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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
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21 Asymmetric Breasts
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c
d
Fig. 21.15 (a) A submuscular dissection of the pocket was undertaken
through the presumed inframammary incision. Hemostasis was
achieved and a round expander of 425cc capacity was placed in the
pocket which was inated to 200cc (b). The port was placed in the
normal side inframammary area. (c, d) Gradual expansion of the
expander was undertaken to 450cc and then it was left in place for
2months.g. An 18year old lady with Amastia, hypoplastic Pectoralis
major and Latissimus dorsi muscle and short upper limb due to Poland’s
syndrome. There is a deformity of the rib cage too which is depressed
330
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Fig. 21.16 4months after the initial placement of the expander, it was removed (a) and replaced with a 375 gm silicon cohesive gel implant in
the same pocket (b)
M. Thomas and J. D’silva
c
d
Fig. 21.17 12 months after placing the breast implant, NAC reconstruction was planned using a CV ap technique. (a) The ap has been
marked centered on the most prominent part of the breast mound. (b)
The ap has been raised and sutured to create the new nipple. (c, d) The
new NAC 8weeks after the surgery
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21 Asymmetric Breasts
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Fig. 21.18 Marking of the new areola (a), the color is matched with the other side and tattooing is done (b)
331
References
Bavinck JNB, Weaver DD. Subclavian artery supply disruption
sequence: hypothesis of a vascular etiology for Poland, KlippelFeil, and Mobius anomalies. Am J Med Genet. 1986;23:903–18.
Cingel V, Bohac M, Mestanova V, Zabojnikova L, Varga I.Poland syn-
drome: from embryological basis to plastic surgery. Surg Radiol
Anat. 2013;35(8):639–46.
1083- 7. Epub 2013 Feb 19. PMID: 23420344.
da Silva Freitas R, Dall’Ogli o Tolazzi AR, Martins VDM, Knop BA,
Graf RM, Cruz GA.Poland’s syndrome: different clinical presenta-
https://doi.org/10.1007/s00276- 013-
tions and surgical reconstructions in 18 cases. Aesthet Plast Surg.
2007;31(2):140–6.
PMID: 17093886.
Furnham A, Hester C, Weir C.Sex difference in preference for specic
female body shapes. Sex Roles. 1990;22:743–54.
Haller JA Jr, Colombani PM, Miller D, Manson P.Early reconstruction
of Poland_s syndrome using autologous rib grafts combined with
latissimus muscle ap. J Pediatr Surg. 1984;19:423–9.
Reilley AF. Breast asymmetry: classication and management.
Aesthet Surg J. 2006;26(5):596–600. https://doi.org/10.1016/j.
asj.2006.07.006. PMID: 19338948.
https://doi.org/10.1007/s00266- 005- 0140- y.
Gynaecomastia
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HassanNurein
22
Gynaecomastia is the enlargement or proliferation of the male
breast tissue of 2cm or more. Excess fat may be deposited in
and/or around the breast, the appearance of which may also be
determined duration (Alagaratnam 1987 and Cuhaci et al.
2014); diffuse versus discreet on presentation or histologically
orid or brous (Bannayan and Hajdu 1972). This can cause
feminine- looking breasts when severe or cause prominent nipples with or without an increase in the areola diameter when
mild. Pseudo gynaecomastia is the term used when breast
enlargement is caused by fat deposits only. Gynaecomastia is
the most common male breast condition that presents in men of
all ages. It is usually bilateral but may also be unilateral or
asymmetrical at presentation. Prevalence of gynaecomastia has
three peaks: at birth due to maternal oestrogen levels, at puberty
(up to 65% of boys), and with old age (≥65) due to the physiological changes in the oestrogen to androgen ratio. Even
though regression in infant and pubertal gynaecomastia is the
norm, it is persistent in 25% of pubertal cases.
Palpable gynaecomastia has a prevalence of 50–70% of
all male adults. In one autopsy study, it was found in 40–55%
of all men. However, there is still a decit of epidemiological
knowledge and data due to the rise of anabolic steroid use
and environmental xenoestrogens. Gynaecomastia aetiology
is that its appearance is either physiological or pathological
and is potentially multifactorial, but in 25%, it is idiopathic
(Table22.1).
Male breast cancer accounts for 1% of all breast cancers.
