Male Breast Reduction: Liposuction Versus Excision

Charles M. Malata

Samuel G. Coulson

Male breast reduction is performed for gynecomastia and pseudogynecomastia. Gynecomastia is benign enlargement of the male breast due to the proliferation of glandular, fibrous, and fatty tissue. Pseudogynecomastia or lipomastia is proliferation of breast adipose tissue without a concomitant increase in the glandular component. Both conditions may occur with or without skin excess. Male breast enlargement is a common problem and male breast reduction is one of the commonest male aesthetic procedures performed being 3rd in the United States (1) and 4th in the UK (2). In 2018 for instance 24,753 and 285 such cases were performed in the United States and UK, respectively (1,2). This is not surprising as surgery is the most effective treatment modality for male breast enlargement. This dates to the 7th century AD by Paulus Aegineta.

Surgery is indicated if the breast enlargement is persistent, fails to respond to medical therapy, or is in the fibrous phase. By far the commonest indication is the psychological effect of the enlarged male breasts with a female chest wall contour. The goal of any corrective therapy is to restore a normal masculine contour to the chest with minimal scarring while maintaining the viability of the nipple areolar complex (NAC) (3).

There are two principal modalities for reducing enlarged male breasts, namely liposuction and excision, and these may be used alone or in combination. Indeed, the biggest advance in the treatment of gynecomastia was the advent of liposuction when combined with open excisional surgery (3,4,5,6). Contemporary surgical options currently focus on initial liposuction for the removal of excess fatty tissue while several excisional modalities are used for the removal of any residual glandular tissue and/or excess skin. This chapter provides a comparative analysis of the roles of liposuction and excision in the treatment of gynecomastia. It is a distillation of the senior author’s personal experience over a 20-year period (3,7,8,9,10,11,12,13).

Indications and Decision Making

Gynecomastia can be physiologic, pathologic, pharmacologic, or most commonly idiopathic. Diagnosis is made by careful history and clinical examination. It can present as a unilateral or bilateral condition. Unilateral gynecomastia should always raise the suspicion of malignancy, especially if firm, nontender, irregular and not located behind the NAC. Specialized imaging is only indicated where there is suspicion of breast cancer. Most patients present to plastic surgeons after work-up by the endocrinologists, pediatricians, oncologic breast surgeons, urologists, general practitioners (GPs), radiotherapists, etc.

Indications for surgical intervention in gynecomastia are shown in Table 43-1. Psychological “morbidity” is the most frequent indication for surgery. A recent systematic review found that surgical management is beneficial in improving a number of psychological domains in gynecomastia patients (14). The choice of surgical treatment of gynecomastia and pseudogynecomastia depends on the grading characteristics of the breast (Table 43-2). Although Simon et al.’s (15) and Rohrich et al.’s (16) classifications are generally useful, there is some overlap between the categories leading to interobserver variability and therefore a lack of reliability in treatment algorithms based on such grading systems. Additionally, of the many published algorithms none are universally applicable to all causes of gynecomastia (17).
The ideal classification should guide surgery and be easy to use. At the same time Waltham et al. recommend that it must ideally include “a comprehensive set of clinically appropriate patient-related features, such as breast size, breast ptosis, tissue predominance, and skin redundancy” (17). In our practice we classify patients into two groups: small to moderate size with minimal skin excess, and moderate to large size with skin excess (3,10). We also assess the breast shape and consistency besides the presence or otherwise of well-developed inframammary folds (IMFs).

