cme - dr. maurice nahabedianmauricenahabedian.com/resources/articles/breast... · 2012-05-17 ·...

CME

Breast Deformities and MastopexyMaurice Y. Nahabedian,

M.D.

Washington, D.C.

Learning Objections: After reviewing this article, the participant should be ableto: 1. Appreciate the diversity of approaches for the correction of breast de-formities and mastopexy. 2. Review the salient literature. 3. Understand patientselection criteria and indications.Summary: Breast deformities and mastopexy continue to challenge plastic sur-geons. Deformities such as Poland syndrome, tuberous breast, gynecomastia,and other congenital conditions are uncommon; therefore, management ex-perience is often limited. Various techniques have been described, with nogeneral consensus regarding optimal management. Mastopexy has becomemore common and is performed both with and without augmentation mam-maplasty. However, a variety of techniques are available, and a thorough un-derstanding of the indications, patient selection criteria, and techniques isimportant to optimize outcomes. This article will review these and other con-ditions to provide a better understanding of the current available data andevidence for these operations. (Plast. Reconstr. Surg. 127: 91e, 2011.)

When considering all types of breast sur-gery, the category of breast deformity isperhaps the least prevalent and in some

ways the most challenging. The conditions thatmake up this category include tuberous breast,Poland syndrome, and gynecomastia, as well ascongenital and developmental breast asymme-tries. Many of these anomalies have embryologicorigins and manifest during puberty.1 These con-ditions have all been described in variable detailboth in textbooks and in the scientific literature;however, because these conditions are less com-mon, associated with variable degrees of complex-ity, and are sometimes difficult to treat, there is alack of consensus on optimal management. Thissection will focus on and emphasize the variousevaluation and management strategies that havebeen described.

A separate topic in this category is mastopexy.Although mastopexy is used to correct an overlyptotic breast and may be unrelated to the correc-tion of a classic breast deformity, the principlesand concepts of repair are best suited for thissection, as there is some degree of overlap with thecorrection of breast deformities. The subcategoryof augmentation mastopexy will also be covered inthis section.

TUBEROUS BREAST DEFORMITYThere are several features of the tuberous

breast that are important to identify before man-agement. These include a constricted base, con-traction of the skin envelope, relative micromastia,enlarged diameter of the nipple-areola complex,and herniation of breast parenchyma through thenipple-areola complex2 (Fig. 1). Although the ex-act etiology has not been elucidated, it is generallyaccepted that this disorder has an embryologicorigin.3 Most reports have speculated that the su-perficial investing fascia of the breast is abnormaland constricted at the base of the breast. Thisconstriction at the base and deficiency at the are-ola is responsible for the reduced base diameterand areolar herniation.3 A competing theory statesthat there is no constrictive band at the base of thebreast and that the only abnormality is a deficiencyof areolar support, giving rise to the herniation.4

From the Department of Plastic Surgery, Georgetown Uni-versity Hospital.Received for publication April 27, 2010; accepted September14, 2010.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31820a7fa7

Disclosure: The author has no financial interest todeclare in relation to the content of this article.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citationsprinted in the article.

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Several surgical approaches have been describedto correct the tuberous breast deformity.2–11 Reesand Aston first described the correction of thetuberous breast in 1976 and advocated expandingthe base diameter of the breast with radialscoring.2 Dinner and Dowden believed that theconstriction was the result of a cutaneous bandand advocated a skin incision.5 Ribeiro et al. iden-tified a constrictive ring and advocated dividing ithorizontally.6,7 Mandrekas et al. have performed asimilar operation to Ribeiro, except that the con-strictive band was divided vertically3 (Fig. 2). Pa-cifico and Kang have described an alternative ap-proach in which areola reduction, subdermal

undermining, and subglandular implant place-ment are used.4 Their belief is that the deformityis due solely to an areolar abnormality and not toa constrictive band at the base. Coleman and Sa-boeiro have reported on the benefits of lipoaug-mentation by injecting autologous fat into the sub-cutaneous tissues and pectoral muscle.8 In a singlepatient, two sessions were required, with injectionvolumes of 370 cc on the right and 380 cc on theleft. This was followed 4 years later with 300 cc onthe left and 340 cc on the right (Fig. 1).

