast surgery. Developed in 2009 in accordance with international PROM guidelines, it has been translated into 30 languages and is available free of charge for nonprofit academic research and clinical care. Since its introduction, BREAST-Q has expanded to include five modules, each comprising three quality of life domains—psychosocial well-being, physical well-being, and sexual well-being—as well as three satisfaction domains—satisfaction with breasts, satisfaction with outcome, and satisfaction with care. The authors state that a systematic review by Liu et al. identified 54 peer-reviewed articles that employed BREAST-Q to assess patient-reported outcomes following oncoplastic breast surgery, including four studies conducted in Australia. Overall, research utilizing BREAST-Q has increased their understanding of breast surgery-related outcomes, particularly concerning patient education, timing of reconstruction, implant type, and fat grafting. However, the authors acknowledged limitations of PROMs that should be considered, such as significant variation in response rates. In studies that used BREAST-Q in breast surgery, reporting response rates ranged from 32% to 100%. Additionally, poor response rates were compounded by response bias, as patients who were deeply satisfied or dissatisfied were often overrepresented. The authors further reported that patients from more deprived backgrounds, who were younger, sicker, and non-White, were underrepresented in national audits of elective surgeries, which affected the generalizability of findings to individual patients in clinical settings. Morley et al. emphasized that the use of information technology, including electronic, emailed, and app-based questionnaires, may increase response rates and allow patients to provide more accurate responses to sensitive questions in the comfort of their own home.

The BREAST‑Q Physical Well‑being scale is a validated subscale that specifically assesses symptom burden and functional limitations attributable to breast hypertrophy, including difficulty with physical activities such as exercise, lifting, and other routine tasks (Pusic et al., 2009). This domain captures disease‑specific impacts on physical functioning and has demonstrated significant improvement following reduction mammaplasty in prospective and meta‑analytic studies (Wang et al., 2023).

Breast‑Related Symptoms Questionnaire (BRSQ)

The Breast‑Related Symptoms Questionnaire (BRSQ) is a validated symptom‑focused instrument that assesses the frequency and severity of physical symptoms associated with breast hypertrophy, generating a composite symptom score. Prospective studies demonstrate significant postoperative reductions in symptom burden following reduction mammaplasty; however, the instrument primarily measures symptom frequency rather than functional limitation and is best considered supportive of clinical assessment (Valtonen et al., 2014).

SF-36

The SF‑36 is a validated, widely used generic health‑related quality of life instrument that assesses multiple domains, including physical functioning and role limitations due to physical health, which directly reflect limitations in activities of daily living and occupational functioning (Ware & Sherbourne, 1992). In individuals with macromastia, baseline scores are significantly lower than those of unaffected populations, with prospective studies demonstrating significant postoperative improvements across physical and functional domains following reduction mammaplasty (McNamara et al., 2023).

Timing of Reduction Mammoplasty

The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: “Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result.” This is similar to the American College of Obstetricians and Gynecologists' 2011 Guidelines for Adolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: “Preferably, treatment should be deferred until breast growth has been completed. If breast growth has been completed, breast reduction surgery is an option.” Marshall and Tanner (1969) shows that the final stage of breast maturity occurs about age 15 on average, but there is wide variation. Sabiston’s Textbook of Surgery (Burns & Blackwell, 2008) states that breast size should be stable for one year: “There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.”

Risk Factors for Postoperative Complications

Several large observational studies have evaluated factors associated with complications following reduction mammaplasty. Analyses of National Surgical Quality Improvement Program (NSQIP) data found that obesity and active tobacco use are among the most consistent predictors of postoperative complications. Morbid obesity and smoking were associated with increased rates of surgical complications, wound complications, and reoperations, while smoking was identified as a strong predictor of major postoperative morbidity (Fischer et al., 2014a; Karamanos et al., 2015; Nelson et al., 2014b). Increased complication rates have also been reported with higher body mass index (BMI), greater resection weights, older age, and active smoking status (Srinivasaiah et al., 2014).

Despite higher complication rates among certain higher-risk populations, reduction mammaplasty has generally been shown to be safe when appropriate patient selection and perioperative management are employed. In a population-based NSQIP analysis, age alone was not associated with an increased risk of postoperative complications, suggesting that reduction mammaplasty can be performed safely in appropriately selected older individuals (Nelson et al., 2014a).

Post-Operative Wound Drains in Reduction Mammoplasty

The American Society of Plastic Surgeons (ASPS) evidence-based clinical practice guideline states that routine drain placement is generally not indicated for standard reduction mammaplasty procedures; however, the decision to use drains when liposuction is performed as an adjunctive technique should be left to the surgeon's discretion (ASPS, 2011).