The most common type of cancer for both males and females
is invasive ductal carcinoma. There is no increase of cancer
incidence in gynaecomastia patients per se; however, in
Klinefelter’s syndrome, patients have a 60-fold increase of
cancer risk. Hence, this should emphasize the importance of
diagnosis and treatment for this condition.
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978-981-99-3726-4_22.
H. Nurein (*)
Royal College of Surgeons of Edinburgh, London, UK
Table 22.1
cause is unknown
Physiological
1. Neonatal
2. Pubertal
3. Senile
Drugs
1. Anabolic steroids abuse: Oestrogens and antiandrogens
2. Recreational abuse; cannabis, amphetamine, heroine
3. Anti-acids: Omeprazole, cimetidine
4. Chemotherapy drugs: Methotrexate, bleomycin,
5. Others: Certain antifungals (ketoconazole), antihypertensives,
Hypogonadism
1. Primary: Primary testicular failure
2. Secondary: Caused by abnormality with the pituitary or
Systemic illness
1. Alcoholic cirrhosis
2. Chronic kidney insufciency
3. Thyrotoxicosis
Tumours
1. Testicular
2. Bronchogenic
3. Adrenal
Congenital
1. Klinefelter’s syndrome
2. Androgen resistance
3. Increased aromatase activity
Common causes of gynaecomastia, in 25% of all cases the
cyclophosphamide
and antipsychotics
hypothalamus
The most common reason patients seek gynaecomastia
treatment is the physical appearance of feminine like chest
when severe, but often even when only mildly enlarged, it
may cause associated psychological distress. In practice,
there seems to be an increase in the number of patients
requesting surgery because of higher awareness of this condition and earlier visit to the surgeon due to social media effect
and availability of information on treatment options. Treating
gynaecomastia is likely to help address associated problems
of condence, pain, embarrassment, postural problems, and
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_22
333
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H. Nurein
limited clothing choice. We also nd that the psychological
effect of gynaecomastia on a person may not be directly
related to its size or severity but that it affects each individual
differently. Subjectively, this may be dictated by duration of
symptoms, age, cultural background and lifestyle, desire for
athletic contour, or presence of symptoms such as pain.
Therefore, attention to detail during individual patient evaluation is paramount for a good patient selection, and we should
not always dismiss objectively mild cases of affected patients.
A psychological evaluation test may be indicated where
appropriate or body dysmorphia (BDD) is suspected as it is
the second most common cause of BDD in males.
22.1 Pathophysiology andAnatomy
In males, stimulation for excess breast tissue proliferation is
attributed to excess oestrogen or oestrogen-like substances
when its net stimulatory effect is higher than androgenic
inhibition. This imbalance may also be due to increased or
decreased hormonal stimulation due to increased sensitivity
of breast tissue to oestrogen or reduced sensitivity to androgens. Histologically, there is a benign proliferation of breast
ducts. Duct epithelial hyperplasia may be accompanied by
oedema, brosis, and stroma with varying degrees of inammation. In comparison, in female breast tissue, there is differentiation to form lobules (Diagram 22.1) which are very
rarely seen in male breast tissue.
In males, breast tissue is usually at and is dened as normal when it is less than 2cm. when enlarged, it has a head
that lies more medial of the areola, a body that lies directly
under the areola, and a tail that tapers towards the pectoralis
insertion to the axillary crease (Blau et al. 2016).
Gynaecomastia is diagnosed when it is 2cm or larger; however, some authors believe asymptomatic gynaecomastia of
up to 5cm may be a normal physiological variant. In a level
4 study by Yue et al. (2018), the average diameter for the
areola in males was found to be 26.6mm, and for the nipple,
it was 6.9mm. The general description for the ideal placement of nipple-areola complex in men is only a guide as
there are no accepted universal criteria. In gynaecomastia
nipple-areola relocation surgery, one of the positioning guidance is relocating it towards the inferior lateral part of pectoralis major muscle at the level of the intersection with the
midclavicular line. Alternatively, the areola is placed 1 to 2
nger breadths at the intersection of inferolateral pectoralis
muscle border with the breast meridian line.
The areola may be slightly slanted inferiorly and slightly
laterally in athletic body types with well-developed pectoralis muscles.
Circulation and innervation of the breast are shown in
Diagram 22.2.
