INTRODUCTION
Gynaecomastia is the most common benign
breast pathology among male adolescent [1], and
it causes considerable amount of psychological
and social discomfort which push them to seek
medical advice [2]. Amongst the different grades
of gynaecomastia, high-grade gynaecomastia (Simon
grade IIb and III) has the problem of skin
excess along with enlarged ptotic nipple-areola,
which can only be managed surgically [3].
The growth of male breast tissue depends mainly
on the balance between serum estrogen and
androgens. Any physiologic or pathologic factor
that interferes with this balance can result in gynecomastia
[4,5]. Advances in elucidating the pathophysiology
of gynecomastia have been made,
though understanding remains limited. Medical
management has had limited success; however,
surgical removal of the hypertrophic breast tissue
remains the accepted standard in treatment [6-10].
Gynecomastia composed of three components
pathologically which are adipose tissue, mammary
gland, and excess skin. With the appearance of the
era of post-bariatric surgery, in which most of the
patients have a bad skin quality, grade III gynecomastia
become associated with severe degrees of
skin redundancy [11].
Among various classifications of gynecomastia,
the one by Simon et al., in 1973 [12] based on
hypertrophic skin, is most useful: Grade I: Small
breasts without hypertrophic skin. Grade IIa: Moderate
breasts without hypertrophic skin. Grade IIb:
Moderate breasts with hypertrophic skin. Grade
III: Large breasts with hypertrophic skin, similar
to female breasts, with enlarged nipple-areola
complex.
For patients with moderate to severe skin and
soft tissue excess requiring nipple-areola elevation,
liposuction alone is not adequate [13,14]. Reconstruction
should include liposuction of excess fat,
excision of glandular tissue, excision of excess
skin, and repositioning of nipple-areola. The difficulty
of treating severe grades of gynecomastia
lies in the resection of excess skin. This resection
can result in extensive scars located in conspicuous
sites [9,12].
The available skin reduction techniques are
periareolar, lateral wedge, elliptical, inverted T,
and LeJour [11,15-17]. The concentric peri-areolar
technique is the most popular because of less
noticeable scarring [15,16].
Over the years, surgical techniques for management
of high-grade gynaecomastia have evolved
a lot. Malbec in 1945 [18] suggested breast amputation
with free nipple-areolar graft for management
of breast ptosis and skin excess, but the procedure
had its own limitations as there may be total loss
of the graft, there may be hyposthesia of the nippleareolar,
or these patients may develop hypertrophic
scars over chest. The use of the transverse elliptical
incision on a supero-lateral pedicle has been described
as an alternative to amputation and free
nipple grafting [19,20]. This technique involves a
scar that crosses the mid-chest passing around the
areola, the need to maintain a glandular pedicle
can lead to excess remaining tissue, leading to a
contour deformity and undercorrection [21].
Scar-less techniques like glandular excision
through periareolar and intra-areolar incision was
described by Leon Dufourmentel in 1928 [22] and
latter by Jerome Webster in 1946 [23], and remain
a mainstay of treatment [1,12,23]. These incisions
affords a better access to all quadrants of breast
tissue and gives a good aesthetic appearance. With
this technique, the hypertrophied gland could be
removed without leaving a significant scar, but in
cases of grade III gynaecomastia, this intra-areolar
70 Vol. 44, No. 1 / Comparative Study between Reconstruction of Grade III Gynecomastia
incision may be too small, a lateral and medial
extension may be needed [3].
Previously, different researchers like Persichetti
et al., [24] and others [25,26] had described 'periareolar
skin reduction with purse-string suturing'
technique to reduce the skin and areolar excess.
Along with skin reduction, the excess breast parenchyma
was removed by making a 'reverse omega'
incision in the inferior border of the deepithelialized
area from 3-9 o'clock position (180
degree incision).
Tashkandi et al., in 2004 [27], Sarkar et al., in
2014 [3], and Brown et al., in 2015 [21] described
single-stage glandular excision and peri-areolar
concentric skin reduction with de-epithelialization
in grade III gynaecomastia. However, in Tashkandi
et al., study [27], reported that the main disadvantage
of the technique was the mild residual skin redundancy.
While, Sarkar et al., [3] and Brown et al.,
[21] studies reported excellent results with a singlestage
procedure, with liposuction and glandular
excision done through the same lateral peri-areolar
incision.
