The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part XI  Breast Surgery
Clinical Caveats
 When combining these cases with abdominal contouring cases, the abdominal
procedure should be performed first. The inframammary fold will often be low-
ered, and the mastopexy markings may need to be adjusted superiorly.
 A thickness of 1 to 1.5 cm should be maintained on the skin flaps to both improve
contour, as well as to minimize tissue loss at the inverted-T point.
 Preserving the second intercostal perforator medially will ensure a good blood
supply to the overlying skin-parenchymal envelope.
 The surgeon should not leave the operating room if he or she is not happy with
the dermal plication, appearance of the breast shape, and projection after the skin
flaps are redraped. If the shape is not optimal, removal of previous plication stitches
or further plication will be necessary.
 The dermis around the nipple-areola complex can be partially released around its
circumference to allow it to be easily transposed to the keyhole pattern without
tension. Failure to do so may result in a retracted nipple.
Annotated Bibliography
Graf RM, Mansur AE, Tenius FP, et al. Mastopexy after massive weight loss: extended chest
wall-based flap associated with a loop of pectoralis muscle. Aesthetic Plast Surg 32:371-
374, 2008.
The authors describe their experience with a simple and reliable mammaplasty tech-
nique using an extended thoracic wall flap associated with a loop of pectoralis muscle
that results in a pleasing breast shape and long-lasting results.
Hamdi M, Van Landuyt K, Blondeel P, et al. Autologous breast augmentation with the lateral
intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aes-
thet Surg 62:65-70, 2009.
The authors present their experience with the lateral intercostal artery perforator
(LICAP) pedicled flap for breast autoaugmentation in the massive-weight-loss patient.
This tissue provides volume for breast augmentation and improves the lateral thoracic
contour by removing excess skin.
Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap.
Ann Plast Surg 56:481-486, 2006.
The authors discuss the evolution of a technique useful for breast reshaping using the
spiral flap and upper body lift to produce comprehensive, effective, and safe contouring
of the breast and upper torso in massive-weight-loss patients.

Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight
loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg 57:361-365, 2006.
The authors present their experience with a pedicled fasciocutaneous flap based on the
intercostal artery perforators (ICAP) to correct breast ptosis, restore breast volume, and
eliminate upper trunk tissue excess.
Losken A, Holtz DJ. Versatility of the superomedial pedicle in managing the massive weight
loss breast: the rotation-advancement technique. Plast Reconstr Surg 120:1060-1068,
2007.
The authors describe a technique that uses the superomedial pedicle, a versatile, well-
vascularized pedicle that allows glandular plication of the lower pole with concomitant
autoaugmentation of the superior pole of the breast. This method, used to recontour the
breast following massive weight loss, includes parenchymal shaping through plication
as well as suspension. Medial advancement of the lateral breast skin on closure redefines
the lateral breast and eliminates the lateral breast roll.
Rubin JP. Mastopexy in the massive-weight-loss patient: dermal suspension and total paren -
chymal reshaping. Aesthetic Surg J 26:214-222, 2006.
A technique of dermal suspension and total parenchymal reshaping is presented that
eliminates the lateral axillary roll deformity while using this tissue to autoaugment breast
volume. The procedure is safe, reliable, and has a low complication rate. It produces a
pleasing and youthful breast contour and allows great control over skin envelope and
parenchymal shape.
Rubin JP, Gusenoff JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy
after massive weight loss: statistical analysis with concomitant procedures from a prospec-
tive registry. Plast Reconstr Surg 123:782-789, 2009.
Evaluation of the outcomes of the authors’ mastopexy techniques after massive weight
loss is presented; they conclude that the technique is a safe, effective, and durable method
for treating this complex breast deformity.
Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective
auto-augmentation. Clin Plast Surg 35:123-129, 2008.
A versatile technique is presented for restoring an aesthetic, youthful breast shape in
massive-weight-loss patients; the procedure produces overall low complication rates.
Despite the disadvantages of a lengthy scar and the increased operative time required
for deepithelialization, this technique provides a high rate of patient satisfaction.
Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of con-
tour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr
Surg 116:1535-1544; discussion 1545-1546, 2005.
The authors present a validated measure of contour deformities after bariatric weight loss,
with clinical applications in preoperative planning and evaluation of surgical outcomes.
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Chapter 72  Mastopexy and Breast Reduction in Massive-Weight-Loss Patients

Suggested Readings
Abramson DL, Pap S, Shifteh S, et al. Improving long-term breast shape with the medial
pedicle Wise pattern breast reduction. Plast Reconstr Surg 115:1937-1943, 2005.
American Cancer Society. Detailed guide: breast cancer.
Available at
Centers for Disease Control and Prevention. Overweight and obesity.
Available at
de Araujo Cerqueira A. Mammoplasty: breast fixation with dermoglandular mono upper
pedicle flap under the pectoralis muscle. Aesthetic Plast Surg 22:276-283, 1998.
Chen T, Wei F. Evolution of the vertical reduction mammaplasty: the S approach. Aesthetic
Plast Surg 21:97-104, 1997.
Colwell AS, Driscoll D, Breuing KH. Mastopexy techniques after massive weight loss: an al-
gorithmic approach and review of the literature. Ann Plast Surg 63:28-33, 2009.
Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle technique: an
alternative to free nipple and areola grafting for severe macromastia or extreme ptosis.
Plast Reconstr Surg 59:500-507, 1977.
Exner K, Scheufler O. Dermal suspension flap in vertical-scar reduction mammaplasty. Plast
Reconstr Surg 109:2289-2298; discussion 2299-2330, 2002.
Frey M. A new technique of reduction mammaplasty: dermis suspension and elimination of
medial scars. Br J Plast Surg 52:45-51, 1999.
Graf R, Biggs T. In search of better shape in mastopexy and reduction mammoplasty. Plast
Reconstr Surg 110:309-317; discussion 318-322, 2002.
Lassus C. A technique for breast reduction. Int Surg 53:69-72, 1970.
Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg 97:373-380,
1996.
Lejour M, Abboud M. Vertical mammaplasty without inframammary scar and with breast
liposuction. Perspect Plast Surg 4:64, 1990.
Qiao Q, Sun J, Liu C, et al. Reduction mammaplasty and correction of ptosis: dermal bra
technique. Plast Reconstr Surg 111:1122-1130, 2003.
2622
Part XI  Breast Surgery

Management of Breast Asymmetry

GLYN JONES
CHAPTER 73

B
reast asymmetry is a distressing condition that carries significant implications
for patients in terms of psychosexual impact. It also presents daily functional
difficulties with the fit of clothing. The causes are usually developmental but may
also be iatrogenic. Correction involves surgical intervention and may require a staged
approach in more complex deformities.
Indications and Contraindications
To understand the indications for corrective surgery in breast asymmetry, one has to
appreciate the plethora of causes of asymmetry in both the female and male breast.
Causes of Breast Asymmetry
Developmental Causes
1. Developmental hypoplastic breasts
2. Tuberous, constricted breast deformity
3. Poland’s syndrome
4. Gynecomastia
Iatrogenic Causes
1. Asymmetrical breast reduction
2. Incorrect implant positioning during augmentation mammaplasty
3. Consequences of capsular contracture
4. Effects of breast reconstruction
5. Effects of radiation after breast conservation
This list provides a working classification of breast asymmetry. All of these categories
constitute potential reasons to operate for asymmetry. However, contraindications
to surgery are relative and include the following:
1. Body dysmorphic disorder
2. Severe psychiatric illness
3. Poor general health (breast procedures are elective and can be delayed)
4. Active smoking
5. Metastatic disease
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Part XI  Breast Surgery

Pertinent Anatomy
The anatomy of the breast has already been covered, but a few points bear reitera-
tion. Correction of breast asymmetry centers on re-creation of symmetrical lower
poles and good upper pole fullness and symmetry. An abnormally placed infra-
mammary crease must be corrected to achieve symmetry. If the breast base is ab-
normal, the aesthetic outcome will be unsatisfactory. The tight inframammary fold
associated with a constricted or tubular breast is tightly contracted. Correction in-
volves release of the fibrous developmental band using radial scoring along the crease.
This must be done up to the dermis to be completely effective, allowing expansion
of the lower pole of the overlying breast tissue. Care should be taken to note and
mark the correct natural crease position. The uppermost extent of the gland should
be marked, and the surgical plan to correct deficiencies will involve implants, flaps,
or fat injection. These two sets of maneuvers will go a long way toward correcting
the appearance of the asymmetrical breast.
In addition, the contour of the underlying chest wall and sternal contour should be
noted, because conditions such as Poland’s syndrome or pectus excavatum can re-
quire larger than expected implant volumes to correct hypomastia. The level and de-
gree of development of the nipple-areola complex are also essential to the creation
of a symmetrical result. Even if the underlying breast mound has been perfectly
matched, an asymmetrical nipple level will mar the aesthetic outcome dramatically.
Preoperative Assessment
Patients should be evaluated after taking a careful developmental history with spe-
cific reference to age of menarche and thelarche. Patients should be asked about up-
per extremity development and function. During the examination it is also helpful
to attempt to form an impression of the patient’s psychological maturity, particu-
larly when surgery is proposed on younger women and teenagers; parental and peer
pressure should be evaluated as a factor. Clinical examination involves assessment
of breast, chest wall, and upper extremity development to exclude congenital prob-
lems, such as Poland’s syndrome. The level of the inframammary creases and their de-
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Chapter 73  Management of Breast Asymmetry

