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Surgical Treatment of Gynaecomastia: A Prospective Study in 75 Patients

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Introduction: Gynaecomastia is a benign enlargement of male breast; many techniques have been described for management but none have gained universal acceptance. We discuss the outcomes of the surgical management of gynaecomastia and assess the morbidity and complication rates associated with the procedure to determine whether certain surgical techniques produce better outcomes. Materials and Methods: 75 patients with gynaecomastia were operated in our hospital during the period from Jan. 2009 to Jan. 2015. Results: A total of 140 breasts were operated on during the study period. Patients underwent either liposuction alone (20 breasts), excision alone (70 breasts), both excision and liposuction (36 breast) or skin reduction procedure (14 breasts). 19 operated breasts (13.4%) experienced some form of complications. Minor complications included seroma (4 patients), superficial wound dehiscence (3 patients) and two patients developed haematomas requiring evacuation in theatre. Unsatisfactory cosmotic result was present in 10 breasts and surgical revision was done in 5 breasts. Simon grade 111 breasts experienced the highest complication rate. Conclusion: The study has found that moderate sized gynaecomastia whether true or pseudo gynaecomastia with mild to moderate breast redundancy can be managed easily and effectively by liposuction alone or combined with glandular resection while the conventional infraareolar subcutaneous mastectomy still gives satisfactory results and with no need to remove extra skin. On the other hand, large gynaecomastia with severe breast redundancy can be treated effectively by the inferior pedicle technique without vertical scar.
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Surgical Science, 2015, 6, 506-517
Published Online November 2015 in SciRes. http://www.scirp.org/journal/ss
http://dx.doi.org/10.4236/ss.2015.611073
How to cite this paper: Tolba, A.M. and Nasr, M. (2015) Surgical Treatment of Gynaecomastia: A Prospective Study in 75
Patients. Surgical Science, 6, 506-517. http://dx.doi.org/10.4236/ss.2015.611073
Surgical Treatment of Gynaecomastia: A
Prospective Study in 75 Patients
Adel M. Tolba, Mohamed Nasr
Plastic Surgery Unit, General Surgery, Zagazig University, Zagazig, Egypt
Received 29 September 2015; accepted 13 November 2015; published 16 November 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Abstract
Introduction: Gynaecomastia is a benign enlargement of male breast; many techniques have been
described for management but none have gained universal acceptance. We discuss the outcomes
of the surgical management of gynaecomastia and assess the morbidity and complication rates
associated with the procedure to determine whether certain surgical techniques produce better
outcomes. Materials and Methods: 75 patients with gynaecomastia were operated in our hospital
during the period from Jan. 2009 to Jan. 2015. Results: A total of 140 breasts were operated on
during the study period. Patients underwent either liposuction alone (20 breasts), excision alone
(70 breasts), both excision and liposuction (36 breast) or skin reduction procedure (14 breasts).
19 operated breasts (13.4%) experienced some form of complications. Minor complications in-
cluded seroma (4 patients), superficial wound dehiscence (3 patients) and two patients developed
haematomas requiring evacuation in theatre. Unsatisfactory cosmotic result was present in 10
breasts and surgical revision was done in 5 breasts. Simon grade 111 breasts experienced the
highest complication rate. Conclusion: The study has found that moderate sized gynaecomastia
whether true or pseudo gynaecomastia with mild to moderate breast redundancy can be managed
easily and effectively by liposuction alone or combined with glandular resection while the conven-
tional infraareolar subcutaneous mastectomy still gives satisfactory results and with no need to
remove extra skin. On the other hand, large gynaecomastia with severe breast redundancy can be
treated effectively by the inferior pedicle technique without vertical scar.
Keywords
Gynaecomastia, Male Breast, Surgical Management
1. Introduction
The incidence of gynaecomastia in men is 32% - 65% [1]. Gynaecomastia is usually caused by a hormonal im-
A. M. Tolba, M. Nasr
507
balance as may be seen postnatally, during puberty, and in the elderly. Most cases of GM are idiopathic, al-
though, pathological etiologies need to be ruled out; these include congenital and endocrine disorders, tumors,
and drugs. Gynaecomastia may be unilateral or bilateral, symmetrical or asymmetrical. Pain or tenderness may
or may not be present. In contrast to the male breast cancer, which is usually present as a hard mass with or
without skin changes and may occupy a central or peripheral location it is usually centrally located [2].
Gynaecomastia treatment should be individualized according to the patient’s needs and expectations as well
as the specific indication for surgery [3]. Surgery is indicated for patients with gynaecomastia that does not re-
gress spontaneously or, with medical therapy, or causing considerable discomfort or psychological distress or is
long-standing (beyond a 18 - 24-months period) [4]-[6].
The current surgical options for gynaecomastia are subcutaneous mastectomy, suction-assisted lipectomy, or a
combination of these approaches that are performed with different technologic devices and surgical methods [7].
