Gynecomastia Treatment with Subareolar Glandular Pedicle

Background Gynecomastia is enlargement of the male breast. Although treatment is not indicated in most cases, aesthetic reconstructive surgery is commonly performed for psychological reasons. The goals in surgical treatment are to restore the breast contour with minimal scar and to protect areolar anatomy and sensation. This clinical study investigates the results of the subareolar glandular pedicle technique, in which the pedicle is dissected 2 mm wider than the areola with a circumareolar incision and the breast tissue is excised en bloc. The technique differs from the classical circumareolar approach with its thinner pedicle and excision of the breast without leaving prepectoral tissue.Methods We operated on nine patients with grades 1 and 2 gynecomastia using the subareolar glandular pedicle. Exposure was excellent with the circumareolar incision. Neither hematoma nor seroma formation was seen in any of the patients. Partial areola necrosis, which caused suture separation, was the only early postoperative complication seen, and this in a patient who smoked heavily. Patients were followed for at least 6 months.Results Eight patients achieved a good aesthetic contour of the chest, and one patient needed a contour revision for the residual mass because of a bulky pedicle. Circumareolar scars were satisfactory for all the patients, including the patient with partial areola necrosis. Circumareolar hyperpigmentation developed in one patient, and areola sensation was preserved in seven patients.Conclusions The subareolar glandular pedicle is indicated for grades 1 and 2 gynecomastia. Circumareolar incision provides perfect exposure. The technique is reliable if the pedicle is dissected 2 mm wider than the areola and dissection under the pedicle is avoided. Postoperative circumareolar scarring is minimal and nipple–areola sensation is preserved in most cases. However, experience is needed to determine the pedicle girth because a wide pedicle leads to subareolar bulk, whereas a thin pedicle may cause partial areola necrosis.     

双环真皮单蒂缩乳术治疗男性乳房发育症

目的：探讨双环真皮单蒂缩乳术治疗男性乳房发育症的疗效。方法：5年来采用双环形切口,乳头乳晕外上真皮单蒂法治疗男性乳房发育症,共10例,20侧乳房。结果：每侧乳房切除150～500g组织,除1例一侧乳房出现乳晕部分坏死外,余胸部形态美观,感觉恢复,效果满意,随访2～50个月,效果较为满意。结论：双环真皮单蒂缩乳术治疗男性乳房发育症,操作简便,安全,并发症少,术后胸部形态美观,值得推荐。     

Periareolar-transareolar-perithelial incision for the surgical treatment of gynecomastia

Gynecomastia is an abnormal enlargement of the breast tissue in men. It is the most common disorder of the male breast. Surgical sharp resection of the excess breast tissue is still the mainstay of treatment when medical treatment modalities are proved to be ineffective. The authors believe that areolar incisions give the best results, especially for grades I and IIA gynecomastia. The authors review the ever-increasing areolar incision techniques that have been previously recommended, propose a classification for these techniques, and introduce an alternative technique for areolar resection of the enlarged gland in gynecomastia. An inferior pole, periareolar-transareolar-perithelial (PTP) incision was designed and 15 patients were operated successfully using this technique. Twelve cases were bilateral and 3 were unilateral (27 breasts). A 65-mm access port can be obtained from a 30-mm-diameter areola. No color changes or slough was observed in any of the patients. Areolar access incisions can be classified into 4 main groups: circumareolar, periareolar, transareolar, and circumthelial, and their subgroups. Like every incision proposed, the PTP incision cannot be recommended for every grade of gynecomastia. It is best suited for grades I, IIA, and IIB gynecomastia. Its wide exposure and potential advantage for areolar reduction makes this incision a good alternative to other areolar approaches.     

男性乳房发育症的肿胀双环单蒂缩乳术

目的 探讨男性乳房发育症肿胀双环单蒂缩乳整形术式。方法 5年来采用肿胀局麻技术、乳房双环形切口、乳头乳晕外上真皮乳腺单蒂、乳房缩小术治疗男性乳房发育症，共42例80侧乳房。方法 每侧乳房切除100－500g组织，无乳头、乳晕坏死等并发症。随访3－48个月，除乳晕切口处有轻度瘢痕增生、边缘不整齐外，余无异常，效果较为满意。结论 肿胀局麻技术下乳房双环形切口、乳头、乳晕外上真皮乳腺单蒂、乳房缩小术治疗男性乳房发育症，操作简便，安全，损伤轻，出血少，恢复快。     

