Cosmetic Combined Use of Ultrasonic Liposuction with the Pull

Cosmetic
Combined Use of Ultrasonic Liposuction with
the Pull-Through Technique for the
Treatment of Gynecomastia
Dennis C. Hammond, M.D., Jame F. Arnold, M.D., Amy M. Simon, M.D., and Philippe A. Capraro, M.D.
Grand Rapids, Mich.
The authors present a method of treatment for gynecomastia that combines the use of two techniques of softtissue contouring. This method uses ultrasonic liposuction in conjunction with the pull-through technique of
direct excision to effectively remove the fibrofatty tissue of
the male breast and the fibrous breast bud through a
single 1-cm incision. Fifteen patients were treated in this
fashion, and each patient demonstrated a smooth, masculine breast contour with a well-concealed scar, which
eliminates the stigma of breast surgery. The procedure is
technically straightforward and provides consistent results. It is offered as an additional option for the treatment
of gynecomastia. (Plast. Reconstr. Surg. 112: 891, 2003.)
Gynecomastia presents as a persistent enlargement of the breast with variable excess of
skin, fat, and breast parenchyma. It is the most
common breast problem in men,1 occurring in
a bimodal pattern of distribution affecting pubertal and elderly male patients. Pubertal male
patients are most successfully treated with patience and reassurance, because the vast majority of these patients will experience complete
resolution with time. Gynecomastia that persists past puberty or presents in an elderly patient deserves more aggressive management to
restore normal body habitus, relieve associated
pain, and rule out the rare possibility of
malignancy.2
Numerous methods of treatment have been
described that accomplish removal of involved
tissue by direct open excision, liposuction, or
some combination. Direct excision of the male
breast may result in irregular contour defects
and unsightly scarring that can be aesthetically
worse than the presenting problem (Fig. 1).
Liposuction easily removes adipose tissue but is
FIG. 1. Appearance of the chest wall in a mature patient
who underwent bilateral excision of gynecomastia 20 years
previously through a transverse incision across the superior
aspect of the areola. The excessively long and now atrophic
scar is representative of the unfortunate sequelae of male
breast surgery.
less effective in treating the fibrous parenchymal component of the breast.3– 6 Combining
traditional liposuction with direct pull-through
surgical excision of the breast bud has been
described by Morselli.7 We suggest modifying
his technique to incorporate ultrasonic liposuction, which more effectively treats fibrous
fatty tissues.8,9 This method permits both liposuction and sharp resection of breast parenchyma through a single 1-cm incision placed
strategically along the inferior margin of the
areola or in the inframammary fold. This combined approach thus maximizes each of the
individual techniques, resulting in effective resection of the enlarged male breast while maintaining an aesthetically pleasing result.
From the Center for Breast and Body Contouring. Received for publication August 2, 2002; revised October 14, 2002.
DOI: 10.1097/01.PRS.0000072254.75067.F7
891
892
PLASTIC AND RECONSTRUCTIVE SURGERY,
TECHNIQUE
The patient is marked in the upright position in the office the day before the operation.
The inframammary fold is marked. Using the
topographic map technique, the remainder of
the breast is marked to identify the points of
greatest elevation (Fig. 2, above). General anesthesia is used for the procedure, although local
anesthesia with intravenous sedation can be
used if preferred. The patient is positioned
supine on the operating room table with the
September 1, 2003
arms abducted and secured to arm boards. A
1-cm stab incision is made along the inferior
border of the areola, and tumescent solution is
infiltrated into the breast parenchyma. Early in
our series, the incision was placed in the inframammary fold. To strategically camouflage the
scar, we later placed the incision in the periareolar location. This also offered the advantage of a more direct and precise “pullthrough” of the breast bud. Ultrasoundassisted liposuction is then performed in a
FIG. 2. (Above) Preoperative appearance of a 16-year-old male patient with persistent unilateral enlargement of the right breast. The marks delineate the area to be treated with ultrasonic
liposuction. (Below, left) After ultrasonic liposuction is complete, the residual mound of fibrous
breast tissue in the subareolar region is sharply excised using the pull-through technique. (Below,
right) Appearance of the excised breast bud removed from under the areola. The tissue is
removed in strands after being “morselized” with the ultrasonic liposuction probe.
