One of the serious malaise that has effected modern western world is the mania of publications. Before one has any clue of the subject, a publication is born. In most cases the thought process is blocked and there is a compulsive socio-career oriented compulsion to publish. Invariably this lands up with lot of junk or the repetition of same idea again and again and again.
In case of gynaecomastia the number of publications reflects this fact. The original operation of removing breast by a subcutaneous mastectomy underwent several modifications of approaching the breast tissue either by an infra-mammary route or axillary route or through or around the nipple. All these techniques were basically aiming at a position of hiding the scar.
There are few basic questions to be answered before we step in to manage gynaecomastia:
- What is the grade of gynaecomastia?
- Do we remove breast tissue only, or adjust the skin with it?
- Is the breast predominantly of fatty tissue or fibro-glandular tissue?
- What is the best way to avoid scars?
- How to prevent the saucerisation to give cosmetically good results?
Before contemplating surgery, these questions have to be answered. Grade I gynaecomastia can be treated with reduction of fat, but Grade II (sometimes) and Grade III (always) requires skin excision alongside.
Liposuction, as the only treatment is applicable to fatty breasts in Grade I and early Grade II gynaecomastia.
In other cases excision must be performed. The choice of approach is individual. I tend to use a superior pedicle based peri-areolar approach and reduce the skin if needed. The removal of breast is an art. Anterior approach to the breast invariably results in saucerisation. Sometimes this can be masked by adjuvant peripheral liposuction. Over-reduction at nipple-areolar complex can cause severe nipple retraction. I use a posterior approach, my own technique, which has until now produced consistent cosmetic results.
In Grade III ‘giganto-gynaecomastia' an inferior or superior pedicle technique or bipedicled technique or even a free nipple transfer may be necessary.
In fibro-glandular breast which does not need skin excision, I use the endoscopic technique.
Fashions will change. The process of describing yet another technique will go on .