gree of tightness should be evaluated carefully. Nipple size, level, and the degree of
development are noted. Measurements include nipple-to-notch and inframammary
fold-to-nipple distances as well as pinch thickness tests to evaluate the thickness of
available breast tissue in all quadrants of the breasts. Pectoralis major muscle bulk,
thickness, and function are also worth assessing. The presence of pectus excavatum
or carinatum can have an impact on the nature and success of a reconstructive at-
tempt. Autologous fat donor sites on the abdomen and hips should be evaluated.
Preoperative Planning and Operative Technique
Management of Developmental Breast Asymmetries
Many women develop minor breast asymmetry during otherwise normal pubertal
breast growth. It is not uncommon to see a young adult woman with one nipple
slightly higher than the other or the lower pole of one breast slightly lower than the
opposite side. These minor discrepancies are insignificant to most patients, and cor-
rection would require breast scarring, which is rarely justified, given the subtlety of
the deformity. In other patients, however, the discrepancy in breast volume may ap-
proach one or even two bra cup sizes. These deformities are embarrassing for the pa-
tient and can lead to psychosexual problems in adult life as well as during puberty,
when insensitive comments from peers during gym and sports activities can lead to
social withdrawal. While catch-up growth may occur in the early to mid-teen years,
it is rare in my experience to see a severely lagging hypoplastic breast achieve ac-
ceptable symmetry in the late teens to early adulthood. It is my preference to defer
surgical intervention until after the patient is 18 years of age, but occasionally a se-
vere deformity mandates earlier surgery.
Asymmetrical Hypoplasia
Developmental hypoplasia may range from mild to severe and can be unilateral or
bilateral. In one sense, a bilateral deformity can be easier to correct, because it al-
lows the surgeon the luxury of operating on both breasts to achieve a symmetrical
outcome, particularly when implants are being used.
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Part XI  Breast Surgery

This 36-year-old woman developed severe breast asymmetry in her teens. She had a
constricted hypoplastic right breast and a ptotic, almost tubular left breast. She re-
quested breast augmentation. An asymmetrical breast augmentation with overlying
mastopexy was performed. A 325 cc implant was placed on the right side with peri -
areolar mastopexy, and a 250 cc implant was placed on the left side with a vertical
mastopexy. The patient was delighted with the early postoperative outcome.
Unilateral Hypomastia With a Normal Contralateral Breast
Unilateral hypomastia requires augmentation of the hypoplastic breast to achieve
volume symmetry. If ptosis is an additional component, mastopexy augmentation is
indicated. Hypoplastic breasts often have an element of lower pole constriction that,
if not corrected, will lead to a double-bubble deformity developing postoperatively.
Every effort should be made to recognize and correct this problem at the initial op-
erative procedure. Correction can be challenging and involves serial radial scoring
along the tight inframammary crease to allow it to expand laterally over the implant
curvature. These scoring incisions are passed through the fat up to the dermis, taking
care not to burn the dermis with cautery. Cuts should be placed every centimeter
along the old inframammary crease until the deformity is eliminated. The downside
of performing these radial incisions is that they increase the likelihood of implant
palpability in the lower pole. Inflatable, disposable implant sizers are extremely use-
ful in assessing final implant volumes for these patients. I usually use a round im-
plant in these cases. An inframammary approach to the subpectoral plane is accept-
able if no mastopexy is planned. If a mastopexy is required, it is often relatively minor
in extent, and a periareolar approach can provide access for both the augmentation
and the required periareolar mastopexy scar. If there is any element of tuberous de-
formity with herniation of the breast into the areola, this approach provides the op-
timal exposure for correction. Assessment of patient symmetry in the erect position
on the operating table is essential before skin closure.
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Chapter 73  Management of Breast Asymmetry

Tuberous Breast Deformity
Patients with tuberous breasts often have a bilateral problem in that one or both
breasts are relatively constricted, with one side larger and more ptotic than the other
(see Chapter 63). Breast crease levels may be asymmetrical, with a very short infra-
mammary fold-to-nipple distance present on the more hypoplastic side. The infra-
mammary crease may be very tight and well defined, with clearly visible banding
along the fold. Nipple-areolar diameters are often dilated, and the breast may ex-
hibit a tendency to herniate into the areola, further worsening the appearance of de-
formity. If the larger breast falls within an acceptable size range for the patient, a
mastopexy alone may be required on this side. However, if the larger side is also rel-
atively small, it is preferable to perform a mastopexy augmentation on both sides,
with a larger implant inserted on the more severely hypoplastic side. A periareolar
mastopexy is usually sufficient on the smaller side, whereas a vertical mastopexy
augmentation may be mandated on the larger side to help correct some of the glan-
dular ptosis that accompanies the lower pole development on this side. The larger
lower pole can be either imbricated or resected to allow a more symmetrical cor-
rection compared with the smaller side and its deficient lower pole fill.
It is essential to radially score the tight inframammary creases to achieve an adequate
release of the breast tissue and skin over the implants to avoid the troublesome and
unsightly double-bubble deformity. As with all mastopexy-augmentation procedures,
it is essential to perform the augmentation first before committing to any skin exci-
sion. Failure to follow this simple dictum may result in excessive skin resection, cre-
ating a tight closure with risk of wound dehiscence or necrosis. I make the initial in-
cision in the lower periareolar quadrant, at the juncture of the areolar-cutaneous
junction. Once the implant is in place, tailor-tacking the skin gives a good idea of
how much of the areolar skin disk may be safely resected as a periareolar mastopexy.
Any vertical resection can be assessed in the same way on the larger, more ptotic
side, if necessary.
For implant positioning, it has always been my preference to use the subpectoral
plane in primary cases. This allows safe manipulation of the overlying breast tissue
during mastopexy without concern for nipple and skin viability. Using this approach,
the entire breast becomes the pedicle, because the relationship between the breast
gland and the pectoralis major muscle is unaffected.
Poland’s Syndrome
Poland’s syndrome is a developmental abnormality involving the breast, nipple, and
entire upper extremity and shoulder girdle. Typical patients have varying degrees of
hypomastia and abnormal nipple-areola complex development, coupled with the ab-
sence of the sternal head of the pectoralis major muscle. This may be accompanied by
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Part XI  Breast Surgery

varying degrees of shoulder muscle hypoplasia as well as symbrachydactyly of the
ipsilateral hand. All muscles of the upper extremity are potentially at risk, including
the deltoid and less commonly, the latissimus dorsi. The presence and function of
the latissimus dorsi should always be tested, because it can be used to reconstruct
the ipsilateral anterior axillary fold and the lack of pectoral muscle bulk. Fat injection
has recently been offered as an alternative to muscle transposition in less severe cases
(see Chapter 63).
Surgery for Poland’s syndrome aims to achieve three major aesthetic goals: creation
of a breast mound, recreation of the anterior axillary fold, and restoration of the
missing infraclavicular fill afforded by the absent sternal head of the pectoralis ma-
jor muscle. Breast augmentation coupled with either latissimus flap transposition or
later fat injection can achieve these goals. If the skin envelope is extremely tight, it
can be preexpanded with the use of an integrated valve tissue expander, followed by
an expander-implant exchange and latissimus transposition, if indicated.
If athelia exists, nipple reconstruction is also necessary. If the nipple is severely hy-
poplastic and located too high on the chest wall, it may be preferable to resect the
nipple and perform a complete nipple reconstruction de novo. If the nipple is cor-
rectly placed but merely smaller than normal, soft tissue augmentation with a roll
of acellular dermal matrix such as AlloDerm can be placed to increase projection.
Tattooing if performed skillfully, can improve the diameter of the areola. If correc-
tion is performed in the early to mid teens, the patient and family should be warned
that the breast implant will have to be exchanged for a larger one when the patient
reaches maturity so that the normally developing contralateral breast can be matched.
Patients should also be warned that a ptotic but otherwise normal contralateral breast
may require a mastopexy at some point in the future to achieve symmetry. When
dealing with Poland’s syndrome, the surgeon should recall that the chest wall itself
may be less developed and have an unnaturally steep lateral curvature that may make
attaining symmetry even more difficult. An implant may tend to slide laterally off the
chest wall in such patients, causing the appearance of less anterior projection from
the implant than would normally have been achieved. In addition, the sloping chest
wall may require a much larger implant volume to be used to compensate for the
lack of lateral fill that would be provided by a normal chest wall contour.
Some authors have advocated the use of deepithelialized free flaps, such as a super-
ficial inferior epigastric artery (SIEA) or parascapular flap, as an alternative to latis-
simus dorsi transposition in an effort to spare as much upper extremity function as
possible. Autologous fat injection has also been used with increasing frequency and
will probably attain greater significance in the management of this condition as tech-
niques to maintain graft integrity improve (see Chapter 63).
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Chapter 73  Management of Breast Asymmetry

The sternal head of the pectoralis major muscle was absent in this 9-year-old girl,
and her nipple was underdeveloped and located abnormally high on her chest wall.
Despite her young age, the upper chest deformity was so disturbing to her that cor-
rection was indicated, and her family was very supportive of surgical intervention.
She is shown 9 years after her initial latissimus dorsi transfer, 7 years after an asym-
metrical bilateral augmentation mammaplasty with saline-filled implants. She is now
18 years old, and breast symmetry has remained acceptable.
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Part XI  Breast Surgery

This 24-year-old woman presented with a moderate degree of Poland’s syndrome de-
formity. Although missing almost all of the pectoralis major muscle, she had mod-
erate breast development, which helped to soften the appearance of the breast de-
formity. Although a latissimus dorsi transposition and augmentation were certainly
a reasonable option for this patient, fat injection was selected as a simpler alterna-
tive. A vertical mastopexy was planned to achieve better symmetry with the nonptotic
hyperplastic breast. Staged fat grafting was performed, with three procedures in-
volving injection of 260 cc, 350 cc, and 157 cc. Her result is shown at 1 year. Her
breasts are now symmetrical, with complete correction of her deformity and a pleas-
ing breast contour.
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Chapter 73  Management of Breast Asymmetry
Courtesy Emmanuel Delay, MD