Resection with skin reduction is generally added to the surgical procedure in Simons grade III gynecomastia [6].
In spite of the variety of methods and tools used in gynecomastia surgery, in mild gynacomastia the results are
satisfactory while severe gynaecomastia presents a surgical challenge [8]. As some postoperative frustrating
problems still cannot be completely eliminated. The most common of these are a saucer-like deformity (over re-
section under areola), bleeding, followed by seroma, infection, ischaemic necrosis of nipple-areola complex re-
sidual gynaecomastia (under resection), persistence of inframammary fold, contour irregularities, and asymme-
tries between breasts [9].
In this study, we aim to discuss the outcomes of the surgical management of the gynaecomastia and assess the
morbidity and complication rates associated with the procedure to determine whether certain surgical techniques
produce better outcomes.
2. Patients and Methods
The current study was carried out at Plastic surgery unit of Zagazig University Hospitals, Egypt, during the pe-
riod from Jan. 2009 to Jan. 2015. It includes 75 patients that were presented by gynacomastia. Patients with
chronic liver and renal disease, hyperthyroidism, alcoholics and patients on medical treatment as anabolic ster-
roids were excluded.
For the purpose of this study, we considered each operated breast as an individual case.
Patient demographics, the grade of gynaecomastia, the presence of skin excess, causative factors, duration of
symptoms and surgical procedure were recorded. Short and long-term minor and major complications, poor re-
sults, and revision rates were recorded and analysed.
Each patient completed an assessment sheet evaluating their satisfaction with surgery, recording overall satis-
faction, appearance of scars and improvement in chest shape and self confidence, with a linear score out of a
maximum of 10.
An informed consent about surgery, possible outcome, and complications was obtained. This study was ap-
proved by the IRB of Zgazig University Hospitals.
3. Operative Techniques
Pre-operative marking of the patient in the upright position and under general anaesthesia, the breast tissue was
infiltrated with a solution of normal saline, 1% lignocaine and 1:1000 adrenaline. All patients received one dose
of intra-operative intravenous broad-spectrum antibiotics.
3.1. Procedures without Skin Reduction
3.1.1. Excision through Semicircular Peri-Areolar Incision
A semicircular incision extending from 3 o’clock to 9 o’clock along the inferior margin of the areola was used.
Through this incision, the whole glandular tissue was excised, apart from a 1-cm disk that was left on the un-
dersurface of the areola to avoid the saucer” deformity. The tissues were closed in layers with absorbable su-
tures (Figure 1 & Figure 2).
3.1.2. Liposuction
Suction assisted liposuction (SAL).
A. M. Tolba, M. Nasr
508
(a) (b)
Figure 1. (a) Preoperative; (b) postoperative.
(a) (b)
Figure 2. (a) Preoperative; (b) postoperative.
After a super wet/tumescent infiltration of the breast tissue by the previously mentioned infiltrate, liposuction
started by continuous movement of the cannula in fanlike long strokes, starting deep and working superficial-
ly ,with special effort to disrupt the inframammary fold. The endpoint was determined by loss of tissue resis-
tance and appearance of the aspirate (Figure 3).
Laser assisted liposuction (LAL).
The 600-μm laser fiber cannula was introduced (The fiber was adjusted so as to protrude from the tip of the
cannula by approximately 2 mm .The system used was a 1064-nm wave length ND laser (Fotona XP2, Solova-
nia) at a power of 15 W with continuous emission, and 8 - 12 kJ total average accumulated energy per breast.
Laser energy emission was directional following the plane of the cannula. Care was taken that the cannula was
moved back and forth in two fat tissue planes whenever the laser was actuated. First, the cannula was passed in a
deep plane, followed by a faster movement in a more superficial skin layer. Care was taken not to stop the
movement of the cannula. If the cannula was stopped and irradiation was continued, there was a risk that the
skin surface would burn. When acting on a superficial plane, hand movements were careful and quicker in the
areola/nipple complex area to avoid damage of the vascular pedicle. After the procedure, aspiration was per-
formed at 1 bar negative pressure with the 1-mm cannula previously used for tunneling (Figure 4).
3.2. Skin Reduction Procedures
3.2.1. Complete Concentric Circumareolar Approach Benelli Type”
Marking of the midline, sternum, infra-mammary folds and areola was done with the patient in upright position.
