Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia Antonio Carlos Abramo Chapter 69 69 69.1 Introduction Gynecomastia or hypertrophy of breast tissue is a serious cosmetic c
Trang 167.8
Concluding Remarks
Large-volume liposuction is a procedure that can
remove substantial amounts of subcutaneous fat,
in-cluding fat from the localized fat depot that has many
biochemical features reminiscent of those found in
the visceral adipose tissue that is tightly linked to the
conditions of syndrome X Liposuction and lipectomy
have been used in some cases as adjuncts to more
es-tablished bariatric surgery, and recent developments
have raised the possibility of the utility of liposuction
as a primary surgical option for obesity management
The effects of large-volume liposuction on AVD risk
still require intensive, detailed investigation as there
are two opposing theories as to what happens to AVD
risk following this procedure On the basis of clinical
and animal data it appears that there is a threshold
effect: where removal of excessive subcutaneous fat
may result in AVD risk improvement, while removal
of significantly greater amounts may result in
delete-rious effects Clear definition of what determines this
threshold in the individual patient is an important
is-sue that needs to be resolved The results of ongoing
human and animal studies on this subject are eagerly
awaited
Acknowledgement. This research was supported by the
National Institute of Child Health and Human
Devel-opment, NIH (ZO1 HD-00641)
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li-References
Trang 4Liposuction for Gynecomastia
Enrique Hernández-Pérez, Hassan Abbas Khawaja, Jose A Seijo-Cortes
Chapter 68
68
68.1
Introduction
Male breasts are one of the four most requested
ar-eas for liposuction in men (after love handles,
abdo-men, and submaxillary fat) [1] This is true not only
in teenagers but also in adult men The reason being
the cosmetic inconvenience and the loss of
self-confi-dence produced by a feminine self-image
Pseudogynecomastia is defined as an excessive
amount of adipose tissue in the male breast, along
with a normal amount of glandular breast tissue [1]
True gynecomastia is the increase in size of male
breasts due to glandular tissue proliferation [2, 3] A
mixed variety combines excessive fatty and glandular
tissue
68.2
Pathogenesis
Pseudogynecomastia is typically an idiopathic
con-dition [1] A central issue in the evaluation of breast
tissue in adult men is the separation of the normal
from the abnormal A common belief is that no breast
tissue is palpable in the normal adult man; however,
gynecomastia (less than 4–5 cm in diameter) may
oc-cur in normal men [4]
Physiological gynecomastia occurs in at least three
circumstances: (1) at a few weeks of age (transitory
enlargement); (2) in adolescence (median age onset
is 14, it is grossly asymmetric, frequently tender, and
regresses spontaneously) [5]; and (3) gynecomastia in
elderly men (40% have gynecomastia)
There also exists a pathological gynecomastia that
can result from one of four basic mechanisms [1–4, 6]:
1 Deficiency in testosterone production or action
(congenital anorchia, Klinefelter syndrome,
tes-ticular feminization syndrome)
2 Increase in estrogen production (aberrant
produc-tion of chorionic gonadotropin by testicular or by
bronchogenic carcinoma or even estrogen
produc-tion caused by true hermaphroditism) [5, 7]
3 Increased conversion of androgens to estrogens in peripheral tissues (congenital adrenal hyperpla-sia, hyperthyroidism, and feminizing adrenal tu-mors)
4 Drugs such as digitalis, alkylating agents, ronolactone, cimetidine, busulfan, isoniazid, tri-cyclic antidepressants, d-penicillamine, anabolic steroids, phenytoin, clomiphene, and diazepam Abuse of heroin and marijuana also may cause gy-necomastia
spi-5 Consecutive to trauma [5, 7]
When the physician discovers unilateral enlargement
in a male breast with obvious asymmetry it is tory to rule out a primary breast tumor and a mam-mogram must be ordered [1]
manda-68.3 Surgical Anatomy
Breast tissue has increased vascularity and the dency for bleeding with breast liposuction is greatly attenuated by tumescent anesthesia [1] However, it is important that the surgeon remember the proximity of the pectoralis muscle because it makes this tissue vul-nerable (by either infiltration or liposuction) to trauma during male breast liposuction with the potential risk
ten-of bleeding and hematoma [8] Therefore, a careful exploration is important in order to locate the breast tissue–pectoralis interface [1] In this sense, the patient
is asked to tighten the pectoralis muscle so that the surgeon can appreciate the textural difference between soft fat, the firm muscle, and the glandular tissue An-other way to distinguish it is by asking the patient to put his hands behind his head in the supine position This maneuver will stretch the pectoralis muscle and again the palpation will reveal which tissue is fat.Another important point is in relation to the adi-pose tissue; the male breast is very fibrous and there-fore additional effort will have to be made in order to perform reduction with liposuction [1]
Finally, true breast glands in men are located cent to the nipple-areolar complex and are firmer than
Trang 5the surrounding fatty tissue When glandular tissue
predominates (true gynecomastia), liposuction will
not be as successful as with only fatty tissue A
rou-tine mammogram may facilitate the assessment of the
amount of glandular tissue versus adipose tissue [1]
68.4
Preoperative Preparation
An extensive discussion about patient expectations
related with the procedure is important as well as
photographic documentation Also, it is useful to
draw on the patient in order to define the objectives
of the proposed surgery
The increase of male pseudogynecomastia with
age and degree of obesity as well as with increasing
obesity means that fat may also be augmented along
the anterior axillary area and on the lateral chest wall
Therefore, it is important to treat those areas at the
same time in order to reach a satisfactory result
All patients, irrespective of age, are sent to the
cardiologist for a complete cardiac and vascular
checkup, mentioning especially that we are going to
use epinephrine for the procedure Only patients in
categories ASA I or II should be included Patients
with congestive cardiac failure are excluded Patients
undergo a complete hematological checkup which
includes especially liver function tests, fasting blood
sugar fasting, hepatitis B and C profile, and HIV
studies [9] A detailed history of drugs and other
etio-logic factors are taken into consideration Patients are
advised to use an antiseptic soap bath 3 days prior to
surgery, especially in the areas to be liposuctioned
The authors use povidone iodine or clorhexidine All
medications especially aspirin, β-blockers, vitamin E,
and herbal drugs are discontinued 10 days prior to
surgery [9] Patients are advised not to smoke 2 weeks
prior to surgery An oral antibiotic (cefadroxil
mono-hydrate) is started 1 day before surgery and
contin-ued for 7 days postoperatively Clonidine (0.1 mg),
as a premedication, is given 1 h prior to surgery to
those patients whose blood pressure is greater than
90/60 mmHg As an α2 adrenergic agonist (besides
its hypotensive action), clonidine has hypnotic,
seda-tive, and analgesic actions; therefore, this drug has
a synergistic sedative effect which decreases the
re-quirements and the total dosage of intravenous
seda-tion–analgesic medication, with the obvious benefits
in the postoperative period [10] The authors also use
150 mg of ranitidine in a suspension and 10 mg of
methoclopramide orally in order to reduce the risk of
postoperative vomiting [10]
68.5 Operative Technique
A careful cleaning of the areas is done using povidone iodine from the neck, including the axillae to the um-bilicus A second cleaning of the breasts with povidone iodine is done starting from the nipple and areola and moving centrifugally After careful scrub-up using a double-brush technique and 10 min for scrubbing us-ing povidone iodine and disposable gowns and sterile disposable gloves, the procedure is started
A sterile operating room technique is mandatory Using insulin syringes, 1% lidocaine/1:400,000 epi-nephrine is injected intradermally in the incision sites in the anterior axillary line The incision sites are incised using a no 11 blade The infiltration is started with a 10-ml syringe using a Lamis infiltra-tion syringe system and chilled Klein’s solution [11, 12] Light intravenous sedation using midazolam and fentanyl is performed by an experienced anesthesi-ologist, who monitors carefully the patient during the surgery [11] Immediately prior to surgery, an 1 g of antibiotic (from the same group as a cephalosporin) is administered by the anesthesiologist If there is exces-sive hypertrophy, and the procedure exceeds 3 h, the same dose of antibiotic is repeated A very small inci-sion is made with the tip of a no 11 blade scalpel The placement of the incision is different when working in gynecomastia or in pseudogynecomastia (Fig 68.1)
An infiltration pump for the anesthesia is hardly ever necessary A modification of Klein’s solution without bicarbonate (0.05% lidocaine 0.05%, 1:1×106 epineph-rine) is used [9, 11] We believe bicarbonate in Klein’s solution causes excessive inflammation and shortens the anesthetic period Triamcinolone is not used [11] The infiltration is carried out not in the gland, but in the retromammary space between the gland and the muscle (pectoralis major) While one hand is inject-ing, the other hand feels the tumescence [11–14] The
Fig 68.1. The placement of the incisions is different in a dogynecomastia and b gynecomastia
pseu-68.5 Operativce Technique
Trang 6462 68 Liposuction for Gynecomastia
infiltration is stopped only when the breasts become
stony hard
Liposuction is started using 3-mm keel cobra tip
cannulas working in the retromammary space [9, 14]
Liposuction is started using a machine at a pressure
of –30 mmHg Syringe liposuction can also be