In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. However, it is unclear if there is any evidence to support this practice. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialized Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase (2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). There were no restrictions on the basis of date or language of publication. Three review authors undertook independent screening of the search results. All randomized controlled trials (RCTs) that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction, and breast reconstruction) in women were eligible. Two review authors undertook independent data extraction of study characteristics, methodological quality, and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). Risk of bias was assessed independently by two review authors. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). Analysis was on an intention-to-treat basis. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. No new trials were identified for this first update. In total, there were 306 women in the 3 trials, and 505 breasts were studied (254 drained and 251 who were not drained). Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95% CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation.

Sugrue and associates (2015) evaluated the current practice patterns of drain usage by plastic and reconstructive and breast surgeons in the United Kingdom (UK) and Ireland performing bilateral breast reduction (BBR). An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an email containing a link to a web-based survey. Statistical analysis was performed with the Student t-test and chi-square test. A total of 211 responding surgeons were analyzed, including 80.1% (171/211) plastic surgeons and 18.9% (40/211) breast surgeons. Of the responding surgeons, 71.6% (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an outpatient; however, this was not statistically significant (p = 0.07). The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice.

Special Considerations for Reduction Mammoplasty

In patients with a history of breast cancer undergoing contralateral reduction mammaplasty for symmetry, pathologic evaluation of resected tissue may identify occult malignancies or high-risk lesions. Merkkola-von Schantz et al. (2017) reported abnormal histopathologic findings in approximately one-fifth of reduction specimens, supporting the value of routine histopathologic evaluation in this population.

Reduction mammaplasty may also be performed as a secondary or revision procedure. Mistry et al. (2017) reported favorable outcomes following breast re-reduction surgery using contemporary surgical techniques, demonstrating that repeat breast reduction can generally be performed safely and predictably, even when details of the prior procedure are unavailable.

Gynecomastia Surgery

Gynecomastia is a very common concern of male adolescence. Sixty to 70% of males develop a transient sub-areolar breast tissue during their adolescence (Tanner Stages II and III). Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels.

Gynecomastia has been classified into 2 types. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Type II gynecomastia is more generalized breast enlargement. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles.

Gynecomastia may be drug-induced. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, methyltestosterone, human chorionic gonadotropins, and estrogens. Klinefelter’s syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia.

Henley et al. (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia).

Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Work-up of gynecomastia may include the following (GP Notebook, 2003):

1. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use.
2. A detailed physical examination, including testicular examination.
3. Liver and thyroid function tests.
4. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS)
5. An ultrasound scan of testicular masses
6. Computed tomography scan of adrenal glands to identify adrenal lesions.

Treatment should be directed at correcting any underlying reversible causes. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Resolution of idiopathic gynecomastia may take several months to years. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. However, these medications should be reserved for those with no decrease in breast size after 2 years. Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder.

Many men with breast enlargement are found to have pseudo-gynecomastia. Removing the adipose tissue in pseudo-gynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. A physician-supervised diet and exercise plan may be indicated in obese patients.

Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Mental health care professionals may be consulted to address psychological distress from gynecomastia.

In a review on “Surgical treatment of primary gynecomastia in children and adolescents”, Fischer et al. (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention.

Autologous Platelet Gel During Breast Surgery

In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al. (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. The primary outcome was the difference in wound drainage over 24 hours. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty.

Changes in Psychological Aspects after Gynecomastia Surgery

Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. For many patients the psychological impact of the disease is substantial. Surgical treatment is indicated when medical treatments fail. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Little is known about the effect of surgical treatment on the psychological aspects of the disease. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. A systematic search of the published literature was performed. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment.

Tamoxifen in the Treatment of Idiopathic Gynecomastia

Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D:4D) as a marker of ER and PR over-expression in the male breast. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. ER expression did not correlate with the right (p = 0.51) and left 2D:4D (p = 0.97). Also, there was no correlation between PR expression and 2D:4D. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). The authors concluded that a high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio.

Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. In a prospective cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. This trial included all male patients who presented to the authors’ breast clinic who were diagnosed with primary gynecomastia and were treated with a trial of tamoxifen 10 mg daily therapy over a 10-year period from October 2004 to October 2015. All patients underwent routine investigations to exclude secondary causes of gynecomastia. The endpoint was the complete resolution of gynecomastia. A total of 81 patients were included in this study. The mean age was 42.8 years (SD 19.5 years). Of these, 28.4% had bilateral gynecomastia and 71.6% had unilateral. The majority (87.7%) of cases presented with accompanying mastalgia. Following treatment, 90.1% (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Only 8 (9.9%) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. The authors concluded that this study was the largest to date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed that approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. These investigators support its use for idiopathic gynecomastia in eligible men following a careful discussion of its risks and benefits.

