Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction

Single Axillary Incision Reverse Sequence Endoscopic Nipple-Sparing Mastectomy in the Management of Gynecomastia: Short-Term Cosmetic Outcomes, Surgical Safety, and Learning Curve of the Preliminary 156 Consecutive Procedures from a Prospective Cohort Study

BACKGROUND

Currently, a standard, optimal surgical procedure is still lacking for gynecomastia. Despite the development of a variety of surgical interventions, these techniques were often limited to patients with Simon I and II. The present study aimed to introduce a novel technique for all types and grades of gynecomastia, and reported the preliminary results.

METHODS

Patients who received single axillary incision reverse sequence endoscopic nipple-sparing mastectomy (R-E-NSM) from March 2021 to March 2023 were enrolled at a single institution. The data from 3-month follow-up cut-off were collected prospectively and analyzed to determine the short-term esthetic and safety results of this technique, as well as the learning curve.

RESULTS

A total of 159 single axillary incision reverse sequence endoscopic nipple-sparing mastectomy procedures were performed in 81 gynecomastia patients. Among these 81 patients, 7 patients (8.6%) were classified as Simon grade I, 29 patients (35.8%) as grade IIa, 24 patients (29.6%) as grade IIb, and 21 patients (25.9%) as grade III. In the patient-reported cosmetic results, the overall satisfaction score was 8.4 ± 1.4. A total of 74.1% of patients were highly satisfied, and 25.9% were satisfied. The overall complication rate was 10.1%, and only 1 patient had a major complication. According to the cumulative sum plot analysis, approximately 12 cases were needed for surgeon B and 11 cases for surgeon C to decrease their operation time significantly.

CONCLUSIONS

R-E-NSM is safe and effective for all Simon grade gynecomastia patients, with excellent cosmetic results and a short learning curve. However, a long-term follow-up assessment is still needed.

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 .

Surgical Technique Selection in the Management of Pediatric Gynecomastia

INTRODUCTION

Although the majority of pubertal onset gynecomastia is self-resolving in nature, persistent deformity may require surgical intervention. This study aims to identify patient factors associated with surgical technique selection and proposes an algorithm for the surgical management of pediatric gynecomastia.

METHODS

A retrospective analysis was performed of all surgically managed pediatric gynecomastia patients operated on at a single institution from 2012 to 2022. Charts and patient photos were analyzed for patient and operative demographics, endocrinologic comorbidities, complications, and outcomes. Data were analyzed using bivariate and logistic regression analysis.

RESULTS

Fifty-six surgically managed gynecomastia patients less than 18 years of age were included. The average age at surgery was 16.1 years old, with a mean BMI of 26.9. Most patients were overweight or obese (54.8%) and had Simon grade IIb or greater gynecomastia (55.4%) at presentation. All patients underwent 1 of 4 mastectomy techniques with or without liposuction: inferior periareolar (n=25, 44.6%), circumareolar (n=13, 23.1%), transverse with pedicled nipple (n=4, 7.1%), or free nipple graft (n=14, 25.0%). Bivariate and logistic regression analysis revealed significant differences in sternal notch-to-nipple distance, nipple-to-inframammary fold distance, breast resection weight, and gynecomastia grade between the 4 surgical techniques used in this study. An algorithm incorporating these factors was devised to guide surgical decision-making.

CONCLUSIONS

The proposed algorithm guides surgical technique selection for pediatric gynecomastia and is contingent upon the degree of ptosis and skin excess, anticipated resection weight, and skin quality.

Evaluating Large Language Model (LLM) Performance on Established Breast Classification Systems

Medical researchers are increasingly utilizing advanced LLMs like ChatGPT-4 and Gemini to enhance diagnostic processes in the medical field. This research focuses on their ability to comprehend and apply complex medical classification systems for breast conditions, which can significantly aid plastic surgeons in making informed decisions for diagnosis and treatment, ultimately leading to improved patient outcomes. Fifty clinical scenarios were created to evaluate the classification accuracy of each LLM across five established breast-related classification systems. Scores from 0 to 2 were assigned to LLM responses to denote incorrect, partially correct, or completely correct classifications. Descriptive statistics were employed to compare the performances of ChatGPT-4 and Gemini. Gemini exhibited superior overall performance, achieving 98% accuracy compared to ChatGPT-4's 71%. While both models performed well in the Baker classification for capsular contracture and UTSW classification for gynecomastia, Gemini consistently outperformed ChatGPT-4 in other systems, such as the Fischer Grade Classification for gender-affirming mastectomy, Kajava Classification for ectopic breast tissue, and Regnault Classification for breast ptosis. With further development, integrating LLMs into plastic surgery practice will likely enhance diagnostic support and decision making.

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System

Background

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals.

Methods

The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects.

Results

For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed.

Conclusions

In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

Liposuction as a Treatment for Lipedema: A Scoping Review

Background

Lipedema is the progressive symmetrical deposition of subcutaneous fat and fluid in the lower body, ordinarily sparing the trunk, upper limbs, face, and neck. It may follow an autosomal dominant inheritance pattern. The gold standard treatment for lipedema is complete decongestive therapy, consisting of manual lymphatic drainage and compression garments. This scoping review assessed the existing literature on the effectiveness of liposuction as an alternative treatment for lipedema.

Methods

A scoping review of electronically available literature within PubMed, Scopus, and Cochrane focused on liposuction as a treatment for lipedema considering the following inclusion criteria: human studies, case series of 10 or more, controlled trials, randomized controlled trials, patient-reported outcome measurement studies, survey analyses, descriptive studies, retrospective analyses, recurrence included, follow-up of 6 months or more, age 18 years or older, and treatment modality being liposuction.

Results

Thirteen studies were selected. Nine studies reported decreased compression therapy use among patients following liposuction. No studies reported a long-term increase in compression therapy following liposuction. Studies found self-reported improvements in pain, mobility, bruising, and overall quality of life for patients following liposuction, many of whom had previously been on compressive therapy. Studies reported low rates of serious adverse events following liposuction, including deep vein thrombosis, pulmonary embolism, and infection.

Conclusions

These results suggest that liposuction can be a viable treatment alternative to compression therapy for lipedema in patients whose compression therapy has not been helpful. However, there is not enough evidence to say whether liposuction is as effective as compression for patients first presenting with lipedema.

