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.
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Received: July 29, 2002
Accepted: January 24, 2003