Surgical Removal of Gynecomastia
The surgical procedure to remove gynecomastia is called subcutaneous mastectomy, which may be performed alone or combined with liposuction depending on the grade and composition of breast tissue. 1, 2, 3
Terminology and Procedure Names
Subcutaneous mastectomy is the standard term for surgical removal of gynecomastia, involving excision of glandular breast tissue while preserving the nipple-areola complex 1, 4
Liposuction subcutaneous mastectomy refers to the combined approach using both liposuction and direct tissue excision 2
In transgender men undergoing gender-affirming surgery, this procedure is commonly referred to as "top surgery" and typically involves reduction mammoplasty or mastectomy 5
Endoscopic gynecomastia removal is an emerging minimally invasive variant performed through small axillary incisions 6
Procedure Selection Based on Severity
Low-grade gynecomastia (Simon grade I-II):
- Liposuction alone is the preferred treatment for lower grades with minimal glandular tissue 1, 2
- This approach provides effective contouring with minimal scarring and low complication rates 2
High-grade gynecomastia (Simon grade III):
- Subcutaneous mastectomy with concentric circumareolar skin reduction is the standard approach 1
- Single-stage subcutaneous mastectomy with deepithelialization prevents the need for secondary procedures to address skin redundancy 1
- In rare cases of tubular breast deformity or massive weight loss patients, simple mastectomy with free nipple graft may be required 1
Technical Approaches
Standard subcutaneous mastectomy technique:
- Direct excision of glandular tissue through periareolar or inframammary incisions 4
- May be combined with hand-assisted liposuction for optimal contouring 4
Liposuction technique:
- Involves injection of low-dose lidocaine with epinephrine followed by cannula-based tissue removal 2
- Multiple cannula types are used to reduce the tissue mound effectively 2
- Proper incision placement along the mid-axillary line minimizes visible scarring 6
Important Clinical Considerations
When surgery is indicated:
- Drug therapy with tamoxifen may be considered at early stages, but for gynecomastia persisting over 12 months, surgical excision becomes the treatment of choice 3
- Observation is appropriate for physiologic gynecomastia, as spontaneous resolution occurs in up to 50% of patients 7
Risk factors for complications:
- Body mass index and resected specimen weight greater than 40g are significant risk factors for surgical complications 4
- Large resections carry increased complication rates and require careful surgical planning 4
Mandatory histological analysis:
- Histological tissue analysis should be routinely performed in all true gynecomastia corrections, as atypical findings (spindle-cell hemangioendothelioma, papilloma) occur in approximately 3% of cases 4
- This is critical to rule out male breast cancer, which though rare (median age 63 years), must always be excluded 7, 8
Common Pitfalls to Avoid
- Performing liposuction alone on high-grade gynecomastia results in significant residual skin redundancy requiring secondary procedures 1
- Failing to obtain histological analysis risks missing occult malignancy or atypical pathology 4
- Inadequate preoperative evaluation may miss underlying endocrine disorders requiring medical management before surgery 3