15 year old boy with conical enlargement of breast and caved-in appearance of chest

A case of gynaecomastia with pectus excavatum

What are the criteria for diagnosis of Gynecomastia?

In the nonobese male, breast tissue measuring at least 2 cm in diameter must be present before a diagnosis of gynecomastia may be made. Mammography and ultrasonography are used to differentiate breast tissues. 

What is the differential diagnosis of Gynaecomastia?

I. Estrogen excess states

A. Gonadal origin

1. True hermaphroditism

2. Gonadal stromal (nongerminal) neoplasms of the testis

a. Leydig cell (interstitial)

b. Sertoli cell

c. Granulosa-theca cell

3. Germ cell tumors

a. Choriocarcinoma

b. Seminoma, teratoma

c. Embryonal carcinoma

B. Nontesticular tumors

1. Adrenal cortical neoplasms

2. Lung carcinoma

3. Hepatocellular carcinoma

C. Endocrine disorders

D. Diseases of the liver—nonalcoholic and alcoholic cirrhosis

E. Nutrition alteration states

II. Androgen deficiency states

A. Senescence

B. Hypoandrogenic states (hypogonadism)

1. Primary testicular failure

a. Klinefelter's syndrome (XXY)

b. Reifenstein's syndrome

c. Rosewater-Gwinup-Hamwi familial gynecomastia

d. Kallmann syndrome

e. Kennedy's disease with associated gynecomastia

f. Eunuchoidal state (congenital anorchia)

g. Hereditary defects of androgen biosynthesis

h. Adrenocorticotropic hormone deficiency

2. Secondary testicular failure

a. Trauma

b. Orchitis

c. Cryptorchidism

d. Irradiation

C. Renal failure

III. Drug effects

IV. Systemic diseases with idiopathic mechanisms

What are various grades of Gynaecomastia?

Grade I	Mild breast enlargement without skin redundancy
Grade IIa	Moderate breast enlargement without skin redundancy
Grade IIb	Moderate breast enlargement with skin redundancy
Grade III	Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

What is the surgical management of Gynaecomastia?

The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion.

Webster's Incision