The combined use of laser assisted liposuction and endoscopic surgical excision of grade II gynecomastia

The combined use of laser assisted liposuction and endoscopic surgical excision of grade II gynecomastia

Mohammed MahmoudAbdelaal, MD;  Yasser Abdallah Aboelatta, MD; MRCS;

Abdelrahman MohamedAbdelaal, MD;  Basim MohammedZaki,

MD;  Ibrahim Hussien Kamel, MD

Department of Plastic and Reconstructive Surgery, Ain -Shams University, Egypt.

Abstract

Background: Surgical excision offibroglandular tissue and liposuction offatty element are the standard now in treatment of grade II gynecomastia.  However, the combined use of laser assisted liposuction and endoscopic  surgical excision have not been studied before.

Patients  and  methods:  Thirty  male  patients  with grade !fa  and  Jib were  included.  15

patients underwent  laser  assisted liposuction  followed by endoscopic  excision  of glandular tissues (Group I), and 15 patients underwent  conventional (vacuum assisted) liposuction and endoscopic surgical excision (group II).

Results: Patients of group I showed good to excellent outcome with mild edema, indurations, and ecchymosis. Group II patients showed also overall satisfactory results but with moderate to severe edema, ecchymosis, and hematomas.

Conclusion: Endoscopic surgical excision of grade!!gynecomastia combined with traditional or laser assisted liposuction can achieve satisfactory results. However, the use of laser assisted liposuction offers additional advantages such as; intraoperative (less bleeding, less operative time) or postoperative either immediately (less pain, indurations,  ecchymosis, and edema) or late as improved skin tightness.

Introduction:

The term gynecomastia is derived from Greek  words  meaning female  breast. It is defined   as  the  presence   of  palpable   breast tissue in males and is common in normal individuals,particularly in the newborn period, at puberty, and in the elderly.l  It has variable incidence ranging from 30-60% ofmen2 and it is mostly  bilateral,  but  it may  sometimes be unilateral or asymmetric.3 Gynecomastia is different  from  pseudogynecomastia, which is an accumulation of excess fat in a male breast.4 It is  believed   that   most   cases   of gynecomastia are caused by an imbalance of estrogen to androgen  ratio. 5

Depending on morphology and volume, gynecomastia  is  classified, according to Simon,6 into: !-Minor breast  enlargement without  skin redundancy.

IIa- Moderate  breast  enlargement without skin redundancy.

lib-Moderate breast  enlargement with minor skin redundancy.

III-Gross breast  enlargement with skin redundancy that mimics  female  breast ptosis.

Although the  condition may  be symptomatic,  psychological  aspects   of surgical  treatment is at the same  importance to restore normal body image with minimal scar.7    Paulus     Aegineta   (635-690   AD) had been the first to described reduction mammoplasty for gynecomastia using a semi lunar inframammary incision.s The surgical correction of gynecomastia significantly changed    in   the   last   decades   from   open surgery  to  less  invasive  procedure including liposuction or combined liposuction and surgery      through       different       incisions.9

Endoscopic   exclSlon  of  gynecomastia   has emerged as a new less invasive approach.

Liposuction   represents   the   other   arm of gynecomastia treatment. Traditional liposuction can work well in loose areas; however, in dense areas such as gynecomastia, it is difficult.   Refinement in liposuction emerged  and  involved  laser  assisted liposuction to overcome this special problem.

Although     endoscopic     exclSlon     and laser  assisted  liposuction   of  gynecomastia offer new advantages, combination of both modalities has not been studied before.  The aim of this work  was to  study the  benefits and drawbacks  of combined  both  laser assisted liposuction and endoscopic  excision of glandular tissues (group I) in comparison to conventional liposuction combined with endoscopic  excision  of glandular tissues (group II).

Patients and methods:

This study included thirty male patients complaining of grade II gynecomastia (either IIa or II b). Patients with pseudogynecomastia, unilateral gynecomastia, patients with female like breast (grade III gynecomastia), and patients  receiving  anticoagulant  or  anti­ platelet drug therapy were excluded.

