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Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture (2021)
Alfredo E. Hoyos, M.D. Mauricio E. Perez, M.D. Rodrigo Domínguez-Millán, M.D
Background: Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors’ first report of pectoral etching in 2012, patients and surgeons became more aware of gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia.
Methods: The authors reviewed their records on pectoral high-definition liposculpture between January 2005 and October 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years.
Results: Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index.
Conclusion: Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. (Plast. Reconstr. Surg. 147: 1072, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV
The number of patients asking for pectoral enhancement through liposuction has been increasing in recent decades. Some individuals are not even aware of or are ashamed of gynecomastia and would not directly request treatment for it. Gynecomastia is defined as a benign condition of the male because of mammary tissue overgrowth1 and can occur in as many as three of four teenagers2; this is different from pseudogynecomastia, which is basically adipose tissue deposits. Pectoralis muscle development and shape are strongly correlated to male aesthetic standards, which is the reason why its anatomical features and some surgical approaches to achieving such standards have already been described.3 Techniques include fat extraction around and over the pectorals to improve definition, but most of them neither succeed with augmentation for the volume-deficient chest nor solve other problems such as gynecomastia.4 Treatments have been focused on overall resection and/or combination with other procedures5–7 but often lack an aesthetic approach, and results are far from pleasant for most patients. In 2012, we described different biotypes for the male pectoral treatment, including patients with gynecomastia. We also outlined the pectoral anatomical zones, where negative spaces and transition and deep resection zones became the cornerstones for muscular and athletic definition.8 Pectoral inferior pole liposuction plus superior pole lipoinjection was one of the most frequently performed procedures, in some cases with the addition of gynecomastia resection. We have used overlapping techniques of liposuction plus open resection for patients in which fat aspiration is usually not enough. Several techniques (conventional, ultrasonic, power-assisted, or combined) for pectoral fat extraction have been described,9–13 but they usually leave visible scars around the areola, which are a great concern for men who regularly expose their chest (e.g., at the beach, the pool, at home).
ANATOMY AND ARTISTIC ANATOMY
*Surgical Technique Markings
Step 1: Infiltration and Emulsification
Step 2: Liposuction
Step 3: Gynecomastia Resection and Fat Grafting
*Fat Grafting
DISCUSSION
Since our first description of pectoral etching in 2012,8 several authors have reported multiple improvements and citations in their articles.4,13,21 Nevertheless, gynecomastia treatment has been challenging because patients face a substantial concern about aesthetic and unnatural results. The inverted-omega incision has allowed us to decrease the risk of residual breast tissue that will, at some point, relapse.22–25 Moreover, dynamic definition liposculpture was enough for most patients, whereas the pull-through technique was reserved for those with true breast tissue overgrowth (gynecomastia), regardless of whether they were fat or thin. This new approach combines superficial, intermediate, and deep lipoplasty with fat grafting in addition to gynecomastia resection with the aim of reproducing the normal superficial anatomy and improving the athletic definition of the pectoral area, because the first author (A.E.H.) is the creator and developer of the high-definition liposculpture technique with 18 years of experience.18 A long learning curve is required to obtain the results reported in this study; however, the technique is considered easily reproducible and safe.
Although misdiagnosis of gynecomastia has led to undertreatment of the pectoral area and might result in relapse and/or pitfalls,26,27 it is now easier to recognize the breast tissue enlargement that could end up in open resection by following the markings in the preoperative period. As mentioned before, gynecomastia management remains challenging because of its visual results and sometimes residual deformities, which mostly delay surgical decisions and treatments within most patients. Gynecomastia surgical management is sometimes delayed because of anatomical abnormalities and/or previous residual deformities in some patients. The pull-through technique (through an inverted-omega incision) combined with dynamic definition liposculpture and fat grafting has improved outcomes, with high satisfaction among patients. This incision (inverted-omega) is a versatile extension of the initial stealth incision for liposuction that will barely affect the aesthetics and shape of the areola and/or the nipple. Severe gynecomastia patients are not common in our country and are usually rare in private practice. They are usually treated by surgeons affiliated with their health insurance and subsequently out of our patient spectrum. One patient was included in our revision; in this patient, we performed complete axillary fold resection to lift up the entire pectoral skin (Fig. 9) in addition to circumferential abdominoplasty and liposculpture. Further clinical studies must be conducted to evaluate how successful the procedure could be without skin excision in severe gynecomastia presentations.
