Introduction

“Gynecomastia,” an enlargement of the male breast, mainly occurs in three phases of life, corresponding to the times of hormonal changes [1]: during the neonatal period, during puberty, and among adults between the age of 50 and 80 years [2,3,4,5,6,7].

According to Webster, gynecomastia can histologically be divided into three classes: (I) periductal connective tissue hypertrophy tissue change, (II) increase in the amount of both of these, and (III) adipose tissue hypertrophy alone [8]. Although being mostly idiopathic, gynecomastia can be associated with medication, drug abuse, and the exposition of chemical substances such as phenothrin [9], liver function disorders, and endocrine or malign disorders.

Especially in adolescent males, gynecomastia is associated with an increased risk of psychological disorders such as depression, anxiety, and social phobia [10, 11]. Thus, even though spontaneous remission of gynecomastia occurs in up to 75% of cases [2, 12], gynecomastia needs to be treated in case of psychological distress. Pharmacological treatment and prophylaxis of gynecomastia with selective estrogen receptor modulators such as tamoxifen or testosterone derivatives like danazol have proven to be successful, with tamoxifen showing stronger effects but higher relapse rates than danazol [13,14,15,16,17]. Surgical treatment consists of liposuction with or without resection of glandular tissue (Fig. 1) depending on the type and grade of gynecomastia present [18,19,20,21,22,23,24]. To date, apart from studies evaluating the outcome of different operative techniques, no studies have been performed analyzing the risk factors for recurrence of gynecomastia.

Fig. 1
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Intraoperative view of resection of glandular tissue through caudal semi-areolar incision. a Preoperative marking. b Caudal semi-areolar incision. c and d Resection of glandular tissue. e Postoperative result

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Our study aims to evaluate differences in recurrence rates in lipomatous and glandular gynecomastia and its association with BMI increase 10–19 years postoperatively, furthermore assessing patient satisfaction.

Patients and Methods

Forty-one gynecomastia patients undergoing surgical treatment from 1997 to 2005 were invited for a follow-up examination 10–19 years postoperatively. Of these, 16 patients presented for a clinical examination. The treatment modality was chosen according to the preoperative clinical finding: Liposuction combined with direct excision was performed in patients with partially fibrous or dense glandular breast tissue. If a good result was obtained with just liposuction, excision was not performed. Photo-material and patient charts were evaluated concerning preoperative macroscopical type of gynecomastia, BMI, and operative technique. When classified as Simon Grade I [25] or higher, reappearance of gynecomastia after surgery was considered as recurrence.

Patient satisfaction was measured with a validated questionnaire, whose format was adopted from the consultation satisfaction questionnaire 9 (CSQ-9). The CSQ-9 is easily scored and consists of ten items. Each item of the CSQ-9 shows a score of 1–4. Final scoring is carried out by adding the individual item scores to yield a range of 10–40, with higher scores representing greater satisfaction. Patients were informed that participation in the study is voluntary and that answers would be anonymous and would not influence subsequent therapy in our department.

The local Ethics Committee approved the study. The study has been registered in the German Clinical Trials Register (DRKS) (clinical trial registration number: DRKS00009630) which meets the requirements of the International Committee of Medical Journal Editors (ICMJE). The design and performance of the study is in accordance with the Declaration of Helsinki. Statistical analysis was performed using GraphPad Prism 5 (GraphPad Software, San Diego, CA, USA). Comparison of normally distributed, continuous data between different groups was performed with unpaired Student’s t-test and categorical data with Chi-square test.

