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Arch Aesthetic Plast Surg > Volume 30(4); 2024 > Article
Elsakka and Louri: Minimally invasive intervention for gynecomastia excision: two case reports

Abstract

Gynecomastia is characterized by abnormal and excessive development of breast tissue in male patients. Depending on the volume of the breasts and the amount of excess skin, it may be unilateral or bilateral. Surgery is considered the standard of care, with several techniques documented, including different types of incisions made in the periareolar or intra-areolar skin. The most common surgical technique is conventional open surgery, which utilizes a semicircular inferior periareolar incision. To achieve superior aesthetic outcomes, various alternatives to open surgery have been proposed, including vacuum-assisted excision, endoscopic mastectomy, and liposuction Herein, we present two cases involving male patients, aged 29 and 24, who reported bilateral breast enlargement. We used the same incision for both liposuction and glandular excision. Our patients underwent combined liposuction on two planes: subcutaneous and subglandular, accompanied by sharp parenchymal excision. These small incisions, measuring 1–1.5 cm, are discreetly placed within the inframammary fold across the breast width. The patients experienced an uneventful recovery without any complications.

INTRODUCTION

The term “gynecomastia” is derived from the Greek words “gyne” (female) and “mastos” (breast) and describes the enlargement of the male breast due to the proliferation of both stromal and epithelial cells. It presents as either unilateral or bilateral breast enlargement that is palpable, visible, and can be painful. Patients often seek medical assistance due to fears of cancer, anxiety, or embarrassment in social situations [1].
Gynecomastia is a benign condition responsible for 85% of male breast masses and 60% of all male breast abnormalities. It can affect individuals of any age, but teenage boys between the ages of 14 and 15.5 represent 40% of cases. Approximately 40% of healthy men have palpable breast tissue, a figure that rises to 70% among older men admitted to hospitals [2]. There are three peak periods for physiological gynecomastia: in neonates, during puberty, and in old age.
By contrast, female breast ductal and periductal tissues continue to grow and produce terminal acini, which depend on progesterone and estrogen. Gynecomastia has long been considered a result of an imbalance between these hormones, as androgens counteract the effects of estrogens on breast tissue stimulation [3].
Gynecomastia can be either physiological or pathological. Physiological gynecomastia most commonly arises during periods of hormonal changes in males, specifically during infancy, puberty, and aging [4,5].
Three distinct histological patterns–florid, fibrous, and intermediate–have been identified, each characterized by varying levels of stromal and ductal proliferation. These types represent different stages of the pathology’s evolution. For instance, most hypertrophic breast tissue becomes irreversibly fibrotic after more than a year, which explains the generally low effectiveness of medical treatments.
There are several classifications for gynecomastia, with Simon’s classification being the most commonly used. This system categorizes gynecomastia into three grades based on size and skin redundancy [6]. Another widely recognized system is Rohrich’s classification, which categorizes the condition based on the amount and character of breast hypertrophy, as well as the degree of ptosis (Table 1) [7].
A basic and practical guideline for determining the optimal surgical treatment for gynecomastia considers whether the breast is drooping. If there is no sagging, a small infraareolar incision is typically sufficient. In cases of severe drooping, various incisions are often necessary to remove excess skin and realign the areola [8].
The most widely used surgical technique is the traditional open surgery performed through a semicircular inferior periareolar incision. However, this method can lead to significant side effects, including asymmetry, poor scarring, and retraction or necrosis of the nipple-areola complex [9-11]. To achieve improved aesthetic outcomes, several alternative techniques have been suggested, such as vacuum-assisted excision, endoscopic mastectomy, and liposuction [11,12].

CASE REPORT

We present two cases: the first involves a 29-year-old male patient, and the second, a 24-year-old male patient. Neither patient had comorbidities. Both sought care at our outpatient clinic, reporting bilateral breast enlargement and dissatisfaction with their appearance, attributing their discontent to the feminine look of their breasts.
Examination of the first case revealed bilateral breast hypertrophy and a noticeable discoid mass in a retroareolar position, measuring approximately 5×2 cm. The second case exhibited enlarged bilateral breasts with a retroareolar mass approximately 3×3 cm in size. Both patients (cases 1 and 2) exhibited no tenderness upon palpation, no nipple discharge, and no palpable axillary lymph nodes, but they did present with moderate skin redundancy. Both patients were diagnosed with grade 2A or 2B bilateral gynecomastia according to Simon’s classification. The surgical procedure was carried out under general anesthesia. Both patients were marked while standing. The markings included: (1) the inframammary fold; (2) the boundaries of liposuction; or (3) skin incisions, 8–12 mm long located in the bilateral inframammary crease along the breast width, in order to achieve favorable access to the glandular tissue in the periareolar area, as well as a hidden scar.
Tumescent fluid was infiltrated through bilateral inframammary crease incisions. In the first case, the total infiltration was 800 mL for the right breast and 700 mL for the left breast. In the second case, it was 650 mL for the right breast and 750 mL for the left breast. Fifteen minutes later, liposuction was performed to achieve adequate fat tissue removal. In the first case, the total aspiration was 800 mL from the right breast and 900 mL from the left breast. In the second case, both breasts had 500 mL of fat tissue aspirated.
The parenchyma could be mobilized after being released from its superficial and lower attachments. The section of parenchyma designated for excision was grasped between the thumb and index finger, and then clamped with surgical forceps that were passed through the skin incisions.
The surgical forceps were then withdrawn through the skin incision initially made for liposuction. This exposed the glandular tissue, which was subsequently excised using dissecting scissors (Figs. 1, 2). To minimize bleeding and prevent the excessive removal of tissue that could lead to skin abnormalities, careful examination and palpation are essential throughout the resection process. Each fragment of the excised breast tissue is collected and sent for histological analysis as separate specimens from the left and right breasts (Fig. 3). In the first case, the excised glandular tissue from the right breast weighed 24 g, and from the left breast, it weighed 18 g. In the second case, the weights were 20 g for the right breast and 21 g for the left breast.
Both patients had uneventful stays and were discharged home without any complications. Furthermore, the patients were instructed to wear a pressure garment for at least 6–8 weeks postoperatively and to avoid any weight lifting or physical exercises such as push-ups for at least 6 weeks postoperatively.
The follow-up protocol involved outpatient department visits once a week for the first month after surgery, followed by reviews at 3 months, 6 months, and 1 year. However, the first patient was lost to follow-up after discharge, as he returned to his home country. The second patient adhered to the follow-up schedule and experienced uneventful visits without complications. Figs. 4 and 5 show the preoperative and postoperative results for the second patient.