In case of wide areolae, the areola was marked to a diameter of 25 - 30 mm. A concentric or mildly eccentric, (in
case the nipple needed to be lifted) circum-areolar incision (14 - 20 mmwide) was marked to include the epi-
dermal doughnut”, which was then resected. Under general anaesthesia, the doughnutshaped epidermal ring
was de-epithelialized, followed by a semicircular inferior transdermal incision within the de-epithelialized area
extending from 3 to 9 o’clock position. Then the excessive glandular tissue was excised, adequate thickness un-
der the nipple was left to avoid areolar retraction or ischemia. The breast skin was sutured to the areola inverting
the de-epithelized segment in 2 layers. An additional 2/0 PDS intradermal circumareolar purse-string suture was
used to decrease the diameter of the breast skin border and to decrease the tension on the suture line was used in
A. M. Tolba, M. Nasr
509
(a) (b)
Figure 3. (a) Preoperative; (b) postoperative.
(a) (b)
Figure 4. (a) Preoperative; (b) postoperative.
some cases.
3.2.2. Inverted T (Modified Wise) Pattern Scar
Gynaecomastia with severe ptosis and excessive skin and tissue redundancy. A modifiedwise patterninverted
T approach was used. The new position of areola-inframammary fold was 3 - 3.5 cm and the blood supply to the
nipple was maintained by inferior pedicle (Figure 5).
3.2.3. Inferior Pedicle Technique without Vertical Scar
The midline sternum was marked, as well as the inframammary crease lines. Vertical lines were drawn from the
mid-clavicle and extended down to the inframammary crease, the pedicle was marked. With a scalpel, the pe-
dicle is de-epithelialised and then elevated, the inframammary incision was made to the fascia of the muscle.
Next, blunt digital dissection was performed. After complete elevation of the glandular tissue of the fascia, the
flap was then pulled down in an inferior direction, in order to ascertain the exact amount of resection possible. It
was important to avoid any undue tension with the planned amount of skin excision. The excess skin was then
excised, with a resulting long horizontal incision. Excess glandular tissue would be excised at this point if any
thinning of the flap is necessary. Closure of the incision was performed in layers. The new nipple site with a 3
cm areolar diameter was then marked on the skin at the level of the 4th intercostal space in the midclavicular line
in an even and symmetrical fashion bilaterally (Figure 6).
3.3. A Combination of 2 Surgical Procedure
Liposuction and subcutaneous mastectomy (Figure 7).
Following the procedure, suction drain for 3 - 5 days and a pressure dressing consisting of gauze was applied
and held in place with microfoam tape. Patients were instructed to wear a pressure garment day and night for six
weeks. Follow up was 3 - 9 months.
A. M. Tolba, M. Nasr
510
(a) (b)
Figure 5. (a) Preoperative; (b) postoperative.
(a) (b)
Figure 6. (a) Preoperative; (b) postoperative.
(a) (b)
Figure 7. (a) Preoperative; (b) postoperative.
4. Results
75 patients and a total of 140 breasts were operated on during the study period. Patients were referred from a va-
riable sources. General practitioners referred 25 (33.3%) patients, 5 (6.6%) were referred by the general surgical
unit and 3 (4%) from the paediatric unit while the other 42 patients seeks our plastic unit from the start (56%).
Ages ranged from 14 - 37 years (Mean 22.5 years).All patients cited emotional problems as the reason for them
seeking help, except 2 who complained of pain and discomfort (Table 1).
Endocrine blood tests were performed 25 times (33.6%). In some cases, those tests were performed by the re-
ferring physician. Breast imaging was used in 24 cases (32%): 8 (10.6%) had a mammography, 12 (16%) had an
ultrasound, and in 4 (5%), both modalities were used. In 4 patients (5%), systemic imaging was used to investi-
gate the adrenals or the testes. None of the imaging yielded pathological findings. Fine-needle aspiration for cy-
tology was performed in 3 patients (4%) (Table 2).
The periareolar approach was used on 70 breasts, and a circumareolar skin reduction with subcutaneous
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511
Table 1. Age, body weight, duration of symptoms, grade of gynaecomastia.
Patient details Results
Age 14 - 37 y (22.5 Year)
Body weight 55 - 95 kg (63 g)
Body mass index 22 - 36 (26)
Duration of symptoms 6 y (2 - 17 year)
Grade of gynacomastia
1 55
2A 25
2B 40
3 20
Side involved
Unilateral 10 pt
Bilateral 65 pt
Table 2. Endocrinal blood tests and imaging.
Examination Number of patients
Endocrine blood test 25 (33.6%)
Imaging
Mammogrm 8 (10.6%)
Breast ultrasound 12 (16%)
Mammogram and ultrasound 4 (5%)
Systemic imaging 4 (5%)
FNA 3 (4%)
mastectomy was used on 6 breasts. An inverted T pattern and inferior pedicle technique without vertical scar
were performed each on 4 breasts. Liposuction alone was used on 20 breasts, and as an adjunct to periareolar
approach on 36 breasts.
Tissue was submitted for histological examination in 15 breasts. There were no pathology results. No malig-
nancies were found, but, atypical ductal epithelial hyperplasia was seen in 3 breasts of 2 patients.
