Surgical correction of gynecomastia in thin patients

Comprehensive aesthetic corrections of gynecomastia using the reproducible safe and minimally invasive surgical strategy

BACKGROUND

Minimally invasive access and fast recovery are trends of gynecomastia surgery. We placed great importance on liposuction and modified original pull-through technique. The purpose of this study was to present a refined surgical strategy for gynecomastia in grade I and II.

METHODS

The refined strategy embraced enhanced liposuction to remove the intraglandular fat sufficiently, followed by open resection of gland using the pull-through and bottom-up technique with adjuvant liposuction in the end. Surgical data were recorded and satisfactory questionnaires with 5-point scales were administered during follow-up.

RESULTS

Between January 2017 and May 2022, 165 patients underwent enhanced liposuction combined with the pull-through and bottom-up technique for gland excision. Age ranged from 12 to 56 years. The median length of surgery was 100 min. A median of 300 ml of fat was aspirated and a median of 20.8 g of gland was excised. Seventy-seven patients (46.7%) responded the questionnaires at least 6 months postoperatively, and the average overall satisfaction was 4.68 ± 0.52 points. Thirteen sides of breasts developed complications with a rate of 4.0%.

CONCLUSION

Enhanced liposuction combined with pull-through and bottom-up technique proved effective to treat grade I and II gynecomastia with minimal scarring and high satisfaction. The refined strategy was simple and safe, and would obtain optimal outcomes even for inexperienced surgeons.

Is Breast Magnetic Resonance Imaging Superior to Sonography in Gynecomastia Evaluation and Surgery Planning

BACKGROUND

Data on the value of magnetic resonance imaging (MRI) in the preoperative evaluation and surgery planning of gynecomastia are limited. The purpose of this study is to reveal MRI features and categories of gynecomastia and compare surgical outcomes following MRI and sonography as well as their diagnostic accuracy.

METHODS

The area of the gland and the whole breast on the transverse plane via nipple of MRI were measured to calculate the ratio between them. Areola, mass and branch patterns were categorized to represent three different gynecomastia type on MRI. 183 patients were included, with 38 in MRI group and 145 in sonography group. Diagnostic accuracy was assessed by the level of agreement between preoperative imaging findings and intraoperative observations. Surgical data, patients' satisfaction and complications were compared between the two groups.

RESULTS

MRI in 75 gynecomastic breasts demonstrated the average ratio of the gland to the whole breast was 10.6%±13.3%. The most common MRI categories were branch patterns (45.3%). The diagnostic concordance rate of MRI was higher than sonography (100% vs. 86.8%, p = 0.001). Among those junior surgeons, the length of surgery was reduced in MRI group (100 min vs. 115 min, p = 0.048). There was no difference in terms of patient's satisfaction and complication rate between MRI and sonography.

CONCLUSION

MRI was superior to sonography in diagnostic accuracy to assess the tissue components of gynecomastia and provided informative guidance especially for junior surgeons. Surgical outcomes were comparable regardless of the use of MRI or sonography for evaluation.

LEVEL OF EVIDENCE IV

IThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A New Clinical Classification for Gynecomastia Management and Predictive Outcome

Aim and objectives  The aim of this study is to propose a new clinical classification for gynecomastia management based on our experience. Introduction  We believe that the prevalent gynecomastia classifications need to be more detailed. Several key aspects that we noticed have either been incompletely represented or not mentioned at all, leaving them unclassified. Materials and Methods  This study was conducted at the authors' center over 24 months from May 2020 to May 2022, and included 1,571 patients who were classified and treated as per our new classifications and small iterations were done to strengthen the classification. Results  We were able to better classify our patients and previously unclassified situations. Skin sagging or a potential for skin sagging and puffy nipples were managed better. This classification allowed recommendation of each step of the procedure, resulting in high patient satisfaction, as all problem areas were sorted and outcome that was explained to them preoperatively was clearly visible postoperatively. Conclusion  The new clinical classification for gynecomastia is a simple, clinical, straightforward, comprehensive, grading system, the use of which has helped the authors and the team in achieving precise and predictable results while ensuring patient satisfaction.

