Dr. Linder's Blog
Category: Male Plastic Surgery
Gynecomastia has been well-defined as “woman-like breasts” in fact it has been found in as many as 40 to 60 percent of men, and can occur in one or both breasts. Risk factors associated with gynecomastia have included decrease in androgen production or increase in estrogen formation. It can also be associated with hormones such as anabolic steroids or even certain antibiotics, anti-ulcer medications, cancer chemotherapeutic drugs as well as recreational drugs such as marijuana and alcohol.
WHO QUALIFIES FOR THIS?
The best candidates are healthy men who are psychologically stable and have no medical conditions. Obese men should be discouraged from having gynecomastic surgery until they have had sufficient weight loss; they should be as close as possible to their normal baseline. Most risks are minimal and secondary, small revision surgeries can help with these if problems should arise. The risks of gynecomastic surgery may include: bleeding, hematomas, seromas, fluid collection, infections, skin loss, nipple loss, skin necrosis, asymmetry, and dimpling of the nipple areolar complex. We urge our patients who smoke to refrain from smoking for at least 14 days prior to their surgery; this is to reduce the incidence of vascular compromise and bleeding problems. Patients should be cleared prior to surgery by an endocrinologist in order to determine hormonal assay levels of testosterone and estrogen.
TYPES OF GYNECOMASTIA SURGERY
The surgery is performed on an outpatient basis in our Beverly Hills Surgical Center under general anesthesia by a Board Certified Anesthesiologist. Brighton Surgical Center is a State Licensed, Medicare certified, ambulatory facility. Surgical approaches include; Liposuction with direct excision through a periareolar incision (“partial subcutaneous mastectomy with liposuction”) or a direct breast reduction and lift with Wise-pattern-like incisions or anchor scars. The approach is specifically dependent upon the amount of and the stage of gynecomastic tissue that you have.
For mild to moderate forms usually direct liposuction as well as an incision under the areolar and a partial subcutaneous mastectomy can be performed with a fantastic result. It is extremely important that compressive garments be worn after surgery and in most cases we have the patient use a chest upper pole band for four to six weeks after surgery to help you achieve the best result.
Over the past year, I have seen an increase in the procedure gynecomastia. Gynecomastia surgery is a procedure to reduce enlarged male breasts. I believe the stigma for cosmetic surgery for men has disappeared, and men are excited to correct the size and shape of their breasts.
For men who feel self-conscious about their over sized breasts, this procedure can help restore self-confidence and appearance. For more information, contact our office at 310-275-4513 or fill out our online contact form.
Gynecomastia is referred to as male breast reduction. It is associated with glandular tissue and fatty tissue found in the entire chest area. This extends from the infraclavicular, under the clavicle, along the parasternal to the inframammary fold and all the way laterally to the anterior axillary line. There are two different types of tissue that can be found in gynecomastia patients. They include glandular tissue and fibrofatty tissue. The fatty tissue can usually be sculpted around the chest area, while the gynecomastic tissue normally requires direct excision through a periareolar approach.
Our patients are normally placed under general anesthesia and an incision is made underneath the nipple areolar complex from approximately the 5:00 to 7:00 o’clock position. At this time infiltration of tumescent fluid with a Klein needle is performed and liposuctioning with a 3 mm triple lumen Mercedes cannula to 1 atmosphere of vacuum suction pressure is used to sculpt the chest area, again extending along the sternum to the infraclavicular at the anterior axillary line and down to the inframammary fold. A large wedge of tissue is then removed, usually it’s a wafer of tissue in the shape of a football, from the posterior retroareolar region. A platform of glandular tissue is however maintained with the undersurface of the nipple areolar complex to contour and depression deformities.
After removing this large wedge of tissue, it is taken down to the fascia overlying the pectoralis major muscle. Hemostasis is acquired using electrocautery. Deep closure is performed to close the dead space, 2-0 Vicryl sutures and the simple subdermal and simple subcuticular sutures to close the skin.
A simplified technique for removal of a large pannus is described. The case presented involves a 63-year old morbidly obese man (more than 500 pounds) with multiple medical problems. Complications encountered when operating on the morbidly obese because of the sheer size of the patient and the body part to be operated on are briefly discussed.
Two operating tables were necessary to accommodate the patient’s large bulk. Preparation of the skin as well as the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. No injuries were sustained by the surgeons of the operating room staff. Total operative time was 2.5 hours, and there were no intraoperative or postoperative complications. This technique may be used to perform other procedures in the morbidly obese that require elevation of a body part.
A 63-year old morbidly obese male (estimated weight: 515 pounds) was admitted for surgical correction of an enormous pannus. Indications for panniculectomy included mechanical compression of the lower extremity lower venous system, lower abdominal hygiene, and decreased mobility. The patient initially was admitted to the cardiology service with multiple medical problems associated with his morbid obesity including congestive heart failure, artial fibrillation, and marked chronic venous stasis of the lower extremities. On examination, the abdominal pannus and lower legs appeared markedly lymphadematous.
