Surgical
Correction of Massive Gynecomastia Sheldon Artz, MD, James A. Lehman, Jr, MD
\s=b\ Massive gynecomastia can produce severe psychological problems for the patient. The surgical techniques employed for simple gynecomastia are not effective in correcting the displaced nipple and excess skin. Utilizing a dermal pedicle technique, the excess fat and breast tissue have been removed, along with relocation of the nipple. Satisfactory results and acceptable scars have been obtained in four patients. (Arch Surg 113:199-201, 1978)
the size of the male breast approaches that of the female breast, the psychological manifestations are often severe. The affected male becomes a self-induced social outcast, not joining in any activities that require removal of his shirt. His clothes are often loose fitting and this adds a sloppy appearance to an already disturbed male. Because the individual's self-image is diminished, his schoolwork, job, etc, are all affected adversely. X-ray therapy has proved to be ineffective and has often caused additional tissue damage to this benign condition. Hormonal therapy with androgens, even when effective, shows an 80% recurrence rate once the therapy has been discontinued. The only effective treatment of extreme gynecomastia is surgery. Historically, Paulus Aeginita in 625 ad described the removal of excess breast tissue in males, either through a submammary incision or two parallel semilunar incisions. In 1933, Menville1 stated that the nipple as a rule is of little consequence in the male, and he used a similar elliptical
When
Accepted for publication Aug 26, 1977. From the Division of Plastic Surgery,
Akron General Medical Center. Reprint requests to 300 Locust
Akron
(Ohio) City Hospital and
St, Akron, OH 44302 (Dr Lehman).
incision including nipple, areola, and breast tissue. The loss of the nipple areola complex and the excessive scarring make these procedures unacceptable for gynecomastia. Webster- in 1946 described a semicircular intra-areolar incision for gynecomastia. Pitanquy:1 utilized a horizontal incision, splitting the nipple to gain access to the abnormal breast mass. Letterman and Schurter' in 1969 utilized a superior semicircular incision with the excision of skin to elevate the nipple. All of these procedures are excellent for the relatively small or moderate gynecomastia, but are not adequate for the correction of massive gynecomastia. In 1974, Wray et al5 described their technique for correction of extreme gynecomastia. They resected the
through two parallel transverse incisions, replacing nipple-areola complex as a full thickness skin graft. They stated that, although the scars are extensive, the patients much preferred the surgical scars to the gyneco¬ mastia. This statement is probably true; however, we mass
the
believe that these extensive scars call as much attention to the patient as did the original gynecomastia, and have the added risk of nipple loss. In 1972, Letterman and Schurter6 utilized a modification of the Dufourmentel-Mouly procedure for the correction of massive gynecomastia. They recognized that, as well as resecting the excess skin, fat, and breast tissue, the nipple must be rotated superiorly and medially. Bearing in mind the work of Skoog,7 who showed that the nipple can survive on a dermal pedicle, we have adopted a modified Dufourmentel-Mouly procedure for the treat¬ ment of four patients with extreme gynecomastia. This procedure is satisfactory because it (1) removes excessive skin, fat, and breast tissue; (2) allows the nipple to be rotated into its normal position on a dermal pedicle; and (3) leaves acceptable surgical scars.
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Fig 1.—Left, Point A and are marked and then connected by pushing breast up and laterally and then down and medially. Nipple is preserved on a dermal pedicle and moved to its new location. Right, incision is then closed in layers.
Fig 2.—Left and right, Twenty-one-year old man with Klinefelter's syndrome and excessive gynecomastia.
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Fig one
TECHNIQUE
Markings are made with the patient in the upright position, prior to the introduction of anesthesia. Point A is marked just superior and medial to the areola (at the junction of tangential lines drawn through the superior and medial aspects of the areola) and this represents the new nipple location. Care must be taken not to mark point A any more medial than the medial border of the areola, or the new nipple will be too close to the midline. Point A may be marked above the superior border of the nipple, as shown in Fig 1, to raise the nipple to the desired location. Point is marked at the intersection of the inframammary crease and the anterior axillary line (Fig 1, left). Line AB (the inferior line) is drawn with the breast pushed up and outward, and line BA (the superior line) is drawn with the breast pushed down and inward. An ellipse of skin is thus delineated, the so-called lateral wedge. The nipple-areola complex is then outlined with a 2 cm diameter marker and the lateral extent of the dermal pedicle is marked approximately 2 cm lateral to the nipple. The medial unshaded area will have the epidermis removed to create the dermal pedicle for vascular supply to the nipple, and the lateral triangular area will be completely excised (Fig 1, left). The epidermis is first removed and then the outer wedge of skin, fat, and breast tissue is excised. The dermal pedicle is elevated based on the upper wound margin, retaining sufficient subcuta¬ neous tissue and breast tissue so that the nipple will not be depressed. The glandular resection is then continued beneath the dermal pedicle and along the chest wall until the desired amount of tissue has been removed (Fig 1, left). The incision is then closed up to the medial 2 cm. The dermal pedicle with the nipple is then rotated upward and a 2 cm diameter circle of skin is excised. Care must be taken not to injure the base
pedicle. position (Fig 1, right). of the dermal
3.—Left and right, Postoperative result year following surgery.
