ORIGINL RTICLE http://dx.doi.org/10.14730/.2014.20.1.31 rch esthetic Plast Surg 2014;20(1):31-35 pissn: 2234-0831 rchives esthetic Plastic Surgery Correction Lipomastia through a Stab Incision on the Nipple reolar Junction Sang Yub Yoon, Min Gu Kang Silhouette Clinic Center for reast and ody Contouring (CC), Seoul, Korea No potential conflict interest relevant to this article was reported. ackground Lipomastia (pseudogynecomastia, fatty-type gynecomastia) is defined as the benign enlargement the male breast attributable to accumulation the adipose tissue. The aim this study is to describe the experiences a stab incision on the nipple areolar junction method to the correction lipomastia. The authors present a combined method ultrasound-assisted liposuction in conjunction with a shaver technique to effectively remove the fatty and fibro-glandular tissues the male breast and avoid noticeable scar. Methods retrospective analysis was made 500 cases lipomastia operated on in the last 16 months via sub-nipple approach. The extent the clinical result, the technique employed, and the complications were observed. Results The volume liposuction from each side ranged from 30 to 500 ml (median, 175 ml) and the median weight the fibro-glandular tissue was 10.5 grams. Major complications from this procedure include undercorrection, overcorrection, infection, and hematoma. Our total major complication rate was 1.8%. Conclusions These techniques a sub-nipple stab incision are also alternative to correct lipomastia, avoiding undesirable scars. Keywords Gynecomastia, Liposuction, Nipple INTRODUCTION Male breast enlargement can occur transiently in up to three fourths adolescents and is persistent in 7% cases [1]. Gynecomastia is the most common benign condition the male breast and present in 65 % normal adolescents [2-4]. It is ten selflimiting and resolves, usually during the teenage years. The adolescent with gynecomastia should not be operated on until 3 years have passed and it has been amply demonstrated that spontaneous regression will not occur [2]. Pubertal male patients are most successfully treated with patience and reassurance, because the vast Received: Jan 25, 2014 Revised: Feb 7, 2014 ccepted: Feb 10, 2014 Correspondence: Sang Yub Yoon Silhouette Clinic, Silhouette /D 4-6F, 830 Nonhyeon-ro, Gangnam-gu, Seoul 135-893, Korea. E-mail: pssurgeon@korea.com Copyright 2014 The Korean Society for esthetic Plastic Surgery. This is an Open ccess article distributed under the terms the Creative Commons ttribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-.org majority these patients will experience complete resolution with time. The persistent large breasts may cause significant emotional distress and embarrassment to male. Pseudogynecomastia refers to benign enlargement the male breast attributable to excessive breast adipose tissue, a condition termed lipomastia or fatty type gynecomastia. True gynecomastia and lipomastia can generally be differentiated by carefully palpation and/or ultrasonography examination [3-5]. The development liposuction techniques has enabled correction lipomastia with only inconspicuous scarring [1,2]. The direct resection the fibro-glandular tissue with ultrasonic liposuction is one the most commonly used alternatives. To remove the fibro-glandular tissues effectively and aesthetically, not tumor excision concept but chest contouring concept is necessary [5,6] Unfortunately, the result the tumor excision method is ten as physically and psychologically disturbing to the patient and doctor. uthor technique consist the flattening the thorax can be achieved by means stab incision on the nipple areolar junction, ultrasound-assisted liposuction (UL) [7-9], scavenging suction-assisted lipectomy (SL) [10], fibro-glandular tissue shaving using cartilage tissue shaver [11] and pull-through method 31
