Cosmetic Combined Use of Ultrasonic Liposuction with the Pull
Transcription
Cosmetic Combined Use of Ultrasonic Liposuction with the Pull
Cosmetic Combined Use of Ultrasonic Liposuction with the Pull-Through Technique for the Treatment of Gynecomastia Dennis C. Hammond, M.D., Jame F. Arnold, M.D., Amy M. Simon, M.D., and Philippe A. Capraro, M.D. Grand Rapids, Mich. The authors present a method of treatment for gynecomastia that combines the use of two techniques of softtissue contouring. This method uses ultrasonic liposuction in conjunction with the pull-through technique of direct excision to effectively remove the fibrofatty tissue of the male breast and the fibrous breast bud through a single 1-cm incision. Fifteen patients were treated in this fashion, and each patient demonstrated a smooth, masculine breast contour with a well-concealed scar, which eliminates the stigma of breast surgery. The procedure is technically straightforward and provides consistent results. It is offered as an additional option for the treatment of gynecomastia. (Plast. Reconstr. Surg. 112: 891, 2003.) Gynecomastia presents as a persistent enlargement of the breast with variable excess of skin, fat, and breast parenchyma. It is the most common breast problem in men,1 occurring in a bimodal pattern of distribution affecting pubertal and elderly male patients. Pubertal male patients are most successfully treated with patience and reassurance, because the vast majority of these patients will experience complete resolution with time. Gynecomastia that persists past puberty or presents in an elderly patient deserves more aggressive management to restore normal body habitus, relieve associated pain, and rule out the rare possibility of malignancy.2 Numerous methods of treatment have been described that accomplish removal of involved tissue by direct open excision, liposuction, or some combination. Direct excision of the male breast may result in irregular contour defects and unsightly scarring that can be aesthetically worse than the presenting problem (Fig. 1). Liposuction easily removes adipose tissue but is FIG. 1. Appearance of the chest wall in a mature patient who underwent bilateral excision of gynecomastia 20 years previously through a transverse incision across the superior aspect of the areola. The excessively long and now atrophic scar is representative of the unfortunate sequelae of male breast surgery. less effective in treating the fibrous parenchymal component of the breast.3– 6 Combining traditional liposuction with direct pull-through surgical excision of the breast bud has been described by Morselli.7 We suggest modifying his technique to incorporate ultrasonic liposuction, which more effectively treats fibrous fatty tissues.8,9 This method permits both liposuction and sharp resection of breast parenchyma through a single 1-cm incision placed strategically along the inferior margin of the areola or in the inframammary fold. This combined approach thus maximizes each of the individual techniques, resulting in effective resection of the enlarged male breast while maintaining an aesthetically pleasing result. From the Center for Breast and Body Contouring. Received for publication August 2, 2002; revised October 14, 2002. DOI: 10.1097/01.PRS.0000072254.75067.F7 891 892 PLASTIC AND RECONSTRUCTIVE SURGERY, TECHNIQUE The patient is marked in the upright position in the office the day before the operation. The inframammary fold is marked. Using the topographic map technique, the remainder of the breast is marked to identify the points of greatest elevation (Fig. 2, above). General anesthesia is used for the procedure, although local anesthesia with intravenous sedation can be used if preferred. The patient is positioned supine on the operating room table with the September 1, 2003 arms abducted and secured to arm boards. A 1-cm stab incision is made along the inferior border of the areola, and tumescent solution is infiltrated into the breast parenchyma. Early in our series, the incision was placed in the inframammary fold. To strategically camouflage the scar, we later placed the incision in the periareolar location. This also offered the advantage of a more direct and precise “pullthrough” of the breast bud. Ultrasoundassisted liposuction is then performed in a FIG. 2. (Above) Preoperative