Beyond the Metabolic Syndrome: Non-Obvious Complications of Obesity in Children

Obesity is currently one of the most significant public health challenges worldwide due to the continuous increase in obesity rates among children, especially younger children. Complications related to obesity, including serious ones, are increasingly being diagnosed in younger children. A search was performed from January 2023 to September 2023 using the PubMed, Cochrane Library, Science Direct, MEDLINE, and EBSCO databases. The focus was on English-language meta-analyses, systematic reviews, randomized clinical trials, and observational studies worldwide. Four main topics were defined as follows: disorders of glucose metabolism; liver disease associated with childhood obesity; the relationship between respiratory disorders and obesity in children; and the effects of obesity on the hypothalamic-pituitary-gonadal axis and puberty. Understanding potential complications and their underlying mechanisms can expedite the diagnostic process and enhance the effectiveness of treatment. We aspire that this study will bring insight into the often-overlooked complications associated with obesity.

"Post Bariatric Male Chest Re-shaping Using L-shaped Excision Technique"

BACKGROUND

Male chest deformity after massive weight loss is complex and challenging to treat because of differing grades of excessive parenchyma/fat ptosis, nipple malposition, over-stretched skin, ill-defined infra-mammary fold, and prominent axillary rolls. Patients are eager to restore balanced upper body dominance. Two fundamental techniques are used for large breasts with moderate to poor skin elasticity; (1) the inferior pedicle Wise skin pattern and (2) double incision with free nipple graft technique.The author presents his experience in treating such severe breast deformities, besides correcting the prominent axillary rolls using an L-shaped mastectomy excision.

MATERIALS AND METHODS

Between March 2017 and December 2020, 55 consecutive patients were treated surgically for male chest re-contouring using the L-shaped mastectomy technique. Ages ranged from 20 to 57 years (median, 31 years). The average body mass index (BMI) was 29. The average follow-up period was 17 months (13-44 months).

RESULTS

Fifty-one patients (92.8%) reported greater levels of postoperative satisfaction with their results owing to lack of any major complication and minimal minor complications (two cases of minor ischemia that healed spontaneously, two small hematomas, two small seromas, and four hypertrophic scars).

CONCLUSION

The L-shaped excision is a useful procedure for severe grade gynecomastia with an atypical presentation in the form of complex chest deformity and prominent axillary roll after massive weight loss patients. The technique is associated with minor complications that are treated in an office setting. The technique preserves normal pigmentation and sensitivity of the nipple-alveolar complex.

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 Retrospective Review of Arthroscopic Shaver Utilization in Adolescent Gynecomastia

Background

This study compares the arthroscopic shaver and liposuction with other established methods for treatment of adolescent gynecomastia.

Methods

Surgical management was via four operative techniques: open excision, open excision/liposuction, arthroscopic shaver/liposuction, or open excision and free nipple graft. Data were collected and compared using independent t tests, linear regression models, and one-way analysis of variance.

Results

Patients were stratified by Rohrich grades I -II (low) (N = 47) or III -IV (high) (N = 13). The groups were similar in age (P = 0.662) with lower BMI in the low-grade group (x̄ = 25.36 ± 2.1) vs. high-grade group (x̄ = 27.62 ± 4.0; P < 0.001). The low-grade group showed no significant difference in operative time across surgical techniques with decreased mean operative time in the high-grade group using the arthroscopic shaver technique (x̄ = 55.8 ± 7.56) compared with open excision (x̄ = 70.83 ± 11.02, P = 0.04), open excision plus liposuction (x̄ = 89.5 ± 24.93, P = 24.93), and open excision plus free nipple graft (x̄ = 81.67 ± 19.11, P = 0.05). There was no significant difference in complication (P = 0.84) or reoperation (P = 0.68) rates across surgical techniques regardless of grade.

Conclusions

These findings suggest that the arthroscopic shaver is safe and effective for treatment of both low- and high-grade gynecomastia in adolescents. The results yielded a similar incidence of complications and reoperation across surgical techniques, and the arthroscopic shaver approach demonstrated a shorter operative time compared with other techniques for high-grade gynecomastia.

Anthropometric Measurements and Analysis for Objective Assessment of Gynecomastia Surgery Results

Background

Gynecomastia surgery is one of the most common aesthetic procedures in males. There is a lack of objective analytical parameters to judge outcomes. In this study, the authors aim to introduce novel anthropometric measurements and analysis techniques for the objective assessment of surgical outcomes based on specific aesthetic targets.

Objectives

To introduce quantification of gynecomastia surgery outcomes and compare the results among the different grades of gynecomastia.

Methods

A total of 192 patients with gynecomastia were included. The patient cases were grouped according to grades and a set of anthropometric measurements were taken both before the operation and 6 months postoperatively. Liposuction and glandular excision were done through minimal incisions in all grades of gynecomastia, with the addition of ultrasound and nipple areola complex (NAC) lifting plaster in selected Grade 3 and all Grade 4 cases.

Results

A statistically significant improvement in the perimeter of the triangular relationship of sternal notch and nipples, the elevation of the NAC, the reduction of the area of the NAC, and the correction of asymmetry of the chest were seen in all grades of gynecomastia, with increased differences in higher grades.

Conclusions

A systematic objective analysis of the specific aesthetic targets helps to reliably compare results in a standard way and for carrying out improvisation of surgeons' techniques. Meanwhile, this approach helps identifying the need for customization, eventually providing symmetric and aesthetically pleasing surgical results.

Level of Evidence 3

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.

Erdheim-Chester Disease of the Breast: First Review and First Case of Isolated Severe Gynecomastia

(1) Introduction: Erdheim-Chester disease (ECD) is a life-threatening condition and often a diagnostic challenge. It has recently been classified as a hematopoietic tumour, and the cases of ECD reported in the literature has dramatically increased during the last 15 years. (2) Methods: We describe the case of a 57-year-old male patient with severe gynecomastia, with a detailed description of his diagnostic iter and consequent surgical operation. We provide the first systematic review of the literature of breast involvement in ECD, following PRISMA guidelines, including 13 studies and 16 patients. (3) Results: Our report resulted to be the first case of gynecomastia as a single clinical and imaging feature of ECD described in English literature. A total of 81.3% of patients included were female. Among them, 76.9% had unilateral and nodular presentation, while male patients presented bilateral heterogeneous breast enlargement. Globally, 87.5% expressed breast alterations as their first manifestations of ECD. Only 50% presented skeletal involvement. (4) Conclusion: The reported case represents a unique addition to the literature. We found two different patterns in ECD-related breast involvement between male and female patients, an unusual M/F ratio, and a lower rate of bone involvement. Breast involvement is frequently the first clinical feature; therefore, breast caregivers should be aware of this dangerous and most likely underestimated condition.

