Breast Surgery

Assessment of a Suction-Assisted Cartilage Shaver Plus Liposuction for the Treatment of Gynecomastia
Jess Benito-Ruiz, MD, PhD; Mauricio Raigosa, MD; Marisa Manzano, MD; and Laura Salvador, MD
Background: The development of feminized breasts in men may cause significant emotional distress and embarrassment, particularly in young men and adolescents. Numerous techniques have been described for the correction of gynecomastia, many of which include the removal of fat and glandular tissue. Objective: The authors assess the utility of combining vibroliposuction with the use of a power-assisted arthroscopicendoscopic cartilage shaver to correct gynecomastia and suggest a treatment algorithm for patients with gynecomastia. Methods: Forty consecutive patients with a median age of 32 years (range 1957 years) and with varying degrees of gynecomastia underwent a combined approach that included vibroliposuction (power-assisted tumescent liposuction) for the removal of fatty tissue, followed by the removal of fibrous tissue with the use of a power-assisted cartilage shaver. Follow-up periods ranged in duration from six to 18 months. Results: All patients had satisfactory results. However, expansive hematomas requiring surgical drainage developed in three patients. Other complications included one case of insufficient resection requiring reoperation and three cases of hyperpigmentation and skin irregularities in patients with grade I gynecomastia. Conclusions: Combination treatment using vibroliposuction and a power-assisted arthroscopicendoscopic cartilage shaver is an effective treatment for gynecomastia, but the technique has a learning curve. This procedure is most appropriate for patients with grades II and III gynecomastia, or as a first-stage treatment for patients with grade IV gynecomastia. (Aesthetic Surg J 2009;29:302309.)

ynecomastia is defined as the benign enlargement of the male breast secondary to gland proliferation. It is a commonly occurring condition, with an overall incidence of 32% to 36%.1,2 It most often develops during the neonatal period, during puberty, or in men 50 years of age or older.3 Approximately 25% of cases are idiopathic. Other forms of this condition include persistent gynecomastia related to puberty (approximately 25% of cases) and gynecomastia secondary to pharmaceutical treatment (approximately 20% of cases).4 The development of gynecomastia is believed to be secondary to an alteration in the balance of progesterone and estrogen and must be differentiated from male breast cancer.5 While treatment of the underlying cause is important, it may fail to correct breast development, particularly if gynecomastia has been present for some time.6 The gland becomes hyalinized and fibrous, leaving surgery as the only effective treatment.

Drs. Benito-Ruiz, Raigosa, and Manzano are plastic surgeons in private practice in Barcelona, Spain. Dr. Salvador is a general surgeon in private practice in Barcelona, Spain.

Many surgical techniques for the correction of gynecomastia have been described; the technique often depends on the type and severity of the condition. Surgical options include open excision, conventional liposuction, or a combination of the two methods. Ultrasound-assisted liposuction has been reported to be particularly effective in the treatment of gynecomastia.7-9 Recently, Prado and Castillo10 described a technique that combined conventional liposuction with the use of a power-assisted arthroscopicendoscopic cartilage shaver. They reported that this procedure enabled them to avoid incisions in the nippleareolar complex and led to improved outcomes with less scarring, good skin retraction, a shorter operative time, minimal complications, and good cosmetic results. In our practice, we have performed vibroliposuction (power-assisted liposuction that uses compressed air to vibrate the cannula) to treat patients with pseudogynecomastia that required the removal of fat only. We have also employed vibroliposuction as an adjunctive treatment in procedures involving open excision, using an areolar or axillary approach. In this article, we report a consecutive
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Figure 1. Close-up views of the tip of the instrument. The rotating teeth allow excision of the gland by taking bits and aspirating the pieces.

series of patients with gynecomastia who were treated with a combination of vibroliposuction with the use of a cartilage shaver, as described by Prado and Castillo.10 Our goals were to determine whether we could introduce a minimal scar procedure into our practice and to develop a new treatment algorithm for patients with gynecomastia.

METHODS
Between 2006 and 2007, 40 consecutive patients received treatment combining vibroliposuction and use of a power-assisted cartilage shaver. The patients were classified according to the system proposed by Rohrich et al9 as follows: grade Iminimal hypertrophy (250 g of breast tissue) without ptosis; grade IImoderate hypertrophy (250500 g of breast tissue) without ptosis; grade IIIsevere hypertrophy (500 g of breast tissue) with grade I ptosis; and grade IVsevere hypertrophy with grade II or III ptosis. Using this system, six patients were classified as grade I, 17 as grade II, 14 as grade III, and three as grade IV. The patients ranged in age from 19 to 57 years (median age 32 years). Preoperative examinations revealed gynecomastia with surrounding fat tissue. Each of the patients needed different amounts of breast gland removed which was determined by the senior author.

