INTRODUCTION
Benign enlargement of the male breast is what
is called gynecomastia. It negatively affects the
psychosocial well-being of affected adolescent
patients. Social functioning, mental health, and
self-esteem are specifically affected by such condition
[1].
Waltho and colleagues, 2017, systematically
reviewed various classification systems and identified
10 breast characteristics that were included
in the 11 classification systems that met their
inclusion criteria. They included 4 common features
namely; breast size, skin redundancy, breast ptosis
and tissue predominance. The remaining features
that were variably used by the studied classification
105
systems included; upper abdominal laxity, breast
tuberosity, nipple malposition, chest shape, absence
of sternal notch and breast skin elasticity [2].
One of the oldest classification systems is that
presented by Webester who has classified gynecomastia
into glandular type, fatty glandular type
and simply fatty type [3]. Gynecomastia can be
classified into three grades: Grade I: Small visible
breast enlargement and no skin redundancy, Grade
IIA: Moderate breast enlargement without skin
redundancy, Grade IIB: Moderate breast enlargement
with skin redundancy, Grade III: Severe breast
enlargement with marked skin redundancy according
to morphology and degree of skin redundancy
[4].
The American Society of Plastic Surgeons
(ASPS) has adapted a classification system based
on descriptive terms rather than quantitative [5]:
• Grade I: Small breast enlargement with localized
button of tissue around the areola.
• Grade II: Moderate breast enlargement exceeding
areola boundaries with indistinct edges from the
chest.
• Grade III: Moderate breast enlargement exceeding
areola boundaries with distinct edges from the
chest and skin redundancy.
• Grade IV: Marked breast enlargement with skin
redundancy and feminization of the breast.
Current surgical options are tailored to each
grade of gynecomastia, hence a variety of technique
that can be used solely or in combinations have
evolved. These include liposuction, either conventional,
power assisted or ultrasound assisted, pullthrough
techniques, subcutaneous mastectomy and
finally breast reduction techniques [6-9]. Achieving
a good aesthetic outcome in patients with highgrade
gynecomastia can be challenging. In this
specific group of patients, patient's satisfaction is
considered an essential measure of treatment success
apart from objective aesthetic outcomes evaluation
[10-12].
The aim of this study is to compare between
the results of two surgical techniques of reduction
mammoplasty: No vertical scar and circumareolar
scar and the impact on patients satisfaction following
surgical treatment of high grade gynecomastia
(grade IV according to ASPS classification which
is equivalent to grade III by Simon's classification).
MATERIAL AND METHODS
This is a prospective, comparative, randomized
and descriptive study of 30 male patients suffering
from high grade gynecomastia, conducted in the
period from 1/6/2017 to 1/12/2018. The patients
were divided into two groups undergoing breast
reduction with one of two techniques; Group A
subjected to no vertical scar technique (15 patients).
Group B subjected to donut circumareolar technique
(15 patients). Both groups were compared for
patient's satisfaction score.
Inclusion criteria:
Patients (male) presented with severe breast
tissue enlargement and marked redundancy in the
skin.
Exclusion criteria:
Age less than 18 years and above 65 years,
severe comorbidity interfering with anesthesia and
uncontrolled Diabetes Mellitus (DM). All patients
were subjected to the following:
Pre-operative work up:
Explanation and an informed consent before
admission preserving all ethical considerations of
the patients, the patient was informed about the
location of the incision and placement of drains.
Proper clinical evaluation of each case was done
to exclude underlying factors (pharmacological or
pathological). Relevant laboratory investigations
were ordered accordingly. Also, breast ultrasound
was done to exclude presence of abnormal mass.
Marking and operative steps:
Group A (Fig. 1): While in upright position the
midline of the chest, inframammary fold, breast
meridian (from the mid-clavicular point to the
nipple normally=18cm) were marked, and then
with the patient lying down three concentric circles
centered at the nipple were drawn.
