What are the steps involved in gynaecomastia surgery?

Gynecomastia Surgery: Step-by-Step Procedure

Gynecomastia surgery typically involves liposuction combined with direct glandular excision through a periareolar incision, with additional techniques such as nipple-areola complex lifting used when skin redundancy is present. 1, 2

Pre-Surgical Assessment

• Determine the composition of gynecomastia:

  • Glandular tissue predominance
  • Fatty tissue predominance (pseudogynecomastia)
  • Mixed presentation

• Classify the grade of gynecomastia to guide surgical approach

• Evaluate skin elasticity and redundancy

• Obtain appropriate imaging if clinically indicated

• Consider pathologic diagnosis through fine needle aspiration or core biopsy in suspicious cases

Surgical Techniques

1. Liposuction Technique

• Indications: Predominantly fatty gynecomastia (pseudogynecomastia) 3

• Procedure steps:

  • Administer appropriate anesthesia
  • Make small incisions (typically in the inframammary fold or periareolar region)
  • Insert cannula and perform suction to remove fatty tissue
  • Ensure symmetry between both sides
  • Close incisions with minimal scarring

• Advantages:

  • Minimal scarring
  • Shorter recovery time
  • Lower complication rates
  • Superior aesthetic results 3

2. Direct Excision (Mastectomy) Technique

• Indications: Predominantly glandular tissue 3, 4

• Procedure steps:

  • Administer appropriate anesthesia
  • Create periareolar incision (following the lower half of the areolar border)
  • Elevate skin flaps to expose breast tissue
  • Excise glandular tissue completely while preserving appropriate contour
  • Ensure hemostasis
  • Close in layers with attention to aesthetic outcome

• Advantages:

  • Complete removal of glandular tissue
  • Allows for histopathological examination
  • Better for dense fibrous tissue that cannot be removed by liposuction 3

3. Combined Approach (Most Common)

• Indications: Mixed fatty and glandular tissue 1, 2
• Procedure steps:
  • Perform liposuction first to remove fatty component and improve access
  • Follow with direct excision of glandular tissue through periareolar incision
  • Ensure smooth contour and symmetry
  • Close incisions with attention to aesthetic outcome

4. Nipple-Areola Complex (NAC) Lifting Technique

• Indications: Cases with skin redundancy after tissue removal 2
• Procedure steps:
  • Complete the liposuction and glandular excision
  • Apply specialized plaster technique to reposition the nipple-areola complex
  • Avoid additional skin excision and associated scarring

Post-Surgical Management

• Apply compression garment for 4-6 weeks to reduce swelling and support healing

• Monitor for common complications:

  • Seroma (most common complication) 2
  • Hematoma
  • Infection
  • Contour irregularities
  • Nipple/areola sensory changes
  • Skin necrosis (rare)

• Schedule follow-up visits to assess results and manage any complications

Important Considerations

• The surgical approach should be tailored based on the composition of the breast enlargement (glandular vs. fatty) 1, 3
• Complete gland removal is essential to prevent recurrence when glandular tissue is present 2
• Modern techniques focus on minimizing scarring while achieving optimal contour
• Patient satisfaction rates are high with combined approaches that address both fatty and glandular components 2

Potential Complications

• Seroma formation (most common) 2
• Superficial skin necrosis
• Contour irregularities
• Asymmetry requiring revision
• Hematoma
• Infection
• Nipple/areola sensory changes
• Reoperation rates range from 0.5% (liposuction) to 1.4% (mastectomy) 3

The combined approach of liposuction with complete glandular excision has become the standard of care for most gynecomastia cases, providing superior aesthetic outcomes with manageable complication rates 1, 2.