[Treatment of pseudogynecomastia in massive weight loss patients: Liposuction assisted and made-to-measure desepidermization technique]

BACKGROUND

After massive weight loss (MWL), the chest in men may show significant deformities. The surgical treatment of gynecomastia after MWL remains a difficult and partially misunderstood surgery due to 4 main factors: a complex excess of skin in height and width that sometimes continues in the axilla or dorsal region, a predominantly fatty rather than glandular component, the malposition of the nipple-areola complex (NAC) that is often enlarged and an inframammary fold (IMF) that is often marked. The techniques currently described are either insufficient or lead to frequent and/or significant complications. The authors describe a new approach that dissociates the treatment of the volume and the skin with a customized resection that is simple, reproducible and safe. Our goal is to improve patient satisfaction while reducing complication rates.

METHODS

Seventeen patients with adipomastia with excess skin after massive weight loss were operated on using liposuction and skin redraping technique. The authors describe the technique, indications and contraindications of the procedure and analyze the results.

RESULTS

The average age of the patients was 39 years. The average body mass index (BMI) before weight loss is 42,7kg/m², the average weight loss before body correction is 49kg, with an average delta of BMI loss of 15,34kg/m^2. The average stay in hospital is 1,3 nights. No patient had major complications (hematoma, hemorrhage, necrosis, thrombophlebitis, immediate surgical revision to treat complications). Minor complications including scar dehiscence, infection, steatonecrosis, and distant scar correction were reported in 2 patients, i.e. 11%.

CONCLUSION

Liposuction assisted and desepidermization torsoplasty is a new technique for correction of pseudogynecomastia in MWL patients. The results are reproductible and the complication rates are low. There is no dead space and therefore no drains are needed. There is little pain and a short hospital stay. This technique is simple, quick and easy to learn. However, it is only applicable in adipomastia. A different technique should be used in the presence of firm glandular tissue.

Scar versus shape: patient-reported outcome after different surgical approaches to gynecomastia measured by modified BREAST Q®

OBJECTIVES

The challenge in the operative therapy for enlargement of the male breast is to deal with the skin excess. Shape and scars are the major parameters after which patients assess their operative result. Therefore, we assessed the satisfaction rate among patients undergoing subcutaneous mastectomy at our institution with special regard to scar tissue formation and the postoperative appearance of the chest wall in dependence of the surgical approach (periarolar versus inframammary fold).

METHODS

The study includes n = 36 male patients who underwent subcutaneous mastectomy at AGAPLESION Markus Hospital Frankfurt/Main. Patient's satisfaction dependent with the appearance of the chest wall and scar formation was evaluated by a modified BREAST Q® questionnaire plus two male-based additional questions.

RESULTS

There is no statistically significant difference in satisfaction with the operative result depending on the pattern of incision (periareolar versus submammary periareolar; 81.9% versus 75.5%) with the operative result. Evaluation of additional questions of the modified BREAST Q® questionnaire showed that 86% of the patients (n = 31) would rather have more scars and a flatter chest wall. A BMI >25 kg/m² is accompanied by a higher risk for complications (p = 0.04).

CONCLUSIONS

Periareolar incision is still the method of choice, if promising an aesthetic appealing result. When reaching its limits though, we showed that a flat and male-shaped appearance of the chest wall is priority for the patients and should therefore be for the surgeon as well.

A Single-Center Experience With Gynecomastia Treatment Using Liposuction, Complete Gland Removal, and Nipple Areola Complex Lifting Plaster Technique: A Review of 448 Patients

Background

Gynecomastia is defined as a benign enlargement of male breast glandular tissue. It is the most common breast condition in male, and the prevalence ranges from 32% to 72%. No standardized treatment exists for gynecomastia.

Objectives

The authors treat gynecomastia patient with liposuction and complete gland excision through periareolar incision without skin excision. In case of skin redundancy, the authors use their special technique called nipple areola complex (NAC) plaster lift technique.

Methods

The authors conducted the retrospective analysis of patient who underwent gynecomastia surgery between January 2020 and December 2021 at Chennai Plastic Surgery. All patients were treated with liposuction, gland excision, and NAC lifting plaster when required. The follow-up period ranges from 6 to 14 months.

Results

A total of 448 patients (896 breasts) were included in our study with average age of 26.6 years. Grade II gynecomastia was most common in our study. The average BMI of the patients was 27.31 kg/m². One hundred and sixteen patients (25.9%) experienced some form of complication. Seroma was most common complications in our study followed by superficial skin necrosis. Patient satisfaction rate was high in our study.

Conclusions

Gynecomastia surgery is safe and highly rewarding procedure for surgeons. Various technologies and methods like liposuction, complete gland excision, and NAC lifting plaster technique should be adopted in gynecomastia treatment to give a better patient satisfaction. Complications are common in gynecomastia surgery but easily manageable.

Level of Evidence 4

Mondor’s disease as a complication in breast surgery in a male patient. The first ever reported case in literature

Mondor’s disease (MD) is an uncommon clinical condition characterized by thrombophlebitis of the superficial veins of the anterolateral thoracoabdominal wall. In this paper we present the first ever reported case of Mondor’s disease in male patient after surgical correction of gynecomastia with liposuction assisted skin sparing adenectomy.

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 .

[Gynécomastia. Management of diagnosis and therapy. Apropos of 148 cases]

Gynecomastia is the most frequently breast lesion in males. 148 patients (mean age 24,7 years) operated in our department were reviewed with a mean follow-up of five years. Gynecomastia occurred most frequently during puberty (77,7 %), was bilateral (86,5%) and idiopathic (89,9%). The size of the enlargement was evaluated according to Simon's-classification based on breast-volume and skin-redundancy. 17 (11,5%) stage 1, 77 (52%) stage 2A, 32 (21,6%) stage 2B, 22 (14,9%) stage 3. Clinical examination and mammography determined the consistency of gynecomastia: adipose or firm. 4 different surgical managements were used: 17 (11,5%) subcutaneous mastectomies, 4 (2,7%) liposuctions, 110 (74,3%) liposuctions associated with subcutaneous mastectomy, 17 (11,5%) total mastectomy. All techniques gave good morphologic results. Nonetheless, the authors recommend the combination «liposuction and subcutaneous mastectomy», as this technique presents many advantages: small intraoperative blood loss, good skin redraping, short hospital stay, complete histologic examination of the material removed.

Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men

BACKGROUND

Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life.

METHODS

Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test.

RESULTS

Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively.

