Gynecomastia is the unilateral or bilateral enlargement of male breast tissue attributed mainly to proliferation of ductular elements and not merely excessive breast tissue. Mastectomy for gynecomastia is a surgical procedure performed to remove glandular breast tissue from a male with enlarged breasts. This document addresses mastectomy for gynecomastia.

Note: Please see the following related document(s) for additional information:

• SURG.00086 Reduction Mammaplasty
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Medically Necessary:

Mastectomy (including reconstruction if necessary) for gynecomastia in males over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered medically necessary when the following criteria are met:

1. The tissue to be removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued (this would include drug-induced gynecomastia remaining unresolved six months after cessation of the causative drug therapy); AND
2. Appropriate diagnostic evaluation has been done for possible underlying etiology; AND
3. The individual has pain or tenderness directly related to the breast tissue (documented in the medical record) which has a clinically significant impact upon activities of daily living and has been refractory to a trial of analgesics or anti-inflammatory agents (for a reasonable time period adequate to assess therapeutic effects); AND
4. Pre-operative photographs are provided.

Mastectomy for gynecomastia is considered medically necessary, regardless of age, when there is legitimate concern that a breast mass may represent breast carcinoma. Mammography may be of value to determine the need for surgery in some instances. 

Reconstructive:

Mastectomy (including reconstruction if necessary) for gynecomastia in males over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered reconstructive if it does not meet the medical necessary criteria above and is for drug-inducedgynecomastia that does not resolve by 6 months after the cessation of drug therapy. Examples of some agents associated with the occurrence of gynecomastia are listed in the Rationale section of this document (not an all-inclusive list).         

Not Medically Necessary: 

Mastectomy for gynecomastia is considered not medically necessary when the above criteria are not met.

Investigational and Not Medically Necessary: 

The use of liposuction to perform mastectomy for gynecomastia is considered investigational and not medically necessary.

Gynecomastia typically presents during adolescence and may also occur later in adult life (Hammond, 2009). The enlargement is often due to hormonal imbalance and may be unilateral or bilateral. Adolescent gynecomastia is considered a normal variation of puberty and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before completion or at near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence (Cakan, 2007).

The use of mastectomy for gynecomastia in males under the age of 18 or in those who are not yet at least 18 months after the end of puberty (unless there is legitimate concern that a breast mass may represent breast carcinoma) is not considered an acceptable alternative to non surgical forms of treatment. A standard system used to describe the normal development of puberty and to determine if an adolescent is at or near completion of puberty is the Sexual Maturity Rating (SMR, Tanner Stage). The late stage of male puberty (Tanner stage 5) is evidenced by adult genitalia and adult type pubic hair. Completion of the Tanner stage 5 milestones typically signifies the end of puberty. Skeletal and muscle growth are also late events in male puberty (Blondell, 1999).

Gynecomastia has also been linked to several disorders of or affecting the endocrine system such as chronic liver disease, Klinefelter's syndrome (47XXY), adrenal tumors, pituitary tumors, testicular tumors, and endocrine disorders (e.g., hyperthyroidism). Gynecomastia may also result as a side effect from certain drugs including, but not limited to: estrogens, androgens, spironolactone, digitalis preparations, flutamide, ketoconazole, cimetidine, anabolic steroids, alcohol, amphetamines, and marijuana. When identified, treating the underlying condition, such as removal of a tumor, or eliminating drug exposure, will often resolve the gynecomastia. Accordingly, treatment of the identified underlying conditions should be attempted prior to any surgical approach to gynecomastia.

Gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. In such cases, mastectomy is indicated regardless of age to properly address those concerns.

Surgical Techniques

A variety of surgical techniques have been described as being used to perform mastectomy for gynecomastia, including direct excision, liposuction or a combination of both.