The Vacuum-Assisted Breast Biopsy System for the Treatment of Gynecomastia

He and associates (2011) examined the safety and feasibility of a vacuum-assisted biopsy device in the treatment of gynecomastia. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated using an 8-G vacuum-assisted biopsy device. The average age was 24.7 years (range of 18 to 47 years). The operation was successfully performed in all 20 patients, with a mean operating time of 51 minutes and a hospital stay of 4 days. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. No other operation-related complications were observed. A satisfactory chest contour was achieved in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. The Mammotome procedure represented another novel therapeutic option for gynecomastia. These preliminary findings need to be validated by well-designed studies.

Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia—vacuum-assisted minimally invasive mastectomy. With approval from the authors’ institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed up with physical examination and ultrasonography (US). Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. The operation had a mean duration of 73.5 minutes per side, ranging from 40 to 102 minutes. An average of 320 specimens were excised from each side, with a mean blood loss of 34 ml. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100%). Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before the operation. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications.

Qu and colleagues (2021) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. The characteristics of patients as well as the curative effects between the two groups were analyzed. The two vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. The safety, efficacy, complications, and patient satisfaction were recorded during post-operative follow-up periods. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 ± 1.3 cm versus 0.8 ± 0.2 cm, p < 0.001) and shorter hospital stay time (5.5 ± 2.4 days versus 3.1 ± 1.6 days, p < 0.001). Patients in the vacuum-assisted breast biopsy group had a better cosmetic outcome than those in the open surgery group. There were no statistically significant differences between the two vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. Furthermore, no serious complications were observed in the vacuum-assisted breast biopsy group. All the patients recovered well and were satisfied with the cosmetic outcomes. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. Level of Evidence = IV.

Liposuction-Assisted Gynecomastia Surgery with Minimal Peri-Areolar Incision

In a systematic review, Prasetyono and colleagues (2022) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. There were 18 out of 415 studies eligible to review. A total of 244 out of 1,628 patients with the average age of 23.13 years. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Complication rates were inconsistent throughout the studies, ranging from 0.06% to 26.67%. Re-operation rate of liposuction-assisted surgery was between 0.6% and 25%. There were only 2 studies of a total 25 patients that were considered as good in quality. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. Level of Evidence = III.

Pectoral High-Definition Liposculpture Combined with Inverted-Omega Incision Resection for Gynecomastia

Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. After these researchers’ 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Follow-up ranged from 2 months to 3 years. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n=132; liposuction, n=304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2%) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6%) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A non-standardized survey showed a very high satisfaction index. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Level of Evidence = IV.

Radiotherapy for the Prevention or Management of Gynecomastia Recurrence

Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. In a systematic review, these investigators examined the role of radiotherapy in this context. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. A total of 15 articles met the inclusion criteria for review. The mean incidence of gynecomastia was 70% in the high-risk population examined, representing prostate cancer patients on estrogen or anti-androgen therapy. Radiotherapy was shown to significantly reduce the incidence to a median of 23%, with all 6 randomized controlled trials (RCTs) assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. The median complication rate was 12.4%, with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economic utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients.

Spagnolo et al. (2025) conducted a systematic review and meta-analysis to quantitatively evaluate the effectiveness of tamoxifen, anastrozole, and radiotherapy in preventing gynecomastia and breast pain induced by bicalutamide in prostate cancer patients. Following PRISMA-P guidelines, the researchers performed a comprehensive search of PubMed, Scopus, and Web of Science for English-language studies without temporal restrictions, including randomized controlled trials (RCTs) that involved prostate cancer patients treated with bicalutamide and receiving preventive interventions compared to bicalutamide alone or with placebo/sham. Data extraction focused on the incidence of gynecomastia and breast pain, and study quality was assessed using the Jadad scale. The analysis calculated risk ratios (RR) with 95% confidence intervals (CI) using fixed- or random-effects models, while heterogeneity was evaluated with the I² statistic, and publication bias was explored through funnel plots and the trim-and-fill method. The review identified nine RCTs that met the inclusion criteria, revealing that tamoxifen significantly reduced the risk of breast events by 82% (RR: 0.18, 95% CI: 0.08-0.38 for gynecomastia and RR: 0.18, 95% CI: 0.07-0.43 for breast pain). Radiotherapy also demonstrated effectiveness, reducing gynecomastia risk by 52% (RR: 0.48, 95% CI: 0.38-0.59) and breast pain by 34% (RR: 0.66, 95% CI: 0.48-0.90), while anastrozole showed no significant benefit. The authors concluded that tamoxifen is the most effective strategy for preventing bicalutamide-induced breast events, with radiotherapy as a viable alternative, and emphasized the need for further large-scale, high-quality studies to confirm these findings and refine preventive treatment recommendations.

