COSMETIC

Correction of Gynecomastia in Body Builders and Patients with Good Physique

Mordcai Blau, M.D. Background: Temporary gynecomastia in the form of buds is a com- Ron Hazani, M.D. mon finding in young male subjects. In adults, permanent gynecomastia is an White Plains, N.Y.; and Beverly Hills, aesthetic impairment that may result in interest in surgical correction. Gyne- Calif. comastia in body builders creates an even greater distress for patients seeking surgical treatment because of the demands of professional competition. The authors present their experience with gynecomastia in body builders as the largest study of such a group in the literature. Methods: Between the years 1980 and 2013, 1574 body builders were treated cpt surgically for gynecomastia. Of those, 1073 were followed up for a period of 1 to 5 years. Ages ranged from 18 to 51 years. Subtotal excision in the form of subcutaneous with removal of at least 95 percent of the glandular tissue was used in virtually all cases. In cases where body fat was extremely low, was performed in fewer than 2 percent of the cases. Results: Aesthetically pleasing results were achieved in 98 percent of the cases based on the authors’ patient satisfaction survey. The overall rate of hemato- mas was 9 percent in the first 15 years of the series and 3 percent in the final 15 years. There were no infections, contour deformities, or recurrences. Conclusions: This study demonstrates the importance of direct excision of the glandular tissue over any other surgical technique when correcting gynecomas- tia deformities in body builders. The novice surgeon is advised to proceed with cases that are less challenging, primarily with patients that require excision of small to medium glandular tissue. (Plast. Reconstr. Surg. 135: 425, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

ynecomastia is the benign enlargement of the in male subjects. The Disclosure: The authors have no financial interest incidence of gynecomastia in the general to declare in relation to the content of this article. G 1 population varies from 32 to 65 percent. The cause is most frequently idiopathic, although sometimes it may be secondary to hormonal dysfunction, med- Supplemental digital content is available for ications, or related to a syndrome (e.g., Klinefelter this article. A direct URL citation appears in syndrome).2–6 In adolescents presenting with breast the text; simply type the URL address into any buds that are not significantly enlarged, gyneco- Web browser to access this content. A click- mastia is frequently a temporary finding,7 but it can able link to the material is provided in the turn into a permanent condition in adulthood. In HTML text of this article on the Journal’s Web the presence of other signs—namely, small testis, site (www.PRSJournal.com). scarce or no pubic and axillary hair, or micrope- nis—an endocrine survey is recommended. A Video Discussion by Alan Matarasso, M.D., In body builders, gynecomastia is generally accompanies this article. Go to PRSJournal. the result of use8–10 or ingestion com and click on “Video Discussions” in the of over-the-counter hormones, frequently sold in “Videos” tab to watch. various sport and general nutrition stores. In most cases, gynecomastia becomes a permanent finding,

From private practice. A "Hot Topic Video" by Editor-in-Chief Rod J. Received for publication February 14, 2014; accepted May Rohrich, M.D., accompanies this article. Go to 28, 2014. PRSJournal.com and click on "Plastic Copyright © 2015 by the American Society of Plastic Surgeons Hot Topics" in the "Videos" tab to watch. DOI: 10.1097/PRS.0000000000000887