Disadvantage of the concentric peri-areolar
skin reduction technique is the excessive pleating
of periareolar skin, because performing liposuction,
peri-areolar de-epithelialization, skin excision, and
delivery of the mammary gland in a single-stage,
leads to sudden reduction in the size of areola
which don't allow for skin retraction and recoil to
occur gradually leading to excessive wrinkling and
pleating of periareolar skin post-operative [21,27,28].
In addition that, performing the peri-areolar
de-epithelialization, and delivery of the mammary
gland in a single-stage, leads to excessive thinning
of subdermal pedicle of the nipple-areola, results
in high rate of vascular compromise to nippleareola
with its possible total or partial loss [21,27,28].
While, two-stage reconstruction with liposuction
of fat, and resection of excess skin with elevation
of nipple-areola in the first stage then, delivery of
the gland in a second stage three months later. May
be associated with less pleating of periareolar skin,
because staged reconstruction allows for skin retraction
and contraction to occur staged and gradually,
leading to minimal pleating of periareolar
skin post-operative. In addition that in staged
reconstruction, the nipple-areola vascularity will
be preserved.
No previous studies found in the literature
described two-stage reconstruction of grade III
gynecomastia, and hence, no previous studies
Egypt, J. Plast. Reconstr. Surg., January 2020 71
compared between single-stage and two-stage
reconstruction of high-grades of gynecomastia.
Aim of work:
Is to compare between reconstruction of grade
III gynecomastia with skin excess and enlarged
displaced nipple-areola in single-stage versus twostage,
as regard the complications rate. Specially
pleating of periareolar skin, and nipple-areola
vascular compromise.
PATIENTS AND METHODS
The current study performed from September
2016 to September 2018, the study included 12
patients who underwent surgical reconstruction for
bilateral grade III gynecomastia. Their ages ranged
from 18 to 40 years. On physical examination, all
patients exhibited enlarged breasts with large areolar
diameters, and ptotic nipple-areola Figs. (1A-
15A). Patients with small areolar diameter are
excluded.
After a written consent. Surgical reconstruction
done in the form of traditional liposuction of both
breasts through trans-axillary incisions, concentric
peri-areolar de-epithelialization for reduction of
excess skin and nipple-areola transposition, and
delivery of mammary gland by “pull-through”
technique through lateral pei-areolar incision. The
study patients divided into two groups, in group
I, six patients underwent gynecomastia reconstruction
in a single-stage, while in group II, six patients
underwent staged-reconstruction. In the first stage,
liposuction was done, with transposition of the
nipple-areola through concentric peri-areolar deepithelialization
of excess skin, and in the second
stage, which performed three months later, delivery
of the gland was done using the “pull-through”
technique through a lateral trans-dermal peri-areolar
incision at the lateral margin between the skin and
de-epithelialized area, with some minimal liposuction
just to facilitate the delivery of the gland.
Pre-operative markings:
After thorough evaluation of each patient, including
a detailed history and physical examination,
markings were made to outline the boundaries of
the area to be suctioned. The infra-mammary fold
was marked pre-operatively while the patient is
standing. The planned elevation of nipple-areola
was marked with the new position at 19cm from
the sternal notch. In cases with significant increase
of areolar diameter, the areolae were marked to be
reduced to 2.5 to 3.0cm, i.e. the average diameter
of male areola as proposed by Beckenstein et al.,
[29]. In addition to its reduction, the nipple-areola
should be positioned in an appropriate site at the
chest. The nipple position was estimated at the
mid-humerus level just medial to the mid-clavicular
line [3]. Pre-operative photos were taken for the
patient before and after markings Figs. (1A-15A).
Surgical technique:
The procedure was performed under generalanesthesia,
with the patient in supine position and
the upper limbs abducted 90 degrees from the
trunk. Trans-axillary incision 3-4mm was made
with a no. 15 blade scalpel in the upper most part
of the anterior axillary folds bilaterally for optimal
access to the dense breast parenchyma. This route
also provides access to the infra-axillary and lateral
chest area.
Subcutaneous infiltration of wetting solution
in the intermediate fat layer over the area of the
breast and the surrounding chest wall including
the infra-axillary area bilaterally, with infiltration
of the glandular tissue was performed using a
standard infiltration 3.0-mm cannula. A “superwet”
technique, with a 1:1 ratio of infiltrate to estimated
aspirate, was used with a solution containing 500ml
of saline or lactated Ringer solution mixed with 1
ampules of 1mg/ml (1:500.000) epinephrine.