car-ried out using a Toomy or a Tulip system and 60-ml
syringes The base of the cannulas is protected with
a gauze to prevent damage to the lips of the incision
sites Gentle homogeneous movements are carried
out While one hand performs the liposuction, the
other hand lifts the breast tissue upwards in order to
prevent unnecessary damage to the breast tissue itself
and for smooth working of the cannula in the
retro-mammary space The idea is not to perform
liposuc-tion in the breast tissue itself, but to perform it in the
retromammary space that is filled with fat between
the gland and the pectoralis major muscle Tunnels
are created centrally from below and from the lateral
edge of the breasts [9, 14] The axillary approach for
liposuction is not used A number of complications
(vascular, nerve) can take place with that approach
and when using the ultrasonic method of liposuction,
especially internal ultrasound [15] A touch-up is
pro-vided with a 2-mm cannula After the procedure, all
the remaining fluid, as much as possible, is pushed
out of the incision sites using roller towels The
inci-sion sites are not closed Sterile padding and French
tape are applied over areas of liposuction The French
tape is applied in the form of a plus, corresponding
to the direction of the tunnels [9, 14] The pressure
garment is applied on top of the French tape Steroid
injection, 4–8 mg of dexamethasone, perioperatively
and an antiemetic injection in the immediate
postop-erative period are given by the anesthesiologist
The situation with true gynecomastia is a little
dif-ferent Once the incision has been made several
pass-es of the cannula are made to dissect and liberate the glandular tissue The tissue is grasped with a Kocher forceps and all adhesions are dissected carefully and gently Special care must be taken with the nipple and the areola All the remaining fluid is removed at the end
68.6 Postoperative Considerations
All the garments and dressings are removed on the second day postoperatively and the areas are exam-ined and cleaned Only pressure garments are advised for the next week [16] Postoperative tenderness usu-ally settles quickly [17] Low-dose steroids are pre-scribed, if necessary, which decrease the inflamma-tion Urea (10%) and 1% hydrocortisone cream, to be used twice daily, is applied over areas of liposuction to improve the inflammation and decrease the hardness The results are generally excellent (Figs 68.2–68.5) A touch-up is hardly ever necessary An anti-inflamma-tory ultrasound procedure is started after 1 week and
is repeated once a week for 4–6 weeks
Most patients are able to go back to work the day after surgery and can resume full sport activities in
2 weeks
68.7 Complications
68.7.1 Hematoma
Hematoma can take place if the tumescent technique
is not utilized or ultrasonic liposuction is used ternal ultrasound is dangerous and can damage the
In-Fig 68.2 a Preoperative
pa-tient with gynecomastia
b Postoperative patient
a
b
Trang 7vasculature of the breast via penetrating rays On the
other hand, seroma and/or hematoma are/is avoided
with the correct compression
68.7.2
Edema/Irregularities
Postoperative edema usually settles down quickly
Ir-regularities are generally not seen unless the
opera-tion is performed by an inexperienced surgeon [18]
68.7.3
Vascular Injuries
Damage to the perforating branches of the internal
thoracic artery, intercostal arteries, lateral thoracic
and thoracoacromial branches of the axillary
ar-tery, and corresponding veins can take place over
the breast, leading to hematoma formation [19, 20]
Damage to the axillary artery, its branches, and the
axillary vein can occur if the axillary approach is
used with either conventional cannulas or ultrasonic
ones Ultrasonic cannulas over the left breast are very
dangerous owing to the close proximity of the heart,
while on the right side, damage to the lung and liver
can take place
68.7.4
Nerve Injuries
Damage to the roots, trunks, and divisions or cords
of the brachial plexus can take place if an axillary
ap-proach is used [15, 20]
68.7.5
Dysesthesia
There also exists the possibility of some degree of
nip-ple hyperesthesia or, on the other hand, loss of nipnip-ple
sensation Both are transient
68.8 Conclusions
Male breast liposuction usually offers very nice results for this common problem of gynecomastia Improve-ment in the body contouring as well as in the self-es-teem constitutes the aim of this operation
References
1 Klein JA: Tumescent Technique Tumescent Anesthesia
& Microcannular Liposuction Mosby, St Louis, 2000: 404–412
2 Carlson HE Gynecomastia N Eng J Med 1980; 303;795
3 Wilson JD, Aiman J, Mc Donald PC The Pathogenesis of Gynecomastia Adv Intern Med 1980; 25:1–32
4 Nuttall FQ Gynecomastia as a Physical Finding in mal Men J Clin Endocrinol Metab 1979; 48:338
Nor-5 Mann CV, and Russell RCG: Bailey and Loves Short tice of Surgery, 21st Edition London: Chapman and Hall, 1992:820–821
Prac-6 Spence RW et al Gynecomastia Associated with dine Gut 1979;20:154
Cimeti-7 Kirk RM, and Williamson RCN: General Surgical erations, 2 nd Edition London: Churchill Livingstone, 1987:339
Op-8 Ratz JL, Geronemus RG, Goldman MP: Textbook of matologic Surgery, 1st edition Philadelphia: Lippincott Raven, 1998:547–564.
Der-9 Hernández-Pérez E, and Lozano-Guarin C: Volume sculpture: variations on a technique Cosmet Dermatol 1999; 35–39
lipo-10 Hernández-Pérez E, Espinoza-Figueroa D Clonidina
en Liposucción ¿Es realmente util? Act Terap Dermatol 2003;26:60
11 Hernández-Perez E, and Henríquez A: Clarifying concepts
in modern liposuction Int J Aesth Restor Surg 1994;4: 65–67
12 Klein JA: The tumescent technique for liposuction gery Am J Cosm Surg 1987; 4:263–267
13 Klein JA: Anesthesia for liposuction in dermatologic gery J Dermatol Surg Oncol 1988; 10: 1124–1132
sur-Fig 68.3 a Preoperative
pa-tient with
pseudogynecomas-tia b Postoperative patient
References
Trang 8464 68 Liposuction for Gynecomastia
14 Fournier PF: Therapeutic megalipoextraction or
megali-posculpture: indications, technique, complications and
results Am J Cosm Surg 1997;14:297–310
15 Shiffman MA, and Mirrafati S: Possible Nerve injuries in
the Axillary Approach to Breast Augmentation Surgery
Am J Cosm Surg 2001; 18(3):149–151
16 Fulton JE, Rahimi AD, Abuzenik P Breast Reduction with
Tumescent Liposuction Am J Cosm Surg 200;18:15
17 Baxt S The Scarless Breast Reduction Plastic Surgery Products July, 2000.
18 Fodor PB Breast Reduction Liposuction- only attracts tention Cosmetic Surgery Times 2000;3:1
at-19 Snell RS: Clinical Anatomy for Medical Students, 4 th tion Boston: Little, Brown and Company 1992:440–448
Edi-20 Chaurasia BD: Human Anatomy Regional and Applied,
2 nd Edition Delhi: Jain Bhawan, 1992:22–32
Trang 9Axillary Approach in
Suction-Assisted Lipectomy of Gynecomastia
Antonio Carlos Abramo
Chapter 69
69
69.1
Introduction
Gynecomastia or hypertrophy of breast tissue is a
serious cosmetic compromise for either adolescent
or adult men Male breast enlargement is a relatively
common occurrence during puberty In the majority
of patients no pathologic cause for the problem can be
found A minimal degree of hypertrophy of breast
tis-sue is a normal happening in the adolescent man,
re-gressing spontaneously with maturity Maintenance
of the breast enlargement addresses surgical
treat-ment of the gynecomastia Breast enlargetreat-ment in the
adult man occurs owing to excess adipose tissue or to
combination of adipose and glandular tissue
Sponta-neous regression in adult men is occasional and
surgi-cal treatment is indicated most of the time
69.2
Anatomy
The breast is rudimentary in men, although the
structure is identical with that of the female breast
The glandular tissue distributes radially from the
nipple in fifteen to twenty lobes, which are composed
by multiple small ducts of lobules [1] Adipose tissue
fills the interstices between the lobules but is absent
or in small amount at the nipple-areola complex A
framework of fibrous strands transverses the breast
supporting its lobules, connecting with the skin as
the suspensory ligaments of Cooper and reaching
back to the pectoralis fascia Layers of adipose tissue
infiltrate into the framework of fibrous strands also
extending around the glandular tissue [1] This
rudi-mentary structure becomes enlarged in gynecomastia
with prevalence of either glandular or adipose tissue
regarding the etiology of the gynecomastia
69.3 Etiology
The etiology of gynecomastia is not completely certained In late adolescence and in the adult man gynecomastia can be associated with endocrine dis-orders, usually related to tumors of the adrenal gland Hormonal imbalance increases both glandular and adipose tissues The indiscriminating use of anabolic steroids causes gynecomastia, including its recur-rence after clinical or surgical treatment [2] Con-genital anomalies, such as the Klinefelter syndrome, affect men with gynecomastia and feminine fat dis-tribution, exhibiting elevated amounts of estrogen and progesterone receptors [3] The Peutz–Jeghers syndrome associated with feminizing Sertoli cell tu-mor, also affects men with prepubertal gynecomastia [4] Various medications or medical conditions, such
as-as tumors of the prostate gland, develop glandular gynecomastia with moderate acinar and lobular for-mation Patients presenting idiopathic gynecomastia have an obscure or unknown cause, with the breast enlargement arising spontaneously owing to the de-velopment of adipose tissue, glandular tissue, or both adipose and glandular tissue
69.4 Classification
Propositions to arrange into classes the multiple pressions of gynecomastia include an oversimplifica-tion of the male breast deformities regarding the size
ex-of the breast enlargement and the etiology ex-of the order
dis-Simon et al [5], on the basis of morphological formities, classify the size of the male breast enlarge-ment according to the breast volume and the skin redundancy, distributing the gynecomastias into four grades:
de-1 Grade 1: Minimal enlargement of the breast tissue
2 Grade 2A: Moderate enlargement of the breast sue without skin redundancy