The
nipple
is then sutured into its
new
COMMENT
Since Skoog has shown that the nipple can be supported on a short dermal pedicle alone,7 and with the modifica¬ tions of the Dufourmentel-Mouly reduction mammoplasty, a very satisfactory result can be obtained for massive gynecomastia. The scarring is very acceptable, since it is an oblique scar on the lateral aspect of the chest and therefore does not draw attention to the surgical procedure (Fig 2 and 3). The amount of breast tissue, fat, and skin to be excised varies from patient to patient and is easily adjusted with this procedure, as are the positions and size of the nipple-areola complex. This procedure has produced very satisfactory results in four patients with massive
gynecomastia.
References 1. Menville JG: Gynecomastia. Arch Surg 26:1054, 1933. 2. Webster JP: Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg 124:557-575, 1946. 3. Pitanquy I: Transareolar incision for gynecomastia. Plast Reconstr Surg 38:414-419, 1966. 4. Letterman G, Schurter M: The surgical correction of gynecomastia. Am Surg 35:322-325, 1969. 5. Wray RC, Hoopes JE, Davis GM: Correction of extreme gynecomastia. Br J Plast Surg 27:39-41, 1974. 6. Letterman G, Schurter M: Surgical correction of massive gynecomastia. Plast Reconstr Surg 49:259-262, 1972. 7. Skoog T: A technique of breast reduction. Acta Chir Scand 126:453-465, 1963.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/05/2015
Correction of Massive Gynecomastia Sheldon Artz, MD, James A. Lehman, Jr, MD
\s=b\ Massive gynecomastia can produce severe psychological problems for the patient. The surgical techniques employed for simple gynecomastia are not effective in correcting the displaced nipple and excess skin. Utilizing a dermal pedicle technique, the excess fat and breast tissue have been removed, along with relocation of the nipple. Satisfactory results and acceptable scars have been obtained in four patients. (Arch Surg 113:199-201, 1978)
the size of the male breast approaches that of the female breast, the psychological manifestations are often severe. The affected male becomes a self-induced social outcast, not joining in any activities that require removal of his shirt. His clothes are often loose fitting and this adds a sloppy appearance to an already disturbed male. Because the individual's self-image is diminished, his schoolwork, job, etc, are all affected adversely. X-ray therapy has proved to be ineffective and has often caused additional tissue damage to this benign condition. Hormonal therapy with androgens, even when effective, shows an 80% recurrence rate once the therapy has been discontinued. The only effective treatment of extreme gynecomastia is surgery. Historically, Paulus Aeginita in 625 ad described the removal of excess breast tissue in males, either through a submammary incision or two parallel semilunar incisions. In 1933, Menville1 stated that the nipple as a rule is of little consequence in the male, and he used a similar elliptical
When
Accepted for publication Aug 26, 1977. From the Division of Plastic Surgery,
Akron General Medical Center. Reprint requests to 300 Locust
Akron
(Ohio) City Hospital and
St, Akron, OH 44302 (Dr Lehman).