Under general anesthesia with the patient in
the supine position, prepping and draping were
106 Vol. 44, No. 1 / Surgical Treatment of Grade IV Gynecomastia
done followed by infiltration of the subcutaneous
tissue with tumescent solution composed of 250-
350ml mixture of normal saline 1000ml, lidocaine
2% 25ml, and 1ml adrenaline 1:1000 was carried
out. In order not to jeopardize the vascularity of
the nipple-areola complex meticulous deepithelialization
between the inner and the outer circle
was performed. Careful tailoring of this area to fit
the degree of skin redundancy and the size of the
breast for each patient should be done. Leaving
10-15mm thickness of tissue on the undersurface
of the nipple and areola and to the pectoral fascia
deeply without insulting it, the gynecomastia structure
with a decent amount of breast tissue was
dissected from the nipple and areola through a
semicircular incision at the lower edge of the large
circle this was followed by proper hemostasis and
negative suction drain was inserted. With the aid
of a purse string proline 4/0 suture through the
large circle to fit the size of the small one, the
wound was closed. Subsequently, deep dermal
interrupted vicryl 4/0 sutureswere applied, followed
by subcuticular skin closure using vicryl 5/0 sutures.
The excised tissue was sent for histopathological
examination.
Group B (Fig. 2): Two horizontal lines were
drawn at the level of the supra-sternal notch and
at the center of the infra-mammary creases.
The distance between the two lines was measured.
A point, having the same distance from the
suprasternal plane was marked on the breast at the
midclavicular line, point A. This is the length of
the upper flap and the inferior limit of the breast.
The medial and lateral limits of the breast were
marked at the level of the infra-mammary crease,
points B and C respectively. Point C was made
slightly higher than point B. Point D was marked
on the infra-mammary crease in the same vertical
plain as point A. An ellipse was marked, joining
points A, B, C and D.
The new nipple position was marked over the
fourth intercostal space in the same vertical plain
as the present one unless there was a need to
transpose it horizontally, point E. A circular mark
was drawn around the areola at the desired size.
Two dotted circles were drawn on the skin
delineating the contour of the breast to determine
the limits of the excision and feathering.
With the patient in the semi-sitting position
and under general anesthesia, the operation was
carried out. The points and lines are scored, and
the breasts are infiltrated with diluted epinephrine,
1/200,000.
Egypt, J. Plast. Reconstr. Surg., January 2020 107
Fig. (2): Patient with bilateral
gynecomastia grade IV, (A)
Pre-operative marking for no
vertical scar breast reduction
approach, (B) Nipple areola
preserved on a de-epithelialised
inferior pedicle, (C,D) Pre and
3 months post-operative results.
Fig. (1): Patient with bilateral gynecomastia
grade IV, (A) Pre-operative marking for circumareolar
breast reduction approach, (B) Doughnut
de-epithelialization of the periareolar skin,
(C) Excised fatty-glandular tissue, (D & E) Pre
and 3 months post-operative pictures.
(A) (B) (C)
(D) (E)
(A) (B)
(C) (D)
The area between points ABC and D is deepithelialized
excluding the areola. This will be the
lower dermo fascial flap.
The line BAC was incised down to and including
the superficial fascia. All the breast tissue
between the dermo-fascial layer and the pectoral
fascia was removed with care not to disrupt the
sensory nerves at the lateral part of the breast,
creating the inferiorly based lower dermo-fascial
flap. The excision was feathered at the margins,
and the deep attachment of the infra-mammary
crease was disrupted.
The upper flap was dissected as high as needed
to excise all the remaining breast tissue and to
allow fixing of the lower flap to the pectoral fascia.
The thickness of the flaps could be increased
proportional to the amount of the subcutaneous fat
elsewhere in the chest to prevent saucer deformity
or nipple inversion.
The lower flap was fixed to the pectoral fascia
high under the upper flap by 2/0 proline sutures.
The transverse excess in the lower flap can be
excised or tucked under the lateral margins of
the upper flap to achieve smoothening of the
contour. The upper flap was then sutured to the
line BDC.
The nipples were exteriorized through the upper
flap and sutured at their marked position. If there
was difficulty in transposing the nipple in the
transverse direction, a medial or lateral back cuts
were made as desired to facilitate its movement.
A3/0 burse-string prolene® sutures might be placed
around the areolae but were not often necessary
as there was no tension on the circumareolar sutures.
After careful hemostasis, wound was closed
in two layers. Drains were not usually needed, and
compressive dressing was applied for a week to
be followed by an elastic garment.
Both groups were compared as regard the demographics
of the patients, volume of gland resected,
time to drain removal, duration of hospital stay,
post-operative complications and patient satisfaction
score.
Statistical analysis:
The results had been collected, evaluated, calculated,
tabulated and statistically analyzed using
a computer statistical package (IBM SPSS Statistics
for Windows, Version 21.0. Armonk, NY, USA:
IBM Corp.) with a significant p-value £0.05%.
108 Vol. 44, No. 1 / Surgical Treatment of Grade IV Gynecomastia
Table (1): Pre-operative data: Showing no significant difference
between patient characteristics in each group.
