Transaxillary Excision of Gynecomastia (Andromastia)

Why is Gynecomastia Important?

When my breasts developed as an adolescent male, I was winning medals for swimming, but I never swam in public again. The embarrassment felt by the patient may be very large and may cause unreasonable restrictions in lifestyle, in my opinion mainly because of joking by other males.

I think gynecomastia should be termed andromastia, because these are male breasts, not female breasts. All mammals, both male and female, have breasts, and they all vary in size.

The average male breast is very small, but genetics causes some to be above-average size. Some Polynesian Islanders have a very high percentage of andromastia, suggesting that genetics is the main factor.

If a man takes female hormones, he will change to a female shape, and his breast, thigh, and hip fat deposits will enlarge. This can be intentional or a byproduct of drug therapy (e.g., for benign enlargement of the prostate or for prostate cancer), body-building drugs, or hair growth promoters—often the same drug is used for an enlarged prostate, but in a different dose—where levels of female hormones can rise. There is a very long list of drugs that may cause male breast enlargement and, unfortunately, if these cause breast growth, the tissue does not revert to normal when the treatment is finished, and surgery becomes the only cure.

Very rarely, hormones can be caused by tumors of the endocrine system, notably the testis and pituitary gland, and may even be associated with actual milk production, thereby proving that male and female breasts are the same. These tumors arise in adulthood so if andromastia appears in a grown man for no apparent reason, blood tests and testicular ultrasound scanning need to be carried out.

If you do a good job, you will have lots of very happy patients who will tell you how much you have improved the quality of their lives, which is what cosmetic surgery is all about.

Examples of Andromastia

There is no need for complicated classification. The use of M, L, XL, and XXL is fine.

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  M—puffy nipple syndrome (<50 g total breast tissue; Fig. 30.2 )

  

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  L—Large andromastia (50–200 g; Fig. 30.3 )

  

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  XL—very large andromastia (200–400 g; Fig. 30.4 )

  

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  XXL—extra large andromastia (>400 g; Fig. 30.5 )

  

The main objectives for this surgery are as follows: (1) to keep skin scars to a minimum using a 1-cm anterior axillary wound; and (2) to remove all the gland, including subareolar breast tissue, to prevent further excisional surgery.

I have only done one circumareolar skin reduction at the time of glandular excision, and this was because of the unfavorable result, as shown in Fig. 30.6 ). Since changing to the axillary miniscar and avulsion technique, there have been no patients requesting areolar size reduction.

Preoperative Preparation

First, get the patient to wash his chest and axillae with 2% chlorhexidine (on ward). Then, take preoperative photos in the anesthesia suite.

Mark out the extent of the breast tissue, and draw a vertical line from the anterior axillary fold and position of the incision. Arrange the patient square on the table, with his arms at his side, held by angle restraints.

Procedure ( Video 30.1 )

• Step 1. Puncture the skin of the anterior axilla and stretch to 2 cm to achieve minimal scarring.

• Step 2. Inject 750 mL of liposuction fluid on each side, and wait 7 to 10 minutes.

• Step 3. Tunnel in the subcutaneous and subglandular planes with a 3-mm cannula.

• Step 4. Separate the skin from the gland with long Nelson scissors.

• Step 5. Divide the milk ducts from the nipple, excising all subareolar tissue.

• Step 6. Remove the gland with long Kocher or Lane forceps.

• Step 7. Use a 3-mm cannula for liposuction to the periglandular tissue to make the subcutaneous fat layer even over the upper chest.

• Step 8. Spray 2.5 mL thrombin and fibrinogen (Evicel, Ethicon, Somerville, NJ) into each cavity.

• Step 9. Suture with one or two subcutaneous Vicryl sutures and take a preoperative photograph.

• Step 10. Apply a cooling pad (e.g., Hilotherm pad, PROSPOT d.o.o. Radovljica, Slovenia) and pressure band loosely (otherwise the cooling water may not circulate properly).

• Step 11. Wake the patient up slowly and gently to avoid hematomas.

The average surgery time is 90 minutes.