Answer:
Gynecomastia is divided into four grades: grade I: small enlargement, no skin excess; grade IIA: moderate enlargement, no skin excess; grade IIB: moderate enlargement with extra skin; and grade III: marked enlargement with extra skin. Grades IIB and III require some skin excision. Letterman and Schuster simplified the classification into three types of gynecomastia based on the required correction: (1) intra-areolar incision with no excess skin; (2) intra-areolar incision with mild skin redundancy corrected with excision of skin through a superior periareolar scar only; and (3) excision of chest skin with or without shifting the nipple.One can reduce the gland through a periareolar incision and perform a skin correction at a later date if necessary.
For surgical planning, there are three classifications of gynecomastia.
Grade I: A localized button of tissue that is concentrated around the areola. These buttons are usually easy to remove; the chest is not fatty, and there is no skin excess.
Grade II: Diffuse gynecomastia on a fatty chest where the edges of the tissue are indistinct. This tissue is difficult to taper. Dishing was common before the addition of suction lipectomy.
Grade III: Diffuse gynecomastia with excessive skin. These patients require external (outside the areola) skin excisions or nipple repositioning, or both.
The selection of local or general anesthesia is a personal preference.
Preoperative markings are performed with the patient in a sitting position, arms at the sides. A felt-tipped pen marks the area to be resected, leaving a button of tissue under the nipple. If liposuction is required at the periphery of the resection, appropriate markings are made to indicate the edge of the surgical excision. Raising the arms for a second marking helps the surgeon define the edges of the gynecomastia.
The incision must be placed at the junction of the areola and skin. If placed in the pigmented area, the scar shows as a white line, especially on a dark areola, and if placed on the skin, a hypertrophic scar may develop. The exact position is not easy to find, especially after the epinephrine is injected; the vasoconstriction coupled with a bright operating room light will wash out the color differentials. One should mark with the light off the field before the vasoconstriction is begun.
The incision is made in the described periareolar area 5 mm to 10 mm deep and the areola-nipple is undermined at this level to leave tissue under the nipple to prevent it from sticking on the chest wall. Note that the nipple normally protrudes slightly from the chest wall so that in thin individuals less tissue is needed under the areola to effect this protrusion. It is always better to leave more tissue beneath the nipple than the surgeon believes is necessary, since it can always be trimmed at the conclusion of the procedure. The chest skin is undermined between the subcutaneous fat and the breast to the extent of the preoperative markings, and tapering is begun with scissors. This plane usually separates easily. All edges of resection must be tapered.
Correction of grade I (localized) gynecomastia is usually a simple surgical procedure. The major problem is leaving enough tissue under the nipple to prevent retraction. The surgical plane is distinct and adequate subcutaneous tissue can be left on the thin skin of the chest wall so that it does not stick down.
Grade II is more difficult and presents several problems. The nipple button may be difficult to leave because much of it is fat rather than fibrous tissue. The plane is more indistinct and waviness of the chest skin can occur after healing. The position of the arms and the direction of the surgical assistant’s retraction must be taken into account as the skin flaps are dissected. Waviness may occur on the fatty chest because of fat necrosis after surgery and may leave a depression in the center or at the edges of the resection. Tapering at the edges is important. A combination of surgical resection and suction lipectomy at the edges gives the best results.
Dissection is easier in the patient with grade III gynecomastia because of the exposure, especially if the nipple is moved at the same time. A headlight or fiberoptic retractor makes it easier to obtain hemostasis. Drains (Penrose or suction) are brought out through the periareolar incision. Bringing drains out through the chest wall skin may leave a hypertrophic scar that is always visible. A pressure dressing helps to get the flaps to adhere and may reduce seroma formation.