After a period of 20 minutes, trans-axillary
traditional liposuction started for the pre-marked
area using liposuction 4 and 5-mm blunt-tip titanium
cannula. Stroke technique involves constant,
deliberate passes of the cannula through the intermediate
fat layer in a radial fashion from the transaxillary
incisions were done, with fanning movement
to obtain a uniform results.
The periphery was treated for feathering and
contouring. Disruption of the infra-mammary fold
is essential in achieving a more gradual transition
of the breast to the abdomen, which is characteristic
in men. Liposuction of the glandular tissue were
also performed to detach the glandular tissue both
from the deep plane and the superficial one to
facilitate its delivery.
Concentric peri-areolar skin reduction technique
was used to treat skin excess and nipple-areola
ptosis, de-epithelialization of excess skin at the
peri-areolar area was done, extending from the
nipple-areola border to the previously marked limit.
In cases with significant increase of areolar diameter,
the areolae were marked to be reduced to 2.5
to 3.0cm. A small transdermal incision 1cm in
extension was made at the lateral margin of the
circular de-epithelialized area. It preserves the
subdermal neurovascular plexus of the nippleareola
and were found to be the least to affect the
vascularity of the areola [30].
The author used the “pull through” technique
to deliver the mammary gland which is the preferred
technique by the senior author (Elshahat A). The
gland was sharply dissected from the overlying
skin and the nipple-areola complex. There is no
need to do sharp dissection on the undersurface of
the gland. The mammary parenchyma is clamped
using a Kokher forceps and pulled-out through the
small lateral peri-areolar incision in a piece meal
manner. The gland can be easily avulsed from the
underlying pectoral fascia without injuring the
pectoralis fascia or muscle, this is mandatory to
prevent future seroma and hematoma formation.
No diathermy or scalpel needed in this technique.
Any further liposuction especially at the inframammary
area was performed through “crossthoracic
approach” using the lateral periareolar
incision of one side to reach the infra-mammary
fold of the other side.
After delivery of the gland, “purse-string suture”
of concentric periareolar skin incision was performed
for periareolar closure which was accomplished
in layers, with interrupted sutures, using
2/0 Vicryle suture for subcutaneous layer, and 4/0
Monocryle sutures for skin closure. This “pursestring
suture” maintain the width of the areola
postoperative and prevent its widening to maintain
long-lasting results. Liposuction incisions are
closed with 4/0 rapidly-absorbing Vicryle sutures.
No drains were used. A compressive vest was
applied immediately after the surgery. All patients
underwent the operation as a 1 day surgery.
Six patients in group I, were operated upon in
single-stage with liposuction, delivery of mammary
gland, concentric peri-areolar skin resection, and
nipple-areola transposition Figs. (1-5). While, the
other six patients in group II, underwent stagedreconstruction,
with liposuction of excess fat, and
concentric peri-areolar skin resection, and nippleareola
transposition in the first stage Figs. (6-10)
then, three months later, patients underwent minimal
liposuction just to facilitate delivery of the
gland, with pull-through of the gland in the 2nd
stage Figs. (11-15).
Post-operative:
Post-operative broad spectrum antibiotic, analgesic,
and anti-edema medications were prescribed.
Semi-sitting position were recommended for three
weeks post-operative. A compressive vest was
worn for 6 weeks continuously, followed by 4
weeks at nighttime only. Patients were advised to
72 Vol. 44, No. 1 / Comparative Study between Reconstruction of Grade III Gynecomastia
limit their physical activities for one month postoperative.
Post-operative photos were taken at 6 weeks,
3 months, 6 months post-operative visits, with
anterior, oblique lateral, and dead lateral views
(Figs. 1B-15B).
RESULTS
Fellow-up period was six months post-operative.
No hematoma, seroma, breast skin necrosis, breast
asymmetry, contour irregularities, inadequate resection,
disruption or dehiscence of peri-areolar
suture line, keloid or hypertrophic scarring, infection,
nipple-areola malposition or retraction were
detected post-operative in both groups.
Results were reported as “uniformly good to
excellent” on a patient satisfaction scale in both
groups, as all patients were satisfied with their
breasts contour and nipple-areola position postoperative.