rchives esthetic Plastic Surgery VOLUME 20. NUMER 1. FERURY 2014 [12-14]. The present study evaluates the results correction lipomastia with a special focus on sub-nipple approach procedure and outcomes. METHODS This was a retrospective analysis all lipomastia patients treated with a stab incision on the nipple areolar junction at the Silhouette Clinic CC over 16-month period, between 2011 and 2013. ll patients had bilateral lipomastia grade Yoon I to IV [5]. ccording to the Yoon classification [5], 34 patients could be include in grade I (6.8%), 123 patients in grade II (24.6%), 267 patient in grade III (53.4%) and 76 patients in grade IV (15.2%). ll patients were preoperatively assessed by the single surgeon, who recorded the characteristics their breasts in terms size, firmness, skin elasticity and overall skin quality. Then by ultrasonography examination, authors confirmed lipomastia and measured the size and boundary the male breast. The areas treated were marked preoperatively with the concen- tric topography map technique, while the patient was in a standing position. The patient was positioned supine with arms abducted for the procedure. The procedure was performed under intravenous sedation and local anesthesia. Preoperative antibiotic prophylaxis was administered with 1.0 g cefazolin routinely. 3 mm stab incision was made at the nipple areolar junction with a No. 15 blade for liposuction and fibro-glandular tissue removal (Fig. 1). We infiltrated all areas to be suctioned with tumescent Klein solution. Tumescence was accomplished using one ample (1 ml 1:1,000) epinephrine and 40 ml 2% lidocaine per liter infiltrated isotonic saline solution. To prevent incision site maceration, we applied paper skin protection (Fig. 1). fter 10-15 minutes, we performed liposuction and fibro-glandular tissue removal to flat the chest. t first, we use the ultrasonic machine (Contour Genesis, Mentor Medical Systems, Santa arbara, Calif.) to sten the fibrotic breast parenchyma. nd then manual suction was applied to scavenge the remained adipose tissue with cannulas 3 or 4-mm in diameter. fter complete liposuction we removed fibro-glandular tissues employing the shaver system C D Fig. 1. stab incision and operative instruments. () a stab incision on the nipple areolar junction and tacking suture with 4-0 stitch. () Skin protection for prevent from maceration. (C) Ultrasonic liposuction cannula (diameter 3 mm), manual suction cannula (diameter 3 mm and 4 mm), and tissue shaver. (D) Immediate postoperative view. Note; cannot find the incision site. 32
Yoon SY et al. Correction Lipomastia rchives esthetic Plastic Surgery (Stryker Corp., Kalamazoo, Mich.). We could aspirate and collect the fibro-glandular tissues. Then pull-through technique is performed to scavenge the remaining fibro-glandular tissue beneath the nipple-areola complex (Fig. 1C). The surrounding subcutaneous fat the chest bordering the breast is feathered by suction to avoid noticeable saucers deformity. It is very important to leave a small amount fibro-glandular tissue behind the areola to avoid severe depression. Regularity was determined by using the pinch test and by observing the smooth contour. The incision is closed with one or two intradermal absorbable stitches. Tissue adhesive is placed over the skin suture line (Fig. 1D). compressive sponge and elastic bandage dressing is applied in the operating room. The patients remained recovery room for 1-2 hours for observation. Oral antibiotics and pain killer medications are given during the first three days after surgery. Patient is discharged the day after surgery. Light activity is required for the first 24 hours. fter 24 hours, we recommended patients to remove all dressing materials and to take shower. Patients were allowed to return to work starting from the third operative day. We routinely advise to wear a compressive dressing with an elastic bandage for 2 to 4 weeks during the postoperative course. The bandage allows for even skin redistribution and decreased third-space collection serum or blood. Sport activities were permitted beginning from the second or fourth week. Table 1. Major Complications Complications 1.8% (9/500) Undercorrection 0.4% (2/500) Overcorrection 0.6% (3/500) Infection 0.2% (1/500) Hematoma 0.6% (3/500) RESULTS During a 16-month period, we operated on 500 male patients ranging in age from 18 to 57 years (median age, 21.7 years) underwent surgery with a stab incision on the nipple areolar junction. The postoperative follow-up period ranged from 3 to 24 months (average follow-up, 6 months). The volume liposuction from each side ranged from 30 to 500 ml (median, 175 