Keywords
gynecomastia - power-assisted liposuction - ultrasound-assisted liposuction - pull-through
technique - surgical outcomes
Introduction
Gynecomastia, derived from the Greek words gynos (woman) and mastia (breast), is a benign condition characterized by increased glandular and fatty tissue
in the male chest.[1] Its incidence ranges from 4 to 69% in adolescents, with 36% persisting into adulthood.[2] This condition can lead to significant psychological concerns, including anxiety,
social phobias, and depression.[3] Common causes include increased estrogen levels, decreased androgen levels, and
idiopathic factors.[1]
[4] In adult males with long-standing gynecomastia, medical treatments are often ineffective,
leading to surgery as the preferred option due to the fibrous nature of the tissue.[4]
[5]
The surgical goal is to achieve a flat, contoured chest with minimal visible scars,
enhancing patient confidence with or without clothing. Early techniques involved surgical
excision of fat and gland, often leaving scars. One of the reasons for patients coming
for gynecomastia surgery is they avoid going bare chest for swimming/beach vacation.
If there are visible scars on the front of the chest after surgery, then complete
rehabilitation of the patient is not achieved.
In 1983, Teimourian and Perlman introduced liposuction for gynecomastia, yet incisions
near the nipple areola complex (NAC) were still necessary, leading to complications
such as visible scarring and altered sensation.[5] Morselli later introduced the “pull-through” technique with two small incisions,
but it struggled with the removal of dense glandular tissue.[4] Subsequent advancements like ultrasound-assisted liposuction (UAL) and power-assisted
liposuction (PAL) improved outcomes.[6]
[7]
[8]
This article presents a refined technique combining PAL and UAL for effective removal
of dense fibroglandular tissue through a single small incision, strategically placed
on the lateral chest wall. This approach minimizes visible scarring by employing liposuction
(using the SAFE [separation, aspiration, and fat equalization] technique)[9] and the pull-through method for gland removal,[10] via a single lateral incision. Simon's classification for gynecomastia was used,
with grades I, IIa, and IIb treated effectively using this technique.[6]
Materials and Methods
This retrospective cohort study included 967 patients treated consecutively between
January 2022 and December 2023. The study was a multicentric study conducted across
multiple centers in New Delhi, Gurugram, and Mumbai, India. Approved by the GeneBandhu:
Independent Ethics Committee (Ref- ECG031/2024), the study excluded cases of pseudo-gynecomastia
and grade III gynecomastia.
Preoperatively, patients were marked in a standing position to delineate areas for
liposuction and incision sites. Standardized preoperative photographs were taken.
All surgeries were performed as daycare procedures under general or local anesthesia
with sedation, based on patient preference. Patients were positioned supine with the
arms abducted.
The procedure comprised five steps:
-
Infiltration and separation: Infiltration was performed with a 4-mm basket cannula connected to a power-assisted
device through an infiltration pump, delivering a solution of 1-L normal saline, 10 mL
of 2% lignocaine, and 1 mL of epinephrine (1:1,000). Approximately 300 to 800 mL of
fluid was infiltrated per side, facilitating the breakdown of dense fibroglandular
adhesions. The role of infiltration is to facilitate the breakdown of fibrous-glandular
adhesions. During infiltration, a power-assisted system with a basket cannula is used,
which simultaneously aids in breaking these adhesions.
-
Fat emulsification with Vibration Amplification of Sound Energy at Resonance (VASER): VASER was utilized to emulsify fat in superficial and deep planes, aiding in gland
loosening for the pull-through technique and promoting skin contraction. Apart from
this, UAL also creates an air brush effect at the tip of the probe. This reduces the
need for cross-tunneling.
-
PAL: PAL was performed with straight and curved 4-mm basket cannulas through a single
lateral chest wall incision. In tougher fibrous cases, 5-mm cannulas were used. The
average aspirated fat volume per side ranged from 350 to 950 mL. The 4-mm basket cannula
(with a basket area diameter of approximately 6–7 mm) is introduced through a 4-mm
incision by angling the cannula and sliding it inside the incision. The incision does
not need to be larger than the flared dimension of the cannula.