The use of a combined technique in reduction mammaplasty (inferior pyramidal and superior glandular techniques)

The management of mammary hypertrophy is a developing process. The common surgical options for reduction mammaplasty include amputation with free nipple graft as well as the bipedicled, inferior pedicle and vertical pedicle techniques. All techniques are used widely. Disadvantages of these procedures include nipple areola necrosis, insensitivity, hypopigmentation, and poor breast projection. Even with the standard modifications of the original techniques, the resultant breast and nipple may be wide and flat. The purpose of this study was to assess whether combined inferior pyramidal pedicle and superior glandular pedicle reduction mammaplasty can optimize nipple and breast projection. Attention will focus on the viability and sensation of the nipple areola complex. Nine patients with mammary hypertrophy were studied. The change in nipple position ranged from 7 to 13 cm. The amount of tissue removed from each breast ranged from 500 to 1150 g. Nipple/areola sensation was retained in all cases with the exception of one breast. Nipple/areola necrosis or hypopigmentation were not observed. Optimal central breast projection was maintained in all patients, and postoperative evaluation was carried out at 12 and 22 months. The patient satisfaction was very high.     

The dermal overlap subareolar mastopexy: A preliminary report

Background: The major disadvantage of the circumareolar mastopexy is the risk of hypertrophic scarring and relapse or widening of the areola. Objective: The author describes a new technique that gives added support to the scar by means of a dermal overlap flap that is buried under the areola. Methods: A doughnut incision is made, with the size of the outer circle dependent on the amount of ptosis to be corrected. The areolar flap is elevated close to the nipple pedicle, a circumferential incision is made through the dermis between the pedicle and the outer incision, and the dermal edge is elevated. After the mastopexy, closure is performed with nonabsorbable purse-string sutures. Results: Initial results in a series of 34 cases have been encouraging, with no loss of nipple sensation and with less scarring and more natural nipple projection than occurs in conventional doughnut mastopexy procedures. Conclusions: This technique can be used to reduce scarring in procedures such as mastopexy, breast reduction, and tubular breast correction. (Aesthetic Surg J 2001;21:423-427.)     

Circumareolar Dermo-Glandular Plication: A New Concept for Correction of Breast Ptosis

Circumareolar dermo-glandular plication is the latest advancement of the periareolar dermopexy with a retromammary mastopexy technique I published in 1969. Rather than a technique, the new concept is a procedure which originates new techniques covering multiple indications, i.e. for all conditions combined with ptosis: for mastopexy in ptotic breasts, for hypertrophic or hypoplastic breasts with resection or implant augmentation, respectively; for subcutaneous mastectomy, gynecomastia, asymmetries, and tuberous breasts. It is useful for reoperations to correct secondary ptosis as well as to reduce the length of the scar in vertical techniques. The corresponding techniques are described. The procedure has proved to be safe and reliable in over 200 patients with the following advantages: no full thickness skin incision or excisions are performed; only the epidermis is excised. Except for hypertrophies, the skin is not dissected from the gland, nor the gland from the pectoralis fascia, which increases vascular safety and preserves NAC innervation; the dermoglandular unit of the breast through Cooper's ligaments is stabilized by a single or multiple plications. The scar is only circumareolar, reducing psychological stress and discomfort and achieving an early recovery and patient satisfaction. The inconveniences are puckering and some widening of the periareolar scar, which requires a secondary revision in approximately 50% of the cases, also frequently necessary in conventional techniques. There is a tendency to flattening of the NAC and periareolar bulging with tendency to a ``tomato breast appearance.' The prevention of the latter is described.     

