IDEAS AND INNOVATIONS Surgical Correction of Gynecomastia: A Geometric Approach Antony E. Martin, M.D. Thomas A. Olinger, B.S.B.E. Jack C. Yu, M.D. Augusta, Ga.
Summary: Many techniques are available for surgical correction of gynecomastia. In this article, we describe a technique based on geometrical principles that is simple to execute, effective, highly reproducible, and relies less on intuition of the surgeon. (Plast. Reconstr. Surg. 135: 1392, 2015.)
P
atients with gynecomastia seek medical help mainly for social reasons.1 Surgical techniques for gynecomastia include liposuction,2 combination techniques using both liposuction and minimal access incisions,3,4 transnipple removal,5 ultrasonic liposuction,6 and arthroscopic shavers with liposuction.7 We use geometrical principles to identify where to place incisions, estimate how much skin to resect, and guide us as to how much fibroglandular tissue to remove.
obtained. Half of the difference between D and d gives us the excess skin in the mediolateral axis (Y in Fig. 3). Because there is no consensus on the diameter of the nipple-areola complex for male subjects, we use approximately 28 to 30 mm as the diameter for the future nipple-areola complex (inner incision). In the craniocaudal axis, the outer line is X distance from the inner line, and in the mediolateral axis, the outer line is Y distance away from the inner line.
PREOPERATIVE MARKINGS
OPERATIVE TECHNIQUE
Markings are done with the patient standing. Figure 1 shows the schematic representation of the geometric basis of our technique, represented by the equation [D − d/2 = B = X = Y]. First, excess skin that needs to be removed is marked in the craniocaudal axis. The distance from the inframammary fold to the point where the breast mound appears to fade into the chest wall (Fig. 2) is measured (d). Then a measurement is taken between the same points around the perimeter of the breast mound (D in Fig. 2). Half of the difference between the two measurements (D − d = A) is X (Fig. 3). Similar measurements are done in the mediolateral axis. Both medially and laterally, a point is marked where the breast mound appears to fade into the chest wall at the level of the nipple-areola complex. The straight line connecting these two points (d) is measured. The measurement between these two points curving over the nipple-areola complex is
Both arms are placed in 90 degrees of abduction. Before injection of local anesthesia, another line is marked starting at the nipple level, from the outer line curving over the inferior aspect of the inner line reaching to the outer line on the other side at the same level (red line in Fig. 4). The vertically striped portion bound by the outer line, caudal to this marking, is excised at full thickness. The stippled portion cranial to this marking is deepithelialized. We infiltrate approximately 10 cc of local anesthetic solution per side. The incisions are made along both the outer and inner lines, sparing the dermis. The principle of this technique requires leaving the same thickness of skin and subcutaneous
From the Department of Plastic and Reconstructive Surgery, Georgia Regents University, Medical College of Georgia. Received for publication August 25, 2014; accepted November 5, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001198
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Disclosure: The authors have no financial interest to declare in relation to the content of this article. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).
www.PRSJournal.com
Volume 135, Number 5 • Surgical Correction of Gynecomastia
Fig. 1. Schematic representation of geometric basis of the technique. NAC, nipple-areola complex.
Fig. 2. Measurements are taken at the base and periphery of the breast mound.
Fig. 4. Stippled area will be deepithelialized. Striped area will be excised at full thickness.
tissue all around the nipple-areola complex (Fig. 1). This is done to ensure the chest wall surface is even, without any depression or bulge. Figure 1 shows the excess subcutaneous fat and fibroglandular tissue that needs be excised.
The volume of the skin and subcutaneous tissue that is left on the breast mound should fill the rectangular area bound by skin surface and
Fig. 3. Half of the difference between D and d gives the excess skin to be removed.
Fig. 5. Final appearance after completion of excision.
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Plastic and Reconstructive Surgery • May 2015
Fig. 6. Frontal view at 8 weeks postoperatively.
pectoralis fascia underneath the breast mound. Using T as a reference length, we were able to deduce that the thickness of the caudal and cephalic flaps (t) should be about half the thickness of T. While doing that, care must be taken not to extend the dissection beyond the boundaries marked earlier, which delineates the breast mound from the normal chest wall (arrows in Fig. 3). This is to avoid removal of too much subcutaneous fat, which may result in a contour deformity. The plane of dissection is along the pectoralis fascia, leaving it intact. Figure 5 shows the final appearance after completion of excision. A purse-string suture is placed using 2-0 polydioxanone along the periphery of the outer incision at dermis level. It is tightened gently to the final nipple-areola complex diameter of 28 to 30 mm. While doing so, it may be necessary to thin the soft tissue behind the nippleareola complex, to avoid bulging of the nippleareola complex. The dermis is approximated with 4-0 Vicryl sutures, followed by skin closure using interrupted 4-0 and 5-0 chromic sutures. Eightweek postoperative results are shown in Figure 6, and in Figure, Supplemental Digital Content 1, which shows the right lateral view, 8 weeks postoperatively, http://links.lww.com/PRS/B277, and Figure, Supplemental Digital Content 2, which shows the left lateral view, 8 weeks postoperatively, http://links.lww.com/PRS/B278.