-
Gland excision (pull-through technique): Glandular tissue was removed using Allis forceps through the lateral incision, ensuring
precision. In the cases where gland tissue resisted removal, small sections were removed
piecemeal, excising with a no. 11 blade through the same lateral incision only. The
no. 11 blade is not introduced into the 4-mm incision. Instead, the gland is pulled
out using a pair of Allis forceps, and if necessary, it is gradually incised under
direct vision.
-
Fat equalization: Fat equalization was performed using a 4-mm basket cannula to smooth out irregularities.
The incision was typically closed with a single 5–0 Ethilon suture, and a closed suction
drain was applied in cases of significant lipoaspirate. The drain is placed through
the same incision using a 16/18 drain in selected cases. It is fixed with a suture
and removed once the drainage reduces to less than 25 mL/d. The maximum duration for
drain placement is 48 hours.
The data collected included patient demographics, gynecomastia grade, and postoperative
outcomes such as complications, satisfaction, and cosmetic results. Follow-ups were
conducted at 48 hours, 1 week, 3 weeks, 6 weeks, and 6 months.
Results
Of the 967 patients studied, all presented with bilateral gynecomastia and the mean
age was 26.3 years (range: 12–55 years). Most patients (95%) were aged 18 to 35 years,
with psychological distress commonly driving the decision for surgery ([Table 1]).
Table 1
Demographic profile
|
Parameters
|
No. of patients (n = 967)
|
Percent
|
|
Age group (y)
|
|
12–17
|
11
|
1.1
|
|
18–30
|
725
|
75.0
|
|
31–40
|
216
|
22.3
|
|
41–50
|
12
|
1.2
|
|
>50
|
3
|
0.3
|
|
Mean ± SD (range)
|
26.3 ± 5.7 (12–57)
|
Abbreviation: SD, standard deviation.
Most patients had grade IIa (78.2%) gynecomastia, followed by grade IIb (15.4%) and
grade I (6.4%) gynecomastia ([Table 2]).
Table 2
Grade of gynecomastia
|
Grade of gynecomastia
|
No. of patients (n = 967)
|
Percent
|
|
I
|
62
|
6.4
|
|
II
|
756
|
78.2
|
|
III
|
149
|
15.4
|
Note: Simon's classification of gynecomastia.
Almost all patients (99.3%) underwent liposuction with gland removal (UAL + PAL).
Only seven patients (0.7%) required additional periareolar gland excision due to dense
tissue ([Table 3]).
Table 3
Type of surgery
|
Type of surgery
|
No. of patients (n = 967)
|
Percent
|
|
Liposuction (UAL + PAL) + gland removal
|
960
|
99.3
|
|
Liposuction (UAL + PAL) + periareolar gland excision
|
7
|
0.7
|
Abbreviations: PAL, power-assisted liposuction; UAL, ultrasound-assisted liposuction.
Fluid infiltration during surgery ranged from 300 to 800 mL (average: 450 mL), fat
aspiration from 350 to 950 mL (mean: 549 mL), and gland resection from 20 to 125 g
(average: 56 g). Surgery duration averaged between 45 and 90 minutes.
Complications included seroma in 0.8%, crater formation in 0.5%, and hematoma in 0.2%.
No cases of NAC necrosis, infection, or dehiscence were reported ([Table 4]). Patients were highly satisfied at the 2-week follow-up (93.3% were highly satisfied);
96.7% reported excellent breast contour, 97.1% reported excellent scar quality, and
96.3% reported no significant discomfort or pain ([Table 5]). [Figs. 1] and [2] represent the side and front views of patients who underwent gynecomastia surgery.
[Fig. 3] shows a close-up view of the scar 6 months postsurgery. Follow-ups revealed that
only seven patients (<1%) required a periareolar incision due to dense tissue, particularly
in those with a history of anabolic steroid use ( [Figs. 4]
[5]
[6]
[7]).