Lanitis and colleagues (2008) assessed gynecomastia surgical outcomes at a single institution between 1998 and 2007. A total of 748 males were referred to the center for breast symptoms of which 65 subjects (102 breasts) with a median age of 26 years underwent surgery for gynecomastia. A total of 82 breasts were treated with mastectomies and 22 with skin reduction. The procedures carried out were subcutaneous mastectomy or breast disk excision, with or without skin reduction. Major post surgical complications occurred in 12 breasts and consisted of hematomas requiring evacuation, wound infection, partial nipple necrosis, dehiscence, and wound break down. The authors concluded that most males with gynecomastia can be managed conservatively and after excluding malignancy, conservative treatment could include counseling for reassurance, optimization of an individual's weight and medications.

Petty and colleagues (2010) analyzed outcomes of ultrasound-assisted liposuction with an arthroscopic shaver (arthroscopic mastectomy) to remove breast tissue and compared it with other surgical techniques for the management of gynecomastia. A retrospective study was performed on a total of 227 subjects divided into four groups: group 1 consisted of open incision only (n=45); group 2, open incision and liposuction (n=56), group 3 liposuction only (n=50); and group 4, liposuction and arthroscopic shaver (n=76). The authors used photographs and medical records to compare surgical results and determine complications. Complications using the liposuction plus arthroscopic shaver technique noted included hematoma (n = 1), scar revision (n = 1), seroma (n = 2), and skin buttonhole from the arthroscopic shaver (n = 1). There was no difference between groups in the overall incidence of complications or the need for reoperation. Surgical results were scored on a scale of 1 (poor) to 5 (excellent) based on photographs when available and on chart review if photographs were absent. Group 4 (liposuction plus arthroscopic shaver) was reported to have the overall highest mean score based on appearance and symmetry, presence of residual tissue, nipple contour, and prominent scarring. The authors noted that liposuction alone is unable to remove glandular/fibrous breast tissue seen in many cases of gynecomastia and that the arthroscopic shaver allows for resection of fibrous remnant tissue after liposuction. Study limitations included that this was a retrospective review in which unblinded examiners based their determinations on photographs and charts. Also there were small sample sizes for each type of technique. Larger, high quality studies are needed to determine the safety and efficacy of ultrasound-assisted liposuction with an arthroscopic shaver.

Qutob and colleagues (2010) investigated the use of a vacuum-assisted biopsy device (VABD) and liposuction for surgical correction of gynecomastia. Thirty-six males with gynecomastia were recruited (22 bilateral, 14 unilateral) with an average age of 33.3 years (range, 16-88 years). All underwent VABD excision and liposuction. There were no conversions to an open procedure. Thirty-four individuals reported excellent satisfaction; two had residual gynecomastia and needed another procedure. Study limitations included a small sample size and lack of randomization. The authors concluded that a randomized, control trial comparing the minimally invasive approach to an open technique could help establish the best surgical options for this condition.

Conclusion 

The medical literature indicates that gynecomastia is due to the stimulated growth of glandular breast tissue and does not significantly affect the disposition of fatty tissue. Therefore, mastectomy for gynecomastia should focus on the removal of glandular tissue underlying the condition. The use of liposuction as a method of mastectomy for gynecomastia has not been sufficiently proven to remove glandular tissue and is not considered an acceptable alternative to standard surgical approaches.

Gynecomastia results from the growth of glandular breast tissue in males. This condition should not be confused with pseudo-gynecomastia, which is an enlargement of the male breast due to excess fat deposition. Gynecomastia is a transient phenomenon in up to 60 to 70 percent of pubescent boys and is considered a normal part of male adolescence. About 30 to 40 percent of adult men have been found to have gynecomastia. Gynecomastia that is unilateral in post-adolescent age groups or that has a rapid onset is frequently associated with an underlying pathology. For this reason, careful clinical evaluation is warranted to rule out possible pathological etiologies, prior to any surgical intervention. In such cases, when doctors are able to determine the cause of the gynecomastia and address it appropriately, spontaneous resolution of the gynecomastia usually occurs over a short period of time.

Gynecomastia: An excessive development of the male mammary glands, resulting in enlargement of the male breast, due mainly to ductal proliferation with periductal edema. Mild gynecomastia may occur in normal adolescence.

Mastectomy: The surgical removal of a breast.

Pseudogynecomastia: Enlargement of the male breast due to excess fat deposition.