Preoperative medical workup included pulmonary function tests, echocardiogram, and upper and lower gastrointestinal endoscopy for investigation of microcytic anemia. With aggressive preoperative diuresis, a weight loss of 45 pounds was achieved.
Intraoperative monitoring was performed using an arterial line and a Swan-Ganz catheter. Two operating tables were necessary to accommodate the patient’s bulk (Figure 1). Preparation of the skin and the operative procedure were greatly facilitated by using a hydraulic lift to elevate the pannus. With assistance from the biomedical engineering department, two intramedullary rods (1/4-inch stainless steel) were bent into lifting hooks. The “Ruger hoist” included an extension book with variable standing positions (450, 750, and 1000 pounds) determined by its length (Figure 2). In order to gain maximum extension of the boom for positioning at the side of the surgical table, a total weight of 450 pounds could be elevated safely. The hooks were connected by rope to a gamble that was mounted on the hydraulic lift. (Figure 3)
The total operative time was 2.5 hours, and there were no intraoperative complications. Equally important, no injuries occurred to either the operating room staff or the surgeons in association with the physical difficulty of maneuvering a morbidly obese patient intraoperatively. The entire operative specimen weighed 100 pounds. The estimated blood loss was approximately 450cc. The patient received one unit of packed red blood cells and two liters of crystalloid intraoperatively. No further transfusions were required.
There were no postoperative complications. The patient was extubated with removal of a central line on the second postoperative day. Embolic prophylaxis with subcutaneous heparin was administered for five days until ambulation. Unna boots were placed on the lower extremities every three days to aid in the reduction of edema and as a treatment for chronic venous ulcerations. After one week, the patient was transferred to a skilled nursing facility from which he was discharged on postoperative day 13.
The pathophysiology of Panniculus morbidus was described by Petta et all in 19921. A large pannus creates a vicious cycle of lymphatic and venous congestion leading to further ischemia and lymphedema, ultimately resulting in celluitis, abcess formation, and infarction. During surgical dissection it was ecident that this patient has a markedly lymphadematous pannus.
Surgery in the obese patient has been associated with an increased incidence of complications and mortality including deep vein thrombosis, pulmonary embolism, pneumonia, sepsis, and would dehiscence with fat/skin necrosis. Obesity is commonly defined as being more than 20% over the ideal body weight; morbid obesity is defined as being more than twice the ideal body weight. In a review of the literature published in 1985, Hirsch et al2 found a variable, but nonetheless high (20-78%), incidence of complications following surgery in the morbidly obese patient. Abdel-Moneim noted a 2.6% mortality rate from surgery in obese patients.3 According to Foley and Lee,4 the incidence of would infections in morbidly obese patients is as high as 40%, and would dehiscence is ten times more likely to occur in this patient population. Reducing operative time may decrease the incedence of would sepsis, would dehiscence, and hernia formation.
Various techniques have been described to aid in suspension of the pannus. Richard5 described placement of a rigid bar through the pannus to provide suspension and enhance manipulation. Meyerowitz et al6 described the transverse placement of Rush nails for suspension. The skewered Rush nail method has been modified by bending the intramedullary rods into hooks. Sterilized “shark hooks” also could be used easily. Matory (7) et al described a pannus elevation technique using rope suspension with towel clips and Steinmann pins.
The method of suspension used in this case allows complete surgical resection of the pannus without requiring multiple assistants. The hydraulic lift boom was extended to its greatest length to maintain the sterile field. The nurse controlled the manual pump that is used to elevate the pannus on the hoist. Our biomedical engineers recommended using a thicker rod, at least 3/8-inch in diameter, to prevent the bending that was evident with the 1/4 inch rod.
The technique describes for panniculectomy will expedite the operation, reduce blood loss, and optimize the volume and venous return. Visualization of the vessels is easier and hemostasis is more readily accomplished with reduced blood loss. Prevention of injury to the operating room staff and surgeons also is an important consideration.
- Petty P, Mandon PN, Black R, et al: Panniculus morbidus. Ann Plast Surg 28:442-454, 1992.
- Hirsch J, et al: Health implications of obesity: NIH Consensus Development Conference statement. Ann Intern Med 103:1073, 1985.
- Abdel-Moneim RI: The hazards of surgery in the obese. Int Surg 70:101, 1985.
- Foley K, Lee R: Surgical complications of obese patients with endometrial carcinoma. Gynecol Oncol 39:171, 1990.
- Richard EF: A mechanical aid for abdominal panniculectomy. Br J Plast Surg 18:336, 1965.
- Meyerowitz BR, Gruber RP, Laub DR, et al: Massive abdominal panniculectomy. JAMA 225:408, 1973.
- Matory WE, O’Sullivan J, Fudem G, Dunn R: Abdominal surgery in patients with severe morbid obesity. Plasty Reconstr Surg 94:976:987, 1994.
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