The surgical management of high-grade gynecomastia

It is now well accepted that low grades of gynecomastia are best treated with liposuction alone. However, the surgical management of the high-grade gynecomastia (Simon's grade III) has remained problematic because both liposuction and conventional subcutaneous mastectomy (without skin excision) have frequently resulted in significant residual skin redundancy, requiring a second operation for skin resection. Our preferred approach to high-grade gynecomastia has been the single-stage subcutaneous mastectomy and circumareolar concentric skin reduction with deepithelialization. However, in the rare case of tubular breast deformity in the male and also in patients with gynecomastia who underwent massive weight loss, simple mastectomy and free nipple graft is performed. Therefore, these 2 groups of patients will be excluded from the current series. Twenty-four consecutive males with high-grade gynecomastia were reviewed. All patients underwent subcutaneous mastectomy with concentric skin resection. There were no major complications such as infection, hematoma, seroma, or nipple-areola complex necrosis. The main disadvantage of the technique was the mild residual skin redundancy, which was noted in all 24 patients. This redundancy, however, was never severe enough to require a secondary procedure, and all patients were satisfied with the final result.     

Incidental discovery of bilateral breast cancer in a 24-year-old man presenting with gynecomastia

We present a case of a 24-year-old man who was treated for gynecomastia with bilateral mastectomy and free nipple grafts with subsequent discovery of bilateral breast cancer in the submitted specimens. Surgical treatment of gynecomastia is becoming more popular with over 16,000 procedures of gynecomastia reduction performed in 2005, an increase of 17% compared with the previous year. This case underscores the rare but real possibility of detecting breast cancer in men who present with gynecomastia to plastic surgeons. We caution that male breast tissue should be regarded with the same oncologic principle as female breast tissue. In cases in which ultrasound-assisted suction lipectomy is used, the inability to analyze the breast tissue should be disclosed to the patient.     

Submuscular Periareolar Approach to Augmentation Mammoplasty in Korean Women

Augmentation mammoplasty can be approached by various methods according to the type of implant and implantation site depending on the status of the patient or surgeon's preference. The advantage for submuscular placement is based on problems associated with subglandular placement, especially capsular contracture and sensory changes in the nipple, and interference with the interpretation of mammograms is avoided. There are fewer complications such as hematoma, infection, and extrusion of the implant with submuscular dissection and relatively avascular, minimal sensory changes in the nipple compared with subglandular approach. The submuscular periareolar approach to augmentation mammoplasty was first described in the 1970s. This approach provides easy access to both the subglandular and subpectoral planes. It also provides a central point of access for creation of the implant pocket, which allows for easier and more accurate dissection in all diameters. The resultant periareolar scar is usually minimal with less injury to breast parenchyme and eventual biopsy or mastectomy incision to be performed through or around the areola. During the period of March 1999 to January 2000, 19 cases of who received submuscular periareolar augmentation mammoplasty under general anesthesia resulted in favorable scars with accurate access to pocket margin, easier dissection, and less bleeding compared with submuscular transaxillary augmentation mammoplasty. In our experience with the submuscular periareolar approach to breast augmentation it was highly versatile, safe, and less painful; postoperative hematoma incidence was greatly reduced and breast tissue injury was minimized.     

Treatment of adolescent gynecomastia

Purpose

Adolescent gynecomastia is common but variable in severity. The disease may be self-limited. Although antiestrogen therapy can be used in persistent gynecomastia, results are mixed. Subcutaneous mastectomy via a circumareloar incision is familiar to most pediatric surgeons and provides excellent cosmetic results in most cases. Severe gynecomastia may require alternative procedures. There is little information in the pediatric surgical literature to provide the pediatric surgeon with treatment options for these children. A variety of techniques have been used by plastic surgeons for female patients requiring breast reduction and are sometimes a useful addition to the surgical repertoire for the management of very large breasts in adolescent gynecomastia. We reviewed our experience with the use of inferior pedicle reduction mammaplasty and subcutaneous mastectomy in adolescents with gynecomastia and describe the techniques used.

Methods

After obtaining institutional review board approval, a retrospective review was conducted on all patients operated on for gynecomastia from January 1999 to March 2009. Data recorded included patient demographics, diagnostic evaluation, medical and surgical treatment, complications, and outcome.