Trang 10tis-466 69 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia
3 Grade 2B: Moderate enlargement of the breast
tis-sue with moderate skin redundancy
4 Grade 3: Massive enlargement of the breast tissue
with expressive skin redundancy
Geschikter and Copeland [6] associate etiological
and parenchymal disturbances of the male breast to
classify the breast enlargement, distributing the
gy-necomastias in four types regarding the influence
of etiological and parenchymal disturbances in the
morphological deformity:
1 Type 1 or diffused hypertrophic form: usually
oc-curs during adolescence owing to hormonal
im-balance with feminine characteristics for the male
breast
2 Type 2 or fibroadenomastosa form: similar to the
diffuse hypertrophic form with nodules of either
glandular or fibrous tissue spread in the breast
3 Type 3 or true gynecomastia: increase of both
glandular and adipose tissue, resembling the
fe-male breast in size and shape
4 Type 4 or pseudogynecomastia or adipose form:
increase of adipose tissue without compromise of
the glandular tissue, usually encountered in the
adult man
69.5
Indications
Indication for the surgical correction of
gynecomas-tia by use of suction-assisted lipectomy through the
axillary approach is based on careful patient selection
and accurate diagnosis of the breast deformity
Clini-cal examination in conjunction with
ultrasonogra-phy and mammograultrasonogra-phy is capable of determining the
consistency and density of the breast enlargement,
making a distinction between soft or adipose
gyneco-mastia, firm or glandular gynecomastia and adipose–
glandular gynecomastia Examination of the patient
with the arms in an upright position is helpful to
define the limits of the glandular tissue in the breast
enlargement Skin compromise such as flaccidity,
re-dundancy, and striations rather than the breast
en-largement must be appraised in detail during clinical
examination Young patients with good skin tone are
the ideal candidates for suction-assisted lipectomy;
however, old age is not a contraindication Although
a decrease in skin elasticity occurs with increased
age, the ability of the skin to shrink still remains
Pa-tients with less than ideal indication are more
com-monly encountered, but recovery of the chest contour
with suction-assisted lipectomy through the axillary
approach is almost the same as for those with ideal
indication
69.6 Surgical Procedures
Surgical correction of the multiple expressions of gynecomastia involves subcutaneous mastectomy and/or suction-assisted lipectomy with individual ap-proaches The commonest approach for direct subcu-taneous mastectomy in the treatment of gynecomas-tia is the semicircular intra-areolar incision described
by Webster [7] Balch [8] proposed the transaxillary approach to avoid noticeable scars after subcutaneous mastectomy in surgical correction of gynecomastia Ohyama et al [9] used the transaxillary approach for endoscope-assisted en bloc removal of fat and glandular tissue in treating gynecomastia However, unpleasing scars, skin redundancy, irregularities on chest contour, and deformities of the nipple-areola complex, as result of subcutaneous mastectomy, ad-dress surgical correction of gynecomastia to mini-mally invasive procedures According to Abramo [10] combination of the axillary approach with suc-tion-assisted lipectomy decreases, significantly, the morbidity in the treatment of multiple expressions of gynecomastia, avoiding these disagreeable results
69.6.1 Suction-Assisted Lipectomy Through the Axillary Approach
Suction-assisted lipectomy through the axillary proach can be performed with or without fluid infil-tration of the breast tissue The «dry technique» that does not use preinfiltration of fluid is accompanied
ap-by a higher percentage of blood in the aspirate The
«wet technique» uses preinfiltration of fluids with a low-dose of epinephrine and dilute local anesthetic added, regardless of the breast enlargement Applica-tion of the wet procedure reduces the blood loss to approximately 4–8% of the aspirate [11]
69.6.2 Equipment
Accurate selection of appropriate equipment is of utmost importance in suction-assisted lipectomy through the axillary approach The standard instru-mentation technique and the syringe technique are the most commonly employed procedures in surgical correction of gynecomastia because of the excellence
of aesthetic results and the very low rate of cations The standard instrumentation procedure uses an electric pressure vacuum pump connected to the suction cannula by non-collapsible tubing The syringe technique utilizes a syringe directly connect-
compli-ed to the suction cannula, generating the negative pressure required to aspirate breast tissue drawing back the syringe plunger The repetitive and linear
Trang 11movement of the suction cannula prior to its suction
mechanically disrupts the breast tissue
Despite the effectiveness in aspirating fibrous
tis-sue, ultrasound-assisted lipoplasty and
power-assist-ed lipoplasty through the axillary approach are not
widely used in surgical correction of gynecomastia
The higher complication rates and long-term
un-known effects of the ultrasonic waves as well as the
excessive cost with no prospective studies of the
pow-er-assisted lipoplasty have not stimulated its use
69.6.3
Suction Cannulas
Breast tissue is accessible to the suction cannula
Con-ventional round-pointed suction cannula are effective
to remove fat tissue in treating gynecomastia, but
in-sufficient to penetrate into the glandular tissue
How-ever, the adipose tissue scattered amongst the breast
lobules decreases the resistance of the glandular
tis-sue and this becomes accessible to special pointed
suction cannulas Sharp-pointed suction cannulas
are employed successfully to penetrate the hardness
of the glandular breast tissue, and the residual
glan-dular tissue is removed after suction-assisted
lipecto-my of the fat tissue The use of sharp-pointed suction
cannulas avoids direct subcutaneous mastectomy in
several types or grades of gynecomastia
69.6.4
Incision
Surgical correction of gynecomastia through
suction-assisted lipectomy alone employs a single incision at
the axillary fold [12] Suction-assisted lipectomy, in
conjunction with subcutaneous mastectomy, employs
more than one incision Usually, the first incision is
made on the axillary fold next to the anterior axillary
line for suction-assisted lipectomy and the second
incision is made directly over the breast tissue at the
periareolar area for subcutaneous mastectomy [12]
As scars follow all incisions, failure in healing is
considered an unfavorable effect not a complication
However, either dystrophic or dyschromic scars,
caused by the repetitive movements of the cannula
against the incision margins during suction-assisted
lipectomy, are cosmetically not desirable Abramo
[13] proposes a protector tube guide for the margins
of the incision to avoid damage of its borders during
suction-assisted lipectomy The device exhibits a
T-shaped design composed by a hard tube with a
sup-port plate at its proximal end (Fig 69.1) The tube is
5.0 cm in length and has a diameter of 0.5 cm,
some-what bigger than the diameters of the suction
can-nulas employed in suction-assisted lipectomy, using
the axillary approach, of gynecomastia The support
plate has two holes located laterally to the tube ing, to fix the device at the incision margins, avoiding injury of the skin during suction-assisted lipectomy The suction cannula is inserted into the hard tube through the central opening of the support plate, re-maining without contact with the incision margins during suction-assisted lipectomy
open-69.6.5 Operative Technique
An electric high-pressure vacuum pump aspirator generating negative pressure up to 1.0 bar (equal to 0.987 atm) has been used successfully for suction-assisted lipectomy of the breast tissue The average pressure during suction of breast tissue ranges from 0.8 to 0.9 bar of negative pressure The level of nega-tive pressure is increased as suction is performed in
an enclosed space The dry technique is employed for small volume removals and the wet technique, infus-ing small quantities of fluid with dilute lidocaine and epinephrine solutions, is employed for moderate to large volume removals
The marking of the breast enlargement is done with the patient in a sitting position, defining the lim-its of the breast enlargement (Fig 69.2) The marking
of the patient in the sitting position is important, cause the horizontal position added by adduction of the arms on the operating table displaces the breast enlargement upward in the direction of the shoul-der, changing the position and circumference of the breast enlargement (Fig 69.3a) The incision for suc-tion-assisted lipectomy is drawn in the axillary fold, following the projection of the anterior axillary line,
be-at the lbe-ateral border of the pectoralis major muscle (Fig 69.3a) The length of the incision ranges from 0.5 to 1.0 cm, regarding the circumference of breast enlargement From the incision marking at the axil-
Fig 69.1. Tube guide for protection of the internal borders of the incision The holes of the support plate are located laterally
to the tube opening
69.6 Surgical Procedures
Trang 12468 69 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia
lary fold, several straight lines are drawn toward the
boundaries of the breast enlargement, following the
direction of the fibers of the pectoralis major muscle,
in a fan shape (Fig 69.3b) The straight lines outlined
over the breast surface guide the suction cannula
dur-ing suction-assisted lipectomy
A full-thickness incision of the skin over the
mark-ing in the axillary fold exposes the superficial
aponeu-rosis of the pectoralis major muscle From the axillary
incision a small tunnel, 5.0-cm long and 0.5-cm wide,
is dissected over the superficial aponeurosis of the
pectoralis major muscle The protector tube guide is
inserted within the tunnel and anchored in the
inter-nal border of the incision margin, through the holes
located on the support plate of the device (Fig 69.4a)