Table 4
Postoperative complications reported
|
Complications
|
No. of patients (n = 967)
|
Percent
|
|
Seroma
|
8
|
0.8
|
|
Hematoma
|
2
|
0.2
|
|
NAC necrosis
|
0
|
0.0
|
|
Induration
|
39
|
4.0
|
|
Crater/saucer deformity
|
5
|
0.5
|
Abbreviation: NAC, nipple areola complex.
Table 5
Quality of surgical outcomes (shape, scar quality, and pain)
|
Quality of surgical outcomes
|
No. of patients (n = 967)
|
Percent
|
|
Shape
|
|
Excellent
|
935
|
96.7
|
|
Good
|
32
|
3.3
|
|
Fair
|
0
|
0.0
|
|
Poor
|
0
|
0.0
|
|
Scar quality
|
|
Excellent
|
939
|
97.1
|
|
Good
|
28
|
2.9
|
|
Fair
|
0
|
0.0
|
|
Poor
|
0
|
0.0
|
|
Discomfort: pain
|
|
No
|
931
|
96.3
|
|
No response
|
36
|
3.7
|
Fig. 1 Before and after pictures a 32-year-old patient with grade II gynecomastia with 375 mL
of lipoaspirate on each side.
Fig. 2 Before and after pictures of a 22-year-old patient with grade II gynecomastia with
250 mL of lipoaspirate on each side.
Fig. 3 Before and after pictures of a 26-year-old patient with grade II gynecomastia with
335 mL of lipoaspirate on each side.
Fig. 4 Before and after pictures of a 29-year-old patient with grade II gynecomastia with
300 mL of lipoaspirate on each side.
Fig. 5 Before and after pictures of a 38-year-old patient with grade III gynecomastia with
750 mL of lipoaspirate on each side.
Fig. 6 Before after pictures of a 42-year-old patient with grade III gynecomastia with 585 mL
of lipoaspirate on each side.
Fig. 7 Close-up view of scar 6 months postsurgery.
Minor complications included mild induration in 4% of patients, treated with triamcinolone
acetonide injections. Saucer deformity occurred in 0.5% of cases, with one requiring
fat grafting. Seromas developed in 0.8 of patients with grade IIb gynecomastia, resolving
with conservative management. Importantly, no hematoma, NAC necrosis, or infections
were noted, reinforcing the approach's safety. Mild bruising resolved within 3 weeks.
Discussion
Gynecomastia surgery has undergone significant evolution over recent years, with particular
focus on optimizing patient outcomes and minimizing visible scarring. Early gynecomastia
surgeries primarily involved the removal of glandular tissue via submammary or periareolar
incisions, often resulting in visible scarring. However, the introduction of the pull-through
technique by Morselli[11] represented a breakthrough in minimizing scarring while effectively excising glandular
tissue. This technique, aimed at providing better aesthetic results, has now been
integrated with advanced liposuction modalities to further enhance the outcomes of
gynecomastia correction.
