Surgical approach to the treatment of gynecomastia according to its classification

Background: Gynecomastia is the most common benign proliferation of the glandular tissue of the male breast and is caused by an alteration of the balance between estrogen and androgen concentrations. In most cases, the treatment of choice is surgery. In this study, we aimed to indicate the efficacy of established surgical procedures for the correction of gynecomastia, as evaluated according to Simon’s classification, and to present a novel contribution. Methods: This study was performed between March 2009 and March 2011. It included 32 male patients, aged between 13 and 45 years. The type of incision was chosen on the basis of the need for skin resection. We used 4 techniques described in the literature and a modified procedure of circular incision with inferior, superior, lateral, and medial extensions, which we employed when excess skin was also present in the lower pole of the breast. Results: Idiopathic gynecomastia was the most common etiology among our patients, followed by obesity and by use of anabolic steroids. Conclusions: The common procedure to correct gynecomastia was based on the inferior periareolar incision proposed by Webster, which we employed in patients who did not require skin resection. In the presence of excess skin, the technique chosen varied according to the amount of tissue to be resected. In the present report, we propose a novel technique that facilitates larger dermal, glandular, and fatty breast tissue removal when compared to other procedures previously used by this surgeon.


INTRODUCTION
Gynecomastia affects 40-65% of adult men and is characterized by a soft, symmetrical, and discoid enlargement of the male breast [1][2][3][4][5] .Gynecomastia is known as the most common benign proliferation of the glandular tissue of the male breast and is usually caused by an increased concentration of estrogen as a consequence of aging, disease, drug consumption, or idiopathic factors.In rare cases the condition may be caused by an endocrine tumor 1,2,6,7 .Gynecomastia progresses as a result of an alteration in the balance between estrogen and androgen concentrations 1 .This balance is essential for normal breast cell growth.
Classifications of different grades of gynecomastia ha ve been proposed; among these, Simon's classification is the most accepted 1,7 , and it has been adopted in the present study.
Gynecomastia may result from physiological changes du ring growth and development or may be pathologically induced.There are 3 peaks of physiologic gynecomastia.The first occurs during the neonatal period and the second occurs during puberty, usually regressing by approximately age 17 years.In both cases, gynecomastia usually regresses spontaneously.The third peak occurs in older men and seems to have a variety of causes, such as a decrease in testosterone due to testicular aging 2,4,[7][8][9][10] .
The correlation between male breast cancer and gynecomastia is controversial, with reported coexistence ranging from 2% to 35%; however, there is much evidence to suggest that the 2 conditions are not related 1,6 .
Most cases are idiopathic, and surgery is the primary choice of treatment for patients whose gynecomastia does not regress spontaneously or when psychosocial issues become severe 3,7 .Recently, several hormonal therapies have been suggested for the treatment of gynecomastia but have not met with success 1,6,7 .
The second leading cause of gynecomastia is due to the use of drugs that may trigger this condition.In this case, however, gynecomastia in adult males is usually conside red a side effect compared to the other adverse effects cau sed by the body's reaction to consumption of the drug 1 .Risperidone, phe nothiazine, selective serotonin (5-hydroxytryptamine; 5HT) reuptake inhibitors, methyldopa, tricyclic antidepressants, marijuana, heroin, saquinavir, minocycline, finasteride, sulpiride, and domperidone are some drugs that have been reported to induce gynecomastia 1,[4][5][6]11,12 .
The diagnosis requires a careful analysis of the patient's clinical history and physical examination 2,6 .The detection of a palpable mass in a male patient's breast could lead to the diagnosis of pseudogynecomastia, gynecomastia, breast cancer, and numerous other benign conditions.
The most common surgical procedure employed for gynecomastia treatment is subcutaneous mastectomy, which involves resection of the glandular tissue by a periareolar or transareolar approach, with or without liposuction.Skin resection is required in patients presenting with accentuated breast size, ptosis, and excess skin 6,8 .The main problems caused by the surgery are unsightly scars, redundant skin, and migration of the nipple 7 .
The aim of this study was to indicate the efficiency of 4 established surgical procedures for the correction of gynecomastia, as categorized by Simon's classification.We also present a modification of the circular incision technique with superior, lateral, and medial extensions that may be used when excess skin is also present in the lower pole of the breast.