Results

Twenty patients underwent an operation for gynecomastia. Eight patients had bilateral inferior pedicle reduction mammaplasty, and 12 patients underwent either unilateral or bilateral subcutaneous mastectomy. The mean age at operation was 15.5 years (range, 14-18 years). In all cases, the histopathologic feature was consistent with gynecomastia. There were no postoperative wound infections. One patient developed a seroma after subcutaneous mastectomy requiring drainage. The mean amount of tissue removed after bilateral reduction mammaplasty was 275.1 g. No patients had devascularization of the nipple-areolar complex or nipple loss. One patient had mild subcutaneous asymmetry after a reduction mammaplasty that required no further intervention. Seven patients (87%) had an excellent cosmetic outcome after reduction mammaplasty. Mean length of follow-up was 18.8 months.

Conclusions

Although many adolescents with true gynecomastia have mild or self-limited disease, operative treatment may provide significant benefit to the remainder. Milder grades of gynecomastia can be managed with subcutaneous mastectomy. Selected severe cases can be safely and effectively treated with reduction mammaplasty.     

侧胸壁脂肪筋膜肌肉瓣在乳腺癌术后即刻乳房成形中的应用

目的:探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术后应用侧胸壁脂肪筋膜肌肉瓣即刻乳房成形的适应证、疗效及可行性。方法:对43例扁平或小乳房、IIIA期前的乳腺癌患者行保留NAC的乳腺癌改良根治术,术中即刻应用侧胸壁脂肪筋膜肌肉瓣乳房成形或同时联合假体乳房重建,术后评价美容效果,观察并发症,对治疗效果进行随访。结果:43例患者均成功手术。平均手术时间1.7(1.3~2.2)h,平均住院时间17(13~24)d,术后平均住院时间13(10~18)d。术后随访2~12个月,无乳头坏死,组织瓣感染2例;无局部复发及远处转移;患者总体满意度8.5分,乳房外观客观评价良好率86.0%(37/43)。结论:保留NAC的乳腺癌改良根治术后即刻应用侧胸壁脂肪筋膜肌肉瓣修复重塑乳房外形具有操作方便、手术快捷、技术可行的特点,特别适合于扁平小乳房、IIIA期前的乳腺癌患者。     

Mammoplasty with an L-shaped limited scar and retropectoral dermopexy

In mammoplasty the goal of the surgeon is giving the breast new form and volume and good, durable shape with minimal scarring. This article presents a simple technique of reduction mammoplasty that avoids incisions in the so-called hypertrophic areas of the chest, the medial and the lateral extremities of the submammary fold. The technique is based on nipple transposition on a superior semicircular flap in the new predetermined side, supra-areolar dermopexy. The skin of the inferior pole of the breast is internally de-epithelized to two curvilinear incisions that end near the projection of the anterior axillary line to form an inferior dermal flap for retropectoral dermopexy. The limited residual scar is L-shaped. Ptotic and hypertrophic breasts can be treated with this method.     

Management of recurrent bilateral multifocal pseudoangiomatous stromal hyperplasia (PASH)

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two‐stage implant‐based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery.     

Subcutaneous mastectomy using an inferior nipple pedicle.

A technique for subcutaneous mastectomy is described which permits a reduction mammoplasty or mastopexy to be performed at the same time. The nipple is based on an inferior dermal pedicle. This appears to provide a safe blood supply to the nipple and safe cover for the prosthesis. The dermal pedicle for the nipple reinforces the submammary suture line and lessens the chance of extrusion of the prosthesis.     

SUBCUTANEOUS MASTECTOMY USING AN INFERIOR NIPPLE PEDICLE

A technique for subcutaneous mastectomy is described which permits a reduction mammoplasty or mastopexy to be performed at the same time. The nipple is based on an inferior dermal pedicle. This appears to provide a safe blood supply to the nipple and safe cover for the prosthesis. The dermal pedicle for the nipple reinforces the submammary suture line and lessens the chance of extrusion of the prosthesis.     

Mammoplasty with an L-shaped limited scar and retropectoral dermopexy

In mammoplasty the goal of the surgeon is giving the breast new form and volume and good, durable shape with minimal scarring. This article presents a simple technique of reduction mammoplasty that avoids incisions in the so-called hypertrophic areas of the chest, the medial and the lateral extremities of the submammary fold. The technique is based on nipple transposition on a superior semicircular flap in the new predetermined side, supra-areolar dermopexy. The skin of the inferior pole of the breast is internally de-epithelized to two curvilinear incisions that end near the projection of the anterior axillary line to form an inferior dermal flap for retropectoral dermopexy. The limited residual scar is L-shaped. Ptotic and hypertrophic breasts can be treated with this method.Presented at the XXXIVth National Congress of Italian Society of Plastic Surgery, Bari, 2–5 October 1985     

