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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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a
Fig. 9.16 (a) Pinch test being done to conrm the completeness of evacuation. (b) Further grating being done to break down the residual tissue
a
b
b
c
Fig. 9.17 (a) Fullness seen on the left side of the chest. A curvilinear incision is planned on the inferior aspect of left areola. (b) Dissection of the
bro-glandular tissue is completed. (c) Asymmetric excised specimens usually sent for histopathology
When a two-stage gynecomastia procedure is undertaken,
then we rst undertake aggressive liposuction in stage 1. We
crescent has to be marked (more like a helmet) to reduce the
chances of the dog ear being formed (Fig.9.19a–d).
allow 3 months for the area to shrink and skin to retract. If
the NAC is lower than the ideal position as calculated in
Fig. 9.3, then a superior crescent excision is planned as
shown in Fig.9.18a–c.
When the NAC has to be moved to a larger distance (equal
or more than the diameter of the NAC), then an extended
9.8.1.8 Patients Having Grade IV Gynecomastia
withSignicant Glandular Ptosis (Grade
II or III)
Grade IV gynecomastia is usually found in people who have
been overweight and have lost weight due to diet or bariatric
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a
Fig. 9.18 (a–c) A 29-year-old patient who had undergone gynecomas-
tia reduction by liposuction as well as weight loss was not happy with
the position of the NAC.The NAC had to be moved superiorly by
2.5cm. (a) A crescent-shaped incision was planned in the upper quad-
b
c
rant of the NAC. (b) Tissue was excised up to the subcutaneous layer. If
bro-glandular tissue has to be excised, which has not been done
before, it can be done from the same incision. (c) Closure done using
interrupted sutures
a
c
b
d
Fig. 9.19 (a, b) Patient with Grade III gynecomastia showing ptosis of
the breast. The NAC is lower by 4cm. Patient wanted the NAC to be
repositioned at the same time as the tissue removal. (c) Helmet-shaped
skin excision with tissue removal is planned. (d) After closure using
interrupted sutures
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surgery. More extensive surgeries are required in such
patients as the skin fold excision is required in the armpits
and also at times to the back.
Once the excess skin has been marked, NAC can be relocated on an inferiorly based skin pedicle [7] or a free FTSG—
full thickness skin graft.
The marking of the “boomerang technique” includes outlining the superior two-thirds of the nipple–areola complexes
rst. Then, the receiving mosque-like dome approximately
3cm superior to the inferolateral pectoralis muscle is marked.
The medial oblique excision ellipse is drawn descending to
approximately the seventh costochondral junction. Next, the
lateral ellipse excision is drawn after assessing the tissue to
be excised using a pinch technique and descending toward
the ninth rib at the anterior axillary line. Finally, the midlateral excision is marked extending if required to the back,
based on the lateral chest and back skin laxity (Fig.9.20a–d).
The technique of free NAC graft involves two important
markings: (1) marking the excess tissue to be removed,
which is done through a pinch technique with the patient
standing (Fig.9.21a), and (2) the new position of the NAC
that is based on a technique mentioned in Fig.9.3. The areola
to be excised should be marked rst and it should be close to
27mm in diameter and the nipple, 7mm in diameter [4].
The full thickness graft is rst harvested after inltrating
the NAC with local and adrenaline. The graft should be harvested having partial thickness of dermis (the dermis in the
chest is very thick), with NAC held in a stretched position.
The tissue behind the nipple (total thickness of the nipple)
should not be more than 5mm else the nipple will not completely revascularize and will cause delayed healing. The
NAC is placed in cold moist gauze safely and then the excision of the tissue and closure is completed. The new NAC is
marked and de-epithelized, taking care of the following:
• Slightly oval (horizontal greater than vertical)
• Smaller (with diameter lesser than 3cm)
• Positioned around the fourth or fth intercostal space
• NAC is positioned on an average 2.5 cm medial to the
lateral border of the pectoralis muscle and 2.5cm above
the new inferior pectoral margin
The NAC is sutured after hemostasis with tie-over suturing, which is changed after 7 days (Fig.9.21b–d).
a
c
d
b
Fig. 9.20 (a, b) Marking of the “boomerang ap” for excision and pedicled NAC relocation. (c, d) Excision and suturing of the NAC and inferior
ap in the new position
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M. Thomas and J. D’silva
a
c
b
d
Fig. 9.21 (a) Excess breast tissue marked as an ellipse along with position of the new NAC. (b–d) De-epithelization and resuturing of the NAC
on the chest
9.8.1.9 Dressing andPostoperative Care
All the access areas are sutured and dressed. Patient is placed
in a custom-made corset to prevent collection in the operated
area. Patients are advised to have limited upper limb mobility, especially after tissue excision and free nipple graft. The
rst dressing is planned at 7 days when all non-absorbable
sutures are removed.
• Bleeding
• Seroma
• Infection
• Under-correction
• Overcorrection (Saucer deformity)—can be corrected by
tissue graft and fat transfer (Fig.9.22)
• Hypertrophic scar/Keloid formation
• Very rarely loss of nipple–areola area
Risks andComplications
The risks of surgery include standard risks of anesthesia and
the following:
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a
c
b
d
Fig. 9.22 (a) “Saucer deformity” in a 23-year-old engineer who had
undergone open excision of the gynecomastia from an incision in the
anterior axillary line. (b) Dermofat graft harvested from the supraglu-
9.9 Post-surgery Results (Figs.9.23, 9.24,
9.25, 9.26, 9.27, 9.28, and 9.29)
Pearls and Pitfalls
1. Always assess the male chest visually as well as through
palpation. Presence of a nodular mass usually indicates a
need for open excision.
2. Always suggest ultrasound of the breast, which will provide you with a baseline study as well as rule out cysts
and tumors.
teal region being placed in the defect. (c) The grafts being held in place
using bolster sutures. (d) The patient 3 years after the tissue graft as
well as fat graft in the area
3. Patients presenting with “puffy nipples” always need
direct excision. Liposuction with or without technology
is just not good enough.
4. It is normal to have some tissue behind the nipple areola.
Explain to the patient about it pre-surgically.
5. When relocating the NAC, err on keeping it lower than
higher.
6. Recurrence of fullness in the retro-areolar region is possible if the patient uses anabolic steroids. This may lead
to painful nodular swelling. Fullness in the overall chest
region is possible if the patient puts on weight.
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M. Thomas and J. D’silva
a
c
b
d
Fig. 9.23 (a, b) Preoperative photographs of a 25-year old having a Grade Ia gynecomastia with glandular and fatty predominance. (c, d) 6 weeks
post-surgery involving only power-assisted liposuction
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a
c
b
d
Fig. 9.24 (a, b) Pre-surgical photographs of a 27-year-old male who was concerned about his puffy nipples. He has Grade Ib gynecomastia that
was brous in nature and he needed direct excision of the tissue below the areola to get the at result (c, d)
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M. Thomas and J. D’silva
a
c
b
d
Fig. 9.25 (a, b) Pre-surgery photographs of a young boy of 18years having Grade IIa type of gynecomastia. (c, d) Post-surgery photographs 2
weeks after surgery, which shows adequate skin shrinkage
ab
cd
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Fig. 9.26 (a, b) Pre-surgery photographs of a 22-year-old male having Gr IIb type of gynecomastia needing lipocontouring with direct tissue
excision. (c, d) Post-surgery pictures after 4 weeks
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a
c
b
d
Fig. 9.27 A 37-year-old male having Grade III gynecomastia (a, b) underwent power-assisted liposuction only of the area as he did not want an
additional scar for skin removal. (c, d) Photographs taken 6 weeks after the surgery
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