Trans-nipple removal of fibro-glandular tissue in gynaecomastia surgery without additional scars: An innovative approach.

CONTEXT: The established techniques that have been used to treat gynaecomastia are said to have relatively less patient satisfaction rate as they leave some visible scars or mild elevation over the nipple areola complex, resulting in aesthetically unsatisfactory results. Even the slightest elevation or smallest scar over nipple areola complex leave patients extremely self conscious and in a dilemma of having a second intervention to get rid of that blemish. AIMS: The aim of the study is to achieve - A flat chest without adding a scar and with no chances of re-occurrence of the condition. This article suggests an innovative approach to address the problem.
MATERIALS AND METHODS: The author presents trans-nipple incision approach for the delivery of fibro-glandular tissue component following liposuction for maximum patient satisfaction. This method consists of a unique small criss-cross incision right on the nipple itself for retrieving any volume of tough fibro-glandular tissues. Between the duration of January 2012 to October 2013, 28 male patients of different ages were operated with this technique.
RESULTS: The surgery resulted in well-shaped, symmetric chest contour without any visible elevation or additional scars on nipple areola complex. No complications were noticed in any of the patients.
CONCLUSIONS: The presented technique is proved to have a high patient satisfaction rate and to be promising method to achieve good aesthetic results in gynaecomastia surgery.

INTRODUCTION

The treatment and surgical background of gynaecomastia has history of evolution over and above 60 years. In 1928, Dufourmental described a semi circular intra-areolar incision which was later documented by Webster[1] in 1946, who recognised the fact that the conspicuous scarring left by older techniques is more embarrassing than the original condition. The categories were classified by Simon in 1973[2] and later on, liposuction was introduced in 1983.[3] Ultrasound-assisted liposuction[4] remains the accepted standard that gained much popularity for addressing dense adipose tissue for the management of relatively glandular or fibrous gynaecomastia.

It is significant to mention the wide range of alternatives and advancements with minimally invasive approaches developed to eliminate the condition of gynaecomastia in a more refined way. But glandular component still remained the main concern that needed a more refined approach. It has been observed that Liposuction technique alone has its limitation with removal of adipose tissue only and unable to address the problem of tough glandular component[56]; therefore, combining liposuction with different kinds of direct incisions was introduced to deliver the fibrous architecture of the breast by many authors.[78] A minimally invasive approach was advocated by some authors that consist of minimal access incisions in either peri-areolar, circum-areolar or trans-areolar region,[91011] while some proposed arthroscopic shavers to break down the fibrous capsule of the glandular tissues and deliver it with liposuction.[12] But they have few drawbacks such as less access to the fibro-glandular tissue due to the minimal incision, visible unattractive scarring at nipple areola complex left after the peri-areolar incision as shown in Figure 1, dermal necrosis and subsequent scarring due to arthroscopic shavers and poor results.[6]

Figure 1

Scarring left after peri-areolar incision

The gynaecomastia surgery is basically sought for aesthetic purpose and such operation should not leave any tell-tale signs of the procedure. There had to be a solution for the smooth delivery of fibro glandular tissues without added scarring. This article presents an innovative approach that consists of a criss-cross trans-nipple incision to retrieve the fibro-glandular tissues following liposuction method for excellent outcomes. No additional scarring is visible, even on the operation table and even in a close up view right after the procedure with this trans-nipple approach. In all the cases, the trans-nipple incision is proved to give “No Signs of Surgery” over the nipple areola complex after a recovery period of three to six months following the surgical procedure.

MATERIALS AND METHODS

Between the duration of January 2012 to October 2013, 28 candidates suffering from various degrees of gynaecomastia (except Grade-4, which definitively required skin excision) were surgically treated by this method. Their age ranged between 20 years and 45 years. After proper consultation and examination, it was concluded that a surgical approach would be needed and all of them underwent the process of routine medical investigations for the anaesthesia fitness.

Right before the procedure, markings were made to limit the boundaries of treatment [Figure 2]. The surgery was performed under general anaesthesia (mostly LTA Mask). The procedure started with liposuction to retrieve adipose tissues through a tiny hole (approx 6-7 mm) at both sides of the chest using number 4 liposuction canullae. After performing thorough liposuction of the marked area, a small criss-cross incision was made right on the top of the nipple with the help of no-11 blade [Figure 3].

Figure 2

Pre-operative marking of the treatment boundaries for liposuction

Figure 3

The Criss-Cross incision at the centre of the nipple

Through a fine curved hemostat, the tough fibro-glandular tissues were delivered while creating slight pressure with thumb and forefinger (broad pinching) over the base of nipple areola area [Figure 4a and 4b]. Only tough tethering bands, which obstructed the path, were cut with a fine curved scissors [Figure 4c]. Care was taken to keep the point of scissors away from the dermis of areola. An amount of 3-5 mm tissue beneath the areolar skin was preserved to prevent any vascular complications [Video 1].

Figure 4a and b

Removal fibro-glandular tissues through the incision

Figure 4c

Cutting the tethering band through scissors keeping tip away from areolar skin to preserve at least 3-5 mm tissue beneath areolar skin

The incision was then closed with 4-0 monocryl in a single purse-string suture manner [Figure 5]. The liposuction incisions were left open to drain any collection of fluid without any freshening of margins or stitches. The compression garment was applied on the operation table right after the procedure and was replaced with new compression garment on seventh day of the surgery when the patient was called for first follow up. The patient was discharged from the hospital 5-6 hours after the procedure. Antibiotics and pain management medication were advised for a week. All the patients were advised to do proper massage of the chest area after 7 days of procedure with any moisturiser of their choice and to wear the compression garment for the next three months following the surgery. Serial medical photographs - front, lateral and semi-lateral views were taken prior to the procedure, after three, six and twelve months from the surgery to assess the final outcomes.

