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Plastic surgeons as well as clinicians should not underestimate gynecomastia;
although transient and benign by denition, it might have serious psychological
consequences.
Other disorders that can lead to masses in the male breast include the following:
lipomas, hemangiomas, neurobromas, lymphangiomas, dermoid cysts, and breast
carcinoma distinguished from true gynecomastia due to eccentric breast enlargement.
399
Diagnosis/Patient Presentation
Several classications exist for gynecomastia (Rohrich etal. 2003) considering different parameters such as degree of ptosis, type of tissue, size, skin redundancy,
NAC’s position, neither of which is universally accepted nor applicable to all cases.
The lack of consensus in the classication of this condition limits the prospective
comparison of successful treatment outcomes as well as the existence of an effective
treatment algorithm for either medical or surgical treatment.
History and physical examination are the basis for the diagnosis of gynecomastia. Physicians must inquire about the duration of symptoms, if any, and presence of
nipple discharge, skin changes, rm masses, presence of testicular masses, review
patient’s prescription and OTC medications as well as the use of alcohol and/or
illicit recreational drugs.
Physical examination requires palpation of the breast tissue with assessment of
consistency and symmetry.
Ultrasound is the imaging modality of choice for diagnosing gynecomastia by
revealing hyperechoic broglandular tissue. A mammogram may be needed to
exclude breast cancer. Other tests like chest X-rays, computerized tomography (CT)
scans, and magnetic resonance imaging (MRI) scans may be recommended if
tumors and pathologies of other organs are suspected to be the cause behind
gynecomastia.
Grade IGynecomastia
Grade I gynecomastia presents as a glandular enlargement with elastic skin and no
inframammary fold, therefore liposuction is not required. The surgical approach
recommended is the following: minimally invasive adenectomy through a semicircular periareolar incision followed by xation of the NAC dermis to the fascia of the
pectoralis major and either vertical mattress suture (Allgöwer type) or continuous
intracutaneous suture (Fig.26.1).
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Fig. 26.1 Grade I gynecomastia: Before and after pictures (10 days Post Op). Technique used:
simple adenectomy
L. F. de Córdova and R. CavalcantiRibeiro
Grade II Gynecomastia
Grade II gynecomastia is characterized by moderate hypertrophy of the structural
components of the breast, glandular and fat tissue, (250–500 g). No excess skin is
present and an inframmary fold appears.Surgery must act on both components,
glandular and adipose tissue, ensuring that the skin loses the memory of the neoinframammary fold. There is a rst phase of vacuum- or power-assisted liposuction
followed by minimally invasive adenectomy by means of a semicircular periareolar,
intra-areolar, endoscopic, or pull-through incision.
Grade III Gynecomastia
Grade III gynecomastia (>500 g of breast tissue) presents excess adipose tissue,
skin redundancy, inframammary fold, and grade II/III ptosis; this group can include
male tuberous breast. Generally, skin sparing techniques doesn’t sufce to offer a
satisfying attening of the thorax.
The surgery begins with liposuction to address the adipose tissue component of
the gynecomastia followed by adenectomy. After the adenectomy is performed,
periareolar deepithelialization takes place for NAC repositioning as well as reducing the areolar diameter. Always consider the contralateral side for symmetry and
the reference canons for the male thorax. Closure carried out by round-block suturing and either vertical mattress suture (Allgöwer type) or continuous intracutaneous suture.
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401
Pseudogynecomastia
Pseudogynecomastia (Fig.26.2) patients present cutaneous and fat excess with different grades of ptosis, and lateral chest roll may or may not be present. Generally,
these patients went through a massive weight loss. Surgical treatment will leave
residual scars since the focal point of the treatment is skin resection by means of
reduction mastoplasty. The magnitude of skin and fat excision is determined by
push, grasp, and pinch tests after establishing a reasonable and stable weight.
Multiple techniques have been described for the treatment of pseudogynecomastia. Nowadays, the development of new techniques, focusing on aesthetic surgery
and female breast surgery, makes it possible to solve severe cases of gynecomastia,
such as the boomerang pattern correction of gynecomastia, which allows attening
of the torso from the axilla to the redundant skin around the areola. Renement of
the inferior pedicle may be achieved through vacuum- and/or power-assisted
liposuction.
