INTRODUCTION
Gynecomastia is a common disorder; caused
by increase in ductal tissue, stroma and/or fat in
male breast, it may be associated with excess skin.
Idiopathic is the most common cause; followed by
obesity then secondary causes (systemic disorders,
drugs). Nydick determined that there was an incidence
of gynecomastia in 65% of pubertal males.
Resolution almost always occurs but persists in
small percentage [1]. In another study of 477 unselected
autopsies, a 40% rate of gynecomastia was
observed by Williams [2]. In a study of 306 adult
males, clinical gynecomastia was seen in 36% with
greater incidence (57%) in men older than 44 years
[3].
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Gynecomastia was classified by Simon et al.,
into 3 grades [4]:
• Grade 1: Small enlargement, no skin excess.
• Grade 2A: Moderate enlargement, no skin excess.
• Grade 2B: Moderate enlargement with extra skin.
• Grade 3: Marked enlargement with extra skin.
On the other hand, Rohrich classified gynecomastia
according to ultra sound assisted liposuction
[5]:
• Grade I: Minimal hypertrophy (250g) without
ptosis.
• Grade II: Moderate hypertrophy (250-500g)
without ptosis.
• Grade III: Severe hypertrophy (500g) with grade
1 ptosis.
• Grade IV: Severe hypertrophy with grade 2 or 3
ptosis.
While Letterman and Schurter classified management
of gynecomastia [6-8]:
• 1: Intra-areolar incision with no excess skin.
• 2: Intra-areolar incision with mild redundancy
corrected with excision of skin through a superior
peri areolar scar.
• 3: Excision of chest skin with or without shifting
the nipple.
MATERIAL AND METHODS
Retrospective study included 23 cases, 18 cases
were operated upon; 5 cases were observed. The
treatment of gynecomastia should be aimed at
correction of underlying cause. The pubertal male
is most successfully treated with patience and
reassurance. Thorough history taking, medical and
laboratory evaluation should be done in order to
exclude secondary causes.
Physical examination should enable the surgeon
to determine the type of gynecomastia, Is it fibrous
or fatty? Accordingly, the type of management is
determined.
The management protocol was: Persistent gynecomastia
less than 12 months and normal history
and physical examination, observation and reassurance
is recommended.
Persistent gynecomastia more than 12 months
and normal history and physical examination, then
surgical management is advised.
Preparation:
While the patient is standing identify the inframammary
fold, pectoralis major muscle bulk,
extent of gynecomastia and its type; whether fibrous
or fatty or fibrofatty.
If there is significant breast enlargement and
ptosis, identify the new nipple and areola complex
position and approximate amount of skin excision.
Mark the patient while standing.
All cases are done under general anesthesia.
Surgical technique:
Quadruple attack technique:
• Extensive liposuction.
• Excision of excess tissue.
• Extensive undermining.
• Excision of the skin.
Extensive liposuction:
Using tumescent technique, the standard wetting
solution is: 1 liter of lactated ringer, 1ml epinephrine
(1:1,000), 30ml 1% Xylocaine. Wetting
solution is allowed 7 to 10 minutes for maximal
vasoconstrictive effect.
Power assisted liposuction with cannula number
5 in deep levels above pectoralis major, cannula
number 3 in superficial level.
12 Vol. 44, No. 1 / Quadruple Attack of Gynecomastia
Excision of excess tissue:
Through an inferior peri areolar incision, open
resection or pull through of breast disc.
Extensive undermining:
Sharp dissection and release of inframammary
fold. The fold is released mediallyup to 1cm from
midline; released laterally until the anterior axillary
fold and released superiorly above the disc.
Excision of the skin:
First De-epithelialization of the distance for
nipple elevation (superior pedicle) with preservation
of 2cm of de epithelialized tissue below areola.
Through Peri-areolar incision, concentric skin
excision is done followed by Purse string sutures
for closure, in 2 separate rings.
Drains are inserted.
Post-operative care:
Remove drains when it drains less than 40cm.
Compressive garment is used continuously for first
3 weeks; the patient is allowed to remove the
garment for a few minutes each day for bathing.
Then followed by using it for only 12 hours for
the following 3 months.
The patient applies antibiotic ointment to the
suture lines twice per day for the first week. After
7 days the sutures are removed. During the first
24 hours the patient is encouraged to rest. After
48 hours, the patient may return to work. After 1
week the patient is encouraged to return to full
activities including all sports. It is evident that
those patients who return to full activities early
heal much quicker and have resolution of edema,
soreness, and ecchymosis much more rapidly. Sun
exposure is avoided for 1 month.
RESULTS
We had no complications in 89% of the cases.
We had Seroma in 1 case out of 18 cases (5.5%).
Delayed wound healing in 1 case (5.5%) who
was smoker and unsatisfactory scar in the same
case.
Appearance of the scars were satisfactory to
both doctor and the patient except 1 case (5.5%)
who complained of 2mm widening of the scar
whom was smoker.
Egypt, J. Plast. Reconstr. Surg., January 2020 13
DISCUSSION
According to Simon classification and the type
of gynecomastia parenchyma, the following is the
most common used techniques:
Fatty Gynecomastia:
• 1, 2a: Liposuction of the breast with tumescent
rate (1:1).
• 2b: Liposuction and use chest garment for 6-12
months before skin excision.
Fibrous Gynecomastia:
• 1, 2a: Peri areolar skin incision and pull through
tissue resection or ultrasonic assisted liposuction.
• 2b: Open approach through Peri areolar skin
incision and resection and garment or ultrasonic
Fig. (1A): Pre-operative case of gynecomastia grade 3. Fig. (1B): Post-operative case of gynecomastia grade 3.
Fig. (2A): Pre-operative case of gynecomastia grade 3. Fig. (2B): Post-operative case of gynecomastia grade 3.
Fig. (3A): Pre-operative case of gynecomastia grade 3. Fig. (3B): Post-operative case of gynecomastia grade 3.
assisted liposuction and pull through tissue resection.
• Grade 3: Skin resection through superior, inferior,
concentric, omega, nipple transposition and liposuction
and pull through tissue resection and
garment usage.
Complications from previously mentioned techniques
varied from Hematoma, under resection,
over resection (saucer-type deformity), infection,
Widening of scar and Asymmetry.
We are introducing a modification and an addition
to the above-mentioned techniques and we
named it: Quadruple attack to the problem of
gynecomastia.
Conclusion:
Using suction lipectomy alone for grade II, III
gynecomastia may not reach the desirable aesthetic
results for patient and doctor. Quadruple attack is
a new surgical technique which is simple, reliable
and easily attained by young surgeons. Nevertheless,
it has good results with less complication rate.
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