All patients were referred to endocrinology clinic to exclude secondary causes of gynecomastia.   Physical   examination included breast size, consistency, skin excess, suspicious masses, and nipple areola position in relation to inframammary fold.

Preoperative ultrasound was done for all patients to confirm the  presence of glandular tissue  and fatty tissues  and to exclude presence of non palpable breast masses.

The  idea   of  this  paper  was  approved by the hospital scientific committee. The benefits  and  possible  drawbacks  were discussed with all patients and informed consent was obtained. Patients who accepted the treatment, underwent combined laser assisted liposuction and endoscopic  excision of glandular tissues  (Group I). Patients who refused this new treatment were treated by conventional  (vacuum  assisted)  liposuction and endoscopic  excision of glandular tissues

(Group II).

Surgical technique:

All surgical procedures were performed under general sedation using IV Profolol or general anesthesia  and by the same surgeon (the first  author).  Patients  were  marked  in the upright position to map the areas of liposuction and surgical excision. Two small incisions  15-20 mm were  made laterally  at the anterior axillary line above and below the level of nipple areola complex. Liposuction tumescent  was  injected  through  these incisions.  About  250-350  cc  of  tumescent was injected depending on the breast size.

In   group   I,   laser   assisted   liposuction was done using 1,320nm ND YAG (Cool LipoTM, New Star Lasers, 12 J, 40Hz). The endpoints of laser procedure were tactile warmth   and  ease  of  canula  advancement during the procedures, with skin temperature not exceeding 34°C.

In group II, a liposuction triple-hole canula (usually size 4) connected to a vacuum was used for liposuction of the whole breast fatty tissue.  Liposuction  was  continued  until  we felt empty breast except for glandular tissue. Liposuction   also  was  done  to  chest  wall beyond markings ofthe breast and below the inframammary line in order to fade the edges between beast and chest wall.

After   liposuction   (either   traditional   or laser  assisted),  endoscopic  excision  of glandular tissue was carried on using rigid laparoscope 0 10 mm, 300 mm, 0° (Richard Wolflaparoscopy, Germany). The endoscopic camera was introduced through the upper lateral incision to enable visualization  of the remaining tissue and scissor was introduced through the lower incision for dissecting remammg  fibroglandular  tissue.  After complete dissection of glandular tissue, it was removed en bloc or divided into 2 or 3 pieces and extracted through the lower incision. Closure  of incision  using  5/0  PDS  sutures was   done   and  dressing   also  was  applied without drains.

Postoperatively,         patients         received

perioperative antibiotic and analgesic. Preoperative  and  postoperative   digital pictures  were  taken  at  least  3 month  after

operation using Nicon-coolpex 995 digital camera (3.3 Mpx, 5X optical zoom).

Results  were  interpreted  by  evaluating: the aesthetic outcome of breast shape, the incidence   of  complications,   hospital   stay, and time of operative  procedure. The degree of aesthetic outcome was evaluated by the treating doctor assessment and the patient satisfaction. The assessment criteria was adopted from the (THE BREAST-Q) scale.lO These criteria included overall breast shape, overall   shape   in  relation   to   chest   wall, nipple   areola   position   and  shape,   breast size,  psychosocial  relief,  and  scar  quality. Each item  was graded  as 0 (not  accepted),

1(accepted),   and   2   (satisfactory).   Results were graded as excellent(> 75%), good (51-

75%), fair (26-50%), and poor (<25%) based on degree of improvement. Complications (hematomas, seromas, nipple areola sensation

deficit, nipple areola loss...) were graded into

either absent (0), mild (1), or moderate to severe (2).

Results:

This study included thirty male patients complaining of grade II gynecomastia over a period of 2 years. Patients' age ranged from

18-36 years with mean of 23.4 years. The follow up period ranged from 6- 15 months with mean of 8.3 months. Eleven patients (6 patients in group I and 5 patients in group II) were overweight.