Reduction Mammaplasty for Macromastia in Adolescents

Hudson et al. (2017) stated that reduction mammaplasty for macromastia is one of the most common operations performed by plastic surgeons; however, there remains hesitancy in operating on adolescents, as there is ongoing debate regarding breast re-growth and potential impact on breast-feeding. In a systematic review and pooled analysis, these investigators examined these concerns by reviewing the current literature. They carried out a systematic review of Medline, Scopus, and Google Scholar using the following terms: "breast reduction" or "mammaplasty" or "breast reconstruction" and "adolescent" or "youth" or "pediatric" or "child" or "teen". Primary outcomes were success of breast-feeding following the procedure and procedure-related complications. A total of 23 studies (87% retrospective), consisting of 2,926 patients with pre-operative cup sizes of C to KK (mean of DDD), met inclusion criteria. Mean age at the time of surgery ranged from 16 to 21 years, with the youngest patient being 12 years old. The overall complication rate was 27.3% (95% CI: 14.4 to 42.5%). Minor complications (22.8%; 95% CI: 10.2 to 38.5%) were more common than major (4.2%; 95% CI: 1.6 to 7.9%); 18% of patients (95% CI: 2.2 to 43.8%) reported re-growth of their breast tissue post-operatively, with 2.7% (95% CI: 0.9 to 5.5%) undergoing a 2nd revision mammaplasty; 53% of patients (95% CI: 36.0 to 69.3%) did not attempt breast-feeding. Of those who attempted, 55.1% (95% CI: 34.4 to 74.9%) were successful. The authors concluded that prospective data are lacking. These investigators stated that patient counseling should focus on encouraging a trial of breast-feeding, despite surgical history; and 20% of adolescent patients may notice breast re-growth post-operatively; however, the amount of re-growth was likely small and unlikely to re-exacerbate symptoms, as the rate of revision surgery was small.

Reduction Mammoplasty and Mastopexy in the Previously Irradiated Breast

Lorentzen et al. (2021) noted that breast cancer is the most common cancer diagnosed in women, and early stages are treated with lumpectomy and irradiation. Irradiation, however, results in reduced vascularization and fibrosis, which may influence the cosmetic outcome unfavorably and increase complications after subsequent surgery on irradiated breasts. Patients with significant asymmetry after treatment may desire corrective reduction mammoplasty or mastopexy; however, this may be associated with increased complication rates. In a systematic review and meta-analysis, these investigators examined post-operative complication rates following bilateral reduction mammoplasty or mastopexy in women who had undergone unilateral lumpectomy and irradiation. PubMed, Medline, Embase and Cochrane databases were searched for eligible studies. After screening titles and abstracts, a total of 14 full text studies were reviewed, and 7 of these were included in the analysis. The meta-analysis showed a significantly higher complication rate in the irradiated breast compared to the non-irradiated breast, rate ratio 4.82 (95% CI: 1.58 to 14.70, p = 0.006). The complication rate was 54 % in the irradiated breast (58/107) compared to 8% (9/107) in the non-irradiated breast (p = 0.034). The authors concluded that the findings of this study suggested that reduction mammoplasty or mastopexy in the previously irradiated breast was associated with a significantly increased risk of complications. Careful patient selection and information are paramount in the treatment of this patient group.

