TUMESCENT LIPOSUCTIONIN GYNAECOMASTIA

Dr Venkataram Mysore-Dr Jayashree Venkataram

Venkat Charmalaya-centre for advanced dermatologyBangalorewww.bangaloreliposuction.comwww.bangalorehairtransplant.com

MALE BREASTS ( GYNAECOMASTIA)

Gynaecomastia is a common condition causing psychological disturbance and social embarrassment

CAUSES Puberty Steroid abuse Obesity Tumours Genetic disorders Chronic liver disease Side effects of many medications Castration Klinefelter Syndrome Gilbert's Syndrome Aging

CAUSES

In most cases, underlying cause cannot be found Tamoxifen, Danazol has been found to be useful for

oestrogen sensitive gynaecomastia However, treatment of the condition is usually by

surgery

SURGERY Liposuction, surgical resection are

suggested as the surgical techniques

IS LIPOSUCTION ALONE ADEQUATE?

Studies have suggested that liposuction or suction lipectomy alone is an excellent treatment

In Indian culture, dress code for men demands that, during religious occasions, visit to temples, marriages, breast area is exposed

Limitation of outdoor activities such as swimming, while playing sports, Gymnasium

Limitation in wearing tight shirts Source of embarrassment for students in hostels

with common baths

Gynaecomastia-Situation in India

INDICATIONS IN INDIAN PATIENTS

There are very few centres in India performing tumescent liposuction alone.

655 liposuction surgeries from 2004-2013 MALE vs FEMALE: 333:322

WOMEN were more than MEN; marginally

Our Experience

DIFFERENT AREAS IN MEN

BREAST ABDOMEN Flanks Thighs Buttocks Arms CHIN

MALE breast was the most common indication

SIMPLIFIED CLASSIFICATION OF GYNAECOMASTIA

Mild( with prominence of central part of breast and nipple areas only)

Moderate( prominence of entire breast region without skin hanging)

Severe( prominences of entire breast area with hanging resembling female breast).

Mild

Moderate

Severe

MALE BREASTS OUR DATA Most patients were in the age group of 15-30

years. Four patients below 20 years Youngest was 15 years in age (was

counseled with parents ) Oldest patient was 60 years-

PRE-OPERATIVE INSTRUCTIONS

Routine blood investigations such as blood counts , Coagulation profile, LFT, Blood sugar, HbS Ag, HIV - and ECG, Ultrasound in moderate & severe male breasts

Advice to stop smoking Avoidance of oral NSAIDs Preoperative tranquillizer such as diazepam or

lorazepam on the night before surgery Injection Vitamin K to minimize postoperative bruising

PREOPERATIVE ULTRASOUND OF BREAST

Preoperative evaluation by ultrasound was performed in all the moderate and severe cases of gynaecomastia

Most cases had an admixture of fat and glandular tissue

Severe cases had predominant glandular tissue

PREPARATION OF PATIENT a) Preoperative antibiotic such as cephalexin b) Preoperative tranquillizer such as oral lorazepam

1 mg c) Oral Clonidine 0.1 mg to prevent epinephrine

induced tachycardia and as an adjuvant anxiolytic drug.

PREPARATION OF PATIENT

Surgical cleaning of the area with povidone iodine The area for liposuction is topographically marked, with

marker ink of different colours to delineate the bulges and asymmetry

Monitoring-we have a standby anesthetist for emergencies

ADITS NUMBER : 1-2 on each side SIZE : 2 to-2.5mm PLACEMENT : We avoid upper medial

quadrant in breast as this area is seen when shirt is not buttoned as it is more prone for Keloid

SUCTION APPARATUS OF 1HP POWER

INSTRUMENTS -MICROCANNULAE

Infiltration microcannulae have diameter of 0.5-1 mm

Aspiration microcannulas have an outside diameter upto 2.8 mm.

Cause less bleeding as they are small and hence safer

POWERED LIPOSUCTION We use power Assisted Liposuction-Microair,

Euromi machines are available No thermal component We have found that it reduces surgeons strain

and fatigue Cuts short Surgery time

LASER LIPOLYSIS We use Nd yag laser for lipolysis for

additional benefit. Laser can access difficult areas Laser also helps reduce fat and induce

tightening of skin to prevent hanging

ASPIRATION Amount of fat aspirated was between 1 - 4 liters ,

with an average of 2.5 liters Duration of surgery was between 2 -4 hours

SEVERE GYNAECOMASTIA-USE OF EXTRACTION

In patients with severe gynaecomastia, an additional larger adit of 6 mms was placed, just adjacent to areola and the fibrofattyglandular tissue was extracted and excised.

This greatly reduced the subareloar lump

Severe gynaecomastia-result after liposuction and extraction

Severe gynaecomastia-result after liposuction and extraction

POSTOPERATIVE DRESSING AND FOLLOW UP

No suturing of adits in most cases In severe cases, which need manual extraction, we put

an infraareolar incision which is sutured

This facilitates drainage of fluid

Tight pressure bandages are essential to ensure proper drainage of the tumescent fluid.

Pt goes home the same day

POSTOPERATIVE DRUGS ANTIBIOTIc PARACETAMOL PROXYVON

FOLLOWUP Patient is advised to come for follow up

for dressing daily for two days.

More than 50% of results will be seen on day 2

Further improvements happen gradually due to breakdown and absorption of fat

Final result is seen after 4-6 weeks

Clinical Results

Clinical Results

Clinical Results

DOES IT HAVE ANY COMPLICATIONS? All patients had uneventful recovery

with out any serious side effects. Post operative pain and tenderness

were mild in all patients. Adit sites healed well in all patients

SAGGING OF SKIN No sagging was seen except in patients

Even in severe cases, there was no obvious hanging and the resultwas mild and was acceptable to patients.

CONCLUSIONS Tumescent liposuction is a very safe and effective

surgery for gynaecomastia

Thorough tumescence and use of microcannulae are important for safety

Most cases can be treated effectively, without the need for more aggressive and expensive surgery

Severe Gynaecomastia needs additional extraction through a juxtaareolar adit

Skin hanging is not a significant problem except in the severe cases

OUR DOCTORS- EXPERIENCED TEAM Dr venkataram MD DNB

DipRCPAth(Lond)- Consultant Dermatosurgeon. Past President of Assn of Cutaneus Surgeons India

Dr Jayashree Venkataram MRCOG Liposuction Surgoen trained with Dr Jeffrey Klein