madman
Super Moderator
With this article [1] the authors fill a gap in the scientific landscape regarding gynecomastias and their treatment. In medicine, it is always desirable to have a complete and rigorous classification of each pathology, which should possibly be correlated precisely with the most effective specific treatment. Although other authors have previously proposed similar analyses, this article undoubtedly offers the most detailed description of the different types of gynecomastia to date. Each type is correctly linked with a reasoned and elaborated therapeutic approach on the basis of a vast experience. In fact, the number of cases referred to by the authors (522 in about 12 years) is truly impressive for this particular operation, which is normally not among the most common ones in any plastic surgeon’s practice. Four main groups of gynecomastia are identified, in turn, divided into subgroups. This classification is based on several characteristics of hypertrophic male breasts, such as their size and skin quality. But the overall physical structure of the patient is also taken into consideration, including parameters such as BMI and muscle trophism, as well as the mobility, shape, and position of the breasts. The doubt often faced by the surgeon dealing with this type of surgery concerns the choice of the technique based on tissue quality. As the authors state, small glandular hypertrophy in a ‘‘bodybuilder’’ with optimal tissue tone can be easily resolved by removing the overabundant gland through a Hemi-periareolar incision and completing the surgery with a subcutaneous dissection in order to redistribute the skin, as it was originally described by Morselli P by the ‘‘pullthrough’’ technique [2–4]. Conversely, at the opposite end, important glandular hyperplasia with thick subcutaneous fat pad and inelastic skin must be corrected not only by removing the glandular excess but also by adding liposuction and excess skin removal. The main problem is precisely the technique to be used to remove excess skin when necessary. The authors rightly recommend trying to resort to procedures that limit the residual scar to the periareolar (round-block). Moreover, they suggest using these techniques only when it is strictly necessary since the tension between the edges of the wound, despite the Goretex purse-string suture, could still cause an enlargement of the scar or of the areola itself. To eliminate significant amounts of excess skin, they also suggest first considering the use of an ‘‘extreme’’ round-block, postponing by a few months the grafting of the NAC, temporarily preserved in the groin fold. In some particularly severe cases (in their classification group III b), the authors admit that they had to use a classic breast reduction technique with vertical or inverted T scar. We have some doubts on this point since in our opinion even in severe hyperplasia in ‘‘overweight patients in which the amount of breast tissue was greater than 240 g and inelastic sagging skin was present’’ it is advisable to try to avoid the vertical scar, which in men (who obviously do not use bras) is almost always clearly visible (Fig. 1a, b). We believe that, as far as possible, it is advisable to carry out the skin resection by means of two convergent transverse incisions, which leave one scar only, better if along the lower edge of the pectoralis muscle. This approach, which in our opinion should also be used in post-bariatric patients, makes this scar longer than the one obtained by adding a vertical segment, but in most cases, it will still be less evident (Fig. 2a, b, and c). A very important concept, introduced for the first time by this article, concerns the possibility that breasts affected by gynecomastia, besides showing the classic glandular hyperplasia, also take on a tuberous shape. In fact, although rarely, it is possible that even in the hypertrophic male breast a very defined infra-mammary groove, positioned too high and close to the areola, may worsen the situation. More frequently, in these cases, the predominant defect is the herniation of the glandular tissue through the areola, which usually tends to widen. The authors describe this situation in great detail and insist on the need to eliminate the typical too narrow footprint of this type of breast, which often does not change even by scoring the constricting ring. For this purpose, they propose two different techniques. One can first perform a large subcutaneous dissection, separating the gland from the overlying skin (NAC included). Then, the mammary gland is divided into two parts with a transverse incision perpendicular to the thoracic plane (not vertical as described in the text). The lower part of the gland is removed, whereas the upper portion is transposed caudally to smoothen out the old infra-mammary groove and better define the lower edge of the pectoralis muscle. The second procedure described for treating tuberous gynecomastia refers to the so-called unfurling technique, described for the first time by C. Gasperoni [5, 6]. It involves detaching the gland from the pectoralis muscle and then obtaining a flap from its posterior portion, which is folded down and used as in the previous technique. The authors recommend using this second option in particular to exploit its telescopic effect in correcting herniations of the gland through the areola. In our opinion, both techniques can contribute significantly to the correction of any male tuberous breast. Regarding the scarce complications of this type of operation, the authors report a modest number of seromas and hematomas, mentioning the possible preventive use of transcutaneous quilting sutures, already described in detail by Auerswald initially for the facelift and then for every area in which a large subcutaneous dissection is performed [7]. As the authors point out, the correction of gynecomastia has an almost zero incidence of recurrence, provided that the hypertrophic gland has been correctly remodeled. Conversely, in most cosmetic surgeries, such as facelift, blepharoplasty, and female mammaplasty, a relapse is expected over time. In its almost total absence of relapses, this surgery is similar to very few others, such as for example, otoplasty. The article highlights how the reasons that lead patients to request the correction of gynecomastia are different depending on the structure of their bodies. In fact, a ‘‘bodybuilder’’ will be disturbed even by minor gynecomastia, sometimes consisting of minimal glandular hyperplasia, which, however, can represent a problem for achieving the pursued perfect shape of the pectoral area. Conversely, a man with a less athletic body, but with hypertrophic breasts, usually requires surgery to avoid the embarrassment of having a feminine appearance. We would like to conclude this commentary by reminding that, although the authors’ indications on the most appropriate technique for treating the various types of gynecomastia are didactically flawless, sometimes the tissues do not react to surgery as one would expect. As a demonstration of this, see Fig. 3a–d in which we can observe the dissatisfactory result of a gynecomastia surgical treatment performed by a competent surgeon, who, however, evidently had not adequately evaluated the possibilities of retraction and adaptation of the skin. When the patient then came to us for correction, we convinced him that a transverse resection was necessary. We explained to him (as we always do in these cases) that, if on the one hand, the scar would have been a bit more extended, on the other, it would have probably been less noticeable. In conclusion, the authors are truly to be complimented on the careful and detailed analysis of a problem that in recent years plastic surgeons have been facing more and more often. Perhaps it would be worthwhile investigating in more detail the reasons behind the increase in gynecomastia, probably also linked to the presence of hormones in food and the intake of hormones to increase muscle mass. But this has little to do with surgery.