TABLE 43-1 Indications for Male Breast Reduction

Persistent enlargement following puberty >2 yrs and exclusion of medical causes
Failure of medical treatment
Severe breast enlargement
Unilateral disease or significant asymmetry
Severe psychosocial effects or morbidity
Patient wishes
Gynecomastia in the fibrous phase
Post massive weight loss
Specific pharmacologic causes:
- Prostate cancer treatment
- Anabolic steroid or cannabis use (likely to fail medical treatment)

TABLE 43-2 Classification of Gynecomastia

Simon et al.’s Classification of Gynecomastia (1973) (15)
Grade	Features
Grade 1	Small enlargement, no skin excess.
Grade 2a	Moderate enlargement, no skin excess.
Grade 2b	Moderate enlargement, with skin excess.
Grade 3	Marked enlargement, with skin excess.
Rohrich et al.’s Classification of Gynecomastia (2003)^a (16)
Grade	Features
Grade I	Minimal hypertrophy (<250 g) without ptosis.
IA	Primarily glandular.
IB	Primarily fibrous.
Grade II	Moderate hypertrophy (250–500 g) without ptosis.
IIA	Primarily glandular.
IIB	Primarily fibrous.
Grade III	Severe hypertrophy (>500 g) with grade 1 ptosis (glandular or fibrous).
Grade IV	Severe hypertrophy with grade 2 or 3 ptosis (glandular or fibrous).
^a The problem with this classification is that it does not refer to the fatty glandular tissue with predominantly fatty tissue, a common occurrence.

As with any aesthetic procedure, another crucial factor in technique selection is the willingness of the patient to accept the invasiveness of the surgical modality weighed against its achievable results. There are multiple surgical treatment options available for reducing male breasts and these have been eloquently described elsewhere (12). These various techniques fall into the broad categories of liposuction, minimally invasive excision, and open excision with the latter including skin excision (Table 43-3). Historically surgery comprised open excision in the form of subcutaneous mastectomy with or without skin excision. While this is very effective at removing the subareolar fibrous discs and firm glandular tissue, it can leave unacceptable scars, contour irregularities, and/or saucer deformities. Liposuction revolutionized the treatment of gynecomastia by being less invasive, reducing the scars, and decreasing the pool of patients who needed open excision. It also improved the results of or complemented open excisions (principally by feathering the peripheries and facilitating the excision). Consequently a number of treatment algorithms were proposed to rationalize the surgical treatment of gynecomastia/male breast reduction (3,4,15,16,17,18).

TABLE 43-3 Surgical Options for Reducing Enlarged Male Breasts

Liposuction/Lipolysis	Minimally Invasive Excision Techniques	Open Excision Techniques
Liposuction—conventional (SAL)	Pull-through	Webster periareolar
Liposuction—ultrasonic (UAL)	Arthroscopic morselisation/shaver	Circumareolar
Liposuction—power assisted (PAL)	Vacuum-assisted biopsy (VAB) device	Transareolar
Laser-assisted lipolysis (LAL)	Endoscopic, for example, single incision	Circumthelial
Radiofrequency-assisted liposuction	Microdebrider	Subcutaneous mastectomy
VASER^a assisted		Skin reduction^b
^a Vibration amplification of sound energy at resonance. ^b See Table 43-6 for skin reduction types.

Treatment

Enlargement of the male breast due to benign proliferation of ductal, stromal, and/or fatty tissue is a common condition which may affect up to 70% of men at some stage of their lives (12,19). However, not all patients require treatment. Mild cases of gynecomastia or pseudogynecomastia can adequately be treated by dietary advice, reassurance, and weight management (20). Certainly, in pubertal cases there is a high rate of resolution without intervention and so observation for at least 1 to 2 years should be the first-line treatment following appropriate investigation (20). However, if gynecomastia is in its fibrous phase, or present for more than 1 year, it is unlikely to regress. In these circumstances it is best to resort to surgery to achieve aesthetic correction and psychological amelioration of the symptoms. Surgery is the mainstay of treatment and falls into two main categories, namely liposuction and excisional techniques (Table 43-3).

The focus of the remainder of this chapter will be on the use of liposuction and surgical excision (including skin reduction). The authors feel that these two treatment modalities should not be viewed as mutually exclusive, rather that they are tools to be employed dependent on the surgeon’s assessment and patient’s wishes and in practice are indeed complementary and carried out simultaneously.

