External Quilting: New Technique to Avoid Haematoma in Gynaecomastia Surgery

Available techniques to minimize scars in surgical management of gynecomastia - a comprehensive review

Objective

Gynecomastia and lipomastia are benign proliferations of the male breast affecting 32-65% of men. Numerous surgical procedures often result in stigmatizing scars when it comes to skin resection. The purpose of this study was to review skin-sparing techniques and to describe our skin-sparing approach to treat skin excess using transcutaneous netting.

Materials and Methods

A comprehensive review of the literature was conducted aiming at identifying available techniques to avoid skin resection in gynecomastia or lipomastia patients (Simon's grade IIb and III). Surgical techniques, patient satisfaction, time of follow-up, and complications were assessed.

Results

Seven studies detailed skin retraction techniques, including laser-, ultrasound-, and radiofrequency-assisted liposuction (LAL, UAL, and RAL), microneedling, and nipple-areolar complex (NAC) plaster lifting. All articles provided Simon's grade classification, with most studies including patients with and without skin laxity. Complication rates were low (1.5-10%), and patient satisfaction ranged from 87.5% to 100%.While transcutaneous netting has been reported to reduce hematoma in gynecomastia surgery, no studies specifically examined its role in managing skin redundancy.

Conclusions

Limited data exist on scarless skin retraction techniques for gynecomastia. While LAL, UAL, and RAL show some potential, controlled studies are lacking, and skin resection is often performed for high skin redundancy. We recommend a skin-sparing approach using liposuction and transcutaneous netting for gynecomastia up to Simon's grade III, which allows for skin retraction and NAC fixation. No literature was found assessing the efficacy of transcutaneous netting in promoting skin retraction in gynecomastia.

Evolution of the Surgical Net

The surgical net technique, originally conceptualized to mitigate postoperative hematomas, has evolved into a versatile tool, transcending its initial purpose, and signaling a new era of surgical innovation. This article provides a comprehensive overview of the surgical net's journey from a targeted solution to a multifaceted surgical asset and explores its burgeoning applications, challenges, and future trajectories. Despite early reluctance due to anatomical concerns and unfamiliarity with the novel technique, the surgical net's consistent success in various surgical contexts from facial surgeries to gynecological applications has catalyzed its widespread global adoption. The technique's integration of the progressive tension method and enhanced skin redraping capabilities underscores its contribution to optimal aesthetic outcomes and improved surgical control. Noteworthy is its role in the innovative concept of gliding surgery, marked by procedures like the gliding brow lift and Glidelift, demonstrating the surgical net's adaptability and effectiveness in diverse surgical environments.Contributions from international surgeons have expanded its applications to areas like axillary space obliteration after breast implant, postmastectomy closure, and the management of postpartum hemorrhage, showcasing the surgical net's global impact and universal commitment to optimizing surgical outcomes. The article delves into the anatomical considerations essential for adapting the surgical net technique to various surgical contexts, emphasizing the need for continuous research, clinical trials, and multidisciplinary collaboration to navigate emerging challenges and ensure its sustained efficacy and safety.In conclusion, the article highlights the surgical net technique's unwavering potential for further advancements, greater procedural efficiency, and the continued elevation of patient care standards. The consistent evolution of its applications, paired with a dedicated approach to addressing emergent challenges, reinforces the surgical net's enduring contribution to surgical innovation and global patient welfare.

The GLAND-IQ Technique for Surgical Correction of Moderate to Severe Gynecomastia

Surgical correction of gynecomastia currently ranks in the top five cosmetic procedures performed in men in the United States. Although removal of excess gland is relatively straightforward, the combination of glandular/fatty excess, significant skin redundancy, nipple ptosis, and nipple-areolar complex hypertrophy poses a significant challenge in the male patient desiring inconspicuous scars. The latter renders any form of skin and nipple reduction/elevation using traditional mastopexy patterns or breast amputation with free nipple grafting less favorable due to the surgical stigmata and scars produced with these techniques. To that end, we present our experience treating cases of moderate to severe gynecomastia involving significant skin excess (defined as Simon grade IIb and III) with a technique focused on avoiding visible extra-areolar scars, called the glandular excision, liposuction-assisted, areolar mastopexy for nipple repositioning and skin reduction with internal quilting sutures.