Incidence of Complications for Different Approaches in Gynecomastia Correction: A Systematic Review of the Literature

Background

Gynecomastia is nowadays a very common disease, affecting a large cohort of patients with different ages. The aim of this literature review is to assess the incidence of complications with all proposed techniques and for combined procedures versus single approach procedures in gynecomastia correction.

Materials and Methods

A systematic review of the literature was performed to identify all reported techniques for gynecomastia correction covering a period from January 1, 1987 to November 1, 2020. For all selected papers, demographic data, proposed technique, and complications’ incidence have been recorded.

Results

A total number of 3970 results was obtained from database analysis. A final total number of 94 articles was obtained for 7294 patients analyzed. Patients have been divided into three groups: aspiration techniques, consisting in 874 patients (11,98%), surgical excision techniques, consisting in 2764 patients (37,90%), and combined techniques, consisting in 3656 patients (50,12%). Complications have been recorded for all groups, for a total number of 1407, of which 130 among “Aspiration techniques” group (14,87%), 847 among “Surgical excision techniques” group (30,64%), and 430 in “Combined techniques” group (11,76%).

Conclusions

Several techniques have been proposed in the literature to address gynecomastia, with the potential to greatly improve self-confidence and overall appearance of affected patients. The combined use of surgical excision and aspiration techniques seems to reduce the rate of complications compared to surgical excision alone, but the lack of unique classification and the presence of several surgical techniques still represents a bias in the literature review.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Liposuction Assisted Gynecomastia Surgery With Minimal Periareolar Incision: a Systematic Review

BACKGROUND

This study aims to analyse the quality of studies and revisit the liposuction assisted gynecomastia surgery performed through minimal incision.

METHODS

A systematic review, based on the literature in the PubMed, Scopus, Science Direct, and Cochrane, to the treatment of Simon's grade I and II gynecomastia was conducted using keywords "gynecomastia" AND "liposuction." Study appraisal was performed using MINORS to assess the methodological quality of the paper.

RESULTS

There were 18 out of 415 studies eligible to review. A total of 244 out of 1628 patients with the average age of 23.13 years. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved quality of life in terms of satisfaction after surgery. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Complication rates were inconsistent throughout the studies, ranging from 0.06 to 26.67%. Reoperation rate of liposuction-assisted surgery is between 0.6 and 25%. There are only two studies of a total 25 patients that are considered as good in quality. The two studies, which discuss laser-assisted liposuction technique, show minor complication of seroma in two patients. While one study shows high patient's satisfaction rate; both studies indicate high surgeon's satisfaction rate.

CONCLUSION

Small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in quality of life. However, only 2 studies reported good quality methods of non-randomized case series urging for a better quality of studies in the future.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Minimal Incision Technique for Gynecomastia

Background:

Gynecomastia or enlargement of the male breasts affects a large proportion of males, with most patients requiring surgical intervention as only a few lesions are actually resolved with medical management alone. Surgery cures the patients of their problems, albeit, at the cost of scarring and other cosmetic problems in some patients. Therefore, refinements in the surgical process are still ongoing so as to provide the best results with minimal scarring.

Aims and Objectives:

To find out the feasibility of a minimal incision technique for glandular excision after liposuction in patients with gynecomastia so as to decrease the final visible scars in these patients.

Materials and Methods:

From July 2018 to September 2018, eight patients were subjected to gynecomastia surgery employing liposuction and gland removal through a single transverse 5–7 mm incision in the nipple. All the patients subjected to this technique had Grade IIa gynecomastia as per Simon’s scale. The Global Aesthetic Improvement Scale, comprising a 5-point Likert scale, was employed to find out the satisfaction level of the patients 12 months after surgery; this level was compared with that of a similar population of patients being operated on by employing liposuction and subcutaneous mastectomy by the periareolar technique.

Results:

The mean operating time was 110 min, and there was minimal bleeding during the procedure. Complications were also negligible, and all patients achieved an excellent chest contour with restoration of protective nipple sensation when evaluated 12 months after surgery. The difference in mean between the 2 patient groups was 0.125 with a p-value of 0.64.