In group I, patients' age ranged from 18-

36 years with mean of 24.6 years. Seven patients had gynecomastia grade IIa and 8 patients had grade lib.   All patients of grade IIa  had  excellent  outcome.   Regarding  the

8  patients  of  grade  lib,  three  patients  had

excellent outcome and 4 patients had good outcome. All patients showed substantial improved skin tightness  with improved skin

Figure (1): Preoperative and postoperative views of a 23 years old male patient of group I.

Figure (2): Preoperative  and postoperative views of a 21year sold male patient of group II.

Table (1): Summary of aesthetic improvement in both groups.

redundancy.  No   visible   skin   irregularities were  recorded except  for 2 patients  that  had minimal  irregularities which  required  no treatment.

In  group   II,  patients' age  ranged   from

22-36  years  with  mean  of  22.3  years.  Nine patients   had  gynecomastia grade  Ila  and  6 patients  had grade  lib.    All patients  of grade Ila  had  excellent outcome.   Regarding the  6 patients  of grade  lib, four  patients  had good outcome   and  2  patients   had  fair  outcome. All patients  showed  moderate  improvement of  both  skin  tightness and  skin  redundancy. Visible  skin  irregularities were  recorded   in

2 patients. All these results were statically insignificant in relation  to group I (p>0.05).

Regarding complications in group  I, no hematoma  was  recorded  and  two   patients had  seromas  that  were  treated  by aspiration and compression. One patient had transient tingling   sensation  in  nipple   and  areola  of one breast that resolved  after 3 months. Postoperative ecchymosis was mild in all patients  and disappeared after 8-12 days. Postoperative edema  was  mild  to  moderate and faded within  8-10 weeks.

In group II, 2 patients developed hematoma that   required    aspiration  and   compression. In  addition, three  patients   had  seromas; 2 out  of  the  3  patients  needed  aspiration and compression while  the  3rd patient  had  mild seroma  that   faded   by  compression  alone. Postoperative  ecchymosis  was  moderate  to severe  in  all  patients   and  disappeared after

15-  20 days.  Postoperative edema  was  mild and faded  within  6-8 weeks.  No areola  dish­ pot   deformity,    areola   necrosis,   infection, or   hypertrophic  scarring   was   recorded  in both groups. No recurrence or secondary operations  were   recorded  in   any   patients during  study time.

All  patients   in  group   I  were  discharged home  at  same  day  of  surgery except  for  2

patients  who  stayed  an additional day  upon their request.  In group  II, ten patients  were discharged  home   at  same   day   of  surgery and  five  patients  spent  another   day  due  to marked  postoperative pain  that  required opioid  analgesics. Operative procedure time ranged  from  85-110  minutes  with  mean  of

98.3  minutes  in  group  I, whereas, in  group II, operative procedure ranged  from  90-  135 minutes  with mean of 108.6 minutes.

Discussion:

Surgical  treatment of gynecomastia aims at adequate  treatment of the disease  while minimizing apparent  scarring.  Combined liposuction and excision  ensure  adequate treatment ofthe disease.9,11

Traditional open resection leaves inframammary or periareolar visible scar that may be more  disappointing than the original problem.l2 The intra-areolar incision  or Webster incision  also has limited exposure.l3

In   addition,    more    serious    complications can  occur  such  as  over-resection leading  to breast asymmetry,  nipple tethering to pectoral muscles, or unsatisfactory outcome  in  up to

50% of cases.l4

Surgery  and  liposuction  have  been combined in different  manners.  Excision through a single puncture incision ofthe areola combined with  an incision  for  liposuction at the anterior axillary fold has been describedl5 or  through  one  periareolar stab   incision.l 6

Tumescent liposuction  was  also  combined with  blind scissors  dissection.! 7 Liposuction and vacuum-assisted biopsy  device  excision ofbreast tissue was also reported.l8