www.PRSJournal.com 425 Plastic and Reconstructive Surgery • February 2015 lasting beyond the cessation of steroid use. Patients (no signs or symptoms of pituitary, thyroid, liver, with gynecomastia typically request surgical treat- adrenal, renal, or testicular disease) dysfunction. ment for aesthetic purposes, and body builders Each gynecomastia patient with good physique with gynecomastia who compete on a professional was asked whether he used anabolic steroids or pro- level are no exception. Their sport requires that hormones, and whether the gynecomastia occurred they have an extremely low percentage of body fat after the consumption of those supplements. We (9 percent) before a competition, which makes the asked about medical problems such as hyperten- glandular tissue even more pronounced. More- sion, and recent significant and major or over, in the senior author’s (M.B.) experience, weight gains. When there was no history of anabolic body builders with gynecomastia suffer more fre- steroid intake but a recent history of gynecomastia quently than the general population from tender- was evident, the patient was referred to an endocri- ness, pain, and occasional discharge, which nologist for further testing. If a testicular mass or lead them to seek assistance from a medical profes- tenderness was found, we referred him to a urolo- sional. Given the multiple indications for surgical gist for workup for possible neoplasm. correction of gynecomastia in body builders and Routine laboratory tests demonstrated an the growing demand for this procedure in recent increase in their hematocrit/hemoglobin levels. years, a large retrospective study of our experience Basic metabolic panels showed an increase in the with gynecomastia in body builders is presented. blood urea nitrogen and higher than Surgical treatment of gynecomastia in body- normal blood urea nitrogen–to-creatinine ratios. builders is more challenging than in other patients Patients were given clear preoperative instruc- because of various factors. There is an increase in tions regarding the avoidance of alcoholic bever- the vascularity of the chest as a result of hypertro- ages; strenuous activity 1 week before surgery; and phic pectoralis muscles, the use of various anabolic the use of anabolic steroids, prohormones, fish oils, steroids, and an increase in the intake of different aspirin, nonsteroidal antiinflammatory medications, omega fatty acids, all of which are known to cause high doses of vitamin E, or protein snacks that are excessive bleeding perioperatively. Moreover, these not regulated by the U.S. Food and Drug Adminis- patients are perfectionists with regard to their phy- tration containing unreported additives and blood sique and chest aesthetics; thus, their level of expec- thinners. All cases were performed in a Joint Com- tations is higher. There is a need to excise the entire mission on Accreditation of Healthcare Organiza- gland because of high recurrence if the gland is only tions–approved outpatient ambulatory setting. partially removed. The penetration of the pectoralis muscle has to be avoided by all means because of Technique potential scarring, bleeding, and subsequent defor- Tumescent solution consisting of lidocaine, mities. The circumareolar incision should be in a Carbocaine (Sanofi, Paris, France), epinephrine, position that minimizes scar visibility. Lastly, during and bicarbonate mixed in 250 cc of normal saline the competition, the chest is more scrutinized com- solution was used in all cases. The operative tech- pared with the general population. Because of these nique consisted of a incision in the inferior challenges, the senior author (M.B.) developed periareolar location, 2.0 to 2.5 cm in length (Figs. 1 methods to reliably circumvent potential complica- and 2). Incisions were placed more laterally in an tions and gain an exceedingly high rate of patient satisfaction and virtually no recurrences.

PATIENTS AND METHODS Between the years 1980 to 2013, well over 5000 patients were treated for various gynecomastia defor- mities in the senior author’s (M.B.) practice. Of these, 1574 were male body builders who were treated sur- gically for gynecomastia, 1073 of whom continued to return for follow-up between 1 and 5 years after surgery. A significant number of these 1073 patients (15 percent) were professional body builders with superior physiques. Patient ages ranged from 18 to 51 years. Our patient population consisted of adult Fig. 1. Intraoperative view of the gynecomastia tissue dissected male subjects with no history of hormonal or physical out sharply with the use of a blade and a piercing towel clamp.