Gynecomastia
Gynecomastia involves abnormal enlargement of one or both breasts in men. It has
two peaks of incidence: the first in puberty and the second in late middle age as male
hormone balance changes. Most pubertal cases are idiopathic, but endocrine and
chromosomal abnormalities should be identified when present. Obesity is an in-
creasingly common cause of large breast development in males. Young men devel-
oping symmetrical, increasing breast enlargement after puberty in the absence of
obesity should be questioned about marijuana use, which can stimulate breast growth
quite strongly. In older men, the use of medications such as spironolactone should
also be investigated. Most older men who develop gynecomastia do so as a result of
changing hormone status with age, but breast cancer should be excluded, particu-
larly in unilateral cases in the elderly. The use of systemic steroids can also result in
gynecomastia.
Management of gynecomastia in obese patients should focus on weight loss before
resorting to surgery. If medications such as spironolactone are the likely cause, their
use should be discontinued and alternative medications tried. Once conservative
measures have been exhausted, surgery becomes the only option. Many insurance
companies do not cover these procedures, because they are regarded as essentially
cosmetic in nature.
Surgery usually involves a two-pronged approach incorporating both liposuction
and surgical resection. Liposuction is used to contour the chest wall fat peripheral
to the enlarged gland; resection of the hypertrophied gland while leaving a small sub-
areolar breast bud improves the central contour. Ultrasound-assisted liposuction has
been touted as a successful means of removing both fat and glandular tissue, but
I have not found it particularly helpful in dealing with the dense, fibrotic subareo-
lar breast disk. I use power-assisted liposuction for the fatty component and then re-
sect the excess glandular tissue.
Resection is performed through an infraareolar incision. When dissecting beneath
the areola, great care should be taken to leave enough subareolar breast tissue in
place to prevent the unsightly hollowing that can occur when too much tissue is taken
beneath the nipple. This problem creates an extremely unattractive excavated look
that is very difficult to correct, because the nipple adheres to the underlying pec-
toralis muscle and animates with arm motion. I leave a subareolar disk of breast tis-
sue and then bisect the deep gland down to the pectoralis major fascia. Each half of
the deeper gland can be resected in turn, which provides easier access than is feasi-
ble when performing a monobloc excision. Drains should always be inserted and a
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Part XI  Breast Surgery

circumferential pressure garment worn in an effort to prevent seroma formation. Ul-
trasonic liposuction seems to be associated with a higher incidence of seroma than
is seen with power-assisted or conventional liposuction. Any resected tissue should
always be evaluated histologically to exclude malignancy.
Management of Iatrogenic Breast Asymmetries
Asymmetrical Breast Reduction
The achievement of symmetry during breast reduction is an essential goal of the op-
eration. Underresection or overresection on one side can produce asymmetry that
will require subsequent revision. Breast symmetry should always be checked with the
patient in the erect position on the operating table before a dressing is applied. Asym-
metry caused by a focal problem, such as inadequate resection of the inferomedial
or inferolateral quadrants of the breast, can be addressed with minor excisions of
both skin and breast tissue with the patient under local anesthesia. Localized lipo-
suction can also be used to address these issues if the breast is more fibrofatty than
densely glandular. More gross asymmetries require a re-reduction procedure. Revi-
sionary breast reduction can be a harrowing experience when performed by another
surgeon, who may not have access to the original records and an understanding of
the pedicle technique used. Generally speaking, if the patient had a Wise pattern re-
duction performed more than 10 to 15 years previously, it is likely that an inferior
pedicled technique was used. Rarely, a superomedial technique may have been used.
Vertical scar techniques are usually associated with superior or superomedial pedicles,
unless a Hammond short-scar periareolar inferior pedicle reduction (SPAIR) mamma -
plasty technique was used. It is prudent to leave as much bulk around the pedicle as
possible when performing re-reductions, and patients should be carefully counseled
about the potential for nipple loss and fat necrosis. Suctioning of the periphery of
the breast is usually safe in revisionary reduction, and skin laxity resulting from suc-
tion should be tightened by excision as needed. Stretched nipple-areolar diameters
can be reduced, but this should only be done at the end of the procedure, because
tension on the periareolar skin inset is often tighter than anticipated in re-reduction
procedures. In thin-skinned patients, a Gore-Tex periareolar purse-string suture, as de-
scribed by Hammond, is very useful in limiting skin stretch postoperatively.
Asymmetry Resulting From an Augmentation Procedure
Implant insertion for breast augmentation can lead to asymmetry, usually as a re-
sult of a failure to recognize and correct a preexisting asymmetry, or asymmetrical
implant placement and overdissection of an implant pocket on one side.
2633
Chapter 73  Management of Breast Asymmetry
5
73-1 SPAIR
mammaplasty
technique

Preexisting asymmetry requires the use of a larger implant on the smaller side and a
smaller implant on the larger side. This may be more easily achieved with saline im-
plants, which allow minor intraoperative adjustments to achieve as near perfect a
result as possible. However, asymmetry may also arise when implants are placed in
overdissected pockets, most commonly superior or inferolateral overdissection. Ex-
cessive upward dissection toward the clavicle creates abnormal fullness in the infra -
clavicular area, creating a top-heavy appearance to the breast. This is a particular
risk of closed transaxillary augmentation, where inadequate release of the lower pole
attachments of pectoralis major can displace the implant superiorly. The use of the en-
doscopic approach has alleviated this tendency considerably. Correction can be per-
formed with an endoscopic transaxillary release of the lower pole, which allows the
implant to settle in a more inferior position.
Overdissection of the inferomedial pocket allows the implant to bulge into the ax-
illa, but what is more important, it creates an unattractive double-bubble appear-
ance as the implant bulges beyond the lateral breast crease. Correction is extremely
difficult, because the breast skin needs to be tacked down to the serratus fascia or
muscle, all the while facing the outward force of a large implant being squeezed lat-
erally by an active pectoralis major muscle. Fixation sutures of a nonabsorbable ma-
terial such as 2-0 or 0 Mersilene or Ethibond can be useful, but the tendency to tear
through with failure of the repair is high. Recently the use of a Strattice inlay an-
chored to the serratus muscle deeply and to the breast tissue and skin more superfi-
cially has met with better success. Another approach is advancement of an inferior
skin flap, which can be tacked to the serratus muscle deeply; the overlying lateral
breast crease skin is then sutured to the advanced skin, similar to the Ryan approach
used in breast reconstruction. The attachment of skin to skin provides a more stable
support mechanism than sutures between tenuous breast fat and serratus muscle.
Avoiding this problem is definitely preferable to necessity of subsequent attempts at
repair.
Overdissection of the medial breast pocket creates the potential for synmastia, an
extremely unattractive deformity that is very difficult correct. Acellular dermal ma-
trices have found an immensely useful role in this area: they provide a strong su-
turable material that, once incorporated and vascularized, can provide a firm bar-
rier to subsequent implant migration medially. The procedure is combined with a
suture plication capsulorrhaphy reinforced with Strattice or AlloDerm.
2634
Part XI  Breast Surgery

This patient presented with breast asymmetry and recurrent ptosis after a mastopexy-
augmentation performed 5 years previously. Her right nipple was significantly lower
than the left, and the right implant was higher than the left. A right open capsulot omy
was performed to lower the implant on the right. An asymmetrical mastopexy was
performed, raising the right nipple more than the left to achieve symmetry. The pa-
tient is shown 2 months after revision surgery.
2635
Chapter 73  Management of Breast Asymmetry

This 34-year-old woman with hypomastia and ptosis had a subpectoral breast aug-
mentation with saline-filled implants. The patient was concerned that her breasts
were not large enough, and she had a clear double-bubble deformity on the left side.
This was worsened by pectoral muscle action. The patient was advised to have an
implant exchange to a larger size with subglandular conversion. The problem was
corrected completely with this approach, and the patient is shown postoperatively
with a symmetrical result.
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Part XI  Breast Surgery

This young woman had undergone transaxillary endoscopic breast augmentation
with saline-filled implants. She was referred to me for correction, complaining of ex-
cessively high-riding implants. Clinically her implants had been placed too high, with
at least 60% of the implant volume lying above the equator of the breast. Through
the original transaxillary incision, I performed an inferior capsulotomy, allowing the
devices to be placed into a more natural position. She is shown in the early postop-
erative period with a more acceptable aesthetic appearance of her breasts.
Asymmetry From Capsular Contracture
Capsular contracture is the single most common complication of breast augmenta-
tion. As the condition deteriorates, contraction causes increasing deformation of the
augmented breast. Grade III and IV contractures may pull the implant into an ab-
normal position, displacing it in almost any direction and causing the shape of the im-
plant to change from a teardrop to a more globular form on the chest wall. The net
result of these compressive forces is breast asymmetry that deteriorates over time.
Surgical intervention is the only means of correcting the deformity.
Closed capsulotomies are no longer performed; they have given way to open proce-
dures. A capsulotomy with implant exchange, or better still, total capsulectomy with
implant exchange, has become the mainstay of treatment. Once an established cap-
sule has created a deformity, a recurrence is more like with a capsulotomy than with
a capsulectomy. Capsulectomy provides the surgeon an opportunity to allow a fresh
implant to generate a new capsule around the device, in the process adjusting the
pocket position and size as required to achieve a more aesthetic result. If needed,
acellular dermal matrices such as AlloDerm can be incorporated into the procedure;
it is becoming apparent that this material may limit the formation of a purely fibrous
capsule within the area in which it is placed. The high elastin content of human der-
mis in this biologic mesh is possibly partially responsible for the elastic nature of the
capsule, as is the lack of cellular inflammatory response that is seen in the usual fi-
brous capsules forming around breast implants.
2637
Chapter 73  Management of Breast Asymmetry