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。     

Surgical treatment of gynecomastia: complications and outcomes

ABSTRACT: Gynecomastia is defined as the benign enlargement of the male breast. Multiple surgical options have been used to improve outcomes. The aim of this study was to analyze the surgical approaches to the treatment of gynecomastia and their outcomes over a 10-year period. All patients undergoing surgical correction of gynecomastia in our department between 2000 and 2010 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and revision rate. The surgical result was evaluated with self-assessment questionnaires. A total of 41 patients with 75 operations were included. Techniques included subcutaneous mastectomy alone or with additional ultrasound-assisted liposuction (UAL) and isolated UAL. The surgical revision rate for all patients was 4.8%. The skin-sparing procedure gave good surgical results in grade IIb and grade III gynecomastia with low revision and complication rates. The self-assessment report revealed a good level of overall satisfaction and improvement in self-confidence (average scores 9.4 and 9.2, respectively, on a 10-point scale). The treatment of gynecomastia requires an individualized approach. Subcutaneous mastectomy combined with UAL could be used as the first choice for surgical treatment of grade II and III gynecomastia.     

Reduction mammoplasty using a modified "B" shape method

This article presents a technique of reduction mammoplasty that is modified from the "B" operation for breast reduction devised by Dr Regnault. The overall excision line resembles the letter "B". The advantages of this technique are as followings: 1. It avoids incision in the so-called hypertrophic areas of the chest. 2. The patient has only a short curved scar (the medial horizontal branch of classic inverted-T incision is eliminated) that is not visible laterally. 3. Because there is no skin undermining, and the nipple is transposed on a upper semicircular dermal flap, so the blood supply of the nipple and areola is very good. 4. Ptotic and hypertrophic breasts can be treated with this method. 5. The resulting shape of the breast was satisfactory.     

Papillary carcinoma of the male breast: Report of a case

Intracystic papillary carcinoma of the male breast represents an extremely rare entity that accounts for less than 1% of all malignancies, and histologically may range from papillary hyperplasia in gynecomastia to invasive papillary carcinoma. This report presents the case of a 61-year-old Caucasian man who presented with a 5-year history of a centrally located painless swelling of his right breast with occasional nipple discharge. Triple assessment was very helpful in establishing the diagnosis. Treatment included a mastectomy and hormonal therapy because the neoplasm expressed hormone receptors. Although male breast carcinomas tend to behave more aggressively than their female counterparts, the prognosis of this neoplasm is excellent.     

Surgical Management of Gynecomastia—a 10-year Analysis

Background Gynecomastia is defined as the benign enlargement of the male breast. Most studies on surgical treatment of gynecomastia show only small series and lack histopathology results. The aim of this study was to analyze the surgical approach in the treatment of gynecomastia and the related outcome over a 10-year period. Patients and methods All patients undergoing surgical gynecomastia corrections in our department between 1996 and 2006 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and histological results. Results A total of 100 patients with 160 operations were included. Techniques included subcutaneous mastectomy alone or with additional hand-assisted liposuction, isolated liposuction, and formal breast reduction. Atypical histological findings were found in 3% of the patients (spindle-cell hemangioendothelioma, papilloma). The surgical revision rate among all patients was 7%. Body mass index and a weight of the resected specimen higher than 40 g were identified as significant risk factors for complications (p < 0.05). Conclusions The treatment of gynecomastia requires an individualized approach. Caution must be taken in performing large resections, which are associated with increased complication rates. Histological tissue analysis should be routinely performed in all true gynecomastia corrections, because histological results may reveal atypical cellular pathology.     

Bilateral DCIS following gynecomastia surgery. Role of nipple sparing mastectomy. A case report and review of literature

Bilateral ductal carcinoma in situ of breast is a very rare disease in men. Ductal carcinoma in situ (DCIS) is an abnormal proliferation that involves the ductal epithelium and it has the potential of evolving into an invasive tumour. Gynaecomastia (female like breast in men) is a benign condition though it is associated with a reported 3% incidence of unilateral invasive breast cancer.(2) Synchronous bilateral breast cancer in association with gynaecomastia is exceptionally rare. The recommended treatment for DCIS in male is mastectomy. So far only 2 cases of bilateral DCIS in male patients has been reported in the literature treated with skin and nipple sparing mastectomies. We report another case of synchronous bilateral DCIS in a male treated with skin and nipple sparing mastectomies. A 44 year-old man with history of long-standing gynecomastia. He had no identifiable risk factor for the development of cancer. His pre operative assessment of breast including mammograms was normal. He underwent bilateral subcutaneous mastectomies, with subsequent incidental diagnosis of synchronous bilateral ductal carcinoma in situ. The case was discussed in multidisciplinary team meeting and the need for further surgery was felt including excision of nipple areola complex. However considering patient wishes, cosmetic outcome and recent literature it was decided to preserve nipple areola complex (NAC) with regular follow up evaluation. Our patient at completion of 18 months of treatment is doing well with no signs of local recurrence.     