It is generally believed that correction of tu-berous breast deformity requires attention to sev-eral salient points. The approach that is advocated

Fig. 1. Preoperative and postoperative views of a patient with tuberous breast deformity. (Left) The nipple-areola complex isenlarged with a herniated appearance, and the base diameter of the breast is constricted. In this case, the breast was corrected withautologous fat grafting. (Center) Results following first session of fat grafting. (Right) Results following second session of fat grafting.(Reprinted from Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg. 2007;119:775–785.)

Plastic and Reconstructive Surgery • April 2011

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by most is to outline a circumareolar patternaround the perimeter of the desired nipple-areolacomplex. A donut-type mastopexy pattern is out-lined. After skin excision, the circumference ofthe surrounding tissues is undermined; however,the inferior subcutaneous plane is underminedto the level of the inframammary fold and chestwall. The inferior breast parenchyma is under-mined and ultimately divided centrally or scoredto disrupt or divide the fibrous constrictive ring.The lower pole of the breast can be contoured byutilizing an inferiorly based flap or the medial andlateral lower breast pillars to provide the paren-chymal tissue needed to reconstruct the lowerpole. A prosthetic device is usually inserted in theprepectoral plane and covered entirely by paren-chymal tissue. In rare circumstances, a prostheticdevice may not be necessary if there is enoughparenchymal tissue to create a flap of tissue toenhance projection and contour.

Complications include recurrence, loss of sen-sation, asymmetry, scar, delayed healing, and im-plant-related complications. Mandrekas et al., intheir review of 11 patients, and Pacifico and Kang, in

their review of eight patients, reported nocomplications.3,4 Reported outcomes have rangedfrom good to excellent. Mandrekas et al. reported100 percent patient satisfaction and 100 percent sur-geon satisfaction.3 Pacifico and Kang reportedoutcomes on eight patients and 13 breasts follow-ing areola reduction and subglandular augmenta-tion.4 An independent panel graded the outcomesas excellent in 75 percent and good in 25 percent;however, all patients reported that they were verysatisfied with the outcome.

MASTOPEXYSee Video 1, in which Dr. Elizabeth Hall-

Findlay shows the marking of the breast formastopexy and reduction, available in the “Re-lated Videos” section of the full-text article onPRSJournal.com. Video for Ovid users is avail-able at http://links.lww.com/PRS/A309.

See Video 2, in which Dr. Hall-Findlay showsthe dissection for mastopexy, including inferiorflap rearrangement, the superior pedicle, and ver-tical skin resection, available in the “Related Vid-eos” section of the full-text article on PRSJournal.

Fig. 2. The Mandrekas technique is illustrated. (Above, left) A periareolar approach isadvocated. (Above, center) The dissection proceeds in the subcutaneous plane to thepectoral fascia. (Above, right) The dissection continues to the desired inframammaryfold. (Below, left) The inferior pole of the breast is exteriorized, and the constrictiveband is divided vertically. (Below, right) Finally, the areola is reduced, and the breastis recontoured. (Reprinted from Mandrekas AD, Zambacos GJ, Anastasopoulos A, et al.Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg. 2003;112:1099 –1108.)

Volume 127, Number 4 • Breast Deformities and Mastopexy

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http://links.lww.com/PRS/A309

com. Video for Ovid users is available at http://links.lww.com/PRS/A310.

See Video 3, in which Dr. Hall-Findlay showsthe skin closure and liposuction for mastopexy,available in the “Related Videos” section of thefull-text article on PRSJournal.com. Video forOvid users is available at http://links.lww.com/PRS/A311.

