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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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H. Nurein
a
b
Photo 22.6 Stab incision
Photo 22.7 Inltration of tumescent solution
Photo 22.8 Tumescent anaesthesia on one side
Photo 22.9 Emulsication of fat using the VASER technique
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Photo 22.10 Liposuction of the fat deposit of lateral chest
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Photo 22.11 Periareolar gland excision after denition liposuction
a
Photo 22.12 (a, b) Adequate lighting and instrumentation are essential for safer gynaecomastia surgery
An inltrate to aspirate ratio of 2–3:1 is achieved with this
method of anaesthesia.
Energy-based liposuction with power-assisted or
ultrasound- assisted (VASER, LySonics, Mentor, etc.) is
widely recognized as adjunctive. I use VASER system for
ultrasound generation at a setting of 70% using a single ring
probe either in continuous or VASER mode to emulsify the
fat rst before aspiration. This enables us to achieve less side
effects of liposuction such as swelling, bleeding, bruising,
pain and with a shorter downtime for recovery.
For most cases where skin excision is not needed, an inferior periareolar incision can be used for both gland excision
(Photos 22.11 and 22.13) and liposuction.
Appropriate retraction (instrumentation) and lighting are
of utmost importance for good visualization in order to per-
b
form safe surgery through relatively small incisions (Photos
22.12 and 22.13) and to avoid emergency extension of the
incision. The surgical approach is stepwise, starting the dissection and gland excision either inferiorly (Photo 22.13) or
superiorly and leaving behind a disc of subareolar tissue that
is crucial to avoid a sunken areola.
We avoid this problem by assessing and reducing the sub-
areolar thickness in a direct and gradual method (Photo
22.15). The glandular tissue can be excised in single or mul-
tiple pieces depending on the difculty of the case and experience of the surgeon (Photo 22.14).
For successful gynaecomastia surgery, it is challenging to
not need a redo or touch up for all cases but with experience,
a surgeon will learn to reduce the rate of under or overresection of glandular tissue (Photo 22.15). Achieving this
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Photo 22.13 Enlarged gland excision safely excised through an inferior hemi periareolar incision. The central images show the jar with lipoaspirate and excised brous tissue
balance also applies to liposuction and skin excision. This
balance is as important to the subareolar tissue in that what is
left behind is thick enough (usually ≤3mm) to give a normal
looking areola that is neither sunken nor too prominent.
Internal space closure or manipulation of subcutaneous fat
may be employed if the risk of cavity deformity is high.
Once liposuction is complete, glandular tissue with or
without skin is excised, any cavity is reduced, a thorough
check for haemostasis is done. The incision is closed by a
double layer method and using a running subcuticular dissolvable stitch for the skin (Photo 22.16).
With development in technology and ever-increasing
experience in liposculpture, gynaecomastia surgery is also
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Most patients with grade 1–3 can achieve a good or a
decent result without the need for skin excision and resultant
permanent scarring but for gynecomastia with associated
severe ptosis (grade III), these skin tightening modalities
usually will not be sufcient and hence a more extensive skin
excision technique may be required.
We invariably use methods described in (Diagrams 22.5,
22.6, 22.7, 22.8, and 22.9) for all our patients who some-
times need crescent nipple lift to correct persistent mild to
moderate sagging (Diagram 22.8) and only advocate use of
more extensive skin excision methods for grade 4 with severe
ptosis (Diagrams 22.9, 22.10, and 22.11).
Photo 22.14 Gland excision from the subareolar attachment
Photo 22.15 Incremental reduction of subareolar disc of tissue
22.5.1 Grade 1. Gynaecomastia Excision
(Gland Only)
Grade 1 gynaecomastia with prominent or puffy nipples is
the most commonly seen grade in younger adults with persistent pubertal gynaecomastia or resulting from anabolic
steroid use. The main goal in these cases is to atten the protrusion and achieve a atter nipple-areola complex and to
allow the areola to retract or subsequently reduce in size.
Adequate tissue width must be left to support the areola skin
due to its tendency to look weak and sunken if the gland is
over resected.
22.5.2 Grade 2. Gynaecomastia Excision
withor Without Liposuction
Grade 2 gynaecomastia patients, in some cases if treated by
gland excision alone, it can leave areas of fat deposit with
central hollowness also known as doughnut (saucer) deformity. This risk can also be reduced by subtle or ne denition liposuction (liposculpture) which can achieve a
better-dened male chest or a more athletic look which is
sometimes the patient’s main wish. Nevertheless, a cautious
approach is necessary when intending to achieve a sculpted
look to avoid irregular ridges and indents. Ultrasoundassisted liposuction is used by the author to reduce this risk.
Debulking liposuction may also be needed if there are large
fat deposits especially on the lateral chest.
Photo 22.16 Subcuticular skin closure
benetting from their use such as achieving relative skin
retraction with ultrasound-assisted liposculpture and radiofrequency skin tightening (Photo 22.17) as a modality used
specically to achieve this goal. Other modalities that are
used for skin tightening include J-plasma, SkinFinity,
Ultherapy, Thermage, and Tripolar.
