Introduction

Gynecomastia is a benign abnormal enlargement of the male breast due to proliferation of glandular tissue, which presents as a rubbery or firm mass extending concentrically from the nipple. It is the most common benign condition of the male breast and is estimated to affect about 40–65 % of males [1, 2]. Gynecomastia has several causes, including an imbalance in the testosterone-to-estrogen ratio in male breast tissue [2]. The primary mechanisms include decreased androgen production, increased estrogen production, and increased availability of estrogen precursors for peripheral conversion to estrogen [3]. The most common cause is physiologic gynecomastia, which occurs mainly during the adolescent period. Although 85–90 % of pubertal gynecomastia regresses within 6 months–2 years, in the remaining cases, gynecomastia persists into adulthood [4]. The condition may develop as a result of obesity, cancer, or consumption of estrogens, anabolic steroids, or H2 blockers such as cimetidine [5].

For a man, the development of feminized breasts may cause significant emotional distress and embarrassment; thus, proper treatment crucially affects quality of life and self-confidence. The choice of treatment for gynecomastia is affected not only by the underlying cause, but also by symptoms such as severity of pain, tenderness, palpability, and emotional distress due to appearance. When symptoms are severe or spontaneous regression does not occur, surgical intervention is required. This involves removal of glandular and fat tissue via various incisions. Some surgeons report that liposuction can be a substitute for direct excision regardless of the grade of gynecomastia, whereas others believe that liposuction cannot completely remove the glandular tissue [6–8]. Although whether one technique is superior to the other is still controversial, surgeons supporting the removal of glandular tissue by liposuction recommend it as a less invasive surgery with minimal scarring, and surgeons supporting conventional subcutaneous mastectomy claim that complete surgical excision of the glandular tissue is essential to cure gynecomastia.

In this study, we divided patients into two groups according to the surgical modality, which was based on the classification of gynecomastia. We compared outcomes between groups and suggested the proper management depending on the severity of gynecomastia.

Materials and Methods

Patients

We conducted a retrospective analysis of 64 patients diagnosed with gynecomastia who underwent surgery between January 2009 and May 2015. Their average age was 23.8 ± 5.8 years old. Sixty-one patients underwent bilateral surgery, and three underwent unilateral surgery. The examinations for all patients included careful history taking, physical examination, and laboratory tests to identify any underlying pathologic conditions such as hypogonadism, hyperthyroidism, or Klinefelter’s syndrome. We also performed ultrasound preoperatively for the differential diagnosis of pseudogynecomastia and estimated the amount of glandular tissue to remove. Sixty-two patients had gynecomastia that had developed in adolescence and persisted in the absence of any underlying medical condition. Two patients had Klinefelter’s syndrome. The average body mass index of the patients was 26.5 ± 3.3 kg/m2. Preoperative grading was based on the criteria of the American Society of Plastic Surgeons® (Table 1) [9]. We classified the subjects as 4 pseudogynecomastias, 22 grade I gynecomastias, 22 grade II gynecomastias, 12 grade III gynecomastias, and 4 grade IV gynecomastias. Our work was carried out in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards, and written consent was obtained for each patient.

Table 1 Classification of gynecomastia [9]
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Surgical Procedure

Based on the preoperative classification and ultrasound evaluation, patients with pseudogynecomastia, grade I gynecomastia, or grade II gynecomastia with minimal glandular component received liposuction only. Patients of grade I or II gynecomastia with palpable glandular tissue received power-assisted liposuction and subcutaneous mastectomy. Patients with grade III or IV gynecomastia received ultrasound-assisted liposuction and subcutaneous mastectomy, because ultrasound-assisted liposuction aids in skin retraction during the postoperative healing period when performed in the appropriate subdermal plane. Additional procedures such as a mastopexy were performed only in grade IV gynecomastia cases with excessive skin redundancy and breast ptosis.

Preoperatively, the areas of fat and glandular tissue were marked with the patient in a standing position (Fig. 1a). All procedures were performed under general anesthesia with the patients placed in the supine position. The combined procedures of subcutaneous mastectomy and liposuction were performed with an inferior periareolar incision around one-third to one-half of the circumference of the areola (Fig. 1b). Liposuction only was performed with single puncture incision in the subareolar area. When mastopexy was necessary, a circumareolar incision was made.