It is important to have a meticulous approach to haemostasis during surgery and know where the surgeon is most
likely to encounter small bleeders to avoid potential sources
of hematoma. Commonly there is bleeding from the lateral
thoracic artery or its branches, the lateral perforators and the
medial perforators from the internal thoracic artery.
Haematoma in gynaecomastia surgery was found to be the
third most common in all of aesthetic surgery procedures by
(Hood et al. 2018 and Koutzanis et al. 2017)) (Table22.3).
Other authors have shown in studies that male patients
Diagram 22.1 Drawings illustrating the morphological difference between female and male breast tissue with and without gynaecomastia
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Diagram 22.2 Drawing showing anterior male chest wall circulation and innervation
undergoing breast surgery have a signicantly higher risk of
developing hematoma than in female breast surgery. The
vascularity of the skin and the subcutaneous tissue depends
mainly on the subdermal plexus. Nerve supply to the breast
has been controversial but it is mostly agreed to be from lateral and anterior cutaneous branches of the upper intercostal
nerve. There is no unanimity on the innervation of the nipple
and areola as well as on the role of breast innervation by the
Table 22.2 Haematoma incidence in aesthetic surgery
Procedure Haematoma incidence (%)
Lower body lift 4
Thigh lift 2
Male breast surgery 1.8
Abdominoplasty 1.1
Breast augmentation 1.0
Rhytidectomy 1.0
descending branches of supraclavicular nerve.
Nipple sensation loss or abnormality post-surgery is usually transient, and reassurance is all that is needed when a
periareolar approach is used for glandular excision.
specialist when required is the safest approach. Second,
when surgical intervention is being considered, it is
important to assess the main patient concerns and expectations to be able offer the right options, the correct management plan or referral for further evaluation when
22.2 Clinical Evaluation
appropriate. There is no one size t all solution; treatment
should be individualized. History should be thorough and
Like in all other medical conditions, the rst goal should
be to diagnose and treat gynaecomastia by addressing any
treatable causes especially when presenting early and
investigating further where a sinister aetiology is suspected (Table22.2). This means referral to an appropriate
include systems review to check for symptoms of thyroid
problems, alcoholic liver disease, chronic kidney disease,
and testicular mass or abnormality. To help with the dif-
ferential diagnoses investigation as further workup is oth-
erwise rarely necessary. Where indicated, ultrasound or
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mammography may be used to differentiate benign from
malignant tissue.
22.2.1 Physical Examination
A good clinical assessment starts by observing the patient
from the moment they walk into the consultation room. Their
demeanour, body type, posture, and choice of clothing may
show how much the patient has been affected by this
condition.
On inspection, one can elicit chest wall abnormality, presence of asymmetry, skin tone and elasticity, signs of systemic
illness, anabolic steroid abuse as well as the presence of any
red ag signs (Table22.3). These are only some of the factors that may inuence treatment options or limit the
outcome.
On palpation (Photo 22.1), the glandular tissue is either
rubbery soft or rm. The boundaries and extension should be
noted. While palpating, assessment for the presence of axillary
nodules and any satellite lesions or lumps is carried out. In the
physical examination, it is useful to include and document all
the relevant ndings such as the extent of fat deposit (Photo
22.2), degree of breast ptosis, breast size, anterior and lateral
Table 22.3 Red ag signs and symptoms
History and symptoms
Short duration or rapid
progression of symptoms
Strong family history of breast
cancer
Nipple discharge
Klinefelter’s syndrome
Signs
Unilateral enlargement
Firm or xated mass
Nodule
Distorted nipple
Peau d’orange skin, tethering
or irregularity
Skin ulceration
Unexplained weight loss
H. Nurein
Photo 22.2 Pinch test
chest skin folds, or laxity as well as shape and size of the nipple-areola complex. The areola tends to retract to some extent
once the stretching effect of enlarged glandular and fatty tissue
is removed or reduced. Obesity is not an absolute contraindication to gynaecomastia surgery (Rosen et al. 2010).
Systemic examination to include the thyroid, testes (suspect atrophy if less than 2cm), and abdomen (for organomegaly or signs of liver disease) is guided by the information
gathered from thorough checking of the patient.
With clinical ndings noted, good and adequate documentation is paramount, because occasionally, a patient may
note a feature that was present before surgery only during the
follow-up consultation. This may be of issues such as asymmetry or a bid nipple on one side only that, if not documented or photographed earlier, may be perceived by the
patient as a new feature or complication.