Mastopexy is indicated in women who desirean improvement in breast contour without a vol-ume change. Traditionally, mastopexy has beenperformed using primarily skin excision tech-niques; however, since the mid-1990s, there hasbeen an emphasis on internal shaping of the pa-renchymal tissue as well. The classic skin excisionpatterns for mastopexy have included crescent,periareolar, circumvertical, and inverted-T de-signs. Internal shaping can be performed usingvarious supportive materials or parenchymal pil-lars. This section will review the indications as wellas various methods and techniques described.

The type of mastopexy performed will dependon the degree of breast ptosis. Breast ptosis isgraded using Regnault’s classification (Table 1).An excellent review of the standard mastopexytechniques was compiled by Rohrich et al.12 Acrescent mastopexy can be considered when thedegree of nipple-areola complex elevation doesnot exceed 1 cm. A periareolar mastopexy can be

Video 1. Video 1, in which Dr. Elizabeth Hall-Findlay shows themarking of the breast for mastopexy and reduction, is available inthe “Related Videos” section of the full-text article on PRSJournal.com. Video for Ovid users is available at http://links.lww.com/PRS/A309. Presented with permission from Elizabeth Hall-Find-lay, M.D., and Tracker Productions, Banff, Alberta, Canada.

Video 2. Video 2, in which Dr. Hall-Findlay shows the dissectionfor mastopexy, including inferior flap rearrangement, the supe-rior pedicle, and vertical skin resection, is available in the “RelatedVideos” section of the full-text article on PRSJournal.com. Videofor Ovid users is available at http://links.lww.com/PRS/A310.Presented with permission from Elizabeth Hall-Findlay, M.D., andTracker Productions, Banff, Alberta, Canada.

Video 3. Video 3, in which Dr. Hall-Findlay shows the skin closureand liposuction for mastopexy, is available in the “Related Vid-eos” section of the full-text article on PRSJournal.com. Video forOvid users is available at http://links.lww.com/PRS/A311. Pre-sented with permission from Elizabeth Hall-Findlay, M.D., andTracker Productions, Banff, Alberta, Canada.

Table 1. Regnault’s Classification of Breast PtosisBased on the Position of the Nipple-Areola ComplexRelative to the Inframammary Fold

Scale Criteria

Pseudoptosis NAC is above the IMFType I (mild) NAC is at or 1 cm below the IMFType II (moderate) NAC is 1–3 cm below the IMFType III (severe) NAC is at the lowest portion of

the breastNAC, nipple-areola complex; IMF, inframammary fold.


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considered when the distance of nipple-areolacomplex elevation ranges from 1 to 2 cm, whichwould be classified as a Regnault I or II. After theskin excision, the outer perimeter of the dermis isscored, and the subcutaneous plane is under-mined circumferentially to allow for adequate re-draping of the skin envelope over the paren-chyma. The periareolar mastopexy can beperformed as a “donut” and in an eccentric pat-tern (Fig. 3). A circumvertical mastopexy will liftthe base of the breast as well as reposition thenipple-areola complex and is usually used for aRegnault II (Fig. 4). The inverted-T technique isuseful for the moderate to severely ptotic breastclassified as a Regnault II or III (Fig. 5). The hor-izontal incision will reduce the distance from thenipple-areola complex to the inframammary fold,while the vertical incision will reduce the basediameter. The L-shaped mastopexy will eliminatethe medial portion of the inverted-T incision andis indicated for women with grade I to II breastptosis (Fig. 6).

Recent innovations have expanded the op-tions for traditional mastopexy. Traditional ap-