An Ameliorated Approach for Sharp Resection in Gynecomastia Surgery

Surgery has become the accepted standard for the majority of patients with gynecomastia to get rid of feminine-looking breast enlargement. Many surgical techniques have been proposed according to grade of gynecomastia. The sharp resection of glandular tissues is a keystone for most of them. However, technical difficulties in application and inexperience in mastectomy often lead to poor cosmetic outcomes. Over excision and saucer-like deformity, under resection, and asymmetries are most common ones among them. The author presents an ameliorated subcutaneous mastectomy method to facilitate the learning curve and to improve the esthetic results avoiding saucer-like deformity and other breast contour deformities. This method consists of an en bloc tissue dissection via superior periareolar incision and excision of fatty glandular tissue in suprafascial plan, with slicing and trimming procedure. It is possible to adjust the degree of tissue reduction during surgery; hence, it may be labeled as a “cut-as-you-go” technique. Between 2008 and 2012, 23 male patients were operated with this technique. Medical photographs and drawings were used to describe the technique. The operation resulted in smooth, symmetric breasts befitting to men in all 23 patients. No major complications were observed in any of the cases. None of the patients reported a discomfort in sensation of nipple–areolar complex. The presented technique provides high degree of patient satisfaction and excellent esthetic outcomes and is a promising choice in gynecomastia surgery with extremely low recurrence rates and easy learning curve.     

Correction of areolar depression in postsurgically treated gynecomastic patients

Nipple-areolar depression after resection for gynecomastia can be avoided by preserving an ample amount of breast tissue and fat under the areola. If a marked depression of the areola occurs, correction can be difficult. Each patient requires an individual assessment, but the principle of rotation of soft tissue under the areolar complex is usually necessary. An effective way to accomplish this is by deepithelialization of a semilunar area inferior to the original subareolar scar, freeing it at its caudal boarder and advancing this deepithelialized flap under the areola and repairing the wound. The technique is simple in design and may be a useful tool in dealing with this difficult problem.     

Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction.

INTRODUCTION: Previous anatomical and clinical studies have shown that nipple-areola sensitivity decreased significantly after conventional superior and inferior pedicle technique for 3-6 months postoperatively. We found it necessary to modify our techniques in breast reduction to achieve a better outcome regarding breast sensation. Since 1999, we have been using a new technique of breast reduction with a latero-central glandular pedicle. The pedicle for the nipple-areola is based on a horizontal septum and it is designed to incorporate the anterior ramus of the lateral branch of the fourth inter-costal nerve and perforator vessels. Using this technique, a prospective study was conducted in order to quantitatively assess the nipple-areola sensitivity. MATERIAL AND METHODS: The sensitivity of the nipple-areola complex (NAC) was evaluated in 20 consecutive patients undergoing breast reduction with the septum-based lateral pedicle technique. The sensitivity was assessed preoperatively, 2 weeks and 3 months postoperatively by the same examiner. The nipple and four cardinal points of the areola were tested. Pressure thresholds were measured with Semmes-Weinstein monofilaments, temperature sensitivity with hot (40 degrees C) and cold (4 degrees C) metal probes and vibratory thresholds with the Biothesiometer. Average sensation of the areola was calculated by means of the four areas tested. RESULTS: Average values of different patterns of sensitivity decreased significantly on the tested areola 2 weeks postoperatively. Three months postoperatively, pressure and vibration values were statistically comparable in averages to preoperative values (nipple: 46.2+/-3.8 versus 34.6+/-2.2 g/mm2 and 6.4+/-1.2 versus 3.7+/-1 micron; areola: 57.4+/-5.7 versus 49+/-6.8 g/mm2 and 6.7+/-1.2 versus 3.1+/-0.6 micron). Concerning the ability to recognise temperature, 27.5 and 20% of patients could not distinguish between cold and hot 3 months after surgery, on the nipple and the areola, respectively. Numbness was found only on two NAC despite the significant decrease of sensitivity after 2 weeks. This may be attributed to postoperative oedema or neuropraxia. CONCLUSION: Our results showed that using the latero-central glandular pedicle technique preserves the sensitivity of the NAC.     

Twenty-two year experience with recurring subareolar abscess andlactiferous duct fistula treated by a single breast surgeon

BACKGROUND: Recurring subareolar abscess and lactiferous duct fistula are frequently difficult to manage. METHODS: Personal experience with 67 cases treated during the past 22 years is reviewed. RESULTS: There were 38 cases of subareolar abscess and 29 of lactiferous duct fistula. Thirty-three patients had resolution with antibiotics and needle aspiration or with incision and drainage,but 34 patients required definitive duct excision. Eight patients had duct excision through circumareolar incisions, and 5 of these had prolonged healing problems or recurrence within 1 year. Twenty-six patients had duct excision by placing a probe into the duct and radially excising an elliptical area of the nipple and areola like a "slice of pie," and these all healed primarily (P <0.001). CONCLUSIONS: Approximately half of the patients with subareolar abscess can be managed medically, but the other half will require definitive duct excision. A radial elliptical incision with primary closure results in excellent cosmesis and low long-term recurrence rates.     