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staying within the confines of the outer border of the gland. On the deep layer, undermining tis- sues remained strictly above the pectoral fascia. Penetration of the fascia resulted in unnecessary hemorrhage and potential contour deformities. In addition, excessive bleeding was encountered more frequently with dissection on the far lateral aspect compared with the medial side of the gland. Meticulous hemostasis was achieved throughout with electrocautery. Care was taken to excise the entire gland as one entity, resulting in a single spec- imen. All glandular specimens were sent for patho- logic analysis. This approach, which circumvents the need for piecemeal excisions, resulted in fewer complications and less operative time. Fig. 2. Complete excision of the gynecomastia tissue demon- In 3 percent of the cases, a ¼-inch Penrose strating the fibrous consistency of the specimen. drain was placed through the surgical incision or the axilla for a total of 24 to 72 hours. Compression attempt to avoid medial scars (e.g., a 4-o’clock to dressing was applied over the surgical site for 3 to 5 7-o’clock position). Suction-assisted lipectomy was days. No antibiotics were prescribed postoperatively. performed in only 5 percent of the cases using Postoperative instructions consisted of light the contralateral breast periareolar incision as activity with restricted range of motion of the reported by Webster,11 Aiache,10 and Huang et al.12 shoulders for the first week. This is because of the Indications for the use of liposuction were removal attachment of the pectoral muscle to the proxi- of peripheral fatty tissue in patients with medio- mal humerus. Movement of the pectoralis muscle cre physique. Professional body builders have a often results in increased bleeding because of the much higher ratio of glandular to fatty tissue and excessive vascularity in body builders. Motion is required no liposuction in this study. In virtually all permitted in the elbow and wrist early in the post- cases, a subcutaneous mastectomy was performed, operative period, as it is unrelated to the pectoralis leaving behind only 2 to 3 mm of tissue under the muscle. Elastic compression dressing was applied skin. In this manner, the nipple- complex over the chest for 5 days. Patients were instructed was flush with the contour of the pectoral muscle. to keep the dressing intact and dry for that time, Given the young age and good physique of our with minimal activities. Desk work is allowed after patient population, almost all patients had a tight and 3 to 5 days. More physical work was restricted for elastic skin that conformed to an ideal shape after sur- at least 1 to 2 weeks. Modified activity was resumed gery, even when the gynecomastia itself was very large. after 1-week follow-up with light, non–chest-related The rate of sagging skin postoperatively was extremely exercises for 2 to 3 weeks. Any exercise resulting in rare but the deformity was discussed extensively with movement of the pectoralis muscles, including lift- the patient before the surgical procedure, to ascertain ing, extension, or abduction of the shoulders, was that patients were aware of possible imperfections, discouraged. For example, patients were asked to and it is also stated in oral and printed consent that wear button-up shirts to avoid arm lifting on the is discussed with the patient before surgery. Should first week after surgery. A regular chest exercise possibly occur, extensive skin undermining was regimen was resumed after 4 to 6 weeks. performed, at least a few inches beyond the gland lim- Patients were followed up for a minimum of its, to the surrounding skin. This maneuver helped to 12 months and up to 5 years. Satisfaction ratings lessen and even eliminate this problem. were collected from all patients at a 1-year inter- In patients with low fat content, care was taken val. Patients were contacted by phone or e-mail to remove all of the glandular tissue. Bodybuilders’ over the remaining 3 to 4 years. Given the limited fat content is negligible compared with patients data in the literature regarding satisfaction rates in that have a high fat content where the surgeon may gynecomastia surgery, each patient was also asked have to leave more of the glandular tissue. Sharp to complete our Joint Commission on Accredita- undermining was performed initially under direct tion of Healthcare Organizations patient satisfac- vision to an area that extended to the area around tion survey (see Appendix, Supplemental Digital the nipple-areola complex. The remaining tissue Content 1, which shows an example of a patient was dissected bluntly when possible, while always satisfaction form provided for each patient at

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1-year follow-up, http://links.lww.com/PRS/B216). In the senior author’s (M.B.) experience, body These surveys were collected over the past 13 years. builders were very cooperative, had realistic expec- tations, and were most concerned with removal of RESULTS the entire gland. In all cases where these criteria The continued use of anabolic steroids was were met, all patients were extremely satisfied with found in the vast majority of cases. Excised glandu- the result (Figs. 3 through 5). lar tissue weight ranged from to 9 to 110 g. Two per- Seroma formation was the most common cent of the bodybuilders had a pathology report of minor complication in 12 percent of the patients gynecomastia with atypical intraductal hyperplasia. but occurred more frequently in patients who Patients were then referred to their primary care underwent revisions or secondary, corrective pro- for additional workup and treatment. No cedures (Table 1). The absence of drains did not reports of disease progression to malignant breast appear to correlate with the formation of seromas. cancer were reported back to our office. Fluid collections were resolved after one to three Static postoperative depressions in body build- needle (16-gauge) aspirations in the office. ers were extremely rare and found in less than 1 The overall rate was 6 percent for percent of patients. Dynamic depressions were the entire length of the study; however, an interest- found in 7 percent. Permanent resolution of the ing trend was noted within that period. Symptom- growth with good symmetry was observed in all atic signified by pain, major swelling, patients. Based on a 13-year-long Joint Commis- and significant ecchymosis occurred in 9 percent sion on Accreditation of Healthcare Organizations of the cases in the first 15 years, whereas the rate patient satisfaction survey, aesthetically pleasing was reduced to 3 percent in the last 15 years of results were ranked as high as 98 percent (Fig. 3). the study. The rate of major hematomas requiring All patients presented in these series had a standard exploratory surgical intervention was 3 percent and 1-inch subareolar incision. With adequate thinning 1.5 percent, respectively. Smaller hematomas were of the areola, the areola shrunk almost instantly treated with a needle aspiration using a 16-gauge in the postoperative phase. There was no need for needle or by creating a small opening in the sur- an areola reduction. The thinner the residual nip- gical site and expressing the fluid through the ple-areola complex, the further it shrunk, similar wound. Hematomas were more likely to be found to the principles of skin grafting. No instances of in the noncompliant group of patients. The rate of necrosis or sloughing of the areola-nipple complex noncompliance in bodybuilders who admitted to were seen even after substantial areolar thinning. being noncompliant was 6 percent over the past 10