19 operated breasts (13.4%) experienced some form of complications. Minor complications included seroma
(4 breasts) and superficial wound dehiscence treated conservatively (3 breasts). The only acute major complica-
tion encountered were haematomas requiring evacuation in theatre (2 breasts). Unsatisfactory result was present
in 10 breasts and second gynacomastia surgery was needed in 5 breasts. The causes of the unsatisfactory cosme-
sis were equally distributed between nipple tethering or inversion, ugly scar and contour irrigularity (Table 3).
Analyses of the operative data showed that age of the patients, specimen weight, grade of gynaecomastia and
the specific surgical approach used were not significant predictors of minor or acute major complications.
However, it indicated that the grade of Gynaecomastia and weight of the specimen was a significant predictor of
poor cosmosis Patients with grade III (7/40) gynaecomastia were more likely to have poor cosmetic results and
need late revision operation than patients with grade I (1/35) and grade II (2/65) gynaecomastia. Comparing all
approaches used for grade 111, it was found that the inferior pedicle without vertical scar gives the best cosmot-
ic result and showed that the surgical approach used is a significant predictor for the cosmetic outcome. Finally,
age was not found to be a significant predictor of the cosmetic outcome. We found that 65 patients (93%) were
very satisfied (score: 8 - 10) with their cosmetic outcome. One liposuction patients returned overall-satisfaction
scores of less than eight. This patient was also less satisfied with the improvements in his chest shape and
A. M. Tolba, M. Nasr
512
Table 3. Surgical approach, operative time, hospital stay and complications.
Surgical approach
Liposuction 20 breasts (14.2%)
Periareolar approach 70 breasts (50%)
Circumareolar with skin resection 10 breasts (7.1%)
Inverted T 4 breasts (2.8%)
Liposuction plus periareolar 36 breasts (25.7%)
Operative time 30 - 130 (60 minutes)
Weight of spicmen 95 - 450 (200 gm)
Hospital stay 1 - 2 days
Minor complication 7 (5%)
Acute major complication 2 (1.4%)
Late non satisfactory 10 (7%)
self-confidence. The scars of all breasts treated by open excision were scored between 9 and 10, and those
treated by skin reduction were scored between 5 and 7.
5. Discussion
Gynaecomastia is classified into true gynaecomastia with proliferation of ducts and periductal tissues and Pseu-
dogynaecomastia due to deposition of adipose tissue or to the presence of an excessive amount of skin [10]. The
most common and practical classification is that of Hoffman and Simon who classified true gynacomastia into:
Grade 1: Minor enlargement and no redundant skin
Grade 2A: Moderate enlargement and no redundant skin
Grade 2B: Moderate enlargement and minor skin redundancy
Grade 3: Gross enlargement and major skin redundancy [11]
Three age groups are usually affected. The first one is in neonatal period (60% - 90% of infants have transient
gynaecomastia due to transplacental transfer 0f oestrogen) [2] [12]. The 2nd is during puberty (10 - 12 years) af-
fecting 48% - 64%. 90% of them resolves spontaneously before the age of 17 and only 10% persist. The highest
prevalence is among middle aged and older man (50 - 80 years old), 40% - 65% of whom are reported to have a
degree of gynaecomastia that is often multifactorial [8] [11] [13]. The oldest patient in our study was 37 years
old. This may be related to the fact that the cause for surgery in almost all cases was emotional distress, and old-
er men may be less affected by this stimulus compared to the younger age group.
Surgery is considered when gynaecomastia present for more that 2 years as gynacomastia is unlikely to re-
gress spontaneously or with medical treatment since the tissue is irreversibly fibrotic [14] [15]. Surgery is indi-
cated to correct the deformity, restoring a normal body contour and image with maintaining the viability of the
nipple-areola complex, avoiding excessive scarring and preventing a saucerdeformity aiming to relieve emo-
tional discomfort, psychosocial distress and intolerable pain [5].
A number of aesthetic surgical techniques are available for management of gynaecomastia and surgeons often
find it difficult to choose the technique that will achieve the best results for a given patient [16]. Liposuction
techniques are enough for some forms of gynaecomastia; others require open procedures using either intra-areo-
lar or extra-areolar incisions [3].
On reviewing literature about the management of gynaecomastia Simon grade 1 and 2, it was found that lipo-
suction is the technique of choice in non glandular cases (pseudo-gynaecomastia) .On the other hand, manage-
ment of true gynaecomastia grade 1 and 2, includes subcutaneous mastectomy alone, liposuction alone or lipo-
suction combined with subcutaneous mastectomy [17] [18]. The classic surgical approach with semicircular pe-
riareolar incision was described by Webster in 1946 and it is the ideal approach for mild and moderate gynae-
comastia. Alternative to surgery, the suction-assisted lipectomy was introduced in 1970. While the Laser-as-
sisted liposuction has been proven to be safe and effective for the treatment of gynecomastia [19]. For mild gy-
A. M. Tolba, M. Nasr
513
naecomastia, all approaches seem to have similarly good results.