Fig. 26.2 Before and after pictures of pseudogynecomastia after liposuction
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L. F. de Córdova and R. CavalcantiRibeiro
Treatment/Surgical Technique
Medical therapy, is described in the literature (Williams 1979; Andersen and Gram
1982) as most effective during the proliferation phase. Proliferation phase is charac-
terized histologically by presenting ductal proliferation with epithelial hyperplasia,
an increase in the stromal and periductal connective tissue, and an increase in vascularity and periductal edema.The end of the proliferation phase is dened by stromal hyalinization, dilation of the ducts, and a marked reduction in epithelial
proliferation after a year of onset. The brotic tissue does not respond to medical
therapies. If a trial period of medical therapy (danazol, clomiphene, testolactone,
tamoxifen) is reported unsuccessful or if gynecomastia has been present for more
than a year or if the etiology is not endocrine or drug related, the accepted standard
treatment is the surgical removal of glandular tissue.
The objectives of the surgical treatment of gynecomastia are elimination of the
inframammary fold and attening of the male thoracic region, repositioning of the
NAC, and removal of redundant skin. At least 25 surgical techniques can be traced
in the literature.
The sequence of gynecomastia surgical treatment is as follows:
• Markings
• Anesthesia
• Antisepsis
• Inltration of anesthetic-vasoconstricting solution
• Liposuction
• Minimally invasive adenectomy
• Correct positioning of the NAC (if applicable)
• Excision of redundant skin and fat (if applicable)
• Dressing
Markings in the sitting position using the aesthetic unit denitions of the male
chest proposed by Caridi, R. (Fig.26.1) and using anatomical references as follows:
anterior median line, right and left midclavicular lines, right and left anterior and
midaxillary lines, sternal notch, and NAC (Fig.26.2).
Following anesthesia with the patient in the supine position, antisepsis rst with
chlorhexidine 2% with the sterile technique is performed. The next step is a new
degermation of the area with 0.2% aqueous chlorhexidine solution, carried out by
the surgical assistant, already duly attired.
The next step is the placement of sterile surgical drapes. The incisions are made,
after inltration of 0.5ml of lidocaine (2%) with epinephrine with a surgical blade
#11 with a mean longitude of 0.5cm. In our practice, we perform the inltration
process using 60 cc syringes in a fan-shaped pattern monitoring skin turgor by continual palpation. After a 20min window for the vasoconstrictor effect to begin,
liposuction may begin.
Once we had achieved satisfactory attening of the chest, by means of a semicircular intra-areolar incision, the adenectomy is performed. Fixation of the NAC
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403
dermis to the fascia of the pectoralis major followed by either vertical mattress
suture (Allgöwer type) or continuous intracutaneous suture ends the surgery.
Massive Weight Loss Patient
Boomerang Pattern Correction
Boomerang pattern correction proposed by Hurwitz refers to the right angle elliptical skin excisions that drape each NAC removing redundant skin in both vertical
and horizontal planes and correcting nipple position.
Postoperative Care Protocol
To achieve better results, complications must be minimized and NAC vascularization should be frequently monitored. Surgical vacuum drains are not placed routinely, unless otherwise indicated. A compression garment is placed at the conclusion
of the surgery and maintained for 4–6 weeks.
References
Fruhstorfer BH, Malata CM.A systematic approach to the surgical treatment of gynaecomastia.
Br J Plast Surg 2003;56:237–246
Daniels IR, Layer GT.How should gynaecomastia be managed? ANZ J Surg 2003; 73:213–216.
Dunbar B, Dundar N, Ecri T, Bober E, Büyükqebiz A.Leptin levels in boys with pubertal gyneco-
mastia. J Pediatr Endocrinol Metab 2005; 18:929–93
Ersoz H, Önde ME, Terekeci H, etal. Causes of gynaecomastia in young adult males and factors
associated with idiopathic gynaecomastia. Int J Androl 2002; 25:312–316.
LaFranchi SH, Parlow AF, Lippe BM, etal. Pubertal gynecomastia and transient elevation of
serum estradiol level. Am J Dis Child 1975; 129: 927–931.
Rohrich, R., Ha, R., Kenkel, J., and Adams, W.P., Jr. Classications and management of gyneco-
mastia: dening the role of ultrasound-assisted liposuction. Plast Reconstr Surg 111: 909, 2003.
Williams MJ.Gynecomastia as a physical nding in normal men. J Clin Endocrinol Metab 1979;
48: 338-40
Andersen JA, Gram JB. Male breast at autopsy. Acta Pathol Microbiol Immunol Scand
1982; 90:91-7
Chapter 27
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Importance ofMastoplasty Combined
withAbdominoplasty Concerning Body
Contouring
PauloRobertoBecker-Amaral, LeonardoPossamai,
andLucianaCarvalhoda Cunha
Abstract In this chapter, we discuss patient evaluation, key safety points, useful
techniques, and how to apply them. Data from the literature on complications highlight the need to carefully select patients, limit the duration and extent of surgery,
and reduce the risk of adverse events via supportive measures and medication. A
vigilant surgeon is a safe surgeon.