Fat grafting is also crucial for our results,8, and because the main aesthetic outcome is an athletic chest, the greater the projection and definition of the muscles, the more muscular the appearance. This is achieved not only by intramuscular and subpectoral fat grafting to the upper pole but also because of the definition of the surrounding negative spaces, which allows the eye to appreciate a greater depth of the visual contour and creates a greater sense of projection (artistic anatomy and high-definition liposculpture concepts18). Although implants have been widely used for pectoral enhancement, many patients complain of their fictitious and unnatural appearance.28–30 In contrast, multilayer lipoinjection combined with muscle definition has become the treatment of choice for pectoral augmentation.4,8,31 In our experience, the graft injection in multiple planes has somehow improved its survival, but further focused and comparative studies need to be carried out to support our theory.
CONCLUSIONS
Gynecomastia resection through the invertedomega incision and dynamic definition liposculpture is a safe and reproducible technique for the management of male patients with chest contour defects. Multilayer fat grafting and high-definition liposculpture are fundamental to ensure the natural athletic appearance of the postoperative male chest. Further studies need to be performed to compare fat graft survival and long-lasting results, although our follow-up period included patients with up to 2 years of follow-up with promising results. A high satisfaction index can be reached with this improved technique, although the survey used in this study is not standardized. The inverted-omega incision for breast tissue resection is a new option for those patients in which liposuction or other techniques may not be sufficient for gynecomastia definitive treatment.
Alfredo E. Hoyos, M.D. Mauricio E. Perez, M.D. Rodrigo Domínguez-Millán, M.D
Background: Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors’ first report of pectoral etching in 2012, patients and surgeons became more aware of gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia.
Methods: The authors reviewed their records on pectoral high-definition liposculpture between January 2005 and October 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years.
Results: Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index.
Conclusion: Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. (Plast. Reconstr. Surg. 147: 1072, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV
The number of patients asking for pectoral enhancement through liposuction has been increasing in recent decades. Some individuals are not even aware of or are ashamed of gynecomastia and would not directly request treatment for it. Gynecomastia is defined as a benign condition of the male because of mammary tissue overgrowth1 and can occur in as many as three of four teenagers2; this is different from pseudogynecomastia, which is basically adipose tissue deposits. Pectoralis muscle development and shape are strongly correlated to male aesthetic standards, which is the reason why its anatomical features and some surgical approaches to achieving such standards have already been described.3 Techniques include fat extraction around and over the pectorals to improve definition, but most of them neither succeed with augmentation for the volume-deficient chest nor solve other problems such as gynecomastia.4 Treatments have been focused on overall resection and/or combination with other procedures5–7 but often lack an aesthetic approach, and results are far from pleasant for most patients. In 2012, we described different biotypes for the male pectoral treatment, including patients with gynecomastia. We also outlined the pectoral anatomical zones, where negative spaces and transition and deep resection zones became the cornerstones for muscular and athletic definition.8 Pectoral inferior pole liposuction plus superior pole lipoinjection was one of the most frequently performed procedures, in some cases with the addition of gynecomastia resection. We have used overlapping techniques of liposuction plus open resection for patients in which fat aspiration is usually not enough. Several techniques (conventional, ultrasonic, power-assisted, or combined) for pectoral fat extraction have been described,9–13 but they usually leave visible scars around the areola, which are a great concern for men who regularly expose their chest (e.g., at the beach, the pool, at home).