Fig. 1
figure 1

Surgical design and operation procedure. a Preoperatively, the areas of fat and glandular tissue were marked with the patient in a standing position. b The periareolar incision around one-third of the circumference of the areola in a patient undergoing combination treatment consisting of subcutaneous mastectomy and liposuction

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After a tumescent solution was infiltrated into the breast, power-assisted or ultrasound-assisted liposuction was performed along the preoperatively marked area. In subcutaneous mastectomy, the entire glandular tissue was excised except a disk of tissue beneath the areola to prevent a sunken areola and preserve nipple sensation (Fig. 2a, b). A negative drain was inserted through the subareolar incision in each breast, and then the incision was meticulously repaired. Compression dressing was applied postoperatively.

Fig. 2
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Schematic design and specimen. a The resection range of glandular tissue with a periareolar incision. b Glandular tissue removed by subcutaneous mastectomy

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Assessment

Standardized photographs were taken preoperatively, immediately after the operation, and during the follow-up period (3 and 6 months). We divided the patients into two groups: group A consisted of patients who underwent liposuction only; group B consisted of patients who underwent liposuction and subcutaneous mastectomy.

The serial photographs of all patients were clinically evaluated by three plastic surgeons who were not involved in the operations. Separate analyses were performed for each breast of a subject. The aesthetic aspects evaluated by the plastic surgeons included (1) size, (2) shape, (3) scarring, and (4) overall outcome. They were assessed using the following grading scale: 1, poor; 2, fair; 3, good; 4, very good; and 5, excellent. Furthermore, all patients completed a satisfaction survey to assess (1) palpable lump, (2) size, (3) shape, (4) scarring, and (5) overall outcome of the surgery using a visual analogue scale of 1–10: 1–2 is poor, 3–4 is fair, 5–6 is good, 7–8 is very good, and 9–10 is excellent.

To analyze the outcomes of the two groups, the surgeon evaluations and patient satisfaction survey results were compared by independent samples t test. The significance level was set at p < 0.05.

Results

Of the 64 subjects, 16 received liposuction only, and 48 received both liposuction and subcutaneous mastectomy (total of 125 breasts). Of the patients who received both subcutaneous mastectomy and liposuction, 15 had grade I gynecomastia, 18 had grade II gynecomastia, 11 had grade III gynecomastia, and 4 had grade IV gynecomastia. Only one patient with grade IV gynecomastia underwent periareolar doughnut mastopexy combined with ultrasound-assisted liposuction and subcutaneous mastectomy. Of the patients who received liposuction only, 4 had pseudogynecomastia, 7 had grade I gynecomastia, 4 had grade II gynecomastia, and 1 had grade III gynecomastia. No patients with grade IV gynecomastia were treated with liposuction only. The mean follow-up period was 30.9 ± 13.7 months. The mean volume of fat tissue removed from each breast with liposuction was 235.0 cc (range 100–550 cc) in group A and 169.5 cc (range 50–375 cc) in group B. The mean volume of glandular tissue removed with mastectomy was 40.9 g (range 2–155 g) (Table 2).

Table 2 Characteristics of gynecomastia patients in both treatment groups
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Regarding the surgeons’ evaluations of patients in group A, who received liposuction only, the average scores were 3.20 for overall size, 3.57 for shape, 4.52 for scarring, and 3.67 out of 5 for overall outcome. The scores for patients in group B, who underwent both liposuction and mastectomy, were 4.06 for overall size, 3.72 for shape, 4.08 for scarring, and 4.01 for overall outcome. The average score for scarring was significantly higher in group A, and the scores for size and overall outcome were significantly higher in group B (Table 3). Figures 3, 4, and 5 show the postoperative outcomes of several patients who underwent operations for gynecomastia.

Table 3 Evaluated outcomes for all patients in both treatment groups
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Fig. 3
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An 18-year-old male patient with grade I gynecomastia. a Preoperative view. b Postoperative 6-month view of the patient after treatment with power-assisted liposuction and subcutaneous mastectomy

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Fig. 4
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A 19-year-old male patient with grade II gynecomastia. a Preoperative view. b Postoperative 6-month view of the patient after treatment with power-assisted liposuction and subcutaneous mastectomy

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Fig. 5
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A 15-year-old male patient with grade III gynecomastia. a Preoperative view. b Postoperative 3-month view of the patient after treatment with ultrasound-assisted liposuction and subcutaneous mastectomy

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When we surveyed the satisfaction levels of patients who underwent liposuction only, the average satisfaction scores were 7.87 for palpable lump, 6.74 for overall size, and 6.61 for shape. The score for satisfaction with respect to scarring was 9.32. The overall satisfaction with the surgery was 7.39 out of 10. The satisfaction levels of the patients who underwent the combination procedure were 8.06 for palpable lump, 7.52 for overall size, 6.90 for shape, and 8.10 for scarring. The overall satisfaction was 7.57 out of 10. In both groups, the patients were generally satisfied with their results, because scores higher than seven mean “very good.” Satisfaction regarding size was significantly higher in group B, and satisfaction regarding scarring was significantly higher in group A (Table 3).

