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Arch Aesthetic Plast Surg > Volume 20(1); 2014 > Article
Yoon and Kang: Correction of Lipomastia through a Stab Incision on the Nipple Areolar Junction

Abstract

Background

Lipomastia (pseudogynecomastia, fatty-type gynecomastia) is defined as the benign enlargement of the male breast attributable to accumulation of the adipose tissue. The aim of this study is to describe the experiences of a stab incision on the nipple areolar junction method to the correction of lipomastia. The authors present a combined method ultrasound-assisted liposuction in conjunction with a shaver technique to effectively remove the fatty and fibro-glandular tissues of the male breast and avoid noticeable scar.

Methods

A retrospective analysis was made of 500 cases of lipomastia operated on in the last 16 months via sub-nipple approach. The extent of the clinical result, the technique employed, and the complications were observed.

Results

The volume of liposuction from each side ranged from 30 to 500 mL (median, 175 mL) and the median weight of the fibro-glandular tissue was 10.5 grams. Major complications from this procedure include undercorrection, overcorrection, infection, and hematoma. Our total major complication rate was 1.8%.

Conclusions

These techniques of a sub-nipple stab incision are also alternative to correct lipomastia, avoiding undesirable scars.

INTRODUCTION

Male breast enlargement can occur transiently in up to three fourths of adolescents and is persistent in 7% of cases [1]. Gynecomastia is the most common benign condition of the male breast and present in 65 % of normal adolescents [2-4]. It is often self-limiting and resolves, usually during the teenage years. The adolescent with gynecomastia should not be operated on until 3 years have passed and it has been amply demonstrated that spontaneous regression will not occur [2]. Pubertal male patients are most successfully treated with patience and reassurance, because the vast majority of these patients will experience complete resolution with time. The persistent large breasts may cause significant emotional distress and embarrassment to male. Pseudogynecomastia refers to benign enlargement of the male breast attributable to excessive breast adipose tissue, a condition termed lipomastia or fatty type gynecomastia. True gynecomastia and lipomastia can generally be differentiated by carefully palpation and/or ultrasonography examination [3-5]. The development of liposuction techniques has enabled correction of lipomastia with only inconspicuous scarring [1,2]. The direct resection of the fibro-glandular tissue with ultrasonic liposuction is one of the most commonly used alternatives. To remove the fibro-glandular tissues effectively and aesthetically, not tumor excision concept but chest contouring concept is necessary [5,6] Unfortunately, the result of the tumor excision method is often as physically and psychologically disturbing to the patient and doctor. Author technique consist of the flattening of the thorax can be achieved by means of stab incision on the nipple areolar junction, ultrasound-assisted liposuction (UAL) [7-9], scavenging suction-assisted lipectomy (SAL) [10], fibro-glandular tissue shaving using cartilage tissue shaver [11] and pull-through method [12-14]. The present study evaluates the results of correction of lipomastia with a special focus on sub-nipple approach procedure and outcomes.