In addition to the ndings, as aforementioned, documenting and also understanding the particular or main patient
concerns is crucial before discussing the most suitable and
effective treatment options and management plan.
Photo 22.1 Assessing the consistency of the breast tissue
22.2.2 Diagnostic Evaluation
Biochemical and imaging investigation is not necessary for
the majority of cases (Niewoehner and Nuttal 1984) but may
be indicated where there is suspicion of a systemic illness or
due to other specic clinical ndings (Table22.3). In addition to kidney and liver function tests, hormonal prole testing for gynaecomastia may involve checking for levels of
total testosterone, (SHBG), thyroid function test, luteinizing
hormone (LH), oestradiol, prolactin, alpha fetoprotein, dehydroepiandrosterone (DHEA), and beta hCG levels. If an
abnormal nding is discovered (Table22.4), we recommend
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Table 22.4 Hormonal tests ndings with possible causes
Test result Possible causes
Normal tests Idiopathic
Low testosterone with raised LH Primary testicular failure (hypogonadism), Klinefelter’s
Low testosterone with normal LH Secondary hypogonadism (pituitary or hypothalamic)
Raised testosterone with raised oestradiol Androgen exposure, testicular tumour
Raised oestradiol with raised SHBG Oestrogen exposure
Raised DHEA or raised beta hCG Adrenal or testicular tumour, respectively
High prolactin Pituitary tumour
Diagram 22.3 Simon classication for gynaecomastia
treating the aetiological condition rst or further referral to a
relevant specialist such as an endocrinologist or oncological
breast surgeon for further management before offering any
aesthetic surgery. Use of ultrasound is indicated as part of the
preoperative assessment of gynaecomastia.
22.3 Classication ofGynaecomastia
There are many proposed good clinical classications of
gynaecomastia, but none is ideal. The ideal classication
system is universal, fully encompassing, easy to apply, and
practical. It should address various levels of gland enlargement, ptosis level, fat deposit, skin excess or laxity, nippleareola complex shape, size, and extent of areola
stretching.
Gynaecomastia classication by Simon et al. 1973
(Diagram 22.3) is the most commonly used system.
22.3.1 Simon etal. (1973)
Grade I.Small enlargement with no excess skin
Grade IIA.Moderate enlargement with no excess skin
Grade IIB.Moderate enlargement with excess skin
Grade III.Marked enlargement with excess skin (pendulous female type breast)
22.3.2 Rohrich
Grade I: minimal hypertrophy (< 250 g of breast tissue)
without ptosis:
IA: primarily glandular
IB: primarily brous
Grade II: moderate hypertrophy (200–500g of breast tissue) without ptosis:
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Diagram 22.4 Types and grading of ptosis according to Regnault system showing inframammary fold as the reference point
H. Nurein
IIA: primarily glandular
IIB: primarily brous
Grade III: severe hypertrophy (>500g of breast tissue)
with grade I ptosis glandular or brous
Grade IV: severe hypertrophy with grade II or III ptosis
glandular or brous
22.3.3 Grades ofPtosis According toRegnault
True ptosis
• Grade I. (mild ptosis) Areola is at the level of inframammary crease and above the lower pole contour of the
breast.
• Grade II. (moderate ptosis) Areola is below the inframammary crease and above the lower pole contour of the
breast.
• Grade III. (severe ptosis) Areola is below the inframammary crease and below the lower contour of the breast.
Partial ptosis. (gland ptosis) Areola is above the inframa-
mmary crease but gland is below and has normal breast
shape. This is also known as parenchymal or gland
maldistribution.
Pseudoptosis. (lower pole sagging) Areola is above the
inframammary crease only loose skin is below (Diagram
22.4).
For practical purposes, we have modied Simon et al.
classication to use as 1–4 group grading rather than the
mentioned I, IA, IIB, and III systems. We have made it more
encompassing and hence easier to apply for our documentation, easy to standardize and communicate the severity of the
condition and to incorporate and individualize the different
treatment options at the author’s disposal to give the best
possible aesthetic outcome.
22.3.4 Author’s Classication andTreatment
Algorithm
Grade 1: Small increase in breast tissue size causes nippleareola complex protrusion only with or without areola diameter increase but with no ptosis (nipple-areola complex above
the inframammary fold).