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。     

肿胀吸脂加乳晕下缘小切口腺体部分切除术治疗男性乳房肥大

目的总结肿胀吸脂加乳晕下缘小切口腺体部分切除术治疗男性乳房肥大的方法及临床效果。方法2004年6月-2006年6月,收治40例男性乳房肥大患者。年龄11～41岁。单侧3例,双侧37例。脂肪型10例,乳房区明显凸出,无腺体增生;脂肪腺体混合型30例,其中22例乳房区明显凸出并伴有肿块,8例呈女性乳房形态并伴有结节增生。38例血清催乳素、黄体生成素、血清卵泡刺激素、雌二醇、睾酮、皮质醇水平均正常;2例血清催乳素、黄体生成素、血清卵泡刺激素、雌二醇水平增高,睾酮水平降低。10例单纯采用肿胀吸脂术,30例联合乳晕下缘小切口腺体部分切除术。结果2例分别于术后第1、2天出现皮下血肿和少量积液,经对症处理后达Ⅰ期愈合;其他患者切口均Ⅰ期愈合。3例术后第1天即出现乳头麻木,未予特殊处理,随访6个月乳头感觉部分减退。其余患者无乳头、乳晕坏死及乳头感觉减退等并发症发生。40例患者均获随访,随访时间6～24个月,平均13个月。乳房区外形良好,无复发。结论肿胀吸脂加乳晕下缘小切口腺体部分切除术具有安全、瘢痕小、外观自然、患者满意度高等优点,是治疗男性乳房肥大有效方法之一。     

Free nipple graft reduction mammoplasty.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.     

The spring-back phenomenon: does the final position of the nipple areola complex correspond to the pre-operative markings in reduction mammoplasty?

This study investigates whether tissue recoil or patient intrinsic factors influence the final position of the nipple areola complex (NAC) after reduction mammoplasty. The age, pre-operative ptosis, BMI and weight of the tissue resected were recorded as patient intrinsic factors in 37 patients undergoing reduction mammoplasty. The “spring-back” value was defined as the distance from the sternal notch to a nipple landmark on the breast meridian with the patient sitting up, minus the same measurement repeated with the patient recumbent to eliminate the pull of gravity on the breast. Spring back was measured pre-operatively for the nipple and nipple mark then post-operative for the nipple. The difference in centimeters between the final post-operative distance from the sternal notch to the nipple and the level intended by the pre-operative nipple mark was termed the “judgment error.” The final position of the post-operative nipple and the judgment error was compared to the spring-back values and patient intrinsic factors. Pre-operative ptosis was statistically related to increasing patient BMI and mass of tissue resected per breast. Pre-operative spring-back values for the nipple increased with increasing ptosis, BMI and decreasing age. Spring-back values were greater in the lower pole of the breast than in the upper pole. The final position of the nipple was higher than the pre-operative mark in 65% of cases, lower in 8% and as marked in 27% of cases. The post-operative NAC was, on average, 0.6 cm higher than planned pre-operatively. The post-operative distance from the sternal notch to the nipple increased with increasing pre-operative ptosis, mass of breast tissue resected per breast and all three spring-back values. The difference between the level of the pre-operative mark and the final nipple position showed a weak correlation with post-operative spring-back values. The parameters of ptosis, BMI, weight of tissue resected per breast and pre-operative nipple spring back reflect body habitus and breast size. Spring-back values vary between the upper and lower pole of the breast. The final NAC position was higher than that intended at pre-operative marking in the majority of cases. The surgeon instinctively marks the nipple lower in patients with greater pre-operative ptosis and in whom a larger resection is anticipated. Judgment error did not relate to intrinsic factors nor to pre-operative spring-back values; hence, these parameters cannot be applied as predictive tools for more accurate pre-operative marking of the nipple position. This study suggests that the pre-operative nipple mark should be placed, with the patient sitting up, at least 23 cm from the sternal notch and 0.6 cm lower than the final position estimated using the inframammary crease as a landmark. An invited commentary on this paper is available at .