Treatment of gynaecomastia has been described by several methods. Here the author describes his own modification to achieve better cosmetic results.
Gynaecomastia is one of the commonest male cosmetic surgery that aesthetic surgeons are called upon to perform.
In medical terms it signifies benign enlargement of male breast. Obviously it is customary to differentiate true gynaecomastia (proliferation of mammary ducts and periductal tissues) from pseudo-gynaecomastia (either by deposition of fat or skin might be lax as result of weight loss after obesity).
The imbalance in growth may be neonatal, pubertal or involutional which are physiological causes of gynaecomastia. Endogenous endocrine imbalance due to hypogonadism, adrenocortical tumours, hyperthyroidism, cromophobe adenoma and drugs and hormones.
While pseudogynaecomastia due to excess fat can be effectively treated by liposuction , and excess skin can be treated by excision, true gynaecomastia though easy to treat surgically is difficult to get contour right.
While numerous operations have been described to correct true gynaecomastia ranging from semicircular infra-areolar or lateral areolar incisions of Webster, to transnipple-transareolar incisions of Pitanguy18, to radical incision of Eade7, or superior semicircular incisions of Letterman 11,15 and Schurter, or intra-areolar Z incision of Sinder , to inferior semicircular intra-areolar incision of Barsky, Simon, Hoffman9 or subcutaneous mastectomy incisions of Gillard Thomas or extra-areolar incisions of Campos . Modifications have been proposed by Malbec, Kurtzahns and Iglesiaas.
The shear volume of techniques involved show that all the techniques are less than perfect. While most techniques emphasise better cosmetic appearance by placement of scars art different positions very few highlight methods of getting the contour right.
The author here proposes Davidson's30 modification to obtain an aesthetic good contour.
The amount of breast tissue to be excised is drawn out .A circumareolar incision 1 to 1.5cm width away from areolar margin is drawn parallel to areolar margin as per Davidson. Further parallel circles are drawn to mark the chamfering edges. Local anaesthesia with adrenaline injected by a spinal needle.
Superior pedicle is de-epithelised. Through the inferior half dissection s carried through breast keeping significant fat on inferior flap to sub-mammary fold. Breast is lifted up in the breast augmentation plane, i.e. between breast and pectoral fascia . Excision is carried out from posterior surface upto the margins previously marked gauging the thickness of skin and fat by bimanual palpation. Excision is carried out until the correct thickness is reached, i.e. thickness of chest wall fat.
After inserting drains closure is affected by 5/0 Vikryl and 6/0 Prolene.
The advantage of this method of posterior dissection is two-fold:
1. It prevents saucerisation which seems to be the commonest problem in cosmetic correction of gynaecomastia.
2. The operator can accurately gauge the thickness of chest wall (skin callipers may be used, if needed) thereby preventing undue indentation.
This technique is a further improvement to Davidson's technique. For very large breasts the areolar diameter is brought to the standard size by a subcuticular 4/0 Maxalon.
The advantage of this technique is that since thickness of remnant breast tissue is felt by bimanual palpation (rather than guessing) chances of error are less. Moreover slight amount of unevenness on posterior breast is masked by breast tissue lying over it and is less noticeable.
1.Lipinski J. Kondrat W. Wojszwillo-Geppert E. Mlodkowska A.,
Surgical treatment of gynecomastia using Webster's method. [Polish]
; Polski Przeglad Chirurgiczny. 48(12):1487-90, 1976 Dec.
2.Damele C. Lancellotti L.:Statistical notes and long-term results in 178 patients operated for benign breast diseases. [Italian]
Minerva Chirurgica. 30(22):1145-51, 1975 Nov 30.
3.Kabza R. Pasz S. Strzeminski A.:Gynecomastia. [Polish]
Wiadomosci Lekarskie. 28(22):1859-62, 1975 Nov 15.
4. Bretteville-Jensen G.:Surgical treatment of gynaecomastia.; British Journal of Plastic Surgery. 28(3):177-80, 1975 Jul.
5. Kurock W. Schniepp K.:Therapy of gynecomastia. [German]
Deutsche Medizinische Wochenschrift. 100(35):1741-2, 1975 Aug 29.
6. Hamer DB.:Gynaecomastia.:British Journal of Surgery. 62(4):326-9, 1975 Apr.
7.Eade GG.:The radial incision for gynecomastia excisions.:Plastic & Reconstructive Surgery. 54(4):495-7, 1974 Oct.
8.Wray RC Jr. Hoopes JE. Davis GM.: Correction of extreme gynaecomastia.:British Journal of Plastic Surgery. 27(1):39-41, 1974 Jan.
9.Simon BE. Hoffman S. Kahn S.: Classification and surgical correction of gynecomastia.:Plastic & Reconstructive Surgery. 51(1):48-52, 1973 Jan.