Fig. 3. (Left) A 30-year-old body builder, 5 feet 10 inches tall and weighing 200 pounds, with severe true gynecomastia resistant to medications after taking prohormones 4 years before presentation. (Right) Eight-month postoperative view. The glandular excision was per- formed through a 1-inch infraareolar incision. A minimal amount of was excised. No liposuction was used.

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Fig. 4. (Left) A 25-year-old bodybuilder, 6 feet 0 inches tall and weighing 230 pounds, pre- sented with moderate gynecomastia present since his early teenage years. His gyneco- mastia became more pronounced after he began his career with 9 percent body fat. Antiestrogen therapy was unsuccessful. (Right) The 6-month postoperative view demonstrates excellent chest contour with inconspicuous scars after a 1-inch incision in the infraareolar region. Surgical excision was performed without liposuction. The right breast specimen weighed 5 g and measured 2.9 × 2 × 0.5 cm. The left breast specimen weighed 7.5 g and measured 3.9 × 2.9 × 0.5 cm.

Fig. 5. (Left) A 20-year-old bodybuilder, 5 feet 7 inches tall and weighing 210 pounds, presented with severe gynecomastia. The condition erupted at and worsened progressively after a few cycles of anabolic steroids. The patient’s body fat is 8 percent. (Right) A 6-month postopera- tive view of the patient with an aesthetically pleasing result and no visible scars after a 1-inch incision in the infraareolar region. Surgical excision of the glandular tissue was performed with no liposuction. Pathology report of the right breast specimen measured 7.5 × 6 × 2 cm and the left breast specimen measured 7 × 6 × 3 cm.

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Table 1. Review of the Literature Summarizing the Complication Rate following Gynecomastia Surgery in Body Builders and Patients with Good Physique Reference No. of Patients Seroma (%) Hematoma (%) Recurrence (%) Aiache, 198910 38 N/A 4 (10.5) N/A Reyes et al., 199513 23 N/A 3 (13.0) N/A Babigian and Silverman, 200114 20 2* (10.0) 2 (10.0) 3 (15.0) Blau et al. (present study) 1073 128 (12.0) 64 (6.0) None (0) N/A, not applicable. *One patient with bilateral seromas. years. It is the senior author’s (M.B.) opinion that narrow in comparison with the head, and is the lat- the rate is more than 10 percent. A total of 71 per- eral extension of the gland toward the axilla. This cent of all hematomas were unilateral. anatomical division of the gland is more noticeable In the management of postoperative hemato- in larger, or more persistent, glands. In the senior mas, control of a single bleeding vessel resulted author’s (M.B.) opinion, visualizing the male breast in a shorter surgical time, whereas treatment of parenchyma in this manner can facilitate a more diffuse bleeding increased the operative time comprehensive and precise excision of the gland. and blood loss significantly. However, none of Aggressive excision of the glandular tissue is the patients in this series required a transfusion. used to the point where the nipple-areola complex No major complications were noted in which thickness superficial to the gland is almost equal inpatient hospitalization was necessary, and no to a full-thickness skin graft. Even in cases with a surgical-site infections or significant contour large nipple-areola complex preoperatively, it is deformities were observed in this series. the senior author’s (M.B.) observation that it is not necessary to reduce the size of the areola by a cir- DISCUSSION cumareolar incision,19 as elasticity of the thin skin Body builders suffer from gynecomastia because will facilitate sufficient contractility. Lastly, if most of the continued use of anabolic steroids.8–10 It has or all of the tissue to be excised is glandular in been our observation that approximately 15 per- nature, suction-assisted lipectomy is seldom used. cent of body builders with permanent gynecomas- The senior author’s experience with ultrasonic tia also had a history of temporary gynecomastia liposuction is limited; however, several patients in . As little as one or several cycles of who underwent ultrasonic liposuction in the past anabolic steroid use had caused the growth to reap- required further glandular excision to eliminate pear in the form of permanent gynecomastia. The the gynecomastia tissue. Therefore, when the pathologic finding of gynecomastia is hypertrophy gland is the cause of gynecomastia, it should be of the glandular tissue.15 A typical pathology report treated with direct excision of the gland. reveals benign ductal epithelial hyperplasia and periductal stromal .16,17 Based on the senior author’s (M.B.) experi- ence, nearly full excision of the glandular tissue is the most appropriate treatment of gynecomastia in body builders, whereas suction-assisted lipectomy18 should be used only scarcely. Recurrence is fre- quently caused by insufficient primary excision, as the remaining breast tissue will continue to act as a target organ in the face of continued steroid use.14 To achieve a nearly complete excision of the glandular tissue, the entire gland as described by the senior author (M.B.), composed of three dif- ferent components, requires surgical attention (Fig. 6). The body of the gland is located immedi- ately deep to the nipple-areola complex. The medial Fig. 6. A specimen collected after surgical excision of gyneco- expansion of the body is the head of the gland. It mastia from a bodybuilder. The specimen demonstrates the extends toward the mid-chest and is usually short high glandular content of the tissue with its distinct shape of a and round. The tail of the gland is usually long and head, body, and tail.

