Plastic & Reconstructive Surgery:
Gynecomastia: Tips and Tricks—Classification and Surgical Approach
Monarca, Cristiano M.D., Ph.D.; Rizzo, Maria Ida M.D.
Sapienza University of Rome, Rome, Italy
Supplemental digital content is available for this article. A direct URL citation appears in the text; simply type the URL address into any Web browser to access this content. A clickable link to the material is provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).
Correspondence to Dr. Rizzo, Viadotto Gronchi 11/13, 00139 Rome, Italy, email@example.com
Gynecomastia continues to challenge plastic surgeons. Nahabedian reviews the breast deformities to provide a better understanding of the current available data. The state of the art is centered on gland and fat removal by liposuction and its derivatives.1,2
We suggest that it is important to keep in mind the reconstruction of an athletic appearance to obtain a virile chest, with the trapezoidal shape (larger side on the top), the nipple-areola complex adherent to the pectoral muscle, and downward orientation. We propose a new approach that classifies gynecomastia (Table 1) considering the volume excess but also the shape of the chest, and describe here how we treat gynecomastia, including our tips and tricks.
We evaluate the patient by pinching the fat on the breast with the patient in the standing position. Then, he contracts the muscles to enhance the sternal notch and the pectoral muscle borders that we have drawn. The new inframammary fold is designed close to the areola (0 to 3mm).
We perform mastectomy through an areolar single-puncture incision at the 6-o’clock position, excising the gland in strips, which leaves an imperceptible scar3 (grade I to III) (Fig. 1, above) or periareolar subcutaneous mastectomy in grade IV (Fig. 1, below). Any residual gland is removed, avoiding unaesthetic projection of the areola.
Liposuction is performed in two steps. First, careful liposuction removes the adipose tissue, ensuring skin adhesion to the muscular plane. Second, powerful liposuction is performed with basket/accelerator cannulas at the pectoral borders, and at the sternal notch to emphasize the medial insertions. Residual adipose tissue homogenization by cannula avoids irregularity of the treated areas.
Twenty-four patients were recruited for this study. Seven were classified as type 1, 12 were classified as type 2, four were classified as type 3, and one was classified as type 4. Patients themselves evaluated the cosmetic appearance, based on a scale of 1 (excellent) to 4 (unsatisfactory). All patients achieved a major improvement (Fig. 1) and 91.6 percent of the patients evaluated their chest as excellent.
Traditional liposuction cannot accomplish the higher aesthetic goals imposed by modern standards of beauty, nor can it create a virile chest if one does not plan to correct the gynoid rounded shape, the nipple malposition and its forward projection, the gynoid inframammary fold, and the absence of midsternal insertions. We perform a liposuction procedure that closes the skin to the muscle and sculpts the borders of the pectoralis muscle, creating an obtuse angle (between the axilla pillar and the new inframammary fold) that emphasizes the trapezoidal shape (see Video, Supplemental Digital Content 1, which shows an intraoperative view of selective liposuction, http://links.lww.com/PRS/A722) and a new inframammary fold near the areola to redefine nipple downward oriented.
Video. Supplemental ...Image Tools
Mentz et al. first design the pectoral etching for the delineation of the thoracic musculature in men without gynecomastia that desire an athletic appearance or for body builders.4 These authors state that to augment muscle bulk appearance, fat over the pectoralis muscle may be two to three times thicker than the etched perimeters. We reduce fat over the muscle at the minimum closing the skin to the muscle and avoiding nipple and upper pole projection. We believe that a sculpted thorax should resemble not “a three-dimensional Roman breast-plate”4 but the “warrior who wore it” like the classical male breast sculptures.
The authors have no financial interest to declare in relation to the content of this article.
Cristiano Monarca, M.D., Ph.D.
Maria Ida Rizzo, M.D.
Sapienza University of Rome
1. Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg. 2011;127:91e–102e
2. Gruntmanis U, Braunstein GD. Treatment of gynecomastia. Curr Opin Investig Drugs. 2001;2:643–649
3. Mentz HA, Ruiz-Razura A, Newall G, Patronella CK, Miniel LA. Correction of gynecomastia through a single puncture incision. Aesthetic Plast Surg. 2007;31:244–249
4. Mentz HA, Ruiz-Razura A, Newall G, Patronella CK, Miniel LA. Pectoral etching: A method for augmentation, delineation, and contouring the thoracic musculature in men. Plast Reconstr Surg. 2007;120:2051–2055
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
* Text—maximum of 500 words (not including references)
* References—maximum of five
* Authors—no more than five
* Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
©2013American Society of Plastic Surgeons