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R. CavalcantiRibeiro et al.
Glandular Tissue Consistency
In younger women, the breast is generally more glandular; however, when they get
older, a fat substitution is always observed. Thus, more compact result is obtained
in young patients.
Height oftheNipple-Areola Complex
This aspect is fundamental in the choice of the vascular pedicle that will supply the
areola. The distance from point “A” to the NAC determines the degree of ascent, and
it can be performed through direct ascension, migration techniques, or graft. As
much greater the distance to reach “A” point, more will be the risk of
devascularization.
Breast andChest Asymmetries
Several congenital or acquired factors can interfere with the “normal” shape of the
breasts. Among the congenital anomalies are breast agenesis, Poland’s syndrome,
supernumerary gland, inverted nipple, Pectus excavatum and scoliosis. Another
situation that must belooked for and evaluated,is tuberous breast. Therefore, the
evaluation aims to dene the parameters that will be modied with the surgery and
clarify the types of asymmetry that cannot be corrected.
Previous Injuries or Scars
In order to identify previous aesthetic or reconstructive surgeries and exclude breast
neoplasms, a careful investigation of what happened should be done, and, if possible, request the mastologist’s evaluation. In addition, observe the presence of scar
retractions due to burns among others and the quality of the scars and question
whether there was any type of complication during the same.
Inframammary Fold andDegree ofPtosis
The degree of breast ptosis depends on the position of the NAC in relation to
theIMF, according to Regnault´s classicationof ptosis (Table25.2).
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Table 25.2 Regnault´s classicationof ptosis
Complete or true
ptosis
Partial ptosis NAC above the inframammary fold and gland ptosis
Pseudoptosis NAC above the inframammary fold; loose, hypoplastic skin (e.g., marked
Grade I NAC at the height of the inframammary fold
and above the breast
Grade II NAC below the inframammary fold and above
the breast contour
Grade III NAC below the inframammary fold and the
contour of the breast
weight loss after pregnancy)
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Imaging Exams
We routinely recommend performing at least one imaging study before the procedure, either to identifyabenign or malignant condition that may interfere with the
surgical schedule. For patients under 35 years, ultrasound is mandatory. On the
other hand, high-resolution mammography is recommended for women over 35
years old. If there is family history for breast cancer or suspicious lesions, previous
evaluation by the mastologist is required.
Photographs
At the rst consultation, patients must be advised regarding differences between
each breast and keep in mind that each breast’s approach will be in an alternative
way. Therefore, standardized photographs, preoperative and postoperative, with
frontal, oblique, and prole views, are mandatory. The preference is for digital photography that offers the opportunity to show immediately the differences to the
patient and later allows comparing and evaluating the results of the procedure.
Informed Consent Form
An exhaustive explanation of the procedure and the signing of informed consent
terms regarding its limitations, risks, and complications are mandatory. The documents should be individualized for each patient. In Brazil, due to local laws, any
resected surgical tissuemustbe sent for histopathological analysis.
Patient’s expectations and understanding about the surgery and anesthesia must
be claried, as well as alerts regarding asymmetries, scar size, and unrealistic expectations. In addition, the procedure should be discouraged in cases of lactation, pregnancy, papillary discharge, palpable nodule, axillary and supraclavicular lymph
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nodes, skin and NAC lesions, and active infections. In these cases, surgery should
be postponed until the diagnostic investigation and appropriate treatment are completed. The minimum age recommended is 18 years old.
R. CavalcantiRibeiro et al.
Patient Selection
In the Brazilian context, we follow Pitanguy’s principles and their variations, which
include a wide variety of techniques for the most diverse breast characteristics.
Therefore, the InvertedTpattern reduction mammoplasty is one of the most used
techniques and has been improvingcontinuouslyin order to minimize the scarring
sequelaeresulting from it.
There is a current tendency to seek reduced scars, in search of a higher aesthetic
standard and in line with the increasing body exposure; however, it is very important
to clarify to the patient that the best result cannot be sacriced at the expense of a
reduced scar.