2638
Part XI  Breast Surgery
In addition, if a patient has a gel-filled implant associated with severe capsular con-
tracture, this can be exchanged for a saline-filled device in an attempt to minimize
recurrence. The addition of a textured surface may also help mitigate the capsular
response, although at the expense of potentially increased palpability and wrinkling
of the implant beneath the skin.
Fat injection is also showing promise as a means of softening the periprosthetic cap-
sule, although data are still limited (see Chapter 65).
Effects of Breast Reconstruction
Breast reconstruction, particularly when performed unilaterally, may result in con-
siderable asymmetry, particularly when implant reconstruction is performed. It is
not within the scope of this chapter to cover all of the options available to achieve
symmetry in breast reconstruction. Bilateral implant-based reconstructions tend to
achieve a higher degree of symmetry because both breasts are shaped by an identi-
cal implant, often with the assistance of acellular dermal matrices placed at the time
of the initial mastectomy and implant insertion. Unilateral implant reconstructions,
however, often require adjustment of the opposite breast in the form of a mastopexy/
augmentation or reduction, depending on the size and shape of the breast before
mastectomy. In addition, fat injection has proved to be a powerful tool in helping
shape the upper pole of the reconstruction, where implants often fail to achieve ad-
equate volume fill. Autologous reconstructions have the potential to achieve greater
symmetry without having to adjust the contralateral breast, because large quantities
of skin and fat are available for shaping the reconstruction.
This elderly woman had undergone a right mastectomy for breast cancer 10 years
earlier, with immediate expander-implant reconstruction. She developed capsular
contracture around the high-riding implant, with severe acquired breast asymmetry.
She was then diagnosed with a new left breast cancer requiring mastectomy. Treat-

ment involved immediate implant insertion, with AlloDerm coverage of the lower
pole. On the right side, an open inferior capsulotomy with capsulorrhaphy to the
upper pole of the implant pocket was performed. This allowed inferior placement
of the implant into a more anatomic position. Shape and symmetry were vastly im-
proved; the patient declined nipple reconstruction.
Effects of Radiation After Breast Conservation
Radiation is a powerfully negative force influencing breast shape after reconstruc-
tion of breast-conserving therapy. Breast-conserving therapy has been shown to be
associated with deteriorating breast aesthetics over time; patients with larger breast
volumes develop the most serious retraction, fibrosis, and fat necrosis when com-
pared with women with smaller breasts. In addition, the deformity caused by the
lumpectomy itself can also deteriorate with the addition of radiation therapy. To
ameliorate these consequences, oncoplastic reduction plays an increasingly impor-
tant role in treating patients undergoing breast-conserving therapy. Once the defor-
mity is established, however, complex reshaping of the irradiated breast is the only
means available to correct the asymmetry.
Correction of a breast-conserving therapy–induced breast deformity after radiation
has been delivered involves the movement of breast flaps damaged by ionizing radi-
ation. This results in compromised blood flow to the tissues and decreased tissue
compliance from radiation-induced fibrosis and edema. Irradiated flaps do not move
as well or as far as nonirradiated flaps, and seroma formation and infection rates are
all increased in radiated beds. If edema is still resolving after radiation, I prefer to
wait at least 3 to 6 months so that with massage and compression therapy, edema
will be reduced. Referral to a lymphedema specialist can often expedite this process.
Softer flaps are more pliable and move far easier than stiff, edematous tissues do.
Extreme caution should be exercised when dealing with such patients, and under-
mining of irradiated skin should be kept to a minimum. Skin necrosis is much more
common after radiation therapy because of the reduction in cutaneous blood flow
that accompanies the treatment. It is preferable to lift and/or reduce the contralat-
eral breast to match the smaller irradiated side and keep tissue redistribution on the
irradiated side to a minimum. In severely asymmetrical radiation-damaged breasts,
it may be necessary to perform a completion mastectomy with immediate autolo-
gous reconstruction rather than attempt to reshape compromised, poor-quality lo-
cal tissue. This may achieve a volume and shape match similar to the contralateral
side. Alternatively, a contralateral balancing procedure may be necessary to match
the reconstructed breast as a secondary procedure.
2639
Chapter 73  Management of Breast Asymmetry

This 60-year-old woman presented 6 years after a right lumpectomy and radiation
therapy for breast cancer. She had developed severe breast asymmetry and requested
improvement without resorting to extensive flap procedures. The right breast was
stiff and fibrotic, with lower pole edema. Treatment involved a left vertical breast re-
duction and a very conservative periareolar mastopexy to elevate the right nipple
into a more acceptable position without extensive undermining. Although postop-
eratively her symmetry is not perfect, she is very happy with the outcome, achieved
through a conservative outpatient procedure with minimal risk to the irradiated side.
Postoperative Care
The postoperative management of these patients varies enormously, depending on
the nature of the deformity and the procedure required for correction. It is beyond
the scope of this chapter to detail all of these procedures; see the appropriate operative
descriptions in other chapters for this discussion.
Postoperative management involves the careful support of implants in their correctly
placed location and may require the use of external taping or bras to assist with this
process. Careful preoperative counseling and preparation for the possible need for
revisions must be clearly explained to the patient to avoid postoperative disap-
pointment, particularly with sever congenital deformities or radiation-induced asym-
metry, both of which can be particularly challenging to correct.
2640
Part XI  Breast Surgery

Problems and Complications
Breast asymmetry surgery generates the same spectrum of risks and complications
as the component operations used to correct the deformities. Congenital anomalies
such as constricted, tubular breasts run the increased risk of double-bubble defor-
mity if the original crease is not fully expanded and obliterated to make way for a
new one. The position of the new crease must be placed accurately to match the con-
tralateral normal position. Similarly, overdissection of the new crease position will
result in an extremely unattractive bulge of the implant beyond the desired breast
crease level, and such a deformity is extremely difficult to correct. A capsulorrhaphy
is necessary between the breast capsule and the correct position on the chest wall,
but the tissues are thin and hold sutures poorly, easily tearing through when a large
implant exerts pressure against the repair. The use of a piece of acellular dermal ma-
trix, such as AlloDerm or Strattice, is helpful in providing a more robust material to
anchor such a repair.
Revision surgery for breast asymmetry requires operating in a previously scarred bed.
The use of breast pedicles in such situations or raising scarred or radiated skin flaps
may result in skin and fat necrosis or nipple loss. Every effort must be made to main-
tain blood flow to tissues by ensuring thick, broad-based pedicles and thicker flaps
than might otherwise be used.
Outcomes
Breast asymmetry surgery is often difficult and may require revisions. Given the wide
range of deformities and the spectrum of procedures required to correct them, it is
almost impossible to provide outcomes data for this subset of clinical conditions.
Concluding Thoughts
Breast asymmetry is a distressing to the patient and carries a potentially profound
psychological impact. The treatment of an established deformity requires the use of
a broad range of procedures and techniques to attempt to restore a close facsimile
of the normal breast from a less than ideal foundation. Achieving good results in
these patients taxes the ability and skills of even the best surgeons and should not
be embarked on lightly.
2641
Chapter 73  Management of Breast Asymmetry

Clinical Caveats
 Symmetry of the mound and nipple position must be created.
 Abnormally placed breast creases should be eradicated and re-created at a natu-
ral level.
 Radial scoring is performed perpendicular to the crease to eliminate a tight crease.
 Broad-based pedicles are raised in revisionary surgery.
 A herniated areola can be reduced by performing a periareolar mastopexy.
2642
Part XI  Breast Surgery
Annotated Bibliography
Baroudi R, Lewis JR.The augmentation-reduction mammaplasty. Clin Plast Surg 3:301-308,
1976.
The authors present a technique of augmentation mammaplasty with simultaneous treat-
ment of glandular ptosis for patients with small, ptotic breasts. The technique has sev-
eral advantages: it is simple and poses no circulatory problems to the flaps, the hospi-
tal stay and recovery are short, and only one procedure is required.
Gliosci A, Presutti F. Asymmetry of the breast: some uncommon cases. Aesthetic Plast Surg
18:399-403, 1994.
Six cases of significant asymmetry are presented. Treatment involved elaborate correc-
tive methods.
Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg 124(1 Suppl):61e-
68e, 2009.
The author describes two types of tissue in patients with gynecomastia as well as treat-
ment modalities.
Spear SL, Davison SP. Aesthetic subunits of the breast. Plast Reconstr Surg 112:440-447,
2003.
A subunit principle for breast reconstruction is presented based on a review of 10 years
of autogenous reconstruction. Patterns of breast subunits are identified for defects of
various sizes.
Vandenbussche F. Asymmetries of the breast: a classification system. Aesthetic Plast Surg 8:27-
36, 1984.
The author proposes four main categories of breast asymmetry based on a review of
150 cases. These groups are true malformative asymmetry of breast, precocious primary
asymmetry of breast, secondary or progressive acquired breast asymmetry, and tertiary
or induced breast asymmetry.