乳晕内下缘弧形切口皮内缝合治疗男性乳房肥大症

目的:探讨通过乳晕内下缘弧形切口切除增生乳腺组织,并采用皮内缝合治疗男性乳房肥大症的手术方法和临床效果。方法:回顾性分析5年来采用局部浸润麻醉或基础麻醉+局部浸润麻醉,在乳晕内下缘取弧形切口切除肥大增生乳腺组织,保留乳头下方的部分乳腺组织垫,治疗59例,76侧男性乳房肥大症的临床资料。结果:59例,76侧男性乳房肥大症患者,经治疗后手术效果确切,血运障碍发生少,术后患者胸部平坦,无凹陷,乳头无异常感觉,外形满意,切口隐蔽,切口痕迹不明显。结论:采用乳晕内下缘弧形切口皮内缝合治疗男性乳房肥大症能有效去除多余的腺体和脂肪组织,创伤小,恢复快,减少了术后乳头乳晕血运障碍的发生,无感觉障碍,而且切口隐蔽,瘢痕细小,是治疗男性乳房肥大症的良好手术方法。     

A Superior Vertical Dermal Pedicle for the Nipple–Areola: An Alternative for Severe Breast Hypertrophy and Ptosis

Background  

Nipple–areola nourishment and sensation have been the main concern in reduction mammaplasty for severe breast hypertrophy and ptosis. Free grafting for the nipple–areola can cause flatness and loss of sensation. These complications can be improved by pedicle techniques for the nipple–areola, no matter the pedicle orientation. The aesthetic outcomes and complications are similar for the inferior and superior pedicle techniques. The pedicle length has been crucial to nipple–areola viability and sensation.     

内上腺体蒂乳房缩小成形术

目的 探讨一种能够保持乳房功能和形成良好外观的乳房缩小成形术。方法 根据乳房肥大的程度设计不同类型的皮肤切口，采用内上腺体蒂技术，切除外上方和下方过多的乳腺组织，将保留的乳腺组织重新塑形，切除多余的皮肤后缝合切口。结果 本组36例72侧乳房术后形态良好，无并发症，乳头乳晕感觉良好，效果满意。结论 内上腺体蒂技术是一种安全、有效的手术方法，能获得持久的塑形效果，通过选择不同类型的皮肤切口可以适用于各种程度乳房肥大的矫治。     

应用乳腺旋转瓣固定矫正轻中度乳房下垂

目的:介绍采用乳房外下象限乳腺旋转瓣固定矫正轻中度乳房下垂的方法和经验。方法:经乳晕周缘"双环形"切口,去除内外环之间的表皮。在皮下脂肪组织与腺体之间广泛分离。在乳房下方正中垂直剖开乳腺,并向外侧分离,形成乳房外下象限乳腺瓣,并向内上方旋转固定,缩小乳房基底,重塑乳房外形,并上提下垂的乳头乳晕复合体。伴有明显乳腺萎缩者,同期或Ⅱ期行胸大肌下假体隆乳术。结果:2011年2月~2013年12月采用该方法共治疗轻中度乳房下垂19例,无血肿、感染、乳头乳晕坏死等并发症发生,术后随访1~2年,无乳房下垂复发,乳房下垂明显矫正,双乳对称,外形良好。切口瘢痕呈环线状,乳头乳晕感觉功能正常。结论:乳腺旋转瓣固定法结合了"双环法"和"垂直法"两种技术的优势,对轻中度乳房下垂的治疗,提供了一种新的思路和方法。     

Surgical therapy of pronounced gynecomastia

Surgery for gynecomastia is primarily aimed at the complete removal of the breast tissue and the reconstruction of the normal breast and chest contour while leaving minimal telltale signs of the surgery. Dufourmentel and Webster described a technique that placed the incision along the border of the nipple-areola complex. The aesthetic results are good by smaller and moderate cases of gynecomastia. The surgical correction of the larger cases requires the correction of both glandular tissue and skin. The concentric circle operation - described by Schrudde - permits the complete removal of breast tissue and corrects the skin redundancy. The periareolar operative scar is relatively inconspicuous. Our technique and the results are described.     

