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Gynecomastia is operated by cutting out excess gland as the incision around the middle of the capsule of the breast nipple. In the case of a significant enlargement of the gland, excess skin is also excised.

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Gynecomastia is an enlargement of the nipples in men caused by the growth of glandular tissue. Hyperplasia of fibrous and fat tissues often coexists. Most often, it disappears spontaneously. Gynecomastia may be a symptom of another disease. Long-term gynecomastia is treated surgically and by liposuction (liposuction).

The benefits of gynecomastia reduction

• modelling the figure,
• improving the appearance of the chest,
• increasing self-confidence - reduction of stress associated with undressing in public places (swimming pool, beach, sports locker).

Indications for reduction of gynecomastia

The primary cause of gynecomastia is the predominance of female hormones (oestrogens) over men (androgens, e.g. testosterone) or increased sensitivity of nipples to oestrogens. A large part is gynecomastia idiopathic (without a clear cause). Attention should be paid to the patient's motivation for treatment. It is often associated with stress before undressing in public places such as swimming pool, beach, sports locker room.
Gynecomastia physiologically (in healthy) occurs in three periods of life: in new-borns, in adolescence and in the elderly. Gynecomastia of new-borns is caused by a high concentration of maternal oestrogens that pass through the placenta. During puberty, the production is more estrogenic than testosterone.
In the elderly, gynecomastia is caused by decreased testosterone synthesis and peripheral conversion of testosterone to oestradiol.
Gynecomastia may be a symptom of disease, result from the use of drugs or stimulants. Diseases in which enlargement of the male nipples may occur include: testicular tumours, adrenal tumours, hyperthyroidism, liver disease, pituitary gland disease, Klineferter's syndrome. Drugs: diuretics (spironolactone), antifungals (ketoconazole), proton pump inhibitors (omeprazole), angiotensin converting enzyme inhibitors (enalapril, captopril), calcium channel blockers (verapamil) and others. Drugs and drugs: marijuana, alcohol, amphetamine, heroin, methadone. In obesity: testosterone is converted into oestradiol in adipose tissue.
Diagnosis of gynecomastia is extended in the event of an abnormality in a history of a disease or a physical examination. Attention should be paid to the female body structure and the female distribution of hair. Physical examination should pay attention to thyroid, nipples, abdominal cavity (liver) and testicles. The nipples can be swollen, tender, and with a wart nipple. If deviations are found, further imaging and hormonal diagnostics should be performed. A visit to an endocrinologist may be needed. If the cause of gynecomastia is diagnosed, the cause should be treated first, not gynecomastia.
Gynecomastia often subside spontaneously. If obesity occurs, weight reduction is recommended. Treatment should be implemented after 12-18 months. After this time, in addition to glandular tissue, the nipples also contain fibrous tissue, which rarely undergoes spontaneous reduction.
Gynecomastia should be distinguished from lipomastia, which is an enlargement of the male nipples due to the accumulation of adipose tissue. Lipomastia is rarely a disease symptom. In cases of doubt, the ultrasound examination (ultrasound) is resolved.
Male nipples can be enlarged to varying degrees, there are many grades for their enlargement.

Division of gynecomastia according to Simon:
Type I: Enlargement of low grade nipples without excess skin
Type II: Enlargement of middle-grade nipples
• IIa: without excess skin,
• IIb: with excess skin.
Type III: Enlargement of high grade nipples with excess skin and falling

Division of gynecomastia according to Rohrich:
• Grade I: Enlargement of small stage nipples (<250g), without drooping I a: with a predominance of glandular tissue I b: with a predominance of fibrous tissue Grade II: Enlargement of middle-grade nipples (250 - 500g), without lowering II a: with a predominantly glandular tissue IIb: with a predominance of fibrous tissue,
• Grade III: Enlargement of high grade nipples (> 500g), with Grade I falling,
• Grade III: Enlargement of high grade nipples, with grade II or III falling.

Degrees of descent (ptosis) of the nipples:
• Grade I (light): wart is located at the level of the chest crease,
• Grade II (moderate): the wart is located below the breast crease, but above the lower breast contour,
• Grade III (severe): wart is located at the level of the lower breast contour.
Pseudoptosis: the wart is above the breast fold, but most of the nipple is below the breast fold.

Contraindications to reduction of gynecomastia

Reduction of gynecomastia is performed in a planned mode, therefore, when applying for surgery / surgery, the patient should be unloaded, in good general condition. If the patient has a large number of other diseases and low physical capacity then the risk of surgery is too high.
If the cause of gynecomastia is diagnosed, the cause should be treated first, not gynecomastia.
The patient applying for the procedure should not be during or shortly after respiratory infection or herpes infection.
Local skin infections are also contraindicated - bacterial or fungal.
Patients with chronic diseases that increase the risk of surgery may be disqualified or asked to perform additional consultations and preparation with a specialist in a given field.
A contraindication may be some medications - especially those that reduce blood clotting. The gynecomastia reduction procedure should be performed after the nipples have stabilized - otherwise a relapse may occur.
Contraindication may be unstable body mass. An increase in body weight may result in a relapse, while a significant reduction in body weight will result in excessive correction or flaccidity of the nipples' skin.

