Description of Gynecomastia Excision Surgery Using Tumescent Liposuction and Scissors Dissection Technique
2002 AMERICAN JOURNAL OF COSMETIC SURGERY
VOL. 19, NO. 3, 2002
Many surgeons are now attempting to treat male gynecomastia by liposuction. Whereas this is effective at times, sometimes it results in a less than optimal outcome. Not only does the breast tissue not respond perfectly well even to the sharpest cannulas, but with overly vigorous liposuction, complications such as nipple slough or irregularity become more likely. Many times the surgeon will be forced to do excisional surgery either at the time of the primary surgery or at the time of revision surgery. Also, after liposuction, the breast tissue sometimes seems to be stimulated and actually grow, requiring excision. At other times, the scarring in the breast tissue coalesces in a peri-areolar mass that is cosmetically unsightly. An extensive literature exists on the treatment of gynecomastia by surgery and liposuction. 1-46
The initial exam can help determine whether fat or breast tissue is primarily present. If there is not much fat, and the breast tissue can be felt clearly as a discreet shoddy mass, excision may be necessary. An attempt to perform liposuction during the initial surgery will reveal to the surgeon if liposuction is likely to be productive (see subsequently). If there is a great deal of fat around any breast tissue and the patient seems to be the sort who might be satisfied with a partial reduction in the area, liposuction alone is usually best because of the shorter recovery period and lower morbidity. We always warn (in writing) that secondary surgeries may be necessary. Steroid (bodybuilder's) gynecomastia, which is usually quite firm and just under the areola, in general, needs a primary excision to achieve a decent result.
After sedation, a generous amount (a liter or often, two) of tumescent anesthetic is placed into the pectoralis muscle, the fat surrounding the breast tissue, the axillae, and the breast tissue itself, with a blunt rainbird infiltrator and a pump. Depending on what other surgeries the patient is having on that day (and the total lidocaine load), an increased concentration of lidocaine is usually employed, commonly 0.15 or 0.2% with 1:300,000 epinephrine instead of 1:1,000,000 epinephrine. It is advisable to wait for 15 minutes before surgery.
We then test the gynecomastia tissue by liposuction with a 3-4 mm "candy cane" cannual (KMI, Anaheim, CA). If the tissue responds, sharp surgery may not be optimal. If sharp surgery is elected, liposuction is performed in two distinct planes: the first plane above the breast tissue and below the dermis, with the second plane above the pectoralis fascia and below the breast tissue. If there is very little fat, this may be done without suction to establish the dissection planes.
After this is performed from 3 or 4 angles through liposuction incisions at the periphery of the breast, and the edges are feathered in such a fashion as to produce a smooth transition with the fatty layers around the breast, the incision is made. The inferior 50% of the circumference of the areola-skin margin is incised to fat with a 15 blade. At this point, the planes that had been developed with the liposuction cannula fall apart easily with facelift scissors.
After these planes are completely developed, one after the other, it becomes a simple matter to dissect around the edges of the breast tissue and extract the gynecomastia tissue through the peri-areolar incision. The scissors' bevels are up in the fascial plane and down in the subdermal plane to protect these structures, respectively. Rarely does it become necessary to take out the breast tissue in pieces; most of the time it is small enough to be delivered through the incision. If "morselization" of the tissue is performed, it becomes more difficult to establish even, smooth planes of dissection, and the cosmetic result may suffer. Of key importance is holding the breast tissue at all times up from the chest wall with towel clips. Pneumothorax is a possibility if this admonition is not heeded. As breast tissue is elevated with the nondominant hand, the scissors dissection can be easily done with the other hand. I recommend an inferior approach to the lower plane above the pectoralis fascia. If these planes are properly developed and the pectoralis not invaded, bleeding is rarely much of a problem because large amounts of tumescent anesthetic and 1:300,000,000 epinephrine are used. Leaving a substantial button of ductal tissue attached to the areola ensures that this structure heals in a convex and natural fashion.
After the scissors dissection and removal of the breast tissue, any remaining fat particles and fluid are milked out through the incision. Further feathering is performed if necessary with scissors or cannula. Examination of the cavity with a headlight for bleeders should be performed. Cautery is seldom necessary if the pecoralis has not been violated and enough anesthetic has been used. Then the peri-areolar incision is closed in an everted subcuticular fashion and a Jackson-Pratt drain sutured in place. Tight compression is applied with an elastic band (typically used for the waist), over doubled foam dressings and sterile dressings. The elastic bandage should be quite snug, to hopefully provide hemostasis and prevent seroma formation.
The drains should be assiduously emptied over the course of the first 48 hours. The patient is checked at 24 hours and then as judged proper by the surgeon. Usually the drains are left in up to 2-4 days. Fifteen milliliters of clear drainage per day is to be expected as a normal consequence of having the Jackson-Pratt in place, and this generally means that it can be removed. If the compression was good, hemostasis was attained, and the drains are working, usually no seroma or hematoma occurs.
Although some irregularity is common in the first month after the procedure, generally with skilled surgery the breasts ultimately look smooth and acceptable. Compression is worn for at least 2 (and usually 4) weeks. Slight nipple distortion and scarring is inevitable, with elliptical shapes common. This often improves over the course of a year or more. Occasionally, skin excision becomes necessary. Crescent mastopexy techniques will raise and shape the areola. Epidermal skin slough may occasionally occur (like a skin graft) and is not a disaster, although for a week or two, the surgeon may wonder if the nipple will be lost. The color change caused by this - usually hypo-pigmentation — is temporary.
Evacuation of any hematomas or seromas at the earliest possible interval is of key importance in postoperative management. Sometimes an active bleeder will be found. Although breast cancer in males is exceedingly rare, the specimen should be sent to the pathologist for examination.
Tom Reese, in his classic surgery textbook, Aesthetic Surgery, 47 has recommended that no workup for gynecomastia is necessary unless there are some other complaints found on review of systems or physical exam, but some sources 48-50 feel that endocrine referral for consideration of pituitary tumor is reasonable.
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