You are on page 1of 8

COSMETIC

Correction of Gynecomastia in Body Builders
and Patients with Good Physique
Mordcai Blau, M.D.
Background: Temporary gynecomastia in the form of breast 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.
cpt Methods: Between the years 1980 and 2013, 1574 body builders were treated
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 mastectomy 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,
liposuction 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.

G
ynecomastia is the benign enlargement of
the mammary gland 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.
population varies from 32 to 65 percent.1 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 anabolic steroid 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 Surgery
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

Incisions were placed more laterally in an tions and gain an exceedingly high rate of patient satisfaction and virtually no recurrences. ages. 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. When there was no history of anabolic body builders with gynecomastia suffer more fre. There is an increase in tions regarding the avoidance of alcoholic bever- the vascularity of the chest as a result of hypertro. Tumescent solution consisting of lidocaine. Lastly. prohormones.5 cm in length (Figs. nonsteroidal antiinflammatory medications. Given the multiple indications for surgical gist for workup for possible neoplasm. which nologist for further testing. or testicular disease) dysfunction. 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. which makes the asked about medical problems such as hyperten- glandular tissue even more pronounced. we referred him to a urolo- sional. and phic pectoralis muscles. tenderness was found.0 to 2. or protein snacks that are excessive bleeding perioperatively. steroids. and occasional nipple discharge. 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. Paris. all of which are known to cause high doses of vitamin E. Our patient population consisted of adult Fig. mities. and whether the gynecomastia occurred they have an extremely low percentage of body fat after the consumption of those supplements. 426 . a large retrospective study of our experience Basic metabolic panels showed an increase in the with gynecomastia in body builders is presented.B. and an increase in the intake of different aspirin. sion. strenuous activity 1 week before surgery. epinephrine. 1073 of whom continued to return for follow-up between 1 and 5 years after surgery. 1574 were male body builders who were treated sur- gically for gynecomastia. Food and Drug Adminis- patients are perfectionists with regard to their phy. omega fatty acids.) experience. More. 1.) developed periareolar location. Moreover. Plastic and Reconstructive Surgery • February 2015 lasting beyond the cessation of steroid use. thus. during and bicarbonate mixed in 250 cc of normal saline the competition. tration containing unreported additives and blood sique and chest aesthetics.B. these not regulated by the U. blood urea nitrogen and creatinine higher than Surgical treatment of gynecomastia in body. France). well over 5000 patients were treated for various gynecomastia defor- mities in the senior author’s (M. All cases were performed in a Joint Com- tations is higher. pain. If a testicular mass or lead them to seek assistance from a medical profes. and 2).S. position that minimizes scar visibility. PATIENTS AND METHODS Between the years 1980 to 2013. We (9 percent) before a competition. The penetration of the pectoralis muscle has to be avoided by all means because of Technique potential scarring. their level of expec. Of these. Patients (no signs or symptoms of pituitary. liver. bleeding. ment for aesthetic purposes. the senior author (M. the chest is more scrutinized com. and recent significant and major weight loss or over. fish oils. was evident. renal. The circumareolar incision should be in a Carbocaine (Sanofi. with gynecomastia typically request surgical treat. 1 methods to reliably circumvent potential complica. the use of various anabolic the use of anabolic steroids. adrenal. builders is more challenging than in other patients Patients were given clear preoperative instruc- because of various factors. A significant number of these 1073 patients (15 percent) were professional body builders with superior physiques. Patient ages ranged from 18 to 51 years. 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. thinners.B. Because of these nique consisted of a skin incision in the inferior challenges. steroid intake but a recent history of gynecomastia quently than the general population from tender. in the senior author’s (M. thyroid. normal blood urea nitrogen–to-creatinine ratios. 2. years. and subsequent defor. Their sport requires that hormones. The operative tech- pared with the general population.) practice. solution was used in all cases. the patient was referred to an endocri- ness. weight gains. partially removed.