Before surgery to reduce gynecomastia

Before the operation, please consult a doctor who will perform it. It is good to prepare for consultations. It is worth to write down on a sheet of paper:
• other diseases - current and past
• operations carried out
• cosmetic and aesthetic medicine treatments performed in a given region of the body
• a list of medicines (including those without a prescription) including dosing. e.g., Piramil 2.5mg 1-0-1 (morning and evening after one tablet). You can also deliver packaging from the medicines you are taking.
During this consultation, the patient is examined and qualified for surgery. The plan and scope of the operation is presented. If necessary, the doctor will commission additional tests and consultations, e.g. at the endocrinologist. This is a very good time to ask questions and raise concerns.
Consultation with the doctor performing the procedure should take place several days to a few weeks before the procedure. The interval between consultation and treatment is beneficial, because at that time the patient "calmly" can rethink everything, talk to family or friends.
Before gynecomastia reduction, body weight should be stabilized. The patient should not be in the process of slimming or shortly after slimming.
Smoking should be reduced or ceased.

Reporting to the operation:
• the patient should provide the results of tests commissioned during the consultation. In some clinics, tests carried out on the spot, after the patient has applied to the clinic, however, it extends the time from coming to the surgery.
• 6 hours or more should pass between the last meal and surgery. Most often you can eat a light meal before leaving the house. This applies in particular to general anaesthesia (narcosis).
• in the morning you should take medications taken permanently (unless the doctor recommends otherwise during consultations)
• Avoid sunbathing and tanning for 2 weeks before surgery
• it is good to remove the hair from the chest (shaving with a razor blade is not recommended, because it damages the epidermis, it is better to use a depilatory cream)

The next medical consultation takes place on the day of the surgery. During the consultation, the patient is examined, the treatment is discussed in detail. On the patient's body with a marker, the areas to be treated are marked. Photographic documentation is made. This is a very good time to ask questions. During this consultation, the patient should sign the consent for the procedure.

Type of anaesthesia during gynecomastia reduction

After applying to the clinic for the procedure, in addition to consultations with a surgeon, an anaesthesiologist (doctor carrying out anaesthesia) should be consulted. During this consultation the patient will be examined. Anaesthesia and period after anaesthesia will be discussed. This is a very good time to ask questions about anaesthesia. The patient should sign a consent for anaesthesia. If the procedure is performed under local anaesthesia, consultation with an anaesthesiologist may not be necessary.
The operation can be performed in: general anaesthesia (anaesthesia), sedation combined with local anaesthesia, only local anaesthesia. The type of anaesthesia depends primarily on the extent of the procedure and the experience of the team working in the clinic. The most commonly used anaesthesia is anaesthesia or sedation with local anaesthesia.
The procedure is performed under general anaesthesia (narcosis). This means that the patient will sleep during the procedure and will not be aware of what is going on around him. A plastic tube (intubation) will be inserted through the mouth into the trachea, through which air will flow (a mixture of respiratory and anaesthetic gases). This tube will be connected to the machine (respirator), which will give the right amount of gases to breathe. During the course of anaesthesia, the anaesthetist and anaesthesiologist nurse supervises the patient's safety.
A treatment performed in sedation with the addition of local anaesthesia. During this anaesthesia, the patient is not intubated - he breathes on his own. The patient is hypnotic, confused and usually does not remember the course of the operation. During the procedure the surgeon soaks the tissue of the nipples with the local anaesthetic.

How does the gynecomastia reduction procedure work?