DISCUSSION A circumareolar incision, with preservation of fibroglandular tissue underneath the nippleareola complex to preserve the blood supply, has been described earlier.8 However, the distance between the outer and inner incision is left to
1394
the discretion of the surgeon without a clear and reproducible basis of how much to resect. Another technique describes use of a circumareolar incision, with ultrasound-assisted liposuction for removal of fibroglandular tissue and subcutaneous fat.4 The pull-through method is used for remaining strings of glandular tissue. The outer incision is placed in such a way to place the nippleareola complex just above the inframammary fold. This paves the way for operator dependency, with reliance on experience and intuition about how much tissue to resect in the retroareolar region. Preservation of the subcutaneous fat layer attached to the skin and nipple-areola complex also preserves blood supply and innervation to the nipple-areola complex. Care must be taken not to over-resect the retroareolar fat/glandular pad to avoid retraction of the nipple-areola complex. It is important to leave an adequate fat layer underneath the superior quadrant skin because the nipple-areola complex may not survive on the dermal flap alone if it is thinned too aggressively. In a few cases, we also used minimal liposuction to even out the surface of chest wall. This technique is easy to learn and a useful tool for surgical correction of gynecomastia. Antony E. Martin, M.D. Department of Surgery Medical College of Georgia Georgia Regents University 1120 15th Street, BB 4522 Augusta, Ga. 30912 [email protected]
references 1. Lablow B. Psychosocial impact of adolescent gynecomastia: A prospective case control study. Plast Reconstr Surg. 2013;131:890–896. 2. Teimourian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast Surg. 1983;7:155–157. 3. Rohrich RJ, Ha RY. Combined use of ultrasonic liposuction with the pull through technique for treatment of gynecomastia (discussion). Plast Reconstr Surg. 2003;112:896–897. 4. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. 2009;124:61e–68e. 5. Mishra RK. Trans nipple removal of fibro glandular tissue in gynecomastia surgery without additional scars. Ind J PlastSurg. 2014;47:50–55. 6. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg. 2005;116:646–653. 7. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: Evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010;125:1301–1308. 8. Persichetti P, Berloco M, Casadei RM, Marangi GF, Di Lella F, Nobili AM. Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy. Plast Reconstr Surg. 2001;107:948–954.
Summary: Many techniques are available for surgical correction of gynecomastia. In this article, we describe a technique based on geometrical principles that is simple to execute, effective, highly reproducible, and relies less on intuition of the surgeon. (Plast. Reconstr. Surg. 135: 1392, 2015.)
P
atients with gynecomastia seek medical help mainly for social reasons.1 Surgical techniques for gynecomastia include liposuction,2 combination techniques using both liposuction and minimal access incisions,3,4 transnipple removal,5 ultrasonic liposuction,6 and arthroscopic shavers with liposuction.7 We use geometrical principles to identify where to place incisions, estimate how much skin to resect, and guide us as to how much fibroglandular tissue to remove.
obtained. Half of the difference between D and d gives us the excess skin in the mediolateral axis (Y in Fig. 3). Because there is no consensus on the diameter of the nipple-areola complex for male subjects, we use approximately 28 to 30 mm as the diameter for the future nipple-areola complex (inner incision). In the craniocaudal axis, the outer line is X distance from the inner line, and in the mediolateral axis, the outer line is Y distance away from the inner line.
PREOPERATIVE MARKINGS
OPERATIVE TECHNIQUE
Markings are done with the patient standing. Figure 1 shows the schematic representation of the geometric basis of our technique, represented by the equation [D − d/2 = B = X = Y]. First, excess skin that needs to be removed is marked in the craniocaudal axis. The distance from the inframammary fold to the point where the breast mound appears to fade into the chest wall (Fig. 2) is measured (d). Then a measurement is taken between the same points around the perimeter of the breast mound (D in Fig. 2). Half of the difference between the two measurements (D − d = A) is X (Fig. 3). Similar measurements are done in the mediolateral axis. Both medially and laterally, a point is marked where the breast mound appears to fade into the chest wall at the level of the nipple-areola complex. The straight line connecting these two points (d) is measured. The measurement between these two points curving over the nipple-areola complex is
Both arms are placed in 90 degrees of abduction. Before injection of local anesthesia, another line is marked starting at the nipple level, from the outer line curving over the inferior aspect of the inner line reaching to the outer line on the other side at the same level (red line in Fig. 4). The vertically striped portion bound by the outer line, caudal to this marking, is excised at full thickness. The stippled portion cranial to this marking is deepithelialized. We infiltrate approximately 10 cc of local anesthetic solution per side. The incisions are made along both the outer and inner lines, sparing the dermis. The principle of this technique requires leaving the same thickness of skin and subcutaneous
From the Department of Plastic and Reconstructive Surgery, Georgia Regents University, Medical College of Georgia. Received for publication August 25, 2014; accepted November 5, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001198
1392
Disclosure: The authors have no financial interest to declare in relation to the content of this article. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).
www.PRSJournal.com
Volume 135, Number 5 • Surgical Correction of Gynecomastia
Fig. 1. Schematic representation of geometric basis of the technique. NAC, nipple-areola complex.