discouraged.. Elastic compression dressing was applied skin. was that patients were aware of possible imperfections. resulting in a single spec- imen. drain was placed through the surgical incision or the axilla for a total of 24 to 72 hours.12 shoulders for the first week. 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. at least 1 to 2 weeks. Penetration of the fascia resulted in unnecessary hemorrhage and potential contour deformities. 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. On the deep layer. to keep the dressing intact and dry for that time.g. In addition. almost all patients had a tight and 3 to 5 days. Desk work is allowed after patient population. Patients were instructed was flush with the contour of the pectoral muscle. 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. non–chest-related The rate of sagging skin postoperatively was extremely exercises for 2 to 3 weeks. a 4-o’clock to dressing was applied over the surgical site for 3 to 5 7-o’clock position). 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. Bodybuilders’ over the remaining 3 to 4 years. 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. resulted in fewer complications and less operative time. Any exercise resulting in rare but the deformity was discussed extensively with movement of the pectoralis muscles. Given the young age and good physique of our with minimal activities. In virtually all permitted in the elbow and wrist early in the post- cases. Care was taken to excise the entire gland as one entity. Fig. Patients were followed up for a minimum of its. excessive bleeding was encountered more frequently with dissection on the far lateral aspect compared with the medial side of the gland. Supplemental Digital the nipple-areola complex. Meticulous hemostasis was achieved throughout with electrocautery. Number 2 • Gynecomastia in Body Builders staying within the confines of the outer border of the gland. operative period. For example. No antibiotics were prescribed postoperatively. which circumvents the need for piecemeal excisions. as it is unrelated to the pectoralis leaving behind only 2 to 3 mm of tissue under the muscle. All glandular specimens were sent for patho- logic analysis. The remaining tissue Content 1. 2. including lift- the patient before the surgical procedure. a ¼-inch Penrose strating the fibrous consistency of the specimen. This approach. In 3 percent of the cases. Complete excision of the gynecomastia tissue demon. the nipple-areola complex over the chest for 5 days. care was taken val. undermining tis- sues remained strictly above the pectoral fascia.Volume 135. Movement of the pectoralis muscle cre physique. extension. while always satisfaction form provided for each patient at 427 . More physical work was restricted for elastic skin that conformed to an ideal shape after sur. Suction-assisted lipectomy was days. at least a few inches beyond the gland lim. performed. extensive skin undermining was regimen was resumed after 4 to 6 weeks. Motion is required no liposuction in this study. or abduction of the shoulders. were collected from all patients at a 1-year inter- In patients with low fat content. Compression attempt to avoid medial scars (e. a subcutaneous mastectomy was performed.11 Aiache. In this manner. to the surrounding skin. mal humerus. each patient was also asked have to leave more of the glandular tissue. which shows an example of a patient was dissected bluntly when possible. 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. even when the gynecomastia itself was very large. Satisfaction ratings lessen and even eliminate this problem. to ascertain ing. after 1-week follow-up with light. Patients were contacted by phone or e-mail to remove all of the glandular tissue.10 and Huang et al. Modified activity was resumed gery. Should first week after surgery. This maneuver helped to 12 months and up to 5 years. A regular chest exercise ptosis possibly occur.

lar tissue weight ranged from to 9 to 110 g. The thinner the residual nip. builders were very cooperative. 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. 3 through 5). needle (16-gauge) aspirations in the office. whereas the rate patient satisfaction survey. ers were extremely rare and found in less than 1 The overall hematoma rate was 6 percent for percent of patients. Symptom- growth with good symmetry was observed in all atic hematomas signified by pain. corrective pro- physician for additional workup and treatment.B. and significant ecchymosis occurred in 9 percent sion on Accreditation of Healthcare Organizations of the cases in the first 15 years. No cedures (Table 1). (Right) Eight-month postoperative view. an interest- found in 7 percent. The absence of drains did not reports of disease progression to malignant breast appear to correlate with the formation of seromas. A minimal amount of adipose tissue was excised. 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. 3). and were most concerned with removal of RESULTS the entire gland. 428 . aesthetically pleasing was reduced to 3 percent in the last 15 years of results were ranked as high as 98 percent (Fig. Two per. 5 feet 10 inches tall and weighing 200 pounds. being noncompliant was 6 percent over the past 10 Fig. In the senior author’s (M. Excised glandu. all patients were extremely satisfied with found in the vast majority of cases. patients. (Left) A 30-year-old body builder. The glandular excision was per- formed through a 1-inch infraareolar incision. Dynamic depressions were the entire length of the study. similar wound. major swelling. with severe true gynecomastia resistant to antiestrogen medications after taking prohormones 4 years before presentation. respectively. however. 3. cancer were reported back to our office.5 percent. the result (Figs. Hematomas were more likely to be found to the principles of skin grafting. The rate of necrosis or sloughing of the areola-nipple complex noncompliance in bodybuilders who admitted to were seen even after substantial areolar thinning. With adequate thinning 1. the further it shrunk. No instances of in the noncompliant group of patients. There was no need for needle or by creating a small opening in the sur- an areola reduction. Based on a 13-year-long Joint Commis.lww.com/PRS/B216).) experience. but occurred more frequently in patients who Patients were then referred to their primary care underwent revisions or secondary. gical site and expressing the fluid through the ple-areola complex. Plastic and Reconstructive Surgery • February 2015 1-year follow-up. the study. In all cases where these criteria The continued use of anabolic steroids was were met. Smaller hematomas were of the areola. body These surveys were collected over the past 13 years. Permanent resolution of the ing trend was noted within that period. the areola shrunk almost instantly treated with a needle aspiration using a 16-gauge in the postoperative phase. had realistic expec- tations. Fluid collections were resolved after one to three Static postoperative depressions in body build. No liposuction was used. http://links.