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TREATMENT OF MALE GYNECOMASTIA
FIG. 3. (Left) Preoperative appearance of a 14-year-old male patient with bilateral gynecomastia. (Right) The 10-week postoperative result shows a normal chest wall contour with well-concealed scars.
radial fashion, with care taken to feather the
breast along the periphery. The ultrasonic liposuction cannula is passed multiple times in
the area of the more fibrous breast bud to
morselize the tissue. Scavenging liposuction is
then performed to remove any excess fluid and
retained fat. The endpoint of suction lipectomy is assessed by pinch test, by the quality
and quantity of aspirate, and by resistance to
passage of the cannula. Completion of the suction reveals a residual mound of fibrous breast
tissue of varying size directly beneath the nipple and areola. This subareolar breast bud can
be successfully resected through the periareolar incision. The tissue is grasped with a clamp,
pulled out through the incision, and sharply
excised under direct vision (Fig. 2, below, left).
Typically, the fibrous breast bud is removed in
strands until no further palpable tissue remains, allowing complete control of the resection (Fig. 2, below, right). Caution must be taken
to avoid overly aggressive resection to prevent a
depression of the nipple-areola complex or
“saucer” deformity. The excised breast tissue is
sent to the pathology laboratory to rule out the
rare possibility of malignancy. The incision site
is then closed with interrupted dermal and
running subcuticular 4-0 Monocryl sutures
(Ethicon, Inc., Somerville, N.J.). Drains are not
necessary. Steri-Strips (3M, Minneapolis,
Minn.) and a gauze dressing are then applied.
The patient is fitted with a compression garment that is worn for 1 week after the
operation.
RESULTS
Twenty-seven breasts in 15 patients were
treated by a single surgeon using this combined method of ultrasonic liposuction with
the pull-through technique. Patients ranged in
age from 12 to 69 years and had an average age
of 27 years. Follow-up time ranged from 1 day
to 47 months, with an average follow-up time of
8.2 months. In the first five patients, all of
whom had bilateral gynecomastia, an inframammary incision was used as previously described by Morselli.7 In the remaining 10 patients, seven of whom had bilateral disease, the
inframammary incision was replaced with a less
conspicuous inferior periareolar incision. Both
894
techniques were noted by the surgeon to produce a smooth, masculine breast contour (Figs.
3 and 4) and an inconspicuous scar (Fig. 4,
below). The periareolar incision offered the
added benefit of a strategically camouflaged
scar in the margin of the areola, thus minimizing the stigma of breast surgery. A retrospective review of patient charts revealed that all
patients were pleased with their results. Long-
PLASTIC AND RECONSTRUCTIVE SURGERY,
September 1, 2003
term follow-up showed that results were stable
over time.
There were no cases of nipple-areola complex necrosis, saucer deformity, contour irregularity, hematoma, or infection. One patient
had a slight scar retraction at the nipple-areola
complex incision site that resolved spontaneously. Another patient developed a seroma that
resolved promptly after a single aspiration.
FIG. 4. (Left, above and center) Preoperative appearance of a 15-year-old male patient with bilateral gynecomastia, with the left
side greater than the right side. (Right, above and center) The 7-month postoperative result demonstrates a smooth masculine
contour with no surface irregularities. (Below) The inferiorly located periareolar scar remains well concealed.
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TREATMENT OF MALE GYNECOMASTIA
One ultrasound-assisted liposuction entrance
site burn was noted, and one patient developed
a small area of epidermolysis; both conditions
healed spontaneously. Although nipple-areola
complex sensitivity was not specifically assessed, only one patient reported a decrease in
sensation in this area. Each of the complications listed was minor and did not compromise
the final result. No revisions were necessary.
Histologic analysis of the resected specimens
revealed a benign hypertrophy consistent with
gynecomastia. There was no evidence of malignancy in any of the specimens.