Suggested Readings
Abramo AC, Viola CJ. Liposuction through an axillary incision for treatment of gyneco-
mastia. Aesthetic Plast Surg 13:85-89, 1989.
Baroudi R, Lewis JR. The augmentation-reduction mammaplasty. Clin Plast Surg 3:301-308,
1976.
Berrino P, Galli A, Rainero ML, et al. Unilateral reduction mammaplasty: sculpturing the
breast from the undersurface. Plast Reconstr Surg 82:88-98, 1988.
Bi DJ. Inverted nipple: a method of correction. Plast Reconstr Surg 87:1147-1148, 1991.
Cannistra C, Piedimonte A, Albonico F. Surgical treatment of gynecomastia with severe pto-
sis: periareolar incision and dermal double areolar pedicle technique. Aesthetic Plast Surg
33:834-837, 2009.
Corso PF. Plastic surgery of unilateral hypoplastic breast. Plast Reconstr Surg 50:134-141,
1972.
Courtiss EH. Suction lipectomy: a retrospective analysis of 100 patients. Plast Reconstr Surg
73:780-796, 1984.
Crestinu JM. Correcting the inverted nipple. Plast Reconstr Surg 89:1181-1182, 1992.
Eade GG. The radial incision for gynecomastia excisions. Plast Reconstr Surg 54:495-497,
1974.
Eaves FF III, Bostwick J III, Nahai F, et al. Endoscopic techniques in aesthetic breast surgery.
Augmentation, mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy,
and reconstructive techniques. Clin Plast Surg 22:683-695, 1995.
Fee TE, Caffee HH. Predictors of postoperative aesthetics following explantation of the aug-
mented breast. Ann Plast Surg 38:217-222, 1997.
Ferreira LM, Neto MS, Okamoto RH, et al. Surgical correction of nipple hypertrophy. Plast
Reconstr Surg 95:743-754, 1995.
Gliosci A, Presutti F. Asymmetry of the breast: some uncommon cases. Aesthetic Plast Surg
18:399-403, 1994.
Hammond DC. The SPAIR mammaplasty. Clin Plast Surg 29:411-421, 2002.
Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg 124(1 Suppl):61e-
68e, 2009.
Hauben DJ, Mahler D. A simple method for correction of the inverted nipple. Plast Reconstr
Surg 71:556-559, 1983.
Juri J. Mammary asymmetry: a brief classification. Aesthetic Plast Surg 13:47-53, 1989.
Kaye BL. Axillary breasts. Plast Reconstr Surg 53:61-63, 1974.
Kolker AR, Austen WG Jr, Slavin SA. Endoscopic-assisted transaxillary breast augmenta-
tion: minimizing complications and maximizing results with improvements in patient
selection and technique. Ann Plast Surg 64:667-673, 2010.
Letterman G, Schurter M. History of the surgical correction of mammary asymmetry. In
Owsley JQ, Peterson RA, eds. Symposium in Aesthetic Surgery of the Breast. St Louis:
CV Mosby, 1978.
2643
Chapter 73  Management of Breast Asymmetry

2644
Part XI  Breast Surgery
Lewis CM. Lipoplasty: treatment for gynecomastia. Aesthetic Plast Surg 9:287-292, 1985.
Lista F, Ahmad J. Power-assisted liposuction and the pull-through technique for the treat-
ment of gynecomastia. Plast Reconstr Surg 121:740-747, 2008.
Mladick RA. Gynecomastia. Clin Plast Surg 18:815-822, 1991.
Murphy TP, Ehrlichman RJ, Seckel BR. Nipple placement in simple mastectomy with free
nipple grafting for severe gynecomastia. Plast Reconstr Surg 94:818-823, 1994.
Netscher DT, Sharma S, Thornby J, et al. Aesthetic outcome of breast implant removal in 85
consecutive patients. Plast Reconstr Surg 100:206-219, 1997.
Perras C. Asymmetry of the breast and the thoracic cage: a brief presentation of cases with
their operative treatment. Aesthetic Plast Surg 4:117-134, 1980.
Radlauer CB, Bowers DG. Treatment of severe breast asymmetry. Plast Reconstr Surg 47:347-
350, 1971.
Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg 3:339-347, 1976.
Rees TD, Dupuis CC. Unilateral mammary hypoplasia. Plast Reconstr Surg 41:307-310, 1968.
Regnault P. Nipple hypertrophy. Clin Plast Surg 2:391, 1975.
Regnault P. Ptosis, asymmetry, tubular breast, and congenital anomalies. In Owsley JQ, Pe-
terson RA, eds. Symposium on Aesthetic Surgery of the Breast. St Louis: CV Mosby,
1978.
Reyes RJ, Zicchi S, Hamed H, et al. Surgical correction of gynecomastia in bodybuilders. Br
J Clin Pract 49:177, 1995.
Rintala AE, Nordstrom RE. Treatment of severe developmental asymmetry of the female
breast. Scand J Plast Reconstr Surg Hand Surg 23:231, 1989.
Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-Assisted Liposuction. St Louis: Quality Med-
ical Publishing, 1998.
Rohrich RJ, Parker TH III. Aesthetic management of the breast after explantation: evalua-
tion and mastopexy options. Plast Reconstr Surg 120:312-315, 2007.
Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary solution. Plast Recon-
str Surg 80:379-386, 1987.
Scuderi N, Dessy LA, Tempesta M, et al. Combined use of power-assisted liposuction and
trans-areolar incision for gynaecomastia treatment. J Plast Reconstr Aesthet Surg 63:e93-
e95, 2009.
Scutt D, Lancaster GA, Manning JT. Breast asymmetry and predisposition to breast cancer.
Breast Cancer Res 8:R14, 2006.
Shulman Y, Westreich M. Treatment of mild breast asymmetry. Plast Reconstr Surg 67:31-
33, 1981.
Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast
Reconstr Surg 51:48-52, 1973.
Simon BE, Hoffman S, Kahn S. Treatment of asymmetry of the breasts. A report of 30 cases
of developmental origin. Clin Plast Surg 2:375-390, 1975.
Smith GA. Hazard of inferior pedicle breast reduction concurrent with explantation of old
subglandular implants. Plast Reconstr Surg 97:254, 1996.
Smoot EC III. Eccentric skin resection and purse-string closure for skin reduction with mas-
tectomy for gynecomastia. Ann Plast Surg 41:378-383, 1998.

Spear SL, Davison SP. Aesthetic subunits of the breast. Plast Reconstr Surg 112:440-447,
2003.
Spence RJ, Feldman JJ, Ryan JJ. Symmastia: the problem of medial confluence of the breasts.
Plast Reconstr Surg 73:261-269, 1984.
Teimourian B, Adham MN. Simple technique for correction of inverted nipple. Plast Recon-
str Surg 65:504-506, 1980.
Teimourian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast Surg 7:155-157, 1983.
Vandenbussche F. Asymmetries of the breast: a classification system. Aesthetic Plast Surg 8:27-
36, 1984.
Von Heimburg D, Exner K, Kruft S, et al. The tuberous breast deformity: classification and
treatment. Br J Plast Surg 49:339-345, 1996.
Williams G, Hoffman S. Mammoplasty for tubular breasts. Aesthetic Plast Surg 5:51-56,
1981.
2645
Chapter 73  Management of Breast Asymmetry

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Treatment of Gynecomastia

DAX GUENTHER, RICHARD Y. HA,
ROD J. ROHRICH, JEFFREY M. KENKEL
CHAPTER 74

G
ynecomastia is a condition in which unilateral or bilateral benign excessive
breast development occurs in males. This is often an embarrassing and psy-
chologically troubling problem that prompts the patient to seek correction. Initially
thought to be a rare condition, a Navy study of recruits during World War II reported
an incidence of 25% with excess breast tissue; more recent studies have reported an
overall incidence of 32% to 36%, even as high as 40% of men in an autopsy series,
and 64.6% in adolescent boys. The incidence of bilateral involvement also varies in
the literature. The condition occurs bilaterally in 25% to 75% of patients. This wide
variation probably stems from an increased appreciation of the psychological, phys-
ical, and social impact of the condition, as well as the lack of a clear and standard-
ized definition within the plastic surgery and medical literature.
Etiologic Factors
The cause of gynecomastia is multifactorial, but in many cases an identifiable cause
is elusive. Most authorities attribute the condition to stimulation of breast tissue by
excess circulating estrogens or estrogen-like substances; this has been the basis for
recent attempts at medical therapy for gynecomastia. However, surgical removal of the
hypertrophic breast tissue remains the standard of treatment.
Gynecomastia has many identifiable causes, although idiopathic causes are the most
common (25%). Recent investigations have demonstrated pathophysiologic mecha-
nisms that involve a relative or absolute excess of estrogens, a decrease in circulating
androgens, or a defect in androgen receptors. There is strong evidence for the estrogen-
stimulating effects of breast tissue development as well as support for an inhibitory
androgenic effect. Decreases in the androgen-to-estrogen ratio have also been asso-
ciated with development of gynecomastia. No clear etiologic classification has been
suggested based solely on hormonal influences. Instead, most accept an arbitrary
classification based on physiologic, pathologic, pharmacologic, and idiopathic causes.
Physiologic gynecomastia can be further subdivided into neonatal, pubertal, and
elderly periods. Circulating maternal estrogens transferred by the placental-fetal cir-
culation are thought to contribute to excessive development of breast tissue in
neonates. Because this is usually a self-limiting process lasting from weeks to months,
treatment is rarely indicated. Up to 65% of adolescent boys exhibit varying degrees
of gynecomastia, which usually resolves over several months to years. The degree of
breast enlargement can be so minor as to escape recognition unless the area is clin-
ically palpated. Relative excess of plasma estradiol compared with testosterone is im-
plicated in the pathogenesis of pubertal gynecomastia. Older men (beginning at age
65) will often develop breast enlargement as plasma testosterone levels decline and
peripheral conversion of testosterone to estrogen (peripheral aromatization) occurs,
thus effectively increasing the plasma estrogen-to-androgen ratio.
2648
Part XI  Breast Surgery