5 cm. (Right) The 6-month postoperative view demonstrates excellent chest contour with inconspicuous scars after a 1-inch incision in the infraareolar region.5 g and measured 3. 5. The right breast specimen weighed 5 g and measured 2. His gyneco- mastia became more pronounced after he began his bodybuilding career with 9 percent body fat.9 × 2. The patient’s body fat is 8 percent.5 cm. Surgical excision of the glandular tissue was performed with no liposuction. 5 feet 7 inches tall and weighing 210 pounds. (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. 4. The condition erupted at puberty and worsened progressively after a few cycles of anabolic steroids.9 × 0.5 × 6 × 2 cm and the left breast specimen measured 7 × 6 × 3 cm. Pathology report of the right breast specimen measured 7. The left breast specimen weighed 7. Antiestrogen therapy was unsuccessful. Number 2 • Gynecomastia in Body Builders Fig. 429 . pre- sented with moderate gynecomastia present since his early teenage years. presented with severe gynecomastia.9 × 2 × 0.Volume 135. (Left) A 20-year-old bodybuilder. 6 feet 0 inches tall and weighing 230 pounds. Surgical excision was performed without liposuction. Fig. (Left) A 25-year-old bodybuilder.

Therefore.14 To achieve a nearly complete excision of the glandular tissue. It is the senior author’s (M. requires surgical attention (Fig. reveals benign ductal epithelial hyperplasia and periductal stromal edema. not applicable.0) Blau et al.) opinion. however.8–10 It has or all of the tissue to be excised is glandular in been our observation that approximately 15 per. A total of 71 per. anatomical division of the gland is more noticeable In the management of postoperative hemato. 200114 20 2* (10. years. several patients in adolescence. *One patient with bilateral seromas. Even in cases with a surgical-site infections or significant contour large nipple-areola complex preoperatively. the senior author’s (M.B. 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. This cent of all hematomas were unilateral. A specimen collected after surgical excision of gyneco- expansion of the body is the head of the gland. of Patients Seroma (%) Hematoma (%) Recurrence (%) Aiache.) experi- ence. and blood loss significantly. nature.5) N/A Reyes et al.15 A typical pathology report treated with direct excision of the gland. it should be of the glandular tissue. The medial Fig. 6.0) None (0) N/A.) opinion that narrow in comparison with the head. As little as one or several cycles of who underwent ultrasonic liposuction in the past anabolic steroid use had caused the growth to reap. glands. 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 senior author’s experience with ultrasonic tia also had a history of temporary gynecomastia liposuction is limited. The the gynecomastia tissue. as the remaining breast tissue will continue to act as a target organ in the face of continued steroid use. when the pathologic finding of gynecomastia is hypertrophy gland is the cause of gynecomastia.16. it is deformities were observed in this series.B. none of Aggressive excision of the glandular tissue is the patients in this series required a transfusion.). in larger. or more persistent. 199513 23 N/A 3 (13. control of a single bleeding vessel resulted author’s (M. It mastia from a bodybuilder. whereas treatment of parenchyma in this manner can facilitate a more diffuse bleeding increased the operative time comprehensive and precise excision of the gland. 198910 38 N/A 4 (10. 6).0) 2 (10. visualizing the male breast in a shorter surgical time. nearly full excision of the glandular tissue is the most appropriate treatment of gynecomastia in body builders. required further glandular excision to eliminate pear in the form of permanent gynecomastia. (present study) 1073 128 (12.0) 64 (6. Plastic and Reconstructive Surgery • February 2015 Table 1. suction-assisted lipectomy is seldom used.) observation that it is not necessary to reduce the size of the areola by a cir- DISCUSSION cumareolar incision.0) 3 (15.. Recurrence is fre- quently caused by insufficient primary excision. Lastly. the entire gland as described by the senior author (M.17 Based on the senior author’s (M. whereas suction-assisted lipectomy18 should be used only scarcely. and no to a full-thickness skin graft.19 as elasticity of the thin skin Body builders suffer from gynecomastia because will facilitate sufficient contractility. 430 .B. The tail of the gland is usually long and head.B.B. composed of three dif- ferent components. and tail. In the senior mas. The body of the gland is located immedi- ately deep to the nipple-areola complex.  Review of the Literature Summarizing the Complication Rate following Gynecomastia Surgery in Body Builders and Patients with Good Physique Reference No. and is the lat- the rate is more than 10 percent. body.0) N/A Babigian and Silverman. eral extension of the gland toward the axilla. However. cent of body builders with permanent gynecomas. if most of the continued use of anabolic steroids.

