16 yr old son

[mark22]

Good morning, and thank you in advance for your input.  My son is 16 years old, 5"10 and about 140#.  At the age of 12, I had noticed that he was getting a little "chunky" and I figured getting ready for a growth spurt.  Also at the time I noticed that he had developed some puffiness around the nipples which at the time I disregarded because of a little weight gain.  Since that time, he has grown, thinned down but the tissue around the breast and the puffiness has not diminished.  We didn't really discuss it until this past fall, which was when he approached me about it.  As I read the posts of others, he is in the same category psychologically where he wears multiple layers, rolls his shoulders forward, never shirtless(except around me), he has stopped exercising regularly and told me last evening he is feeling depressed and the gynecomastia never leaves his mind.  I have no problem considering surgery, but here may be the "kicker".  He has an autoimmune disorder and currently has a platelet count of around 30-40K (normal 150-300K). This is where his platelet level stays most of the time.  He has had a lot of issues with this since birth, but has somewhat stabilized as he is getting older.  He currently takes 3 types of meds, Prednisone, Hydroxychloroquine, and mycophenolate to keep it at that low level.  Platelet infusions, or IVIG last a few days getting his level into the low 100K's.  I am searching for your opinion on where to turn, as I feel somewhat helpless by not being able to help him.  This is another "issue" for a great young man, and I am afraid this one is really weighing heavily on him.  I would appreciate your input greatly and would be happy to discuss more if needed. Thank you.

[Litlriki]

Sorry to hear about your son's gynecomastia--and the compounding factor of his hematologic disorder.  It's reasonable for him to proceed with surgical correction, presuming his hematologist is comfortable with that. I would anticipate that he would require a platelet transfusion at the time of surgery (presuming that his clotting function is impaired with his low platelet count).  This would be the case no matter what sort of surgery he'd need.  I'm sure all of the surgeons on this forum have done procedures on patients who require some sort of "optimization" for bleeding disorders or other disorders that require correction or stabilization for surgery.  The challenge will be dealing with your insurance company.  It's unlikely that they will cover his gynecomastia surgery, but will they still cover any hematologic treatment he requires for the surgery.  The only similar situation I've dealt with in the past was a woman with a mild clotting disorder, who desired breast augmentation.  We worked it out so that she had her breast surgery at the same time as a carpal tunnel procedure--which she needed to have done anyway.  Obviously, your son shouldn't undergo an unnecessary procedure to accommodate his gynecomastia procedure, but your hematologist may need to be creative in order to manage him peri-operatively. 

I must say, your son is lucky to have you there for support, as some kids just don't know how to approach their parents with this problem.  Good luck,

Rick Silverman

[DrPensler]

It's good that the two of you have talked about this. What I would do in this type of situation would be 1) evaluate your son and 2) have a hematologist evaluate him with respect to the surgery. Safety is obviously the primary concern here and this point will essentially revolve around your son's platelet issues. It may require surgery in the hospital setting so platelets are available if necessary or it may be beneficial to wait if the platelet issue will resolve.There are a number of options and I would stress that to your son. As you are coming to appreciate this is a complex problem that requires technical expertise and support on a number of levels.

[mark22]

Thank you Dr. Silverman and Dr. Pensler for your input as it is greatly appreciated.  I would agree with both of you on your commments, and we will proceed with further discussion with my son's hematologist, whom we see in a couple of weeks.  I agree about the insurance company and what may happen with them.  I guess at this point, my son's emotional, physical and social well-being far outweigh what the insurance company will dictate what they pay for, and we will find a way to get things done even if they do not contribute.  Obviously, his safety is primary as well and I agree that we must be thoughtful of that issue.  The main thing that your brief words have given is that there is potential options and that is what I am sure he wants to hear, because so many times there has not been that opportunity for him.  "Hope" can be powerful. Thank you for your kind words as well, I have to give credit to my son because he typically shows a tremendous amount of courage which I admire and appreciate. Thanks again.