Surgical Management of High Grade Gynecomastia: Combination of Liposuction, Glandular Resection and a Circumareolar Skin Reduction

INTRODUCTION
Gynecomastia refers to an abnormal and evident
increase in the volume of male breast, mimicking
that of females [1,2]. The development of such
feminine breast shape in gynecomastia patients
severely affects social life and may cause significant
emotional distress and embarrassment, particularly
in adolescents and young men [3].
Regarding to the etiological factors, gynecomastia
could be either physiological, or pathological
on the basis of endocrinal imbalance, and when
no specific cause could be found, it is diagnosed
by exclusion as idiopathic, which is being the most
common one [1]. Gynecomastia is considered as
the most common benign problem affecting male
breast, it occurs in about 30% of middle-aged males
and increases with old age due to decline in testosterone
level [4]. Also gynecomastia could be
categorized to (true) when excess glandular tissue
predominates, pseudo-gynecomastia in case of
excess adipose tissue, or (mixed type) [5].
Spontaneous regression or an effective nonsurgical
treatment is only theoretically possible in
early gynecomastia induced by pubertal hormonal
fluctuation with recent glandular proliferation,
which has not produced any skin ptosis [6]. In
persistent longstanding cases for over a year, irreversible
process of fibrosis and hyalinization of
the loose peri-ductal tissue and the surrounding
stroma causing a glandular hypertrophy, which
once it has established in it cannot regress [7], and
so in most cases it requires surgical treatment.
The challenging issues in high grades of gynecomastia
with large ptotic breasts are the presence
of excess redundant skin, hypertrophied glandular
tissue, and abundant adipose tissue. In such cases,
this skin has lost its elastic properties, mainly skin
retraction, while the excess glandular tissue is
located mainly subjacent to nipple areola complex
[NAC] which is firmer than the surrounding fatty
tissue, resulting in distended and displaced NAC
[8,9].
The ideal surgical approach aimed not only to
reduce the breast mound size but also to obtain an
accepted breast shape and restore masculine chest
contour by resecting excessive glandular tissue,
fatty tissue and excess skin, reducing and adequately
relocating the NAC, and removing the submammary
fold while avoiding residual unsightly
postoperative scarring to the chest [9,10,11].
The surgical methods used for severe gynecomastia
were ranging from older techniques such
as reduction mammoplasty with free grafting of
the NAC, to currently used one as modified breastreduction
techniques either (no vertical scar or Tshaped
scar pattern), or subcutaneous mastectomy
with peri-areolar concentric skin excision [Benelli
type] [12], although these procedures might succeed
in reducing the breast size [13], but a high rate of
unacceptable outcomes had observed, mainly because
of the unhidden residual scars, contour irregularities,
residual redundancy, and NAC deformities
[12].
The purpose of this study was to evaluate the
combination of liposuction, glandular excision and
periareolar concentric skin resection technique in
males with high grade gynecomastia as regard
technical refinements and outcome, in the hope of
reshaping the breast and achieving an ideal aesthetic
result of this condition.
PATIENTS AND METHODS
The present study was an prospective interventional
study (pre-post), it was carried out on 18
healthy male patients who had bilateral gynecomastia
persistent at least for more than one year,
between January 2016 and June 2017, their ages
ranged from [17-61 years old, with mean ± 30.94],
while patients who have any pathological etiology
for their gynecomastia (after consultation of endocrinologist,
and hormonal assay) or massive weight
reduction with or without bariatric surgery, or
recent gynecomastia, were excluded from the study.
Preoperatively, the included patients were classified
as grade IV gynecomastia according to ASPS
[American society of plastic surgeons] scale [14]
adjusted from Simon et al., [15] classification; it
classifies breasts based on morphology and volume
into four grades (Table 1).