CONCLUSIONS

Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

Pubertal induction and transition to adult sex hormone replacement in patients with congenital pituitary or gonadal reproductive hormone deficiency: an Endo-ERN clinical practice guideline

An Endo-European Reference Network guideline initiative was launched including 16 clinicians experienced in endocrinology, pediatric and adult and 2 patient representatives. The guideline was endorsed by the European Society for Pediatric Endocrinology, the European Society for Endocrinology and the European Academy of Andrology. The aim was to create practice guidelines for clinical assessment and puberty induction in individuals with congenital pituitary or gonadal hormone deficiency. A systematic literature search was conducted, and the evidence was graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. If the evidence was insufficient or lacking, then the conclusions were based on expert opinion. The guideline includes recommendations for puberty induction with oestrogen or testosterone. Publications on the induction of puberty with follicle-stimulation hormone and human chorionic gonadotrophin in hypogonadotropic hypogonadism are reviewed. Specific issues in individuals with Klinefelter syndrome or androgen insensitivity syndrome are considered. The expert panel recommends that pubertal induction or sex hormone replacement to sustain puberty should be cared for by a multidisciplinary team. Children with a known condition should be followed from the age of 8 years for girls and 9 years for boys. Puberty induction should be individualised but considered at 11 years in girls and 12 years in boys. Psychological aspects of puberty and fertility issues are especially important to address in individuals with sex development disorders or congenital pituitary deficiencies. The transition of these young adults highlights the importance of a multidisciplinary approach, to discuss both medical issues and social and psychological issues that arise in the context of these chronic conditions.

Total Gynecomastia Removal with Layered Closure: A Study of 567 Cases

Conventional teaching dictates subtotal removal of gynecomastia tissue to ensure a cosmetically acceptable result. Modern-day concerns regarding gynecomastia treatment include continued "puffy nipples," possible recurrence, and compromised aesthetic results resulting from incomplete tissue removal. The author practiced complete tissue removal with a layered closure technique to optimize the cosmetic result while addressing treatment complications.

Methods

A single surgeon treated 567 patients using a standard four-step approach with complete tissue removal. A retrospective chart review was performed to assess complications and reason for surgical revision.

Results

All revision procedures were for postoperative scar tissue accumulation. No revisions for complaints of contour depression, recurrence, or continued puffy nipples were noted. No necrosis of the nipple-areola complex or skin was noted.

Conclusions

Complete removal of gynecomastia tissue was not only possible but also essential to achieve optimal cosmetic results. The layered closure technique is a useful adjunctive treatment after gynecomastia total tissue removal.

Safety, Efficacy, and Tolerability of Simultaneous Bilateral Cryolipolysis Using a Rapid Cycling Contoured Cup Applicator for Noninvasive Fat Reduction in the Enlarged Male Breast: A Pilot Study

BACKGROUND

A previous study using a parallel cooling plate cryolipolysis applicator demonstrated the efficacy of cryolipolysis for pseudogynecomastia. Although the procedure was safe and effective, treatment times were prolonged and anesthetic was needed to reduce treatment discomfort.

OBJECTIVE

To evaluate the safety, efficacy, and tolerability of a short cycle, reduced vacuum contoured cup cryolipolysis applicator for the treatment of pseudogynecomastia.

MATERIALS AND METHODS

Twelve male subjects received simultaneous bilateral treatment consisting of a 35-minute cryolipolysis cycle, followed by a short manual massage, and a second 35-minute cycle with 50% treatment area overlap in a single treatment visit. At the 6-week follow-up, a second treatment was performed with up to 2 overlapping cycles per side. Efficacy was assessed after the second treatment using transcutaneous ultrasound, standardized clinical photography, and subject surveys.

RESULTS

Ultrasound analysis showed a mean fat layer reduction of 5.1 ± 2.3 mm (p < .001). Blinded, independent reviewers correctly identified 97% of baseline/treatment photography results. Surveys revealed 100% subject satisfaction with 91% reporting visible fat reduction and 100% stating they would recommend treatment. Transient side effects included mild intratreatment discomfort, paresthesia, and tenderness.

CONCLUSION

A rapid cycling, reduced vacuum cryolipolysis applicator provides rapid, safe, effective, and tolerable treatment of pseudogynecomastia.

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.

Percutaneous Intradermal Purse-String closure for Correction of Male Tuberous Nipple-Areola Complex Deformity

BACKGROUND

Male tuberous breast is an exceedingly rare condition that not fit properly into the majority of existing classifications of gynecomastia. This deformity has been categorized by Cordova and Moschella as gynecomastia grade III; however, they do not make any reference to the isolated tuberous deformity of the nipple-areola complex (NAC). Considering that the areolar area is the main ''esthetic unit'' in the male chest, surgical correction of the isolated tuberous NAC deformity can be challenging. There is a belief that this deformity is unsuccessfully corrected when approached through a limited periareolar incision at the lower pole. A complete periareolar incision, with a concentric excision of excess areolar skin, is usually required leaving an unnatural-looking round periareolar scar on the male thorax.

METHODS

We describe a variation of a surgical technique for the correction of a male tuberous NAC deformity in a teenager who rejected a conspicuous round periareolar scar after surgery. This modification combines a conventional lower hemiareolar approach with a percutaneous intradermal purse-string suture in the superior areolar margin to reduce the areolar diameter, avoiding an evident circumareolar scar.

RESULT

At the six-month follow-up, areolar widening or tuberous deformity relapse was not observed. The patient felt satisfied with the outcome.

CONCLUSION

The use of percutaneous intradermal purse-string periareolar suture for correction of this rare deformity is a simple and reproducible surgical technique that could help to obtain a better cosmetic result by restoring the contour of the male chest while minimizing the visibility of the residual scar.

LEVEL OF EVIDENCE V

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 .

The Relationship between Psychopathology, Self-esteem, Body Perception and Serum Sex Steroids in Pubertal Gynecomastia

Objective

The current study aimed to investigate the psychopathology behind gynecomastia and potential associated problems regarding self-esteem and body perception, and the relationships of these variables with sex steroid levels in adolescents with pubertal gynecomastia.

Methods

The study included 50 normal weight male adolescents aged between 11 and 18 years with gynecomastia but without any chronic organic pathology, and 50 healthy pubertal male adolescents matched for age. The adolescents underwent psychopathology assessment by Development and Well-Being Assessment interviews; self-esteem was assessed using the Rosenberg Self-Esteem Scale; body perception was evaluated using the Body Image Perception Scale, and the relationship between these variables and sex steroid levels were explored.