It depends mainly on the stage of gynecomastia. Gynecomastia in most cases is treated surgically. One common practice is simultaneous liposuction to remove fatty tissue and chest modelling, as well as surgical removal of glandular and fibrous tissue. Some surgeons use only liposuction to remove gynecomastia of low and medium degree without excess skin. The literature describes the removal of fibrous tissue (in addition to adipose tissue) during liposuction.
The surgeon makes small (about 4 - 5 mm) incisions on the skin. These incisions may be located in various places, e.g.: the border of the envelope and the skin, the chest fold, the axillary region. In individual clinics, the location of incisions may vary, certainly they should be in places less visible and providing good access to the sucked adipose tissue. Scars after cuts are usually not visible. Then a probe is injected through the skin incisions to inject fat tissue. The probe is a thin metal tube (about 2 - 3 mm in diameter). There are holes on the sides of the probe through which the liquid is delivered to adipose tissue. The composition of the fluid is different in individual clinics. It most often contains 0.9% sodium chloride (saline) and adrenaline. It may also contain other substances such as lignocaine and sodium bicarbonate. The purpose of saline is to hydrate body fat which facilitates its subsequent suctioning. The goal of adrenaline is to shrink the blood vessels, which limits bleeding. The goal of lignocaine is to reduce pain in the postoperative period. After the injection of adipose tissue, wait a few minutes for the adrenaline to start working. During this time, you can inject a second nipple. Then the surgeon inserts a suction probe through the incisions on the skin. The surgeon vigorously moves the probe forward and backward to reach any place in the marked area. This is to break down fat, which will facilitate its subsequent suctioning. The probe is connected with a rubber hose to a vacuum generating mammal. Negative pressure causes suction of adipose tissue. For liposuction of male nipples, PAL or UAL liposuction is most commonly used:

• Vibrating liposuction (PAL) - the probe makes small movements within a few millimetres. They can be circular movements, sideways, forward and backward. It facilitates the breaking of fat tissue.
• Ultrasound liposuction (UAL) - energy from ultrasound waves helps break up fat tissue.

The surgical technique that leaves the smallest scar is "pull-through". A 1.5 cm long cut is made at the border of the capsule and skin (less often on the lateral side of the nipple). Through cutting, the forceps are inserted, by which the surgeon grasps the tissue, pulls it onto the skin's surface and erases it. The operation is repeated until the desired shape of the nipple is obtained. The disadvantage of the technique is the lack of full insight into the wound.
The most frequently used surgical technique is the one with the cut on the middle of the sheath (on the border of the envelope and the skin, on the lower half of the sheath). It can be used if there is no excess skin and falling. The surgeon under the control of eyes removes excess tissue. In order to ensure a natural look, leave 1-2 cups of tissues under the nipple shell complex. Then the seams are put on. The scar on the lower half of the cap remains scarcely visible.
If the excess skin is not large (the nipples are small and narrow), a cut is made at the border of the skin and the nipple complex (around the perimeter of the capsule). Part of the skin gets epithelialised. Then the course of the operation looks like above. During this operation, the wart-wart complex is not moved. There is a scar around the envelope.
In the case of a large enlargement of the nipples with excess skin and falling, the surgical technique starts with cutting the skin around the nipple complex and its excision as a thin patch. Then two horizontal skin incisions are made - above and below the nipple, along the incision will be removed excess skin and glandular, fibrous and fatty tissue. The wound is stitched - a horizontal scar will form in the breast fold. A new place will be appointed for the papillary-wart complex. Typically, it is at the height of the rib V on the side of the greater pectoral muscle. The superficial layer of the skin is removed, in this place a previously cut nodule-wart complex is sewn into place. After surgery, scars will remain in the breast fold and around the wart-wart complex.
Another surgical technique leaves a scar in the shape of an inverted letter "T" and around the papilla coat complex.
If, in addition to enlarged nipples, there is also a fold of skin on the side of the chest, it can be removed in one operation. The L-shaped scar will remain.
The choice of surgical technique is selected individually for each patient during pre-operative consultations.
Usually, drains are installed during surgery. Drain is a thin (diameter about 0.5cm) plastic tube. Its one end is placed under the skin at the operation site, at its other end a container (bottle, syringe) is attached. The drain's task is to remove the blood from the wound. It is also used to monitor bleeding during the postoperative period - if a large amount of blood flows through the drain, a second operation may be necessary to control the bleeding.
After the operation is completed, a pressure dressing is put on.
It can be a flexible bandage, a hernia belt (put on the chest) or a compression vest. The use of pressure reduces the risk of bleeding in the postoperative period.
After surgery, the patient is awakened from anaesthesia and transported to the post-operative room.
The operation lasts from 1 - 2 hours.

Time and course of convalescence after reduction of gynecomastia

Immediately after the surgery (in the post-operative room), the patient remains under supervision and receives painkillers. Postoperative supervision may vary in individual clinics. It is smaller after sedation, larger after anaesthesia. The following is an example of how to proceed in the post-operative room.
Life parameters are usually displayed on the cardio monitor. Electrodes are stuck on the chest, thanks to which the heart is visible on the monitor. A cuff, periodically filled with air, is placed on the arm to measure blood pressure. A pulse oximeter is placed on the finger to measure the saturation of blood (oxygen content in the blood). The patient receives a pilot who can be summoned by the staff. There is a nurse in the post-surgery room.
In the postoperative room, the patient stays for a few to a dozen or so hours.
If the scope of the procedure was small, it can be discharged the same day.
Most often, the next morning, the patient is transported to another (normal) room and stays there for discharge from the clinic. On the first day you can move freely around the clinic and eat light meals. The patient receives painkillers. The dressing is changed and the drains removed. The patient can look in the mirror. The body is swollen, bruises or small hematomas can be seen. Sills and small hematomas are normal. A dressing and compression garment is again put on. Most often on this day the patient is discharged from the clinic. In the case of a large resection, the stay in the clinic is prolonged.
On the day of discharge, the patient receives recommendations, instructions on how to proceed, dates of the inspection.
In the second week after surgery the bruises disappear.