In order to choose the best technique, besides the issues already mentioned, we
must take into consideration gland texture, skin quality, the degree of breast hypertrophy and the estimation of fat and parenchyma volume. Anatomical landmarks
and distances between structures such as the distance between the NAC and the
sternal notch determine the necessary end position of the NAC and are of outmost
importance in surgical planning. Thus, we propose the following algorithm:
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Once the criteria for choosing the technique are established, it is essential to
carry out complementary exams and to evaluate the surgical and anesthetic risk,
which has the following objectives:
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• Detect new diseases that could interfere with the surgical and postoperative act.
• Assess known diseases.
• Determine if the patient can be submitted to the proposed procedure.
• Establish conducts that minimize morbidity and mortality.
We routinely requesta completebloodcount, coagulogram, blood glucose, urea,
creatinine, chest X-rays (PA and prole), and EKG.
R. CavalcantiRibeiro et al.
Treatment/Evidence-Based Surgical Technique
Marking:
• The preoperative marking in a Tpatternbreast reduction varies from author to
author, but the geometricconcept and principles proposedstay unchanged instru-
ments as well may vary, but for academic purposes, we will describe our
preference.
• Marking step by step with the patient standing up position, with the smaller
breast as the main reference:
– Hemiclavicular line: can vary from 5.5 to 7cm and divides the breast into two
equal parts.
– “A” point: reects the projection of the inframammary fold over the hemicla-
vicular line.
– Extension of the sternal notchto “A” point that can vary depending on the
patient’s height between 18 and 22cm. Note: We use this reference because
geometrically it gives greater precision and symmetry to the marking.
– Marking of the anterior axillary line, the inframammary fold, and the mid-
sternal line.
– “B” and “C” points: bi-digital handling through the pinching of the estimated
skin and breast tissue, equidistant from the areola, forming a triangle with the
“A” point.
Note: In this marking time, verify the amplitude of the angle formed between
these two points, under the principle that what matters is the tissue left and not
the removed one. Usually this angle varies from 40 to 60° during this marking.
– “D” and “E” points: marking at the medial and lateral limits in the inframam-
mary fold, without going beyond the groove and keeping them equidistant
from “B” and “C” points.
– Joining the stitches: if there is excess skin, the design must be concave to the
groove, and if there is excess gland, it must be convex.
– Transfer the marking to the other breast by using wire or compass.
In additionto this standard markings, additional markings for the technique proposedmay be performed, for example, aninferiorly based dermal pedicle nippleareolar ap, resection areas, or liposuction areas, either of which may be indicated
for a particular type of breast.
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Once checked, the patient goes to the operating room, and anesthetic induction
is performed, which we give preference to general anesthesia.
Surgical sequence:
• After the anesthetic procedure, followed by strict asepsis and placement of surgi-
cal elds, with the patient in the supine position at 0° and the shoulders abducted
at 90°, the areola is marked under light tension with at hands.
• Next, the inltration, with a saline solution with adrenaline in a 1:200,000 dilu-
tion, makes at the breast marks. Inltration of the breast base, parallel to the
chest, can be performed.
– Across tension performed by the assistant at the base of the breast, incisions
are made around the areola of triangular shape.
– De-epithelialization around theNACin a triangular designed area, with pres-
ervation of the supercialvascularplexus until approximately 2 cm below
the areola.
– A hook is placed to hold at “A” point.
– With the breast perpendicular to the chest wall, between “B” and “C” points,
we amputate the base of the breast, according to the classic technique of the
upper pedicle ap. In addition, a wedge or keel resection of the central excess
of the mammary gland can be performed.
– We do a medial approximation on the pillars with nylon 2-0 or 3-0 and its
xation to the pectoral fascia. This point will reect the NAC’s projection.
– Pre-modeling of the breast through a suture between “B” and “C” points and
the medial point of the inframammary fold, where we will observe the breast
in a conical shape. This modeling must be reproduced in the contralat-
eral breast.
– Mark the nal positioning of the NAC with areolotome between 5.5 and 7
cmabove the IMF or where the apex of the cone is.
– NAC nal position is handled asadirect transposition,withdermoglandular
aps (monopediculate or bipedicled) or evenasa graft.