Results

The results of the study revealed that the gynecomastia group had significantly greater internalization disorder (χ² = 12.96, p < 0.001), and impairments in self-esteem (z = −1.975, p = 0.024) and body perception (z = −2.286, p = 0.022), and these variables were correlated with the gynecomastia stage. In the study group, cortisol levels were significantly higher (z = −2.330, p = 0.02) in adolescents with internalization disorder compared to those without, and cortisol levels increased in parallel with increased gynecomastia duration (r = 0.386, p = 0.006).

Conclusion

In our study, we found that gynecomastia, depending on its stage, may lead to internalization disorder and impair self-esteem and body perception. It was found that there was no direct relationship between these parameters and sex steroids in pubertal gynecomastia, except for high cortisol levels in adolescents with internalization disorder.

Gynecomastia: Ultrasound-Confirmed Classification Pertainent to Surgical Correction

BACKGROUND

Gynecomastia is the most common form of breast alteration in men, due to proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drugs suspension), the surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture.

MATERIALS AND METHODS

A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound-confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles.

RESULTS

The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients' and surgeons' satisfaction were performed, showing excellent feedbacks regarding the results accomplished.

CONCLUSIONS

The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients' satisfaction.

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 .

Rupture and hemorrhage of a seminoma mixed with yolk sac tumors in 46XY partial gonadal dysgenesis: a case report and literature review

Background

46XY partial gonadal dysgenesis (PGD) is a rare subtype of disorder of sex development (DSD). 46YY PGD is a congenital disease with atypical chromosomal, gonadal, or anatomical sex development. The patient in this case report had male and female genitalia simultaneously. We created a flowchart of the differential diagnosis for clinicians.

Case presentation

A 41-year-old male was admitted to the hospital complaining of lower quadrant abdominal pain for 1 day. Physical examination revealed that his penis size was normal, but a urethral orifice was located in the perineum area between the scrotum and anus. One small testicle was in the left scrotum, but no testicle was present on the right. The patient’s abdomen was bulging, and he had lower abdominal pain. According to the emergency CT scan, a lesion (74*65 mm) was found in the right pelvis between the bladder and rectum. The lesion showed an unclear boundary and hematocele appearance. The lesion was removed by emergency surgery, and the pathology report indicated a mixed germ cell tumor with a seminoma and yolk sac tumors.

Conclusion

This article is a case report of germ cell tumors in 46XY PGD patients. The literature review summarizes the clinical diagnosis, and a flowchart is provided for physicians in future practice. The importance of this report is that it will help acquaint physicians with this rare disease and make the right initial clinical decision quickly through the use of this flowchart. However, the variants of special subtypes of 46XY DSD are myriad, and all the diagnoses could not be covered in one flowchart.

Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture

BACKGROUND

Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors' first report of pectoral etching in 2012, patients and surgeons became more aware about gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia.

METHODS

The authors reviewed their records on pectoral high-definition lipo sculpture between January of 2005 and October of 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years.

RESULTS

Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index.

CONCLUSION

Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ginecomastia: Consideraciones médicas y quirúrgicas en cirugía general

La ginecomastia, definida como el crecimiento del tejido glandular mamario en los hombres, aparece desde la etapa neonatal hasta la senil, puede ser unilateral o bilateral, y es de causa multifactorial, incluyendo aquellos pacientes asociados al uso de medicamentos, donde predomina un desbalance en la relación testosterona–estrógeno. Relativamente, la idiopática es la más frecuente. La mayoría involucionan espontáneamente, las neonatales por perdida del influjo transplacentario en las primeras semanas, y las puberales entre 12 a 24 meses. Se presenta como un aumento del tamaño mamario, asintomático o con hipersensibilidad por inflamación durante el crecimiento del tejido fibroglandular mamario, con una repercusión psicológica enorme, sobre todo en la etapa de la adolescencia. El estudio y manejo es interdisciplinario y se ofrece de acuerdo con las condiciones y la etiología. Aquellos pacientes púberes en quienes no involuciona reciben tratamientos médicos, o tratamientos quirúrgicos cuando falla la terapéutica o hay presión social, e incluso radioterapia en casos donde desarrollan ginecomastia con hipersensibilidad al tratamiento hormonal del cáncer de próstata.

Use of Tumescent Anesthesia in Surgical Excision of Gynecomastia

Background. Gynecomastia, benign enlargement of the male breast is the most common breast pathology amongst males. The most widely used modality of treatment is liposuction under general anesthesia. To date however there is no published study that specifically addresses to use tumescent anesthesia & use of tranexamic acid in it for excision of gynecomastia. Objective. To evaluate the efficacy of tumescent anesthesia in surgical excision of gynecomastia. Methods. A 4-year study with 100 patients of gynecomastia aged 14 to 47 years were enrolled with follow up for 3 months. All patients were given tumescence anesthesia in each breast comprising subcutaneous infiltration of 500 ml RL, 20 ml 0.5% bupivacaine, 30 ml 2% lignocaine, 1 mg adrenaline & 1 gm tranexamic acid. Breast tissue was excised in each breast by a single infraareolar incision & patients were assessed for intra-op pain and post-op pain by using numeric rating scale (NRS). Results. Bilateral presentation was there in 69 patients and 31 unilateral with 4 recurrent cases. Size of gland excised were 12-14 cms in 53 cases, 15-18 cms in 38 & 19-20 cms in 9 patients. Average surgical time required for each breast was 30 minutes. Intraoperative pain NRS-0 for 66, NRS-1 for 31 & NRS-5 for 03 patients. Postoperative pain for first eight hours was NRS-0 for 69 and NRS-1 for 31 patients. Conclusion. Tumescent anaesthesia for surgical excision of gynecomastia using a periareolar incision is a minimally invasive bloodless and painless technique in which ductal and stromal tissue can be removed resulting in a high level of patient satisfaction. In todays covid era it avoids the use of general anesthesia and electrocautery.

Expected Reduction of The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone

BACKGROUND

The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia.

OBJECTIVE

The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL).

MATERIALS AND METHODS

A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed.

RESULTS

The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=<0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cm² (SD 1.48) or 23.37% (SD 9.78) after 5.82 years and in the SCM+UAL cohort 2.60cm² (SD 1.60) or 35.85% (SD 6,86) after 7.43 years. As independent significant factors for reduction of the NAC, the resection weight and SCM+UAL combination were identified. There were no significant differences regarding the patients' satisfaction measured with the BODY-Q (p=0.222) and the ordinal scale (p=0.445) between the two cohorts.

CONCLUSIONS

The SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered.

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 .

