Pseudogynecomastia and a Novel Approach to Its Treatment

Goals/Purpose: Male obesity frequently results in an accumulation of adipose tissue as a broad fold that cascades over the inframammary crease and in many cases extends around the back.  Massive weight loss in these men results in a broad, transversely oriented envelope of redundant skin. This type of enlarged male breast is distinct in cause and presentation from adolescent, drug induced and other types of adult onset gynecomastia. Other causes of an enlarged male breast are characterized by overgrowth of breast bud fibrous stroma predominantly in the subareola area and a variable amount of surrounding adipose tissue.  The skin envelope typically expands in a female breast pattern and exhibits a high degree of elasticity after removal of the excess volume.  The need for skin excision after removal of the excess volume is the exception. In contrast, the enlarged breast of the obese male represents the anterior portion of a transverse skin fold based on the inframammary crease. The transverse fold extends laterally around the back and represents an adipose filled expansion of the normal truncal skin fascial attachments.  After massive weight loss this skin fold becomes a deflated, ptotic envelope of redundant skin. The term, pseudogynecomastia, best describes the redundant, transverse skin folds which result from massive weight loss in the male chest.  The purpose of this article is to report our surgical experience with a paradigm for tailoring the redundant skin in pseudogynecomastia distinct from the female breast and true gynecomastia.

Methods/Technique: The preoperative markings involve placement of two important landmarks; the proper location for transposition of the nipple areola complex and the inframammary fold. To place the nipple areola complex a vertical line is dropped through the existing nipple. The new location of the nipple is placed along this line just above the inferior border of the pectoralis major muscle. This avoids postoperative ptosis of the nipple. The areola diameter is reduced to 32-36 mm with the lower border just at or slightly overhanging the inferior border of the pectoralis.  The location is confirmed by inspection. The inframammary fold is marked in the standing position. The transverse incision is marked 1-2 cm above the actual inframammary crease and extended posteriorly as far toward the midline of the back as needed to remove the redundant fold. The medial extent of the incision is carefully limited to avoid crossing the midline.

A pedicle is deepithelialized to carry the nipple areola complex. The pedicle is based inferiorly usually, but may be based on a superior, lateral or medial pedicle as well.  A pedicle as narrow as 8 cm is adequate to carry the nipple areola complex but typically a wider pedicle base is designed and thinned as needed to contour the chest. After the central pedicle is created, the skin and adipose flap is dissected from the pectoralis fascia cranially and the pedicle is transposed as marked. The redundant skin and adipose tissue is marked with tailor tacking sutures. The flap is pulled over the pedicle as a window shade. The transverse skin excision is carried out as marked and the nipple areola is produced through a window in the repositioned flap. The cranially based flap is thinned as needed. A vertical incision is typically not made between the nipple and the transverse closure. The skin is then closed after placement of JP drains. The above approach was employed by three plastic surgeons at the Cedars-Sinai medical center. Our study population consisted of 18 males followed over a 12 month period.

Results/Complications: The surgical technique described in this study is performed with a high overall patient satisfaction and excellent cosmesis as agreed by all three surgeons, without incidence of infection, seroma, wound dehiscence, or nipple necrosis.

Conclusion: The redundant chest skin folds in the male post-weight-loss patient represents a wholly different entity from gynecomastia and is best described as pseudogynecomastia. We advocate the use of a transverse skin resection and transposition of the nipple areola complex to the caudal border of the pectoralis muscle carried on a central pedicle.