Many surgeons prefer subcutaneous mastectomy for the treatment of true gynaecomastia [20] [21]. Various
incisions and techniques have been described for the treatment of gynaecomastia, the periareolar incision is the
most commonly used techniques because the final scars are almost inconspicuous [22]. Decreased or absent nip-
ple sensation, necrosis of the nipple-areola complex and skin, haematoma, seroma, infection, contour deformity,
distorted shape of the areola, and retraction of the areola and skin are the most common complications of subcu-
taneous mastectomy [11].
In this study, subcutaneous mastectomy was done 70 cases with grade1, 2 gynaecomastia and several patients
with moderate-to-large breasts, it was felt that the skin elasticity was sufficient, and thus no skin reduction was
performed. One patient was left with a mild degree of redundant skin in the nipple-areolar complex (Figure 2).
This did not affect the overall result, and extra-areolar scars were avoided. In this study, incidence of complica-
tions was 7 cases (10%), 3 of them were minor complications in the form of seroma, and superficial wound de-
hiscence and these were managed in the outpatient clinic during the postoperative visits, haematoma which was
evacuated in operating theatre, These complications did not affect the final cosmotic result while the other three
cases were contour deformities and depression in the area of nipple and areola and surrounding area. 67 patients
were very satisfied with their results, returning the highest scores for overall satisfaction, improvement of
self-confidence and the shape of the chest. The longer semicircular scar at the periareolar margin was well ac-
cepted and usually faded with time.
Suction assisted lipectomy to gynaecomastia is easy and does not impair areolar vascularity or sensation, and
because the postoperative scars are excellent. It permits more rapid, efficient and controlled tissue removal, faci-
litating consistently good results without some of the drawbacks of open surgical excision particularly contour
irregularities. It also has decreased the incidence of haematoma. So far the advantages of this technique justify
its use in almost all gynaecomastia procedures [23]. Bjorn found that glandular tissue was included in their as-
pirate. They concluded that Tissue suctionis a very valuable technique for correcting most gynaecomastias
and that the advantages of this technique justify its use in almost all gynaecomastia procedures. Although estab-
lished for lipomatous pseudo gynaecomastia, value of liposuction for treating true glandular hypertrophy in male
breasts is controversial [18]. several other authors [24] [25] have recommended liposuction for the treatment of
true gynaecomastia but with the use of special cutting cannulas, these cannulas, however, are traumatic and
make damage to blood vessels and nerves more likely.
In this work, 10 breasts with pseudo-gynacomastia were managed with suction assisted liposuction the en-
trance sites for liposuction were chosen in submammary crease and lower axilla as was stated by Coelman and
colleagues [26] to allow crisscross tunneling. A small cannula (3 mm) was used to remove tissues in retroareolar
region. As they can easily penetrate through the fibrous glandular tissue beneath the areola as recommended by
Pitman .Surgeons believe that skin retrapping and retraction and thus reduction of skin envelop is maintained by
intact connective tissue bands [23]. In this work, there was no postoperative skin redundancy even in the cases
with mild to moderate skin excess.
The reported complications were three cases, two of them were seromae and the third was contoured formity.
9 patients were very satisfied with their results, returning the highest scores for overall satisfaction, improve-
ment of self-confidence and the shape of the chest.
Laser-assisted lipolysis (LAL), introduced by Apfelberg in 1996 [27], has the advantages of excellent patient
tolerance, quick recovery time, and the additional benefit of dermal tightening and is an excellent method for the
treatment of lipodystrophy, mainly in difficult fibrous areas, such as gynaecomastia [28].
Ten breasts with grde 1 and 2 gyanacomastia were treated by Laser assisted liposuction (LAS). The postoper-
ative period in all patients was incident-free. There were no signs of ischemia, skin burning, or loss of sensation
in the nipple, and no infection, seroma or scarring was noted. Inspite of the small number of our study, we can
conclude that LAL for gynecomastia is safe, and produces significant effects on fatty tissue with a reduction in
volume of the breast, together with visible skin contraction. Provided an appropriate amount of energy is deli-
vered by an experienced operator, the results are significant and consistent.
Suction assisted liposuction combined with open excision was first described by Teimourian and Perlman in
1983 [29] and has become one of the most widely used method foe management of gynaecomastia, because of
the frequent difficulty of removing breast parenchyma by suction alone [30]-[32]. In order to have the best re-
sults, many surgeons choose direct excision of residual glandular tissue after completing the suction as the oper-
ation of choice for cases of true gynaecomastia [31] [33] [34].
This concept was adopted in this study for cases of true gynaecomastia grade 2 and several patients with
A. M. Tolba, M. Nasr
514
moderate-to-large breasts it was felt that the skin elasticity was sufficient, and thus no skin reduction was per-
formed.