Hyposthesia of nipple-areola were observed
in most patients immediately post-operative,
but it was transient and resolved spontaneously
within 6 months. Excessive gland removal or excessive
liposuction can lead to irregularities of the
skin surface, but we don't have any in our patients.
Complete nipple-areola necrosis and loss happened
in one case of group I, which managed with
purse-string suture under local anesthesia and
frequent dressings, and completely healed with
secondary intension within 2 weeks. One case of
nipple-areola vascular compromise and partial
necrosis were also detected in group I, which
managed conservatively in an out-patient clinic
with minimal debridement and frequent dressings,
and also completely healed. While, no cases showed
compromised vascularity of nipple-areola in group
II patients with two-stage reconstruction.
Pleating of peri-areolar skin were detected and
was very apparent in patients of group I (Figs. 1B-
5B). While, this skin pleating were much less
apparent in patients of group II (Figs. 11B-15B).
On a patient satisfaction scale, patients of group
I complained of noticeable pleating in comparasion
to group II patients, who reported less noticeable
and accepted degree of pleating.
By comparing the complications rate between
both groups, results showed that single-stage reconstruction
in group I was associated with higher
complications rate as regard the nipple-areola
vascularity, and as regard the presence of excessive
pleating of periareolar skin post-operative than in
group II.
Egypt, J. Plast. Reconstr. Surg., January 2020 73
Fig. (1): Anterior view for a patient of group I:
(A) Pre-operative. (B) Post-operative, with single-stage reconstruction.
Fig. (2): Right oblique lateral view for the same patient of group I:
(A) Pre-operative. (B) Post-operative.
Fig. (3): Right dead lateral view for the same patient of group I:
(A) Pre-operative. (B) Post-operative.
(A) (B)
(A) (B)
(A) (B)
74 Vol. 44, No. 1 / Comparative Study between Reconstruction of Grade III Gynecomastia
Fig. (5): Left dead lateral view for the same patient of group I:
(A) Pre-operative. (B) Post-operative.
Fig. (4): Left oblique lateral view for the same patient of group I:
(A) Pre-operative. (B) Post-operative.
Fig. (6): Anterior view for a patient of group II:
(A) Pre-operative. (B) Post-operative, with two-stage reconstruction, after the 1st stage.
(A) (B)
(A) (B)
(A) (B)
Egypt, J. Plast. Reconstr. Surg., January 2020 75
Fig. (7): Right oblique lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 1st stage.
Fig. (8): Right dead lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 1st stage.
Fig. (9): Left oblique lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 1st stage.
(A) (B)
(A) (B)
(A) (B)
76 Vol. 44, No. 1 / Comparative Study between Reconstruction of Grade III Gynecomastia
Fig. (11): Anterior view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, with two-stage reconstruction, after the 2nd stage.
Fig. (10): Left dead lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 1st stage.
Fig. (12): Right oblique lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 2nd stage.
(A) (B)
(A) (B)
(A) (B)
Fig. (13): Right dead lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 2nd stage.
Fig. (14): Left oblique lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 2nd stage.
Fig. (15): Left dead lateral view for the same patient of group II:
(A) Pre-operative. (B) Post-operative, after the 2nd stage.
Egypt, J. Plast. Reconstr. Surg., January 2020 77
(A) (B)
(A) (B)
(A) (B)
DISCUSSION
Most of the patients with grade III gynecomastia
had not only skin excess, but also had enlarged
and infero-medially displaced nipple-areola complex.
These patients need both skin and nippleareola
complex reduction to achieve a good aesthetic
result [21]. Surgical techniques for grade III
gynecomastia, however, have been largely limited
in their inability to address significant skin excess
and nipple-areolar ptosis [21].
In the most severe cases, breast amputation
with free nipple grafting remains an effective
option, but this technique is associated with multiple
complications most importantly the extensive scarring,
possible depigmentation of nipple-areola,
loss of nipple-areola sensitivity, possible total loss
of free graft, and hypertrophic scars over chest
[18]. For patients unwilling to accept loss of nipple
sensation or possible depigmentation seen with
free nipple graft techniques, elliptical excision
patterns allow for significant skin excision while
still maintaining NAC viability on a pedicle [11,20].
Its disadvantage is the need to maintain a glandular
pedicle which can lead to excess remaining tissue,
leading to a contour deformity and undercorrection
[21]. So, less invasive techniques were proposed
for management of such cases.