ml) and the median weight the fibro-glandular tissue was 10.5 grams. Major complications from this procedure include undercorrection, overcorrection, infection, and hematoma (Table 1). Our total major complication rate was 1.8%. Two patients (0.4%) required secondary suctioning because undercorrection. Three overcorrection cases (0.6%) required autologus fat injection to improve the chest contour. One patient (0.2%), who revisited after 1 week showed the redness on the surround the nipple areola complex. We could treat the infectious sign through just one needle aspiration. In three patients (0.6%), a small to moderate hematoma developed, which required 2-3 times needle aspiration at the outpatient based clinic. No other significant complication or recurrences were encountered. Minor complications (defined by without revision demanded) include swelling, bruising, transient sensory change, areola wrinkling, nipple partial necrosis and hypertrophic scar or protrusion the nipple due to scar formation. For 22 patients (4.4%), postoperative subareola fullness develops as a result scar deposition. To prevent and treat hypertrophic scar or protrusion the nipple, 2-3 times 0.3-0.5 ml triamcinolone may be injected under the nipple into the deeper scar tissue to smooth excess collagen formation. In five patients, the nipple partial necrosis was occurred, which solved just observation and minor touch. Redundant areola skin (slightly areola wrinkle) occurred after fibro-glandular removal for 2 (0.4%) the 500 patients who underwent this technique, requiring a minor revision to flatten areola Fig. 2. 21 year-old patient (178 cm, 86 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 320-350 cc, excision 12-17 g). () Preoperative view. () Postoperative view after 7 months. 33
rchives esthetic Plastic Surgery VOLUME 20. NUMER 1. FERURY 2014 Fig. 3. 22 year-old patient (170 cm, 63 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 190-240 cc, excision 10-14 g). () Preoperative view. () Postoperative view after 15 months. Fig. 4. 25 year-old patient (175 cm, 70 kg) treated with sub-nipple stab incision, ultrasound-assisted liposuction and tissue shaving (suction 200-250 cc, excision 20-22 g). () Preoperative view. () Postoperative view after 11 months. skin using autologus fat injection. In the early postoperative days, swelling, bruising and transient sensory change was commonly observed. Fig. 2, 3, and 4 illustrate postoperative results. DISCUSSION The three terms typically used to categorize gynecomastia are true gynecomastia, referring specifically to glandular enlargement; mixed gynecomastia, which describes a breast with both fatty deposits and glandular hypertrophy; lipomastia, referring to chest lipodystrophy [4]. Lipomastia may develop at puberty as a result obesity [4,5,11,15,16]. The surgical treatment remains the main solution for longstanding lipomastia. Tumescent liposuction and/or ultrasonic liposuction are an effective remedy for chest lipodystrophy. ut liposuction alone usually will not fully correct a significant proportion lipomastia cases because the presence fibroglandular tissue [7,11] Rosenburg [2] and Rohrich [7] claimed that isolated liposuction could adequately remove the breast parenchyma. ut we feel that excision is necessary for removal the fibroglandular tissue the lipomastia [5,17]. In our experience, these dense fibrotic tissues cannot be adequately removed by liposuction alone and excision glandular tissue is needed in lipomastia. Ultrasonic liposuction is an interesting alternative for lipomastia correction and produces good skin retraction, but we needed additional procedure to remove the fibro-glandular tissue. Liposuction alone was only used in patients with lipomastia with no fibro-glandular tissue, but seldom. The removal fibro-glandular tissues necessitates additional consideration because excisional technique may create a relatively high complications rate. lthough they ten produce good results, they are not free complication. For many years, the periareolar approach has been our first choice for correct lipomastia; it allows good control the operative field. The periareolar approach methods for extract the fibro-glandular tissue may result in prominent scar. The extent and placement postoperative scarring is an important consideration. When invisible external scarring is request- 34