324 Vol. 42, No. 2 / Surgical Management of High Grade Gynecomastia
Patients were selected from the outpatient clinic
of Plastic Surgery Unit of Zagazig University
Hospitals. All participating patients were informed
about the steps of the procedure and possible
complications and were consented. The patients
were evaluated for evident excess glandular tissue
by clinical examination and ultrasonography.
Operational design:
Preoperative marking was done while the patient
in the upright standing position, the entire breast
mound, plus to the chest areas lateral, medial and
inferior to pectoralis muscle and also epigastrium
area were outlined. Marking the inframammary
crease and breast median and NAC boundary (the
inner circle), in case of large NAC diameter; it
was reduced to 2.5-3cm in diameter (the average
diameter of male areola is ranging from 2.67 to
2.8cm in the anatomical studies [16].
The excess skin was outlined in a concentric
circumareolar manner (the outer circle), depending
on the size and shape of the breast, or determined
by the following equation (the radius of outer circle
equals the sum of adding [0.8 x radius of the areola]
to the radius of the areola) [17], so it ranges from
2cm-2.5cm in width from the edge of inner circle.
In hairy patients, shaving was limited only to the
marked concentric area (Figs. 1A,2A).
Operational procedure:
The procedure was carried out under general
anesthesia. At first, all the above outlined areas
was infiltrated with tumescent solution, through a
2-3mm skin incision was done at the middle of
inframammary crease, Mercedes liposuction cannulas
3mm cannula was introduced. Liposuction
of adipose tissue was performed in two planes;
deeper and superficial to breast parenchyma until
evident reduction of the breast volume, contour
remodeling, and parenchymatous tissue freeing
(assessed by pinch test). After liposuction, the
Table (1): ASPS Gynecomastia scale.
Small breast enlargement with localized button
of tissue that is concentrated around the
areola.
Moderate breast enlargement exceeding areola
boundaries with edges that are indistinct from
the chest.
Moderate breast enlargement exceeding areola
boundaries with edges that are distinct from
the chest with skin redundancy present.
Marked breast enlargement with skin redundancy
and feminization of the breast.
Grade I
Grade II
Grade III
Grade IV
Egypt, J. Plast. Reconstr. Surg., July 2018 325
residual palpable glandular tissue was located
mostly in the sub-areolar area.
The concentric circumareolar doughnut shaped
skin ring was de-epithelialized with care to avoid
injury or damage to the sub dermal blood flow to
NAC, Then the glandular tissue is entirely excised
through a small transdermal incision lower down
at de-epithelized area between 5 to 7 o'clock position
leaving only enough disk of tissue attached
underneath the areola to a prevent development a
depressed or ischemic areola, then NAC was relocated
to a higher level at mid humerus level by
suturing it to pectoralis fascia, just medial to the
mid-clavicular line (Fig. 3A).
After glandular tissue has been completely
removed, the consistency, uniformity of the mammary
area and any remaining lumps of tissue are
checked by pinching the skin, additional liposuction
could eventually be done; by using a thin 2m
cannula to smooth out any contour irregularities,
especially at the margins of the pectoral area and
along the anterior axillary pillar.
After ensuring proper hemostasis, the breast
pocket is irrigated with saline, a suction drain was
coming out from the same stab for liposuction, left
for the first 24-48 hours, then the trans dermal
incision was closed with interrupted 3-0 Vicryl
sutures, then an interrupted subcuticular suture of
3-0 Vicryl suture was used to closely approximate
the external skin with the internal areola in a serial
bisecting sutures. Next, a 4-0 polyproproline running
subcuticular suture was placed for better
approximation of skin edges (Fig. 3B).
A compressive garment is worn for 6-8 weeks,
and suture removal after two weeks (Figs. 1,2,4,5).
The only suspicious resected glandular tissue (any
nodularity, or calcifications) was sent to histopathological
examination.
Follow-up examinations: The follow-up period
was up to 6 months after the surgery. Postoperative
analysis included pre and postoperative photographic
documentation, early and late post-operative
complications, and aesthetic result by the use of
the qualitative evaluation scale by Kasielska and
Antoszewski [18] (Table 2).
