Keywords
gynecomastia - liposuction - aesthetic outcomes - peri-areolar glandular excision
- patient satisfaction
Introduction
Gynecomastia refers to the benign growth of the male breast. It has a prevalence of
around 30% in young males.[1] It happens because of an imbalance in the ratio of estrogen to testosterone. The
most effective approach to address physiological gynecomastia is through reassurance.[2] The underlying disease must be addressed to treat pathological gynecomastia. Over
time, the surgical treatment of gynecomastia has evolved, advancing from the excision
of breast tissue with or without skin removal using lunate inframammary incisions
to the intra-areolar incision and finally to liposuction.[3]
Gynecomastia patients also experience sadness, poor body image, and low self-esteem.[4] Any procedure that triggers memories of prior disease is certain to have an adverse
effect on the patient's mental health and may not fully address the ailment. Therefore,
the major goal of gynecomastia surgery is scarless surgery. This issue is effectively
solved with liposuction, which leaves barely noticeable scars. Although adipose tissue
can be removed by liposuction, the glandular tissue that is frequently left behind
results in an unattractive end result, continuing to give the patient emotional distress
and embarrassment. It is believed that treating grade IIb and III gynecomastia with
liposuction alone does not solve the issue of skin excess.[3] The fundamental tenet of gynecomastia surgery would be violated if the extra skin
was removed because it would leave unsightly scars. In more severe cases of gynecomastia,
liposuction combined with excision of the glands by a small incision is an effective
treatment option.[5]
[6]
[7]
[8]
[9] In this study, we assess the clinical and aesthetic results of gynecomastia patients
after vacuum-assisted liposuction (VAL) and peri-areolar glandular excision. We contrast
the outcomes with liposuction alone as well.
Materials and Methods
After obtaining the required informed consent and ethical approval, patients who underwent
gynecomastia surgery in the department of plastic surgery between February 2022 and
February 2024 were included in the study. A thorough history was collected, including
drug use and jaundice. The grade of gynecomastia was evaluated through examination.
Abdominal examination, assessment of secondary sexual characteristics, and testicular
examination to rule out any cancers were also performed. Blood tests were performed
as part of the pre-anesthesia workup to rule out liver diseases and to check the hormone
levels if needed. Breast ultrasound imaging was done. Clinical photography was done
under proper lighting against blue/green background in standard positions.
Operative Technique
Preoperative markings were done in the standing position on the day of surgery. All
the surgeries were performed under general anesthesia.
Liposuction
The surgery was performed with the patient in the supine position with both arms in
90 degrees of abduction under general anesthesia. Following meticulous painting and
draping, a 4-mm stab incision was placed in the anterior axillary line within the
anterior axillary fold. Tumescent solution infiltration into the breast tissue and
its surrounding area was executed using a blunt-tipped 4-mm infiltrating cannula (Klein's
infiltration cannula). A second stab incision was made in the anterior axillary line
at the level of the inframammary fold after 7 minutes allowing for the tumescent to
start its action. Employing a 3.5-mm blunt-tip cannula (Coleman cannula), VAL was
meticulously performed, adhering to established surgical protocols. For fine-tuning
and precision fat removal toward the end of the procedure, a 3-mm spiral cannula was
employed. This meticulous approach ensured the achievement of the desired chest contour.
An endoscope (Karl Storz Endoskope TP100) was introduced via the liposuction port.
Suture packet technique as shown in [Fig. 1A] was used to lift the skin and subcutaneous tissue off the pectoralis muscle and
fascia to create space for visualization. If extra-glandular tissue was visualized
([Fig. 1B]), patients were planned for glandular excision. In patients in whom there was no
excess glandular tissue, the endoscope was removed while simultaneously placing drains
via the inferior port site. Compression dressing was done.
Fig. 1 (A) Suture packet holding technique to lift the skin and subcutaneous tissue off the
pectoralis muscle. (B) Endoscopic view of the excess glandular tissue below the nipple areola complex.
Glandular Excision
The patient was prepared to undergo glandular excision if extra-glandular tissue was
found after liposuction by endoscopic evaluation, as discussed earlier. An inferior
peri-areolar incision was made that ran from the 3 o'clock position to the 9 o'clock
position. Metzenbaum scissors were used to cut the glandular tissue free from the
anterior skin attachments. Using Allis forceps, the gland was grabbed, extracted through
the incision, and excised. To avoid adhesions, care was taken not to breach the pectoralis
fascia. Once hemostasis was attained, suction drains were cautiously introduced through
the inferior liposuction incision to prevent complications such as hematoma or seroma.