Liposuction-Assisted Gynecomastia Surgery

Wen et al. (2021) presented a case of complicated gynecomastia that was successfully managed with an innovative technique, which offered acceptable operative time, minimal complications, good recovery, and satisfactory aesthetic outcomes. The case involved a 39-year-old man who developed gynecomastia along with self-injection of a foreign body (salad oil) over the past 10 years for breast enlargement, presenting as symptomatic bilateral breast lumps. Bedside sonography revealed multiple large droplets of oil in the subcutaneous tissue bilaterally, resembling cystic lesions. Bilateral single-port 3D videoscope-assisted endoscopic subcutaneous mastectomy was carried out after bilateral breast liposuction. Operative findings included bilateral gynecomastia and previous bilateral breast foreign body material. The total weight of lipo-aspirate was 400 g and 300 g for the right and left sides, respectively. Subcutaneous mastectomy specimen weight was 820 g and 661 g for the right and left breast tissue, respectively. Operative duration was 315 minutes, and intra-operative blood loss was 150 ml. The patient was discharged 2 days after the operation, and subsequent follow-up ultrasound showed complete removal of foreign bodies and fibrotic breast tissue. The patient was satisfied with the post-operative aesthetic outcomes. The authors concluded that single-port 3D videoscope-assisted endoscopic subcutaneous mastectomy with concurrent liposuction is a safe and promising surgical option for patients with complicated gynecomastia and severe fibrosis.

Singamsetty et al. (2022) noted that conventional liposuction, when used for the treatment of gynecomastia, employs incisions for the introduction of the cannula, usually made at the infra-mammary crease or axilla, resulting in consequent scars. The cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. In a prospective, comparative study, these researchers examined the difference between the aesthetic outcomes of conventional liposuction and cross-chest liposuction in the treatment of gynecomastia. This trial included 2 groups with 15 patients, one with conventional and the other with cross-chest liposuction. Excision of residual gland tissue was carried out via circum-areolar incision in both groups. Aesthetic outcomes were evaluated in both groups using the Likert scale and compared. The mean age of the patients was 22.6 years, and the mean duration of presentation was 8.13 years. The satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The satisfaction rate was 80% and 77%, respectively, in both groups as assessed by an independent observer. The complication rate was 13.3% in the conventional group and 20% in the cross-chest group. The difference in outcomes was not statistically significant between the two groups. The difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both techniques. The authors concluded that both conventional and cross-chest liposuction yielded comparable results when used for the treatment of gynecomastia in terms of aesthetic outcome. Level of Evidence = III.

The authors stated that this study had the limitation of a small sample size (n = 15 in each group). Since it was a time-bound study, the COVID-19 pandemic did not permit these researchers to achieve a better sample size. The outcome of this trial can be validated further by future comparative studies with a larger sample size.

In a systematic review, Prasetyono et al. (2022) examined the quality of studies and revisited liposuction-assisted gynecomastia surgery performed via minimal incision. These investigators carried out a systematic review based on the literature in PubMed, Scopus, Science Direct, and Cochrane, focusing on the treatment of Simon's grade I and grade II using the keywords "gynecomastia" and "liposuction." Study appraisal was carried out using MINORS to evaluate the methodological quality of the studies. There were 18 out of 415 studies eligible for review, involving a total of 244 out of 1,628 patients with an average age of 23.13 years. Liposuction facilitated the easy handling of breast tissue removal via small incisional design and showed consistent improvement in quality of life (QOL) in terms of satisfaction following surgery. However, the measuring method of satisfaction rates varied, resulting in difficulties interpreting the results. Complication rates were inconsistent throughout the studies, ranging from 0.06% to 26.67%. The re-operation rate of liposuction-assisted surgery was between 0.6% and 25%. There were only 2 studies of a total of 25 patients that were considered good in quality. The 2 studies, which discussed laser-assisted liposuction techniques, showed minor complications of seroma in 2 patients. While 1 study showed a high patient satisfaction rate, both studies indicated high surgeon satisfaction rates. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case series, urging for better quality studies in the future. These investigators stated that the studies included in this review mostly did not comply with the ideal non-comparative study, primarily due to a high risk of bias. This review could be used as a reference for further studies to achieve better methodological quality, less bias, and a standardized method of measurement regarding satisfaction rates for gynecomastia patients. Level of Evidence = III.

The authors stated that this study had several drawbacks. First, there were limitations on the details of each patient while extracting the data, such as no explanation about complications or satisfaction levels. This resulted in a small number of subjects that could be analyzed. Second, the lack of subjects concerning laser-assisted and suction-assisted liposuction studies also contributed to a higher risk of bias. Third, these researchers found that the studies available for gynecomastia had low quality of methodological technique, resulting in the inability to draw firm conclusions without a high risk of bias.