proaches for mastopexy have emphasized modi-fication of the skin envelope only with minimalparenchymal manipulation. Goes was the first todemonstrate that skin-only excisions were not suf-ficient to maintain long-term benefits.13,14 Heemphasized using a periareolar dermal flap inconjunction with mixed mesh to support the glan-dular structures. As these concepts have evolved,the benefits of internal parenchymal reshapinghave been demonstrated. Foustanos and Zavrideshave described the double-flap technique.15 Themastopexy outline utilizes the inverted-T pattern.An inferiorly based parenchymal flap based onchest wall perforating vessels is created, as well asa medial and lateral pillar. The upper breast ispartially undermined off the pectoral fascia. Theinferior parenchymal flap is sutured to the pec-toral fascia, and the medial and lateral pillars aresutured together. Boehm et al. prefer the sameoperation, except that it is performed through avertical incision.16 Ritz et al. have described thefascial suspension mastopexy in which a vertical orinverted-T pattern is delineated.17 The techniqueis similar to the Foustanos and Zavrides technique,except that the inferior parenchymal pedicle istunneled under a 3 � 5-cm band of pectoralisfascia. The medial and lateral pillars are approx-imated. Graf and Biggs have popularized the pec-toral loop technique in which the inferior paren-chymal flap is passed through a loop of pectoralmuscle to maintain the position of the flap.18 Thisoperation can be performed though various inci-sional patterns that include J, inverted-T, vertical,and horizontal patterns. The use of an interlock-ing Gore-Tex suture to maintain the diameter ofthe nipple-areola complex can be considered.

Complications include delayed healing, skinnecrosis, nipple necrosis, nipple asymmetry, fatnecrosis, and unattractive scars.18 Mammographicchanges can occur following glandular reshaping

Fig. 3. Illustrations of (left) an eccentric mastopexy pattern and(right) a periareolar or donut mastopexy pattern. (Reprinted fromRohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Grunert JG.The limited scar mastopexy: Current concepts and approaches tocorrect breast ptosis. Plast Reconstr Surg. 2004;114:1622–1630.)

Fig. 4. The pattern for a circumvertical mastopexy is illustrated. (Reprinted fromRohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Grunert JG. The limited scar mas-topexy: Current concepts and approaches to correct breast ptosis. Plast Reconstr Surg.2004;114:1622–1630.)


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and include microcalcifications. These can usuallybe distinguished from malignant transformation.

In a recent survey of U.S. plastic surgeons, theskin excision pattern utilizing the inverted-T incisionwas found to be the most common type of mastopexyperformed.19 Physician satisfaction was highest withshort-scar circumvertical techniques and lowest withperiareolar techniques. Morbidities were assessedbased on procedure type. Revisions were highestin the periareolar group (p � 0.002), bottomingout was greatest in the inverted-T group (p �0.043), and asymmetry was highest in the short-scar group (p � 0.008).

AUGMENTATION MASTOPEXYAugmentation mastopexy is a complex oper-

ation that incorporates all of the elements of aug-mentation mammaplasty and mastopexy. Properassessment includes the degree of nipple ptosis,degree of breast ptosis, distance from the nipple-areola complex to the inframammary fold, loca-tion of the nipple-areola complex relative to thebreast, and the quality of the skin envelope andparenchymal tissue. Indications for an augmenta-tion and mastopexy include a nipple-areola com-plex that is below the inframammary fold, Reg-nault’s grade II to III ptosis, excess breast skinrelative to breast parenchyma, and breast ptosisthat is more than 2 cm below the inframammaryfold. The goals of this procedure are to elevate theposition of the nipple-areola complex, enhancebreast volume, and tighten the skin envelope toimprove breast contour and position.

The decision making with regard to mas-topexy alone, augmentation alone, and augmen-tation mastopexy can be complicated. The idealposition of the nipple-areola complex should bedetermined based on the inframammary fold andthe midhumeral location (Fig. 7). If nipple eleva-tion is not required, then augmentation aloneshould suffice. However, if there is some degree ofbreast ptosis, augmentation mastopexy may beconsidered. Mastopexy types include the crescent,circumareolar, circumvertical, and Wise pattern.

Fig. 5. The pattern for the inverted-T mastopexy is illustrated. (Reprinted from Rohrich RJ, Thornton JF, JakubietzRG, Jakubietz MG, Grunert JG. The limited scar mastopexy: Current concepts and approaches to correct breast ptosis.Plast Reconstr Surg. 2004;114:1622–1630.)

