Modularities of Management of Severe Grades of Gynecomastia.

Summary

Gynecomastia is defined as a benign enlargement of the mammary glands, commonly diffused among men. The prevalence of gynecomastia ranges from 38 to 64 percent in the male population.

Gynecomastia can affect normal self-esteem and sexual identity and often patients feel ashamed of their bodies during normal social activities.

The surgical management of the high-grade gynecomastia Simon's grade III or Rohrich's grade IV has remained problematic because both liposuction and conventional subcutaneous mastectomy without skin excision have frequently resulted in significant residual skin redundancy, requiring a second operation for skin resection.

Two Classification Systems of Gynecomastia

Rohrich's Classification I, Minimal breast hypertrophy without ptosis; hypertrophy is either primarily glandular or fibrous II, Moderate breast hypertrophy without ptosis; hypertrophy is either primarily glandular or fibrous III, Severe breast hypertrophy with grade I ptosis glandular or fibrous IV, Severe breast hypertrophy with grade II or III ptosis glandular or fibrous Simon's Classification I, Minor breast enlargement without skin redundancy. IIa, Moderate breast enlargement without skin redundancy IIb, Moderate breast enlargement with minor skin redundancy III, Gross breast enlargement with skin redundancy that simulates a pendulous female breast Smoot stated that this approach for high-grade gynecomastia has several disadvantages. There are difficulties in obtaining precertification from third-party payers for a second operation for skin resection. In addition, the adolescent patient is often very anxious during the ensuring 1 year after the original mastectomy when skin excess is quite apparent and awaiting spontaneous shrinkage.

Currently, there are 4 main different approaches for the management of high-grade gynecomastia:

First is simple mastectomy, which is done with free nipple graft accepting the long transverse scar and the grafted appearance of the nipple areola complex. Second is a modification of breast reduction is done with nipple transposition on a single dermal pedicle or vertical bipedicle. A visible chest scar is also present, but the blood supply of the nipple-areola complex is preserved.

Third is ultrasound assisted liposuction is performed first and after several months, accept that several patients will require a second operation to excise the significant residual skin redundancy. Fourth is a single-stage procedure is done in which sub cutaneous mastectomy and circumareolar skin excision are performed. The purse string skin closure limits the scar to the circumareolar area.

Open excision techniques base their principle on a direct view and management of the gland, through several types of surgical accesses according to the surgeon's preference and entity of the defect. The main advantage of open excision is the direct control of the hemostasis and redundant skin control, with the main disadvantage of permanent scars, whose quality cannot be predicted.

Only Gusenoff et al have proposed a classification with corresponding operative treatment options, whose grades taken into account the laxity of the breast skin and the upper abdomen, the location of the inframammary fold IMF, and the lateral fat role.

Minimal excess skin and fat, minimal alteration of NAC, normal IMF, No lateral skin roll: a Minimal excess skin and fat, minimal alteration of NAC, normal IMF, lateral skin roll: b NAC and IMF below, the ideal IMF, lateral chest roll, minimal upper abdominal laxity: c NAC and IMF below the ideal IMF, lateral chest roll, significant upper abdominal laxity: d

Conditions

• Gynecomastia

Interventions

PROCEDURE

Group A: circumerolar skin excision

Surgical procedure: * Under general anesthesia, patient is in supine position on the operation room table. * After marking the incisions and new nipple position, the areola was slightly stretched and marked with a 3 cm cookie cutter. GROUP A: * The complete circumareolar ring is deepithelialized. * An incision is then made from 3 o'clock to 9 o'clock along the inferior border of the deepithelialized ring. * Subcutaneous glandular excision is completed through that incision. * a closed suction drain is then placed. * A 3-0 polypropylene intradermal circumareolar purse string suture is used for skin closure. * Few interrupted 5-0 absorbable sutures are also used to adjust skin edges at the purse string closure. * An elastic compressive garment is applied intraoperatively and is worn for 6 weeks.

PROCEDURE

Group B: elliptical skin excision with pedicled flap +_ lateral roll excision.

GROUP B: * Following marking, epithelialization of the inferior pedicle flap is performed. The excisable tissue is then resected, and the pedicle is carefully dissected down to the pectoral fascia. * Flap thinning is carried out cautiously, preserving the dermis and a thin layer of subcutaneous tissue to maintain vascularity. A subcutaneous tunnel is subsequently created towards the new NAC site by excising the intervening adipose tissue, allowing for proper transposition of the pedicle. * After preparation of the tunnel, the inferior pedicle is transposed into the new nipple-areola complex (NAC) site. The pedicle is secured in place with interrupted non-absorbable sutures to prevent displacement and to maintain adequate projection. * The NAC is then inset into the newly created pocket, ensuring symmetry and central positioning. Excess skin and redundant tissue are trimmed as required to optimize chest contour. * The wound is closed in layers using deep absorbable sutures for support

PROCEDURE

Group C: elliptical skin excision with free nipple areola complex +_ lateral roll excision.

GROUP C: * After marking, the nipple areola complex will be taken as a full thickness graft * The excisable part will be excised and restitched by 2\\0 vicryl subcutaneously and 3\\0 vicryl subcuticular sutures. * the recipient site of the NAC is deepithelized and the graft will be insit with tie-over for 1 week and the drain inserted for 4-7 days

Sponsors & Collaborators

• Assiut University

  lead OTHER

Study Design

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Max Age

60 Years

Sex

MALE

Healthy Volunteers

No

Timeline & Regulatory

Start

2025-12-31

Primary Completion

2027-10-31

Completion

2028-03-31