Tranexamic Acid Irrigation in Liposuction: A Double-Blind, Half-Body, Randomized, Placebo-Controlled Trial

BACKGROUND

Hematomas are common complications following plastic and esthetic surgeries. Large and complex hematomas might result in prolonged hospitalization, further interventions, additional expenses, and poor esthetic outcome. Tranexamic acid (TXA), an antifibrinolytic agent, has long been used to reduce blood loss. Its use in the field of plastic surgery has gained popularity recently. Several studies have presented the ability of TXA to reduce blood loss, hematomas, and ecchymoses after liposuctions. However, the proper dose and the route of administration remained controversial.

OBJECTIVE

The objective of the study was to quantify the effect of a low dose of TXA in an irrigation method in reducing hematomas and ecchymoses following liposuction.

METHODS

A prospective randomized controlled trial was conducted. Following liposuction, 400 mg of TXA were administered in an irrigation protocol to one side of the body in each patient, while the other side was administered with saline. The patients were photographed on 1, 2, 4, and 11 post-operative days. Ecchymosis and hematoma were measured and rated.

RESULTS

No statistical difference was observed between the intervention and control groups in terms of RBC in liposuction area (p = 0.11), RBC in lipoaspirate (p = 0.79), bruising size on days 1, 2, 4, and 11 (p = 0.68, 0.21, 0.42, and 0.75), and average ecchymosis score on the same days (p = 0.34, 0.72, 0.09, and 1) CONCLUSIONS: The use of a low-dose TXA irrigation solution did not demonstrate a statistically significant difference in post-operative hematoma formations rates and subsequent ecchymosis size and scale.

LEVEL OF EVIDENCE II

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 .

Hemostatic Net in Facelift Surgery: A 5-Year Single-Surgeon Experience

BACKGROUND

The hemostatic net has been promoted as a safe and effective method to prevent hematoma formation following facelift procedures. To date there is little published evidence to validate the replicability and effectiveness of the technique.

OBJECTIVES

This study presents 2 cohorts of facelift patients from a single surgeon's practice to assess the impact of the hemostatic net on hematoma formation.

METHODS

The records of 304 patients were reviewed on whom the hemostatic net was placed following a facelift between July 2017 and October 2022. Data were collected and assessed for complications and compared with a control group of 359 patients who underwent a facelift procedure without placement of a hemostatic net by the same surgeon between 1999 and 2004.

RESULTS

A total of 663 patients were included. In this retrospective cohort study, analysis of available data showed a significantly reduced hematoma rate of 0.6% in the intervention group compared with 3.9% in the control group (P = .006722).

CONCLUSIONS

The use of the hemostatic net is a safe, reproducible, and effective technique in reducing the risk of hematoma in facelift surgery.

LEVEL OF EVIDENCE: 4

Endoscope-Assisted Minimally Invasive Surgery for the Treatment of Glandular Gynecomastia

BACKGROUND

Gynecomastia (GYN) is the most common benign disease in males. A vacuum-assisted biopsy is a minimally invasive surgical technique for GYN treatment that achieves satisfactory aesthetic results. However, due to the operation under non-direct vision, it is difficult to localize the bleeding points and assess the residual glandular tissue. Endoscopy was applied to observe the operative field after subcutaneous mastectomy. The present study aimed to recommend our initial experience in glandular GYN with endoscope-assisted minimally invasive subcutaneous mastectomy.

METHODS

A total of 34 patients diagnosed with glandular GYN (50 breasts), treated with endoscope-assisted minimally invasive surgery at The First Affiliated Hospital with Nanjing Medical University between June 2018 and June 2020, were enrolled in this study. According to Simon's classification of the breast, 10 was grade I, 25 was grade IIA, and 15 was grade IIB. The characteristics of patients, operative data, postoperative complications, cosmetic outcome, and patient satisfaction were recorded.