METHOD
The study was conducted between March 2009 and March 2011.We selected 32 male patients between 13 and 45 years who were referred to Plastic Surgery Service of the Hospital Belo Horizonte/FELUMA da Faculdade de Ciências Médicas de Minas Gerais (Hospital of Belo Horizonte/FELUMA of the Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil) or who presented to the clinic voluntarily.All patients showed dissatisfaction with their condition and sought an aesthetic correction.
The following information was recorded: name, age, weight, height, grade of gynecomastia according to Simon's classification, location (unilateral or bilateral), time of evolution, skin color, cause of gynecomastia, symptoms (aesthetics, palpable mass, pain, or papillary discharge).
The choice of the procedure was based on Simon's classification and the need for skin resection.Surgical correction of gynecomastia in this study was performed using the techniques described below.

Inferior periareolar incision (proposed by Webster):
This technique was used in cases of gynecomastia without excess skin, as described by Freitas and Mélega 13 .
Surgical approach in the treatment of gynecomastia according to its classification

Periareolar circular incision:
This technique was applied in cases of gynecomastia with excess skin, as described by Camargos et al. 14 and Cunha et al. 15 .3. Inferior periareolar incision with superior, lateral, and medial extensions: This technique was applied in cases of gynecomastia with excess skin.First, the ideal position for the papillary-areola complex (PAC) was preoperatively marked.However, due to the superior, medial, and lateral excess skin, additional marks were made with incision extensions in regions measured with a bidigital maneuver (flying saucer), which allowed the resection of as much skin as possible.This avoided flaccidity upon removal of the glandular and fatty tissue and improved PAC positioning.The vertical bipedicled de-epidermized flap was maintained, as per McKissock, to promote a proper blood flow through the PAC 16 .

Periareolar circular incision with transverse lateral extension:
This technique was applied in cases of gy necomastia with excess skin.The preoperative planning followed the same procedure described in 2. However, because of the larger amount of excess lateral skin in the thoracic region, lateral marks were made with a bidigital maneuver, allowing for a greater skin resection without extending beyond the anterior axillary line 16 .5. Circular incision with inferior, superior, lateral, and medial extensions (personal modification): This tech nique is a personal modification developed in si de the clinic that was applied to patients who required a wider resection of breast tissue in the lower pole.
It consisted of a modification of the inferior periareolar incision with superior, lateral, and medial extensions.The preoperative mark followed the same procedure as described in 3; however, in addition, an inferior mirror extension was also performed.The bipedicled flap was maintained (option 1) or, when necessary, resection of the inferior pedicle was performed (option 2), allowing  for better PAC accommodation.The procedure is il lus trated in Figures 1 to 7.
Medeiros MMM

RESULTS
The data of the 32 patients included in this study, obtained during the anamnesis, includes information on the procedures used, the weight of breast tissue removed, whether associated liposuction was performed, any postoperative complications, and patient satisfaction level.
Figure 8 shows the main causes of gynecomastia in the patients evaluated in this study, whereas Figure 9 shows gynecomastia etiologies according to age group.
Figure 10 presents the distribution of incisions used in this study.
Laboratory examinations did not reveal any evidence of pathology associated with gynecomastia in the patients evaluated.Pathological examinations confirmed the presence of gynecomastia in all cases.