Endoscopic Axillary Approach Improves Patient Satisfaction of Gynecomastia Subcutaneous Mastectomy: A Cross-Sectional Study Using the BODY-Q Chest Module

BACKGROUND

Gynecomastia is a common condition that refers to the benign enlargement of male breasts. Several minimally invasive techniques were invented to avoid visible scars in the chest area, but have limited effects on the dense fibroglandular breast tissue, and open excision remains the mainstay of treatment. Endoscopic subcutaneous mastectomy has the superiority of visualization, facilitating accurate dissection and hemostasis, also enabling inconspicuous scars. This study was designed to evaluate the patient-reported outcomes of the endoscopic axillary approach in treating gynecomastia, to interpret the differences between it and the conventional periareolar open excision method, and to present our experience utilizing this technique as a reliable alternative for Simon I and II gynecomastia.

METHODS

Eighty-three participants diagnosed with Simon I or II gynecomastia were included in this cross-sectional study, among which 31 were preoperative and 52 were postoperative patients. Postoperative participants were divided into two groups according to whether endoscopic axillary subcutaneous mastectomy (axillary group, n = 25) or periareolar open excision (periareolar group, n = 27) was performed. Patient-reported outcomes were assessed using the BODY-Q questionnaire, including the chest, nipples, body image, social, appearance-related distress, and scar domain, with scores ranging from 0 to 100.

RESULTS

The BODY-Q score of both axillary and periareolar postoperative groups showed significant improvement on chest (p < 0.001), nipples (p < 0.001), body image (p < 0.001), and appearance-related distress (p < 0.005) scales, compared with the preoperative group. Of the scar scale, the axillary group rated higher scores than the periareolar group (p = 0.019), analysis of the individual scale items showed more positive responses in questions "Location of your scars?" (p < 0.001) and "How your scars look when they are not covered by clothes?" (p < 0.001), the item "Having to dress in a way to hide your scars?" also had a somewhat more positive responses from participants (p = 0.095).

CONCLUSIONS

The present findings indicate that compared with the periareolar excision, patients who underwent gynecomastia subcutaneous mastectomy through endoscopic axillary approach have higher scar satisfaction with postoperative outcomes, this probably because of the well-hidden scar at the axilla, which leverages the psychologic burden of the patient after surgery. Future prospective studies are needed to measure changes over the entire patient journey, to find out the predictable factors of postoperative patient satisfaction, and determine how the objective outcomes relate to changes in patient's health-related quality of life.

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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Surgical Management of Gynecomastia: A Comprehensive Review of the Literature

Gynecomastia is a graded condition characterized by enlargement of the male breast that affects a significant proportion of the male population. A plethora of varying surgical approaches currently exists in the literature; thus this comprehensive review sought to analyze surgical practice patterns and trends as they pertain to gynecomastia grade and severity. The current literature was queried utilizing the PubMed and MEDLINE databases—based on predefined parameters and individual review, 17 studies were ultimately included. Key data points included gynecomastia grade, surgical intervention, rate of complication, including hematoma, seroma, infection, and necrosis, and drain use. Two-sample t test was utilized for further analysis. A total of 1112 patients underwent surgical treatment for gynecomastia. Skin-sparing mastectomy with or without liposuction was the most frequently used procedure followed by mastectomy with skin reduction. Major complication rates ranged from 0% to 33%, with hematoma formation being most common (5.8%) followed seroma (2.4%). There was a higher rate of hematoma/seroma formation among authors who routinely utilized drain placement (9.78% versus 8.36%; P = 0.0051); however, this is likely attributable to the large discrepancy in percentage of grade III patients found in each group (50.23% versus 4.36%; P = 0.0000). As a wide variety of surgical techniques exist for the treatment of gynecomastia, an individualized approach based upon gynecomastia grade and patient preference may assist the surgeon in providing optimal outcomes. This senior author’s preferred method for treatment of gynecomastia is illustrated in the included algorithm.

An Alternative Treatment of Pseudogynecomastia in Male Patients After Massive Weight Loss

BACKGROUND

There has been an increase in body contouring procedures following massive weight loss (MWL), including male breast reduction procedures. Treating male chest deformity after MWL using standard mastopexy techniques often leads to suboptimal results.

OBJECTIVES

The authors describe a technique to treat pseudogynecomastia using a modified elliptical excision and nipple-areola complex (NAC) transposition on a thinned inferior dermal pedicle as an alternative to conventional techniques.

METHODS

A retrospective chart review from January 2011 to January 2019 identified a total of 14 male patients who underwent excision of pseudogynecomastia using the described technique.

RESULTS

Patients were characterized by age, method of weight loss, pre-weight loss body mass index (BMI), post-weight loss BMI, total weight loss, grade of pseudogynecomastia, and concurrent procedures performed. Patients were followed for a period ranging from 3 months to 1.5 years (average, 8.1 months). Pre-weight loss BMI and post-weight loss BMI averaged 52.0 kg/m2 and 29.6 kg/m2, respectively. The average weight lost was 79.72 kg and the average total amount of tissue removed was 2615 g. All patients had concurrent procedures with an average operative time of 274 minutes. Four out of 14 patients (28.6%) experienced minor complications, which included asymmetry, delayed wound healing, seroma, and hyperpigmentation. There were no wound infections, hematomas, flap necrosis, or dysesthesia.

CONCLUSIONS

Due to several cosmetic advantages and low complication profile, our technique using a modified elliptical excision and NAC transfer on an inferior dermal pedicle is an attractive option for treating male chest deformity after MWL.

LEVEL OF EVIDENCE 4

Prospective Analysis and Comparison of Periareolar Excision (Delivery) Technique and Pull-Through Technique for the Treatment of Gynecomastia

BACKGROUND

Gynecomastia is one of the most common disorders affecting adolescent and adult males. It is a benign disorder but has severe psychological manifestations like low self-confidence, depression, anxiety and social phobia in patients suffering from gynecomastia. Different surgical techniques have been described utilizing a variety of incisions, excisions, lipectomy and liposuction methods. Very frequently, these methods are combined for the gynecomastia treatment with variable reported results. However, there is a lack of studies comparing these techniques. The present study was planned to compare cases of gynecomastia treated by liposuction with periareolar excision (delivery technique) and liposuction with a pull-through technique.

METHOD

A prospective randomized control study was conducted at a tertiary care hospital on 20 patients with gynecomastia. The patients were assigned to either liposuction with periareolar excision (delivery technique) or liposuction with pull-through technique. Anthropometric analysis and breast evaluation questionnaire (BEQ) scores were analyzed and compared before and after the surgery.