The hard tube protects the skin from injury caused
by the repetitive movements of the suction cannula,
during suction-assisted lipectomy Through the tube
guide a 3.0-mm straight round-pointed suction nula dissects a narrow tunnel over the superficial apo-neurosis of the pectoralis major muscle, along the lat-eral border of the muscle, to the proximal boundary of the outlined breast enlargement (Fig 69.4b) From the proximal boundary several tunnels are dissected into the breast tissue following the straight lines marked
can-on the skin of the breast, toward the circumference of the breast enlargement (Fig 69.5) The breast tissue is aspirated along the tunnels by repetitive forward-to-backward linear movements of the suction cannula Numerous septa of breast tissue, containing fat and fibrous tissue with intact vessels and nerves, remain through the tunnels, creating a spongy framework between the skin and the muscular plane
Suction-assisted lipectomy through the axillary approach employs four different types of suction cannulas
1 A 4.0-mm straight round-pointed suction cannula with a large central opening and two small open-ings laterally and backward located in relationship
to the central opening
2 A 3.0-mm straight round-pointed suction cannula with three small openings elliptically arranged (Fig 69.6a)
3 A 2.0-mm straight round-pointed suction cannula with three small openings elliptically arranged (Fig 69.6b)
4 A 4.0-mm straight sharp-pointed suction cannula with a single and large opening (Fig 69.6c)
Suction-assisted lipectomy begins with the 4.0-mm straight suction cannula inserted deep at the central portion of the breast, to remove the major volume of fat and fibrous tissue responsible for the enlargement and projection of the breast (Fig 69.7a) Suction-as-
Fig 69.3 a Displacement of the breast
en-largement to the shoulder after adduction
of the arms on the operating table b The
straight lines, outlined over the breast
en-largement, direct the course of the suction cannula during suction-assisted lipectomy
Fig 69.2. Marking of the breast enlargement with the patient
in a sitting position
Trang 13sisted lipectomy follows with the 3.0-mm pointed suction cannula, more peripherally inserted
round-in the breast enlargement, to aspirate the remaround-inder
of the fat and fibrous tissue around the central tion of the breast, defining the glandular tissue re-sistant to the round-pointed suction cannula The 2.0-mm round-pointed suction cannula aspirates fat tissue at the outlined boundary of the breast enlarge-ment, refining the chest contour Finally, the 4.0-mm sharp-pointed suction cannula dissects and aspirates the residual glandular tissue underneath and sur-
por-Fig 69.4 a The tube guide is inserted into the incision, b protecting the skin, at the
incision margins, from injury caused by movements of the suction cannula
Fig 69.5. The suction cannula creates several tunnels into the
breast tissue from the axillary fold to the boundaries of the
Trang 14470 69 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia
rounding the nipple-areola complex, recovering the
male chest contour (Fig 69.7b)
Combination of the high negative pressure
pro-vided by the vacuum pump, increased by the enclosed
compartment created by the axillary approach, and
suitable sharp-pointed suction cannulas allows
pen-etration and aspiration of the glandular tissue of the
breast However, excessive hardness of glandular
tissue creates a significant resistance to the
sharp-pointed suction cannula leaving an unpredictable
amount of glandular tissue, usually at the areolar area
(Fig 69.8a) In such cases, subcutaneous mastectomy
is added to suction-assisted lipectomy with the
axil-lary approach to attempt the direct removal of the
re-maining glandular tissue, without the need for skin
resection (Fig 69.8b) Resection of the residual
glan-dular tissue is done through an inferior periareolar
incision (Fig 69.8c)
A compressive dressing is used to exert strong
pres-sure over the aspirated area for the first 24 h A simple
elastic garment replaces the compressive dressing to
apply moderate pressure over the chest during the
following 4 weeks Moderate pressure avoids seroma
and hematoma and also aids in the skin adjustment
Drainage is not performed either for the resected area
or for the aspirated area
Acceptance by the patients of suction-assisted pectomy through an axillary approach is extremely high because the incision is minimal and is placed on
li-a mli-asked li-areli-a, li-and exli-actness in breli-ast contouring is attained with minimal morbidity (Fig 69.9) In addi-tion, the procedure can be easily repeated to refine the results or accommodate skin redundancy The axil-lary approach further provides a small incision in a hidden area and magnifies the intensity of suction because the breast tissue is aspirated in an enclosed space that is distant from the access for the suction cannula
The narrow tunnels dissected over the pectoralis major aponeurosis, from the axillary incision to the proximal boundary of the breast enlargement, create
a compartment without air inside the breast tissue, increasing the level of the negative pressure provided
by the vacuum pump Reinforcement of the negative pressure makes suction of more resistant tissues, such
as the glandular tissue of the breast, more effective Otherwise, suction in all directions, from the axillary incision to the boundary of the breast enlargement in
a fan shape, allows better skin adjustment
Suction of the fat lobules creates a spongy work in the breast tissue, addressing the skin re-traction through the shrinkage of the fibrous septa
frame-Fig 69.8 a A 15-year-old male patient with hormonal imbalance presenting true gynecomastia of Geschickter or grade 2B of mon b He underwent suction-assisted lipectomy through the axillary approach in conjunction with subcutaneous mastectomy
Si-The good skin tone and the lack of skin redundancy allow skin adjustment
a
b
a
b
Trang 15of the breast located within the septa of the spongy
framework Contraction of the breast septa adjusts
the skin, avoiding skin resection even in patients with
severe gynecomastia and marked skin redundancy
(Fig 69.10) In addition, tunneling and suction
us-ing the 2.0-mm suction cannula refine the peripheral
contour of the breast, achieving a natural contour for
the male chest Removal of the breast tissue by
aspira-tion leaves the vessels intact inside the breast septa of
the spongy framework Also, the nerves preserved in
the breast septa maintain sensation of the breast
Suction-assisted lipectomy through the axillary
approach alone or in conjunction with resection of
glandular tissue has application for the multiple
ex-pressions of gynecomastia including severe breast
en-largement with significant skin redundancy
69.7 Surgical Applications
Application of suction-assisted lipectomy through the axillary approach alone or in conjunction with sub-cutaneous mastectomy takes into account the degree
of skin compromise and the extent of the breast largement, according to the classifications of Simon and Geschikter for gynecomastia
en-Suction-assisted lipectomy through the axillary approach alone is usually performed in patients with minimal to moderate breast enlargement with predom-inance of fat tissue and minimal skin redundancy Gy-necomastia grade 1 and grade 2A of Simon, and type 4
or pseudogynecomastia of Geschikter are indications for suction-assisted lipectomy through an axillary ap-proach alone (Fig 69.11) The difficulty in penetrating the glandular tissue of the breast with conventional round-pointed suction cannulas is relieved by using
Fig 69.9 a A 34-year-old male bodybuilder with unilateral pseudogynecomastia of Geschickter or grade 1 of Simon due to discriminate use of anabolic steroids b Recovery of chest symmetry through suction-assisted lipectomy alone, only employing
in-round-pointed suction cannulas
Fig 69.10 a A 17-year-old male patient with hormonal imbalance presenting extreme true gynecomastia of Geschickter or grade 3
of Simon The massive breast enlargement is determined by increase of fat and glandular tissues with predominance of fat tissue
Severe skin redundancy is also present b He underwent suction-assisted lipectomy through the axillary approach in conjunction
with subcutaneous mastectomy and repetitive suction-assisted lipectomy alone using the axillary approach The skin tone was helpful for skin adjustment
69.7 Surgical Applications
Trang 16472 69 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia
special types of suction cannula [14, 15] In addition,
the layers of adipose tissue spread into the interstices
between the breast lobules, allowing sharp-pointed
cannulas to dissect and aspirate the glandular tissue
With the use of appropriate cannulas, gynecomastia
grade 2B of Simon and type 3 or true gynecomastia of
Geschikter with no significant amount of glandular
tissue are also treatable by suction-assisted lipectomy
through the axillary approach alone (Fig 69.12)
Suction-assisted lipectomy through the axillary
approach in conjunction with subcutaneous
mastec-tomy are also a minimally invasive technique This
association is the most frequently employed
proce-dure in surgical correction of moderate and severe
degrees of gynecomastia with mild or moderate skin
redundancy Subcutaneous mastectomy is performed
as an adjunct to suction-assisted lipectomy,
remov-ing the residual glandular tissue resistant to the
suc-tion cannula, in patients with a significant amount
of extremely dense glandular tissue Suction-assisted
lipectomy through the axillary approach in
conjunc-tion with subcutaneous mastectomy has applicaconjunc-tion
in gynecomastia grade 2A and grade 2B of Simon,
and type 2 or fibroadenomastosa form and type 3
or true gynecomastia of Geschikter An alternative
to avoid excessive skin resection with unacceptable
scars in treating severe gynecomastia with
signifi-cant skin redundancy is achieved by suction-assisted
lipectomy through the axillary approach in
conjunc-tion with subcutaneous mastectomy, followed by