DISCUSSION
The leading cause of gynecomastia is idiopathic, as other authors have found 3,7 , followed by obesity and use of ana bolic steroids.These latter 2 causes reflect, in part, the profile of modern society, in which an excessive weight gain is linked to a sedentary lifestyle or to disorders that might be derived from it, such as anxiety, depression, and others.On the other hand, the use of drugs for aesthetic purposes is a fast and easy way to modify the appearance, although Surgical approach in the treatment of gynecomastia according to its classification  the result is achie ved through an alteration of hormone concentrations.It was found that obesity is the second leading cause of gynecomastia in all age groups, particularly in patients aged less than 20 years old.In patients aged over 20 years, anabolic steroids are the second leading cause of gynecomastia.
The main procedure used in this study for the correction of gynecomastia was the inferior periareolar incision proposed by Webster, because most of the patients did not present with excess skin.This is a simple technique, which leaves a good quality scar that is barely noticeable in most cases; it is used with Simon's classification grade I and IIA.All the patients were satisfied with the aesthetic result 6 months after surgery, which may be attributed to the small size required for the incision and its location.
In cases in which the excision of excess skin was required, the surgical technique most often used was the circular periareolar incision, which was applied to more than 40% of the patients with grades of gynecomastia varying between IIB and III.This technique requires additional surgical care to render the scar acceptable.Moreover, this procedure showed a higher number of complications (38.5%) such as hypertrophic and keloid scars, which accounted for 60% of the complications observed.The complaints were mainly from patients whose obesity was the cause of gynecomastia and where the weight of material removed from the breasts was more than 100 g.These complications were associated with early physical activity performed by the patients, which generated an increased tension in the scar leading to Medeiros MMM dehiscence, hypertrophic scars, and keloids.With an aim toward avoiding future complications in other patients, the surgeon applied a higher number of subdermal stitches and reinforced the postoperative recommendations.
In cases that were classified as grade III according to Si mon, in which more excess skin is involved, elabora te te chniques were employed, including the modification pro posed herein.This consists of a circular incision with inferior, superior, lateral, and medial extensions.This new sur gical contribution allowed a larger removal of excess der mal, glandular, and fatty tissue, which, in the experience of the surgeon, leads to patient satisfaction.All patients with gynecomastia who were treated with the incision described in points 3, 4, and 5 in the Methods were satisfied with their results 6 months after surgery.This was also achieved by an extensive experience in closing the tissue with a higher number of subdermal stitches, which prevented damage du ring healing.Patients were instructed to better collaborate in their recovery activities, by avoiding physical exertion, not raising their arms above the shoulder for at least 20 days, and using a compression vest for at least 30 days.

CONCLUSIONS
The surgical approach used in this study for the treatment of gynecomastia varied according to Simon's classification.Through these results, we conclude that, in cases in which the resection of skin was not required, the inferior periareolar incision proposed by Webster was the best option.In cases wherein excess skin is present, the chosen procedure varied according to the amount of tissue that had to be resected.All the established procedures indicated their importance and efficacy in the correction of gynecomastia; however, in cases in which a more extensive resection of breast tissue in the lower pole was required, the modified technique presented in this study exhibited the best aesthetic result and satisfaction level, according to the patients.

Figure 3 -Figure 4 -Figure 5 -
Figure 3 -PAC de-epidermization with the medial and lateral extension incisions used in the circular incision technique with inferior, superior, lateral, and medial extensions.A B

Figure 6 -Figure 7 -
Figure 6 -Resection of the lower pedicle of PAC (option 2)in the circular incision technique with inferior, superior, lateral, and medial extensions.

Figure 11 associates
Figure 11 associates the surgical procedures employed to the grade of gynecomastia according to Simon's classification.Figures 12 to 15 present preoperative and 6-month postoperative photographs of several patients.

Figure 11 -Figure 12 -
Figure 11 -Correlation between the prevalence of incision type used and the grade of gynecomastia according to Simon's classification.Type 1 = inferior periareolar incision proposed by Webster; Type 2 = periareolar circular incision; Type 3 = inferior periareolar incision with superior, lateral, and medial extensions;Type 4 = periareolar circular incision with lateral transverse extension; Type 5 = circular incision with inferior, superior, lateral, and medial extensions.