Comparative Study Between Different Surgical Modalities in Management of Severe Grades of Gynecomastia.

Gynecomastia is defined as a benign enlargement of the mammary glands, commonly diffused among men. The prevalence of gynecomastia ranges from 38 to 64 percent in the male population.

Gynecomastia can affect normal self-esteem and sexual identity and often patients feel ashamed of their bodies during normal social activities.

The surgical management of the high-grade gynecomastia Simon's grade III or Rohrich's grade IV has remained problematic because both liposuction and conventional subcutaneous mastectomy without skin excision have frequently resulted in significant residual skin redundancy, requiring a second operation for skin resection.

Two Classification Systems of Gynecomastia

Rohrich's Classification I, Minimal breast hypertrophy without ptosis; hypertrophy is either primarily glandular or fibrous II, Moderate breast hypertrophy without ptosis; hypertrophy is either primarily glandular or fibrous III, Severe breast hypertrophy with grade I ptosis glandular or fibrous IV, Severe breast hypertrophy with grade II or III ptosis glandular or fibrous Simon's Classification I, Minor breast enlargement without skin redundancy. IIa, Moderate breast enlargement without skin redundancy IIb, Moderate breast enlargement with minor skin redundancy III, Gross breast enlargement with skin redundancy that simulates a pendulous female breast Smoot stated that this approach for high-grade gynecomastia has several disadvantages. There are difficulties in obtaining precertification from third-party payers for a second operation for skin resection. In addition, the adolescent patient is often very anxious during the ensuring 1 year after the original mastectomy when skin excess is quite apparent and awaiting spontaneous shrinkage.

Currently, there are 4 main different approaches for the management of high-grade gynecomastia:

First is simple mastectomy, which is done with free nipple graft accepting the long transverse scar and the grafted appearance of the nipple areola complex. Second is a modification of breast reduction is done with nipple transposition on a single dermal pedicle or vertical bipedicle. A visible chest scar is also present, but the blood supply of the nipple-areola complex is preserved.

Third is ultrasound assisted liposuction is performed first and after several months, accept that several patients will require a second operation to excise the significant residual skin redundancy. Fourth is a single-stage procedure is done in which sub cutaneous mastectomy and circumareolar skin excision are performed. The purse string skin closure limits the scar to the circumareolar area.

Open excision techniques base their principle on a direct view and management of the gland, through several types of surgical accesses according to the surgeon's preference and entity of the defect. The main advantage of open excision is the direct control of the hemostasis and redundant skin control, with the main disadvantage of permanent scars, whose quality cannot be predicted.

Only Gusenoff et al have proposed a classification with corresponding operative treatment options, whose grades taken into account the laxity of the breast skin and the upper abdomen, the location of the inframammary fold IMF, and the lateral fat role.

Minimal excess skin and fat, minimal alteration of NAC, normal IMF, No lateral skin roll: a Minimal excess skin and fat, minimal alteration of NAC, normal IMF, lateral skin roll: b NAC and IMF below, the ideal IMF, lateral chest roll, minimal upper abdominal laxity: c NAC and IMF below the ideal IMF, lateral chest roll, significant upper abdominal laxity: d