re-petitive suction-assisted lipectomy alone employing
the axillary approach (Fig 69.13) Repetitive
suction-assisted lipectomy stimulates contraction of the skin
adjusting its redundancy, and is beneficial to patients
with severe breast enlargement and significant skin
redundancy, gynecomastia grade 3 of Simon
69.8
Complications
The magnitude of subcutaneous mastectomy and the
lack of tissue between the skin and the pectoralis
apo-neurosis increase the rate of complications in relation
to non-scarring, minimally invasive procedures in
the treatment of gynecomastia Major complications
with long-term effects such as seroma, hematoma,
wound infection, scarring, adherence of the skin to
the deep plane, and breast asymmetry are significant
and are related to the magnitude of the subcutaneous
mastectomy [17] The most frequent complication due
to excessive resection of breast tissue is a permanent
hypesthesia of the nipple-areola complex, eventually
extending to the breast surface [18]
Extensive resection of breast tissue creates a
vir-tual space between the skin and the pectoralis muscle
with depression of the mammary area and deep skin adherence Enlarged subcutaneous mastectomy can compromise the bloody supply of the nipple-areola complex with hypopigmentation and necrosis of the areola [19] Extensive subcutaneous mastectomy with resection of a large amount of skin can be associated with major complications such as nipple distortion, skin necrosis, and cosmetically unacceptable scars
An usual permanent hyperpigmentation ing the areola can occur after hematoma or prolonged ecchymosis
surround-Suction-assisted lipectomy techniques alone or in conjunction with inferior periareolar subcutaneous mastectomy decrease morbidity and provide reliable improvement of the chest contouring with minimal complications in the treatment of gynecomastia Standard instrumentation techniques, ultrasound-assisted lipoplasty, and power-assisted lipoplasty have identical aesthetic results with an unequal rate
of complications Waviness of the chest contour has not been observed with suction-assisted lipectomy techniques in treating gynecomastia
69.8.1 Standard Suction-Assisted Lipectomy Through
an Axillary Approach
Currently, suction-assisted lipectomy with wetting solutions is considered the most widely used standard procedure capable of producing few complications and excellent aesthetic results Minimal complica-tions are related to the use of the standard instrumen-tation technique or the syringe technique in conjunc-tion with the wet technique Breast sensation most
of the time is similar to that present prior to surgery, despite a transitory hypoaesthesia from 2–4 weeks Seroma, hematoma, and skin depression or adher-ence in the deep plane are rare Small quantities of serum or blood are naturally drained through the numerous breast septa with intact vessels distributed through the tunnels of the aspirate breast The same fat septa avoid adherence of the skin in the deep plane
of the chest and provides an accurate contour for the aspirated breast Depressions in the aspirated area are avoided by using suction cannulas with small diam-eters used in the peripheral areas of the breast Skin necrosis is rare in the treatment of gynecomastia with standard suction-assisted lipectomy Uncommon complications such as unilateral traumatic rupture
of the pectoralis major muscle can fortuitously occur during suction-assisted lipectomy in surgical correc-tion of gynecomastia [20]
Trang 1769.8.2
Ultrasound-Assisted Lipoplasty
Ultrasound-assisted lipoplasty has potential benefits
to aspirate fibrous tissue, for large volume removals,
and for utilization in reoperations However, the
nu-merous complications and the increase in operating
time have not been addressed in ultrasound-assisted
lipoplasty for surgical correction of gynecomastia
Higher levels of seroma seems the most frequent of
the complications [21] Combination of heat and a
large amount of saline with a high concentration of
lidocaine infiltration, and large volume removals can
lead to skin necrosis [22] Cavitation is another
im-portant complication in ultrasound-assisted
lipoplas-ty Thermal injuries from superficial skin blistering
to full thickness skin loss occur because of the higher
rates of heat potentially caused by cavitation A true
loss of blood and albumin occurs with
ultrasound-assisted lipoplasty even when blood is not observed
in the aspirate Troilius [23] verified a significant
re-duction in the levels of hemoglobin, hematocrit, and
albumin after ultrasound-assisted lipoplasty through
blood tests carried out 1 week after
ultrasound-as-sisted lipoplasty with mild and moderate volume
re-movals Long-lasting consequences of internal
ultra-sound-assisted lipoplasty are still unknown
69.8.3
Power-Assisted Lipoplasty
Power-assisted lipoplasty is in a learning curve Its
mechanism of action is not clearly defined and
com-plications are not readily well known In addition to
the cost, the major disadvantages of power-assisted
lipoplasty are the excessive vibration of the cannula
and the high level of noise produced by the powered
system, becoming significantly uncomfortable
dur-ing either short or prolonged use of the system [24]
References
1 Lockhart, R.D., Hamilton, G.F., Fyfe, F.W.: Anatomy of
the Human Body, 1st Ed London, Faber and Faber
Lim-ited 1959:697
2 Babigian, A., Silverman, R.T.: Management of
gynecomas-tia due to use of anabolic steroids in bodybuilders Plast
Reconstr Surg 2001;107(1):240–242
3 Pensler, J.M., Silverman, B.L., Sanghavi, J., Goolsby, C.,
Speck, G., Brizio-Molteni, L., Molteni, A.:Estrogen and
progesterone receptor in gynecomastia Plast Reconstr
Surg 2000;106(5):1011–1013
4 Hertl, M.C., Wiebel, J., Schaffer, H., Willig, H.P.,
Lam-brecht, W.: Feminizing Sertoli cell tumors associated
with Peutz-Jeghers syndrome: an increasingly recognized
cause of prepubertal gynecomastia Plast Reconstr Surg
1998;102(4):1151–1157
5 Simon, B.E., Hoffman, S., Kahn, S.: Classification and surgical correction of gynecomastia Plast Reconstr Surg 1973;51(1):48–52
6 Geschickter, C.H., Copeland, M.: Gynecomastia In: schickter, C.F., Diseases of the Breast 1st Ed, Philadelphia, J.B., Lippincott & Co 1943.
Ge-7 Webster, J.P.: Mastectomy for gynecomastia through a circular intra-areolar incision Ann Surg 1946;194:557
semi-8 Balch, C.R.: Transaxillary incision for gynecomastia Plast Reconstr Surg 1978;61(1):13–16
9 Ohyama, T., Takada, A., Fujikawa, M., Hosokawa, K.: doscope-assisted transaxillary removal of glandular tissue
En-in gynecomastia Ann Plast Surg 1998;40(1):62–64
10 Abramo, A.C.: Axillary Approach for gynecomastia suction Aesth Plast Surg 1994;18(3):265–268
11 Fodor PB Editorial Wetting solutions in aspirative plasty A plea for safety in liposuction Aesth Plast Surg 1995;19(4):379–380
lipo-12 Abramo, A.C., Casas, S.G., Marques, W.B.:
Tratamien-to de la ginecomastia y pseudoginecomastia Cir Plast 1997;7:57–61
13 Abramo, A.C.: A device to protect the incision in ing liposuction Plast Reconstr Surg 1994;94(5):743–744
perform-14 Rosenberg, G.J.: A new cannula for suction removal of parenchymal tissue of gynecomastia Plast Reconstr Surg 1994;94(1):548–551
15 Gasperoni, C., Balgarello, M., Gasperoni, P.: Technical finements in the surgical treatment of gynecomastia Ann Plast Surg 2000;44(4):455–458
re-16 Abramo, A.C., Viola, J.C.: Liposuction through an axillary approach for treatment of gynecomastia Aesth Plast Surg 1989;13(2):85–89
17 Steele, S.R., Martin, M.J., Place, R.J.: Gynecomastia: plications of the subcutaneous mastectomy Ann Surg 2002;68(2):210–213
com-18 Coskun, A., Duzgun, S.A., Bozer, M., Akinci, O.F., koy, A.: Modified technique for correction of gynecomas- tia Eur J Surg 2001;167(11):822–824
Uzum-19 Peters, M.H., Vastine, V., Knox, L., Morgan, R.F.: ment of adolescent gynecomastia using a bipedicle tech- nique Ann Plast Surg 1998;40(3):241–245
Treat-20 Khan, J.I., Ho-Asjoe, M., Frame, J.D.: Pectoralis major rupture postsuction lipectomy for surgical management
of gynecomastia Aesth Plast Surg 1998;22(1):16–19
21 Tebbets, J.B.: Minimizing complications of sisted lipoplasty: an initial experience with no related com- plications Plast Reconstr Surg 1998;102(5):1690–1697
ultrasound-as-22 Cedidi, C.C., Berger, A.: Severe abdominal wall necrosis after ultrasound-assisted liposuction Aesth Plast Surg 2002;26(1):20–22
23 Troilius, C.: Ultrasound-assisted lipoplasty: is it really safe? Aesth Plast Surg 1999;23(5):307–311
24 Young, V.L., PSEF DATA Committee: Power-assisted plasty Plast Reconstr Surg 2001;108(5):1429–1432
lipo-References
Trang 18In the past it has been widely felt that the treatment
of ptosis requires cutaneous scars This is a fallacy,
as, in male gynecomastia (which is a reduction
mam-moplasty in man), by ultrasound-assisted lipoplasty
alone, the nipple-areola complex (NAC) rises to a
new level The author’s experience, which is clearly
reproducible, has shown that breast reduction with
ultrasound-assisted liposuction (UAL) decreases the
weight of the breast by gently elevating the gland and
the NAC rises As in pexy correction with UAL, there
is a limit to the degree of ptosis of the NAC which can
be corrected by decreasing the weight of the breast
Another consideration arises when treating male
breast hypertrophy with emulsification with UAL
when the volume of the breast is reduced and the
are-ola decreases in size
It is not true that the reduction of the size of the
NAC requires direct excision, and thus cutaneous
vis-ible scars This is because when the breast is reduced
in volume, tension of the areola is decreased
All these considerations made surgical treatment of
male gynecomastia (with an open approach through
an inframammary incision, or a periareolar incision,
in order to perform direct excision of male gland or
fat tissue) an obsolete procedure in the majority of clinical cases
70.2 Gynecomastia
Male gynecomastia can be pure, fatty, or mixed The
“pure” type (Fig 70.1) is exclusively glandular type hypertrophy due to overgrowth of the gland during the puberty period, connected to temporary impair-ment of male–female hormones There could be a par-tial lack of male hormones, or a temporary increase