ANATOMY AND ARTISTIC ANATOMY
*Surgical Technique Markings
Step 1: Infiltration and Emulsification
Step 2: Liposuction
Step 3: Gynecomastia Resection and Fat Grafting
*Fat Grafting
DISCUSSION
Since our first description of pectoral etching in 2012,8 several authors have reported multiple improvements and citations in their articles.4,13,21 Nevertheless, gynecomastia treatment has been challenging because patients face a substantial concern about aesthetic and unnatural results. The inverted-omega incision has allowed us to decrease the risk of residual breast tissue that will, at some point, relapse.22–25 Moreover, dynamic definition liposculpture was enough for most patients, whereas the pull-through technique was reserved for those with true breast tissue overgrowth (gynecomastia), regardless of whether they were fat or thin. This new approach combines superficial, intermediate, and deep lipoplasty with fat grafting in addition to gynecomastia resection with the aim of reproducing the normal superficial anatomy and improving the athletic definition of the pectoral area, because the first author (A.E.H.) is the creator and developer of the high-definition liposculpture technique with 18 years of experience.18 A long learning curve is required to obtain the results reported in this study; however, the technique is considered easily reproducible and safe.
Although misdiagnosis of gynecomastia has led to undertreatment of the pectoral area and might result in relapse and/or pitfalls,26,27 it is now easier to recognize the breast tissue enlargement that could end up in open resection by following the markings in the preoperative period. As mentioned before, gynecomastia management remains challenging because of its visual results and sometimes residual deformities, which mostly delay surgical decisions and treatments within most patients. Gynecomastia surgical management is sometimes delayed because of anatomical abnormalities and/or previous residual deformities in some patients. The pull-through technique (through an inverted-omega incision) combined with dynamic definition liposculpture and fat grafting has improved outcomes, with high satisfaction among patients. This incision (inverted-omega) is a versatile extension of the initial stealth incision for liposuction that will barely affect the aesthetics and shape of the areola and/or the nipple. Severe gynecomastia patients are not common in our country and are usually rare in private practice. They are usually treated by surgeons affiliated with their health insurance and subsequently out of our patient spectrum. One patient was included in our revision; in this patient, we performed complete axillary fold resection to lift up the entire pectoral skin (Fig. 9) in addition to circumferential abdominoplasty and liposculpture. Further clinical studies must be conducted to evaluate how successful the procedure could be without skin excision in severe gynecomastia presentations.
Fat grafting is also crucial for our results,8, and because the main aesthetic outcome is an athletic chest, the greater the projection and definition of the muscles, the more muscular the appearance. This is achieved not only by intramuscular and subpectoral fat grafting to the upper pole but also because of the definition of the surrounding negative spaces, which allows the eye to appreciate a greater depth of the visual contour and creates a greater sense of projection (artistic anatomy and high-definition liposculpture concepts18). Although implants have been widely used for pectoral enhancement, many patients complain of their fictitious and unnatural appearance.28–30 In contrast, multilayer lipoinjection combined with muscle definition has become the treatment of choice for pectoral augmentation.4,8,31 In our experience, the graft injection in multiple planes has somehow improved its survival, but further focused and comparative studies need to be carried out to support our theory.
CONCLUSIONS
Gynecomastia resection through the invertedomega incision and dynamic definition liposculpture is a safe and reproducible technique for the management of male patients with chest contour defects. Multilayer fat grafting and high-definition liposculpture are fundamental to ensure the natural athletic appearance of the postoperative male chest. Further studies need to be performed to compare fat graft survival and long-lasting results, although our follow-up period included patients with up to 2 years of follow-up with promising results. A high satisfaction index can be reached with this improved technique, although the survey used in this study is not standardized. The inverted-omega incision for breast tissue resection is a new option for those patients in which liposuction or other techniques may not be sufficient for gynecomastia definitive treatment.
