DATE OF VISIT: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old Hispanic male who presents for concerns regarding left-sided gynecomastia. The patient is accompanied by his father and mother who are supportive. He complains about left-sided gynecomastia that has increased in size over the past one to two years. He initially saw Dr. John Doe for an endocrine workup. His blood work was all negative, including analysis of testosterone levels. He was then referred to Dr. Jane Doe, a breast surgeon. Dr. Jane Doe has referred him to us for evaluation.
OBJECTIVE: On examination of the chest, the patient has left-sided gynecomastia. There is mild areolar hypertrophy with palpable excess breast tissue. There is minimal adiposity that the patient presents with. The breast tissue is firm to palpation, and there is some mild ptosis and excess skin of the left chest as well. There are otherwise no masses to palpation of his chest.
ASSESSMENT AND PLAN: Left-sided reduction gynecomastia. We informed the patient and his family that he has two main issues. There is excess breast tissue causing excess fullness, and there is some possible excess skin. We informed them that the excess breast tissue can be excised directly utilizing a periareolar incision and resultant scar.
Another option would be to make a smaller scar and use the arthroscopic shaver. Due to the fact that he does not have a hairy chest and he is a young male, we are recommending the arthroscopic shaver to start out with at least in order to remove any extra breast tissue. He would then need to wear an abdominal binder to compress the area for several months afterwards to allow the skin to retract as good as possible.
We informed the patient and his family that the arthroscopic shaver may not be quite as aggressive as direct excision, but we do believe may have a slightly lower risk of complications and have a much less visible and obvious scar. We informed them that if insufficient tissue is removed using the arthroscopic shaver, we could always excise it directly as well. They expressed understanding of this.
We also informed him and his family that the tissue that is removed by arthroscopic shaver is not looked at microscopically by the pathologist, and therefore, if there is an occult breast cancer, this may not be detected. They expressed an understanding of this as well. Therefore, we are recommending the arthroscopic shaver to be used first, application of an abdominal binder to compress the area for several months afterwards. If there is some skin excess, we could consider excision of skin approximately six months postoperatively. If there is still some residual breast tissue, then we could consider removal of the breast tissue in that manner as well. They expressed understanding of possible complications, including unevenness, saucer deformity, hematoma, bleeding, and less than optimal tissue excision. They also expressed understanding of the potential for loose skin postoperatively.
