Scandinavian Journal of Surgery 92: 160–162, 2003 SURGICAL TREATMENT OF GYNECOMASTIA: LIPOSUCTION COMBINED WITH SUBCUTANEOUS MASTECTOMY S. Boljanovic, C. K. Axelsson, J. J. Elberg Department of Plastic Surgery, Odense University Hospital, Odense, Denmark Department of Surgery, Division of Breast and Endocrine Surgery, Odense University Hospital, Odense, Denmark ABSTRACT The purpose of the present work has been to evaluate surgical treatment of gynecomastia performed by liposuction combined with subcutaneous mastectomy. It was designed as a prospective consecutive registration of 21 patients (28 breasts) operated in a four month period. Treatment was done in local anaesthesia in the out-patient clinic. Treatment was in one patient complicated with a haematoma. In 86 % of cases the patients were satisfied with the postoperative result. Liposuction combined with surgical excision of the gland performed as an out-patient treatment in local anaesthesia is followed by few complications and good cosmetic results. Key words: Gynecomastia; liposuction; subcutaneous mastectomy INTRODUCTION Before the 1980’s the surgical treatment of gynecomastia consisted of excision of glandular tissue and fat, in some cases combined with skin reduction. Subcutaneous mastectomy ad modum Webster is the method most commonly used in Denmark. It is performed with an infraareolar approach, if necessary extended laterally (1, 2). This procedure has a relatively high complication rate due to haematomas and seromas (10 %), and the results are often disappointing for patients (52 %) and surgeons, because of frequent contour irregularities, disfigured scars and reduced nipple sensibility (2, 3, 4). The introduction of liposuction in cosmetic surgery has resulted in a new treatment modality, as nonscarring sparing methods are preferred. Treatment can be combined with excision of glandular tissue and Correspondence: Slaven Boljanovic, M.D. Department of Plastic Surgery Odense University Hospital DK - 5000 Odense C Denmark Email: [email protected] can be performed under local anaesthesia on an outpatient basis (5, 6). MATERIAL AND METHODS We have treated 28 breasts during a four month period. Seven patients were treated bilaterally, and 14 unilaterally. Mean age was 29 years (range 18–61 years). In 76 % of patients (17/21) gynecomastia was idiopathic. Former intake of anabolic steroids was the cause of gynecomastia in two patients, and the remaining two patients had renal insufficiency and liver insufficiency due to alcoholism respectively. Ten out of 21 patients (48 %) were seeking treatment because of cosmetic and psychological problems. Local pain was the reason in five patients (24 %) while in three patients (14 %) the indication was a combination of these problems. In the remaining three patients fear of cancer was the reason for seeking treatment. In eight out of 21 patients (38 %) local tenderness was found preoperatively. Clinical examination revealed that 81 % (17/21) of patients had considerable fat deposition combined with glandular hypertrophy, while the remaining 19 % (4/21) had predominantly glandular hypertrophy with modest fat deposition. One patient was overweight, while the remaining were normal weight. Preoperatively the area of treatment was marked with the patient in upright position. Breast tissue was infiltrated with 0.5 % lidocain with adrenalin and 100–200 ml of Surgical treatment of gynecomastia 161 Fig. 1. 28-year old man with right unilateral gynecomastia before and after operation. Treated by liposuction (150 ml) and surgical excision. isotonic NaCl depending of the size of the breast. A small infraareolar incision was made. We performed liposuction with 6 mm and 3 mm cannulas. After liposuction glandular tissue was removed through the same incision. We preserved approximately 1 cm of glandular tissue under the areola in order to avoid inversion postoperatively. The incions were sutured and covered with a tightened bandage for two weeks. Patients were followed up at two weeks, three months and 18 months postoperatively. At a three month follow-up, patients filled up the questionary where they were asked about experience with the operation under local anaesthesia. They were also asked about the type of anaesthesia they would prefer next time if they were in the same situation. At an 18 month followup they filled up questionary about satisfaction with the cosmetic result of the operation, and they were asked to compare nipple sensation of operated side with non operated in the case of unilateral gynecomastia, and with situation before the operation in the case of bilateral gynecomastia. RESULTS Treatment was able to be performed by liposuction alone in three of 28 breasts (11 %) while in the remaining 25 breasts (89 %) excision of glandular tissue was done as well. Tissue volume removed by liposuction varied from 30 to 300 ml with a mean volume of 96 ml per