Varlet et al. (2023) described the technical standardization of pediatric endoscopic subcutaneous mastectomy (PESMA) with liposuction. All adolescents with primary gynecomastia operated on using PESMA with liposuction over the period from June 2014 to July 2021 were included. The video recordings of procedures were analyzed to standardize the operative technique. After patient installation, 3 trocars were placed on the mid-axillary line. The technique included 5 steps: First, subcutaneous injection of lipolysis solution and liposuction; second, creation of working space using an inflated balloon; third, gland dissection using a 5-mm sealing device; fourth, specimen extraction via the largest trocar orifice; and fifth, placement of a suction drainage tube. A total of 24 male adolescents operated on for Simon's grade 2B and grade 3 gynecomastia using PESMA with liposuction over the study period were included. The mean patient age was 16 years (range of 15 to 18). Gynecomastia was bilateral in 19/24 (79.2%) and unilateral in 5/24 (20.8%). One (4.1%) conversion to open surgery was reported. The mean operative time was 87 minutes (range of 98 to 160) for unilateral and 160 minutes (range of 140 to 250) for bilateral procedures. The mean length of stay was 2.2 days (range of 1 to 4). Patients wore a thoracic belt for 15 to 30 days post-operatively. Post-operative complications occurred in 5/24 (20.8%): 2- or 3-mm 2nd-degree burns in 4 (16.7%) and subcutaneous seroma in 1 (4.1%). All complications were Clavien grade 2 and did not require further treatment. Aesthetic outcomes were very good in 21/24 (87.5%); 3 (12.5%) boys had persistent minimal breast asymmetry but did not perceive it negatively. The authors concluded that PESMA combined with liposuction was feasible and safe for the surgical treatment of gynecomastia in this selected cohort of patients. These researchers stated that although challenging, this procedure provided good aesthetic results, with no scars on the anterior thoracic wall. Standardization of the operative technique was a key point for successful outcomes.

The authors stated that the principal drawbacks of this trial were the small patient cohort (n = 24) and the relatively short follow-up period (range of 12 to 24 months). In addition, no reliable assessment tool to evaluate the post-operative aesthetic results was available; thus, the observer assessment method was adopted to strengthen the validity and reliability of the results.

Arthroscopic Shaver and Liposuction for the Treatment of Adolescent Gynecomastia

In a retrospective study, Belza et al. (2023) compared the arthroscopic shaver and liposuction with other established methods for the treatment of adolescent gynecomastia. Surgical management was performed using 4 operative techniques: open excision, open excision/liposuction, arthroscopic shaver/liposuction, or open excision with free nipple graft. Data were collected and compared using independent t-tests, linear regression models, and one-way analysis of variance. Patients were stratified by Rohrich grades I-II (low) (n = 47) or III-IV (high) (n = 13). The groups were similar in age (p = 0.662), with a lower BMI in the low-grade group (x̄ = 25.36 ± 2.1) compared to the high-grade group (x̄ = 27.62 ± 4.0; p < 0.001). The low-grade group showed no significant difference in operative time across surgical techniques, with a decreased mean operative time in the high-grade group using the arthroscopic shaver technique (x̄ = 55.8 ± 7.56) compared with open excision (x̄ = 70.83 ± 11.02, p = 0.04), open excision plus liposuction (x̄ = 89.5 ± 24.93, p = 0.24), and open excision plus free nipple graft (x̄ = 81.67 ± 19.11, p = 0.05). There was no significant difference in complication (p = 0.84) or re-operation (p = 0.68) rates across surgical techniques regardless of grade. The authors concluded that the findings of this study suggested that the arthroscopic shaver was safe and effective for the treatment of both low- and high-grade gynecomastia in adolescents. The results yielded a similar incidence of complications and re-operation across surgical techniques, and the arthroscopic shaver approach showed a shorter operative time compared with other techniques for high-grade gynecomastia. Moreover, these researchers stated that further prospective studies are needed to examine patient satisfaction and long-term aesthetic outcomes.

The authors noted that although the retrospective design of this study allowed for efficient data collection over a 5-year period, the design was limited, given its inferior level of evidence compared with a prospective study. Furthermore, the findings were limited in their generalizability, given the relatively small sample size (n = 60) and the fact that all patients were treated at a single institution. These investigators stated that in future iterations, a larger sample size would be beneficial to increase the power of the statistical analysis. Additionally, a longer duration of follow-up would support the use of this technique by showing late results with optimal flat aesthetic breast contour.