RESULTS

Endoscope-assisted minimally invasive mastectomy was performed successfully in all cases. The operative duration of the operation was 55-120 min/side. The total weight of the resected tissue of the 50 breasts was 55-350 g, and the blood loss was 10-105 mL/breast. Endoscopy detected five breasts with bleeding and three with residual glandular during the operation. Postoperative bleeding occurred in 1 breast, subcutaneous seroma in 3 breasts, dysesthesia of the nipple-areolar complex in 2 breasts, and skin redundancy in a bilateral patient. None of the patients experienced severe pain, infection, nipple necrosis, and nipple retraction, a saucer-like deformity. With a median follow-up of 21 months, all patients were satisfied with their cosmetic outcome (100%), and no recurrence occurred.

CONCLUSION

Endoscope-assisted minimally invasive mastectomy could be used as a feasible technique for the treatment of glandular GYN.

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 www.springer.com/00266 .

A Novel Application of the Hemostatic Net in Aesthetic Breast Surgery: A Preliminary Report

BACKGROUND

Obtaining optimum breast aesthetics can be challenging in secondary aesthetic breast surgery, particularly with poor-quality skin, when downsizing implants, and in cases where patients will not accept additional mastopexy scars. Most techniques described in these cases rely on internal suturing and capsulorrhaphy, which can lack precision in tailoring the skin over the internal pocket.

OBJECTIVES

The aim of this study was to present the authors' experience with utilizing the hemostatic net to help address a range of challenging breast cases in their practices.

METHODS

A multicentre retrospective analysis of patients undergoing aesthetic and reconstructive breast surgery between 2019 and 2021 was conducted. A database was established to record patient demographics, indications for surgery, surgical technique, and complications. Following capsulorrhaphy, the hemostatic net was applied in as many rows as required with monofilament sutures and removed 3 to 7 days postoperatively.

RESULTS

Twenty-four women (aged 23-67 years) underwent aesthetic or reconstructive breast surgery with the hemostatic net. This approach optimized stabilization of the inframammary fold and redraping of lax skin or irregularities in the skin envelope. At follow-up review, only 1 instance of the net failing to successfully redrape the skin was seen.

CONCLUSIONS

The application of the hemostatic net is an option for patients who might otherwise require mastopexy but refuse to accept the scars. The technique has now been extended to primary cases where implant malposition or skin tailoring issues are anticipated, thus securing its place as a part of the surgical armamentarium.

LEVEL OF EVIDENCE: 4

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.

Endoscopic subcutaneous mastectomy plus liposuction via a single axillary incision for gynecomastia in Asian patients: A report of 45 cases

BACKGROUND

Most techniques for surgical correction of gynecomastia are performed by anterior and/or lateral chest incisions, showing an "operated" appearance. Our initial experience was introduced in gynecomastia with a combination of endoscopic subcutaneous mastectomy and liposuction via an axillary single incision.

METHODS

Between September 2018 and July 2019, a series of 45 male patients who had Simon grade I or II gynecomastia were enrolled in this study. The demographics, operative data, and postoperative complications were recorded in detail. Four independent observers gave their ratings by assigning scores of 1 to 5 for 6 main aesthetic aspects based on pre and postoperative photographs.

RESULTS

Endoscopic subcutaneous mastectomy combined with liposuction via an axillary single incision was performed successfully in all cases. Mean operative duration was 82.6 minutes for each side (37.5-132.5 minutes). The weight of the resected glandular tissue of the 89 breasts was 26 to 130 g and the aspiration volume was 60 to 700 mL. Three unilateral subcutaneous seromas (3.3%), 5 unilateral hematomas (5.6%), and 1 bilateral minimal skin redundancy (2.2%) were encountered. Observer-reported outcomes indicated that patients with grade Ⅰ gynecomastia had significantly better aesthetic results than those with grade Ⅱb in the aspects of symmetry, shape of nipple, shape of areola, contour regularity, and overall appearance (P < .001). Patients with grade Ⅱa gynecomastia also witnessed better improvement than grade Ⅱb in shape of nipple, contour regularity, and overall appearance (P < .05).

CONCLUSION

Endoscopic subcutaneous mastectomy combined with liposuction via an axillary single incision is a feasible minimally invasive technique for the treatment of gynecomastia. The combined method is effective in achieving satisfied aesthetic results for Simon grades I and Ⅱa gynecomastia, and it can also be an alternative choice for grade Ⅱb.