10.Richards MT.:Breast surgery--as an office procedure.
Canadian Medical Association Journal. 109(4):305-6, 1973 Aug 18.
11.Letterman G. Schurter M.:Surgical correction of massive gynecomastia.
: Plastic & Reconstructive Surgery. 49(3):259-62, 1972 Mar.
12.Walker WW.: The surgical enigma of gynecomastia.
Journal of the National Medical Association. 63(5):385-6, 1971 Sep.
13.Walczak M. Wojciechowski K. Bartkowiak Z. Pawlaczyk J.: Treatment of gynecomastia in boys. [Polish]:Pediatria Polska. 45(9):1041-7, 1970 Sep.
14.Taylor BW.:Mammoplasty: suggested technics.:Southern Medical Journal. 63(3):290-6, 1970 Mar.
15.Letterman G. Schurter M.: The surgical correction of gynecomastia.
American Surgeon. 35(5):322-5, 1969 May.
16.Wojciechowski K. Twardosz W. Walczak M.:Treatment of hyperplasia of the male breast. [Polish]:Polski Przeglad Chirurgiczny. 40(9):1003-9, 1968 Sep.
17.Vaghy I. Ladanyi J. Matolay G.:Data on the treatment of gyneconastia. [Hungarian]:Orvosi Hetilap. 109(21):1130-3, 1968 May 26.
17. Brocker JS. Schornagel HE.:Gynecomastia. [Dutch]
Nederlands Tijdschrift voor Geneeskunde. 111(8):378-80, 1967 Feb 25.
18. Spadafora A. Puchulu GP.:Gynecomastia and pseudogynecomastia: their surgical technics. [Spanish]:Prensa Medica Argentina. 53(38):2135-9, 1966 Sep 23.
18.Pitanguy I.:Transareolar incision for gynecomastia.:Plastic & Reconstructive Surgery. 38(5):414-9, 1966 Nov.
19. Saad MN. Kay S.:The circumareolar incision: a useful incision for gynaecomastia:Annals of the Royal College of Surgeons of England. 66(2):121-2, 1984,Mar.
20. Thielemann FW. Feller AM.:Surgical treatment of distinct gynecomastia in juveniles. [German]: Zeitschrift fur Kinderchirurgie. 39(3):160-3, 1984 Jun.
20.Baroudi R.:Body sculpturing.: Clinics in Plastic Surgery. 11(3):419-43, 1984 Jul.
21. Saad M.N.,:An extended circumareolar incision for breast augmentation and gynecomastia.:Aesthetic Plastic Surgery. 7(2):127-8, 1983.
22.Teimourian B. Perlman R.:Surgery for gynecomastia.: Aesthetic Plastic Surgery. 7(3):155-7, 1983.
23 Reynaud JP. Gary-Bobo A. Merlier C. Selam JL. Bringer J.
: Technical aspects of the surgical treatment of gynecomastia. [French]:Annales de Chirurgie Plastique et Esthetique. 28(4):383-7, 1983.
24..Moss AL. Brown GE.:The surgical approach to gynaecomastia.
New Zealand Medical Journal. 95(712):505-6, 1982 Jul 28.
25. Fissette J.: Surgical treatment of gynecomastia. [French]: Revue Medicale de Liege. 37(13-14):519-20, 1982 Jul 1-15.
26.Huang TT. Hidalgo JE. Lewis SR.:A circumareolar approach in surgical management of gynecomastia.: Plastic & Reconstructive Surgery. 69(1):35-40, 1982 Jan.
27.Fara M. Hrivnakova J.:Reduction surgery of the breasts in severe gynecomastia using a surgical flap with a single pedicle at the top. [Czech]: Rozhledy V Chirurgii. 60(11):723-5, 1981 Nov.
28.Fara M. Hrivnakova J.:Reduction mammaplasty in serious gynaecomastias using a single superiorly based flap.: Acta Chirurgiae Plasticae. 23(3):159-62, 1981.
29.Stockharova D.:Experience with surgical treatment of gynecomastia. [Czech]:Rozhledy V Chirurgii. 59(2):88-92, 1980 Feb.
30.Davidson BA.:Concentric circle operation for massive gynecomastia to excise the redundant skin.:Plastic & Reconstructive Surgery. 63(3):350-4, 1979 Mar.
31.Balch CR.:A transaxillary incision for gynecomastia.:Plastic & Reconstructive Surgery. 61(1):13-6, 1978 Jan.
32.Artz S. Lehman JA Jr.:Surgical correction of massive gynecomastia.:Archives of Surgery. 113(2):199-201, 1978 Feb.
Figure 1: Circumareolar incision and de-epithelize d superior pedicle
Figure 2: Surgical approach plane and elevation
Figure 3: Breast Tissue removed keeping superifical layer of fat