The Final aesthetic result was as follow (on the
basis of the sum of the points): 'Very good' malelike
breast 0-1 point, 'Good' male-like breast between
>1 to 2 points, 'Average' reoperation to be
considered >2-4 points, and 'poor', reoperation
needed >4-8 points.
RESULTS
The average amount of lipoaspirate was 450
ml per side (range = 350-550ml), the early perioperative
complications were 27.7%; two cases of
haematoma was evacuated from drain site, two
cases with seroma formation, which conservatively
managed by needle aspiration and pressure garments
and one case with partial necrosis of areolar
edge; perhaps due to excessive removal of tissues
beneath the areola, (no further management was
done to this areola) (Fig. 1B). While the late postoperative
complication rate was 33.3%, most frequent
complications occurred were saucer-like
deformity in two cases (Table 3). There were 2
cases with suspicious excised biopsies, which were
free of malignancy by histopathological examination.
Table (2): Evaluation scale of the cosmetic results after
gynecomastia surgical treatment.
Breast size
Breast Symmetry
NAC Shape and
symmetry
Scar Visibility
012
012
012
012
Item
- Male sized
- Between 0 and 2
- Female sized,
- Symmetrical Well positioned
- Between 0 and 2
- Asymmetrical Malpositioned
- Symmetrical, and good projection
- Between 0 and 2
- Asymmetrical, and deformed
- Almost invisible
- Between 0 and 2
- Visible, unaesthetic
Points
Table (3): Postoperative complications in the examined group
of grade III gynecomastia (n=18).
Early:
- Hematoma
- NAC necrosis
• Partial
• Complete
- Wound infection
- Seroma
Total
Late:
- Asymmetries between breasts
- Residual gynecomastia (under resection)
- Persistence of inframammary fold
- Contour irregularities
- Saucer-like deformity
(over resection under areola)
- Prolonged hypothesia
- Hypertrophic scar
Total
2
1002
5
10112
01
6
No.
11.1
5.5
00 11.1
27.7
5.5
0
5.5
5.5
11.1
0
5.5
33.3
%
According to qualitative evaluation scale; there
were very good result in 10 patients (56%), good
result in 4 patients (22%), average result in 3 patients
326 Vol. 42, No. 2 / Surgical Management of High Grade Gynecomastia
(17%) and 1 patient (5%) with poor result, it was
due breast asymmetry between both sides and so
revisional surgery was indicated for this patient.
Fig. (1A): Preoperative markings-frontal view.
Fig. (2A): Preoperative markings-oblique view.
Fig. (3A): De-epithelialized circumareolar area, with glandular
excision.
Fig. (1B): Postoperative view 3 months later, partial necrosis
of left areola.
Fig. (2B): Postoperative view 6 weeks later.
Fig. (3B): Serial bisecting stitch closure, drainage through
same stab of liposuction cannula.
Egypt, J. Plast. Reconstr. Surg., July 2018 327
DISCUSSION
It is a great challenge to achieve a very good
or even a good aesthetic outcome in patients with
high grade gynecomastia [18]. The problem to solve
in severe gynecomastia is not localized accumulation
of glandular or adipose tissues but how to deal
with major skin redundancy and how the postoperative
residual scarring would be [6].
In the presence of such issues, the possibility
of simple corrective procedures such as liposuction
or skin sparing techniques is negated. Although
liposuction is considered a milestone in the modern
era of gynecomastia surgery, the fulcrum of treatment
is not liposuction alone and it would not be
sufficient to obtain a good flattening of the chest
without skin excision [2,6].
Nowadays, surgery that combines liposuction
with skin, and glandular excision techniques is
necessary to avoid an inadequate result and the
burden of a reoperation [19,20,21]. Besides it is
advocated for a finest aesthetic result that the scars
should be confined to the periareolar area [6].