of female hormones, which may affect the secondary sexual characteristics, such as the breast gland This can rapidly grow, reaching really great dimensions, in significant cases (brassiere cup size B–C)
The “fatty “ type is predominant in younger tients, with problems of overweight or obesity during their growth Obesity is becoming a severe problem
pa-in the more advanced and occidental countries The excess of nutrition may lead rapidly to a new category
of young obese patients (age range between 16 and
25 years), who develop larger breasts early, and chological problems connected to this unnatural as-pect of the male thorax
psy-Fig 70.1 a Preoperative patient with pure glandular hypertrophy b Postoperatively following ultrasound-assisted lipoplasty
Trang 19The “mixed” type (Fig 70.2) is probably the
com-monest in clinical practice to be found Mild breast
hypertrophy is combined with excess of local fat
de-position typically in the younger male patient with a
slight hormone-related breast hypertrophy that
pres-ents with a tendency to overweight, increasing the fat
deposits in the thorax and mammary region together
with an increase of the abdominal panniculus The
gynoid type with associated obesity can be treated
with UAL to the breast and abdominal contouring
can also be utilized in elderly patients (Fig 70.3)
70.3
Ultrasound- Assisted Lipoplasty
When UAL was initially promoted and introduced all
over the world, there were many critics and
discus-sions on the indications for patient selection One of
the indications unanimously given to UAL was the
treatment of breast male gynecomastia Male
gyneco-mastia in the pure, mixed, or fatty types are an ideal
indication for treatment with ultrasound-assisted
li-poplasty The titanium solid probes can easily break
even the dense fibrotic male breast tissue emulsifying
the fat component of the breast The ability of
ultra-sound to electively target the fatty component of the
breast tissues and thus spare the vascular network
makes this operation easier, with a minimal trauma
to the tissues, minimal blood loss, and the possibility
to thin as desired the breast region and the thorax
In mixed cases, not only the NAC region needs to
be reduced (where the majority of gynecomastia is
lo-calized), but the remaining fat of the thorax normally
presents excessive thickening of the fat component
With a 1.0-cm skin incision at the
infra-mammary crease and another 1.0-cm incision
made at the axilla, it is possible to treat all the male breast tissue Infusion of tumescence Klein solution is mandatory in these cases to allow ultrasound energy
to be delivered efficaciously A typical Klein solution for pure local anesthesia has been modified as follows: 1,000 ml of Ringer’s lactate, 1 mg of epinephrine, 500–1,000 mg of lidocaine
The fibrosis of the male breast often requires a higher concentration of local anesthetia in order to
be really effective When performed under general anesthesia, lidocaine is reduced to 200 mg/l, just to provide long-term postoperative analgesia Lidocaine has recently been substituted with other less toxic anesthetics such as articaine and Naropin Naropin
is produced by Astra, the same manufacturer as for lidocaine It is really effective and less toxic (for the neurovascular and cardiovascular systems) but there
is no study of its utilization as diluted anesthetic filtrated into the fat tissue in association with adrena-line For gynecomastia, the skin incisions are made at the inframammary crease and at the axilla
in-The first stage of the operation consists of tration of the tumescence anesthesia From 500 to 1,500 ml of tumescence solution, depending on the breast size and the extent of the fatty component, can
infil-be necessary to obtain a real superwet tumescence in the thorax
After completing the infiltration, the “port” of entry is stopped with a new device This skin port protector includes a stopper, which prevents the flu-ids from refluxing back It is necessary to wait for between 15 and 20 min to make the local anesthetics and the adrenaline effective When the operation is performed under general anesthesia, I wait no more than 10 min, just to give the adrenaline time to be ef-fective
Fig 70.2 Mixed gynecomastia a Preoperative b Postoperative
70.3 Ultrasound-Assisted Lipoplasty
Trang 20476 70 Ultrasound-Assisted Liposuction for Gynecomastia
With the VASER pulsating device (Sound
Surgi-cal, Denver, CO, USA), I often utilize the 3.7-mm
ti-tanium cannula at 70% of the total power (Fig 70.3)
The grooves on the lateral part of the tip of the solid
probes increase the efficacy of the system The
num-ber of the grooves (two to three) depends on the kind
of tissue encountered
When utilizing the Sculpture-Smei ultrasound
device, I place the total power setting at 55–60% of
the total, and utilize the 5.1-mm solid titanium probe
The amount of fibrofatty tissue which can be
emulsi-fied is variable and 100–200 ml of fat is obtainable in
2–3 min of cavitation, with both devices
The VASER Pulsate mode device has actually three
main advantages over other machines:
1 For emulsifying the same amount of fat, it delivers
50% of the ultrasound energy of previous devices,
thus decreasing the thermal energy employed, and
decreasing the risk of complications and side
ef-fects
2 The solid titanium probes employed are smaller
and have a higher efficiency, and emulsify with the
tip and with the lateral part of the tip These
small-er probes (Fig 70.3) allow smallsmall-er skin incisions
3 The VASER can deliver continuous ultrasound
en-ergy or pulsating ultrasound enen-ergy When
work-ing with the pulsatwork-ing mode, the energy delivered
is reduced by 50% in the same fraction of time,
thus decreasing the total ultrasound energy
de-livered and the thermal energy inside the treated
area As a consequence, potential risks of
compli-cations, such as seromas, burns, skin necrosis, and
fibrosis, are really nearly cancelled The pulsating
mode is indicated in very fibrotic tissue where a lot
of resistance might be encountered by the titanium
probes during attempts at tissue fragmentation
In pure gynecomastia, where most of the
glandu-lar tissue is fibrotic, the VASER pulsating mode
is helpful, together with the utilization of a
one-groove probe, which is particularly efficient in
thicker fibrotic areas
The ideal situation is to deliver lower amounts of
ul-trasound energy, thus obtaining higher tissue
frag-mentation; thus, the efficiency of the device and the
probe is high and the potential risk of complications
is really low In a mixed gynecomastia, the ultrasound
energy is used for 10–30 min depending on the size
and the extent of the tissue to be fragmented
Ultrasound-assisted lipoplasty not only destroys
the glandular tissues responsible for the glandular
hy-pertrophy but also emulsifies the fat tissue normally
present all over the mammary region, including the
axillary sides That is why, with UAL, remodeling of
the thorax is more complete Normally in men there
is no real skin laxity associated with the tissue trophy Working with UAL at the intermediate fatty layers and at the same time inside the gland (in mul-tiple layers) is sufficient to reduce and contour the whole area, which allows significant retraction of the skin envelope In cases where significant superficial skin stimulation is required for skin tone and elastic-ity, as in the majority of male gynecomastia, the re-sults are excellent and retraction is the consequence
hyper-of the reduced volume hyper-of breast and fat tissue
After the application of ultrasound energy for the hypertrophy of the gland, the “cleaning” of the emul-sified, fragmented tissues begins Normally, the emul-sion that flows away and is aspirated is clear, yellow, with a really small blood content Every surgeon who has experienced the “bloody” fibrotic male gland well understands the advantage of a smooth, bloodless procedure, with nice contouring of the thorax not just limited to the glandular tissue, but also extended
to the lateral axillary component that is often trophic
hyper-At the end of surgery, manual remodeling of the region is required to check symmetry, new NAC po-sition, and NAC projection Aspiration drainage is always used to compress the surgical area, together with an elastic garment, which is maintained for 4–8 weeks (Design Veronique, Richmond, CA, USA) (Fig 70.4) The foam pads are maintained for 10 days (EPIfoam, Biodermis, Las Vegas, NV, USA)
Two weeks after surgery, a cycle of intensive saging with Endermologie is begun twice a week, for smoothing and softening the local edema and fibro-sis Results are normally complete 2 months after sur-gery
mas-Fig 70.3. VASER probes of 3.7, 2.9, and 2.2 mm with two grooves
Trang 21der tumescence anesthesia and intravenous sedation,
or with laryngeal mask assistance and no
endotrache-al intubation All the patients were kept overnight in hospital Drains were removed in 24–48 h
70.4
Complications
Seroma
The incidence of seroma is low Having always utilized a
solid titanium probe with a high efficiency for cavitation
and thus tissue fragmentation, the amount of thermal
en-ergy dispersed through the tissue is minimal, and does not
cause long-lasting seroma or fluid accumulation Seroma
has to be attributed to an inside burn with consequent
liq-uefaction of tissue, and interruption of lymphatics
drain-ing the area
Fibrosis
Local areas of induration despite being rare may still occur
in breast reduction with UAL, in women as well as in men
for gynecomastia treatment Localized fibrosis is due to an
internal small, limited burn of the fibrofatty tissue
Post-operative early massaging and eventually an intralesional
cortisone injection are advised to prevent and treat
occa-sional areas of induration
An impairment of the symmetry of the 2 breasts may still
be present at the end of surgery, or 1 month after, when the
reabsorption of the edema is completed When the
asym-metry is conspicuous, the patient may require a secondary