2649
Chapter 74  Treatment of Gynecomastia
Causes of Gynecomastia
Developmental/Physiologic
 Neonatal
 Pubertal
 Aging
Drug-Induced (see box on p. 2650)
Hypogonadism
(decreased androgen synthesis or
increased androgen resistance)
 Primary
 Acquired (trauma, infection, torsion,
radiation exposure, mumps, chemo -
therapy)
 Congenital
 Secondary
 Hypogonadotropic hypogonadism
 Kallmann’s syndrome
 Pituitary failure (infarction, infection,
neoplasm)
Tumors (increased estrogen production)
 Steroid-producing (adrenal, testis)
 HCG-producing (testis and others)
 Aromatase-producing (testis)
 Bronchogenic carcinoma
Systemic
 Thyrotoxicosis (altered testosterone/
estrogen binding)
 Renal failure (acquired testicular failure)
 Cirrhosis (increased substrate for periph-
eral aromatization)
 Adrenal (ACTH deficiency or congenital
adrenal hyperplasia)
Congenital Disorders
 Klinefelter’s syndrome
 Enzyme defects of testosterone syn -
thesis (may be late onset)
 Vanishing testis syndrome (anorchia)
 Androgen resistance syndromes
 True hermaphrodism and related
conditions
 Increased peripheral tissue aromatase
Familial
 HIV
 Chest wall trauma
 Psychological stress
 Spinal cord injury
 Malnutrition/refeeding (increased sub-
strate for peripheral aromatization)
 Herpes zoster infection
 Cystic fibrosis
 Alcoholism
 Myotonic dystrophy
Idiopathic
ACTH, Adrenocorticotropic hormone; HCG, human chorionic gonadotropin; HIV, human immunodeficiency virus.

Pathologic gynecomastia occurs as a result of various metabolic disorders (alcoholic
cirrhosis, refeeding after a starvation state, feminizing adrenal tumors), endocrine
disorders (hyperthyroidism, adrenal cortical hyperplasia, hypothyroidism), acquired
hypogonadal states (orchitis, testicular trauma, granulomatous disease, renal failure,
alcoholism, myotonic dystrophy), congenital hypogonadal states (Klinefelter’s syn-
drome, congenital anorchia, androgen resistance), and increased estrogen states (bron-
chogenic carcinoma, true hermaphrodism, testicular tumors).
2650
Part XI  Breast Surgery
Drug-Induced Gynecomastia
I.
Drug Classes Associated With Gynecomastia
Estrogens
Gonadotropins
Androgens (aromatizable)
Antiandrogens (cyproterone, flutamide)
Cancer chemotherapy agents (especially alkylating agents)
Calcium channel blockers (verapamil, nifedipine, diltiazem)
ACE inhibitors (captopril, enalapril)
Antihypertensives (methyldopa, reserpine)
Digitalis preparations
Dopamine blockers (phenothiazines, metoclopramide, domperidone)
Central nervous system agents (tricyclics, diazepam, phenytoin, diethylpropion)
Drugs of abuse (marijuana, heroin, methadone, amphetamines)
Antituberculous agents (isoniazid, ethionamide, thiacetazone)
II.
Individual Drugs Commonly Associated With Gynecomastia
Cimetidine
Spironolactone
Ketoconazole
III. Miscellaneous Drugs Related to Gynecomastia
Amiodarone
Auranofin
Clomiphene
Etretinate
Metronidazole
Omeprazole
Penicillamine
Sulindac
Theophylline
ACE, Angiotensin-converting enzyme.

2651
Chapter 74  Treatment of Gynecomastia
Pharmacologic gynecomastia can occur by several mechanisms, such as increased
direct estrogenic activity, increased secretion of estrogen, decreased testosterone syn-
thesis, and decreased androgen sensitivity. Also, many drugs with poorly understood
mechanisms of action are associated with gynecomastia.
Bannayan and Hajdu identified three histologic patterns with varying degrees of stro-
mal and ductal proliferation: florid, intermediate, and fibrous types. The florid pat-
tern shows increased numbers of budding ducts in a highly cellular fibroblastic
stroma. The fibrous type has extensive stromal fibrosis with minimal ductal prolif-
eration. The intermediate type demonstrates overlapping of the fibrous and florid
histologic patterns. Most experts agree that these patterns represent a transition re-
lated to the duration of gynecomastia and its symptoms, with the florid type usually
seen in gynecomastia of less than 4 months’ duration and the fibrous type seen when
the gynecomastia has persisted for more than 1 year.
Associated Risks of Male Breast Cancer
One percent of all breast cancer occurs in males. However, patients with Klinefel-
ter’s syndrome have up to a 60 times greater risk of developing breast cancer; the in-
cidence is approximately 1 in 400 to 1 in 1000. Many studies reviewing males with
gynecomastia have demonstrated no increased risk of breast cancer compared with
the normal male population. Thus in all non-Klinefelter’s patients it is reasonable to
treat gynecomastia surgically with both liposuction and excisional techniques with-
out adding considerable morbidity or delaying the detection of male breast cancer.
In patients in whom hypogonadism is suspected, Klinefelter’s syndrome must be
ruled out, because this will ultimately have an impact on treatment. Because of the
oncologic risk, excisional techniques are preferred for these patients.
Evolution of Treatment
Gynecomastia of long duration is unlikely to regress spontaneously and will often
progress to irreversible dense fibrosis and hyalinization despite medical therapy. With-
drawal of an offending drug, correction of a systemic disorder, or the natural course
of physiologic gynecomastia often results in spontaneous regression of gynecomastia;
however, correction of an underlying disorder may not be effective in treating gy-
necomastia, especially if the duration of disease is lengthy and fibrosis of breast tis-
sue has already occurred. Thus surgery remains the standard for management.

2652
Part XI  Breast Surgery
Evolution of Surgical Techniques for Gynecomastia
Year
Innovator(s)
Surgical Technique
1946
Webster
1964
Barsky
and Simon
1966
Pitanguy
1969
Letterman
and Schurter
1972
Letterman
and Schurter
1972
Pers
1973
Simon
1974
Eade
1974
Wray
1978
Balch
1978
Artz and Lehman
1979
Davidson
1981
Fara
1982
Huang
1983
Teimourian
and Perlman
1986
Mladick
1987
Rosenberg
1987
Courtiss
1994
Samdal
1994
Abramo
1998
Smoot
1998
Ohyama
1998
Botta
1998
Rohrich, Beran,
and Kenkel
1999
Chiu
1999
Gingrass
Semicircular intraareolar incision (resection of cone-shaped mass
of breast tissue centrally with peripheral taper; reapproximate
fat beneath areola)
Inverted omega intraareolar incision (improved exposure to under
surface of areola)
Horizontal transareolar/intraareolar incision (improved exposure,
easier dissection, and hemostasis)
Superior periareolar incision with skin excision (for moderate to
large gynecomastia; excess skin resected and nipple transposed
superiorly)
Nipple transposition on single dermal pedicle with oblique incision
(nipple transposed medially and superiorly)
Nipple transposition on vertical bipedicle with horizontal incision
Excision redundant skin/breast tissue with free nipple graft
(excision located as ellipse around nipple)
Radial intraareolar incision
Excision redundant skin/breast tissue, nipple grafting with infra -
mammary fold scar (en bloc excision of breast tissue/skin with
free nipple grafting; inframammary fold scar not in continuity
with new nipple position)
Transaxillary approach (2-inch incision in axilla)
Dermal pedicle
Concentric circle technique (half-circle serves as dermal pedicle;
remaining half resected with breast tissue)
Single superior dermal pedicle
Concentric circle technique modification (no dermal pedicle; “apple
core” around nipple/areola, vascular supply from chest wall)
SAL with excision (SAL used in periphery to smooth contour)
SAL
SAL (SAL used to evacuate both adipose tissue and dense
parenchymal tissue in the breast, citing use of smaller 2.4 mm
cannula as critical component for effective evacuation of the
dense parenchyma)
SAL (useful in selected patients with predominantly fatty breasts
and well-located nipple/areola)
SAL
SAL (axillary approach for suction lipectomy)
Eccentric skin resection and purse-string closure
Endoscopic transaxillary approach
Circumareolar skin and SAL (technique described for patients with
severe gynecomastia)
UAL (UAL technique reviewed, used successfully in all three grades
of gynecomastia)
Pinwheel technique
UAL (excellent results using UAL for most types of gynecomastia)