RESULTS

The majority of the study subjects were between 21 and 30 years of age. Low self-confidence was the main reason for surgery in most of the cases. Twelve patients had gynecomastia grade IIa and eight had grade IIb. Both groups had similar responses to BEQ scores before and after the surgery with no statistically significant difference. A statistically insignificant difference was observed between the groups on comparison of anthropometric analysis preoperatively and postoperatively. The mean lipoaspirate volume was 280 ml for the pull-through technique and 367 ml for the periareolar excision technique. No complications were observed in cases operated on by the pull-through technique, while two cases (10%) operated on by the periareolar excision had hematomas.

CONCLUSION

Both techniques provide excellent cosmetic results with low risk of complications in both small and moderate breast enlargement with skin excess. The pull-through technique combines the benefits of direct excision of glandular tissues along with the minimally invasive nature of liposuction. Thus, performing the procedure via a single incision without the use of drains is a safer alternative to traditional liposuction with the periareolar excision technique.

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.

Do drain tubes help reduce risks of post-operative complications in complex incisional hernia repair (as defined by a recent court ruling)?

BACKGROUND

A recent legal case described in the ANZ Journal of Surgery has sparked significant topical interest in drain tube use in incisional hernia repairs in Australia. This study reviews a single centre experience of drain tube use in incisional hernia repair.

METHODS

Data from online clinical records was collected retrospectively from patients that underwent incisional hernia repair from 1 January 2013 to 31 December 2017. 'Complexity' factors of smoking, obesity and lower midline incision (as identified by the legal case) were also used to stratify groups.

RESULTS

A total of 410 incisional hernia repair cases were identified during the 5-year period. Median length of stay of the non-drain placement group was significantly shorter than that of the drain placement group (2 versus 6 days, P < 0.001). In total, 10.8% of patients with drain suffered from post-op wound infection compared to 3.6% in patients without a drain tube in-situ (P = 0.005). Seroma rates were no different with or without a drain (15.7% versus 16.9% P = 0.78). When stratified by 'complexity', there was a trend towards increased complications when drains were used.

CONCLUSION

Drain tubes were placed in only a small proportion of patients during incisional hernia repairs and were associated with a higher post-operative wound infection rate. When stratified by the 'complexity' factors outlined by the recent legal case, complications in more 'complex' patients may actually increase when a drain tube is used.

Correction of High-Grade Pseudogynecomastia After Massive Weight Loss: Modified Inferior Dermoglandular Pedicled Transverse Scar Reduction

INTRODUCTION

Whereas body-contouring surgery after massive weight loss in women receives much attention, little attention has been devoted to accentuating the male physique. Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. The authors present their approach to high-grade pseudogynecomastia correction with preservation of the NAC on an inferior dermoglandular pedicle with transverse scar only closure and without any meaningful liposuction.

MATERIALS AND METHODS

A description of comprehensive pseudogynecomastia correction with the aforementioned technique followed by review of 58 consecutive patients operated on in our clinic from January 2017 to June 2018. Epidemiological data such as age, weight, height, body mass index (BMI), weight loss, and the medical history of each patient were collected. All patients were photo-documented preoperatively and postoperatively in a standard manner. During the operation, weight of resected tissue and operative time were noted.

RESULTS

Fifty-eight patients were operated on in a single stage. In our series, one patient had unilateral partial necrosis on nipple-areola complex, and two patients had minimal to moderate amounts of hematoma which were followed up without intervention. We did not encounter any infection-related complications or skin redundancy in our patients. Out of 58 patients, 55 of all the patients were highly satisfied with the aesthetic results. Three patients were mildly satisfied with the results, but they stress that moderate scar widening was the reason for the displeasure, not the definition of the chest which was deemed as satisfactory like the rest.

CONCLUSION

Our technique obviates the need for skin resection in a second operation, allows immediate skin recontouring, and provides a viable nipple-areola complex at the desired location. The patient does not have to suffer prolonged stress while awaiting skin retraction and is protected from a second dose of anesthesia and hospitalization.

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.

External Quilting: New Technique to Avoid Haematoma in Gynaecomastia Surgery

BACKGROUND

Haematoma after gynaecomastia surgery is the most common early complication. It may necessitate a return to the theatre and cause increased infection risk, poor wound or delayed healing, and abnormal scar. Strategies to avoid haematoma range from perioperative blood pressure control to the use of tranexamic acid and compressive dressings.

OBJECTIVE

To demonstrate a new technique that would avoid haematoma or limit its expansion should it occur, after gynaecomastia surgery.

METHODS

One hundred and forty-nine patients had surgery for gynaecomastia between 2018 and 2019 by the senior author. External quilting sutures are used to obliterate any dead space following liposuction and piecemeal excision to address fatty, stromal, and glandular components. No drains are used. Patients receive cooling therapy before discharge, and they reattend clinic the following day for suture removal.

RESULTS

Two patients had haematomas which were managed conservatively and healed well. Fine suture tracks, which were observed in another two patients, became unnoticeable at 3 months. Overall, the complication rate in our cohort was 2.7% (haematoma 1.3%, temporary suture track 1.3%).

CONCLUSIONS

Our method is useful in minimising haematoma. It limits expansion of haematoma should it occur. Suture track is the other transient complication. This new technique in gynaecomastia correction is simple, yields good results, and gives the surgeon another option to deal with haematoma.

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.

Surgical treatment of gynaecomastia: a standard of care in plastic surgery

Background

Many techniques for the surgical treatment of gynaecomastia have been reported to be effective with reasonable limited scar formation. The aim of this study was to develop a grade adopted algorithm for effective and scar sparing techniques in reconstruction of the male breast dependent on aetiology and grading.

Methods

Operative techniques, results, rates of revisions and complications were recorded between 2006 and 2018 and results of 164 male patients were analysed, retrospectively. Skin resecting methods have been used in the earlier stage but were later replaced by minimal periareolar incisions and subcutaneous mastectomy. Resections were combined with ultrasound-assisted liposuction up to grade 2b and inferior pedicled breast reduction in 3rd degree gynaecomastias resulting in reduction of scars and effective removal of breast tissue.

Results

Retrospective analysis showed that a periareolar mastopexy was used in 24% of patients with gynaecomastia grade I, IIa and IIb to reshape the breast after subcutaneous mastectomy in the early stage of this study from 2006 to 2010. With the established standardised use of ultrasound-assisted liposuction, only 2% of patients required a mastopexy in the following years. In grade 3 gynaecomastia, the classical approach resulting in an inverted t-scar was later abandoned for an approach with a periareolar and submammary scar and inferior dermoglandular flap. The rate of secondary surgery with the used techniques did not increase.

