Fig:Anatomy of the
breast-Gynecomastia specimen showing glandular tissue sorrounded by fat.
Fig: Anatomy of the
breast-fat – after gynecomastia liposuction.
What are the treatment options?
Most
of the time people will ask for reduction without surgery/by
tablets/ointment/exercise/laser/injections. If they opt for the surgery
they do not want anesthesia /no scar/no complications/no post operative
treatment like pressure garment /massage etc. Most of the times they do
not want to inform relatives/parents/friends.
Why all these
issues? Because he thinks only he is having this swelling, wants to
hide this from others. But it is quite common problem/better to
understand the disease properly/then choose an appropriate treatment.
Most
common question asked is I decided to go for the
surgery
but my friend told me there is something called injection or laser
treatment, where there is no need for the admission, not a surgery, no
pressure garment required.
NON SURGICAL OPTIONS-
Exercise-Unlikely
to go/unless the breast contains only fat. Friends may advice them to
go for gym to reduce the fat. To build the body without their knowledge
they may take steroids/these patients will have low body fat, but the
exogenous testosterone suppresses the endogenous testosterone,
permitting increased production of estrogens resulting in gynecomastia.
Fig-Post exercise fat
loss in grade 3 type resulting in sagging/glandular portion intact.
Tablets-If the person is having harmonal enlargement, the swelling will
reduce/unlikely with other reasons.
Ointment/lotion-Unlikely
Injection
Lipolysis- Only fat component will dissolve/ideal for patients with
only fat enlargement/other cases only improvement will be there
depending on the amount of fat.
Fig-Injection
lipolysis-glandular portion remains.
Laser/carboxy therapy- Only fat will dissolve with improvement
depending on the amount of fat.
Fig-Laser
liposuction-improvement of 40%, hard gland remains.
In
simple words-if one person is having 40% fat & 60% glandular
tissue, 40% improvement will be there by these methods; still 60% of
the glandular tissue will remain resulting in unhappiness.
Fig-Diagram to show the
area of action of injection lipolysis/laser/regular liposuction
resulting in fat absorption/aspiration.
What are the surgical
options?
Multiple
variations in operative technique have been designed to remove the
excess tissue and reduce the scarring and deformity associated with
mastectomy.
The surgical options are-
Excision of the glandular tissue.
Open surgical excision with liposuction
or lipo excision.
Liposuction [SAL].
Ultrasound assisted liposuction with
standard liposuction [UAL].
Endoscopic assisted mastectomy with
liposuction.
Total mastectomy with free nipple
grafting.
Modified reduction mammoplasty with
dermal pedicle
1. Excision of the glandular tissue-Ideal for only glandular
enlargement. Incision will be placed in sub areola region.
Fig-Excision of the
glandular tissue for grade -1 type
2.
Lipoexcision-Here first liposuction done with 4mm sub areola/axillary
/chest incision, then central hard portion[usually not possible to take
out by liposuction]removed by lower peri areolar incision.
Here
care is taken to preserve good amount of fat in anterior chest wall
comparable to anterior abdomen, to avoid something called saucer
deformity.
Fig- Excision of the
gland + liposuction for grade 2A gynaecomastia.
3.
Liposuction-Ideal for the patients with only fat as main
component,
others will have marginal improvement depending on the fat component.
Here by 4mm mid peri areola, axillary, inframammary crease incision,
fat will be removed.
Fig- Liposuction for
obesity induced gynecomastia [including abdomen].
4.
Ultrasound assisted liposuction with standard liposuction-Here after
standard liposuction, the central dense parenchyma removed by
ultrasonic energy. However open surgery may be required if this does
not achieve sufficient correction.
5. Endoscopic assisted
mastectomy with liposuction-This procedure is done with axillary
incision; the main advantage is no scar in sub areola area &
minimal depression of the areola
Fig-Endoscopic assisted
excision of the fibrous type gynecomastia [Storz endoscope]
6. Total mastectomy with free nipple grafting-For stage 3 with too much
skin excess.
7. Modified reduction mammoplasty with a dermal pedicle- For
breasts with ptosis.
