Surgical reduction of gynecomastia seems as though it would be relatively simple and straightforward – just ‘remove the lump’ and the chest will look normal. But it is actually a deceptively challenging procedure that requires detailed preoperative evaluation and planning, a rational and stepwise surgical approach, and careful attention to detail in the operating room with assessment of chest contour several times over the course of the surgery with the patient in upright sitting position (as stepwise contour correction is performed).
There is always much more to consider than the overgrown breast tissue mass when treating primary (not previously operated) gynecomastia patients. One must pay close attention to the surrounding subcutaneous fat excess which is present in the majority of patients, as this must be treated – and treated in a manner that ‘feathers’ the breast tissue and fatty tissue removal peripherally so that there is no obvious demarcation between the area where tissue has been removed and the area where no tissue has been removed. Also, the chest skin must be carefully assessed in order to determine whether and to what degree it contributes to the preoperative appearance of breast tissue excess.
In my practice we see a fairly significant number of patients who have had gynecomastia surgery elsewhere and who find themselves with post-surgical chest contour problems. During preoperative assessment of these patients, it is important to determine how each of the following anatomic concerns contributes to the visible contour deformity:
Condition of the overlying skin, with particular attention to whether or not skin laxity and/or skin tethering is part of the problem
Degree to which breast tissue has been over-resected, and whether or not there are adjacent areas where breast tissue has been under-resected
Volume of fatty tissue excess (or areas of fatty tissue under-removal) peripheral to the area where breast tissue has been removed
Extent of post-surgical scarring which can tether skin and subcutaneous tissues, altering chest area appearance in neutral position and/or with arms raised
The good news is that the vast majority of these post-surgical contour problems can be corrected, and many of them can be corrected completely so that patients have a normal post-correction chest contour, with surgical scars that are inconspicuous or even completely invisible to the casual observer.
I frequently will start a post-gynecomastia contour problem correction procedure with power-assisted scar release and fat redistribution using the MicroAire Power-assisted Liposuction (PAL) device, but with the aspirator TURNED OFF so that no fat is being removed. During this phase of treatment we use flared cannulas which are highly effective in releasing subcutaneous scar tissue and redistributing / smoothing the subcutaneous fat layer. If there are any areas of fatty tissue excess following fat redistribution, these can be carefully reduced by low-volume liposuction using very small, non-flared liposuction cannulas.
Persistent, tethering bands of scar tissue can be corrected with scar ‘subcision’ using ‘V-dissector’ fat grafting cannulas. These cannulas have at their tips a V-shaped cutting surface that is highly effective at releasing scar bands that tether the skin and subcutaneous tissues and distort the surface anatomy of the chest skin.
In many cases this combined PAL / subcision technique can correct 50% or more of the contour problem, without directly removing or replacing any breast area soft tissue. I have occasionally had cases where this first step in the process achieved a complete contour correction.
As mentioned above, the patient is assessed in upright sitting position after completion of each step of the surgical procedure, as this is the only way to confirm the degree of improvement that has been achieved – and what additional correction is still required. The O.R. table flexes at the waist, allowing the back of the table to be elevated until it is almost perpendicular to the lower half of the table. In this manner a patient under deep IV sedation or general anesthesia can be examined in upright position, which of course is the meaningful position for chest aesthetics.
Areas of residual breast tissue excess are marked while the patient is in upright position. These areas can be reduced by two means: by use of an arthroscopy shaver introduced via a tiny incision in the underarm area, and/or by direct excision using small incisions along the border of the areolas. Breast tissue is extremely dense, similar to cartilage in consistency, and therefore only very minimal amounts of breast tissue can be removed by means of liposuction.
Areas of persistent soft tissue depression can be restored by means of structural fat grafting, where fat is harvested by hand from areas of fat excess using small syringes (most commonly the flanks in gynecomastia patients) then processed and reinjected using small blunt cannulas. Areas with major soft tissue deficits / depressions may require solid fat and/or dermal-fat grafts in order to achieve complete contour correction.
The last issue that is assessed and treated is laxity in the overlying chest skin, which can permit some soft tissue contour problems to persist, at least to some degree, if it is not addressed. The dermis of areolar skin is much thinner than the dermis of the surrounding chest skin, which means that it has an inherently lesser ability to contract and smooth out following the correction of problems involving the underlying fat, breast tissue and scar tissue.
Secondary gynecomastia surgery patients frequently require excision of lax and redundant areolar skin. Alternately, removal of a crescent of the surrounding, non-areolar chest skin may achieve a normalization of the vertical areolar diameter, which tends to collapse and shorten in some patients following removal of subareolar breast tissue. As with primary gynecomastia surgery patients, every effort is made to limit the amount of skin excision that is performed, as surgical scars become ever more obvious as the amount of skin excision increases.
It is important to understand and accept that some cases of severe contour abnormality will require a two-stage or even three-stage approach to contour correction. Both structural fat grafting and solid fat grafting procedures rarely result in 100% graft survival, so you must accept that more than one round of grafting may be required to achieve a complete contour correction. Additionally, all surgical sites heal by means of scar tissue deposition, and soft tissue contour can change to some degree over the course of the healing phase (even if contour looks perfect in upright position at the end of a surgical procedure), so some cases inevitably require secondary contour correction procedures.