DISCUSSION

Gynecomastia is primarily treated through the removal of excess breast tissue to achieve optimal symmetry with minimal scarring and satisfactory aesthetic results. Even when persistent gynecomastia is associated with psychological distress due to a negative body image and leads to the avoidance of sports activities that require exposing the chest, open surgery remains the standard preferred approach.
The first study on vacuum-assisted liposuction as a minimally invasive technique for treating gynecomastia was published by the Royal College of Surgeons of England in 2010, reporting outstanding outcomes [12].
Our report aimed to showcase a minimally invasive approach in the surgical treatment of gynecomastia, utilizing the same incision made for the vacuum-assisted liposuction cannula to perform glandular excision. This technique is particularly suitable for patients with small to moderate glandular tissue, classified as Simon grades 1 and 2A, who are also appropriate candidates for liposuction.
Some authors have described variations in their pull-through technique, utilizing three incisions: one at each anterior axillary line and a median incision at the sternal midline [13]. Others have discussed the pull-through method in the context of power-assisted liposuction or have associated the power-assisted liposuction technique with pull-through excision facilitated by endoscopy [14,15].
The approach described above offers the advantage of utilizing a single incision for both liposuction and glandular excision, made through the inframammary fold crease across the breast width. This method also minimizes complications related to the nipple-areolar complex post-surgery. As no incision is made in the nipple-areolar complex itself, it avoids the risks of retraction, distortion, or sensory impairment that are associated with other techniques. However, significant tissue removal directly beneath the areola may lead to areolar deformities.
Furthermore, our technique enables direct visualization of the parenchyma, facilitating a more extensive and radical removal of breast tissue with minimal or no risk of relapse. Additionally, improved accessibility for controlling bleeding and achieving hemostasis significantly reduces the incidence of postoperative hematoma.
The primary limitation of the pull-through technique is that it requires more time compared to methods that utilize wider access or solely liposuction.
Understanding the proper classification of gynecomastia and the morphological appearance of the breast glandular tissue–whether it is predominantly fatty, exhibits a heterogeneous density of fibroglandular and fatty tissue, or is primarily glandular and fibrous– can aid in selecting the most appropriate surgical techniques and achieving optimal outcomes with proper patient selection.
A review of the literature has shown that many surgeons have successfully adopted and utilized the pull-through technique. The primary advantage of this method is that it minimizes and conceals surgical scars, while also offering efficiency and simplicity.

NOTES

Conflicts of Interest

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

Ethical approval

The study was approved by the Institutional Review Board of Royal Medical Services Military Hospital (IRB No. 2024-450).

Patient consent

The patients provided written informed consent for the publication and use of their images.

Fig. 1.
Littlewood clamp (tissue grasping forceps).
aaps-2024-01165f1.jpg
Fig. 2.
Clinical images of case 1. (A) Glandular tissue clamped with long surgical forceps (Littlewood clamps). (B) Glandular tissue is pulled out through a skin incision.
aaps-2024-01165f2.jpg
Fig. 3.
Intraoperative images of case 1. (A) Intraoperative bilateral single incision sites and glandular tissue excision. (B) Intraoperative results after gynecomastia excision.
aaps-2024-01165f3.jpg
Fig. 4.
Preoperative image (A) and postoperative image (B) of case 2.
aaps-2024-01165f4.jpg
Fig. 5.
(A, B) Side views of postoperative results in case 2.
aaps-2024-01165f5.jpg
Table 1.
Simon and Rohrich classification of gynecomastia
Simon classification Rohrich classification
· Grade 1: Minor but visible breast enlargement without skin redundancy · Grade 1: Minimal hypertrophy (< 250 g of breast tissue)
· Grade 2A: Moderate breast enlargement without skin redundancy · Grade 2: Moderate hypertrophy (250–500 g of breast tissue)
· Grade 2B: Moderate breast enlargement with minor skin redundancy · Grades 3, 4: Have severe hypertrophy of breast tissue (> 500 g) but are distinct because of the greater degree of ptosis, grade 3 exhibits grade 1
· Grade 3: Gross breast enlargement with skin redundancy that looks like a pendulous female breast ptosis and grade 4 exhibits grades 2–3 ptosis

REFERENCES

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