Skin reduction techniques other than elliptical
excision, are periareolar, lateral wedge, inverted
T, and LeJour [11,15-17]. The concentric peri-areolar
technique is the most popular because it enable
excision of excess skin and nipple-areola transposition
with the least noticeable scarring, and its
simplicity while provide good access to the gland,
leading to better extraction of fibrous fat, better
contour control, and increased skin contraction
postoperatively [16,17].
The “pull-through” technique, first described
in 1996 by Morselli [31]. Morselli & Morellini in
2012 [32], combined the “pull-through” technique
with liposuction that is performed on two planes,
subcutaneous and subglandular to detach glandular
tissue completely both from the deep plane and
the superficial one, and sharp parenchymal excision
using a scalpel or electrocautery through the small
liposuction incisions hidden in the inframammary
fold and behind the anterior axillary pillar was
done as a single-stage procedure.
Sarkar et al., [3], Brown et al., [21], and El-
Sabbagh [33], reported excellent results with a
single-stage procedure too using a combination of
traditional liposuction in Sarkar et al., [3] and El-
Sabbagh study [33], and UAL in Brown et al., study
[21] with direct glandular excision but, through the
same lateral peri-areolar incision, with periareolar
skin excision in Sarkar et al., [3] and Brown et al.,
[21] studies. But, patients with the most severe skin
redundancy in Brown et al., study [21] underwent
an elliptical skin excision or breast amputation
with free nipple grafting. In El-Sabbagh study [33],
which included 14 patients, 4 of them were grade
III, the author didn't do excision of excess skin
except in older patients with poor skin quality, and
he did it with vertical skin excision technique [34],
which leaves an evident scar. In Sarkar et al., study
[3], which included 12 patients. The margin of the
areola was fixed at mid-humerus level with pectoralis
fascia.
The current study which included 12 patients
of severe grade III gynecomastia, traditional liposuction
and delivery of gland were performed from
two separate incisions, transaxillary incision for
liposuction and lateral peri-areolar incision for
glandular excision. Because liposuction through a
periareolar incision combined with removal of
residual breast tissue (through this same incision)
has several drawbacks, like the possibility of a
friction burn at the incision site.
All patients of our study were very satisfied
with the results, and even in the most severe cases,
we didn't need to do vertical skin excision unlike
El-Sabbagh study [33], or elliptical skin excision,
or breast amputation with free nipple grafting
unlike Brown et al., study [21] to avoid extensive
chest scarring. The technique of skin excision with
concentric peri-areolar scar used in the current
study leaves a well concealed scar. As well as in
the current study, we didn't fix the areola to the
pectoral fascia unlike Sarkar et al., study [3], however
the nipple-areola position was good in all
patients.
Complications of peri-areolar scar may include
changes to nipple sensation, NAC asymmetry,
hypertrophic or keloid scarring, and nipple-areola
necrosis [35,36]. However in the current study, it
didn't show any of these complications except for
nipple-areola necrosis which occurred in 2 patients
of group I with single-stage reconstruction, and
transient hyposthesia, which improved spontaneously
within 6 months.
In Morselli & Morellini study [32], hypertrophy
and/or hyperpigmentation of inframammary scar
were recorded in 2% of cases, wide scars in 3%,
4% had skin irregularities, 1% nipple-areola complex
impairment, 2% excessive post-operative
bleeding and in 1% showed subcutaneous hemato-
78 Vol. 44, No. 1 / Comparative Study between Reconstruction of Grade III Gynecomastia
ma. Advantages of this technique are avoiding risk
of retraction, distortion, and sensory impairment
of nipple-areola. While, the major disadvantage is
that this technique do not allow for skin excision
and will not improve the enlarged ptotic nippleareola.
Although 30% of their patients are grade
III.
El-Sabbagh study [33] included 3 patients with
seroma, 2 patients with partial superficial epidermolysis
of areola, infection in one patient, and
nipple retraction in 3 patients. There were no cases
presented with nipple-areola complex necrosis,
and all the patients were satisfied with the results.
Complications in Sarkar et al., study [3], included
two patients with seroma, one patient with
hematoma due to sharp dissection of the glandular
tissue, peri-areolar pleating of skin, no nippleareola
necrosis occurred. However, all patients
expressed their satisfaction post-operative.