Since the baseline characteristics of the two groups were not comparable in terms of preoperative grading, a post hoc analysis of patients with grade I and II gynecomastia was conducted. Similar results were obtained, as shown in Table 4.

Table 4 Evaluated outcomes for patients with grade I and II gynecomastia in both treatment groups
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Concerning complications, one case of undercorrection was noted in group A, and one case of undercorrection and one case of dimpling deformity were noted in group B. The undercorrected patient in group A underwent an additional combination procedure with liposuction and subcutaneous mastectomy 3 years later. Two years after the re-operation, the patient scored 7 for overall satisfaction. Several patients experienced hypoesthesia immediately after the surgery but recovered without sequela. One patient in group B complained of a hypertrophic scar, but scarring improved after treatment with a local steroid injection.

Discussion

When initiating treatment for gynecomastia, it is imperative to thoroughly review the patient’s medical history and rule out other causative factors such as hormone-related diseases or medications. It should also be noted that gynecomastia is usually self-limiting and is likely to regress spontaneously. Medical treatments that adjust hormonal imbalance can be effective, especially in the early phase. However, surgical intervention is the standard treatment when it comes to gynecomastia that persists longer than 2 years [5, 10].

The choice of surgical technique depends on the severity of breast enlargement and presence of excess adipose tissue. When gynecomastia includes little glandular tissue, liposuction only would be sufficient to correct the lesion. However, if there is glandular tissue that should be removed, subcutaneous mastectomy is a commonly used technique that involves direct resectioning of the glandular tissue using a periareolar or transareolar approach with or without liposuction. In our study, all outcomes other than scarring were superior in patients who received the combination treatment of subcutaneous mastectomy and liposuction compared to patients who received liposuction only. In particular, the outcomes of overall size and overall satisfaction differed significantly between the two groups. Although the average patient score for scarring was higher in group A, the score for scarring in group B was 8.10, showing acceptable results.

In recent years, a new procedure involving the combination of liposuction and use of a cartilage shaver has been introduced [11–13]. Advocates of this method report that the postoperative scar can be less obvious using this technique than with previous methods. As our study reveals, however, the combination treatment of conventional mastectomy and liposuction yields satisfying outcomes regarding the degree of postoperative scarring. The scars are longer than is the case with cartilage shaving, which leaves a postoperative scar of less than 10 mm. However, the scar from a subcutaneous mastectomy is barely noticeable because the incision is only about one-third to one-half of the circumference of the nipple-areolar complex, and the scar is placed on the edge of the areola, making it much easier to hide (Fig. 6).

Fig. 6
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The scar of a 51-year-old male patient who underwent treatment for unilateral grade I gynecomastia with periareolar incisions around one-third of the circumference of the areola. The patient received operation for only left side, and the scar is hardly visible compared to the right side in postoperative 2-year view

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Recently, an increased interest in appearance has motivated patients with low-grade gynecomastia to consider surgical treatment. To achieve a better aesthetic outcome, it is necessary to remove all glandular tissue in the subareolar area. For this purpose, we recommend subcutaneous mastectomy under direct vision instead of a blind procedure with a cartilage shaver or ultrasound-assisted liposuction. In cases of high-grade gynecomastia with larger volumes of glandular tissue, surgical treatment with subcutaneous mastectomy is beneficial.

Our study shows that the combination treatment of subcutaneous mastectomy and liposuction leads to excellent overall outcomes and good results in terms of scarring. One possible limitation of this study is that we did not include patients with glandular tissue who underwent surgical treatment with less invasive procedures such as cartilage shaving. However, we were able to evaluate scarring after combination treatment with liposuction and subcutaneous mastectomy by comparison with patients who underwent liposuction only.

Conclusion

Surgical correction is considered the gold standard therapy for gynecomastia, and many surgical techniques have been developed. Recent studies have reported various methods such as liposuction only or the combination of liposuction and cartilage shaving. However, our study shows that combination treatment with liposuction and subcutaneous mastectomy brings about satisfactory outcomes, including the extent of scarring. We conclude that gynecomastias that include little glandular tissue can be corrected with liposuction only, but when glandular tissue needs to be removed, combination treatment with liposuction and subcutaneous mastectomy is recommended as the standard surgical treatment for gynecomastia.