Monocryl sutures were used to close the incision in a subcuticular manner. A compression
dressing was applied to optimize postoperative recovery.
In the instances where excess skin did not necessitate excision, the approach focused
on glandular tissue removal. Excised glandular tissue was sent for histopathological
examination.
Drains were removed after surgery when the output was less than 30 mL for 24 hours.
The dressing was changed on the fifth postoperative day, following which patients
were required to wear custom-made compression garments with a simple dressing over
port sites. Patients were followed up on days 3, 5, and 14 and then monthly for 6
months, and clinical photography was done. The clinical photographs were assessed
by two plastic surgeons for cosmetic evaluation using a 5-point Likert scale in terms
of symmetry, nipple areola complex (NAC), scar, and flatness (1: very dissatisfied;
2: dissatisfied; 3 - neither; 4: satisfied; and 5: very satisfied). Patients were
required to fill a breast evaluation questionnaire at the 6-month follow-up visit.
The questionnaire consisted of three parts with satisfaction assessed by a 5-point
Likert scale (1: very dissatisfied; 2: dissatisfied; 3: neither; 4: satisfied; and
5: very satisfied).
Results
A total of 32 breasts were included in this study, with 17 undergoing liposuction
with glandular excision and 15 undergoing liposuction alone. Six patients had bilateral
gynecomastia, while eight patients had asymmetrical breasts. In the liposuction with
glandular excision group, three patients (four breasts) presented with Simon's grade
IIb and III gynecomastia. No statistically significant demographic differences were
noted between the two groups ([Table 1]). Most cases were idiopathic, with three patients reporting a history of steroid
intake. Ultrasonography confirmed increased adipose and glandular tissue in all patients.
Table 1
Demographic and clinical data of patients undergoing liposuction alone and liposuction
with glandular excision
|
Liposuction alone
|
Liposuction + glandular excision
|
|
No. of breasts (n)
|
17
|
15
|
|
Mean age (y)
|
22.6
|
23.8
|
|
Body mass index (BMI)
|
26.2
|
25.8
|
|
Grade (
n
)
|
|
I
IIa
IIb
III
|
8
6
3
0
|
5
6
3
1
|
|
Total operative time (min)
|
46
|
65
|
|
Fat volume aspirated (mL)
|
325
|
310
|
|
Mean duration of hospital stay (d)
|
3.5
|
4.2
|
|
Mean follow-up (mo)
|
7.4
|
6.8
|
Endoscopic visualization added 5 to 10 minutes, and glandular excision required an
additional 10 to 15 minutes in the combined procedure group. Drains were removed by
postoperative day 3, except in one patient. All patients were discharged between postoperative
days 3 and 5.
In the liposuction-only group, skin bruising occurred in three patients (four breasts),
resolving spontaneously ([Table 2]). Two patients developed hematomas, which were managed conservatively. There were
no immediate postoperative contour deformities. All but one patient expressed satisfaction
with the surgery. One patient required a redo surgery at the 3-month follow-up due
to persistent “puffy nipples.”
Table 2
Complications following gynecomastia surgery
|
Complications
|
Liposuction
|
Liposuction + glandular excision
|
|
Bruising
|
4
|
1
|
|
Hematoma
|
2
|
1
|
|
Seroma
|
0
|
1
|
|
Hypo- or hyperesthesia
|
1
|
5
|
|
Wound dehiscence
|
0
|
0
|
|
Infection
|
0
|
0
|
|
Irregularities
|
2 (puffy nipples)
|
4 (crater deformity)
|
|
NAC necrosis (partial or total)
|
0
|
0
|
|
Superficial skin necrosis
|
0
|
1
|
|
Redo surgery
|
2
|
0
|
Abbreviation: NAC, nipple areola complex.
In the liposuction plus glandular excision group, three patients (four breasts) developed
a crater deformity below the NAC, likely from over-resection. This was corrected with
fine-tuning liposuction using smaller-diameter spiral cannulas. Residual crater deformities
resolved over time with tissue remodeling. One patient experienced superficial skin
necrosis of the NAC, which healed with dressings. Hematoma and seroma occurred in
one breast each, both resolving without intervention. One patient developed a hypopigmented
scar.
At the 6-month follow-up, two patients with redundant skin achieved a normal chest
appearance without requiring additional intervention. Patients undergoing liposuction
with glandular excision had comparable cosmetic outcomes to those managed with liposuction
alone. However, the liposuction-only group had a higher rate of redo surgeries.