Conclusions:

Glandular excision through a single transverse incision made through the nipple is a safe approach in selected patients and it produces excellent cosmetic outcomes. However, it requires patience on the part of the surgeon to achieve the desired goals of the surgery.

The round-the-clock technique for correction of gynecomastia

Background

Gynecomastia is a common condition that can cause severe emotional and physical distress in both young and older men. Patients in whom symptomatic recalcitrant gynecomastia persists for a long time are potential candidates for surgery.

Methods

From January 2014 to January 2016, 15 patients underwent correction of gynecomastia through a single 3-mm incision at our institution. Only patients with true gynecomastia underwent surgery with this new technique. Through the small incision, sharp dissection was performed in a clockwise and counterclockwise direction describing two half-circles. Health-related quality of life and aesthetic outcomes were evaluated using a modified version of the Breast Evaluation Questionnaire (BEQ).

Results

The patients’ average age was 23.5 years (range, 18–28 years), and their average body mass index was 23.2 kg/m² (range, 19.2–25.3 kg/m²). One case was unilateral and 14 cases were bilateral. The weight of glandular tissue resected from each breast ranged from 80 to 170 g. No excess skin was excised. Bleeding was minimal. The mean operating time was 25 minutes (range, 21–40 minutes). No complications were recorded. All lesions were histologically benign. The patients’ average score was 3.5 (on a 5-point Likert scale) in all domains of the BEQ for themselves and their partners.

Conclusions

In this study, we demonstrated the safety and reliability of a new technique that allows mastectomy through an imperceptible 3-mm incision. We obtained high patient satisfaction scores using our surgical technique, and patients reported considerable improvement in their social, physical, and psychological well-being after surgery.

A journey through liposuction and liposculture: Review

INTRODUCTION

Nowadays, liposuction is the most frequently performed aesthetic surgery procedure in Western Countries. This technique has had rapid development since the 1970s, when it was experimented for the first time by A. and G. Fischer. It is currently widely used in clinical practice for many different situations in aesthetic, reconstructive and functional fields.

MATERIALS AND METHODS

This review aims to describe the historical evolution of liposuction by analyzing the transformation of the method in function of the introduction of innovative ideas or instruments. We have also focused on reporting the major clinical applications of this surgical technique, applicable to almost the entire body surface. We finally analyzed the complications, both major and minor, associated with this surgical technique.

RESULTS

Liposuction is mainly used to correct deep and superficial fat accumulations and remodel the body contour. It has become an essential complementary technique to enhance the aesthetic result of many other aesthetic procedures such as reduction mammoplasty, abdominoplasty, brachioplasty, thigh lift and post bariatric body contouring. However, it can be largely used for the treatment of innumerable pathologies in reconstructive surgery such as lipomas, lipedema, lipodystrophies, pneudogynecomastia and gynecomastia, macromastia e gigantomastia, lymphedema and many others. The complication rate is very low, especially when compared with conventional excisional surgery and the major, complications are generally associated with improper performance of the technique and poor patient management before and after surgery.

CONCLUSION

Liposuction is a safe, simple and effective method of body contouring. It has enormous potential for its application in ablative and reconstructive surgery, far from the most common aesthetic processes with a very low complication rate.

Is the transposition of the nipple-areolar complex necessary in Simon grade 2b gynecomastia operations using suction-assisted liposuction?

OBJECTIVE

The aim of this study was to assess the efficacy of suction-assisted liposuction (SAL) in Simon grade 2b gynecomastia and its effect on sternal notch to nipple areola (SNN) distance.

METHODS

A retrospective analysis was performed on 21 patients with grade 2b gynecomastia who underwent SAL. Preoperative and postoperative SNN distances of the patients were measured, the results were analysed using a Mann-Whitney U test and a p-value <.05 was accepted as statistically significant. Aesthetic results were evaluated by the surgical team considering five criteria: breast size, breast shape, nipple-areolar complex positioning, scarring, and skin tightness of the breast envelope. A 10-point Likert scale was used to assess patient satisfaction with SAL surgery.