– Hemostasis is a dynamic process that occurs with each resection to avoid
unnecessary blood loss.
– Place and x the suction drains on the horizontal scar.
– Suture in three planes with inverted knot with 2-0, 3-0, and 4-0 nylon. Suture
the NAC with Gillies stitch with 4-0 nylon and the intradermal closure
with3-0 monocrylsutures.
The dressing is of the closed compressive type, keeping the wound moist with
antibiotic ointments for the rst 48–72 h. Hospital discharge is 24 h.
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R. CavalcantiRibeiro et al.
Postoperative Care Protocol
The patient must follow a relative rest for 30 days, prevent carrying weight, and do
domestic activities and gym activities during this period. From the fourth week
onward, except in situations of complications, a patient is usually waiting to perform activities with moderate intensity, such as walking, and in the period of 60
days, she is released for activities with a load. In addition, the surgical bra should be
routinely used for 30 days and an anti-thrombus socks for 7 days.
In most cases, suction drains are left at the horizontal portion of the Inverted T
pattern scar, and these will remain until drainage is less than 30 ml per breast and
are usually removed between 3 and 5 days postop.
Postoperative lymphatic drainage has a relative indication and brings benets
such as reducingpain, bruising, swelling, and preventingbrosis, but without inuence on the nal result of the surgery.
In addition, antibiotic prophylaxis with rst- or second-generation cephalosporins (cephalexin or cefuroxime) are routinely recommended, plus analgesics and anti inammatory drugs for aminimum of 7 days. Other medications
such as antiemetics and muscle relaxants are prescribed individually. Opioids are
not necessary.
Prophylaxis of thromboembolism follows the recommendations of the Caprini
scale. For allhospitalizedpatients pneumatic compression and early deambulation.
When recommended, low molecular weightheparin 40 mg in a single dose, 12 h
after the start of the procedure. We do not use heparin routinely for a prolonged
period, except for cases of hemophilia or proven diseases.
Outcomes, Prognosis, andComplications
Complications are the same as those that can occur with other mammoplasty techniques. Breast reduction is considered a signicant procedure, as it includes extensive dissections and resections, which increase the number of complications, and
these vary by up to 10%.
Among the immediate complications, we can highlight seroma and hematoma,
which are usually managed with immediate evacuation. Skin necrosis—mainly at
the junction of the inverted T or NAC—is generally attributed to aggressive surgical
manipulations and consequently poor perfusion of the aps, further aggravated by
postoperative edema and very tight sutures.
Signs of suffering from NAC are associated with ischemia due to excessive tension or venous congestion that leads to a change in perfusion, partial or total loss of
this segment. It is important to note that excessive stress relief can be reversed for a
period of 6 h, avoiding this complication.
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Lessfrequently, steatonecrosis occurs due to circulatory disorders of the fat tissue, presenting with phlogistic signs and uctuation and generally requiring drainage, in addition to strict dressing control.
Late complications are usually related to scarring, such as hypertrophy, enlargement, or keloid formation. The formation of epithelial cysts or a change in NAC
sensitivity (hypo- or hyperesthesia) may also occur.
Prevention of complications:
• Use of the proper technique
• Delicacy with tissues during surgery
• Careful hemostasis
• Early drainage in the event of hematoma
• Absence of tension in the sutures
• Compression of scars
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Pros andCons
A versatile technique provides both the correction of hypertrophy and the improvement of ptosis. It serves both young breasts and older patients and has long-lasting
results. The disadvantage is the size of the scar and possible handling to migrate the
NAC, which may demonstrate technical difculties depending on the surgeon’s
experience.
• Systematization of surgery.
• Good symmetry with natural breast shape.
• We can add other techniques such as inferior pedicle aps to project the upper
pole and ared bottom ap.
• Dermoglandular ap to rotate the NAC in severe ptosis.
• Low level of complications.
Marketing Aspects
This technique brings great functional and aesthetic satisfaction to the patients as it
considerably improves pain complaints, poor posture, and above all psychological
aspects, raises their self-condence, and improves their social life.