Figure 5

Purse string closure of the incision using 4-0 monocryl

RESULTS

It was observed in a close view that there was no visible scar on the nipple areola complex even on the operation table after the surgery [Figure 6] and on long-term follow-up of six months and one year [Figures 7 and 8]. No complications were recorded in any of the cases. None of the 28 patients reported any alteration of sensation in the nipple areola region after 3 to 4 months. Trans-nipple removal of fibro-glandular tissue is an easy, innovative approach in gynaecomastia surgery that removes all the tough fibro-glandular tissue without leaving any visible scars over the nipple areola complex. It produces the most rewarding results and maximum satisfaction to the patient right from their procedure.

Figure 6

Close-up view right after the surgery showing practically no disturbance of nipple-areola complex architecture

Figure 7 and 8

Example cases showing follow-up between six months to one year after surgery. See the close up view of practically scar less Nipple-areola complex after recovery

DISCUSSION

Gynaecosmastia usually requires no attention, unless patient feels uncomfortable or embarrassed due to aesthetic reasons. It is a cosmetic issue but causes great mental discomfort to the patient. Gynaecomastia usually has no significant relation with patient's health. Chances of having this condition can be same in a slender patient as well as in a healthy or over-weight patient. The difference is only the degree or severity that can be noticed differently in obese patients or who are relatively fat can develop significant visibility or enlargement.[13] Though the root cause of this problem is unknown in most of the cases and commonly idiopathic, heredity, consumption of certain drugs, obesity or hormonal changes can be one of the various other reasons. The problem has been noticed in all age groups, especially in adolescence.[14]

Many techniques and refined approaches have been advocated through the years to address the issue that leave visible scars.[7891011] Through the recent years, the surgical techniques that have been supported by many authors advocate liposuction or ultrasound-assisted liposuction alone[151617] or in combination with direct incision of the breast tissue through a peri-areolar incision[18] or a pull-through technique,[19] and various other methods have been advocated to eliminate remnant tough fibro-glandular tissue of gynaecomastia and achieve more aesthetic results.

It is observed that gynaecomastia causes a great mental discomfort and impairs the self-confidence of the patient. They tend to over react and sometimes become extra-conscious about their condition and start to notice even a mild elevation which is left in most cases of liposuction alone methods. This slight elevation can be acceptable for normal people but becomes great matter of mental stress for the patients suffering from this problem. It has been noticed that slight bulges are left as remnant after doing liposuction and it is evident on operation table during the surgery that significant elevation is left after doing liposuction only [Figure 9a]. This elevation is formed by the leftover fibro-glandular tissues that causes visible bulges and cannot be retrieved through only liposuction. That is why liposuction alone cannot serve the purpose as it has its limitations and is only ideal for removal of adipose tissue. In most of the cases where patients are more conscious even about a mild elevation, there remains a need of removal of this fibro-glandular tissue to achieve flat chest appearance [Figure 9b]. The invasive approaches along with liposuction are able to address this issue but they leave some conspicuous scarring (peri-areolar or trans-areolar incisions) or loss of sensation of the nipple areola complex, compromised vascualrity of overlying skin and subsequent complication (arthroscopic shavers or modified liposuction shaver canullae), leading to inadequate outcomes.

Figure 9a

Per-operative view showing visible bulge below nipple-areola complex just after completing liposuction due to remaining tough fibro-glandular tissue

Figure 9b

Per-operative view of same case showing flat chest just after removal of tough fibro-glandular tissues through trans-nipple approach

We consider a trans-areolar incision to remove these tough glandular tissues to achieve flat chest and eliminate any elevation caused by fibro glandular component over the nipple areola complex [Figure 9c]. Our technique is relatively simple and retrieves any volume of the tough fibro-glandular breast tissue without leaving any visible scars on the nipple areola complex, unlike peri-areolar incision or other invasive techniques. The tough fibro-glandular tissues are removed through a criss-cross incision over the centre of nipple right after performing liposuction of the marked area. The key to prevent any complication is to cut only the tethering band coming in way of delivery of fibro-glandular tissue and preservation of 3-5 mm tissue beneath the areolar skin. The technique offers the perfect control over nipple position as there are absolutely no chances to re-positioning or traction on the nipple due to subsequent scar that sometimes causes nipple malpositioning or inversion in peri-areolar incision technique.

Figure 9c

On table final result right after the procedure

In our study, the presented patients had different categories of gynaecomastia and Patient-A [Figure 10a] delivered little amount of tough fibro-glandular component (approx 50 g) and while patient-B [Figure 10b] delivered huge amount (approx 250 g). Both patients were operated with the same modality of treatment, i.e., liposuction for adiposal component and trans-nipple approach for removal of tough fibro-glandular tissue to treat their condition and discharged on the same day of their operation. Both were advised to do regular massage and wear compression garment for three to four months. They both enjoyed flat chest, very faint and thin scar of liposuction incision site and practically invisible scars over the Nipple Areola Complex after 6 months of follow up.

Figure 10a

Example Patients-A (Before and after) with fewer amounts of fibro-glandular tissues

Figure 10b

Example Patient-B (Before and after) with large amount of fibro-glandular tissues

CONCLUSION

Trans-nipple approach is an easy, innovative and practically excellent technique to remove any amount of the residual glandular fibrous tissue after liposuction without leaving any additional visible scars on the nipple-areola complex in gynaecomastia surgery and results in best aesthetic outcomes. All the 28 patients who were operated by this approach reported very satisfactory aesthetic outcomes after their recovery. The procedure offers a promising approach for all the patients of gynaecomastia, especially for the patients who want to keep secret of having any surgical procedure done to their chest.