Sexual Maturity Rating (SMR, Tanner Stage): a commonly used measurement of sexual maturity in children, based upon the work of Tanner et al. (1962); SMR is based upon clinical findings from physical examination, as detailed below:

Classification of Sex Maturity States in Boys*

*From Tanner JM: Growth at Adolescence, 2nd ed. Oxford, England, Blackwell Scientific Publications, 1962. SMR, sexual maturity rating, and Marcell AV. Chapter 12- Adolescence. In: Kliegman RM, Behrman RE, Jenson HB, Stanson BF, Editors. Nelson Textbook of Pediatrics. 18th Ed. St. Louis, MO: WB. Saunders, Inc. 2007.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When Services may be Medically Necessary or Reconstructive when criteria are met:
For the procedure codes listed above for the following diagnoses when medically necessary or reconstructive criteria are met.

When services are Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstsructive criteria are not met; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:

Peer Reviewed Publications:

1. Arca MJ, Caniano DA. Breast disorders in the adolescent patient. Adolesc Med Clin. 2004; 15(3):473-485.
2. Blondell RD, Foster MB, Dave KC. Disorders of puberty. Am Fam Physician. 1999; 60(1):209-218, 223-224.
3. Cakan N, Kamat D. Gynecomastia: evaluation and treatment recommendations for primary care providers. Clin Pediatr (Phila). 2007; 46(6):487-490.
4. Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. 1999; 178(1):60-63.
5. Gruntmanis U, Braunstein GD. Treatment of gynecomastia. Curr Opin Investig Drugs. 2001; 2 (5):643-649.
6. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. 2009; 124(1 Suppl):61e-68e.
7. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003; 112(3):891-895.
8. Hines SL, Tan W, Larson JM, et al. A practical approach to guide clinicians in the evaluation of male patients with breast masses. Geriatrics. 2008; 63(6):19-24.
9. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg. 2005; 116(2):646-653.
10. Lanitis S, Starren E, Read J, et al. Surgical management of Gynaecomastia: outcomes from our experience. Breast. 2008; 17(6):596-603.
11. Matarasso SL. Liposuction of the chest and back. Dermatol Clin. 1999; 17(4):799-804.
12. McGrath MH, Schooler WG. Elective plastic surgical procedures in adolescence. Adolesc Med Clin. 2004; 15(3):487-502.  
13. Mentz HA, Ruiz-Razura A, Newall G, et al. Correction of gynecomastia through a single puncture incision. Aesthetic Plast Surg. 2007; 31(3):244-249.
14. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010; 125(5):1301-1308.
15. Qutob O, Elahi B, Garimella V, et al. Minimally invasive excision of gynaecomastia--a novel and effective surgical technique. Ann R Coll Surg Engl. 2010; 92(3):198-200.
16. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003; 111(2):909-923.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Behrman RE, et al. Nelson's Textbook of Pediatrics, 15th Edition. W. B. Saunders Company, Philadelphia.1996:1634.
2. Marcell AV. Chapter 12- Adolescence. In: Kliegman RM, Behrman RE, Jenson HB, Stanson BF, Editors. Nelson Textbook of Pediatrics. 18th Ed. St. Louis, MO: WB. Saunders, Inc. 2007.
3. Stein's Internal Medicine, 5th Edition.1998 Part Nine – Endocrinology, Metabolism, and Genetics; III Clinical Syndromes, Chapter 293 Gynecomastia, John C. Marshall. STAT! Ref Medical Reference Fourth Qtr. '02. Copyright^© 1994 Mosby-Year Book, Inc.
4. Tanner JM. Growth at Adolescence, 2nd ed. Oxford, England, Blackwell Scientific Publications, 1962. SMR, sexual maturity rating.
5. Townsend. Sabiston Textbook of Surgery, 16th edition. W. B. Saunders Company, 2001:559, 1567.
6. Williams Textbook of Endocrinology, 9th Edition. Copyright 1998, W. B. Saunders Company; Disorders of Breasts in Men Gynecomastia.

1. National Cancer Institute: What you need to know about breast cancer. Available at:  http://www.cancer.gov/cancertopics/wyntk/breast/. Accessed on June 21, 2012.

Gynecomastia
Mastectomy for Gynecomastia