Fig. 6. The pattern for the L-shaped mastopexy is illustrated. (Re-printedfromRohrichRJ, ThorntonJF, JakubietzRG, JakubietzMG,Grunert JG. The limited scar mastopexy: Current concepts andapproachestocorrectbreastptosis. Plast Reconstr Surg. 2004;114:1622–1630.)


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For mild ptosis, a crescent or periareolar approachis considered. For moderate ptosis, a circumver-tical approach is considered. For severe ptosis, aninverted-T incisional pattern is often performed.

All of these options will depend on the desiresand expectations of the patient. If a woman isinterested in mastopexy alone or augmentationalone, this should take priority, assuming that thepatient understands the shortcomings, risks, andbenefits. In a woman with mild to moderate breastptosis, simultaneous augmentation and mas-topexy can be considered. In a woman with severebreast ptosis, a staged procedure can be consid-ered. In these patients, either mastopexy or aug-mentation can be performed first followed by theother. Prosthetic devices can be placed in the sub-pectoral or subglandular plane. These planes areusually accessed through the mastopexy incisionsand do not require remote access.

When either a staged or simultaneous aug-mentation/mastopexy is planned, there are sev-

eral technical points that should be considered tokeep the operation safe and effective. Spear hasreviewed the complexities associated with this op-eration when the mastopexy is performed follow-ing augmentation, including infection, implantexposure, loss of nipple-areola sensation, malpo-sition of the nipple-areola complex, and malpo-sition of the implant relative to the overlyingbreast.20 The complexities are compounded whensimultaneous augmentation and mastopexy areplanned, because of apposing vectors. Risks in-clude devascularization of the central breastmound, skin necrosis, loss of nipple sensation, andnipple malposition. Friedman has outlined severalpreventative measures when considering simulta-neous augmentation and mastopexy.21 These in-clude subpectoral device placement, augmenta-tion before mastopexy, tailor-tacking the skinenvelope, avoidance of inverted-T incisions, andparenchymal resection as needed.

Clinical experience with augmentation/mas-topexy has been generally favorable. Stevens et al.have reported a 10.9 percent implant revision rateand a 3.7 percent tissue revision rate.22 Compli-cations included saline implant deflation, recur-rent ptosis, poor scaring, and areolar asymmetry.The majority of women had silicone gel implants(69 percent) placed in the submuscular position(87 percent). The type of mastopexy included theinverted-T (60 percent), periareolar (21 percent),circumvertical (15 percent), and crescent (4 per-cent). Spear et al. have reported on 166 womenwho had various combinations of augmentation,mastopexy, and augmentation mastopexy.23 Therewere 97 primary procedures and 69 secondaryprocedures. Complications following primary aug-mentation occurred in 1.7 percent compared with17.4 percent following primary augmentationmastopexy. The revision rate following primaryaugmentation was 1.7 percent compared with 8.7percent following primary augmentation mas-topexy. Comparing the complication and revisionrate in women following secondary augmentationand augmentation/mastopexy procedures dem-onstrated no difference.

POLAND SYNDROMEPoland syndrome is an uncommon condition

with a reported incidence that is less than 0.1percent.1 It is characterized by hypoplasia or apla-sia of the breast and nipple-areola complex, ab-sence of the pectoralis minor muscle, absence ofthe sternal head of the pectoralis major muscle,and a subcutaneous soft-tissue deficiency. Thetypical appearance of a patient with Poland syn-

Fig. 7. The position of the nipple-areola complex is based on therelationship to the inframammary fold, as depicted. (Reprintedfrom Spear SL, Boehmler JH, Clemens MW. Augmentation/mas-topexy: A 3-year review of a single surgeon’s practice. Plast Re-constr Surg. 2006;118(Suppl.):136S–147S.)


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drome includes severe asymmetry of the af-fected and nonaffected chest wall, with apathognemonic groove at the junction of thesuperior anterior axillary line and chest wallbecause of the absent sternal head of the pec-toralis major. Brachydactyly and syndactyly aresometimes associated with this syndrome.

