A standard preoperative workup that is age-appropriate should be performed. Long-standing cases of idiopathic gynecomastia that are stable do not require routine endocrine evaluation. Avoiding aspirin or other blood thinners is critical since postoperative hematomas are common.
The technique used depends on the degree of gynecomastia. The incidence of resection to optimize the final results has continued to increase. The authors have found that resection is required in most cases. If the gynecomastia requires surgical resection, the Webster intra-areolar incision is typically the most appropriate. Prior to surgical resection, the breast is infiltrated with tumescent solution and liposuction is performed.
For massive breast gynecomastia, more skin removal and deeper excision are necessary. With an accurate estimation of the extent of the hypertrophied tissue and the thickness of the fat on the chest wall, the dissection should reach the pectoralis major muscle fascia very near to the preoperatively estimated breast limits. The hypertrophied tissue is then excised from pectoralis major fascia. Hemostasis is secured, and a surgical drain may, rarely, be placed. Subcutaneous tissues are reapproximated, and the skin is closed subcuticularly. The authors use a compression vest postoperatively, which has made drains unnecessary in the overwhelming majority of patients.
The coauthor widely elevates the skin from the underlying fibro-fatty-glandular tissue after tumescent liposuction is performed. The skin elevation is aggressive in the "face lift" plane, which takes advantage of maximal skin contracture. The patient is then sat up to 80° on the operating room table and resection is performed. This nearly emulates the standing position and how the patient evaluates his outcome. A suction drain is most always used and comes out in the hair-bearing part of the axilla.
Liposuction-assisted mastectomy is the most popular method used for pseudogynecomastia. The liposuction cannulas are inserted through a 3-mm areolar incision or an incision in the anterior axilla along the pectoralis major tendon. The surgeon the removes fatty and minimal glandular tissues. For small and moderate gynecomastia, suction lipectomy is extended to the clavicle, to the sternum, to 2 cm below the inframammary crease, and to the axilla. For moderate to large gynecomastia, suction lipectomy is extended to the postaxillary fold in conjunction with excision.
Compression garments are applied for at least 4 weeks. A small amount of blood, injection fluid, and liquified fat may leak from the incision sites for approximately 24 hours. The patient may resume his physical activities within few days. Exercise is resumed a few days after surgery and is gradually increased over time. Patients return to work typically after 1-2 days. Drains may or may not be used, depending on the experience of the surgeon and the patient presentation.