Operative Techniques

Liposuction

History

Liposuction, in any of its guises, represents the least invasive technique for the surgical correction of gynecomastia. Modern liposuction, first described in 1975 by Fischer and Fischer (21) and popularized by Illouz, has become the mainstay for gynecomastia treatment (4,10,20,22). As most commonly performed conventional/traditional liposuction, also known as suction-assisted lipectomy (SAL), has been used for gynecomastia treatment since the 1980s (6,22).

General Considerations and Conventional Liposuction

The benefits of liposuction are that it is minimally invasive, allows bespoke contouring with feathering to the peripheries, and leaves minimal scarring (4,6,23,24,25). A number of modalities have been employed to augment the process of liposuction, including power-assisted, ultrasound-assisted, laser-assisted, and vibration amplification of sound energy at resonance (VASER) (26).

Liposuction is accepted to be the gold standard treatment for addressing unwanted lipomatous tissue at any site in the body, and this is no different in the treatment of diffuse breast enlargement of soft to moderately firm consistency in gynecomastia patients (3,8,12,22,27,28). There is however a divide in the literature as to the effectiveness of liposuction alone in addressing the firmer glandular tissue in gynecomastia correction. Some studies contend that liposuction alone is an effective treatment in pseudogynecomastia as well as Simon grade 1 and 2 disease (3,12,13,23,25,27,29,30,31). Certainly, there is some evidence that when addressing the excess skin in grades 2b and 3 disease the use of laser-assisted and conventional liposuction modalities alone can cause sufficient skin retraction and reduce the sternal notch-to-nipple distance consistently by 1 cm as well as reduce the NAC surface area by 20%, with positive satisfaction rates of 92% to 96%, respectively (30,31).

Those wishing to utilize liposuction alone to address the glandular component of the disease recommend a wide range of cannulae to achieve satisfactory results, namely barbed, forked, spatulated, sharp, reverse cutting, to name but a few (23,28,32,33). In our practice we do not employ atypical sharp cannulas due to the potential risk of intra- and postoperative bleeding.

The liposuction is done via a variety of incisions namely IMF (19,22), transaxillary (22,23,34), transareolar (22,35), and anterior axillary fold (3) and often with a combination (Fig. 43-1) (3,19).

The senior author is a proponent of crosstunneling in cases where there is a large volume of excess tissue, ptosis, and a prominent or well-defined IMF in order to give more consistent contraction of the skin and to break up/disrupt the IMF. Some surgeons feel this can be achieved through a single incision, such as a concealed transaxillary approach (34). We prefer to use two-access ports away from the areola to allow crisscross treatment (3,10,21). A superior incision also enables a more efficient undermining and disruption of well-developed IMFs thus allowing better redraping and contraction of the skin in this area (Fig. 43-1).

Power-Assisted Conventional Liposuction

Power-assisted liposuction is a common modality for the treatment of gynecomastia (36,37). It increases the amount of tissue that can be removed compared to standard, conventional, or traditional liposuction. It also reduces surgeon fatigue and allows better surgeon control in the contouring of the chest (36).

Liposuction With New Devices (Nonconventional Liposuction)

Other techniques of liposuction like ultrasound-assisted liposuction (UAL), VASER, laser-assisted liposuction (LAL), radiofrequency-assisted liposuction (RFAL), etc. liquefy the fat at the same time as contracting vessels (to reduce blood loss) and promoting skin tightening (8,19,30,31,38). These modalities are particularly useful in fibrous fatty tissue as this is not amenable to correction alone. They have also widened the pool of gynecomastia patients who can effectively benefit from this minimally invasive technique. They are also particularly effective in redo cases (recurrence, recalcitrant, or persistent cases) (8,19,38). Often these methods are combined with a variety of excisional techniques especially those which are minimally invasive. Rohrich’s group have, for instance, recently presented a technique which combines ultrasonic liposuction and a pull-through removal of residual breast tissue (19). An outline of nontraditional liposuction methods used for male breast reduction is given below.