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In general, unsatisfactory results following the From the early 1990s to recent years, clear verbal use of liposuction in gynecomastia patients may relate and written instructions regarding preoperative to the inadvertent sharp penetration of the pectora- and postoperative care have decreased the rate of lis muscle fascia. When the fascia’s integrity is vio- hematomas by 50 percent in the senior author’s lated, a sizable hematoma can form and patients can practice. Our findings of the first 8 years do cor- even develop scars that are later manifested as breast relate with those of other authors (Table 1) but are depressions, irregularities, or retracted . substantially lower in the later years with the imple- Static postoperative depressions are seen when mentation of stricter perioperative instructions the patient’s chest is relaxed with no flexion of the and a more meticulous intraoperative hemostasis. pectoralis muscle, or with no extension or flexion at the shoulders. Dynamic depressions, in contrast, CONCLUSIONS are only visible when patients extend or abduct the shoulders. They are likely to be evident in the first This study demonstrates the importance of 6 to 12 months because of adhesions, swelling, and direct excision of the glandular tissue over any scarring from penetration of the fascia. Permanency other surgical technique when correcting gyne- of the dynamic depression is less common. Static comastia deformities in body builders. We recom- depressions can be corrected with adipose flaps or mend excision of the glandular tissue under direct fat transfer. An attempt to correct dynamic depres- vision. Avoiding piecemeal excisions and injury of sions with these techniques may result in a pseudo- the underlying pectoral fascia prevents contour gynecomastia deformity. Therefore, it is crucial to deformities and unnecessary bleeding, respectively. allow the adhesions and scarring to resolve on their The novice surgeon is advised to proceed with own over time, which may take 1 year or more. cases that are less challenging than those typically To avoid the aforementioned complications presented by body builders, primarily with patients relating to contour deformities in the general that require excision of small to medium glandular population, it is important to maintain a certain tissue. Once this technique is mastered, he or she amount of bulk under the nipple-areola complex. can feel confident operating on body builders. In body builders, in contrast, the pectoralis mus- cles are extremely developed and hypertrophied, providing significant pectoral bulge with very CODING PERSPECTIVE minute amounts of subcutaneous or glandular fat. This information provided by Dr. These anatomical differences necessitate a more cpt Raymond Janevicius is intended to aggressive approach with regard to direct excision provide coding guidance. as opposed to the use of liposuction. 19300 Mastectomy for gynecomastia, right The complication rate following correction of 19300–50 Mastectomy for gynecomastia, left gynecomastia in body builders can be as high as 30 percent,13,14 depending on the technique used • Code 19300 is global and includes excision and the patient population in the study. Our data of glandular tissue and wound closure. demonstrate the safety and efficacy of this proce- • If liposuction is performed, this maneuver dure in a large group of body builders, provided is included in code 19300, and is not report- that the involved glandular tissue is removed with ed separately. meticulous intraoperative hemostasis. • Although this procedure is, technically, a There is a higher tendency for intraoperative subcutaneous mastectomy, the subcutane- bleeding in patients who use androgenic steroids ous mastectomy code, 19304, should not be and unregulated (over-the-counter) supplements. used, as code 19300 is specific to gyneco- These include protein shakes, vitamins, omega-3 mastia excision. fish oils, and others. It is also attributed to the robust • Some payers prefer a one-line entry for bi- vascularity of the pectoralis muscle that is identi- lateral procedures: fied in body builders.10 Often, body builders would try to increase their level of exercise 1 week before 19300–50 Mastectomy for gynecomastia, bilateral­ surgery to compensate for the month of postopera- tive rest, or resume normal activities and exercise • All gynecomastia procedures should be pre- too early after surgery. Therefore, thorough hemo- authorized with the insurance company, in stasis at the time of surgery is more important than writing, before performing surgery. Many pay- pressure bandages. The use of drainage should be ers consider gynecomastia surgery cosmetic. considered judiciously in special circumstances.