Figure 2. Intraoperative view of the surgical technique. The cartilage shaver is introduced through the same incision that is used for liposuction.

larity were determined using the pinch test. The surgeons nondominant hand indicated how much glandular tissue to remove and controls the thickness of the flap. Care was taken to avoid curetting the dermis. When the procedure was completed, the small incisions were sutured and a sterile, compressive dressing was applied. Drains were inserted and kept in place for 24 hours. The patient was discharged one day after surgery. Patients were instructed to wear a vest compression garment for four weeks.

RESULTS
Forty patients with bilateral gynecomastia were treated using this combined approach. Follow-up periods ranged from six to 18 months (average 12 months). Expansive hematomas that required surgical evacuation in the operating room occurred within hours of treatment in one patient with grade III gynecomastia and two patients with grade II gynecomastia. We observed a close relationship between the development of hematoma and the use of a cuff on the ipsilateral arm to monitor blood pressure in the recovery room. There were no other complications, such as infection, seroma, nippleareolar complex necrosis, or epidermolysis. Hyperpigmentation and skin irregularities associated with dermal injury caused by the shaver developed in three patients with grade I gynecomastia (Figure 3). Two patients with grade III gynecomastia required reoperation to correct asymmetry one year after the initial procedure. A large amount of scar tissue was removed during reoperation. Scarring was inconspicuous, in contrast to the results of traditional gynecomastia surgery. All patients resumed exercise and returned to their normal routine within five weeks after the surgery. Thirty-eight of the 40 patients who received treatment were satisfied with their results (Figures 47).

Surgical Technique
Patients were marked preoperatively while standing upright. All patients received general anesthesia. Each patient was then placed in a supine position on the operating table with the arms abducted at 90. The entire surgical area was infiltrated with a wetting solution through a stab incision located inferolaterally. Vibroliposuction was performed using a Vibrolipo device (Euromi SA, Verviers, Belgium) with a 3- or 4-mm cannula, an air pressure of 3.9 bar, and a negative pressure for aspiration of 1 atm. To remove the gland, we used a power-assisted cartilage shaver (Endoscopic Arthroscopic System SE 5/TPS; Stryker, Kalamazoo, MI). The blade of this device is comprised of two concentric cannulas with diameters of 3 and 4 mm, respectively. The 4-mm outer cannula has an upward-opening hub with a grid that allows the rotating inner cannula to serve as a continuous curette. The 3-mm inner cannula rotates in oscillation mode (Figure 1). The tissue was severed and suctioned using back-and-forth movements of the cartilage shaver (Figure 2). It was necessary to leave a small amount of gland behind the areola to avoid an undesirable depression. Homogeneity and regu-

DISCUSSION
Gynecomastia is the most common breast pathology among males. In most patients (and particularly among adolescents), the condition is benign and self-limiting.11
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Figure 3. A, C, E, Preoperative views of a 32-year-old man with grade I gynecomastia. B, D, F, Six months after treatment with vibroliposuction and a cartilage shaver. Note the presence of some dimples and hyperpigmentation.

Surgery remains the accepted treatment for longstanding cases. The surgeons goal should be correction of the abnormal breast enlargement with minimal scarring. Liposuction alone is not sufficient to remove the fibrous glandular tissue.9 A combined approach using liposuction and the removal of the gland via a periareolar incision is a standard and safe approach for correction of mild and moderate gynecomastia.12 304 Volume 29 Number 4 July/August 2009

The technique reported by Prado and Castillo,10 which combined conventional liposuction with use of the cartilage shaver, permitted the effective resection of the fibrous gland. It was also possible to perform finetissue histopathologic analysis on the resected tissue if necessary.10 Prado and Castillo used a single approach through the inframammary fold and reported no complications in the 25 patients in their study.
Aesthetic Surgery Journal

Figure 4. A, C, E, Preoperative views of a 34-year-old man with grade II gynecomastia. B, D, F, Six months after treatment with vibroliposuction and a cartilage shaver.

We prefer to use the lateral approach at the edge of the pectoralis muscle because we feel that it results in a more inconspicuous scar when compared to the inframammary fold approach. Because the same small incision can be used for both liposuction and gland removal with the shaver, the perceptible stigma resulting from open surgery at the areola or axilla can be avoided. The procedure requires a learning curve. We recommend starting with lower revolutions (around 900 rpm), which

can be increased once the surgeon is comfortable with the technique. Postoperative hematoma developed in three of 40 patients (7.5%). However, we also have experienced an unusually high rate of postoperative hematoma in patients treated with a more traditional areolar or axillary approach (data not shown). We noted a close relationship between the development of a hematoma and placement of the blood pressure monitoring cuff
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Suction-Assisted Cartilage Shaver Plus Liposuction for the Treatment of Gynecomastia

Figure 5. A, C, E, Preoperative views of a 26-year-old man with grade III gynecomastia. B, D, F, Three months after treatment with vibroliposuction and a cartilage shaver.