Introduction
Women seek combined liposuction, abdominoplasty, and mammoplasty when their
body contours change because of their individual characteristics, pregnancy, lifestyle habits, or age. ISAPS 2019 reported that these surgeries accounted for 35% of
all cosmetic procedures performed worldwide (International Society for Aesthetic
Plastic Surgery 2019). This combination has been termed the “mommy makeover.”
Most patients prefer to undergo all surgeries contemporaneously, as this is practical
and saves time and money. Combined abdominoplasty and breast augmentation was
described by Rao in 1969 (Rao 1969); over the years, great efforts have been made
to prioritize safety and ensure that the results are as good as when the surgeries are
performed separately.
P. R. Becker-Amaral · L. Possamai (*) · L. C. da Cunha
São Paulo, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_27
405© The Author(s), under exclusive license to Springer Nature
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P. R. Becker-Amaral et al.
Discussion
When a woman thinks about herself, a body image is formed internally, and this
process may promote condence or anxiety. Negative changes in female body contours can elicit emotional and behavioral responses that deeply compromise the
quality of life. Patients with many defects attach equal importance to each defect
and request liposuction, abdominoplasty, and mammoplasty to restore their bodies
and, much more importantly, their feelings about themselves. Procedures performed
in isolation may increase the level of dissatisfaction with the remaining defects.
Pitanguy reported this phenomenon in patients exhibiting breast hypertrophy, ptosis, and abdominal accidity who opted for only one correction (Pitanguy and
Ceravolo 1983). By contrast, combined surgery transforms the entire body in one
session. Surgeons must decide whether combined procedures are viable in terms of
safety and the quality of the results.
Preoperative Considerations
Preoperative consultations with the surgeon and anesthesiologist reveal the patient’s
complaints and expectations and allow her to become informed about the diagnosis,
anesthesia, indicated surgeries, limitations, care, risks, scars, and costs. Photographs
are taken to allow her to understand the planned surgery as well as the indications
and limitations. The surgeon dispels myths regarding perfect symmetry, results that
last forever, and scars that disappear.
Patient Selection
From an emotional viewpoint, good surgical candidates are those who evaluate
themselves correctly and who can trust and establish a good relationship with their
doctor. When patients intend to maintain the surgical results via diet and physical
activity, they tend to be more satised in the long term (Rohrich etal. 2004). The
following characteristics are associated with possible dissatisfaction despite a good
anatomical result (Table27.1) (Kaye and Gradinger 1984).
Table 27.1 Warning signs of potentially dissatised patients
Sensitivity to small “defects”
A belief that she is very important. A focus on detail, a demanding attitude, and great
expectations
Depression, insecurity, indecisiveness
At least one prior operation with which she was dissatised
Criticism of colleagues of the surgeon (even good ones)
Development of a poor relationship with the doctor and the team
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Clinical andLaboratory Evaluation
Anamnesis covers clinical conditions, previous and current pathologies, current
medications, allergies, previous surgeries, lifestyle habits (alcohol, tobacco, or drug
use), the gynecological and obstetric history (especially miscarriages), physical
activity, any family history of pathologies, and follow-up by other specialists.
Routine laboratory, cardiology, and other tests are scheduled.
Anatomical Evaluation
The body mass index (BMI), biotype, and muscle and fat masses are evaluated,
particularly fat accumulations that may be removed by surgery. Overweight (BMI
>28 kg/m2) and obese patients tend to have higher rates of complications and poor
results and are at higher risk of dissatisfaction, particularly if any emotional feature
in Table27.1 is present. An abdominal wall examination identies accidity, excess
skin and fat, diastasis of the straight abdominal muscles, any hernias, the position of
the navel, and scars. Ultrasound evaluation of the abdominal wall can identify hernias that contraindicate liposuction. The breasts are evaluated in terms of shape,
volume, sagging, stretch marks, symmetry, and scars. Mammography and breast
ultrasound evaluation are routine, and magnetic resonance imaging is scheduled for
breasts with implants over 10 years of age if rupture is clinically suspected. The
areolae are evaluated in terms of their position, diameter, symmetry, and scars.