Results

Mean follow-up time was 13.8 years (range: 10.5–19 years). Mean age of patients at the time of surgery was 32.4 years; mean age at the time of follow-up was 46.2 years (range: 25–71 years). Eight patients (50%) had presented with lipomatous and eight patients (50%) with glandular gynecomastia prior to surgery. In each five of the patients (62.5%) who presented with glandular and lipomatous gynecomastia, liposuction and resection of glandular tissue was carried out, while in each three (37.5%) patients, only liposuction was performed (Table 1). One patient with glandular and one patient with lipomatous gynecomastia had surgery twice due to gynecomastia recurrence within 1 year after the primary surgery. In two patients with glandular gynecomastia undergoing both liposuction and resection of glandular tissue, scar correction was carried out following primary surgery, whereas in one patient, periareolar mastopexy was performed due to postoperative periareolar skin excess. Of the patients presenting with recurrence in the first postoperative year (n = 2), one was primarily treated with liposuction, whereas the other one was treated with liposuction and resection of glandular tissue. Of the patients presenting with recurrence (n = 6), three (50%) were primarily treated with liposuction, whereas three (50%) were treated with liposuction and resection of glandular tissue. Three patients (18.8%) presented with dysesthesia at the time of follow-up.

Table 1 Age, macroscopical and histological type of patients as well as type of surgery performed, increase in BMI units, recurrence rates, and patient satisfaction as rated by the CSQ-9 questionnaire (maximum points: 40)
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One of the patients with glandular gynecomastia (Fig. 2) presented with recurrence at the time of follow-up, whereas five of the eight patients showing lipomatous gynecomastia (Fig. 3) presented with recurrence (12.5 vs. 62.5%, respectively; p = 0.0389; Fig. 4). The mean increase in BMI from the time of surgery until the time of follow-up was 1.7 kg/m2 (range: 0–6.7 kg/m2) in patients with preoperative glandular gynecomastia and 3.8 kg/m2 (range: 1.5–10.0 kg/m2) in patients with preoperative lipomatous gynecomastia (Table 1); however, BMI increase was not significantly different between the two groups (p = 0.1405).

Fig. 2
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Patient with glandular gynecomastia. a Preoperative view. b Postoperative result. c Result at the time of follow-up (no recurrence)

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Fig. 3
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Patient with lipomatous gynecomastia. a Preoperative view. b Postoperative result. c Result at the time of follow-up (recurrence)

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Fig. 4
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Recurrence rates in lipomatous and glandular gynecomastia after 10–19 years of follow-up

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Patient satisfaction was good with a mean score of 33.8 of 40 possible points (84.5%; Table 1).

We did not find statistically significant differences in CSQ-9 scores in patients with lipomatous gynecomastia compared to patients with glandular gynecomastia [34.6 (n = 8) and 32.9 points (n = 8), respectively; p = 0.4410], patients with and without recurrence of gynecomastia [35.2 (n = 6) and 32.9 points (n = 10), respectively; p = 0.3308], patients with and without dysesthesia of the nipple areolar complex at the time of follow-up [30.3 (n = 3) and 34.5 (n = 13) points, respectively, p = 0.1366], and patients with and without follow-up surgery due to skin retraction or skin excess [35.0 (n = 3) and 33.5 (n = 13), respectively, p = 0.5991; data not shown].

However, we found that younger patient groups tend to be more satisfied with the operative treatment than older patient groups, irrespective of the rate of the complication and recurrence rate. Thus, the mean score of 13–17-year (n = 3) and 18–30-year-old patients (n = 4) was 37.0 and 34.8 points, respectively, whereas in patients aged 31–49 years (n = 6) and 50–60 years (n = 3) was 33 and 30.7 points, respectively (Fig. 5). However, these differences were not statistically significant (p = 0.4060; p = 0.4981, and p = 0.5181, respectively). Of interest, younger patient groups showed better improvement of self-esteem after operative treatment of gynecomastia than older patient groups (Fig. 6; p = 0.1608)

Fig. 5
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General patient satisfaction in different age groups as rated by the CSQ-9 questionnaire. (Total maximum points: 40)

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Fig. 6
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Improvement of self-esteem in different age groups as rated by the CSQ-9 questionnaire. (Maximum points: 4)