METHODS

This was a retrospective analysis of all lipomastia patients treated with a stab incision on the nipple areolar junction at the Silhouette Clinic CBBC over 16-month period, between 2011 and 2013. All patients had bilateral lipomastia grade Yoon I to IV [5]. According to the Yoon classification [5], 34 patients could be include in grade I (6.8%), 123 patients in grade II (24.6%), 267 patient in grade III (53.4%) and 76 patients in grade IV (15.2%). All patients were preoperatively assessed by the single surgeon, who recorded the characteristics of their breasts in terms of size, firmness, skin elasticity and overall skin quality. Then by ultrasonography examination, authors confirmed lipomastia and measured the size and boundary of the male breast.
The areas treated were marked preoperatively with the concentric topography map technique, while the patient was in a standing position. The patient was positioned supine with arms abducted for the procedure. The procedure was performed under intravenous sedation and local anesthesia. Preoperative antibiotic prophylaxis was administered with 1.0 g cefazolin routinely. A 3 mm stab incision was made at the nipple areolar junction with a No. 15 blade for liposuction and fibro-glandular tissue removal (Fig. 1A). We infiltrated all areas to be suctioned with tumescent Klein solution. Tumescence was accomplished using one ample (1 mL of 1:1,000) of epinephrine and 40 mL of 2% lidocaine per liter of infiltrated isotonic saline solution. To prevent incision site maceration, we applied paper skin protection (Fig. 1B). After 10-15 minutes, we performed liposuction and fibro-glandular tissue removal to flat the chest. At first, we use the ultrasonic machine (Contour Genesis, Mentor Medical Systems, Santa Barbara, Calif.) to soften the fibrotic breast parenchyma. And then manual suction was applied to scavenge the remained adipose tissue with cannulas 3 or 4-mm in diameter. After complete liposuction we removed fibro-glandular tissues employing the shaver system (Stryker Corp., Kalamazoo, Mich.). We could aspirate and collect the fibro-glandular tissues. Then “pull-through” technique is performed to scavenge the remaining fibro-glandular tissue beneath the nipple-areola complex (Fig. 1C). The surrounding subcutaneous fat of the chest bordering the breast is feathered by suction to avoid noticeable saucers deformity. It is very important to leave a small amount of fibro-glandular tissue behind the areola to avoid severe depression. Regularity was determined by using the pinch test and by observing the smooth contour. The incision is closed with one or two intradermal absorbable stitches. Tissue adhesive is placed over the skin suture line (Fig. 1D). A compressive sponge and elastic bandage dressing is applied in the operating room. The patients remained recovery room for 1-2 hours for observation. Oral antibiotics and pain killer medications are given during the first three days after surgery. Patient is discharged the day after surgery. Light activity is required for the first 24 hours. After 24 hours, we recommended patients to remove all dressing materials and to take shower. Patients were allowed to return to work starting from the third operative day. We routinely advise to wear a compressive dressing with an elastic bandage for 2 to 4 weeks during the postoperative course. The bandage allows for even skin redistribution and decreased third-space collection of serum or blood. Sport activities were permitted beginning from the second or fourth week.

RESULTS

During a 16-month period, we operated on 500 male patients ranging in age from 18 to 57 years (median age, 21.7 years) underwent surgery with a stab incision on the nipple areolar junction. The postoperative follow-up period ranged from 3 to 24 months (average follow-up, 6 months). The volume of liposuction from each side ranged from 30 to 500 mL (median, 175 mL) and the median weight of the fibro-glandular tissue was 10.5 grams.
Major complications from this procedure include undercorrection, overcorrection, infection, and hematoma (Table 1). Our total major complication rate was 1.8%. Two patients (0.4%) required secondary suctioning because of undercorrection. Three overcorrection cases (0.6%) required autologus fat injection to improve the chest contour. One patient (0.2%), who revisited after 1 week showed the redness on the surround of the nipple areola complex. We could treat the infectious sign through just one needle aspiration. In three patients (0.6%), a small to moderate hematoma developed, which required 2-3 times needle aspiration at the outpatient based clinic. No other significant complication or recurrences were encountered. Minor complications (defined by without revision demanded) include swelling, bruising, transient sensory change, areola wrinkling, nipple partial necrosis and hypertrophic scar or protrusion of the nipple due to scar formation. For 22 patients (4.4%), postoperative subareola fullness develops as a result of scar deposition. To prevent and treat hypertrophic scar or protrusion of the nipple, 2-3 times 0.3-0.5 mL of triamcinolone may be injected under the nipple into the deeper scar tissue to smooth excess collagen formation. In five patients, the nipple partial necrosis was occurred, which solved just observation and minor touch. Redundant areola skin (slightly areola wrinkle) occurred after fibro-glandular removal for 2 (0.4%) of the 500 patients who underwent this technique, requiring a minor revision to flatten areola skin using autologus fat injection. In the early postoperative days, swelling, bruising and transient sensory change was commonly observed. Fig. 2, 3, and 4 illustrate postoperative results.