body builders would try to increase their level of exercise 1 week before 19300–50  Mastectomy for gynecomastia. pectoralis muscle. right The complication rate following correction of 19300–50 Mastectomy for gynecomastia. he or she amount of bulk under the nipple-areola complex. a sizable hematoma can form and patients can practice. primarily with patients relating to contour deformities in the general that require excision of small to medium glandular population. and postoperative care have decreased the rate of lis muscle fascia. demonstrate the safety and efficacy of this proce. the pectoralis mus- cles are extremely developed and hypertrophied. used. the subcutane- bleeding in patients who use androgenic steroids ous mastectomy code. providing significant pectoral bulge with very CODING PERSPECTIVE This information provided by Dr. swelling. irregularities. in contrast. When the fascia’s integrity is vio. in stasis at the time of surgery is more important than writing.14 depending on the technique used • Code 19300 is global and includes excision and the patient population in the study. 19300   Mastectomy for gynecomastia. • If liposuction is performed. These anatomical differences necessitate a more cpt Raymond Janevicius is intended to aggressive approach with regard to direct excision provide coding guidance. minute amounts of subcutaneous or glandular fat. vision. it is crucial to deformities and unnecessary bleeding. a There is a higher tendency for intraoperative subcutaneous mastectomy. unsatisfactory results following the From the early 1990s to recent years. technically. Avoiding piecemeal excisions and injury of sions with these techniques may result in a pseudo. 431 . cases that are less challenging than those typically To avoid the aforementioned complications presented by body builders. as code 19300 is specific to gyneco- These include protein shakes. or retracted nipples. this maneuver dure in a large group of body builders. the underlying pectoral fascia prevents contour gynecomastia deformity. provided is included in code 19300. allow the adhesions and scarring to resolve on their The novice surgeon is advised to proceed with own over time. 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. lateral procedures: fied in body builders. meticulous intraoperative hemostasis. 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. which may take 1 year or more.10 Often.13. clear verbal use of liposuction in gynecomastia patients may relate and written instructions regarding preoperative to the inadvertent sharp penetration of the pectora. as opposed to the use of liposuction. Therefore. • Although this procedure is. Static comastia deformities in body builders. They are likely to be evident in the first This study demonstrates the importance of 6 to 12 months because of adhesions. Therefore. Once this technique is mastered. ­bilateral surgery to compensate for the month of postopera- tive rest. In body builders. omega-3 mastia excision. or with no extension or flexion at the shoulders. hematomas by 50 percent in the senior author’s lated. An attempt to correct dynamic depres. CONCLUSIONS are only visible when patients extend or abduct the shoulders. Our data of glandular tissue and wound closure. Many pay- pressure bandages. We recom- depressions can be corrected with adipose flaps or mend excision of the glandular tissue under direct fat transfer. 19304. Dynamic depressions. should not be and unregulated (over-the-counter) supplements. authorized with the insurance company. It is also attributed to the robust • Some payers prefer a one-line entry for bi- vascularity of the pectoralis muscle that is identi. vitamins.Volume 135. The use of drainage should be ers consider gynecomastia surgery cosmetic. it is important to maintain a certain tissue. in contrast. Number 2 • Gynecomastia in Body Builders In general. and is not report- that the involved glandular tissue is removed with ed separately. thorough hemo. before performing surgery. can feel confident operating on body builders. and direct excision of the glandular tissue over any scarring from penetration of the fascia. or resume normal activities and exercise • All gynecomastia procedures should be pre- too early after surgery. Permanency other surgical technique when correcting gyne- of the dynamic depression is less common. respectively. fish oils. considered judiciously in special circumstances. and others. left gynecomastia in body builders can be as high as 30 percent.