In the current study sharp dissection only used
superficially, while blunt dissection on the undersurface
of the gland was performed, so no patients
developed hematoma post-operative. The pursestring
peri-areolar suture secure and maintain the
size of areola post-operative and prevent its widening
in the long-term fellow-up. But the periareolar
pleating is evident in patients of group I
with single-stage reconstruction as in Sarkar et al.,
study [3].
We didn't use either a scalpel nor electrocautery,
because the peri-areolar incision allow direct visualization
of the parenchyma, this allows a more
extensive and radical removal of breast tissue with
no or minimal risk of relapses, because the most
common late complication of gynecomastia is
inadequate resection of glandular tissue or skin
[21], which doesn't happened to any of our patients.
Peri-areolar incision also allow direct control
of bleeding reducing the incidence of post-operative
hematoma, than the remote infra-mammary incision
described in Morselli & Morellini technique [32].
So, we didn't use any drains in the current study,
unlike Morselli & Morellini [32], Sarkar et al., [3]
Brown et al., [21] and El-Sabbagh study [33], who
are performing sharp parenchyma dissection using
scalpel or electrocautery, leading to increase incidence
of post-operative bleeding and post-operative
hematoma formation. Average hospital stay was
2.41 days (range 2-4 days) in Sarkar et al., study
[3]. In the current study, all patients discharged at
the same day of surgery, same as Brown et al., [21]
and El-Sabbagh study [33].
Egypt, J. Plast. Reconstr. Surg., January 2020 79
The vascular pedicle below the NAC, originating
from the intercostal vessels, has been considered
by some authors [37-39] as fundamental for the
blood supply of the NAC. Neither we nor Persichetti
et al., in 2001 [40] agree with this statement,
since the blood supply from the subdermal plexus
by itself is capable of maintaining the NAC, enabling
execution of the lateral peri-areolar technique
for delivery of the mammary gland as we did in
the current study, with the least possible complications
to the vascularity of nipple areola.
No previous studies found in the literature
described staged reconstruction of grade III gynecomastia,
and hence, no previous studies compared
between single-stage and two-stage reconstruction
of severe gynecomastia. In the current study, we
found reconstruction of grade III gynecomastia
with liposuction of fat, delivery of the gland,
resection of excess skin, and transposition of nippleareola
in single-stage is associated with excessive
pleating of periareolar skin Figs. (1B-5B), because
the sudden reduction in the size of areola don't
allow for skin retraction and recoil to occur gradually
leading to excessive wrinkling and pleating
of periareolar skin post-operative [27,28]. While,
two-stage reconstruction with liposuction of fat,
and resection of excess skin with nipple areola
transposition in the first stage, then delivery of the
gland in a second stage three months apart, is
associated with less pleating of periareolar skin,
because staged reconstruction gives a chance for
skin reduction to occur staged and gradually, and
give a chance for skin retraction and contraction
to occur, leading to minimal pleating of periareolar
skin (Figs. 11B-15B).
Also, reconstruction of grade III gynecomastia
in single-stage is associated with higher rate of
vascular compromise to NAC [21], because deepithelialization
and resection of peri-areolar skin
together with delivery of the mammary gland in
the same stage put added risk to the supporting
vascularity of the areolar pedicle, leading to areolar
vascular compromise with possible partial or complete
loss of the areola. While, in staged reconstruction,
with de-epithelialization and resection
of peri-areolar skin in one stage, then delivery of
mammary gland in a separate stage, the areolar
pedicle vascularity will be preserved, leading to
less vascular compromise and complication rate
to the nipple-areola.
In the current study, we included the patients
with enlarged ptotic nipple-areola only, because if
the areola is originally small, the areolar diameter
may be enlarged post-operative with this peri
areolar technique. In addition that, the smaller
areolar diameter is associated with excessive pleating
of periareolar skin post-operative. So, in the
current study, we excluded patients with small
areolar diameter.
Conclusion:
Two-stage reconstruction for correction of grade
III gynecomastia, allows the surgeon to achieve
an aesthetic result while avoiding serious complications.
It is considered a safe procedure which
preserve nipple-areola vascularity, and permits
broad resection of excess skin and submammary
tissue, while avoiding unattractive scars, with
minimal pleating of periareolar skin post-operative.
Using this technique, good results were reported
as regard breast symmetry, contouring, accepted
pleating of skin surrounding the areola, and nippleareola
position, with complete satisfaction of patients.
Single-stage reconstruction is associated
with higher complication rate as regard nippleareola
vascularity, and as regard excessive pleating
of peri-areolar skin.
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