revision Usually this is an office procedure, under local
anesthesia
Loss of sensation
Loss of sensation has always been temporary, limited to the
first 3–6 weeks after surgery
Hematoma
Five cases of hematoma, which required closed evacuation
and compression, were observed in our series (2 of the
pa-tients were heavy smokers)
70.5
Conclusions
From 1992 to 2002, 150 gynecomastia patients were
treated with ultrasound-assisted lipoplasty It became
the technique of choice for pure, mixed, and fatty
gy-necomastia, despite the amount of breast tissue and
the degree of breast ptosis associated Results have
been extremely gratifying for patients and the
sur-geon The technique was shown not to be aggressive
and traumatizing as in the past with the open-surgery
approach or as with traditional old-fashioned
liposuc-tion The majority of patients were operated upon
un-Fig 70.4. Elastic garment – Design Veronique
70.5 Conclusions
Trang 22478 70 Ultrasound-Assisted Liposuction for Gynecomastia
Fig 70.5 a Pre-op frontal view: 33-year-old man with lipodystrophy of abdomen with pure gynecomastia Note extreme laxity
of abdominal skin b Pre-op oblique right view: 33-year-old man with lipodystrophy of abdomen combined with pure mastia c Pre-op lateral right view: 33-year-old man with lipodystrophy of abdomen with pure gynecomastia d Pre-op lateral left view: 33-year-old man with lipodystrophy of abdomen with pure gynecomastia e Post-op frontal view: 2 months after VASER liposelection (breasts 1110 ml aspirate bilaterally; abdomen 900 ml aspirate) f Post-op oblique right view: 2 months after VASER liposelection (breasts 1110 ml aspirate bilaterally; abdomen 900 ml aspirate) g Post-op lateral right view: 2 months after VASER liposelection (breasts 1110 ml aspirate bilaterally; abdomen 900 ml aspirate) h Post-op lateral left view: 2 months after VASER
gyneco-liposelection (breasts 1110 ml aspirate bilaterally; abdomen 900 ml aspirate)
Trang 23Fig 70.6 a Pre-op frontal view: 28-year-old man with pure gynecomastia and lipodystrophy of abdomen b Pre-op oblique right view: 28-year-old man with pure gynecomastia and lipodystrophy of abdomen c Pre-op lateral right view: 28-year-old man with pure gynecomastia and lipodystrophy of abdomen d Post-op frontal view: 3 months after VASER liposelection (breasts 1400 ml aspirated, bilaterally; abdomen 1300 ml aspirated) e Post-op oblique right view: 3 months after VASER liposelection (breasts
1400 ml aspirated, bilaterally; abdomen 1300 ml aspirated) f Post-op lateral right view: 3 months after VASER liposelection
(breasts 1400 ml aspirated, bilaterally; abdomen 1300 ml aspirated)
70.5 Conclusions
Trang 24480 70 Ultrasound-Assisted Liposuction for Gynecomastia
Fig 70.7 a Pre-op frontal view: 25-year-old boy already operated of mixed gynecomastia with standard liposuction Note still permanence of tissue, cutaneous ptosis and skin laxity b Pre-op oblique right view view: 25-year-old boy already operated of mixed gynecomastia with standard liposuction Note still permanence of tissue, cutaneous ptosis and skin laxity c Pre-op lateral
right view: 25-year-old boy already operated of mixed gynecomastia with standard liposuction Note still permanence of tissue,
cutaneous ptosis and skin laxity d Post-op frontal view: 1 month after VASER liposelection to breast and abdomen Note great
skin retraction of the breast with no need for surgical excision Breast tissue has been liquefied by VASER Total 2500 ml of
as-pirate e Post-op oblique right view: 1 month after VASER liposelection to breast and abdomen Note great skin retraction of the breast with no need for surgical excision Breast tissue has been liquefied by VASER Total 2500 ml of aspirate f Post-op lateral
right view: 1 month after VASER liposelection to breast and abdomen Note great skin retraction of the breast with no need for surgical excision Breast tissue has been liquefied by VASER Total 2500 ml of aspirate
Trang 25Lipomas Treated with Liposuction
John Stuart Mancoll
Chapter 71
71
71.1
Introduction
Lipomas are the most frequent soft-tissue tumor
Typically they are a benign tumor of fat and are
thinly encapsulated They appear as slow-growing
bumps of subcutaneous fat Usually they do not
re-spond to changes in body fat fluctuations Patients are
frequently referred to a plastic surgeon in hope that
the mass may be treated with liposuction Therefore
it is important that we as plastic surgeons be aware of
what lipomas are, and perhaps more importantly be
aware of what they could be
Lipomas are soft-tissue deposits of fatty
mate-rial that grow under the skin, causing round or oval
lumps Their reported incidence is 2.1 per 1,000
people [1] They typically appear as a smooth, soft,
non-tender bump under the skin They feel soft and
doughy or rubbery; lipomas range in firmness and
can feel rather hard The skin over the lipoma has a
normal appearance Lipomas rarely grow more than
2 or 3 in across They can develop anywhere on the
body but are particularly common on the forearms,
torso, and back of the neck However, lipomas have
been reported in nearly every organ and body space,
including the brain, spinal cord, parotid gland,
ten-don sheaths, stomach, small bowel and colon walls,
and even the bone marrow Some people have only
one, whereas others develop many lipomas Lipomas
rarely cause problems, although they may
occasion-ally be painful if they grow against a nerve Solitary
lipomas are commoner in women, whereas multiple
lipomas are commoner in men
71.2
Epidemiology
Although most lipomas are sporadic in their
appear-ance some do have an inherited mode of appearappear-ance
Diffuse congenital lipomatosis, benign symmetric
lipomatosis (Madelung’s disease), familial multiple
li-pomatosis, and Dercum’s disease (adiposis dolorosa)
are all inherited disorders Diffuse congenital
lipo-matosis patients who have diffuse poorly demarcated lipomas localized primarily on the trunk characterize this type These tumors are composed of immature fat cells Lipomas in these patients are particularly difficult to treat because they often infiltrate through muscle fibers, making them difficult to remove surgi-cally
Benign symmetric lipomatosis, also referred to as Madelung’s disease, was first described in 1888 [2] Typically patients with benign symmetric lipoma-tosis have lipomas of the head, neck, shoulders, and proximal upper extremities Men are affected 4 times
as often as women There will be a history of sive alcohol consumption or diabetes Other condi-tions associated with Madelung’s disease include ma-lignant tumors of the upper airways, hyperuricemia, obesity, renal tubular acidosis, peripheral neuropathy, and liver disease
exces-Familial multiple lipomatosis is a clinical entity characterized by many, small, well-demarcated, en-capsulated lipomas that commonly involve the ex-tremities This is passed as an autosomal dominant gene and a family history of lipomas will be present Typically, this form appears during or soon after ado-lescence The neck and shoulders are usually spared
in contrast to the situation for benign symmetric pomatosis
li-Dercum’s disease (adiposis dolorosa) is a rare ease characterized by painful lipomas The lipomas typically occur on the extremities of obese postmeno-pausal women Associated conditions include alco-holism, emotional instability, and depression
dis-Some have also been linked to a history of ized trauma
local-71.3 Age
Lipomas can occur at any age, but they typically cur after puberty when the body is gaining fat They will often appear in patients between 40 and 60 years
oc-of age Frequently patients will claim that they have been present for years
Trang 26482 71 Lipomas Treated with Liposuction
71.4
Differential Diagnosis
Although lipomas are the commonest subcutaneous
mass, one cannot exclude the fact it might be some
other subcutaneous mass that is present (Table 71.1)
71.5
Pathology
71.5.1
Histologic Findings
Lipomas histologically resemble normal fat When
completely excised, a thin fibrous capsule
surround-ing the aggregate of adipocytes may be seen Without
a clinical or gross description, it often is impossible
to distinguish between tumor cells and mature
adi-pocytes Lipomas differ biochemically from normal
mature fat Lipomas have increased levels of
lipo-protein lipase
Recent work by Pierantoni et al [3] suggests a
critical role played by HMGA1 rearrangements in the
generation of human lipomas Whereas the role of
HMGA2 has been suggested by Ashar et al [4], most
lipomas, and their benign and malignant variants, have chromosomal abnormalities involving 12q14 The genetic mutation in patients with multiple lipo-mas, however, is in the mitochondria
Spindle cell lipoma is a relatively uncommon variant characterized by a mixture of mature adipo-cytes and bland spindle cells on a fibromyxoid back-ground
71.6 Diagnosis
Most lipomas can be diagnosed on physical nation alone Their characteristics leave little doubt about the etiology However, if there is a history of rapid growth, increasing pain, or other changes are noted, then preoperative studies should be performed
exami-to help confirm the diagnosis
Radiology evaluation may include ultrasound,
a computed tomography (CT) scan or MRI On trasound lipomas can have different echogenic pat-terns depending on the composition of the associated connective tissue and the position of the mass They could be hypoechogenic, hyperechogenic, or mixed, but are easily distinguished by oval shapes with well-demarcated capsules Color Doppler sonography can
ul-be added to help differentiate malignant lipomas verses benign tumors
Ultrasound evaluation may be feasible to evaluate
a suspicious mass Futani et al [5] demonstrated the gray scale Ultrasound was by itself unable to dif-ferentiate between well-differentiated liposarcoma (WDLS) and intramuscular lipomas (ILs) Gray scale images showed no differences between WDLS and ILs However, power Doppler showed more than two flow velocity signals in all WDLSs, whereas only 11%
of the ILs had two signals In all WDLSs, color flow signals occupied more than 30% of the selected area