10605 10. Muldal S. St. due to use of anabolic steroids in bodybuilders. 2nd ed.107:240–242. Minerva Med. McFadyen IJ.13:77–86.124:557–575. Peled IJ. 2003. Clin Pract. Zicchi S. REFERENCES 11. Unilateral gynecomastia induced by the use of anabolic Ann Plast Surg. Lippe BM. Verma K. 2011:2647. Farthing MJ. Cytology of nipple discharge in florid of male breast in association with the Klinefelter syndrome. Rosenberg GJ. Lapid O. BMJ 1965.15:553–560. Acta Cytol. Louis: Quality in surgical management of gynecomastia. 2002. Plast Reconstr mastia. athletes. 1982. Kenkel JM.129:927–931. 1975. Reyes RJ. Ferraris L. Hamed H. Hunter WM. Green JR. 432 . Kapila K. Mordcai Blau. Ann Plast Surg. Bustamante JJ. Progesterone. Lewis SR. 2013.83:575–580. Rohrich RJ. Forrest AP. Ockey CH. Jackson AW. Arch Gen Psychiatry 1994. 17. Re: Pursestring and skin excision in gynecomastia. 8. Plast Reconstr Surg. N. Cytopathology mastia. Frassetto G. prolactin. Odaglia G. Gonadal-pituitary hormone levels in gynaeco. Bolton AE. Hidalgo JE.]. Cytomorphological spectrum in 6.1:223–225. Edwards CR. Plast Reconstr Surg.51:375–382. Plastic and Reconstructive Surgery • February 2015 steroids: A clinical case report (in Italian). 5. Treatment cular intra-areolar incision. Saenger P.42:343. Ann Surg. Pathological findings in gyne- SA. Kapila K. 2.83:61–66. Vol. Silverman RT. Ha RY. Gorrini G. 1987. Dawson AM. Babigian A. ed. ahead of print June 19. M. 1995.32:1123–1140. Verma K. III. Pubertal gynecomastia. O’Connor PJ. and gynaecomastia in men with Surgical correction of gynaecomastia in bodybuilders. Carcinoma 16. Raab 14. Clin Endocrinol (Oxf. Gynecomastia: Suction lipectomy as a con- Endocrinol Metab.) 1980. Fentiman IS. 3. 4. 1992. Pope HG Jr. Pharmacotherapy 2012.80:379–386. gynecomastia. Huang TT. Aiache AE. Drug-induced gyneco. 19. J Pediatr 18. Psychiatric and medical effects of 12 Greenridge Avenue anabolic-androgenic steroid use: A controlled study of 160 White Plains.Y. 1999.23:276–279.69:35–40. Pubertal gynecomastia and transient elevation of serum comastia: Analysis of 5113 breasts. Parlow AF. Am J Dis Child. Private Practice 9.13:300–308. Bowman JD.49:177–179. Mastectomy for gynecomastia through a semicir- 1. Kim H. LaFranchi SH. Surg. Coyotupa J. Chaudary MA. Jolink F. Br J liver disease. temporary solution. The Art of Aesthetic Surgery: 12. Plast Reconstr Surg. Lazala C.D. Surgical treatment of gynecomastia in the body builder. Spiga L. Meijer SL. gynaecomastia: A study of 389 cases. Management of gynecomastia G.47:36–40. 2002. Cameron EH. 1946. Guenther D. 7. 2001. 13. A circumareolar approach Principles and Technques. of gynecomastia. Medical. Katz DL. In: Nahai F. Gut 1982. [Epub estradiol level. Kaplan 15. Webster JP. 1989.