Comparative Technique
pre-operative
features
Age (years):
Range
Mean
Body mass index:
Range
Mean
Group A
N=15
20-48
35.29.07
19.1-39.3
27.98±4.19
Group B
N=15
25-55
35.29.57
19.7-43
26.63±4.72
pvalue
0.944
0.152
Table (2): Intra operative data.
Comparative Technique
intra-operative
features
Resected part
weight (grams):
Range
Mean
Group A
N=15
1350-3850
2673.3±973
Group B
N=15
1550-4550
3028±1068
pvalue
0.006*
Table (3): Post-operative data.
Technique
Comparative
post-operative features
Time of drain removal (days):
Range
Mean
Hospital stay (days):
Range
Mean
Patient satisfaction score in
numbers:
Range
Mean
2-5
3.7±1.42
3-16
4.91±1.70
3-5
4.1±0.841
Group A
N=15
Group B
N=15
2-6
5.14±3.08
4-11
6.8±3.24
2-4
2.9±0.798
pvalue
0.0001*
0.00026*
0.00116*
Table (4): Patient's satisfaction sore.
Post-operative
satisfaction
Very dissatisfied
Dissatisfied
Average
Satisfied
Very satisfied
Group A
0
0
2
3
10
Group B
0
0
4
5
6
No. of
patients
0
0
6
8
16
RESULTS
There was no statistically significant difference
in patients' demographics, age & BMI (Table 1). The
resected volume was significantly higher in group B
undergoing the no vertical scar approach (Table 2).
Also, time for drain removal and duration of hospital
stay were significantly higher in group B. The patient
satisfaction scores were significantly higher in group
A undergoing the circumareolar approach (Tables
3,4). Complications in the form of seroma, asymmetry
and wound dehiscence were more prevalent in group
B 45% than in group A 20% (Table 5).
Egypt, J. Plast. Reconstr. Surg., January 2020 109
DISCUSSION
Physiologic gynecomastia will often regress
spontaneously, as with withdrawal of an offending
drug in drug-induced gynecomastia. However,
most forms of grade III & IV gynecomastia being
idiopathic have only surgery as a gold standard
treatment.
Surgery consists of a combination of liposuction
and excisional techniques. A lot of debate exists
among surgeons upon the techniques used, some
of them advocating that liposuction should be the
only treatment in all cases, regardless of the amount
of parenchyma and excess skin, at least in the first
stage, followed, if necessary, by a second stage of
excess glandular excision or areola reduction (6-
9 months after ultrasound-assisted liposuction to
allow for maximal skin retraction) [13-15].
Most of the difficulties in the surgical treatment
of the gynecomastia are due to the restrict size of
the incision that prejudices the illumination of the
operative field and the hemostasis. The transareolar
mammary and infra-areolar marginal incisions are
not always efficient to correct gynecomastia with
marked skin redundancy and to elevate the nippleareola
complex.
In the current study, we tried to explore the
potentials of two different approaches in surgical
treatment of grade IV gynecomastia and compare
the patient satisfactions following them.
We found the no vertical scar technique provided
better exposure and allowed larger volume of
tissues to be resected with better hemostasis that
permitted the earlier removal of drains and hence
less hospital stay when compared to the circumareolar
approach.
On the otherhand, the patients' satisfaction
scores were significantly higher in the circumareolar
approach group which could be attributed to
the inconspicuous scar at the areola-skin junction.
Other methods of skin resections by means of
inverted T technique result in long scars and can
leave the breast cone like. The illness stigma is
replaced by a scar stigma, especially in patients
with hairless chest wall. The removal of the vertical
component of such scare reduces the scare burden
for patients [16]. In massive gynecomastia, the
amount of skin to be removed is only limited by
tension on digital pinching and by position of the
areola. The patient should be advised about the
possibility of a second-stage procedure to remove
residual skin and adipose tissue. The redundant
adipoglandular tissue in the inferior pole of the
breast is credited to the fear of thinning excessively
the base of the inferior pedicle flap.
Conclusion:
Circumareolar approach for surgical treatment
of gynecomastia has a beneficial effect on decreasing
scar formation, increase patient satisfaction,
on the other hand it the no vertical scar techniques
allows more tissues to be removed but offers better
access reducing the time needed for drain removal
and hospital stay, however the resulting scar and
the residual fatty glandular tissue at the inferior
pedicle leads to less patient satisfaction.
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