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Discussion

Throughout this study, we showed that patients with lipomatous gynecomastia show significantly higher rates of recurrence than patients with glandular gynecomastia. Although one might argue that this is mainly due to the higher increase in body weight/BMI units in patients with lipomatous gynecomastia, one has to consider that only one of eight (12.5%) patients with glandular gynecomastia showed recurrence, whereas five of eight patients with lipomatous gynecomastia (62.5%) presented with recurrence at follow-up, with the difference of BMI increase in patients with lipomatous and glandular not being statistically significant. Of interest, even patients with glandular gynecomastia showing a BMI increase of up to 6.7 BMI units (kg/m2) from the time of surgery until the follow-up examination did not show gynecomastia recurrence. However, one has to take into account that all our data were analyzed in a retrospective manner. Thus, to validate our results, further studies are warranted.

The type of surgery performed was liposuction and resection of glandular tissue in each five of the patients (62.5%) who presented with glandular and lipomatous gynecomastia and liposuction only in each three (37.5%) patients (Table 1). Thus, one of the strengths of our study constitutes the fact that the type of surgery performed does not need to be considered as a confounding factor. Furthermore, of the patients presenting with recurrence (n = 6), three were primarily treated with liposuction, whereas in three patients, liposuction and resection of glandular tissue were performed. Thus, each type of surgery performed was associated with equal recurrence rates.

Nevertheless, the combination of liposuction with resection of glandular tissue has been widely described to provide best results [18, 26]. A further advantage of the resection of glandular tissue is the possibility of a histological examination; however, the incidence of malignancy or abnormal pathology associated with gynecomastia tissue in the adolescent male is extremely low [27].

Regarding patient satisfaction, we found overall good results (84.5% of the maximum score); however, we did not find statistically significant differences in patients with lipomatous gynecomastia compared to patients with glandular gynecomastia, patients with and without recurrence of gynecomastia, patients with and without follow-up surgery due to skin retraction or skin excess, and patients with and without dysesthesia of the nipple areolar complex at the time of follow-up, which indicates that patients were overall content with the operative treatment performed, with minor complications such as skin excess, retracted scars, or even recurrence not altering their level of satisfaction. Of interest, we found that younger patients tend to be more satisfied with the operative treatment than older patient groups, irrespective of the rate of complications or recurrence. This is in contrast to a study conducted by Jaipaul et al., who argue that satisfaction scores of hospital care generally increase until the age of 65–80 and then decline [28].

The fact that throughout our study, adolescents and young adults are generally more content about their surgical treatment and show a better improvement of self-esteem might also be due to the fact that the initial psychological distress caused by the enlargement of their breasts might have been more pronounced when compared to older patients: Gynecomastia has long been known to lead to depression, anxiety, disordered eating, body dissatisfaction, and reduced self-esteem [29]; however, it has only recently been shown that especially in adolescents [1, 10, 11], gynecomastia is an enormous psychological threat to normal self-esteem, social functioning, and sexual identity, with 100% of patients receiving a Diagnostic and Statistical Manual of Mental Disorders-IV diagnosis in a case series of 24 adolescents. Therefore, according to Kinsella et al., future studies examining the postoperative effects on psychological health both with and without psychological treatment might be of great interest [10].

To sum up, we find it important to preoperatively inform the patient about the high recurrence rates after a time period of more than 10 years, especially in lipomatous gynecomastia. However, the second important finding of this study was the fact that the patients’ self-esteem significantly improved throughout the younger patient groups after gynecomastia surgery, which shows that especially adolescents with gynecomastia clearly benefit from operative treatment. Thus, our findings could serve as a helping tool in preoperative patient’s consultation.

Conclusion

Long-term follow-up results showed that recurrence rates are significantly higher in patients with lipomatous gynecomastia than in patients with glandular gynecomastia, with BMI increase in patients with glandular and lipomatous gynecomastia showing no statistically significant differences. Interestingly, we also found that adolescents and young adults tend to present with higher postoperative satisfaction levels than older patients, irrespective of complication and recurrence rates.