Surgical Therapy

The objectives of surgical management for breast gynecomastia are (1) to restore the normal male breast contour and (2) to correct deformity of the breast, nipple, or areola. The surgical options for the patient with gynecomastia are mastectomy, liposuction-assisted mastectomy, or a combination of the 2 approaches. Most patients receive maximal benefit from a combined approach.

Surgical resection (subcutaneous mastectomy)

The choice of surgical technique depends on the likelihood of skin redundancy after surgery. Generally, skin shrinkage is greater in younger individuals than in older individuals. Many different incisions have been described for the excision of male breasts. The most common approach is the intra-areolar incision, or Webster incision. The Webster incision extends along the circumference of the areola in the pigmented portion. The length of the incision varies according to the specific anatomy of the patient.The glandular breast tissue has a greater density than adipose tissue. The glandular tissue is not amenable to liposuction.

   
The Webster intra-areolar incision is placed in the inferior hemisphere. This incision may be enlarged by lateral and medial extensions, though this is rarely required. The transverse nipple-areola incision may be used, but it may often be associated with limited exposure and nipple distortion may result. The triple-V incision is an additional approach that has been advocated. A periareola incision followed by another outer circle of skin. The skin in between is removed and the outer circle has a purse-string closure, which is approximated to the smaller circle. This completes the peiareola donut mastopexy. 
       
     
Forty-eight-year-old male gynecomastia patient with breast ptosis. Courtesy of Miguel Delgado, MD. Three months postoperative after a superior cresant lift, triple-V incision. Note how the areola is elevated so the inframammary fold nearly eliminated. Courtesy of Miguel Delgado, MD.    

The transaxillary incision has been recommended because of its advantage of scars on the chest wall; however, its disadvantage is that it causes glandular resection to be more difficult and incomplete. Obtaining adequate hemostasis is also very difficult through this approach.

In severe gynecomastia, skin resection and nipple transposition techniques may occasionally be necessary. The most common type is the Letterman technique. After the skin is resected, the nipple-areola complex is rotated superiorly and medially based on a single dermal pedicle. See the images below.

   
The most common technique for skin resection and nipple transposition is the Letterman technique. Fifty-two-year-old man with adolescent gynecomastia. The skin is poor quality and the nipple-areola complex is very low. Courtesy of Miguel Delgado, MD. Postoperative photo after gland excision, liposuction, nipple reposition, and lateral skin excision. Three months postoperatively. Courtesy of Miguel Delgado, MD. In massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed using an elliptical incision with a nipple-areola graft.

Sometimes, in massive gynecomastia, an en bloc resection of excessive skin and breast tissue and free nipple grafting can be performed, but such cases are extremely unusual. See the image below.

For moderate-severe gynecomastia, a 2-stage surgical procedure may be an option. The first stage is liposuction followed by a Webster-type periareola incision and removal of gland, fat, and fibrous tissue to obtain a nice contour. The second stage is performed 4-6 months later, after the blood supply has reestablished itself from below and allows for a periareola donut mastopexy. The advantage of this technique is the limited incision around the nipple-areola complex. See the images below.

See the image below.

   
The Webster intra-areolar incision is placed in the inferior hemisphere. Stage 2 - Periareola skin excision with a purse-string closure. Fifteen-year-old boy with severe gynecomastia. Courtesy of Miguel Delgado, MD. Postoperative photo after stage 1 gland excision and liposuction through a Webster incision. Note the significant contraction of the skin, but laxity is still present. Courtesy of Miguel Delgado, MD.
       
      
Postoperatively, after periareola donut mastopexy. Patient seen 3 months after sugery. The skin laxity has been improved. Courtesy of Miguel Delgado, MD.      

Minimally invasive gynecomastia surgery

See the image below.

Incision for minimally invasive gynecomastia surgery.

Minimally invasive gynecomastia surgical procedures have gained popularity. The so-called "pull-through technique" described by Moreslli in 1996 has been further refined by Hammond et al,13 Bracaglia et al,14 and Lista and Ahmad.15 A very small (approximately 5 mm) incision is made at the areolar edge, and liposuction is followed by releasing the glandular tissue from the overlying areola and pulling it through the incision, thus the pull-through technique. The major advantage is the smaller incision. This technique is used in well-selected patients. See the images below.

   
Glandular tissue being pulled through. Courtesy of Miguel Delgado, MD. Breast gland pulled through from each side. Courtesy of Miguel Delgado, MD. Preoperative photo before the pull-through technique. Courtesy of Miguel Delgado, MD. Postoperative photo after pull through technique. Courtesy of Miguel Delgado, MD.

Preoperatively, the surgeon should outline the incision and estimate the thickness and depth of fat and breast tissue to be removed. Liposuction is performed after the infiltration of tumescent solution. The authors presently use a combination of ultrasonic-assisted liposuction (UAL), power-assisted liposuction (PAL), and traditional liposuction. The surgical dissection, which proceeds after the liposuction, entails a dissection that is extended to the pectoralis major fascia. The fat and breast tissue are excised en bloc from the pectoralis fascia. Hemostasis is achieved with a Bovie electrocautery instrument. A catheter may need to be inserted to prevent postoperative hematoma; however, with the use of tumescent solution that contains epinephrine, this is rarely required.

Liposuction-assisted mastectomy

Teimourian and Pearlman, first introduced liposuction with surgical resection in the 1980s.16 Recently, the advent of ultrasonic liposuction has improved the results of gynecomastia correction. In liposuction-assisted mastectomy, less compromise of the blood supply, nipple distortion, saucer deformity, and areola slough occur. In addition, the postoperative complications (eg, hemorrhage, infection, hematoma, seroma, necrosis) are fewer with this technique than with open surgical resection. However, liposuction-assisted mastectomy is not effective for correcting glandular gynecomastia. Therefore, the fatty and glandular components of the breast must be assessed prior to any surgical intervention. Few patients can be sufficiently treated with liposuction only.

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