on the ipsilateral side. The cuff measures blood pressure every five minutes, which may have created a local increase in arterial and venous blood pressure that made bleeding more likely. After we began placing the cuff around the leg, we experienced no more bleeding complications. The Vibrolipo and Lipomatic (also available from Euromi SA) devices use vibration to help remove fat. The cannula vibrates at 10 Hz. Vibroliposuction is more 306 Volume 29 Number 4 July/August 2009

effective and less energy-consuming for the surgeon than conventional liposuction for the removal of the fibrous fat typically found in the breast in patients with gynecomastia. Vibroliposuction enables us to remove up to 90% of this tissue, isolating the gland for additional removal using the shaver. We found the shaver difficult to manage when treating patients with grade I gynecomastia because relatively little fat is present and there is a high risk
Aesthetic Surgery Journal

Figure 6. A, C, E, Preoperative views of a 43-year-old man with grade II gynecomastia who had previously undergone treatment with conventional liposuction only. B, D, F, Twelve months after removal of gland with the cartilage shaver through the same incision used for the previous procedure.

of dermal injury associated with the use of the shaver. Three of our six patients with grade I gynecomastia experienced hyperpigmentation and/or unevenness (Figure 7) because of this problem, which significantly raised the overall complication rate in our patient series. We achieved our best results in patients with grade II or III gynecomastia. These patients had a mixture of fat

and glandular tissue in addition to a sufficient subcutaneous tissue thickness to enable us to gain consistent results by combining vibroliposuction with use of the shaver. In all cases, we warned patients that, at some time following treatment, a touch-up procedure might be necessary to correct any potential asymmetry. In patients with grade IV gynecomastia, the procedure can be considered as a first-stage treatment that removes
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Figure 7. A, C, E, Preoperative views of a 19-year-old man with grade IV gynecomastia. B, D, F, Twelve months after treatment with vibroliposuction and cartilage shaver. No skin excision was performed.

most of the tissue and allows for skin shrinkage. In our series, none of the patients with grade IV gynecomastia requested further procedures, although all of them had some residual sagging. In these cases, skin reduction leaving only a periareaolar scar, as suggested by Filho et al,13 could be advisable. In view of the results obtained with this technique, we propose the following algorithm for the treatment of gynecomastia: 308 Volume 29 Number 4 July/August 2009

Grade I (mainly glandular): areolar or axillary excision of the gland; Grade II: vibroliposuction plus shaver (in cases with a strong glandular component, consider an areolar or axillary approach to remove the gland); Grade III: vibroliposuction plus shaver; and Grade IV: first-stage treatment with vibroliposuction plus shaver to reduce volume; consider skin removal one year posttreatment, if needed.
Aesthetic Surgery Journal

CONCLUSIONS
Shaver-assisted removal of breast parenchyma is a useful approach for the treatment of males with gynecomastia, but it is not indicated in all cases of gynecomastia. Patients with grade II or III gynecomastia are likely to benefit most from this approach.

DISCLOSURES
The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article.

REFERENCES
1. Carlson HE. Gynecomastia. N Engl J Med 1980;303:795799. 2. Nuttall FQ. Gynecomastia as a physical finding in normal men. J Clin Endocrinol Metab 1979;48:338340. 3. Braunstein GD. Gynecomastia. N Engl J Med 1993;328:490495. 4. Gikas P, Mokbel K. Management of gynaecomastia: An update. Int J Clin Pract 2007;61:12091215. 5. Steele SR, Martin MJ, Place RJ. Gynaecomastia: Complications of the subcutaneous mastectomy. Am Surg 2002;68:210213. 6. Hands LJ, Greenall MJ. Gynaecomastia. Br J Surg 1991;78:907911. 7. Fruhstorfer BH, Malata CM. A systematic approach to the surgical treatment of gynaecomastia. Br J Plast Surg 2003;56:237246. 8. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg 2005;116:646653. 9. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: Defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003;111:909923. 10. Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver. Plast Reconstr Surg 2005;115:939942. 11. Wiesman IM, Lehman Jr JA, Parker MG, et al. Gynecomastia: An outcome analysis. Ann Plast Surg 2004;53:97101. 12. Walden J, Schmid RP, Blackwell SJ. Cross-chest lipoplasty and surgical excision for gynecomastia: A 10-year experience. Aesthet Surg J 2004;24:216223. 13. Filho DH, Garcia Arruda R, Alonso N. Treatment of severe gynecomastia (grade III) by resection of periareolar skin. Aesthet Surg J 2006;26:669673. Accepted for publication February 9, 2009. Reprint requests: Jess Benito-Ruiz, MD, PhD, Antiaging Group Barcelona, Institut Dexeus, c/ Sabino de Arana 5-19, 08028 Barcelona, Spain. E-mail: drbenito@cirugia-estetica.com. Copyright 2009 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$36.00 doi:10.1016/j.asj.2009.02.020

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