RESULTS

All of the patients were followed up for an average period of 17.8 months (range = 12-28 months). The mean amount of lipoaspirate was 232 mL per breast (range = 190-310 mL). The mean preoperative SNN distance was 22.3 cm (range = 20-23.5 cm), whereas postoperative was 21.3 cm (range = 19.2-22.8 cm); the difference was statistically significant (p < .05). There was one case of nipple areola necrosis, three hypoesthesia, five persistent pains, and four slight buttonhole deformities. The aesthetic result was evaluated as very good by the surgical team, and the overall patient satisfaction rate in terms of breast shape and volume was 92%.

CONCLUSIONS

It was concluded that SAL provides a good aesthetic outcome in patients with Simon grade 2b gynecomastia and shortens the SNN distance by 1 cm, but further clinical studies are required to support this conclusion.

No-Drain Single Incision Liposuction Pull-Through Technique for Gynecomastia

BACKGROUND

Several different methods have been proposed for treatment of gynecomastia, depending on the amount of breast enlargement and skin redundancy. The liposuction pull-through technique has been proposed as an efficacious treatment for many gynecomastia cases. This work aims to study the outcome of this technique when applied as an outpatient procedure, without the use of drains and through a single incision.

METHODS

Fifty-two patients with bilateral gynecomastia without significant skin excess were included in this study. The liposuction pull-through technique was performed through a single incision just above the inframammary fold and without the use of drains. Patients were followed up for 6 months.

RESULTS

The proposed technique was able to treat the gynecomastia in all patients, with a revision rate of 1.9% to remove residual glandular tissues. There were no seromas, hematomas, nipple distortion, permanent affection of nipple sensation or wound healing problems.

CONCLUSION

The liposuction pull-through technique is an effective treatment for gynecomastia without significant skin redundancy. It combines the benefits of the direct excision of glandular tissues, with the minimally invasive nature of liposuction. Performing the procedure through a single incision without the use of drains and without general anesthesia is a safe alternative.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Functional and Therapeutic Indications of Liposuction: Personal Experience and Review of the Literature

Liposuction is the most common cosmetic surgical procedure worldwide. It has evolved from being designed primarily for body contouring to becoming essential adjunct to various other aesthetic procedures, greatly enhancing their outcome. Despite its hard clear differentiation between an aesthetic and therapeutic indication for some pathologic conditions, liposuction has been increasingly applied to a gamut of disorders as a therapeutic tool or to improve function. In fact, liposuction has ceased to define a specific procedure and became synonymous to a surgical technique or tool same as the surgical knife, laser, electrocautery, suture material, or even wound-dressing products. At present, there seems to be an enormous potential for the application of the basic liposuction technique in ablative and reconstructive surgery outside the realm of purely aesthetic procedures. The present review contemplates the various nonaesthetic applications of liposuction, displaying the enormous potentials of what should be considered a basic surgical technique rather than a specific aesthetic procedure. Implications of this new definition of liposuction should induce third-party public payers and insurance companies to reconsider their remuneration and reimbursement policies.

[Surgical therapy of gynecomastia]

Nowadays surgical intervention is an essential part of the treatment of idiopathic gynecomastia. Choosing the right method is crucial and is based on the current status in the clinical and histological evaluation. Before finalizing the process of choosing a specific method a prior interdisciplinary evaluation of the patient is necessary to ascertain clear indications for a surgical intervention. Liposuction is one of the methods which have become popular in recent years. The advantages are the possible combination with traditional techniques, such as subcutaneous mastectomy or periareolar mastopexy. The main indication is for gynecomastia stage IIa/b and is justifiable due to the reduction in surgical complications and scarring. Furthermore this technique provides an excellent aesthetical outcome for the patient. A total of 162 patients suffering from gynecomastia stages I-III (according to Simon) were surgically treated between 2000 and 2010 and these cases were retrospectively evaluated. The results showed a decline in the use of a T-shaped incision in combination with subcutaneous mastectomy with periareolar tightening compared to an increase in the use of subcutaneous mastectomy in combination with liposuction. The excised tissue should always be sent for histological examination to make sure no malignant cells were present.