Surgery for gynecomastia

In cases of extremely pronounced hypertrophy of the mammary glands, the safest and most reliable operation is reduction mammoplasty with free transplantation of the nipple and areola, similar to a full-layer skin flap.

This operation is indicated in cases where the expected mass of tissue to be removed exceeds 1200 g. In some cases, the determining factor in making a decision is the distance from the jugular notch to the nipple. If it exceeds 45 cm, then it is usually impossible to move the nipple-areolar complex to a new position over 20 cm without disrupting its blood supply.

The principle of the operation is to remove a significant portion of the mammary gland, form a “new” gland from skin-fat flaps and free transplantation of the nipple-areolar complex, consisting of the epidermis, dermis and muscle layer.

Marking. The new location of the nipple is determined with the patient standing. This point is located slightly lower than usual: 1-2 cm below the inframammary fold and 24-28 cm from the jugular notch. After removing a significant amount of tissue, the remaining stretched skin contracts after some time and the nipple-areolar complex moves to a more cranial position.

The marking is continued with the patient in a supine position. The medial resection boundary is determined by moving the gland laterally and drawing a line from the point of the future nipple projection to the submammary fold. The lateral resection boundary is determined in the same way, with the difference that the gland is moved medially (see Fig. 37.3.3). From the top of the nipple projection point, 8 cm are measured down on each line, and from points A and A1, lines are drawn obliquely down to the intersection with the submammary fold (Fig. 37.3.15).

Technique of the operation. After infiltration of the nipple-areolar complex, it is taken like a full-layer skin flap with an areola diameter of 4-4.5 cm.

Excess gland tissue is resected in one block along the marking lines to the fascia of the pectoralis major muscle. The skin and fat flaps are sutured together. The wounds are sutured tightly with multi-row sutures and drained with tubes with active aspiration of the wound contents.

The new site of the areola is de-epidermized. The nipple and areola transplant is placed in this site, fixed with thin sutures and a pressure bandage.

Postoperative period. In some cases, according to indications, at the end of the operation or in the first day after it, the patient requires a blood transfusion. Drains are removed on the 2nd-3rd day; if necessary, the drainage system is left for a longer period. The pressure bandage from the nipple-areolar complex transplant is removed after 10 days. The stitches are removed 2 weeks after the operation.

As a rule, the operation gives a good cosmetic result with a small number of complications. At the same time, the objective consequences of this type of intervention are loss of nipple sensitivity, loss of feeding function, and the possibility of depigmentation of the nipple and areola.

Other types of reduction mammoplasty

In some cases, in the absence of ptosis and with minor (moderate) hypertrophy of the mammary glands, it is possible to reduce their volume without moving the nipple-areolar complex to a new position. The best candidates for this operation are young nulliparous patients whose elastic breast skin is capable of contracting.

Reduction mammoplasty is performed through a submammary access 6-10 cm long. The gland tissue is excised in its lower sector, 4 cm short of the areola and maintaining a skin-fat layer thickness of at least 3 cm.

Naturally, this operation cannot significantly affect the shape of the gland and, even more so, correct its prolapse.

In case of fatty hypertrophy of the mammary glands, it is possible to reduce their volume using liposuction.

Vacuum suction of fat is also used in the standard technique of reduction mammoplasty for additional contour correction.

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