Gynecomastia

Sir: Gynecomastia continues to challenge plastic surgeons. Nahabedian reviews the breast deformities to provide a better understanding of the current available data. The state of the art is centered on gland and fat removal by liposuction and its derivatives.1,2 We suggest that it is important to keep in mind the reconstruction of an athletic appearance to obtain a virile chest, with the trapezoidal shape (larger side on the top), the nipple-areola complex adherent to the pectoral muscle, and downward orientation. We propose a new approach that classifies gynecomastia (Table 1) considering the volume excess but also the shape of the chest, and describe here how we treat gynecomastia, including our tips and tricks.Table 1: Classification of GynecomastiaWe evaluate the patient by pinching the fat on the breast with the patient in the standing position. Then, he contracts the muscles to enhance the sternal notch and the pectoral muscle borders that we have drawn. The new inframammary fold is designed close to the areola (0 to 3mm). We perform mastectomy through an areolar single-puncture incision at the 6-o’clock position, excising the gland in strips, which leaves an imperceptible scar3 (grade I to III) (Fig. 1, above) or periareolar subcutaneous mastectomy in grade IV (Fig. 1, below). Any residual gland is removed, avoiding unaesthetic projection of the areola.Fig. 1: Preoperative (left) and postoperative (right) photographs showing (above) grade III and (below) grade IV gynecomastia. (Above) This patient underwent subcutaneous mastectomy by a single puncture incision and two-step liposuction with nipple reorientation (downward) and chest virilization (trapezoidal shape and sternal notch in evidence); contextually, he underwent delineation of the abdominal musculature. (Below) This patient underwent subcutaneous mastectomy by periareolar incision with nipple-areola complex transposition and two-step liposuction with nipple reorientation and chest virilization; contextually, he underwent abdominoplasty.Liposuction is performed in two steps. First, careful liposuction removes the adipose tissue, ensuring skin adhesion to the muscular plane. Second, powerful liposuction is performed with basket/accelerator cannulas at the pectoral borders, and at the sternal notch to emphasize the medial insertions. Residual adipose tissue homogenization by cannula avoids irregularity of the treated areas. Twenty-four patients were recruited for this study. Seven were classified as type 1, 12 were classified as type 2, four were classified as type 3, and one was classified as type 4. Patients themselves evaluated the cosmetic appearance, based on a scale of 1 (excellent) to 4 (unsatisfactory). All patients achieved a major improvement (Fig. 1) and 91.6 percent of the patients evaluated their chest as excellent. Traditional liposuction cannot accomplish the higher aesthetic goals imposed by modern standards of beauty, nor can it create a virile chest if one does not plan to correct the gynoid rounded shape, the nipple malposition and its forward projection, the gynoid inframammary fold, and the absence of midsternal insertions. We perform a liposuction procedure that closes the skin to the muscle and sculpts the borders of the pectoralis muscle, creating an obtuse angle (between the axilla pillar and the new inframammary fold) that emphasizes the trapezoidal shape (see Video, Supplemental Digital Content 1, which shows an intraoperative view of selective liposuction, http://links.lww.com/PRS/A722) and a new inframammary fold near the areola to redefine nipple downward oriented.Video: Supplemental Digital Content 1 shows an intraoperative view of selective liposuction, http://links.lww.com/PRS/A722.Mentz et al. first design the pectoral etching for the delineation of the thoracic musculature in men without gynecomastia that desire an athletic appearance or for body builders.4 These authors state that to augment muscle bulk appearance, fat over the pectoralis muscle may be two to three times thicker than the etched perimeters. We reduce fat over the muscle at the minimum closing the skin to the muscle and avoiding nipple and upper pole projection. We believe that a sculpted thorax should resemble not “a three-dimensional Roman breast-plate”4 but the “warrior who wore it” like the classical male breast sculptures. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Cristiano Monarca, M.D., Ph.D. Maria Ida Rizzo, M.D. Sapienza University of Rome Rome, Italy