The Doctor-Patient Relationship
A good doctor-patient relationship is based on mutual feelings and is of major medical and legal importance. Postoperative problems can be better solved if they are
supported by a good relationship, which should be established before surgery.
Informed Consent Form
The patient acknowledges the receipt of detailed information on the surgery and the
alternatives, limitations, and risks and conrms that she participated in decisionmaking. The physician and patient sign the form, and the medical record contains
data on the planned surgery and its evolution through discussion.
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P. R. Becker-Amaral et al.
Key Security Points
Each doctor creates a personal safety mechanism and uses this to decide whether or
not to perform the three procedures in one session. Pitanguy, in 1983, emphasized
the importance of the surgeon’s knowledge, correct patient evaluation, anesthetist
competence, training of assistants, and an adequate surgical structure (Pitanguy and
Ceravolo 1983). Smoking, obesity, diabetes, and an American Society of
Anesthesiologists (ASA) class >2 may contraindicate the combination of procedures (Winocour etal. 2015). Age seems to be associated with more complications;
the cutoff ranges from 53 to 60 years (Khavanin etal. 2015). The risk of complications is greatly affected by the duration and extent of surgery. A surgical time over
3 h appears to increase the risks of infection, hematoma, seroma, dehiscence, and
necrosis, with a time over 4.5 h increasing these risks threefold (Hardy etal. 2014).
Finally, liposuction should be performed conservatively when combined with
abdominoplasty and mammoplasty. When procedures performed alone and with
liposuction were compared, the latter procedures were associated with more venous
thrombosis, pulmonary complications, and infection (Kaoutzanis 2017). The
American Society of Plastic Surgeons considers that liposuction of over 5L performed alone may trigger complications, although no “safe” volume is dened. If
liposuction is combined with another procedure, an appropriate limit may be 3 L,
depending on the extent of the associated procedure(s). If it is necessary to aspirate
more fat, liposuction should be performed separately (Klein 1993). Table27.2 lists
important safety considerations.
Intraoperative Considerations
The team aims to achieve the optimal result in the shortest possible time. Resections
ensure that sutures bring tissues together without excessive tension. General anesthesia and local inltration (tumescent in liposuction areas) are established (the
Klein technique) (Klein 1993). The rst intravenous antibiotic injection is given at
the time of anesthesia, followed by more injections, depending on the indications
Table 27.2 Key safety points
1. Patient under 60 years of
age, ASA class ≤2, BMI <28
2
kg/m
2. Competent anesthesiologist
3. Limited surgical duration
and extent
4. Adequate surgical structure
5. Good routines for surgeon
and staff
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Table 27.3 Intraoperative
care
Antibiotic prophylaxis
Maintenance of
oxygenation, body
temperature, hydration, and
arterial tension
Intermittent compression of
the lower limbs
Careful patient positioning
and drug. To avoid perioperative hypothermia, dehydration, and hypotension, the
body area exposed should be minimized, a thermal blanket should be used, and
appropriate volumes of warm liquids should be infused intravenously. Intermittent
compression of the lower limbs during surgery (and to the time of hospital discharge) reduces the risk of venous thrombosis. Although the principal surgeon is
ultimately responsible for safety and the outcomes, the presence of two or three
assistant surgeons who work simultaneously in different locations (establishing
hemostasis and placing sutures) would reduce the surgical time; this is very helpful.
Once anesthesia is established, the patient is placed in a prone position to allow
liposuction of the back, anks, and hips. As all areas are accessed simultaneously,
the correction is optimal, especially if asymmetry is in play. As the muscles are
relaxed, the change to the decubitus position must be performed very carefully
(with the help of several people) to avoid orthopedic lesions. A pyramidal mattress
protects the support points and prevents pain, paresthesia, and postoperative skin
lesions. Table27.3 summarizes the main features of care during and immediately
after surgery.
Surgical Sequence
Back, Flank, andThigh Liposuction
The crisscross technique is employed for liposuction, facilitating ap uniformity.
Also, the cannula cannot burn a portal or create a depression around a portal. A
pneumatic vibrolipoaspirator, 3-mm portals, and cannulae with six holes are used.
Lipoabdominoplasty andAbdominoplasty Without Liposuction
The Avelar technique is employed for lipoabdominoplasty. Liposuction is associated with minimal ap detachment (a safety feature), and umbilicoplasty avoids
retraction and external scarring (Fig. 27.1) (Avelar 1978). If aspiration is not
planned, any necessary detachment is performed. Adhesion points are created in the
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