The endoscope-assisted subcutaneous mastectomy opened new field in gynecomastia management.l9 Ohyama et al in 199820 described transaxillary endoscopic assisted removal of glandular tissue  in gynecomastia through 4 em incision. Endoscopic resection of

gynecomastia was used in different manners; some authors used it only to supervise pull through excision,21 others used it to perform direct  excision  alone,22 or  in  combination with liposuction.23

Another  method  of endoscopic  resection in the form  of arthroscopic  cartilage  shaver combined    with    liposuction    was    used24 that achieved good results.   In endoscopic procedure, trans-axillary incisions could be used alone,22 or periareollar  incisions23 or both.24

Teimourian and Perlman25 m  1983 described      liposuction-assisted      exc1s1on. Fat    in    gynecomastia    consists    of   firm fibrous  connective  tissue  and  compact adipose tissues, which makes conventional liposuction   more   difficult   to   perform.   If force is exerted repeatedly, it causes great damage to the tissues. For that, interventional ultrasound-assisted liposuction,25 external ultrasound-assisted lipoplasty27 and power­ assisted lipoplasty28 have been developed in the1990s.

Laser assisted  liposuction  is another step in treatment  modalities. Apfelberg29 studied laser-assisted  liposuction  in the early 1990s. Various  wavelengths,   including   924,   968,

980,  1064,  1319, 1320,  1344,  and  1440nm have been used.30

The   1320nm   wavelength   demonstrates

greater fat absorption with less tissue penetration and scatter. Therefore, it may be safer for treatment. However, these claims are not well supported and which wavelength is ideal in laser lipolysis is a matter of debate.31

Rho et aP2 and  Trelles et aP3 were the only who used laser lipoplasty in gynecomastia. They concluded that gynecomastia can be treated effectively and safely with laser lipolysis.

Our  technique   takes  the  advantages  of

both these 2 refinements in the management of gynecomastia. Laser assisted liposuction group achieved overall good to excellent aesthetic           outcome   with    greater   patients satisfaction  that  can  be attributed  to  better skin tightening and fat lipolysis in this dense area. Also laser lipolysis diminished trauma caused   by   traditional   liposuction   leading

to   less   postoperative   edema,   indurations, and postoperative pain. In addition laser liposuction   caused   coagulation   of  vessels which resulted in less intraoperative bleeding which  made  the   glandular   resection  easy and fast. This was manifested by reduced operative time in the laser liposuction group. Furthermore, vessel coagulation caused less postoperative ecchymosis and postoperative hematoma formation.

Endoscopic glandular excision offers resection under vision which minimizes over resection and aesthetic deformity or under resection  leading to less satisfactory  results and more recurrence.  Excision  under vision also  allows  good  control  of  any  bleeding even if minor bleeding that minimizes complications  and  reduces  postoperative down time.

Reduced postoperative  pain is a sequel of both reduced trauma by laser liposuction and minimal access incisions through endoscopic surgery  leading  subsequently  to  shorter hospital stay.

Balch34   introduced    the     trans-axillary

approach  to  m1mm1ze scarring.  The transaxillary   incision   leaves   hidden   scar, but its main disadvantage is the difficulty during  glandular  resection43  and  long operative  time.35,36  These  drawbacks  could be overcome by the use of endoscopy that allows under vision resection and shortening of the operative procedure time that is helped by  the  reduced  bleeding  secondary  to  the effect of laser lipolysis.

The main disadvantage of our technique is the cost of equipments which are not available in every institution. In addition, the technique needs to some extent slightly slow learning curve.

The combined use of laser assisted liposuction and endoscopic surgical excision of gynecomastia represents a forward step in the road of management. Further randomized blindly controlled studies on larger patient population are warranted in further researches.

Conclusion:

Endoscopic   surgical   exclSlon  of  grade

II  gynecomastia   combined  with  traditional

or laser assisted liposuction can achieve satisfactory   results.   However,  the   use   of laser assisted liposuction offers additional advantages such as; intraoperative (less bleeding, less operative time) or postoperative either immediately (less pain, indurations, ecchymosis, and edema) or late as improved skin tightness.

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