In the current study, we agreed with cavina [2],
sharker et al., [11], and Gusenoff et al., [22], that a
more optimum result could be accomplished by a
comprehensive approach to include the aesthetic
units outside the breast mound, so synchronous
liposuction of the chest areas and epigasteric area
was done in all cases. The entry point of liposuction
cannula at the inframammary line allowed crisscross
suction of the same and contralateral breast,
chest, epigasteric area and freeing the inframammary
fold from its attachment to the pectoralis
fascia.
As regard glandular excision, we agreed with
Cannistra et al., [23], that preliminary liposuction
Fig. (6): Pie chart illustrates post-operative aesthetic outcome.
Very good
Good
Average
Poor
22%
4 patients
17%
3 patients
5%
1patients 56%
10 patients
Results
Fig. (4A): Preoperative front view.
Fig. (5A): Preoperative lateral view.
Fig. (4B): Postoperative view 6 weeks later.
Fig. (5B): Postoperative lateral view 6 months later.
328 Vol. 42, No. 2 / Surgical Management of High Grade Gynecomastia
step greatly facilitates excision of isolated retroareolar
glandular tissue through a small transdermal
cutaneous incision, in our study an incision between
5 to 7 o'clock was quite enough to ensure subcutaneous
dissection of residual hypertrophied glandular
tissue with proper hemostasis which was helped
by subcutaneous tunnelization by liposuction cannula.
In the current study, the transdermal incision
was done lower down between 5 to 7 o'clock position
in the de-epithelized area, we had followed
the recommendations proposed by Schlenz et al.,
[24] in their an anatomic study, that skin incisions
at the medial edge of the areola should be avoided,
as they showed that the medial innervation of the
NAC by the 3rd and 4th anterior cutaneous branch,
took a “superficial” course within the subcutaneous
tissue to reach the medial areolar edge. This has
been also extrapolated by the results of Cannistra
et al., [23], who reported loss of areolar sensitivity
in 10% of fifty eight patients managed by periareolar
incision and double dermal areolar pedicle
[incisions were between 2 to 4 o'clock and 8 to 10
o'clock].
As regard the circumareolar incision we found
that it is a suitable modality to deal with excess
redundant skin, also excessively large NAC got
benefit from this excision by reducing its diameter,
but excessive skin resection might lead to place
too much tension on the suture line with subsequent
a greater potential of early wound dehiscence or
late scar broadening or hypertrophic scarring, we
encountered hypertrophic scarring occurred in one
case, managed with topical silicone preparations,
it supposed to be due to excessive skin resection.
The periareolar scar might be looked wrinkled in
the early postoperative period but it improved
spontaneously with time, this is agreed with several
authors such as Cordova and Moschella [6], Sarkar
et al., [11] and Li et al., [25].
As regard complications, early complication
rate was 27.7% (5/18) in our series and the revision
rate was 5.5%. Other series of management of high
grade gynecomastia with liposuction and concentric
circumareolar skin excision revealed complication
rates ranging from 10% of fifty eight cases with
Cannistra et al., [23], 16.6% (1/6) cases with li et
al., [25], 25% (3/12) with Sarkar et al., [11], to
29.6% (8/27) with Ibrahim [13], The most common
early complication in this study was hematoma
and seroma which was consistent with other series.
Finally, we evaluated our results by using an
objective scale, it might be claimed that this scale
depends on the subjective evaluation by the surgeon.
While in the other studies the outcomes are
mostly evaluated subjectively by a patient questionnaire
or by the surgeon. We believe it might
be more beneficial to use one unified scheme for
outcome assessment [18].
Conclusion: The strategy of gynecomastia surgery
is advocated to combine more than one procedure,
and to be designed specifically to address
those characterizing problems in severe gynecomastia
cases, through doing liposuction for the
fatty component, direct excision of the glandular
component, and resection of the excess skin, to
achieve a flat male shaped chest with pleasant
concealed scar at the periphery of areola.