Chapter 26
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Gynecomasty
LuisFernandezde Córdova andRicardoCavalcantiRibeiro
Abstract Gynecomastia is a common and distressing benign enlargement of the
breasts, affecting from 38% to 64% of the male population worldwide (Fruhstorfer
and Malata, Br J Plast Surg 56:237–246, 2003); the incidence of bilateral gynecomastia also varies in the medical literature. This male thorax deformity of multifactorial etiology in most cases requires surgical treatment, being one of the most
common plastic surgery procedures performed in men (https://www.isaps.org/wp-
content/uploads/2020/12/Global-Survey-2019.pdf). The rst record of this condi-
tion was made by the Egyptians depicting images of King Tutankhamen with
gynecomastia (Daniels and Layer, ANZ J Surg 73:213–216, 2003).
Plastic surgeons as well as clinicians should not underestimate gynecomastia;
although transient and benign by denition, it might have serious psychological
consequences.
Palpable glandular tissue in the male breast presents itself through three peaks in
the age distribution of gynecomastia occurring in neonates, pubertal boys, and
elderly men, aiding also in the differentiation of physiologic or pathologic
gynecomastia.
Keywords Gynecomastia · Pseudogynecomastia · Male thorax · Breast surgery
L. F. de Córdova
Carlos Chagas Institute, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Casa de Portugal, Rio de Janeiro, Brazil
Division of Plastic and Reconstructive Surgery, Global Plastic Surgery State of México,
México, Mexico
R. CavalcantiRibeiro (*)
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_26
397© The Author(s), under exclusive license to Springer Nature
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L. F. de Córdova and R. CavalcantiRibeiro
Introduction
Gynecomastia is a common and distressing benign enlargement of the breasts,
affecting from 38% to 64% of the male population worldwide (Fruhstorfer and
Malata 2003); the incidence of bilateral gynecomastia also varies in the medical
literature. This male thorax deformity of multifactorial etiology in most cases
requires surgical treatment, being one of the most common plastic surgery procedures performed in men (
Global- Survey- 2019.pdf). The rst record of this condition was made by the
Egyptians depicting images of King Tutankhamen with gynecomastia (Daniels and
Layer 2003).
From an aesthetics point of view, the ideal male thorax is at, rm, and muscular.
The pectoralis major forms most of the muscle component of the chest, at against
the rib cage in its superior portion and convex at its inferior margin. The pectoralis
major can be divided into clavicular, sternocostal, and abdominal portions. The convexity of the male chest is also due to a pectoral fat pad underneath the nipples; it is
responsible for lipomastia, which is the enlargement of the male chest neither due
to muscular hypertrophy nor a palpable glandular tissue disk under the nipple.
Palpable glandular tissue in the male breast presents itself through three peaks in
the age distribution of gynecomastia occurring in neonates, pubertal boys, and
elderly men, aiding also in the differentiation of physiologic or pathologic gynecomastia. Clinically, gynecomastia may present as subareolar breast tissue ranging
from 0.5 to greater than 2cm, appearing at least 6 months after the onset of male
secondary characteristics and typically regresses within 1 year. Multiple causes for
pubertal gynecomastia have been suggested such as transient hormonal imbalance
between estrogens and androgens; however, studies (Dunbar etal. 2005; Ersoz etal.
2002; LaFranchi etal. 1975) found conicting results when comparing hormonal
proles between teenagers with and without gynecomastia. Elderly men will often
develop gynecomastia as testosterone levels decline in plasma and peripheral aromatization increases (Table26.1).
https://www.isaps.org/wp- content/uploads/2020/12/
Table 26.1 Etiology of gynecomastia
Physiologic Pathologic Pharmalogic
Neonatal Metabolic disorders* Hormones
Pubertal Endocrine disorders+ Psychoactive agentes
Elderly Acquired hypogonadal states Cardiovascular drugs
Congenital hypogonadal states Antiandrogens
Hyperestrogenism Cancer chemotherapeutics
*
Alcoholic cirrhosis, adrenal tumors, refeeding after a starvations state
+
Thyroid disorders, adenal cortical hyperplasia
Antibiotics
Antiulcer medications
Drugs of abuse
Metoclopramide
Antiretrovirals
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