2653
Chapter 74  Treatment of Gynecomastia
Surgical management, until recently, mostly consisted of excisional techniques. Stan-
dard suction-assisted lipoplasty (SAL) had an adjunctive role and was also advocated
as a primary mode of treatment. However, limitations were encountered when SAL
was used to treat severe cases or in breasts composed of primarily fibrous tissues.
Ultrasound-assisted liposuction (UAL), with known mechanical advantages in ad-
dressing dense, fibrous lipodystrophy, has extended the role of lipoplasty in the man-
agement of gynecomastia and has emerged as the preferred treatment modality. The
technique was first described with the use of ultrasonic energy transmitted through
excited piezoelectric crystals placed on terminal ends of suction cannulas to emul-
sify fat while preserving adjacent nervous, vascular, and connective tissue elements.
Emulsification is effected through cavitation of fat cells in tumesced fields.
The UAL technique has been further refined, incorporating a three-stage process of
subcutaneous infiltration of a wetting solution, followed by UAL, and completed by
evacuation and final contouring by SAL. Endpoints for UAL (time and loss of re-
sistance) differ from those for standard SAL (pinch and contour) but now provide
parameters for safe and efficient lipectomy. Power-assisted liposuction (PAL) has pro-
vided a useful modality for treating patients with more fibrous gynecomastia. There
have also been reports of laser lipolysis with pulsed 1064 nm Nd:YAG laser for the
treatment of gynecomastia. Regardless of the technology used, an aggressive surgi-
cal approach is required to treat the more fibrous type of gynecomastia.
Advantages of Ultrasound-Assisted Liposuction
UAL has several advantages over SAL in the treatment of gynecomastia. Several stud-
ies have confirmed the selective emulsification of fat, which leaves higher-density
structures such as fibroconnective tissue relatively undamaged. This allows more ef-
ficient removal of fat in areas that have higher densities of fibroconnective tissue,
such as the male breast. At higher energy settings, UAL is effective in removing the
denser fibrotic parenchymal tissue that SAL is inefficient in removing. In addition,
UAL performed in the appropriate subdermal plane affects the dermis, aiding in skin
retraction in the postoperative healing period. Further advantages of UAL include
the reduced physical demand for large-volume liposuction of the breast, which al-
lows the surgeon to contour the chest more precisely.
Indications and Contraindications
Some patients respond to nonsurgical management to correct underlying causes;
these treatments include medications to regulate hormonal imbalances and irradia-
tion. However, medical therapy with testosterone, antiestrogens (clomiphene and ta-
moxifen), and danazol has met with only limited success.

2654
Part XI  Breast Surgery
The surgeon and patient should consider proceeding with surgical management once
a diagnosis of gynecomastia from nonphysiologic causes is established or if gyneco-
mastia persists for longer than approximately 12 months. Hypertrophic breast tis-
sue beyond this stage usually becomes irreversibly fibrotic. Patients with Klinefelter’s
syndrome should be treated by mastectomy because of the increased risk of malig-
nancy. An algorithm for the diagnosis and directed treatment of gynecomastia is sug-
gested (see p. 2660).
Pertinent Anatomy
In a normal male, the breast is typically flat, with some fullness around the nipple-
areola complex. Glandular tissue is limited to the area directly beneath the nipple
and areola and is usually not palpable as a discrete mass. A muscular male chest may
exhibit superior fullness with a transition to a flat inferior chest near the inframam-
mary fold. The nipple-areola complex is normally 2 to 4 cm in diameter and located
over the fourth intercostal space. Nipple-to-sternal notch distance is 20 cm on aver-
age. Swelling associated with gynecomastia may occur as a circumscribed, firm, glan-
dular mass of varying size just beneath the areola, or it may be a diffuse fatty full-
ness of the chest with ill-defined margins. Extensive glandular enlargement extending
well beyond the areola has been described in body builders who use anabolic steroids.

Preoperative Assessment
A thorough medical history and clinical evaluation of the patient with gynecomastia
are paramount. However, further workup is rarely indicated. The history elicited
should include age, duration and onset of breast enlargement, symptoms of pain or
tenderness, medications and recreational drug use, and psychological and social ef-
fects. A review of systems should involve signs and symptoms of hepatic disease, hy-
perthyroidism or hypothyroidism, recent weight gain or loss, adrenal disease, alco-
holism, renal failure, and malignancies.
2655
Chapter 74  Treatment of Gynecomastia
Physical examination of the breasts should involve assessment for glandular or fat
predominance (by the pinch test), degree of glandular ptosis, skin excess, nodules or
masses, and nipple abnormalities or discharge. Glandular or parenchymal tissue is
characterized by rubbery breast tissue that is mobile and extends from a subareolar
centric position. Suspicious nodules or masses may have abnormal firmness, overly-
ing skin ulceration, eccentric location, or abnormal nipple discharge. In addition,
the physical examination should look for testicular enlargement or atrophy and asym-
metry, thyromegaly, hepatomegaly, pulmonary abnormalities, and abdominal masses.
Additional diagnostic testing should be individualized to address abnormalities iden-
tified in the history or physical examination. Cohen et al and McGrath suggested in-
dividualized workups, depending on the patient’s age at the time the gynecomastia
developed. These considerations are important, but arbitrary use of “screening” tests
or laboratory data is not recommended. Rarely is an extensive workup indicated,
and often this will have no impact on treatment.

Certain clinical findings should prompt further evaluation. In the scenario of a young
(especially prepubertal) patient with a normal history and bilateral gynecomastia,
testicular ultrasonography in conjunction with a careful testicular examination has
been found to be cost-effective. The incidence of a functional endocrine tumor in this
group is significant. Physical examination findings of feminization, including small
testicular size (less than 3 cm in length or 8 cc in volume), lack of male hair distri-
bution, or a eunuchoid body habitus, suggest a possible feminizing tumor. Endocrine
testing in this situation (serum testosterone, luteinizing hormone, estradiol, and de-
2656
Part XI  Breast Surgery
FSH, Follicle-stimulating hormone; HCG, human chorionic gonadotropin; LH, luteinizing hormone.
Guidelines for Clinical Evaluation of Gynecomastia
Consider
Tests
Prepubertal girls
Prepubertal boys
Pubertal males with
normal external genitals
Pubertal males
with ambiguous genitals
Adult males
Premature thelarche
Exogenous hormones or drug usage
Premature puberty
Feminizing adrenal carcinoma
Idiopathic cause
Drug use
Premature puberty
Feminizing carcinoma (Leydig cell tumor,
adrenal carcinoma)
Physiologic
Klinefelter’s syndrome
Congenital anorchism
Drug use
Feminizing carcinoma (Leydig cell tumor,
adrenal carcinoma)
Androgen biosynthetic defects
Partial androgen resistance
True hermaphrodism
Mixed gonadal dysgenesis
Testicular failure (viral orchitis, trauma)
Ectopic gonadotropin production
Feminizing adrenal carcinoma
Drug use
Chronic liver disease/cirrhosis
Renal failure
Thyrotoxicosis
Idiopathic causes
Serum estradiol level
CT scan abdomen/adrenal
LH/FSH (elevations may occur only at night)
Bone age
Serum estradiol
LH/FSH
HCG
Bone age
If HCG elevated, testicular ultrasound or
thermography  karyotype
LH/FSH
Testosterone (total and free)
Estradiol
HCG
If testosterone low and LH/FSH elevated,
karyotype
If estradiol is elevated, adrenal CT scan
LH/FSH
Testosterone (total and free)
Estradiol
Karyotype
Scans or exploration as indicated
 Androgen receptor analysis
 Androgen biosynthetic intermediate
LH/FSH
Testosterone
Estradiol
HCG

hydroepiandrosterone) is appropriate. If feminizing characteristics are found in as-
sociation with a marfanoid body habitus, karyotyping and an endocrine referral are
indicated to rule out Klinefelter’s syndrome.
Preoperative Planning
Classification and Treatment
Several treatment classification systems have been developed and excellent guidelines
have been proposed for graduated management of gynecomastia based on degrees
of lipodystrophy and skin excess.
We proposed a classification system in which candidates for surgical treatment are
graded on the basis of the amount and character of breast hypertrophy, as well as
the degree of ptosis. These grades can be further subdivided into grades IA and IIA
for primarily fatty breast tissue and grades IB and IIB for primarily fibrous breast
tissue. In this system, UAL and SAL are the primary treatment modalities.
2657
Chapter 74  Treatment of Gynecomastia
Classification and Management of Gynecomastia
Grade I
Minimal hypertrophy (250 g of breast tissue) without ptosis
IA
Tissue type: Primarily glandular*
Treatment: UAL or SAL
IB
Tissue type: Primarily fibrous*
Treatment: UAL or SAL
Grade II
Moderate hypertrophy (250-500 g of breast tissue) without ptosis
IIA
Tissue type: Primarily glandular*
Treatment: UAL or SAL
IIB
Tissue type: Primarily fibrous*
Treatment: UAL or SAL
Grade III
Severe hypertrophy (500 g of breast tissue) with grade I ptosis
Tissue type: Glandular or fibrous*
Treatment: UAL, 6-month staged excision†
Grade IV
Severe hypertrophy (500 g of breast tissue) with grade II or III ptosis
Tissue type: Glandular or fibrous*
Treatment: UAL, 6-month staged excision†
*Fatty and glandular tissue is determined by a pinch test medially, laterally, and beneath the nipple-areolar complex.
†Delayed excision of remaining ptotic breast skin and/or breast parenchyma is performed 6 to 9 months after UAL to
allow for maximal skin retraction.

2658
Part XI  Breast Surgery
Grade I
Patients with grade I gynecomastia have minimal hypertrophy (less than 250 g of
breast tissue).
Grade II
Patients with grade II gynecomastia have moderate hypertrophy (between 250 and
500 g of breast tissue).

Grades III and IV
2659
Chapter 74  Treatment of Gynecomastia
Patients with grades III and IV gynecomastia have severe hypertrophy (greater than
500 g of breast tissue) but are distinct because they have a greater degree of ptosis.
Patients with grade III gynecomastia exhibit grade I ptosis, whereas patients with
grade IV gynecomastia have grade II or III ptosis.
Power-assisted liposuction (PAL) and UAL are effective in all grades of gynecomastia.
While they remain the primary treatment modality, increasingly it is becoming com-
mon to supplement PAL or UAL with partial resection of the retroareolar fibro -
glandular tissue. This may be accomplished via minimal periareolar incisions or the
incisions used for the liposuction. Usually no further treatment is needed in grade I
or II gynecomastia, and often a single UAL or PAL treatment is all that is necessary
for grades III and IV, especially in patients with mild ptosis and good skin quality.
Suction-assisted liposuction is a suboptimal modality for more severe gynecomastia
(grades III and IV) and for patients whose glandular component is primarily fibrous
tissue. Patients with grades III and IV gynecomastia may require staged excision.