incision including nipple, areola, and breast tissue. The loss of the nipple areola complex and the excessive scarring make these procedures unacceptable for gynecomastia. Webster- in 1946 described a semicircular intra-areolar incision for gynecomastia. Pitanquy:1 utilized a horizontal incision, splitting the nipple to gain access to the abnormal breast mass. Letterman and Schurter' in 1969 utilized a superior semicircular incision with the excision of skin to elevate the nipple. All of these procedures are excellent for the relatively small or moderate gynecomastia, but are not adequate for the correction of massive gynecomastia. In 1974, Wray et al5 described their technique for correction of extreme gynecomastia. They resected the
through two parallel transverse incisions, replacing nipple-areola complex as a full thickness skin graft. They stated that, although the scars are extensive, the patients much preferred the surgical scars to the gyneco¬ mastia. This statement is probably true; however, we mass
the
believe that these extensive scars call as much attention to the patient as did the original gynecomastia, and have the added risk of nipple loss. In 1972, Letterman and Schurter6 utilized a modification of the Dufourmentel-Mouly procedure for the correction of massive gynecomastia. They recognized that, as well as resecting the excess skin, fat, and breast tissue, the nipple must be rotated superiorly and medially. Bearing in mind the work of Skoog,7 who showed that the nipple can survive on a dermal pedicle, we have adopted a modified Dufourmentel-Mouly procedure for the treat¬ ment of four patients with extreme gynecomastia. This procedure is satisfactory because it (1) removes excessive skin, fat, and breast tissue; (2) allows the nipple to be rotated into its normal position on a dermal pedicle; and (3) leaves acceptable surgical scars.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/05/2015
Fig 1.—Left, Point A and are marked and then connected by pushing breast up and laterally and then down and medially. Nipple is preserved on a dermal pedicle and moved to its new location. Right, incision is then closed in layers.
Fig 2.—Left and right, Twenty-one-year old man with Klinefelter's syndrome and excessive gynecomastia.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/05/2015
Fig one
TECHNIQUE
Markings are made with the patient in the upright position, prior to the introduction of anesthesia. Point A is marked just superior and medial to the areola (at the junction of tangential lines drawn through the superior and medial aspects of the areola) and this represents the new nipple location. Care must be taken not to mark point A any more medial than the medial border of the areola, or the new nipple will be too close to the midline. Point A may be marked above the superior border of the nipple, as shown in Fig 1, to raise the nipple to the desired location. Point is marked at the intersection of the inframammary crease and the anterior axillary line (Fig 1, left). Line AB (the inferior line) is drawn with the breast pushed up and outward, and line BA (the superior line) is drawn with the breast pushed down and inward. An ellipse of skin is thus delineated, the so-called lateral wedge. The nipple-areola complex is then outlined with a 2 cm diameter marker and the lateral extent of the dermal pedicle is marked approximately 2 cm lateral to the nipple. The medial unshaded area will have the epidermis removed to create the dermal pedicle for vascular supply to the nipple, and the lateral triangular area will be completely excised (Fig 1, left). The epidermis is first removed and then the outer wedge of skin, fat, and breast tissue is excised. The dermal pedicle is elevated based on the upper wound margin, retaining sufficient subcuta¬ neous tissue and breast tissue so that the nipple will not be depressed. The glandular resection is then continued beneath the dermal pedicle and along the chest wall until the desired amount of tissue has been removed (Fig 1, left). The incision is then closed up to the medial 2 cm. The dermal pedicle with the nipple is then rotated upward and a 2 cm diameter circle of skin is excised. Care must be taken not to injure the base
pedicle. position (Fig 1, right). of the dermal
3.—Left and right, Postoperative result year following surgery.
The
nipple
is then sutured into its
new
COMMENT
Since Skoog has shown that the nipple can be supported on a short dermal pedicle alone,7 and with the modifica¬ tions of the Dufourmentel-Mouly reduction mammoplasty, a very satisfactory result can be obtained for massive gynecomastia. The scarring is very acceptable, since it is an oblique scar on the lateral aspect of the chest and therefore does not draw attention to the surgical procedure (Fig 2 and 3). The amount of breast tissue, fat, and skin to be excised varies from patient to patient and is easily adjusted with this procedure, as are the positions and size of the nipple-areola complex. This procedure has produced very satisfactory results in four patients with massive
gynecomastia.
References 1. Menville JG: Gynecomastia. Arch Surg 26:1054, 1933. 2. Webster JP: Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg 124:557-575, 1946. 3. Pitanquy I: Transareolar incision for gynecomastia. Plast Reconstr Surg 38:414-419, 1966. 4. Letterman G, Schurter M: The surgical correction of gynecomastia. Am Surg 35:322-325, 1969. 5. Wray RC, Hoopes JE, Davis GM: Correction of extreme gynecomastia. Br J Plast Surg 27:39-41, 1974. 6. Letterman G, Schurter M: Surgical correction of massive gynecomastia. Plast Reconstr Surg 49:259-262, 1972. 7. Skoog T: A technique of breast reduction. Acta Chir Scand 126:453-465, 1963.
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/05/2015