[Fig. 2] illustrates the preoperative, postoperative 3-day (with left-sided crater deformity),
and 6-month follow-up images of a patient treated with right-sided liposuction and
left-sided liposuction plus glandular excision. [Fig. 3] displays the preoperative and 6-month follow-up images of a patient with bilateral
gynecomastia treated with bilateral liposuction and glandular excision. Patient satisfaction
and chest feature satisfaction are depicted in [Figs. 4] and [5], respectively.
Fig. 2 (A) Right breast Simon's grade IIb and left breast grade III gynecomastia. (B) Day 3 postoperative image with right-sided liposuction and left-sided liposuction
with glandular excision. (C) The 6-month follow-up image.
Fig. 3 (A) Preoperative image of bilateral Simon's grade IIb gynecomastia. (B) The 6-month follow-up image of bilateral Simon's grade IIb gynecomastia.
Fig. 4 (A) Patient satisfaction (liposuction alone group). (B) Patient satisfaction (liposuction and glandular excision group).
Fig. 5 Postoperative satisfaction with chest-specific features. NAC, nipple areola complex.
Discussion
Contemporary challenges in treating gynecomastia include concerns like “puffy nipples,”
recurrence, and compromised aesthetic outcomes due to incomplete tissue removal.[10] Liposuction enables minimally invasive tissue removal, yielding enhanced quality
of life and satisfaction.[9] Open excision, per Innocenti et al, allows direct hemostasis control and histopathological
analysis, vital for detecting rare breast cancer cases.[11]
Contrary to studies like Arvind et al involving excess skin removal, our study focused
on glandular excision and demonstrated improved cosmetic outcomes with innovative
surgical techniques.[12] Addressing concerns about risks with cutting cannulas, our approach, inspired by
Tarallo et al, used pretunneling and suction before excision for contouring and ease
of glandular removal.[13] The peri-areolar scar, as seen in Arvind et al, was well accepted, and our low complication
rate, including hematoma management, highlights the safety of our approach.[12]
Combining ultrasonic-assisted liposculpture (UAL) with peri-areolar gland excision
(without skin resection) ensures safe and effective outcomes, particularly for grade
III gynecomastia.[14] Standard techniques often integrate UAL with conventional liposuction and partial
gland resection, minimizing morbidity and maximizing aesthetic results.[15]
Abdelrahman et al's study, using a specialized fat disruptor cannula, highlighted
glandular tissue breakdown without UAL or gland excision, showing promise for low-resource
settings.[16] Our study adopted a similar method due to UAL unavailability. While Abdelrahman
et al excluded cases with skin excess, our patients with skin excess did not require
excision, achieving comparable outcomes.
Tarallo et al emphasized sequential liposculpture postexcision to enhance skin redraping
and minimize irregularities.[13] Asal et al recommended leaving approximately 5 mm of retro-areolar disk tissue to
prevent retraction, highlighting the importance of careful glandular excision.[8] Abdali et al compared liposuction with/without skin incision, showing higher satisfaction
for the latter, consistent with our findings of high satisfaction and low complications.[7]
Preoperative counseling, as suggested by Ridha et al[17] and Hasanyn and Said,[14] is vital for managing expectations. Consistent with Prasetyono et al, our results
reinforce the positive impact of liposuction and glandular excision on satisfaction
and quality of life.[9] Financial barriers, noted by Alnaim et al, were reflected in our diverse patient
cohort, with 31.1% being students with no income.[18]
Innocenti et al highlighted complications like hematomas, seromas, and pathological
scars, commonly associated with surgical excision.[11] Our findings align with those of Alnaim et al, with reduced complication rates when
combining excision and aspiration techniques.[18]
Endoscopic evaluation in our study provided a more objective assessment of glandular
tissue, preventing unnecessary excisions. Despite added procedural time and complexity,
it proved valuable for fibrous tissue visualization. Offering endoscopy without financial
burden to low-income patients was an institutional advantage.
Limitations include the small sample size, lack of power-assisted liposuction, and
restricted bed availability, necessitating routine use of drains. Targeting specific
grades, we plan further exploration of endoscopic evaluation in larger cohorts.
Conclusion
This study highlights that the cosmetic outcomes of liposuction with glandular excision
are comparable to liposuction alone in the management of gynecomastia. Despite the
heightened procedural complexity and potential complications associated with the combined
approach, it demonstrates effectiveness. The importance of tailoring surgical techniques
to individual patient needs remains paramount, underscoring the continual necessity
for research to further refine and optimize gynecomastia treatment strategies.