In 36 breasts, liposuction was started then the breast was palpated for any significant residual glandular tissue,
which is then removed through an inferior periareolar incision.
Suction in the non-glandular cases was found relatively easier than in the glandular cases because of the firm
fibrous structure of the glandular breast enlargement [35]. This study agrees with this finding. Therefore, lipo-
suction of gynaecomastia, the threshold for conversion to an open procedure should be low, because it is asso-
ciated with a significant advantage for the patient. As it leads to a high degree of satisfaction and leaves the pa-
tient with a minimal almost invisible scar. The conversion to an open procedure is made intraoperatively [36].
Therefore, all patients undergoing liposuction need to consent for open excision as well. Although, open exci-
sion gives excellent results in smaller breast enlargements with distinct subareolar nodules, it is difficult to
achieve a good result without liposuction in more diffuse enlargements and larger breasts as the pre-tunnelling
and suction achieved with liposuction prior to open excision help to taper the peripheral contour, define the
glandular tissue and make the excision easier.
The incidence of complications is nearly equal those of the conventional subcutaneous mastectomy, In this
study, incidence of complications after liposuction was 4 cases (11%), 2 of them were minor complications in
the form of seroma, and marginal superficial sloughing of areola, and these were managed in the outpatient
clinic during the postoperative visits. The other two cases were contour deformities in the form of depression in
the area of nipple and areola and surrounding area. The cause of this deformity was, as explained by Pitman [23],
due to failure to leave adequate soft tissue on the nipple areolar flap and surrounding skin, in open cases. These
two cases were treated by secondary suctioning to taper the periphery.
For cases of severe gynaecomastia with redundant skin, many techniques have been described in literature
they can be divided into two main groups: extra-areolar [37]-[39] and circumferential [40]-[42] excisions. Extra-
areolar skin excisions are, however, associated with hypertrophic scarring and unacceptable results [3] [22] [43].
Many authors suggested circumareolar skin excision. A concentric circle of periareolar skin is de-epithelialized
and breast tissue can be resected through an infra-areolar incision [44] [45]. The final scar is limited to a circle at
the periphery of the areola. The appearance of the scar is inferior to the semicircular periareolar scar, but it is
well accepted by the patients. Liposuction can be also combined with a concentric mastopexy [18]. 6 breasts
were operated by this technique, three developed complications in the form of seroma, haematoma and ugly scar
as the skin surrounding the nipple-areolar complex was wrinkled, because the width of the circle of skin excised
was too large. Therefore, this procedure is limited to a certain amount of skin excess.
The common techniques used for mastopexy and breast reduction for the female patient may also be used for
the male, although the residual scars or the nipple deformities may cause more distress to the patients [8].
Superiorly or inferiorly based pedicle areolar flaps and free nipple techniques have been described for stage 3
gynaecomastia [3] [11] [16]. Le Jour has popularised a vertical mammaplasty technique without submammary
scar for mastopexy and reduction of the female breast [46]. Apart from the circumferential scar, the breast is left
with only a small vertical scar.
The inverted T technique was applied to 4 breasts with a high rate of unacceptable or unsatisfactory outcomes
and it should be reserved only for those patients with insufficient skin elasticity because the technique is asso-
ciated with less optimal cosmetic results.
Inferior pedicle technique without vertical scar was done for 4 breasts with severe gynaecomastia and excess
skin This procedure is easy, simple and if compared to the concentric circumareolar skin excision, the latter does
not give satisfactory skin excision in Simon grade 3 with marked skin redundancy in addition to the difficulty of
excision of such a big breast tissue through an infrareolar incision. The main disadvantage of this procedure is
the long transverse scar. All the cases done in this study were satisfied. They were all told before the operation
that they will have a long transverse scar, and they all agreed without hesitation.
Our study has several weaknesses: There were differences in the numbers of patients treated by the different
disciplines and the study describes patients who were operated for GM and does not report on patients who were
not suitable for surgery, following the preoperative examination and workup, due to a reversible cause of GM
such as anabolic steroid use or patients with chronic diseases such as liver failure.
6. Conclusions
Surgery is indicated after patient assessment and discussion of their expectation as surgery may yield unsatis-
A. M. Tolba, M. Nasr
515
factory cosmetic results especially in moderate and severe gynaecomastia. In the latter, further revisional sur-
gery is possible.
The surgical approach appears to be the most important predictor for good cosmesis with those gynaecomas-
tias amenable to skin resection. Unrealistic expectations or unwillingness to accept the risks associated with
surgery should be a contraindication for surgery.
Liposuction is an effective method of treatment of gynaecomastia grade 1, 11 because it is easy, does not im-
pair areolar vascularity or sensation, and because the postoperative scars are excellent. It also permits rapid, ef-
ficient and controlled tissue removal, and gives good cosmetic results but still the subcutaneous mastectomy
with the infraareolar incision is widely used with good cosmotic results and high patient satisfaction.