Fig-Reduction mammoplasty
with dermal pedicle for grade -3 type gynecomastia.
Under what anesthesia
surgery will be done?
Most
of the time the surgery will be done under general anesthesia, however
in co operative patients, the procedure can be done under local
anesthesia.
Post operative care
1. Admission will be
required or not?
If
only liposuction done, patient can go home. With other procedures, the
chance of bleeding will be there in empty cavity, hence a small tube
will be put to drain the blood, if not, and the complication of
seroma/haematoma may arise, which requires repeated aspiration of the
fluid for weeks together.
About 48hours of hospital stay will be required.
2. How many days of rest
required?
Usually 48 hours of rest will be enough, if we do this procedure on
Friday; Monday the person can start his work.
3. How painful is the
procedure?
First
1-2 hours moderate pain will be there, then very minimal pain will be
there for few days, which can be controlled by taking tablets. Those
who are very pain sensitive, we are offering something called
PCA-patient himself can control the pain.
4. Pressure
garment/massage for how many days?
Post
surgery some amount of swelling/unevenness will be there. The chances
of seroma or fluid collection will be there in empty cavity. To prevent
all these, pressure garment/16-23 hours in a day for about 2-3 months
will be required. Patient can stop using garments once the swelling
decreases with normal feeling skin [hardness should disappear].Over the
pressure garment the person can wear normal shirt .
Massage about 3 times a day using any oil/elovera to be done for about
2-3 months/till the swelling/hardness disappears.
Advantages of pressure garment-
1. Chances of seroma/or fluid collection will be less in empty cavity.
2. Unevenness will improve/for better contouring.
3. Swelling/hardness will reduce fast.
Fig- Pressure garment
after the procedure.
5. What are the
complications of the surgery?
Swelling,
hardness, temporary numbness/rarely permanent, seroma
formation/hematoma formation, golf hole, saucer deformity,
unevenness, retraction of the nipple/areola, scar are the
complications.
Fig-Scar formation due to
wrong incision [done elsewhere ]
Fig-Hematoma formation
after lipoexcision requiring repeated aspiration of fluid.[refusal for
admission/no drain-done elsewhere]
Fig-Areola
retraction/nipple retraction after lipo excision.
Fig-Unevenness of the
chest wall after lipo excision [done elsewhere]
The rare but serious complications reported are-fat embolism after
liposuction, perforation with pneumothorax.
6. When can he start
exercises?
Patient can start exercises after 2-3 weeks.
7. Gynaecomastia surgery
is covered under insurance or not?
Gynaecomastia comes under cosmetic surgery, hence not
covered under insurance.
8. Any stitches will be
there?
Most of the time dissolvable stitches will be put, no need
to come for the stitch removal, no pain of stitch removal.
9. Any need for
relatives/parents/friends to come on the day of surgery?
If the person’s age is more than 18 years, no need
10. Any need for follow
up/precautions required?
If the person is having scarring tendency, he may require anti scar
treatment.
11. How the scar is going
to look after the surgery?
Fig-Scar after the
lipoexcision/almost merge with normal skin color/but never disappears.
12. Whether the surgery will
affect future sex life?
No.
13. What is about the
confidentiality?
We will respect patient’s privacy and confidentiality.
14. What is the
experience of the surgeon/how often he does this surgery?
The
surgeon is duly qualified cosmetic plastic surgeon/member of national,
international society of cosmetic & plastic surgery. This
surgery
will be done very frequently.
Apollo hospital is JCI accredited
international hospital, known for international standards for quality,
carefully chosen doctors, safety standards, latest equipments.
15. Why Apollo/Dr Naveen
Rao?
We
offer everything under one roof i.e. lipolysis/liposuction/open
surgery/endoscopic assisted method using latest machines/technological
advances.
The person can sit in operation table under anesthesia;
the likely result can be seen on table especially for unevenness/saucer
deformity.
We are using special software/likely result can be seen before hand.
We also offer single hole liposuction.
We will offer revision/complication correction/scar treatment.
Fig- Newspaper article on
the topic of gynecomastia written by Dr. Naveen Rao