Conclusions

When using standardised techniques in reshaping the male breast, an aesthetically pleasing and safe result can be achieved by scar sparing techniques in a safe single-stage procedure.

Level of evidence

Level IV, therapeutic study.

Combined surgical and medical treatment in an adolescent with severe gynecomastia due to excessive estradiol secretion: a case report

Background

Gynecomastia develops due to the reversed estradiol-to-Testosterone ratio in adolescence, and symptoms typically improve within 2 years. The causes vary widely, including estrogen excess and tumors, and surgical treatment is usually given in late adolescence because postoperative symptoms may recur in adolescents. This study reports a case of a pediatric patient with severe gynecomastia due to excessive estradiol secretion who showed a positive outcome after receiving surgical treatment combined with aromatase inhibitor administration.

Case presentation

A 9-year old boy visited to the Department of Pediatric Endocrinology for breast budding. At that time, the patient showed breasts at Tanner stage II and no abnormality on hormone tests. During a follow-up, both gynecomastia had progressed to Tanner stage III–IV at age 13. Tamoxifen 10 mg bid was administered; however, the condition rapidly progressed to Tanner stage V at 13.5 years. The evaluation of pathologic gynecomastia showed an increase of estradiol to 296 pg/mL with normal range 10 ~ 36 pg/mL and microlithiasis in both testes. As the condition worsened, total mastectomy was performed at the age of 13.5 years. Based on the assessment that elevated aromatase activity had induced breast budding, we changed the medication to anastrozole (Arimidex) 1 mg once a day, after which the estradiol level improved to 38.5 pg/mL and was maintained well in the two-year postoperative follow-up.

Conclusions

This case report shows a combined plastic surgery and appropriate medical management bring a positive outcome in severe gynecomastia patient.

Male Tuberous Breast: A Rare Variant of Gynecomastia. Clinical Considerations and Personal Experience: Tips and Tricks to Maximize Surgical Outcomes

INTRODUCTION

Tuberous breast deformity, even rarely, might be observed in the gynecomastia population. It can clinically appear very similar to tuberous breast in females, including a footprint resembling a feminine inframammary fold (IMF). Because of its anatomical characteristics, its correction could benefit from particular surgical measures and therefore it should be careful diagnosed. A clear footprint defining a very feminine inframammary fold is very difficult to correct and renders very difficult the management of the extra skin. Transection of the fibrous constrictions at the level of inframammary fold is not sufficient to obtain a satisfactory result, and adjunctive surgical measurements are required.

MATERIALS AND METHODS

From January 2007 to December 2015, twenty-one patients, affected by gynecomastia with tuberous breast deformity, underwent surgical correction consisting of parenchyma debulking and transection of the stenotic fibrous ring of the footprint. The recontouring of the chest profile was optimized using parenchymal flaps which helped to maximize the surgical correction with minimal scarring.

RESULT

The mean age at surgery was 28.8 years. The average follow-up period was 32 months. The average hospitalization stay was 1.28 days. Routine laboratory tests and histological examinations did not demonstrate any anomalies. No major complications and no recurrences of the disorders have not been observed. No major complications were reported: one seroma, one skin depression, two scar revisions and three cases of bilateral minimal crescent ptotic skin appearance were observed.

CONCLUSION

Although tuberous breast in the gynecomastia population is a rare clinical entity, it should be taken into consideration because it could benefit from some specific surgical measures. The use of glandular flaps showed a satisfactory reshaping of the pectoral area.

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.

Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss

BACKGROUND

Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results.

MATERIALS AND METHODS

A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications.

RESULTS

None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC.

CONCLUSIONS

For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Correction of Tuberous Nipple Areolar Complex Deformity in Gynecomastia: The Deformity That Can Get Forgotten

The desired end point of surgical reduction of gynecomastia is a masculine breast appearance and symmetry. This article concentrates on the tuberous deformity of the nipple areolar complex (NAC) that can present in gynecomastia and is sometimes overlooked at surgical correction.This deformity can be corrected at primary surgery if it is recognized preoperatively. If missed, or not adequately corrected, the postoperative result of primary reduction may be deemed incomplete by the patient and they will request revision.The deformity involves overprojection of the NAC in an anteroposterior direction, yet the base diameter may be close to normal. Correction involves reduction of the herniated breast bud, excision of excess areolar tissue, and careful radial scoring to flatten the NAC to a normal level of projection.For the NAC to have a masculine appearance, the areolae need to be symmetrical, of normal male size, and slightly oval in a transverse direction. The projection of both areola and nipple needs to be low, but present: not flattened. This article presents an operative technique to address primary or residual tuberous NAC deformity in the treatment of gynecomastia.

Evidence-Based Practice in Liposuction

BACKGROUND

The goal of this study is to examine the existing peer reviewed literature comparing modern adjunctive techniques in liposuction including laser-assisted liposuction (LAL) and ultrasound-assisted liposuction (UAL) to standard suction-assisted liposuction (SAL). We intend to interpret these findings into a literature-based clinical application to influence practice patterns.

METHODS

A literature review was conducted using a keyword search in PubMed. Keyword search items included liposuction, lipoplasty, suction assisted liposuction, ultrasound assisted liposuction, laser assisted liposuction, tumescent, liposuction comparison, liposuction review, and combinations therein. Exclusion criteria included articles with a primary focus on histologic effects of energy devices, primary animal models, primary opinion papers with no reference to available data, and industry-sponsored publications. Inclusion criteria included articles with direct comparison of liposuction modalities, randomized or blinded studies, and studies with objective outcomes.

RESULTS

Twenty-five articles that met the inclusion criteria comparing SAL to UAL or LAL out of 9972 articles identified were obtained. The selected literature was assigned into 3 categories: evidence demonstrating an advantage of 1 modality (SAL, UAL, or LAL) over another, evidence that showed no benefit of 1 modality over another, and evidence that demonstrated risks of complications of 1 modality over another.

CONCLUSIONS

The benefits of UAL and LAL over SAL include the following: (1) UAL over SAL in the treatment of gynecomastia, (2) LAL and UAL over SAL with decreased hemoglobin/hematocrit in high-volume lipoaspirates, and (3) LAL over SAL with skin tightening in select areas specifically the submental area. Otherwise, the literature demonstrates equivocal results among the described techniques with no clear benefit to set one apart from the other. There appears to be no demonstrable added benefit to the addition of either UAL or LAL that would urge a change in practice patterns outside the exceptions listed.