22.5.3 Grade 3. Gynaecomastia Surgery
withor Without Skin Excision
Grade 3 gynaecomastia patients may be treated by staged
approach (Photo 22.18a–f), if skin excision is avoidable by
initially excising the gland with liposuction and additionally
using a radiofrequency skin tightening modality through the
periareolar incision. A further touch up surgery after
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Photo 22.17 Radiofrequency skin tightening using Bodytite machine
Diagram 22.5 Inferior periareolar skin excision for grade I gynaecomastia
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Diagram 22.6 Liposuction along with Inferior periareolar skin excision for grade II gynaecomastia
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Diagram 22.7 Grade 3 treatment using liposuction with gland and superior elliptical skin excision
Diagram 22.8 Grade 3 treatment using liposuction with gland and circumareolar skin excision
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Diagram 22.9 Description of circumareolar outer incision reduction techniques using the ‘Cartwheel suturing’ technique
Diagram 22.10 Grade 4 Male chest reduction by transverse excision and inferior dermal pedicle method of niple areola translocation
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Diagram 22.11 Grade 4 Male chest reduction using double incision with free nipple graft technique
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a
d
Photo 22.18 (a–f) Grade 3 treatment without skin excision by staged approach showing before surgery (a, d), 6months after surgery (b, e), and
2weeks after further second stage liposuction and skin tightening (c, f)
6 months may be carried out depending on the initially
achieved results. Where the degree of skin excess necessitates excision, a superior elliptical periareolar or circumareolar skin excision may be employed.
For this group of patients, ptosis is of up to grade II or less
severe and so it is appropriate to offer this type of nipple lift. A
surgeon has to assess skin quality as well as excess and breast
size to decide what approach would benet the patient most.
the nipple-areola complex. Therefore, extent of ptosis and
lateral chest wall laxity correction as well as the extent of
scarring and achievable results should be aesthetically
acceptable by the patient; hence adequate counselling is
required. The staged approach as.
recommended by some authors for treatment of severe
gynaecomastia is to avoid extensive skin excision, where in
the rst stage, the excess gland and fat deposit are addressed
cb
fe
(we add skin tightening modality at this stage) and do the
skin excision if required at the second stage after 6months
22.5.4 Grade 4 Treatment withSkin Excision
when the excess skin has been allowed to achieve a degree of
retraction. At this stage, skin excision required may not be as
In our grading system, grade 4 gynaecomastia patients are
the most likely to need skin excision regardless of the breast
size because of excess skin due to severe ptosis (grade III). In
this group of patients, the challenge is to achieve a proportionally at chest contour with the correct repositioning of
extensive (elliptical or circumareolar). However, for some
patients, when adequate skin retraction is not going to be
achieved (grade 4 and some grade 3), breast reduction techniques with skin excision and nipple-areola complex relocation may be the only solution. Some of the methods and
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Photo 22.19 An ellipse of skin sparing the areola is de-epithelialized
incision patterns that can be used to address this are shown in
(Diagrams 22.9, 22.10, and 22.11).
In the transverse incision (inferior dermal pedicle) male
chest reduction technique for excising the gland, an elliptical
skin is de-epithelialized with intact areola leaving an inferior
dermal ap for nipple-areola complex relocation (Photo 22.19).
Closure of the incision results in a transverse scar
(Diagram 22.9) with the impression of a new inframammary
crease. The nipple-areola complex may also be relocated by
using free nipple graft method.
Other mastoplasty patterns that may be used include anchor
or inverted T (Diagram 22.10), and circumvertical or lollipop
pattern not shown. Choice bias should be avoided and options
should be given to patients regardless of surgeon’s preference
and experience to make an informed decision.
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on the lower pole of the breast and more hidden while in
men, with atter outcome, it becomes more visible which is
less favourable. When used in severe gynecomastia reduction, in addition to the multiple scars, there may be wrinkling
or protrusion in patients with signicant excess skin where
residual skin redundancy may still be seen after surgery.
In men, the most commonly used technique for grade 4
gynaecomastia is the Letterman method Diagram 22.10,
where the breast is amputated, and a free nipple-areola graft
harvested from the excised breast is relocated to the new
areola site after de-epithelialization, resulting in a circumareolar scar with single oblique scar simulating the inframammary crease. Despite having a better control on the
placement of the nipple-areola complex and a good survival
rate, hypopigmentation is still an undesirable aesthetic outcome of this technique as well as loss of sensation of the
nipple-areola complex.
The author is of the opinion that the inferior dermal pedicle underlay technique (Diagram 22.10
) with intact nippleareola complex using the Kornstein and Cinelli (1992)
technique leaving only the transverse incision is superior
aesthetically in that the single scar mimics the inframammary fold and the ap used is broad and appropriately thin
(up to 0.5cm thick dermal ap) giving a atter contour of the
nipple-areolar complex on the pectoralis muscle (male gender conforming chest) compared to the other types pedicled
techniques which tend to leave more residual tissue and
additional scars and more prone to result in inadequate skin
reduction and or fuller breasts. It also avoids free nippleareola graft drawbacks, since the inferior pedicle bears the
nipple-areola complex which reduces the risk of compromised neurovascular supply (Kornstein and Cinelli 1992).