appearance of a 16-year-old male patient with persistent unilateral enlargement of the right breast. The marks delineate the area to be treated with ultrasonic liposuction. (Below, left) After ultrasonic liposuction is complete, the residual mound of fibrous breast tissue in the subareolar region is sharply excised using the pull-through technique. (Below, right) Appearance of the excised breast bud removed from under the areola. The tissue is removed in strands after being “morselized” with the ultrasonic liposuction probe. Vol. 112, No. 3 / 893 TREATMENT OF MALE GYNECOMASTIA FIG. 3. (Left) Preoperative appearance of a 14-year-old male patient with bilateral gynecomastia. (Right) The 10-week postoperative result shows a normal chest wall contour with well-concealed scars. radial fashion, with care taken to feather the breast along the periphery. The ultrasonic liposuction cannula is passed multiple times in the area of the more fibrous breast bud to morselize the tissue. Scavenging liposuction is then performed to remove any excess fluid and retained fat. The endpoint of suction lipectomy is assessed by pinch test, by the quality and quantity of aspirate, and by resistance to passage of the cannula. Completion of the suction reveals a residual mound of fibrous breast tissue of varying size directly beneath the nipple and areola. This subareolar breast bud can be successfully resected through the periareolar incision. The tissue is grasped with a clamp, pulled out through the incision, and sharply excised under direct vision (Fig. 2, below, left). Typically, the fibrous breast bud is removed in strands until no further palpable tissue remains, allowing complete control of the resection (Fig. 2, below, right). Caution must be taken to avoid overly aggressive resection to prevent a depression of the nipple-areola complex or “saucer” deformity. The excised breast tissue is sent to the pathology laboratory to rule out the rare possibility of malignancy. The incision site is then closed with interrupted dermal and running subcuticular 4-0 Monocryl sutures (Ethicon, Inc., Somerville, N.J.). Drains are not necessary. Steri-Strips (3M, Minneapolis, Minn.) and a gauze dressing are then applied. The patient is fitted with a compression garment that is worn for 1 week after the operation. RESULTS Twenty-seven breasts in 15 patients were treated by a single surgeon using this combined method of ultrasonic liposuction with the pull-through technique. Patients ranged in age from 12 to 69 years and had an average age of 27 years. Follow-up time ranged from 1 day to 47 months, with an average follow-up time of 8.2 months. In the first five patients, all of whom had bilateral gynecomastia, an inframammary incision was used as previously described by Morselli.7 In the remaining 10 patients, seven of whom had bilateral disease, the inframammary incision was replaced with a less conspicuous inferior periareolar incision. Both 894 techniques were noted by the surgeon to produce a smooth, masculine breast contour (Figs. 3 and 4) and an inconspicuous scar (Fig. 4, below). The periareolar incision offered the added benefit of a strategically camouflaged scar in the margin of the areola, thus minimizing the stigma of breast surgery. A retrospective review of patient charts revealed that all patients were pleased with their results. Long- PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2003 term follow-up showed that results were stable over time. There were no cases of nipple-areola complex necrosis, saucer deformity, contour irregularity, hematoma, or infection. One patient had a slight scar retraction at the nipple-areola complex incision site that resolved spontaneously. Another patient developed a seroma that resolved promptly after a single aspiration. FIG. 4. (Left, above and center) Preoperative appearance of a 15-year-old male patient with bilateral gynecomastia, with the left side greater than the right side. (Right, above and center) The 7-month postoperative result demonstrates a smooth masculine contour with no surface irregularities. (Below) The inferiorly located periareolar scar remains well concealed. Vol. 112, No. 3 / 895 TREATMENT OF MALE GYNECOMASTIA One ultrasound-assisted liposuction entrance site burn was noted, and one patient developed a small area of