DISCUSSION
Treatment of gynecomastia presents the
dual challenge of adequate treatment of the
disease while minimizing the perceptible
stigma of breast surgery. The proposed technique accomplishes both of these tasks consistently. Ultrasonic liposuction effectively removes dense adipose tissue from within the
fibrous parenchymal framework of the breast.
The remaining fibrous breast bud is then easily
mobilized and sharply excised via the 1-cm
inferior periareolar incision. The removal of
this tissue in small strands facilitates precise
control of the resection, decreasing the potential for contour defects. The resulting periareolar scar is barely perceptible after it has completely matured, thus leaving no stigma of
breast surgery.
Ultrasonic liposuction offers several advantages in the treatment of gynecomastia. It is
physically less strenuous8,10 and much more effective in treating fibrous areas8,9 than traditional liposuction. It also is reported to enhance skin contractility, which, if true, may be
advantageous in reducing skin redundancy associated with more severe cases of gynecomastia.9,10 Although this technique does not rely on
potential skin retraction caused by ultrasoundassisted liposuction, such an effect could be
considered an added benefit of the procedure.
Profound skin retraction was not observed clinically in this series of patients. Because ultrasonic liposuction creates an airbrush effect at
the tip of the probe, there is minimal if any
need for cross-tunneling, which thus enables
the surgeon to minimize the overall number of
incisions.11
A total of five complications were reported
in a series of 27 breasts. These complications
were minor, did not compromise the final result, and did not require further surgical
treatment.
SUMMARY
A surgical approach for the treatment of
gynecomastia is presented that combines the
use of ultrasonic liposuction with direct excision, enabling effective treatment of both the
fibrous and fatty tissues of the male breast. The
addition of ultrasonic liposuction to the pullthrough method of direct excision facilitates
the entire operation via a single 1-cm periareolar incision. This enables a precisely controlled
volume reduction and adds the benefit of an
imperceptible scar. A smooth masculine breast
contour can then consistently be achieved
while eliminating the stigma of breast surgery.
Dennis C. Hammond M.D.
Center for Breast and Body Contouring
4070 Lake Drive, S.E.
Grand Rapids, Mich. 49546
[email protected]
REFERENCES
1. Williams, M. J. Gynecomastia: Its incidence, recognition and host characterization in 447 autopsy cases.
Am. J. Med. 34: 103, 1963.
2. Fodor, P. G. Breast cancer in a patient with gynecomastia. Plast. Reconstr. Surg. 84: 976, 1989.
3. Courtiss, E. H. Gynecomastia: Analysis of 159 patients
and current recommendations for treatment. Plast.
Reconstr. Surg. 79: 740, 1987.
4. Reed, L. S. Gynecomastia: Analysis of 159 patients and
current recommendations for treatment (Discussion). Plast. Reconstr. Surg. 79: 751, 1987.
5. Courtiss, E. H. Reduction mammaplasty by suction
alone. Plast. Reconstr. Surg. 92: 1296, 1993.
6. Lejour, M. Reduction mammaplasty by suction alone
(Discussion). Plast. Reconstr. Surg. 92: 1286, 1993.
7. Morselli, P. G. “Pull-through”: A new technique for
breast reduction in gynecomastia. Plast. Reconstr. Surg.
97: 450, 1996.
8. Maxwell, G. P., and Gingrass, M. K. Ultrasound-assisted
lipoplasty: A clinical study of 250 consecutive patients.
Plast. Reconstr. Surg. 101: 89, 1998.
9. Rohrich, R. J., Beran, S. J., Kenkel, J. M., Adams, W. P.,
and DiSpaltro, F. Extending the role of liposuction
in body contouring with ultrasound-assisted liposuction. Plast. Reconstr. Surg. 101: 1090, 1998.
10. Zocchi, M. L. Ultrasonic-assisted lipoplasty. Clin. Plast.
Surg. 23: 575, 1996.
11. Gingrass, M. K. Lipoplasty complications and their prevention. Clin. Plast. Surg. 26: 341, 1999.