22.6 Pedicled Gynaecomastia Reduction
Surgery
Many other methods have been described for the treatment
of severe gynaecomastia requiring skin excision. In these
patients, glandular excision through the standard periareolar
incision with liposuction and/or skin tightening techniques is
not adequate to address the excess laxity. The extent of surgery depends on patient’s presentation and choice.
In the past, male breast reduction techniques were based
on the female breast reduction methods. In the female
patient, they have different aesthetic intentions in comparison to the desires of the male patient. In females, the pedicle
methods of breast reduction respect and apply the vascular
anatomy for survival of the nipple-areola complex and the
remnant tissue to give the female shape that is desired.
However, the use of such techniques such as anchor type
incision as in Diagram 22.11 when used for male breast
reduction has drawbacks of residual fullness and more extent
of scarring. In females the vertical scar is less obvious as it is
Photo 22.20 The raised superior ap goes over the xated inferior
dermal ap
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Photo 22.21 New areola position after establishing symmetry, good
reduction, and adequate closure
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Closure is multi-layered after initial approximation with
temporary clips or staples and excising skin only after
achieving desired reduction (Photo 22.20).
It may also mean that in severe skin laxity (grade 4 gynaecomastia) or after massive weight loss, in addition to skin
excision for gynaecomastia reduction, the patient may also
need other body contouring procedures such as to combine
with brachioplasty, abdominoplasty, or extend posteriorly to
a body lift to achieve contour harmony.
These patients may have thin skin with long nipple-areola
complex to inframammary fold distance with increased risk
of circulation compromise of the nipple-areolar complex. It
is important also to accept that a dermal ap or pedicled
reduction may not always be the right approach or succeed
and hence excision with free nipple graft may be the better
option for better nipple-areola survival in these cases.
However, where the nipple areola complex to inframammary
fold distance is long (>10 cm), the author prefers double
incision with free nipple graft method.
In the inferior dermal pedicle method, the procedure is
started by de-epithelialization of the inferior ellipse bearing
the nipple-areola complex (Photo 22.19).
The inferior pedicle is then dissected from the gland and
chest wall, after which the breast is excised en bloc leaving
adequate subareolar tissue width.
The superior ap is then raised at a thickness of 1–2cm
(Photo 22.20) and broadly adequate to allow the placement
of the inferior pedicle underneath which secured by stitching
to the pectoralis fascia.
A full thickness disc of skin is excised from the superior
skin ap for the new nipple-areola position (Photo 22.21).
The nipple-areolar complex is then sutured to the new location through a matched buttonhole or disc of skin as
described which also results in reduced risk of periareolar
scar thickening as there is minimal tension during closure.
Nevertheless, in rare cases, kinking of the ap if not foreseen or avoided can cause vascular compromise. This risk is
reduced by suturing and xing the inferior dermal ap to the
pectoralis fascia superiorly. A drain may be placed under the
dermal ap only after the inferior ap is deepithelialized
and tucked under the superior ap and sutured. Once the
nipple-areola complex is placed into the new desired position the buttonhole is created with the aim of achieving symmetry on the contralateral side. Many authors describe ways
to achieve this by considering the size of the areola, the
nipple-areola to inframammary crease distance as well as
the distance to the sternal notch and nipple to nipple distance. This should be individual based, and the aesthetic eye
of the surgeon is sometimes more important than the measurements as not all patients have the same body size or
symmetrical halves.
22.7 Recovery andComplications
Gynaecomastia surgery complications include hematoma,
which seems to be the most common complication, contour
irregularity, over-resection, under-resection, seroma, and
unsightly scarring. In skin excision surgery an initial I.V.
dose of antibiotic is given in addition to triple antibiotic bolster dressing for when free nipple graft method is used. In
grade 4 with skin excision adequate follow-up and preoperative counselling helps an easier recover.
We use double compression during stage 1 of recovery in
the rst 72h. An elastic bandage is applied over the chest in
addition to the surgical compression vest. This reduces the
risk of uid collection, such as seroma and hematoma, and
helps to achieve the desired contoured results. After this
period, the patient continues to wear only the surgical compression vest continuously for a minimum of 2weeks. The
total duration of compression depends on what procedures
were performed. We advise the use of compression vest for
at least 2 months for the severe grade groups where skin
retraction and support are needed most.
Non-resistance training can be resumed 2weeks after surgery, and the majority of patients can resume strength training at 4 weeks. We recommend a longer period for the
resumption of contact or high impact sport.
22.7.1 Examples ofResults (Photos 22.22, 22.23,
22.24, 22.25
Pearls and Pitfalls
Gynaecomastia surgery can be advantageous for both the
patient and the surgeon.
For most patients, this is a life-changing procedure and,
in an age where appearance can have a signicant impact
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