The Impact of Age on Outcomes After Breast Reduction Surgery

Knoedler et al. (2024) noted that reduction mammoplasty is popular among individuals of various age groups; however, the impact of age on post-operative outcomes remains debated. The American College of Surgeons National Surgical Quality Improvement Program (2008 to 2021) was queried to identify adult female patients who underwent reduction mammoplasty. Patients were categorized into 10-year age brackets (i.e., 18 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, and greater than 70 years). These investigators compared age-dependent 30-day outcomes via confounder-adjusted multi-variate analyses. A total of 40,958 female patients (mean age of 41 ± 14 years, and mean BMI of 31 ± 6.1 kg/m²) were identified. Complications occurred in 6.4% (n=2,635) of cases, with 770 (1.9%) and 483 (1.2%) patients requiring re-operation and re-admission, respectively. A total of 1,706 (4.2%) women experienced surgical complications, whereas medical complications were generally rare (n=289; 0.7%). Compared with women aged 18 to 29 years, risks of any, surgical, and medical complications were higher for patients aged 30 to 39 years (OR: 1.22, p < 0.01; OR: 1.05, p = 0.51; OR: 1.84, p < 0.01), 40 to 49 years (OR: 1.34, p < 0.01; OR: 1.17, p = 0.04; OR: 1.54, p = 0.03), 50 to 59 years (OR: 1.45, p < 0.01; OR: 1.31, p < 0.01; OR: 1.78, p < 0.01), 60 to 69 years (OR: 1.38 years, p < 0.01; OR: 1.29, p = 0.01; OR: 1.71, p < 0.01), and greater than 70 years (OR: 1.25, p = 0.18; OR: 1.01, p = 0.98; OR: 1.86, p = 0.14). Patients aged  over 30 years were also more likely to require re-admissions and re-operations. The authors concluded that patient age significantly affected outcomes after reduction mammoplasty, with the lowest risk in patients aged less than 30 years. More importantly, the association between age and post-operative morbidity was not linear. These findings could aid in guiding informed decisions, recognizing that while age is a factor, it is not the sole determinant of risk.

Air-Assisted Nipple-Areola-Sparing Mastectomy and Liposuction for Gynecomastia Correction Surgery

Tukenmez et al. (2024) examined the safety and effectiveness of air-assisted subcutaneous mastectomy in the treatment of gynecomastia. A total of 10 patients with gynecomastia underwent air-assisted subcutaneous mastectomy and liposuction via a single axillary incision, between June 2022 and February 2023 were included in this trial. Demographic and clinical data of the patients, duration of surgery, and complications were recorded. The satisfaction levels of the patients regarding physical appearance, mental status, and social environment were measured. The body Q questionnaire was carried out pre-operatively and 3 months post-operatively. The median age was 26 years (range of 18 to 54 years). Surgical excision was measured as a median of 69 g (range of 41 to 177), and liposuction volume was measured as a median of 210 cc (range of 63 to 400). The median operation time was 50 mins (range of 21 to 60) for excision and 21 mins (range of 20 to 75) for liposuction. Body, chest, and nipples related appearance satisfaction levels were measured pre-operatively as a median of 44 (range of 36.5 to 52), 31 (range of 27.5 to 39), and 51.5 (range of 21 to 69.8) points versus post-operatively as 92 (range of 92 to 100), 93 (range of 93 to 94.8) and 90 (range of 90 to 100) points, respectively. Participants had a median follow-up of 6 months (range of 3 to 11). No complications were observed during the follow-up period. The authors concluded that air-assisted subcutaneous mastectomy and liposuction was a feasible technique that may provide good cosmetic outcomes by avoiding anterior chest wall scarring. Moreover, these researchers stated that although these findings were promising, studies with larger number of patients are needed to validate these preliminary findings.

Liposuction and Peri-Areolar Excision Under Tumescent Local Anesthesia for Gynecomastia Correction Surgery

Matilde et al. (2024) noted that tumescent local anesthesia (TLA) entails infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While liposuction under general anesthesia remains the most used treatment, these researchers introduced a novel TLA approach for gynecomastia surgery, drawing from their experience in recent years. Between the years 2010 and 2023, these investigators carried out gynecomastia surgery on 60 male patients under TLA. Gynecomastia was treated by liposuction plus peri-areolar excision technique. Liposuction was performed on both breasts in every case, regardless of whether the gynecomastia was bilateral or unilateral. The tumescent solution consisted of 25 ml of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 ml of epinephrine (1 mg/1 ml) in 1,000 ml of 0.9% saline solution. The solution was infiltrated between the pectoral fascia and the mammary gland, and then the surgery was performed. The average volume of tumescent solution infiltrated during TLA was 300 ml per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia.  Subjects experienced no pain or discomfort during the pre-operative infiltration or surgical procedure. These researchers observed a major post-operative complications rate of 6.7%, represented by 3 incident of hematoma and 1 case of seroma. A minor complication rate of 5% was observed: 2 cases of retraction of the nipple-areola complex (NAC) and 1 case of gynecomastia recurrence, the latter undergoing an additional combination procedure with liposuction and subcutaneous mastectomy. Follow-up duration ranged from 30 days to 1 year. The authors developed a new outpatient surgical method for gynecomastia using liposuction and peri-areolar excision under TLA. This technique, supported by a comprehensive rehabilitation plan, provided a successful and quick recovery, and high patient satisfaction. Moreover, these researchers stated that these findings suggested the feasibility of this proposed gynecomastia treatment, warranting further consideration of this new approach. Level of Evidence = IV.

