Pectoral etching in early grades gynecomastia

Objective evaluation

Sternal notch to nipple length

The average SSN to nipple length pre and six months postoperative were respectively 21.08 cm and 18.6 cm (Table 3).

Chest circumference 

Mean chest circumference pre and postoperative which were respectively 108.36 cm and 98.77 cm (Table 4).

Postoperative results:

According to postoperative complications, it was found that twelve patients out of thirty patients have shown excessive skin ecchymosis that resolved within two weeks before, and five cases developed nipple retraction (16.6%). two case developed hematoma which needed aspiration. Four patients developed seroma that resolved spontaneously. No infection was detected (Table 5)..

Table 3: SNN-Nipple length.

Table 4: Chest circumference

Table 5 Complication rate.

Fig 1: A, B, preoperatively C, D postoperatively

Fig 2: A, B, preoperatively C, D postoperatively

Fig 3: A, B MRI of chest 6 months postoperatively

DISCUSSION

The gold standard for treatment of gynecomastia is surgical intervention, however; choosing the appropriate technique is challenging as there is a wide range of surgical interventions. Minimal scarring and obtaining masculine looking chest is the most determinant of the surgical technique.⁵In this study, we tried to evaluate to assess high definition liposculpture to get masculinized appearance of the chest for treatment of early grades gynecomastia (grade I &II) Simon classification.

Our study was held on thirty patients with average age 24.73, classified to three bilateral Grade 1, seventeen case grade 2A and ten cases grade 2B according to Simon ‘s Classification.

On postoperative assessment, Patients showed great satisfaction about their final appearance, only twelve patients had postoperative skin ecchymosis that resolved within two weeks, that contributes to 40% of the cases. five patients had nipple retraction due to excess glandular tissue excision that contributes also 16.6% of the cases. Only One patient suffered from contour irregularity due to asymmetric liposuction which forms 3.3% of the cases. Five patients show hematoma formation while 4 patients show seroma formation which resolved spontaneously. No nipple necrosis or infection.

Geddes CR et al studied the arterial supply of the pectoral branch of the TAA has an average diameter of 1.7±0.6 mm. This artery predominantly (60%) gave rise to three secondary branches that traveled obliquely, medially and inferiorly on the deep surface of the PM muscle.

These results are coinciding with our results as we never faced any complications related to fat embolism which makes fat grafting in PM a safe technique. ⁶

Between 2004 and 2007, A. Mentz et al operated on 200 patients, two of whom developed a small hematoma that required evacuation. Another two patients needed corrections; one thought the initial technique was too conservative and needed a second etching process to make deeper pectoral indentations. Following gland removal, a second patient with significant gynecomastia developed excess areolar skin, necessitating a little in-office repair. In our study, we had two patients with hematomas that required one-time aspiration, and skin retraction was satisfying for both patients and surgeons. ⁷

 Between 2010 -2013 Pilanci et al treated 26 cases, On the first postoperative day, one patient out of a total of 26 had a hematoma, which was cleared by secondary hemostasis. During the follow-up period, two patients complained of a bump that went away with simple massage. Late in the monitoring period, one patient developed a depression beneath the areola. During the 11th postoperative month, he received further lipografting, which resulted in a positive outcome. ⁸

Regarding our study we had two patients with hematomas which needed evacuation only once, another five patients developed nipple retraction and none of the cases needed additional fat grafting.

Alfredo Hoyos and Mauricio Perez operated on 154 consecutive male patients between 2005 and 2012, with only three serious complications (2%) noted, all of which were connected to the surgery. One abscess was treated with antibiotics and sonographically guided aspiration. Two hematomas were manually drained through the open nipple incision. As modest difficulties, asymmetry was reported by 15 patients (9.7%), residual skin laxity by 4 patients (2.6%), low definition by 4 patients (2.6%) who may need a second "refinement operation," and oblique form of the inferior pectoral border by 5 patients (3.2 %). ⁹

A.mowlavi agrees with our results as regard patient satisfaction through fat grafting surgeons are able to achieve the pentagonal shape achieving  a well-defined masculine chest although his mean age was 37.5 on 38 patients. ¹⁰

Regarding our study we were able to achieve masculine appearance using fat grafting. Our mean age was 24.73 in 30 patients.

Yue D et al In a study to make suggestions for NAC position, it was advised that the male internipple distance be 22 cm and the SN to nipple distance be 21 cm. According to Murphy, Coleman measured the chests of several US army soldiers and discovered that the SN to nipple distance was 19 cm. Beckenstein et al. recommended an SNND of 20 cm, citing earlier NAC placement suggestions that resulted in nipples that were too inferior and medial. Beer et al. suggested an SNND of 20 cm and an 11.2 cm distance between the midsternal line and the nipple. The SNND was 18.4 cm and the IND was 20.6 cm, according to Shulman et al.¹²

Regarding our study, the average sternal notch to nipple length pre and six months postoperative were respectively 21.08 cm and 18.6 cm which agrees with previous studies

In study conducted by Ridha.H et al on the level of patient satisfaction Only 62.5 percent of all gynecomastia patients treated for gynecomastia were satisfied to very satisfied, according to a 64-questionnaire approved out of 74 submitted to various patients. Three patients suffered hematomas, four got seromas, and four developed abnormal scarring.¹³

In our study 2 patients developed hematoma, 4 patients seroma and 1 patient contour irregularity.  regarding patient satisfaction 23 % scored satisfied and 77% scored very satisfied

Our overall success rate is easily explained by several factors. Liposuction combined with pectoral etching improves the esthetic outcome because of muscle augmentation and skin contraction. pectoral augmentation improves the masculine appearance of male chest known as gladiator chest.

Surgical excision by semicircular periareolar incision also adds other advantages to the maneuver, the glandular tissue is removed completely which prevents under correction present in suction-only procedures. The periareolar incision makes the scar not well defined as it becomes camouflaged by the color change between normal skin and the areola.

CONCLUSION

To achieve masculine appearance of the male chest is the ultimate goal of male breast surgery, however, patients’ expectations must meet with surgeons’ expectation. High-definition gynecomastia surgery brings high satisfaction to the surgeon, but patient selection is a must for this kind of surgery to maintain long term results. The patient must understand the details of the procedure and realize he has to keep up with a healthy lifestyle including sport and diet to keep these results.