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Approaching gynecomastia anatomically

Article-Approaching gynecomastia anatomically

Typical deformities associated with massive weight loss due to both horizontal and vertical excess are shown in this patient prior to surgery (above). The inframammary crease shows lateral descent and there is an upper back/lateral breast roll. The upper body lift procedure lifts the lateral inframammary crease, eliminates the upper back/lateral breast roll and removes horizontal excess. Photos: Al Aly, M.D.
Vail, Colo. — Patients who have lost massive amounts of weight have taught surgeons an important lesson about treating gynecomastia: They need to approach breast reduction in an anatomically correct way, according to Al Aly, M.D., Iowa City, Iowa.

"Our eyes look for certain lines," he says. "For example, they anticipate a junction between the nose and cheek. If we create scars in those junctions, the results appear more natural."

The same, he says, goes for the breast. The natural breast contour, whether female or male, has an inframammary crease that rises as it traverses laterally. A scar in that position does not attract attention.

Etiology of a C cup Most boys going through puberty experience some breast enlargement. However, 70 percent to 80 percent of them regain what is considered a traditional male body form during the maturation process. Of the residual 20 percent to 30 percent, only a small percentage has enough enlargement to seek surgical correction. Researchers believe that genes and possibly other factors cause this condition.

"Another group of patients experience breast enlargement due to use of steroids, marijuana, Lasix and a variety of other more esoteric drugs — and, very occasionally, due to testicular cancer," Dr. Aly says.

The breasts of patients in these categories show tremendous variability. "Some men have the equivalent of a roll of quarters under their nipples," he tells Cosmetic Surgery Times. "Other fellows have C cup breasts."

The obesity epidemic has created a third form of gynecomastia. Weight gain stretches male breast tissue much the same way it does the tissue of pregnant women. If a patient manages to lose weight, his breasts look like deflated balloons.

Correcting the chest "Plastic surgeons are starting to recognize that not only the breast but the entire chest constellation is off in massive weight-loss patients," says the surgeon. "The breasts look like they are falling in toward the middle, with an inframammary crease that often runs parallel to the rib cage, an unnatural position."

He explains that the crease drops laterally because of a vertical excess in the thorax that creates a roll from the breast toward the back. By eliminating the roll, surgeons can lift the crease laterally and recreate the semicircular moon appearance anticipated by the observer's eyes. This is the first step in breast correction.

The second step is to excise a crescent-shaped piece of tissue from the hanging breast, with the inferior edge of the crescent located at the newly created crease. An incision at the crease is taken down to the underlying pectoralis muscle fascia. The breast flap is then elevated superiorly to the second rib and advanced inferiorly. The excised tissue includes the nipple and areola, which are removed as a full-thickness skin graft and reapplied to the newly created breast contour at a point just lateral to the normal meridian of the breast.

This technique, which eliminates vertical excess and reduces upper back rolls, works for any patient with substantial breast enlargement. It can be combined with a brachioplasty that crosses the axilla onto the lateral chest wall to eliminate the horizontal excess created by massive weight loss. The combined procedures, an "upper body lift," treat the chest as a unit.

Correcting others The best approach for patients who have a little extra volume but no extra skin is to excise the gland.

"You can do this with a half-moon incision around the areola or with a small incision on the side of the chest. I don't think there's any advantage to the second approach, because the areolar junction with the breast skin is a natural line," Dr. Aly says.

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