Ultrasound-Assisted Liposuction or Ultrasonic Liposuction for Gynecomastia

UAL, first described by Zocchi, has been found to selectively target adipose tissue, which is particularly useful in the setting of gynecomastia correction (8,13,16,39,40,41,42) and is now a widely accepted (and indeed preferred) treatment for gynecomastia (8,13,18,43). UAL breaks up the dense fibroconnective tissue of gynecomastia

more efficiently than conventional liposuction. It has been established that at higher-energy settings UAL can remove the dense parenchymal tissue that SAL leaves behind (8,16). In a direct comparison of UAL and SAL Wong and Malata found that UAL had a lower intraoperative conversion rate to open excision and lower late revision rate thus confirming the superiority of UAL for gynecomastia. UAL benefits include less bruising, improved contour, increased skin retraction, and lower rates of conversion to open surgical excision and recurrence (8,13,16,27,39,40,41). In the authors’ opinion UAL is the preferred modality of liposuction when available.

FIGURE 43-1 SAL alone: A 59-year-old patient treated with conventional liposuction alone. This is widely available in most hospitals. Planning A–C: Concentric circles denote the areas to be liposuctioned. The + sign signifies the larger left breast. The Xs are the areas not to be suctioned or to be gentle with suction. The old IMF is marked with dots so as to target it during the suction procedure. The inferior extent of the liposuction and pretunneling is well below the IMF. This allows better redraping of the skin. During planning all patients are consented for + or − open excision. There was no need for open excision during surgery. Pre- and 7-month postoperative appearances (D–M).

UAL like other liposuction techniques leads to minimal scarring. Other advantages include superior/improved skin retraction which obviate the need for skin resection even in patients with grade III and IV gynecomastia (19). The key feature of UAL is the “efficient removal of both glandular and fibrotic breast tissue” (19). UAL is an effective treatment and often used as a sole treatment modality for the correction of gynecomastia (Fig. 43-2) (8,16,39,40). High energy levels are used and increased especially under the nipple to help in removing the fibrous glandular tissue. Additionally, targeting the immediate subdermal layer increases skin contraction but caution is needed to avoid thermal injury.

The limitations of UAL are that it is technically more demanding and has a steep learning curve, needs complex and bulky equipment which is more expensive, is not widely available, has a higher potential for complications and notably an increased incidence of skin necrosis (when combined with open excision), and there are a multitude of safety precautions to adhere to (8,44,45,46). There are several reports of successful combination of UAL with subareolar excision techniques (18,47).

Vibration Amplification of Sound Energy at Resonance Liposuction for Gynecomastia

This is a newer form of UAL, using pulsed and continuous ultrasonic energy which many consider safer than standard UAL when treating fibrous areas close to the surface of the skin (26). The process requires similar incisions and infiltration as with SAL, PAL, and UAL, but requires comparatively lower amounts of ultrasonic energy than UAL. As with UAL, VASER is a pretreatment (fat emulsification and liquefaction) prior to evacuation by standard liposuction with a narrow (2.9- to 3.7-mm diameter) probe and a grooved tip. The skin puncture incision still requires protection with a port site and the surrounding skin with a wet towel. The probe is kept moving with gentle axial movements and should require less force than that with PAL or SAL. “End-hits” and “punching” of the dermis should be avoided. The VASER pulsed mode is described for finer more delicate work and the continuous mode for firmer gland areas. Due to the relatively reduced energy the safety profile is better compared to earlier generations of UAL (26).

Laser-Assisted Lipolysis in Gynecomastia

Laser-assisted lipolysis has also been used for the correction of gynecomastia using the Nd:YAG laser at varying wavelengths (25,48). Again, this technique requires similar incisions and infiltration as for SAL and PAL. The absorption of the light energy and conversion to thermal energy causes lipolysis due to expansion and rupture. The 2-mm diameter probe has an exposed 1 to 2 mm of a fiberoptic tip using ultrashort pulses at high peak power. Although this technique is promising the experience is limited, and its usefulness remains to be defined (25,49).

Radiofrequency-Assisted Liposuction in Gynecomastia (38,50)

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