The goals of treatment are to correct the bonedeformity when necessary, address the soft-tissuedeficiency, and to reconstruct the breast. Correc-tion of Poland deformity may require stages. Inyoung children with a severe chest wall deformity,early reconstruction of the thoracic cage may benecessary before breast reconstruction, whichwould be considered in late adolescence or adult-hood when breast development is complete.24

Reconstructive options include remodeling ofthe thoracic cage, use of autologous tissue withfree or pedicled flaps, prosthetic devices, and au-tologous fat transfer using injection techniques.Fokin and Robicsek have described an option forchest wall reconstruction utilizing contralateralsplit-rib grafts that are secured to the defective ribmargins and sternal edge.24 This is resurfaced withprosthetic mesh for support. During the secondstage, latissimus dorsi flap reconstruction is con-sidered. Dingeldein et al. have described a similarprocedure that spares the costal cartilage and uti-lizes the latissimus dorsi muscle immediatelyrather than prosthetic mesh.25 Borschel et al. hadstratified the various types of Poland deformitiesreconstructed with prosthetic devices with andwithout the addition of a latissimus dorsi flaps.26

The prosthetic devices included tissue expanders,customized solid silicone implants, and standardsaline and silicone gel implants. In men, a customsilicone implant is preferred rather than a latissi-mus dorsi flap. In women, a two-stage reconstruc-tion is preferred, starting with a tissue expanderand followed by either a latissimus dorsi flap withor without an implant or a prosthetic device with-out flap coverage. Kelly et al.27 have successfullyused the contralateral latissimus dorsi free flap ina 2-year-old girl, and Laio et al.28 have used thedeep inferior epigastric perforator flap in a 52-year-old woman with severe ipsilateral chest wallabnormalities associated with Poland syndrome.Coleman and Saboeiro have described and pop-ularized lipoaugmentation for breast deformi-ties, including Poland breast.8 Pinsolle et al.have used lipoaugmentation alone in one pa-tient and in combination with prosthetic devicesand/or autologous tissue in seven patients withPoland syndrome.29

Complications following correction of Polandbreast deformity are primarily related to the re-construction itself. Prosthetic devices may becompromised because of capsular contracture,implant rupture, implant distortion, implant mi-gration, and seroma formation.26,30,31 Flap recon-struction may fail due to perfusion problems, re-sulting in partial or total flap failure. Breastasymmetry is almost always a certainty followingunilateral reconstruction; however, secondaryprocedures may improve the imbalance. Rocha etal. have described the phenomena of costal re-sorption and mediastinal shift following pros-thetic reconstruction.31

Outcomes following correction have generallybeen good. Seyfer et al. reported long-term resultsfollowing correction in 27 patients.30 The majorityof women had soft prosthetic devices with or with-out a latissimus dorsi flap and did well. Custom-made devices fared worse requiring prematureremoval in 75 percent. Contralateral proceduresfor balance and symmetry were necessary in 13 of21 women (62 percent).

GYNECOMASTIASee Video 4, in which Dr. Hall-Findlay shows

the reduction surgery, including inferior wedgeexcision, medial pedicle, and vertical skin re-section, available in the “Related Videos” sectionof the full-text article on PRSJournal.com. Video

Video 4. Video 4, in which Dr. Hall-Findlay shows the reductionsurgery, including inferior wedge excision, medial pedicle, andvertical skin resection, is available in the “Related Videos” sectionof the full-text article on PRSJournal.com. Video for Ovid users isavailable at http://links.lww.com/PRS/A312. Presented withpermission from Elizabeth Hall-Findlay, M.D. and Tracker Produc-tions, Banff, Alberta, Canada.


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for Ovid users is available at http://links.lww.com/PRS/A312.

See Video 5, in which Dr. Hall-Findlay showsthe summary and result for mastopexy and re-duction, available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com.Video for Ovid users is available at http://links.lww.com/PRS/A313.