2660
Part XI  Breast Surgery
Abnormal
physical
examination
EVALUATION AND TREATMENT OF GYNECOMASTIA
Negative history
and normal
physical
examination
Persistent
gynecomastia
Drug history: Discontinue drug
Systemic disease: Correct underlying disease
Klinefelter’s syndrome: Karyotype, bilateral mastectomy
Prepubertal, bilateral disease: Testicular ultrasound
Detailed patient history and physical examination
(risk factors and medications)
Testicular mass: Testicular ultrasound, serum testos-
terone, LH, estradiol, and DHEAS; urology and endo -
crine con sultation
Thyroid mass: Thyroid function tests; endocrine consul-
tation
Breast mass: Mammography, ultrasound, biopsy; surgi-
cal oncology consultation
Hypogonadism: Serum LH/FSH, estradiol, testos-
terone, and DHEAS;  karyotype;  adrenal CT
scan; endocrine consultation
Abdominal masses/Hepatomegaly: Liver function tests;
serum LH/FSH, estradiol, testosterone, and DHEAS;
 abdominal CT scan; endocrine consultation
Positive history
Normal after
workup
CT, Computed tomography; DHEAS, dehydroepiandrosterone; FSH, follicle-stimulating hormone; LH, luteinizing hormone.
12 months’
duration
12 months’
duration
Gynecomastia
Classification and Treatment
Grade IA
UAL or SAL
Grade IB
UAL
Grade IIA
UAL or SAL
Grade IIB
UAL
Grade III
UAL  staged excision
Grade IV
UAL  staged excision
Normal after
workup
Observation

Operative Technique
Markings
Markings are made preoperatively to outline
boundaries of treatment. The outer perimeter of
the breast base is marked initially, followed by the
area of breast enlargement. The inframammary
fold should be marked preoperatively with the pa-
tient sitting or standing. Adherent zones in the up-
per outer quadrants, where the breast retreats into
axillary tissue, should be suctioned with caution.
2661
Chapter 74  Treatment of Gynecomastia
Incision Placement
UAL access incisions are made inferolaterally in the inframammary fold. Occasion-
ally, a second incision is made near the anterior axillary fold to facilitate evacuation
and final contouring in patients with grade III ptosis and large fat deposits. UAL
should not be performed through this incision because the overlying skin is quite
thin and prone to thermal injury.
Anesthesia
A general anesthetic is administered, and the patient is positioned supine with the
arms abducted. Incisions (3 to 4 mm) are made with a No. 11 scalpel in the lateral
inframammary folds bilaterally for optimal access to the dense breast parenchyma.
This route also provides superior access to obliterate the inframammary fold and to
suction the medial chest.
Subcutaneous infiltration of wetting solution in the intermediate fat layer is per-
formed using a standard infiltration pump and a 3 mm cannula. A superwet tech-
nique with a 1:1 ratio of infiltrate to estimated aspirate is used with a solution con-
taining 1 L of lactated Ringer’s solution mixed with 1 ampule of 1:1000 epinephrine
and 30 cc of 1% lidocaine. Uniform infiltration can be challenging, and it is impor-
tant to infiltrate all treatment areas in multiple layers systematically.
Technique
UAL is performed with an ultrasound generator (Mentor, Santa Barbara, CA, or
LySonix, Carpinteria, CA), a 5 mm blunt-tipped titanium cannula or a 4 mm golf-tee
cannula, and a standard surgical aspirator for evacuation. The Mentor Contour Gen-
esis generator is set at an energy level ranging from 70% to 90%, with 90% being
especially effective in the denser subareolar areas. The energy level on LySonix gen-
erators should be set between 5 and 7.

2662
Part XI  Breast Surgery
Volumes of aspirate and time of application are recorded. If the Vaser system is used
(see Chapter 78), a single ring probe in the continuous mode at higher energy levels
(greater than 90%) is effective. The stroke technique involves constant, deliberate
passes of the cannula through the intermediate fat layer in a radial fashion from the
lateral inframammary fold incisions. Additional passes are concentrated in the unique
subareolar region where maximal fibroconnective density occurs.
A bimanual technique is used, with the nondominant hand guiding the UAL can-
nula through the subdermal layer. Liposuction of the subdermal layer is not a tra-
ditional level of treatment in UAL, but it is particularly important in addressing the
dense fibrous tissue of gynecomastia and allowing maximal skin retraction. The pe-
riphery is treated for feathering and contouring. Disruption of the inframammary
fold is essential in achieving a more gradual transition of the breast to the abdomen,
which is characteristic in males (as opposed to the distinct demarcation of the in-
framammary fold in females). The adherent zones in the upper outer quadrants, as
the breast retreats into axillary tissue, should be suctioned minimally, if at all (only
for contouring), and extreme caution should be exercised.
PAL is also effective in treating gynecomastia. It is excellent for initial fat removal in
fibrous areas, followed by treatment with SAL.
SAL is performed in standard fashion using 3.0 and 3.7 mm cannulas for final con-
touring and evacuation of emulsified fat. Evacuation should occur from the deep fat
layer to the intermediate fat layer. Great care is taken to avoid overcontouring the
area overlying the upper lateral pectoralis major muscle. After evacuation is com-
plete, incisions are closed with 5-0 fast-absorbing plain gut sutures.
It is important to remember that the goal of UAL, PAL, or SAL in the treatment of gy-
necomastia is to restore normal male breast contour, not to eliminate all breast tissue.
Achieving optimal results involves eliminating the excess breast tissue and perform-
ing peripheral contouring. The normal male breast has some subareolar fullness,

with varying degrees of superior chest wall volume. Using UAL, PAL, or SAL ap-
propriately can avoid the “saucer deformities” that can be seen with overzealous re-
section from excisional techniques.
If additional contouring is necessary, an inferior semicircular periareolar incision is
made to allow for direct access to any remaining fibroglandular tissue. Fibrous frag-
ments are sequentially grabbed with a clamp and sharply excised under direct vision.
Care is taken to not overly thin the subareolar area as this will create a contour de-
pression. Leaving an approximately 0.5 cm thick portion of retroareolar glandular
tissue avoids this complication.
Our preference is not to address skin excess at the initial operation. If removal of re-
dundant skin and/or resistant lipodystrophy is still required after UAL or PAL, a
staged excision is delayed for 6 to 9 months to allow for maximal skin retraction
and healing. Thus the magnitude of the excisional technique and the resultant scar-
ring can be minimized. A staged excision can be accomplished through a periareo-
lar approach in most cases. Excision through extensive breast mound incisions has
rarely been required.
Postoperative Care
The chest wall is dressed with a double layer of TopiFoam, and the patient wears a
compressive vest for 4 weeks, 24 hours a day, followed by 4 weeks at nighttime only.
Compressive therapy is critical in the postoperative period to prevent seroma or
hematoma formation and to provide optimal contouring.
Patients should be followed periodically. Transient alterations in nipple sensation are
rare, and affected patients can be reassured that sensation will return. If redundant
skin or fibrous tissue persists, staged excision can be accomplished 6 to 9 months af-
ter surgery.
Outcomes
Courtiss reviewed 159 patients who underwent surgical management for gyneco-
mastia; 101 patients (192 breasts) were treated with excisional techniques. Courtiss
reported a high rate of complications with excisional techniques, including overre-
section (18.7%), unattractive scarring (18.7%), hematoma (16.1%), seroma (9.4%),
and underresection (21.9%).
2663
Chapter 74  Treatment of Gynecomastia

2664
Part XI  Breast Surgery
In a series of 60 patients treated with UAL reported by Gingrass, no major compli-
cations, hematomas, or episodes of skin necrosis were reported over a 4-year follow-
up period; results were reported as “uniformly good to excellent.”
In a review of 61 patients by Rohrich and colleagues, no additional treatment was
required in 86.9% of patients (53/61). Eight patients, four with grade III disease and
four with grade IV gynecomastia, required staged excision of remaining breast tis-
sue and skin (6 to 9 months after UAL) to optimize results.
Results
The following patients were treated with a combination of SAL and UAL for gy-
necomastia grades I through IV. All postoperative results demonstrate excellent
restoration of normal male breast contour.
This 32-year-old man with grade IA gynecomastia was treated by UAL; 175 cc was
removed from each side. He is seen 6 months postoperatively.

This 13-year-old boy with grade III gynecomastia was treated with UAL of the chest
and disruption of the inframammary fold; approximately 350 cc was removed from
each side. His initial result is seen 1 year later. He requested further improvement,
so a second procedure was performed (bottom row) in which a persistent glandular
remnant was removed and a periareolar skin excision was performed.
2665
Chapter 74  Treatment of Gynecomastia

This 22-year-old man had grade IA gynecomastia. He underwent UAL removal of
200 cc from each side. He is seen 15 months postoperatively.
2666
Part XI  Breast Surgery

This 19-year-old man had grade IIB gynecomastia. He underwent UAL removal of
375 cc from each side. He is seen 6 months postoperatively.
2667
Chapter 74  Treatment of Gynecomastia

This 26-year-old man presented with grade IA gynecomastia. He is seen 6 months
postoperatively after UAL removal of 200 cc from both sides of the chest and dis-
ruption of the inframammary fold.
2668
Part XI  Breast Surgery