In grade 1, 2 gynaecomastia, differentiation between fatty and glandular cases preoperative is not important
since both cases can be treated by the same technique which is liposuction and surgical resection of residual
glandular tissue in true gynaecomastia.
Laser Assisted Liposuction for gynecomastia is safe procedure, and has significant effects on fatty tissue with
a reduction in volume of the breast, together with visible skin contraction.
The inferior pedicle without transverse scar technique for the management of Simon grade 3 gynaecomastia is
a simple easy and satisfactory method for treatment of these severe cases and avoiding the difficulty and less sa-
tisfactory results of other breast reduction techniques.
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... As some postoperative frustrating problems still cannot be completely eliminated. The most common of these are a saucer-like deformity (over resection under areola), bleeding, followed by seroma, infection, ischemic necrosis of nipple-areola complex, residual gynecomastia (under resection), persistence of inframammary fold, contour irregularities, and asymmetries between breasts [5]. ...
... Pain or tenderness may or may not be present. In contrast to the male breast cancer, which is usually present as a hard mass with or without skin changes and may occupy a central or peripheral location it is usually centrally located [5]. ...
... Surgery is indicated for patients with gynecomastia that does not regress spontaneously or, with medical therapy, or causing considerable discomfort or psychological distress or is long-standing (beyond a 18 -24-months period) [5]. Before any intervention is carried out pathological causes of gynecomastia must be ruled out [2]. ...
Article
Gynecomastia is a benign enlargement of male breast; many techniques have been described for management but none have gained universal acceptance. In this article, we have described a challenging case of gynecomastia, which benefited from mastectomy, mastopexy and nipple reduction surgery, and we compare it with other therapeutic options in terms of complications and aesthetic outcome.
... In contrast to the male breast cancer, which is usually present as a hard mass with or without skin changes and it is usually centrally located. 4 The most common symptom of the patient with gynaecomastia is being self-conscious about the appearance of his enlarged breasts. 5 Enlarged breasts can cause anxiety, self-consciousness and embarrassment, functional problems and psychosocial discomfort and fear of malignancy. ...
Article
Background Gynecomastia is one of the most common disorders affecting adolescent and adult males. It is a benign disorder but has severe psychological manifestations like low self-confidence, depression, anxiety and social phobia in patients suffering from gynecomastia. Different surgical techniques have been described utilizing a variety of incisions, excisions, lipectomy and liposuction methods. Very frequently, these methods are combined for the gynecomastia treatment with variable reported results. However, there is a lack of studies comparing these techniques. The present study was planned to compare cases of gynecomastia treated by liposuction with periareolar excision (delivery technique) and liposuction with a pull-through technique. Method A prospective randomized control study was conducted at a tertiary care hospital on 20 patients with gynecomastia. The patients were assigned to either liposuction with periareolar excision (delivery technique) or liposuction with pull-through technique. Anthropometric analysis and breast evaluation questionnaire (BEQ) scores were analyzed and compared before and after the surgery. Results The majority of the study subjects were between 21 and 30 years of age. Low self-confidence was the main reason for surgery in most of the cases. Twelve patients had gynecomastia grade IIa and eight had grade IIb. Both groups had similar responses to BEQ scores before and after the surgery with no statistically significant difference. A statistically insignificant difference was observed between the groups on comparison of anthropometric analysis preoperatively and postoperatively. The mean lipoaspirate volume was 280 ml for the pull-through technique and 367 ml for the periareolar excision technique. No complications were observed in cases operated on by the pull-through technique, while two cases (10%) operated on by the periareolar excision had hematomas. Conclusion Both techniques provide excellent cosmetic results with low risk of complications in both small and moderate breast enlargement with skin excess. The pull-through technique combines the benefits of direct excision of glandular tissues along with the minimally invasive nature of liposuction. Thus, performing the procedure via a single incision without the use of drains is a safer alternative to traditional liposuction with the periareolar excision technique. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Chapter
Gynecomastia is an enlargement of the male breast common in both neonates and adolescent boys and senescent males. The authors discuss classification and the surgical treatment of gynecomastia as well as nonsurgical therapeutic options for treatment of gynecomastia that are based on medical therapy aimed to achieve a spontaneous regression of breast tissue regulating the hormonal imbalance. Described are the authors’ technique of performing the procedure and the results thereof.