Treatment: Needs gland excision only, but liposuction
may be used for denition only where required.
Grade 2: Moderately enlarged gland with or without fat
deposit and protrusion of breast with no ptosis (nipple-areola
complex above the inframammary fold).
Treatment: Gland excision with or without liposuction for
debulking and/or denition.
Grade 3: Moderately enlarged gland with mild or moderate (grade I and II ptosis of the breast).
Treatment: Gland excision and liposuction with or without superior elliptical or circumareolar skin excision. Skin
tightening modalities and staged approach may be benecial
if used for some patients.
Grade 4: Breast with severe ptosis (grade III ptosis) from
severe skin excess or laxity.
Treatment: Reduction surgery with skin excision requiring nipple-areola complex relocation.
22.4 Treatment Options
Medical treatment is not known to be effective in general for
cases that have persisted for longer than 6months but may be a
good option for treatment of idiopathic gynaecomastia
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Table 22.5 Constituents of author’s preferred tumescent anaesthesia
solutions for gynaecomastia surgery
Klein solution
1000ml Saline
1ml Adrenaline 1:1000
12.5ml 8.4% Sodium
bicarbonate
50ml lidocaine 1%
Hunstad’s formula
1000ml Ringer’s lactate at
38–40°C
1:1000 Adrenaline 1ml
1% Lidocaine 50ml
(Alagaratnam 1987 and Mannu et al. 2018) or for symptoms in
the early stages and shrinking the glandular tissue before
brous changes have occurred. These therapies include antioestrogen medication such as tamoxifen clomiphene, aromatase inhibitors such as anastrozole, letrozole and androgens
such as testosterone and danazol may be tried though the
androgen role may be mostly limited. Other non-surgical
modalities such as cryotherapy may have a benet in the fatty
type but more evidence on their effectiveness and treatment
standardization is needed (Munavalli and Panchaprateep 2015).
Surgery is still the gold standard for the treatment of true
gynaecomastia. Male chest reduction surgery that may
include any of or a combination of liposuction, glandular
excision, skin tightening, skin excision with or without
nipple- areola relocation may be employed. This can be done
under general or local anaesthetic. We prefer tumescent
(Kaoutzanis et al. 2017) local anaesthesia using either Klein
or Hunstad’s solution (Table22.5).
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Photo 22.3 Example of preoperative patient marking (red straight
lines depict tapering), laterally and inferiorly is debulked
22.5 Surgical Preparation andTechnique
Preoperatively, the gland, liposuction area, and the anaesthetic inltration boundaries are marked. Depending on the
denition required, areas of shadowing for the anterior, lateral chest and/or contour lines outline the extent for debulking and tapering needed (Photos 22.3 and 22.4). The author
prefers marking in a standing position. Pinch test of the fat in
the lateral chest wall and a good initial inspection helps
determine the extent of liposuction needed for the anterior
and lateral chest.
The maximum lignocaine dose is calculated by the patient
weight (safe dose <35 mg/kg). In the operating room, we
place the patient with arms abducted in a supine position
(Photo 22.4), draping to expose the marked areas, clavicles,
axillae boundaries, lateral chest, and lower anterior chest in
larger cases. A barrier is preferred for patient protection and
psychological comfort by an anaesthetic assistant, auxiliary
nurse, or theatre staff.
We start with anaesthetic injection (Photo 22.5) of the
skin at entry sites and make stab incisions (Photo 22.6)
before inltrating the subcutaneous layers with tumescent
solution (Photo 22.7).
Photo 22.4 Patient positioning
One must give enough time (7–25min) to see the blanching effect of vasoconstriction caused by adrenaline to take
effect and to allow adequate distribution of the solution to
take place (Photo 22.8).
I prefer to use VASER emulsication (Photo 22.9) of the
fat before suction for easier sculpting, but once tumescent
anaesthesia is achieved, direct liposuction of the intermediate subcutaneous layer using relatively thin cannulas (3mm)
can be performed with or without any energy assistance as
per surgeon’s preference. Starting deeper and progressing
supercially to contour or taper the edges and boundaries,
the extent of which will depend on the surgeon’s experience
in denitive sculpting (Photo 22.10). Thicker cannulas (4
and 5mm) are used for debulking of larger fat deposits.
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