epidermolysis; both conditions healed spontaneously. Although nipple-areola complex sensitivity was not specifically assessed, only one patient reported a decrease in sensation in this area. Each of the complications listed was minor and did not compromise the final result. No revisions were necessary. Histologic analysis of the resected specimens revealed a benign hypertrophy consistent with gynecomastia. There was no evidence of malignancy in any of the specimens. DISCUSSION Treatment of gynecomastia presents the dual challenge of adequate treatment of the disease while minimizing the perceptible stigma of breast surgery. The proposed technique accomplishes both of these tasks consistently. Ultrasonic liposuction effectively removes dense adipose tissue from within the fibrous parenchymal framework of the breast. The remaining fibrous breast bud is then easily mobilized and sharply excised via the 1-cm inferior periareolar incision. The removal of this tissue in small strands facilitates precise control of the resection, decreasing the potential for contour defects. The resulting periareolar scar is barely perceptible after it has completely matured, thus leaving no stigma of breast surgery. Ultrasonic liposuction offers several advantages in the treatment of gynecomastia. It is physically less strenuous8,10 and much more effective in treating fibrous areas8,9 than traditional liposuction. It also is reported to enhance skin contractility, which, if true, may be advantageous in reducing skin redundancy associated with more severe cases of gynecomastia.9,10 Although this technique does not rely on potential skin retraction caused by ultrasoundassisted liposuction, such an effect could be considered an added benefit of the procedure. Profound skin retraction was not observed clinically in this series of patients. Because ultrasonic liposuction creates an airbrush effect at the tip of the probe, there is minimal if any need for cross-tunneling, which thus enables the surgeon to minimize the overall number of incisions.11 A total of five complications were reported in a series of 27 breasts. These complications were minor, did not compromise the final result, and did not require further surgical treatment. SUMMARY A surgical approach for the treatment of gynecomastia is presented that combines the use of ultrasonic liposuction with direct excision, enabling effective treatment of both the fibrous and fatty tissues of the male breast. The addition of ultrasonic liposuction to the pullthrough method of direct excision facilitates the entire operation via a single 1-cm periareolar incision. This enables a precisely controlled volume reduction and adds the benefit of an imperceptible scar. A smooth masculine breast contour can then consistently be achieved while eliminating the stigma of breast surgery. Dennis C. Hammond M.D. Center for Breast and Body Contouring 4070 Lake Drive, S.E. Grand Rapids, Mich. 49546 cbbcmain@iserv.net REFERENCES 1. Williams, M. J. Gynecomastia: Its incidence, recognition and host characterization in 447 autopsy cases. Am. J. Med. 34: 103, 1963. 2. Fodor, P. G. Breast cancer in a patient with gynecomastia. Plast. Reconstr. Surg. 84: 976, 1989. 3. Courtiss, E. H. Gynecomastia: Analysis of 159 patients and current recommendations for treatment. Plast. Reconstr. Surg. 79: 740, 1987. 4. Reed, L. S. Gynecomastia: Analysis of 159 patients and current recommendations for treatment (Discussion). Plast. Reconstr. Surg. 79: 751, 1987. 5. Courtiss, E. H. Reduction mammaplasty by suction alone. Plast. Reconstr. Surg. 92: 1296, 1993. 6. Lejour, M. Reduction mammaplasty by suction alone (Discussion). Plast. Reconstr. Surg. 92: 1286, 1993. 7. Morselli, P. G. “Pull-through”: A new technique for breast reduction in gynecomastia. Plast. Reconstr. Surg. 97: 450, 1996. 8. Maxwell, G. P., and Gingrass, M. K. Ultrasound-assisted lipoplasty: A clinical study of 250 consecutive patients. Plast. Reconstr. Surg. 101: 89, 1998. 9. Rohrich, R. J., Beran, S. J., Kenkel, J. M., Adams, W. P., and DiSpaltro, F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast. Reconstr. Surg. 101: 1090, 1998. 10. Zocchi, M. L. Ultrasonic-assisted lipoplasty. Clin. Plast. Surg. 23: 575, 1996. 11. Gingrass, M. K. Lipoplasty complications and their prevention. Clin. Plast. Surg. 26: 341, 1999.