What is the step-by-step guide for Webster surgery in patients with severe gynecomastia (male breast tissue enlargement)?

Webster Surgery for Gynecomastia: Step-by-Step Guide

For patients with severe gynecomastia, Webster surgery with periareolar incision is the recommended surgical approach, providing effective removal of glandular tissue while minimizing visible scarring. 1, 2

Gynecomastia Grading System

Understanding the severity of gynecomastia is essential for selecting the appropriate surgical technique:

• Grade I: Minor enlargement, no skin excess
• Grade II: Moderate enlargement, no skin excess
• Grade III: Moderate to severe enlargement with skin excess
• Grade IV: Severe enlargement with marked skin excess and ptosis

Webster surgery is particularly suitable for Grade I and II gynecomastia, while more severe cases (Grade III-IV) may require additional skin reduction techniques 3.

Preoperative Assessment

• Confirm true gynecomastia (glandular tissue enlargement) versus pseudogynecomastia (fatty tissue deposition) 1
• Evaluate skin quality, elasticity, and degree of ptosis
• Assess nipple-areolar complex position and size
• Rule out underlying causes (medications, hormonal imbalances, etc.)
• Mark surgical boundaries while patient is standing

Webster Surgery: Step-by-Step Technique

1. Anesthesia and Positioning

   • Position patient supine with arms slightly abducted
   • Administer general anesthesia or local anesthesia with sedation

2. Incision Planning

   • Mark semicircular incision along inferior border of areola (following Webster's technique)
   • Typically 3-5 cm in length, depending on the amount of tissue to be removed 2

3. Incision and Access

   • Make incision along the inferior areolar border
   • Develop a plane between subcutaneous fat and breast tissue
   • Create a skin flap extending to the clavicle superiorly, sternum medially, anterior axillary line laterally, and inframammary fold inferiorly

4. Glandular Tissue Removal

   • Identify and separate glandular tissue from overlying skin and underlying pectoralis fascia
   • Carefully dissect the glandular tissue, preserving the subareolar tissue pedicle (3-5mm thickness) to maintain nipple viability
   • Remove the breast tissue en bloc or in segments
   • Ensure symmetric removal between both sides

5. Hemostasis

   • Achieve meticulous hemostasis using electrocautery
   • Irrigate the surgical field with antibiotic solution

6. Contouring

   • Assess breast contour with patient in semi-sitting position
   • Perform additional tissue removal or liposuction as needed for optimal contour
   • For cases with predominant fatty component, consider combining with liposuction 4

7. Drain Placement

   • Place small closed-suction drain through separate stab incision (optional)
   • Higher rates of hematoma/seroma have been reported with drain placement in more severe cases 3

8. Closure

   • Close deep layer with absorbable sutures
   • Close skin with subcuticular absorbable sutures
   • Apply sterile dressings and compression garment

Postoperative Care

• Maintain compression garment for 3-6 weeks
• Remove drain when output <30 mL/24 hours (if placed)
• Limit upper body activities for 2-3 weeks
• Monitor for complications: hematoma (5.8%), seroma (2.4%), infection, nipple necrosis 3

Modifications for Severe Gynecomastia

For Grade III-IV gynecomastia with significant skin excess:

• Consider concentric circle technique (Schrudde method) 2
• For extreme cases, breast amputation with free nipple grafting may be necessary 4
• Combined approaches using both excision and liposuction are often optimal 1, 4

Common Pitfalls and Avoidance Strategies

• Over-resection: Preserve 3-5mm of subareolar tissue to prevent nipple inversion or flattening
• Under-resection: Ensure complete removal of peripheral breast tissue to prevent recurrence
• Contour irregularities: Feather edges of dissection and consider liposuction for smooth transitions
• Asymmetry: Compare sides frequently during surgery and make adjustments accordingly
• Hematoma: Achieve meticulous hemostasis before closure

The American Society of Plastic Surgeons notes that surgical options should be tailored based on the predominant tissue component, with liposuction for fatty tissue and direct excision (Webster technique) for glandular predominance 1.