breast. The volume of tissue removed by liposuction correlated with the breast size and technique was easier in fatty type gynecomastia. Histopathologic examination did not reveal any malignant changes in the removed glandular tissue. One patient developed a haematoma that needed reoperative surgery. He was treated by a combination of liposuction and gland excision. Five out of 21 (24 %) expressed discomfort, three patients (14 %) would choose general anaesthesia if they had been offered the possibility. At 18 month follow-up nipple sensation was found to be normal in all patients. Local tenderness found in 38 % of patients preoperatively was not found in any patient at 18 month follow-up. One patient (5 %) had a recurrence of gynecomastia at 18 month follow-up. 86 % (18/21) of patients found the cosmetic result good or excellent. Three patients were not satisfied with the results. The reason for the dissatisfaction in two of these patients was insufficient volume of tissue removed. There were no cases of inverted nipple or disfigured scars. DISCUSSION Based on our experience most of the patients who seek treatment for gynecomastia have a combination of fat and glandular tissue, however fat tissue makes the largest component. The combination of liposuction with surgical excision of the glandular tissue offers various advantages compared to surgical excision alone. The operation is performed through a shorter incision, and liposuction ensures accurate contouring of the periphery (7). This contributes to achievement of a better cosmetic result (Fig. 1) using a minimally invasive technique. Liposuction before glandular tissue excision facilitates the resection of the glandular tissue (6). Preoperative injection of isotonic NaCl and local anaesthetics with adrenalin ensures compression of the tissue and vasoconstriction which substantially reduces the blood loss (5). Moreover, liposuction causes an increase of coagulative factors in the treated area, which plays an important role in spontaneous hemostasis and implies minimal bleeding in additional surgery (8). Liposuction leaves connections between skin and fascia undisturbed. That is presumably the reason why the sensibility of the region is much less affected compared to surgical excision. Tissue bridges seem to enhance the contractibility of the skin postoperatively, which superfluous skin excision and nipple lift in larger gynecomasties (7, 8) (Fig. 2). Suction alone is not sufficient to remove the glandular tis- 162 S. Boljanovic, C. K. Axelsson, J. J. Elberg Fig. 2. 41-year old man with bilateral gynecomastia before and after operation. Treated by liposuction alone. Removed 300 ml on each side. sue. When followed by sharp resection, it reduces the recurrence rate substantially (6). We had only one case of postoperative bleeding, the only complication which needed treatment. That is less than in other series treated by surgical excision alone. At the same time high patient satisfaction is achieved (2). In accordance with our results Dolsky (9) operated upon 60 patients in a series of liposuction subcutaneous mastectomies, describes the technique and reports excellent and not a single complication. CONCLUSION The combination of liposuction and surgical excision of the gland in gynecomastia can be performed under local anaesthesia on an out-patient basis. Complications are rare. It is our impression that liposuction combined with excision of the gland was followed by higher patient satisfaction, fewer complications and better cosmesis compared to traditional surgical excision, but a final conclusion can only be achieved after conduction of a randomized trial. REFERENCES 1. Webster JP: Mastectomy for gynecomastia through semicircular intraareolar incisions. Ann Surg 1946;124:557–575 2. Noer HH, Søe-Nielsen NH, Gottlieb J, Partoft S: Gynecomastia treated by subcutaneous mastectomy by Webster’s method. Ugeskr Laeger 1991;153:578–580 3. Courtiss EH: Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg 1987; 79:740–750 4. Pitman GH: Liposuction and aesthetic surgery. St. Louis: Quality Medical Publishing Inc 1993:197–209 5. Samdal F, Kleppe G, Almand PF, Åbyholm F: Surgical treatment of gynecomastia. Five years experience with liposuction. Scand J Plast Reconstr Surg Hand Surg 1994;28:123–130 6. Voigt M, Walgenbach KJ, Andree C, Bannasch H, Looden Z, Stark GB: Minimally invasive surgical therapy of gynecomastia: liposuction and exeresis technique. Chirurg 2001;72:1190– 1195 7. Mladick RA: Gynecomastia: Liposuction and excision. Clin Plast Surg 1991;18:815–822 8. Gasperoni C, Salgarello M, Gasperoni P: Technical refinements in the surgical treatment of gynecomastia. Ann Plast Surg 2000; 44:455–458 9. Dolsky RL: Gynecomastia. Treatment by liposuction subcutaneous mastectomy. Dermatol Clin 1990;8:469–478 Received: July 29, 2002 Accepted: January 24, 2003
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