Gynecomastia is a condition of benign prolif-eration of breast tissue in men. Although not com-monly reported, it is present in 40 to 50 percentof men over 40 years of age.32 It can manifest inpubertal boys and in men of advanced years. Theetiology is variable and may be due to excess cir-culating estrogen, decreased circulating andro-gens, or a deficiency of androgen receptors.32,33 Inmiddle-aged and older men, it is thought to be dueto the excessive aromatization of androgens toestrogens.32 Initial evaluation requires differenti-ation between fatty tissue, parenchymal enlarge-ment, and tumor. Imaging studies, such as mam-mography, are useful. Biopsy may be indicated insome cases.

Classification of the gynecomastia will assist withtreatment planning. Rohrich et al. have classifiedgynecomastia based on breast size and degree ofptosis.34 Grade I is minimal hypertrophy without pto-sis. Grade II is moderate hypertrophy without ptosis.Grade III is severe hypertrophy with grade I ptosis.Grade IV is severe hypertrophy with grade II or IIIptosis. Surgical management consists of removal ofthe excess fat and glandular tissue. This is achieved

using direct excision or suction lipectomy. Variousmodalities to assist with these techniques have beenrecently described.

The goals of treatment are to determine theetiology of this condition and to control or reversethe process (Fig. 8). Gynecomastia may be due tothe ingestion of certain medications, systemic dis-ease, body habitus, or genetic predisposition.Medications that have been implicated in causinggynecomastia include, but are not limited to, anti-androgens, exogenous hormones, and cardiovas-cular medications, such as digoxin and spirono-lactone, as well as antiulcer medications, such ascimetidine and ranitidine.32,33 Systemic conditionsinclude thyroid abnormalities, renal failure, andliver disorders. Control of the underlying condi-tion or cessation of medication may improve thecondition; however, if not, then surgical optionsare considered. The goal of surgery is to removethe excess breast tissue and skin, ensure adequatepositioning of the nipple-areola complex, ensuresymmetry between the breasts and chest wall, andto avoid significant scarring.35

There have been several methods by whichexcess breast tissue is removed that range fromdirect excision to suction-assisted lipectomy. Cur-rent standards are to use liposuction and its de-rivatives unless the condition is so severe that di-rect skin excision is required. For when skinexcision and free nipple grafting are necessary,Murphy et al. have described a method by whichnipple-areola placement is optimized.36 Based onpreoperative measurements, the vertical axis is lo-cated 0.33 times the distance of the sternal notchand pubis, and the horizontal axis or internippledistance is 0.21 times the chest circumference. Analternative to free-nipple grafting in cases of severehypertrophy is described by Tashkandi et al.37 Inthese cases, a single-stage subcutaneous mastec-tomy and circumareolar concentric skin reduc-tion is performed.

Traditional suction-assisted liposuction can beeffective in mild cases of gynecomastia; however,in more advanced cases, enhancing the efficacyand strength of liposuction may be necessary.Hodgson has reported on the use of ultrasonic-assisted liposuction in conjunction with suction-assisted liposuction for gynecomastia.38 Thirteenpatients with gynecomastia that ranged fromgrade I to III had successful treatment with aspi-rates that ranged from 100 to 300 cc using ultra-sonic-assisted liposuction and 100 to 600 cc usingsuction-assisted liposuction. Lista and Ahmadhave utilized power-assisted liposuction in con-junction with a pull-through technique to sever

Video 5. Video 5, in which Dr. Hall-Findlay shows the summaryand result for mastopexy and reduction, is available in the “Re-lated Videos” section of the full-text article on PRSJournal.com.Video for Ovid users is available at http://links.lww.com/PRS/A313. Presented with permission from Elizabeth Hall-Findlay,M.D., and Tracker Productions, Banff, Alberta, Canada.