Yoon SY et al. Correction Lipomastia rchives esthetic Plastic Surgery ed by the patient, who does not want periareolar scars, we think a sub-nipple stab incision technique. We describe this technique through small 3-mm sub-nipple stab incisions to hide the scar. Imperceptible 3-mm incisions are particular value to younger lipomastia patients, for whom prominent scar might become a new source shame and self-consciousness. The stab incision has several disadvantages; narrow view field, difficulty the electrocautery, and possibility the areola skin maceration. ut the operative experiences got to be stacked, we could overcome the disadvantages. We applied shaving system [11] and pull-through method [12-14]. These techniques have permitted the effective resection fibro-glandular tissue. It has allowed us to carry out a fibro-glandular gradual and controlled resection the tissue, giving a final good contour the whole chest. uthor method refines and improves upon existing traditional techniques, fering a less outwardly invasive approach. The removal excessive fat with fibroglandular tissue produces an improved appearance and projection the male torso. Correction lipomastia translates to greater confidence and self-esteem. It does more than fix a physical problem. It can make a pround impact on the patient s emotional and psychological life and improve self-confidence. CONCLUSION The surgical treatment lipomastia requires an individual approach, depending on the grade male breast hypertrophy. This technique stab incision on the nipple areolar junction is also alternative to correct lipomastia, avoiding undesirable scars. This technique has improved the final outcome with invisible scar, minimal complications and good aesthetic results. REFERENCES 1. Ersek R, Schaeferele III M, eckham PH, et al. Gynecomastia: a clinical review. esth Surg J 2000;20:381-6. 2. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary solution. Plast Reconstr Surg 1987;80:379-85. 3. Courtiss EH. Gynecomastia: nalysis 159 patients and current recommendations for treatment. Plast Reconstr Surg 1987;79:740-52. 4. Narula HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin N m 2007;36:497-519. 5. Yoon SY, Kang MG. The new classification for fatty-type gynecomastia (lipomastia) and 1000 cases review. J Korean Soc Plast Reconstr Surg 2009;36:773-8. 6. Mladick R. Gynecomastia: continuing medical education articlebody contouring. esth Surg J 2004;24:471-9. 7. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management gynecomastia: defining the role ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909-23. 8. Hodgson EL, Fruhstorfer H, Malata CM. Ultrasonic liposuction in the treatment gynecomastia. Plast Reconstr Surg 2005;116:646-53. 9. Sim H. Treatment gynecomastia utilizing the ultrasound-assisted liposuction. J Korean Soc esthetic Plast Surg 2002;8:19-24. 10. Shin HW, Hong JP. The treatment gynecomastia using power assisted and ultrasound assisted liposuction with periareolar partial resection. J Korean Soc esth Plast Surg 2005;11:207-10. 11. Prado C, Castillo PF. Minimal surgical access to treat gynecomastia with the use a power-assisted arthroscopic cartilage shaver. Plast Reconstr Surg 2005;115:939-42. 12. Morselli PG. Pull-Through : new technique for breast reduction in gynecomastia. Plast Reconstr Surg 1996;97:450-4. 13. Hammond DC, rnold JF, Simon M, et al. Combined use ultrasonic liposuction with the pull-through technique for the treatment gynecomastia. Plast Reconstr Surg 2003;112:891-7. 14. racaglia R, Fortunato R, Gentileschi S, et al. Our Experience with the so-called pull-through technique combined with liposuction for management gynecomastia. nn Plast Surg 2004;53:22-6. 15. Mentz H, Ruiz-Razura, Newall G, et al. Correction gynecomastia through a single puncture incision. esthetic Plast Surg 2007;31: 244-9. 16. Li CC, Fu JP, Chang SC, et al. Surgical treatment gynecomastia; complications and outcomes. nn Plast Surg 2012;69:510-5. 17. Esme DL, eekman WH, Hage JJ, et al. Combined use ultrasonicassisted liposuction and semicircular periareolar incision for the treatment gynecomastia. nn Plast Surg 2007;59:629-34. 35