What is the recommended approach to identify the correct plane in gynecomastia surgery?

Identifying the Correct Plane in Gynecomastia Surgery

The correct plane for gynecomastia surgery should be identified by dissecting until the glandular tissue is reached, which typically has a distinctive head, body, and tail configuration located immediately deep to the nipple-areolar complex. 1

Anatomical Understanding

Understanding the anatomy of gynecomastia tissue is crucial for successful surgical outcomes:

• The glandular tissue has a characteristic shape consisting of:
  • Head: Semicircular and located medially toward the sternum
  • Body: Main portion located directly beneath the nipple-areolar complex
  • Tail: Tapers laterally toward the insertion of the pectoralis major muscle 1

Surgical Approach

Incision Placement

• Make the incision at the inferior border of the areola or in the submammary fold to ensure adequate exposure while minimizing visible scarring
• Avoid tunneling and place the skin incision as close to the lesion as possible for best cosmetic results 2

Dissection Technique

1. Dissect through subcutaneous tissue until reaching the glandular tissue
2. Preserve the subcutaneous tissue with separate closure to improve cosmetic results 2
3. Identify the glandular tissue by its firmer consistency compared to surrounding fat
4. Follow the natural contours of the glandular tissue (head, body, and tail) to ensure complete removal 1

Combined Approach

A combined approach of liposuction and direct excision yields the best results:

1. First, perform liposuction to remove fatty tissue and better define the glandular component
2. Then, perform sharp excision of the remaining glandular tissue through the same incision 3

Important Considerations

Avoiding Common Pitfalls

• Liposuction alone is insufficient for treating true gynecomastia, with recurrence rates of up to 35% when used as the sole treatment 3
• Combined liposuction and glandular excision reduces recurrence rates to under 10% 3
• Meticulous hemostasis is critical to prevent hematoma formation, which can lead to difficult-to-interpret changes and poor cosmetic results 2

Tissue Management

• Excise the primary lesion with a rim of grossly normal tissue, avoiding excessive sacrifice of breast tissue 2
• A superior cosmetic effect is usually achieved when the breast tissue is not reapproximated, as reapproximation that appears adequate with the patient supine often results in distortion when the patient is upright 2
• Avoid drains in the breast when possible 2

Surgical Planning Based on Severity

For optimal outcomes, tailor the surgical approach based on the grade of gynecomastia:

• Grade I-II (mild to moderate): Liposuction combined with glandular excision through minimal incisions
• Grade III (moderate with skin redundancy): Consider periareolar skin removal
• Grade IV (marked ptosis): May require reduction mammoplasty techniques 4

By following these guidelines and understanding the unique anatomy of gynecomastia tissue, surgeons can achieve thorough gland removal with minimal scarring and optimal cosmetic results.