The effects after reduction of gynecomastia

The effects after gynecomastia surgery are not fully visible immediately. If liposuction was performed, the first results are visible after 3 weeks, 95% of the final effect is visible after 3 months. The final effect after 6 months. If the nipple surgery was performed - the result is visible immediately. This is not the final effect, but its major part.
The effects of the treatment are modelling the figure, improving the appearance of the chest, increasing self-esteem and self-confidence.
To obtain the desired effect, a healthy lifestyle should be maintained and the body weight should be stabilized.

Recommendations after gynecomastia reduction

Recommendations given by surgeons vary and depend on the scope of the procedure, the course of the procedure, the course of the period after surgery and the experience of the operator. Recommendations should be followed and not modified without contacting the clinic.
Examples of recommendations:
• compression clothing (vest, belt or bandage) should be worn for 3 - 4 weeks, 24 hours a day, the next 3 - 4 weeks for 12 hours a day (eg at night),
• you can remove pressure clothes for a short shower,
• after shower, the skin should be oiled with cream or balm,
• the pressure clothes should be washed regularly, therefore it is worth having two sets,
• removal of sutures takes place on the 7th - 10th day,
• painkillers may be needed for a few days after surgery,
• you can return to work after a few days, move without effort is recommended,
• you can return to sport after 4 - 6 weeks,
• for 6 weeks to give up the sauna and solarium,
• in doubtful situations, contact the clinic.

How long do the effects persist after gynecomastia reduction?

The effect after the treatment is permanent, while maintaining a healthy lifestyle (diet and physical exercise), the effect lasts until the end of life. If you increase your weight, you may need further liposuction treatments. If gynecomastia was a symptom of disease and the disease was not diagnosed before surgery, gynecomastia can be converted.

How to avoid complications after gynecomastia reduction?

Completely avoiding complications (in all patients) is not possible. It is important that in such a situation the doctor should take special care of the patient.
From the patient's point of view, to avoid complications, two basic rules must be followed: 1) to say everything about your health before surgery; 2) follow the instructions after surgery.
You should stop smoking
You should report to designated inspections.
Wear pressure clothes.
Keep your body weight stable.
Perform regular physical activity.
Do not perform liposuction when surgical nipple surgery should be performed.
It is important not to modify the recommendations without contacting the clinic

Possible complications after gynecomastia reduction

During each surgery and surgery, complications are possible. They happen rarely, it is worth asking a doctor who performs the procedure, for which we are more susceptible to exposure, and for which less.
Possible complications associated with the reduction of gynecomastia are: vascular embolism, pneumothorax, haemorrhage, haemorrhage, surgical site infections, delayed wound healing, overgrown scars and keloids, local skin necrosis, skin discoloration, prolonged pain in the surgical site, unevenness of the site undergoing liposuction, accumulation of serous fluid under the skin, flaccid skin, too small nipple reduction, too much nipple reduction, need for another treatment.
It should be remembered that it is not possible to predict and list all possible complications.

Recommended additional treatments after gynecomastia reduction

Most often, no additional treatments are needed.
Lymphatic massage after liposuction is recommended.

Author: Norbert Czapla, MD
• Aesthetic Plastic Surgery; 2009; Sherrell J. Aston, Douglas S. Steinbrech, Jennifer L. Walden
• Essentials of Plastic Surgery, 2014, Jeffrey E. Janis
• Body Contouring (McGraw-Hill Plastic Surgery Atlas), 2010, Michele Shermak
• Grabb and Smith's Plastic Surgery; 2013; Charles HM Thorne, Geoffrey C. Gurtner, Kevin Chung, Arun Gosain,
• Babak Mehrara, Peter Rubin and Scott L. Spear
• Key Notes on Plastic Surgery, 2014, Adrian Richards, Hywel Dafydd
• Plastic Surgery: Volume 5: Breast, 2012, James C Grotting, Peter C. Neligan MB
• Practical Plastic Surgery, 2007, Zol B. Kryger, Mark Sisco
• Surgery of the Breast: Principles and Art, 2010, Scott L. Spear MD FACS and Shawna C. Willey MD
• Internal diseases, 2005, Andrzej Szczeklik


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