PMC:4134643 / 8198-14492 JSONTXT

{"project":"2_test","denotations":[{"id":"25136214-4687568-58661208","span":{"begin":1065,"end":1066},"obj":"4687568"},{"id":"25136214-1414657-58661209","span":{"begin":2356,"end":2357},"obj":"1414657"},{"id":"25136214-1414658-58661210","span":{"begin":2398,"end":2399},"obj":"1414658"},{"id":"25136214-18551338-58661211","span":{"begin":2449,"end":2450},"obj":"18551338"},{"id":"25136214-9523606-58661212","span":{"begin":2469,"end":2471},"obj":"9523606"},{"id":"25136214-15211192-58661213","span":{"begin":3172,"end":3174},"obj":"15211192"},{"id":"25136214-11715623-58661214","span":{"begin":3467,"end":3469},"obj":"11715623"},{"id":"25136214-12859919-58661215","span":{"begin":3467,"end":3471},"obj":"12859919"},{"id":"25136214-11715623-58661216","span":{"begin":3920,"end":3922},"obj":"11715623"},{"id":"25136214-11252087-58661217","span":{"begin":3982,"end":3984},"obj":"11252087"},{"id":"25136214-1989037-58661218","span":{"begin":3997,"end":3999},"obj":"1989037"},{"id":"25136214-9788217-58661219","span":{"begin":3997,"end":4001},"obj":"9788217"},{"id":"25136214-18675546-58661220","span":{"begin":5051,"end":5053},"obj":"18675546"},{"id":"25136214-11743381-58661221","span":{"begin":5736,"end":5738},"obj":"11743381"}],"text":"DISCUSSION\nGynaecomastia is the benign proliferation of the ductal tissue, stroma, and fat in the male breast. Though it can present in any age, the age of presentation in our study was found to be from 14 years to 43 years. Adolescent patients' had significant emotional distress due to enlarged breast and did not take their shirts off in public places for fear of being mocked.\nThere are many potential causes for gynaecomastia; among them, imbalance between estrogens and androgens is strongly suspected; however, in many cases, an exact aetiology is uncertain.[3] As in our study, no such cause was found and was considered as idiopathic verities. Obesity has a definitive correlation with gynaecomastia[4] , and in our study six patients were found to be obese and along with this breast reduction surgery they underwent liposuction of other areas also.\nSurgical therapy is indicated for long-standing gynaecomastia, at least more than 18 months, which is unlikely to subside spontaneously or with medication.[4]\nFrom the surgical point of view, Simon et al.[5] divided gynaecomastia into four grades as follows:\nGrade I: Small visible breast enlargement- no skin redundancy\nGrade IIa: Moderate breast enlargement without skin redundancy\nGrade IIb: Moderate breast enlargement with skin redundancy\nGrade III: Marked breast enlargement with marked skin redundancy\nAccording to their opinion, in grade IIb and grade III where there is ptosis of breast with skin excess, it is difficult to get a good result without skin excision.\nBut in our experience, we have found that the most of the patients' with grade IIB and grade III breast had not only skin excess but also had enlarged and infero-medially displaced nipple-areola complex. These patients needed both skin and nipple-areola complex reduction and fixation in a normal anatomical place to achieve a good aesthetic result.\nManagement of high-grade gynaecomastia has evolved a lot. Malbec[6] in 1945 suggested breast amputation with free nipple-areolar graft for management of breast ptosis and skin excess, but the procedure had its own limitations as there may be total loss of the free graft or there may be hypoesthesia of the nipple-areolar complex or these patients may develop hypertrophic scars over chest.\nIn latter times, preservation of nipple-areolar complex on a de-epithelised flap[7] , inferior pedicle reduction technique[8] , horizontal ellipse with superior pedicel flap[9] , bipedicle flap[10] etc were described to keep the neuro-vascular supply of the NAC complex intact, but these surgical techniques usually produce scars over male chest, which is aesthetically unappealing.\nScar-less techniques like subcutaneous mastectomy through an intra-areolar incision of gynaecomastia was described by Leon Dufourmentel[11] in 1928 and latter by Jerome Webster[12] in 1946. With this technique, the hypertrophied gland could be removed without leaving a significant scar, but in cases of grade III gynaecomastia, this intra-areolar incision may be too small, a lateral and medial extension may be needed, and later a second surgery may also be needed to excise the redundant skin.\nTashkandi et al.[13] described single-stage subcutaneous mastectomy and circumareolar concentric skin reduction with de-epithelialisation in high-grade gynaecomastia (Simon's grade III) but the main disadvantage of the technique was the mild residual skin redundancy.\nIn the past few years, liposuction assisted[1415] gynaecomastia management has been described by several researchers. This technique gives a good result in grade I and grade IIa gynaecomastia, but the skin and areolar excess in grade IIb and grade III breasts can not be properly addressed by this technique. Thus some degree of breast ptosis still persists, which sometimes needs a second surgery. Secondly as the breast disk is not completely removed there is chance of recurrent gynaecomastia.[14]\nPreviously, different researchers like Persichetti et al.[16] and others[1718] had described ‘circumareolar skin reduction with purse-string suturing’ technique to reduce the skin and areolar excess. Along with skin reduction, the excess breast parenchyma was removed by making a ‘reverse omega’ incision in the inferior border of the de-epithelialised area from 3-9 o'clock position (180 degree incision).\nIn our technique, along with this ‘circumareolar skin reduction’ to reduce skin excess, the simultaneous use of liposuction decreases the breast volume, so the breast disk can be removed through a very small incision (60 degree). This small incision preserves best the subdermal neurovascular plexus of the nipple-areola complex, which if injured, may lead to hypoesthesia or necrosis of nipple-areola complex. As the subdermal neurovascular supply of the nipple-areola complex is excellently preserved, not a single case of such complication was seen in our study. Along this, we have kept a minimum of 1.5-2 cm sub areolar tissue during breast disk excision, which helps to decreases the chance of ‘saucer deformity’.[19]\nAnother advantage of our technique is that, as the liposuction of breast covers a large area, i.e. from clavicle to below the inframammary fold, it gives a better contour of the chest. Simultaneously, liposuction of other areas can also be carried out in the same sitting, which decreases economic burden of the patient, and decreases patient load on the hospital and surgeon.\nThe next issue of concern, i.e. repositioning of the infero-medially displaced nipple-areola complex in high grade gynaecomastia is not well described in literature. Normal position of the nipple-areola complex in male is 4th intercostal space or the mid-humerus level medial to the mid-clavicular line.[20] In this technique, we have fixed the nipple-areolar complex in its anatomical position with pectoralis fascia, which decreases the chance of displacement.\nFinally, as the two incision lines are apposed to each other, the final scar merges with the areola, thus it gives a scar less appearance of the breast.\nTo conclude, the technique described by us is a unique combination of skin reduction and liposuction, which is minimally invasive, has a small intraoperative blood loss, has short hospital stay, and gives a scar less appearance to the male chest."}