Fig. 2. Measurements are taken at the base and periphery of the breast mound.
Fig. 4. Stippled area will be deepithelialized. Striped area will be excised at full thickness.
tissue all around the nipple-areola complex (Fig. 1). This is done to ensure the chest wall surface is even, without any depression or bulge. Figure 1 shows the excess subcutaneous fat and fibroglandular tissue that needs be excised.
The volume of the skin and subcutaneous tissue that is left on the breast mound should fill the rectangular area bound by skin surface and
Fig. 3. Half of the difference between D and d gives the excess skin to be removed.
Fig. 5. Final appearance after completion of excision.
1393
Plastic and Reconstructive Surgery • May 2015
Fig. 6. Frontal view at 8 weeks postoperatively.
pectoralis fascia underneath the breast mound. Using T as a reference length, we were able to deduce that the thickness of the caudal and cephalic flaps (t) should be about half the thickness of T. While doing that, care must be taken not to extend the dissection beyond the boundaries marked earlier, which delineates the breast mound from the normal chest wall (arrows in Fig. 3). This is to avoid removal of too much subcutaneous fat, which may result in a contour deformity. The plane of dissection is along the pectoralis fascia, leaving it intact. Figure 5 shows the final appearance after completion of excision. A purse-string suture is placed using 2-0 polydioxanone along the periphery of the outer incision at dermis level. It is tightened gently to the final nipple-areola complex diameter of 28 to 30 mm. While doing so, it may be necessary to thin the soft tissue behind the nippleareola complex, to avoid bulging of the nippleareola complex. The dermis is approximated with 4-0 Vicryl sutures, followed by skin closure using interrupted 4-0 and 5-0 chromic sutures. Eightweek postoperative results are shown in Figure 6, and in Figure, Supplemental Digital Content 1, which shows the right lateral view, 8 weeks postoperatively, http://links.lww.com/PRS/B277, and Figure, Supplemental Digital Content 2, which shows the left lateral view, 8 weeks postoperatively, http://links.lww.com/PRS/B278.
DISCUSSION A circumareolar incision, with preservation of fibroglandular tissue underneath the nippleareola complex to preserve the blood supply, has been described earlier.8 However, the distance between the outer and inner incision is left to
1394
the discretion of the surgeon without a clear and reproducible basis of how much to resect. Another technique describes use of a circumareolar incision, with ultrasound-assisted liposuction for removal of fibroglandular tissue and subcutaneous fat.4 The pull-through method is used for remaining strings of glandular tissue. The outer incision is placed in such a way to place the nippleareola complex just above the inframammary fold. This paves the way for operator dependency, with reliance on experience and intuition about how much tissue to resect in the retroareolar region. Preservation of the subcutaneous fat layer attached to the skin and nipple-areola complex also preserves blood supply and innervation to the nipple-areola complex. Care must be taken not to over-resect the retroareolar fat/glandular pad to avoid retraction of the nipple-areola complex. It is important to leave an adequate fat layer underneath the superior quadrant skin because the nipple-areola complex may not survive on the dermal flap alone if it is thinned too aggressively. In a few cases, we also used minimal liposuction to even out the surface of chest wall. This technique is easy to learn and a useful tool for surgical correction of gynecomastia. Antony E. Martin, M.D. Department of Surgery Medical College of Georgia Georgia Regents University 1120 15th Street, BB 4522 Augusta, Ga. 30912 [email protected]
references 1. Lablow B. Psychosocial impact of adolescent gynecomastia: A prospective case control study. Plast Reconstr Surg. 2013;131:890–896. 2. Teimourian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast Surg. 1983;7:155–157. 3. Rohrich RJ, Ha RY. Combined use of ultrasonic liposuction with the pull through technique for treatment of gynecomastia (discussion). Plast Reconstr Surg. 2003;112:896–897. 4. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. 2009;124:61e–68e. 5. Mishra RK. Trans nipple removal of fibro glandular tissue in gynecomastia surgery without additional scars. Ind J PlastSurg. 2014;47:50–55. 6. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg. 2005;116:646–653. 7. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: Evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010;125:1301–1308. 8. Persichetti P, Berloco M, Casadei RM, Marangi GF, Di Lella F, Nobili AM. Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy. Plast Reconstr Surg. 2001;107:948–954.