DISCUSSION

The three terms typically used to categorize gynecomastia are true gynecomastia, referring specifically to glandular enlargement; mixed gynecomastia, which describes a breast with both fatty deposits and glandular hypertrophy; lipomastia, referring to chest lipodystrophy [4]. Lipomastia may develop at puberty as a result of obesity [4,5,11,15,16]. The surgical treatment remains the main solution for longstanding lipomastia. Tumescent liposuction and/or ultrasonic liposuction are an effective remedy for chest lipodystrophy. But liposuction alone usually will not fully correct a significant proportion of lipomastia cases because of the presence of fibro-glandular tissue [7,11] Rosenburg [2] and Rohrich [7] claimed that isolated liposuction could adequately remove the breast parenchyma. But we feel that excision is necessary for removal of the fibro-glandular tissue of the lipomastia [5,17]. In our experience, these dense fibrotic tissues cannot be adequately removed by liposuction alone and excision of glandular tissue is needed in lipomastia. Ultrasonic liposuction is an interesting alternative for lipomastia correction and produces good skin retraction, but we needed additional procedure to remove the fibro-glandular tissue. Liposuction alone was only used in patients with lipomastia with no fibro-glandular tissue, but seldom.
The removal of fibro-glandular tissues necessitates additional consideration because excisional technique may create a relatively high complications rate. Although they often produce good results, they are not free of complication. For many years, the periareolar approach has been our first choice for correct lipomastia; it allows good control of the operative field. The periareolar approach methods for extract the fibro-glandular tissue may result in prominent scar. The extent and placement of postoperative scarring is an important consideration. When invisible external scarring is requested by the patient, who does not want periareolar scars, we think a sub-nipple stab incision technique. We describe this technique through small 3-mm sub-nipple stab incisions to hide the scar. Imperceptible 3-mm incisions are of particular value to younger lipomastia patients, for whom prominent scar might become a new source of shame and self-consciousness. The stab incision has several disadvantages; narrow view field, difficulty of the electrocautery, and possibility of the areola skin maceration. But the operative experiences got to be stacked, we could overcome the disadvantages. We applied shaving system [11] and pull-through method [12-14]. These techniques have permitted the effective resection of fibro-glandular tissue. It has allowed us to carry out a fibro-glandular gradual and controlled resection of the tissue, giving a final good contour of the whole chest. Author method refines and improves upon existing traditional techniques, offering a less outwardly invasive approach. The removal of excessive fat with fibro-glandular tissue produces an improved appearance and projection of the male torso. Correction of lipomastia translates to greater confidence and self-esteem. It does more than fix a physical problem. It can make a profound impact on the patient’s emotional and psychological life and improve self-confidence.

CONCLUSION

The surgical treatment of lipomastia requires an individual approach, depending on the grade of male breast hypertrophy. This technique of stab incision on the nipple areolar junction is also alternative to correct lipomastia, avoiding undesirable scars. This technique has improved the final outcome with invisible scar, minimal complications and good aesthetic results.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig. 1.
A stab incision and operative instruments. (A) a stab incision on the nipple areolar junction and tacking suture with 4-0 stitch. (B) Skin protection for prevent from maceration. (C) Ultrasonic liposuction cannula (diameter 3 mm), manual suction cannula (diameter 3 mm and 4 mm), and tissue shaver. (D) Immediate postoperative view. Note; cannot find the incision site.
aaps-2014-20-1-31f1.jpg
Fig. 2.
A 21 year-old patient (178 cm, 86 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 320-350 cc, excision 12-17 g). (A) Preoperative view. (B) Postoperative view after 7 months.
aaps-2014-20-1-31f2.jpg
Fig. 3.
A 22 year-old patient (170 cm, 63 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 190-240 cc, excision 10-14 g). (A) Preoperative view. (B) Postoperative view after 15 months.
aaps-2014-20-1-31f3.jpg
Fig. 4.
A 25 year-old patient (175 cm, 70 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 200-250 cc, excision 20-22 g). (A) Preoperative view. (B) Postoperative view after 11 months.
aaps-2014-20-1-31f4.jpg
Table 1.
Major Complications
Complications 1.8% (9/500)
Undercorrection 0.4% (2/500)
Overcorrection 0.6% (3/500)
Infection 0.2% (1/500)
Hematoma 0.6% (3/500)

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