Article
Full-text available
The treatment of larger types of gynecomastia is significantly different than that of less severe gynecomastias. Special concerns of the former include areola enlargement, nipple-areola ptosis, and redundant skin. Many procedures have been described to address these issues, none of which is completely satisfactory; these are reviewed here. Unsatisfactory results may be due to residual breast hypertrophy, skin redundancy, complications related to nipple-areola placement, form and viability, and cosmetically unacceptable scars. We describe a new technique that uses an inferior pedicle to reposition the nipple-areola complex and to maintain its neurovascular integrity and form. A superiorly based chest wall flap in conjunction with suction-assisted lipectomy maximizes chest wall contour. There are no breast mound scars, only a periareolar and inframammary scar.
Article
Suction lipectomy is adapted for the correction of gynecomastia. Previous attempts using suction lipectomy for gynecomastia still required the use of sharp dissection for removal of the glandular breast tissue as well as excision of redundant skin. With this new technique, gynecomastia is corrected solely with the use of suction lipectomy. The technique is successful if the gynecomastia is due to excess fat or parenchymal hypertrophy. A 7-mm cannula is inserted first, to remove the adipose tissue. Then a 2.4-mm cannula is used to remove the glandular and ductal tissue. The 7-mm cannula is then reinserted to remove subareolar parenchyma and to make final contour adjustments. The surrounding subcutaneous tissue is easily undermined to avoid a saucer deformity and to allow for skin contraction. Patients return to full activities in 48 hours. A compressive garment is worn for 4 to 6 weeks. The results of 10 patients are discussed. (C)1987American Society of Plastic Surgeons
Article
Gynecomastia, or persistent enlargement of the male breast, is a common occurrence during early sexual development. Typically, two types of tissue can be identified during this period of growth. Initially, a dense fibrous growth of supporting stroma and breast tissue forms directly under the areola, creating a prominent mass effect. A supporting fibrofatty stroma variably develops around the periphery of the breast, particularly as the body mass index of the patient increases. Treatment is directed at both of these tissue types and includes liposuction contouring along with direct excision of the fibrous subareolar tissue. Resection of redundant skin is performed as needed either immediately or in a delayed fashion. These various modalities can be used either alone or in combination to restore a normal chest wall contour to affected individuals, thus easing the emotional burden that is associated with the condition.
Article
The use of the laser as an auxiliary tool has refined the traditional technique for lipoplasty. During laser lipolysis, the interaction between the laser and the fat produced direct cellular destruction before the suction, reduced bleeding, and promoted skin tightening. This study sought to perform a comparative histologic evaluation of laser lipolysis with the pulsed 1064-nm Nd:YAG laser versus a continuous 980-nm diode laser. A pulsed 1064-nm Nd:YAG (Smart-Lipo; Deka, Italy) and a CW 980-nm diode laser (Pharaon, Osyris, France) were evaluated at different energy settings for lipolysis on the thighs of a fresh cadaver. The lasers were coupled to a 600-microm optical fiber inserted in a 1-mm diameter cannula. Biopsy specimens were taken on irradiated and non-irradiated areas. Hematoxylin-erythrosin-safran staining and immunostaining (anti-PS100 polyclonal antibody) were performed to identify fat tissue damage. In the absence of laser exposures (control specimens), cavities created by cannulation were seen; adipocytes were round in appearance and not deflated. At low energy settings, tumescent adipocytes were observed. At higher energy settings, cytoplasmic retraction, disruption of membranes, and heat-coagulated collagen fibers were noted; coagulated blood cells were also present. For the highest energy settings, carbonization of fat tissue involving fibers and membranes was clearly seen. For equivalent energy settings, 1064-nm and 980-nm wavelengths gave similar histologic results. Laser lipolysis is a relatively new technique that is still under development. Our histologic findings suggest several positive benefits of the laser, including skin retraction and a reduction in intraoperative bleeding. The interaction of the laser with the tissue is similar at 980 nm and 1064 nm with the same energy settings. Because higher volumes of fat are removed with higher total energy, a high-power 980-nm diode laser could offer an interesting alternative to the 1064-nm Nd:YAG laser.
Article
A technique is described for excising the excess skin in gynecomastia operations, using a concentric "circle" design to remove a calculated amount in the vertical in the horizontal directions. The sole residual scar is a circular one around the periphery of the areola.
Article
This article is a report on long-term followup of a total of 44 serious gynecomastia cases in the stages I-III (according to Deutinger). The treatment consisted of either a semicircular incision and subcutaneous mastectomy or a superiorly or an inferiorly based nipple transposition while performing male reduction mammoplasty. Aesthetically pleasing results could be obtained by a periareolar approach and mastectomy. This inconspicuous procedure is feasible even in massive gynecomastia cases (stage III) or in cases of male breast asymmetry. On the other hand, all cases with breast reduction plasty and nipple transposition resulted in wing-shaped, mainly broad scars, and subjectively unfavorable results. Consequently, we favor the semicircular approach in male reduction mammoplasty in treating serious gynecomastias. With regard to possible male breast cancer etiology, the histological specimen of the mammary gland in gynecomastia is excised prior to any additional liposuction for supplementary body contouring.