环乳晕切口下蒂瓣法矫治巨大乳房

目的:探讨环乳晕切口下蒂瓣矫正特别巨大乳房的临床效果。方法:采取环乳晕切口,以部分去表皮的下蒂瓣为基础,切除乳头乳晕上方、外侧大部分腺体皮肤及内侧部分腺体皮肤组织,上提下蒂瓣,固定重塑乳房腺体形态,再将下蒂两侧的皮肤均匀拉拢,覆盖下蒂瓣,切除多余皮肤,使之形成不超过乳房下皱襞的斜形短切口,乳晕及周围的皮肤真皮层辐射状环缩缝合,缝合皮肤。结果:10例20只乳房,单侧乳房组织平均切除量为1 050g,最大2 200g。随访6~12个月,无乳头坏死、感觉良好,外形饱满。患者对乳房形态、对称性、乳晕大小形状、乳头乳晕感觉及切口瘢痕的满意率分别为100%。结论:环乳晕切口下蒂瓣的巨大乳房缩小整形术,组织切除量大,瘢痕短,并发症少,是一种较好的巨大乳房缩小术式。     

竖直切口内上蒂巨乳缩小术的临床应用

目的 根据巨乳缩小术的手术原则,探讨一种既能保证乳房血供和功能,又能保持良好乳房外观的手术方式,并观察其临床疗效.方法 本组共10例乳房肥大症患者,采用竖直切口结合内上蒂法行乳房缩小术.根据术前设计,去除内上蒂表皮,形成腺体蒂,再切除外下象限多余的皮肤及腺体,重塑乳房形态.结果 术后无皮肤坏死、脂肪液化、乳头乳晕感觉减退、血肿和感染等并发症发生,切口均Ⅰ期愈合.术后随访3～12个月,患者对术后乳房外观形态及功能均表示满意,能接受术后瘢痕.结论 竖直切口内上蒂巨乳缩小术操作简单、安全,对轻、中度,特别是中度乳房肥大患者特别适用,术后和远期均能达到满意疗效.     

乳晕边缘小切口切除乳房多发或巨纤维腺瘤

目的探索采用乳晕边缘小切口切除乳房多发或巨大良性纤维腺瘤,达到既切除病灶又能起到美容目的的可行性。方法2006年1月～2008年2月选择46例乳房多发良性纤维腺瘤和2例巨纤维腺瘤（〉7cm）,根据多数肿瘤或巨大肿瘤存在的部位,选择不同象限的乳晕边缘切口,切口长度不超过乳晕周长的1/2。对于多发乳房良性肿瘤,在皮下脂肪和腺体之间潜行游离到肿瘤表面,放射状切开肿瘤表面的腺体,将肿瘤完整切除;对于巨大良性肿瘤,同法切开腺体至肿瘤表面,将肿瘤分块全部切除。结果46例多发乳房纤维腺瘤共计切除肿瘤165个,其中1例双侧乳房肿瘤数量达19个,均完整切除;乳房巨纤维腺瘤2例,肿瘤最大直径8cm,也将肿瘤完整切除。乳晕边缘切口长度〈3.5cm,术后均未发生乳头坏死。48例随访1～24个月,平均14.4月,11例切口瘢痕不明显,26例注意观察才能发现切口瘢痕,9例比较容易看到切口瘢痕,2例因瘢痕体质切口瘢痕明显。结论乳晕边缘小切口切除乳房多发或巨纤维腺瘤,手术方法简便易行,可达到较好的美容效果,值得推广。     

双环复合组织筋膜瓣法矫正乳房下垂的临床应用

目的 探讨应用双环复合组织筋膜瓣法行乳房悬吊术矫治乳房轻、中度下垂的方法及临床效果.方法 在传统的双环形切口乳房缩小整形术的基础上,在皮肤与乳腺的腺体表面间行广泛剥离后,应用蒂在乳腺上半象限的筋膜瓣垂直下拉,缝合固定于下半象限的乳腺与胸大肌之间,并将乳晕内外环的真皮行荷包缝合,术后将乳房塑形包扎.结果 应用双环复合组织筋膜瓣行乳房悬吊术的方法矫治乳房下垂20例,患者均Ⅰ期愈合,无乳头、乳晕坏死.所有患者术后随访6~12个月,乳晕周围皮肤皱褶基本消失,乳房外形美观持久,乳头、乳晕感觉良好,效果满意.结论 改良手术方法技术简便易行,组织损伤小,瘢痕不明显,是矫治轻、中度乳房下垂的一种比较理想的方法,值得推广应用.