In contrast, ILs were characterized by a low color-dot ratio These findings were attributed to histologically increased vascularity found close to malignant cell invasions
CT scans are very good at differentiating lipomas from other subcutaneous masses CT enables the definite diagnosis by measurement of density values equivalent to fat Thompson et al [6] demonstrated that CT findings were specific for the diagnosis of li-poma in eight of nine patients CT can also be used to diagnose deeper masses and should be used to evalu-ate large submucosal masses in the stomach to estab-lish a preoperative diagnosis
MRI can also be used to differentiate lipomas from other subcutaneous masses Typically a T1-weighted fat suppression sequence with a chemical shift meth-
od confirms the fatty nature of the lesion
Table 71.1. Differential diagnosis of a subcutaneous mass
a Typically, these tender, soft, subcutaneous nodules are
pres-ent in adolescence Tumors are frequpres-ently multilobulated and
are somewhat firmer than ordinary lipomas The associated
pain is vague and may be spontaneous or caused by pressure
b Tumors are solitary well-circumscribed nodules that
typical-ly are asymptomatic Usualtypical-ly, tumors are located in the
inter-scapular region, axillae, neck, or mediastinum Histologically,
hibernomas are composed of embryonic brown lipoblasts
termed mulberry cells because of their appearance
Trang 27Ohguri et al [7] set out to evaluate the reliability of
MRI in distinguishing between benign lipomas and
WDLS In their study benign lesions had irregular
margins, a recognizable non-adipose component, and
non-enhancing septa Malignant liposarcomas on the
other hand demonstrated thick septa and nodular or
patchy non-adipose components Also the septa in
WDLS enhanced more strongly than did those in
be-nign lipomas
Pathologic diagnosis can be done with fine needle
aspiration Kapila et al [8] evaluated cytomorphologic
features of benign and malignant lipomatous tumors
of soft tissue with fine needle aspirates (FNAs) They
determined that lipomas could be diagnosed readily
They noted that arborizing vessels can be seen in
li-pomas and should be interpreted with caution
Sub-classification of liposarcomas on FNAs is possible but
not very reliable Myxoid liposarcomas pose a
prob-lem, and aspirates from them can mimic a wide range
of morphologic subtypes The role of FNAs in
identi-fication of variants of liposarcoma is limited
71.7
Surgery
Surgery for lipomas is indicated in any tumor in which
the diagnosis is in question Additional indications
include masses compressing nerves leading to
neu-ropathies or lesions causing pain or limiting function
by virtue of their location Although some patients
may present for functional concerns most patients
are prompted to seek treatment for aesthetic reasons
Therefore, a surgical approach must be selected that
will not replace the subcutaneous mass with an
unac-ceptable scar The options include conventional
surgi-cal excision and liposuction
Traditionally lipomas are excised through large
in-cisions Hardin was one of the first to suggest teasing
or expressing lipomas through small incisions, thus
minimizing the scar As a rule of thumb if a lipoma is
as small than 4 cm then there is no significant
advan-tage in liposuction Small lipomas may be removed
under local block but larger or recurrent lipomas will
require a general anesthetic I usually start with an
initial incision half the length of the lesion for small
lesions (less than 4 cm) For larger lesions I try to keep
the incision to one third or less of the total length
For very large lipomas, a combination of liposuction
and open excision may be helpful When one starts
to remove the lipoma it does appear distinct from the
surrounding fat In many cases it will border
ana-tomic planes and this will help with the dissection
I find that in anatomically sensitive areas the open
technique is essential Other lipomas that are easier
to remove with open techniques include subperiosteal
and subfrontalis lipomas of the forehead The thicker fascia plane surrounding the lipoma makes it harder
to completely remove the lipoma with a liposuction cannula
71.8 Liposuction
Liposuction for the treatment lipomas is the monest non-cosmetic use of liposuction The use of li-posuction to treat lipomas was first described in 1985
com-by Rubenstein et al [9] The advantages of liposuction over open techniques in addition to smaller scars in-clude shorter operative times, diminished postopera-tive pain, and decreased incidents of hematomas and seromas It has also been advocated when multiple li-pomas are being removed at once Most authors have suggested that liposuction is best reserved for masses greater than 4 cm This observation is based on the fact that smaller lesions can be excision through an in-cision that would be only slightly larger than a typical liposuction access site Wilhelmi et al [10] presented five cases of forehead lipomas all less than 4 cm which were successfully removed with liposuction
When liposuction is used typically I will choose
a 4–8-mm cannula I do use a dilute lidocaine tion similar to cosmetic liposuction, but I try to place the solution around the mass instead of within the capsule This gives me the hemostasis I desire and
solu-I am able to palpate to make sure the entire mass is removed I rarely feather after the lesion is removed regardless of how hollowed the defect is After remov-ing the lipoma, the initial contour deformity almost always resolves This is because unlike gynecomastia
or cosmetic liposuction defects the lipomas have a mass effect After the tumor is gone the compressed native fat cells in that area tend to return to their na-tive positions A compressive dressing is applied and activities are limited based on anatomic locations
71.9 Conclusions
Patients with lipomas are frequently referred to tic surgeons for treatment specifically with the lipo-suction technique Therefore it is incumbent on us to not only confirm the diagnosis prior to surgery, but also to make sure that liposuction is the right tool for the job Proper patient counseling must be given and
plas-a potentiplas-ally high recurrence rplas-ate must be explplas-ained But with proper patient selection liposuction can be successfully employed in treating lipomas
71.9 Conclusions
Trang 28484 71 Lipomas Treated with Liposuction
References
1 Koh HK, Bhawan J Tumors of the skin In: Moschella SL,
Hurley HJ, eds Dermatology 3d ed Philadelphia:
Saun-ders, 1992:1721–1808
2 Enzi G Multiple symmetric lipomatosis: an updated
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3 Pierantoni, G.M., Battista, S., Pentimalli, F., Fedele, M.,
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Trang 29Treatment of Multiple Symmetrical Lipomatosis
Multiple symmetrical lipomatosis (MSL) is a rare
ease, initially reported in 1846 by Brodie [1] This
dis-ease has been described under the eponyms of
Mad-elung’s disease, Launois–Bensaude syndrome, benign
symmetric lipomatosis, and lipoma annulare colli
It is a condition of middle age and occurs
predomi-nantly in men of Mediterranean descent MSL occurs
mostly sporadically, but some cases with familial
inci-dence have been seen The disease is characterized by
enlarging, painless, symmetric, fatty deposits in
spe-cific areas of the body, especially the neck, shoulders,
and proximal upper extremities, giving the patient a
“horse collar” or “buffalo hump” appearance [2]
His-tologically, the tumors are composed of adipocytes
indistinguishable from those of normal subcutaneous
tissue, but the normal lobular architecture is lost and
the fat lobules appear larger than normal In contrast
with ordinary lipomas, fatty deposits in MSL are
un-encapsulated, although they typically demonstrate fat
lobules that are delineated from the surrounding
tis-sue by a thin fibrous pseudocapsule [3]
72.2
Pathogenesis
The etiology and pathogenesis of MSL are unknown,
but lipomatous infiltration of affected tissues may be
due to a neoplastic-like proliferation of functionally
defective brown adipocytes [4] Adipocytes from MSL
lipomas have been found to be relatively insensitive
to the lipolytic effect of catecholamines [4] This
un-derlying primary metabolic defect partially explains
postsurgical reaccumulation of fatty deposits An
association with mitochondrial respiratory enzyme
dysfunction and mitochondrial DNA mutations has
been made in some cases of MSL [5]
72.3 Clinical Signs and Symptoms
The clinical course of MSL is characterized by slow, progressive enlargement of confluent lipomas, whose number may reach as many as over 1,000, and which may range in size between 1 and 20 cm, cosmetically disfiguring the patient, provoking symptoms derived from the compression of vascular and nervous struc-tures and, rarely, dyspnea from compression of the re-spiratory tract Lipomatous tissue may surround and infiltrate underlying tissues, making difficult com-plete excision of the tumors The face, distal extremi-ties, hands, and feet are always spared [2, 6]
According to the localization of the tumors, two types of MSL can be identified [6]:
1 Type I: Characterized by fatty deposits distributed
on the upper part of the body, giving the patient a pseudoathletic appearance Lipomatous tissue may involve the mediastinum with vena cava compres-sion
2 Type II: Distribution of the lipomas is more alized, giving the patient the appearance of simple obesity
gener-MSL is frequently associated with hepatopathy and chronic heavy alcohol consumption It has also been reported in association with endocrine and metabolic abnormalities, such as diabetes mellitus or glucose intolerance, hyperlipidemia, hyperlipoproteinemia, hyperuricemia, hyperthyroidism, hypothyroidism, hypogonadism, and renal tubular acidosis Other conditions associated with MSL include malignant tumors of the upper airway, peripheral neuropathy (sensory, motor, or autonomic) and, less frequently, central nervous system involvement [2, 6, 7]
72.4 Differential Diagnosis
The differential diagnosis of MSL includes sity, familial multiple lipomatosis, adiposis dolorosa