Dear Colleagues ,

I would advice to have first an ultrasound of the breast to evaluate the amount of gland and of fat of the male gland; 2) if you have a prevalence of the fat compartment do lipo and see the resilience of the skin; 3) last resort are the reducing skin procedures : a) periareolar or b) inverted T ( remember to reposition the NAC no farther than 3 cm from the IMF

True Gynecomastia- Excision of glandular tissue with or without excision of skin (as indicated)l skin may be excised later on in next stage

Pseudo Gynecomastia (fat only)- Liposuction with or without excision of skin (as indicated)l skin may be excised later on in next stage + pressure garment 3 weeks

Mixed Gynecomastia (fat+ gland)- Liposuction + excision of glandular tissue with or without excision of skin (as indicated)l skin may be excised later-on in next stage + pressure garment (if glandular tissue is destroyed using canula /sharp canula pressure garment for 3 months minimum- chances of developing hard nodule of healing breast tissue may be seen in these case, which requires re-excision)

refer to Paul Levick in Birmingham,UK,or at least contact him. He is a great teacher. He has an amazingly simple technique- removes true glandular gynaecomastia under LA via small transaxillary incision. Not endoscopic either. Best results that I have seen.

My approach is the following

Use tumescent anesthesia

Liposuction this will help remove fat and separate the gland from the subcutaneus tissue.

Incision is periareolar 3-9 with the sharp development of a “nipple flap”.

Following this the gland is separated from the pectoralis.

In case a skin reduction is necessary I perform a deepithelization around the nipple and incise the skin from within this areas and proceed as above (see the paper by Davidson). I close the skin using Gortex CV-3 on a separate straight needle using a cogwheel pattern followed by monocryl.

I believe the wise pattern anchor form should be avoided if possible in men.

I agree with Pramod Kumar.

Concerning skin resection it may be better in milder cases to perform it in a second stage as the skin often contracts more then expected and skin resection may not be necessary. This may especially be the case in pseudo gynecomastia and when a radical liposuction not only including the breast, but also most of the thorax is performed.

Scars very often have a poor quality and the areola tends to get larger especially after periareolar skin resection.

If skin resection is necessary we prefer an inferior based approach, but instead of an inverted t incision be only use a submammary incision combined with a periareolar one.

Dear Friends,

I have always removed gynecomastia through 1 - 1.5 cm  transareolar keyhole incision since 1989, where I have used liposuction + excision + bipolar cautery + compression graments and have satisfaction of good results and many happy patients as the scars hardly show. The importance of surgery in gynecomastia is to remove the gland in the most imperceptible manner so that patient can take off his shirt in public, in the gym, swimming pool or amongst his peers without embarrassment of being asked , "Hey, what is that scar on your chest / Nipple." Transareolar approach has the benifit of masking the scar in the creases of the nipple and the pigmentation if any does not show. Also keloids are rarely known to have happened in the areola. The nipple is not transacted, as in Pitanguay.

The surgery of gynecomastia is partially successful if the scars of the surgery show and the patient is not willing to take off his shirt in public. i have not done a skin resection ever.

If need be in cases such as shown above, If patient can be persuaded one can  try  to do it in two sittings. In the first sitting, remove the breast tissue, through transareolar approach, as much as possible and anchor the nipple in the normal place to the chest wall with a non absorbable suture.  It is important to ensure strictly that there is no hematoma whatsoever, with strict intraoperative hemostasis as well as adeaquate drainage with compression post operatively. Then give a compression garment for six months, wait for a maximum retraction. Go again and remove the residual gynecomastia through the same approach and reanchor the nipple. We may get amazing  result at the end of one year after compression, without any visible scars on the skin.

Smart Lipo is safe and best option . Two traetments can give good result.

We should not forget to check if gynecomastia is a para-neoplastic phenomenon in older men as a result of cancer of the lung or tumors of the testis or adrenals. If they are ok then consider any type of surgery to remove the excess tissue as it has been described by any of the above doctors. 

I agree with Evangelos Athanassiou.

We should not forget that also the cirrhosis of the liver can be cause of gynecomastia. Surgical procedures has been described excellent.

I agree

subcutaneuos mastectomy with periareolar incision

This seems to be the opinion of most suergons, see the publication:

https://www.researchgate.net/publication/260031291_Gynecomastia_surgery_in_the_Netherlands_What_why_who_where?ev=prf_pub

Article Gynaecomastia surgery in The Netherlands: What, why, who, where ...

Of course we can never standardize our plan. Indication is  most important. We have so

many options now! BUT:

for the standard medium size gynaecomastia i have the following plan:

No smoking for 6 weeks and a normal BMI are mandatory.

my surgical plan consist of some liposuction around the gland.

Usually peri-areolar doughnut de-epthilialisation, followed by nearly total excision of the

gland,  leaving a small flat piece under the nipple to prevent retraction.

I don't put any drains, just a good elastic bandage for 2 weeks is enough.