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the subdermal attachments of the fibroglandularbreast tissue.39 The mean aspirate from the power-assisted liposuction was 459 cc (range, 25 to 1400cc), and the amount of additional tissue extractedwith the pull-through technique ranged from 5 to70 cc per breast. An alternative to the pull-throughtechnique is to use a power-assisted arthroscopic-endoscopic cartilage shaver as described by Pradoand Castillo.40 This was demonstrated to be effec-tive in 20 patients in whom the fibrofatty andglandular tissues were removed without areolarincisions (Fig. 9).

Complications include inadequate resection,overresection, excess skin, complex scars, hema-

toma, seroma, partial nipple necrosis, suture linedehiscence, pain, loss of nipple sensation, andinfection. Lanitis et al. have demonstrated thatpatient age, resection volume, grade of gyneco-mastia, and surgical approach was not predictiveof a minor or major complication using direstexcisional techniques.41 They reported an overallcomplication rate of 15.5 percent, with the ma-jority of complications due to underresection(21.9 percent), overresection (18.7 percent), com-plex scars (18.7 percent), hematoma (16.1 per-cent), and seroma (9.1 percent). Gingrass andShermak have reported no serious complicationsusing ultrasound-assisted liposuction.42 Potential

Fig. 8. A preoperative algorithm for gynecomastia is illustrated based on the possible etiologies. (Reprinted fromRohrich RJ, Ha RY, Kenkel JM, Adams W. Classification and management of gynecomastia: Defining the role ofultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111:909 –923.)


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risks of ultrasonic liposuction include thermalburns and skin necrosis, because one of the by-products of ultrasonic energy is heat. This isavoided by using cool towels over the skin andavoiding superficial planes near the skin surface.38

Outcomes following gynecomastia treatmenthave been generally regarded as good to excellent,regardless of the technique used. After ultrasound-assisted liposuction for gynecomastia, Hodgson etal. used a visual analogue score to assess patientsatisfaction.38 Based on a scale of one to 10, themean score for overall satisfaction, shape, appear-ance of scars, and self-confidence was nine.Rohrich et al. have demonstrated that no addi-tional procedures were necessary in 86.9 percent(53 of 61) of men following ultrasound-assistedliposuction for gynecomastia.34 In eight men withgrade III and IV gynecomastia, staged excision ofskin and breast was necessary to achieve the de-sired outcome. Ridha et al. have recently reportedon gynecomastia outcomes following a question-naire evaluation in 72 men following gynecomas-tia surgery.43 Although postoperative scores wereincreased using a Likert score from zero to fivefollowing either liposuction alone, surgical exci-sion alone, or a combination, the degree of in-crease was moderate. Only 62.5 percent of men

were satisfied to very satisfied. Based on the vari-ability of outcomes, patients must be carefullycounseled regarding the risks and benefits of gy-necomastia surgery.

Table 2 lists CPT codes commonly used in re-construction of breast deformities and mastopexy.

Maurice Y. Nahabedian, M.D.Georgetown University Hospital

3800 Reservoir Road, NWWashington, D.C. [email protected]

Fig. 9. Preoperative and postoperative views following gynecomastia surgery using the endoscopic cartilage shaving device. (Re-printed from Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver. Plast Reconstr Surg. 2005115:939 –942.)

Table 2. CPT Codes Commonly Used inReconstruction of Breast Deformities andMastopexy*

CPTCode Descriptor

14040 Adjacent tissue transfer or rearrangement,trunk; defect 10 cm2 or less

14041 Adjacent tissue transfer or rearrangement,trunk; defect 10.1 cm2 to 30.0 cm2

15734 Muscle, myocutaneous, or fasciocutaneous flap;trunk

19300 Mastectomy for gynecomastia19316 Mastopexy19325 Mammaplasty, augmentation; with prosthetic

implant*This information prepared by Dr. Raymond Janevicius is intendedto provide coding guidance.


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ACKNOWLEDGMENTThe author thanks Elizabeth J. Hall-Findlay, M.D.,

for providing permission to use her videos, which ac-company this article.

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