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steroids: A clinical case report (in Italian). Minerva Med. Mordcai Blau, M.D. 1992;83:575–580. Private Practice 9. Pope HG Jr, Katz DL. Psychiatric and medical effects of 12 Greenridge Avenue anabolic-androgenic steroid use: A controlled study of 160 White Plains, athletes. Arch Gen Psychiatry 1994;51:375–382. N.Y. 10605 10. Aiache AE. Surgical treatment of gynecomastia in the body builder. Plast Reconstr Surg. 1989;83:61–66. REFERENCES 11. Webster JP. Mastectomy for gynecomastia through a semicir- 1. Guenther D, Ha RY, Rohrich RJ, Kenkel JM. Treatment cular intra-areolar incision. Ann Surg. 1946;124:557–575. of gynecomastia. In: Nahai F, ed. The Art of Aesthetic Surgery: 12. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach Principles and Technques. Vol. III. 2nd ed. St. Louis: Quality in surgical management of gynecomastia. Plast Reconstr Surg. Medical; 2011:2647. 1982;69:35–40. 2. Farthing MJ, Green JR, Edwards CR, Dawson AM. 13. Reyes RJ, Zicchi S, Hamed H, Chaudary MA, Fentiman IS. , , and gynaecomastia in men with Surgical correction of gynaecomastia in bodybuilders. Br J . Gut 1982;23:276–279. Clin Pract. 1995;49:177–179. 3. McFadyen IJ, Bolton AE, Cameron EH, Hunter WM, Raab 14. Babigian A, Silverman RT. Management of gynecomastia G, Forrest AP. Gonadal-pituitary hormone levels in gynaeco- due to use of anabolic steroids in bodybuilders. Plast Reconstr mastia. Clin Endocrinol (Oxf.) 1980;13:77–86. Surg. 2001;107:240–242. 4. LaFranchi SH, Parlow AF, Lippe BM, Coyotupa J, Kaplan 15. Lapid O, Jolink F, Meijer SL. Pathological findings in gyne- SA. Pubertal gynecomastia and transient elevation of serum comastia: Analysis of 5113 . Ann Plast Surg. [Epub level. Am J Dis Child. 1975;129:927–931. ahead of print June 19, 2013.]. 5. Jackson AW, Muldal S, Ockey CH, O’Connor PJ. Carcinoma 16. Kapila K, Verma K. Cytology of in florid of male breast in association with the . gynecomastia. Acta Cytol. 2003;47:36–40. BMJ 1965;1:223–225. 17. Kapila K, Verma K. Cytomorphological spectrum in 6. Bowman JD, Kim H, Bustamante JJ. Drug-induced gyneco- gynaecomastia: A study of 389 cases. Cytopathology mastia. Pharmacotherapy 2012;32:1123–1140. 2002;13:300–308. 7. Lazala C, Saenger P. Pubertal gynecomastia. J Pediatr 18. Rosenberg GJ. Gynecomastia: Suction lipectomy as a con- Endocrinol Metab. 2002;15:553–560. temporary solution. Plast Reconstr Surg. 1987;80:379–386. 8. Spiga L, Gorrini G, Ferraris L, Odaglia G, Frassetto G. 19. Peled IJ. Re: Pursestring and skin excision in gynecomastia. Unilateral gynecomastia induced by the use of anabolic Ann Plast Surg. 1999;42:343.

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