A notable advancement in liposuction technology has been the development of UAL and
PAL. The application of UAL in gynecomastia treatment has been shown to improve the
precision of fat removal while promoting skin retraction.[2] Studies have demonstrated that UAL promotes tighter skin, especially in patients
with higher-grade gynecomastia or significant fatty tissue.[6] Similarly, PAL provides a more efficient method for fat removal, reducing the risks
of irregular contouring, and enhancing overall results.[5]
[7] These technologies have become essential tools in gynecomastia correction, allowing
for improved outcomes, especially in complex cases where both glandular and fatty
tissues must be addressed simultaneously.[2]
[8]
Moreover, combining the pull-through technique with UAL and PAL has proven to be highly
effective in achieving optimal chest contour, providing both glandular excision and
fat reduction with minimal scarring.[5]
[6] UAL, with its skin-tightening properties, has been particularly advantageous in
patients with significant skin redundancy, as it aids in the retraction of skin postsurgery.[9] This synergy between liposuction and gland excision offers enhanced results, resulting
in a more masculine chest contour and reducing visible signs of surgery, which is
a critical factor in patient satisfaction.[2]
[6]
However, despite the advantages, there are certain limitations associated with this
combined approach. As highlighted by Sattler and Gout,[12] the learning curve for using these advanced liposuction technologies is steep, and
surgeons unfamiliar with these tools may experience longer operative times during
their initial stages of adoption. Additionally, some patients with excessive glandular
tissue or significant skin laxity may require additional incisions, such as a periareolar
incision, to achieve the desired outcome.[3] For patients with more severe cases, staged procedures may be necessary to allow
natural skin retraction, as outlined by Morselli and Morellini,[13] who observed that such approaches have been particularly effective in treating high-grade
gynecomastia with significant skin redundancy.
Despite these challenges, the combined approach has significantly reduced complications,
such as hematomas, infections, and contour irregularities. A multicenter review by
Lista et al[14] highlighted that using PAL and the pull-through technique together has minimized
the incidence of hematomas and wound dehiscence, contributing to faster recovery and
lower revision rates. Moreover, these methods have helped achieve a smoother chest
contour, which is essential for both aesthetic outcomes and patient satisfaction.[7]
In the cases where the tissue is dense or fibrous, such as in patients with more severe
forms of gynecomastia, there may be challenges in complete tissue removal through
the small lateral incision. However, combining UAL with the pull-through technique
has been shown to enhance tissue removal efficiency in such cases as well.[6] In addition, emerging technologies like radiofrequency-assisted lipolysis may complement
UAL in achieving more uniform results in patients with less elastic skin.[5]
Another important aspect of modern gynecomastia surgery is the consideration of the
psychological impact on patients. Studies have consistently shown that improved chest
contour can significantly enhance a patient's quality of life by reducing body image
concerns and increasing confidence.[9] Patients who undergo successful surgery report high levels of satisfaction, especially
when the aesthetic results align with their expectations of a more masculine chest.[2] Furthermore, as noted by Hidalgo and Elliot,[15] the evolving paradigm of gynecomastia management focuses not only on physical correction
but also on improving patient experience, which has been a key component of this advanced
approach to surgery.
Several patients after traditional periareolar approach though still remain conscious
of their scars (being on the front of the chest) when they are bare chested. This
precludes their complete rehabilitation in social life and patients still avoid going
for swimming or on beach vacation. The OCCULT technique of gynecomastia also solves
this issue, ensuring that the scar is out of sight on the lateral chest wall and not
on the front of the chest, making patients acceptability and satisfaction higher after
this surgical technique. In fact, the location of scar is such that bilateral scars
can never be visible together to anyone else from any view. Hence, this also avoids
any social stigma later on for the patient and there is no visible sign of having
gynecomastia surgery in their past.
Although challenges such as skin management and steep learning curve remain, the integration
of UAL, PAL, and the pull-through technique represents a significant leap forward
in the treatment of gynecomastia. As the field continues to advance, the incorporation
of 3D imaging for preoperative planning and precision, as well as the exploration
of additional complementary technologies, may further optimize outcomes in future
practices.[14]
The OCCULT technique, a combination of minimally invasive techniques such as PAL,
UAL, and the pull-through method for gland excision, provides exceptional results
in the treatment of gynecomastia. These techniques have led to a reduction in complications,
enhanced patient satisfaction, and a more refined aesthetic outcome. As research in
this field progresses, we can anticipate further innovations that will continue to
improve the safety, efficacy, and overall patient experience of gynecomastia correction.[16]
Conclusion
This innovative technique combines PAL, UAL, and a lateral pull-through approach to
enhance the safety and effectiveness of gynecomastia surgery. With minimal scarring
and superior cosmetic outcomes, it is a versatile, reproducible method that has been
proven to be safe across a large patient population.
