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Breast reduction, mastopexy and gynaecomastia
Breast reduction relieves back, neck and shoulder pain in a woman with large breasts, and is done on a pedicle that carries the nipple with a skin pattern (inverted T or vertical); gynaecomastia in a man is usually physiological or drug-related, and is operated on only after work-up and exclusion of a reversible cause.
Why it matters in the exam
In reduction a nipple pedicle is chosen — inferior, superomedial, superior or central — and a skin pattern: Wise (inverted-T scar) for very large breasts, or a short vertical scar (Lejour or Hall-Findlay), in which the inframammary fold rises over time. Complications: wound breakdown at the T junction (the commonest), fat necrosis, reduced nipple sensation, nipple necrosis, and difficulty breastfeeding in some women. When the nipple must rise a very long distance or the pedicle is too long, a free nipple graft is used. Mastopexy suits ptosis by Regnault: grade 1 — nipple at the fold, 2 — below it but above the lower pole of the breast, 3 — nipple at the lowest point; pseudoptosis is descent of the tissue while the nipple stays above the fold.
Gynaecomastia is enlargement of glandular tissue in the male breast, palpable under the nipple — unlike lipomastia, which is fat only. It is physiological in the newborn, at puberty (usually resolving within one to two years) and in older age. Pathological causes: drugs (spironolactone, ketoconazole, cimetidine, anti-androgens, 5-alpha reductase inhibitors, anabolic steroids, digoxin, cannabis), cirrhosis, renal failure, hyperthyroidism, hypogonadism (Klinefelter) and testicular tumours secreting oestrogen or hCG. Work-up includes testicular examination, liver, kidney and thyroid tests, and in a young adult with rapid gynaecomastia — hCG and testicular examination to exclude a tumour. Simon classification: 1 — small enlargement without skin excess, 2a — moderate without skin excess, 2b — moderate with skin excess, 3 — large with marked skin excess. Treatment: stop the drug, wait at puberty, tamoxifen for early painful gynaecomastia, and surgery — liposuction with gland excision, and in grade 3 skin excision as well.
Key points
- Reduction: nipple pedicle and skin pattern.
- Common complication — T-junction breakdown.
- Regnault: nipple position relative to the fold.
- Gynaecomastia — usually physiological or drug-related.
- Young man with rapid gynaecomastia — hCG and testicular examination.
Summary table
| Topic | Classification or option | Key detail |
|---|---|---|
| Reduction — skin pattern | Wise (inverted T) / vertical | In the vertical pattern the inframammary fold rises |
| Reduction — complication | T-junction breakdown, fat necrosis, nipple necrosis | Free nipple graft for a long distance |
| Ptosis (Regnault) | 1 / 2 / 3 / pseudo | Nipple position relative to the fold |
| Gynaecomastia — causes | Physiological, drugs, liver, testis, thyroid | hCG and testicular examination in a young man |
| Gynaecomastia — Simon | 1 / 2a / 2b / 3 | Skin excess decides skin excision |
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Sources
- American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Reduction mammaplasty, 2011 (reaffirmed) — Indications and outcomes
- Endocrine Society and European Academy of Andrology guidance on gynecomastia evaluation, 2019 — Causes and work-up
- Grabb and Smith's Plastic Surgery, 8th edition (2019) — Reduction mammaplasty, mastopexy and gynecomastia
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.