Mastoscopic Subcutaneous Mastectomy for Gynecomastia Correction Surgery

In a single-center, case-series study, Luo et al. (2025) described their experiences on the mastoscopic subcutaneous mastectomy for correcting gynecomastia by the "9-step method" based on the "5S" goal and standardize this operation. Between January 1, 2002 and October 31, 2021, a total of 2,035 breasts of 1,082 male patients with gynecomastia, of which 129 patients with 1 side, underwent mastoscopic subcutaneous mastectomy. The follow-up endpoint was 3 months after surgery. All patients successfully completed the operation, and none of them was converted to open operation. The operation time for unilateral breast was 12 to 28 mins, and the average time was 17.7 ± 6.2 mins. The amount of bleeding during unilateral operation was very small, approximately 5 to 10 mL. The total drainage volume was 5 to 50 mL after the operation, and the drainage tube was removed in 3 to 5 days. Epidermal necrosis occurred in 0.3% nipple; 0.2% chest wall had a little ecchymosis in the supero-medial region of the breast. All subjects had the normal feeling of nipples and areola, the smoothing and symmetrical chest wall, and the natural contour. There was no recurrence during the follow-up period. The authors concluded that mastoscopic subcutaneous mastectomy for correcting gynecomastia by "9-step method" based on the "5S" goal exhibited a short operation time, few surgical complications and good esthetics. It attained the "5S" goals on the complete removal of glandular tissue (sweeping), small and scar-hidden incision were small (scarless), good symmetry of bilateral chest wall (symmetry), normal chest shape (shape), and smoothing chest wall (smoothing). Level of Evidence = III.

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Appendix

Table: Schnur Sliding Scale (22nd Percentile)

Body Surface Area (m2)	Weight of tissue to be removed per breast (grams)
1.35 1.40 1.45 1.50 1.55 1.60 1.65 1.70 1.75 1.80 1.85 1.90 1.95 2.00 2.05 2.10 2.15 2.20 2.25 2.30 or greater	199 218 238 260 284 310 338 370 404 441 482 527 575 628 687 750 819 895 978 1000

Source: Adapted from Schnur et al. (1991)

Calculation of body surface area (BSA):

BSA = the square root of height (cm) multiplied by weight (kg) divided by 3600

• To convert pounds to kilograms, multiply pounds by 0.45
• To convert inches to meters, multiply inches by 0.0254.

See, BMI Calculator (Body Mass Index and BSA)

Drugs Associated with Gynecomastia

1. Estrogens and estrogen like drugs, including:

   • Diethylstibestrol;
   • Exposure to partners using estrogen containing vaginal creams;
   • Cosmetics containing estrogens
   • Digitoxin

2. Drugs that enhance estrogen formation, including:

   • Gonadotrophins such as hCG
   • Following withdrawal of clomiphene

3. Drugs which inhibit testosterone synthesis, including

   • Ketoconazole,
   • Metronidazole,
   • Spironolactone,
   • Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy)

4. Drugs that inhibit testosterone action, including

   • Androgen receptor blockers - bicalutamide
   • 5 α reductase inhibitors - finasteride, dutasteride
   • H2 blockers and proton pump inhibitors
   • Marijuana

5. Drugs whose mechanism of action is unknown:

   • Tricyclic antidepressants
   • Angiotensin converting enzyme inhibitors (captopril, enalapril)
   • Heroin
   • Amiodarone
   • Busulfan
   • Methyldopa
   • Captopril
   • Growth hormone
   • Reserpine
   • Highly active antiretroviral therapy
   • Calcium channel blockers (diltiazem, nifedipine, verapamil)
   • Isoniazid

6. Others situations which can cause or lead to gynecomastia:

   1. Anabolic steroids (e.g., in body builders)
   2. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oil or tea tree oil.

Adapted from General Practice Notebook.

American Society of Plastic Surgeons' Gynecomastia Scale

• Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
• Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.
• Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast.

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References