J. R. Coll. Surg. Edinb., 43, April 1998, 89-92

Gynaecomastia: have Webster's lessons been ignored?

A.J. PARK AND B. G. H. LAMBERTY
Department of Plastic Surgery, Addenbrooke's Hospital, Cambridge, UK

Five cases of cosmetically unacceptable and hypertrophic scarring are presented that follow excision of gynaecomastia by surgeons who used incisions other than the periareolar approach. A periareolar technique of subcutaneous mastectomy is described and recommended.

Keywords: gynaecomastia, hypertrophic scarring, periareolar, subcutaneous mastectomy.

Gynaecomastia is the most common breast problem in men.¹ It was first described by Paulus Aegineta (AD 625-690) who thought that it was due to the formation of fat. He advocated excision of the excess tissue through a single submammary lunar incision.² Gynaecomastia itself requires no treatment unless it causes discomfort or embarrassment to the patient. The results of hormone therapy are disappointing, and surgery is therefore the mainstay of treatment. It is a cosmetic operation, and as such should not leave the individual with ugly, raised scars. The nipple areola complex must be left in the correct position and symmetrical with the other side, with minimal scarring. A smooth contour is important and a central crater should be avoided. Various surgical approaches have been advocated through the years^3-10 Prior to 1946, the recommended incision was submammary, and even then it was recognized as being a cause of broad, conspicuous scarring. Webster in 1934 recognized the fact that the scars resulting from this operation often caused more embarrassment than the original condition, and suggested excision of the breast disc through a semicircular intra-areolar incision (see Figure 6, later). His results were published in 1946.¹¹ However, this incision was first described by Dufourmentel in 1928.¹²

Webster classified gynaecomastia into three types:

1. glandular;
2. fatty glandular;
3. simple fatty.

Patients with a glandular component require surgical removal of the gland. In the fatty glandular form, surgery combined with liposuction gives good contouring.^3-6 In the cases that are primarily fatty in nature, liposuction alone gives good results.

Another classification described by Simon in 1973 groups the patients into categories according to the size of the gynaecomastia:¹

• I-minor but visible breast enlargement without skin redundancy;
• IIa-moderate breast enlargement without skin redundancy;
• IIb-moderate breast enlargement with minor skin redundancy;
• III-gross breast enlargement with skin redundancy so as to simulate a pendulous female breast.

Groups I and II require no skin excision, but in group III the breast development is so marked that excess skin needs to be removed, and in these cases a mastopexy-type procedure is required.¹³ These difficult cases are the only ones requiring a surgical incision outwith the areola.

All tissue removed should be sent for histological examination in order to exclude malignancy, as about 1% of all primary breast tumours arise in men and breast cancer accounts for 0.7% of all male cancers.

CASE PRESENTATIONS

Case 1

A 22-year-old man was referred to a general surgeon complaining of swelling of both breasts since the age of 10 years. A diagnosis of gynaecomastia secondary to Klinefelter's syndrome was made, and arrangements made for his admission for mastectomy. His mastectomies were performed through hemi-circumareolar incisions with both medial and lateral extensions. This has left him with very unsightly scars which have become hypertrophic and painful (Figure 1). In addition, he has been left with an indentation beneath his right areola where a disc of breast tissue has not been left behind to maintain some sort of normal contour. He feels that the resultant scars are more unsightly than his original complaint.

Figure 1 Case 1: hypertrophic scarring in a 22-year-old man (see text).

Case 2

A 16-year-old boy underwent an operation to correct bilateral gynaecomastia, performed by a general surgeon. The incisions were curved, passing around the inferior border of the areolae and extending on to the chest wall both medially and laterally, and the patient subsequently developed hypertrophic scarring which he feels is worse than his original problem with gynaecomastia (Figure 2).

Figure 2 Case 2: hypertrophic scarring in a 16-year-old boy (see text).

Case 3

A 17-year-old boy was referred to a general surgeon with bilateral gynaecomastia. This was treated surgically with curved incisions beneath the areolae, the left being longer and lower than the right. Again, these have become hypertrophic (Figure 3)

Figure 3 Case 3: hypertrophic scarring in a 17-year-old boy (see text).

.

Case 4

A 35-year-old man underwent an operation to correct bilateral gynaecomastia, performed by a general surgeon. This has left him with prominent hypertrophic scars and indentations beneath the areolae which have caused him stress and a great deal of embarrassment (Figure 4), and have required subsequent scar revision by a plastic surgeon.

Figure 4 Case 4: hypertrophic scarring in a 35-year-old man (see text).

Case 5

A 19-year-old man had a left subcutaneous mastectomy performed for gynaecomastia by a general surgeon. The operation was performed through an inframammary incision which has left him with hypertrophic scarring and some residual gynaecomastia (Figure 5). He has since required scar revision.

Figure 5 Case 5: hypertrophic scarring in a 19-year-old man (see text).

DISCUSSION

The five patients presented here have developed ugly, hypertrophic scars following excision of gynaecomastia when the incision was made outside the areola. All five of these patients, with group II gynaecomastia, have been left with unacceptable, hypertrophic scarring that is worse than the original condition for which they sought help. Subcutaneous mastectomy for gynaecomastia is a cosmetic operation, and should be dealt with as such. The aim of surgery is to provide a normal breast and chest contour while leaving minimal tell-tale signs of surgery. Incisions outside the areola should be avoided if possible, as should removal of the nipple, as the resultant deformity is often worse than the original condition and may result in hypertrophic scarring. The incisions should be periareolar, as described by Webster in 1946¹¹ (Figure 6), or circumareolar as described by Saad & Kay in 1984.¹⁰

Figure 6 Illustration of a periareolar incision.

A semicircular incision is made at the junction of the skin and areola (Figure 7a). A disc of breast tissue is left beneath the areola to prevent the formation of a crater and to produce a smooth natural-looking chest. The skin is undermined, leaving a layer of fat beneath (Figure 7b). The breast tissue and fatty disc are then dissected off the pectoral fascia and removed (Figure 7c). The resulting cavity is drained with suction, as haematoma formation is common, and the wound closed. It is important to leave the nipple/areola complex in the correct position and symmetrical with the opposite side, with minimal obvious scarring (Figure 7d). Liposuction can be a useful adjunct, but only if the gynaecomastia is mainly of the fatty variety. It can also be used to feather out the peripheral tissues to allow better contouring. Post-operatively, the breast should be dressed in such a fashion as to prevent ptosis developing in the undermined skin. This is done using an adhesive dressing to support the skin.

Figure 7 Webster's technique of subcutaneous mastectomy-see text for details.

The majority of surgical textbooks suggest a hemi-circum/ periareolar incision.^7,9,14-17 Others are unclear but suggest preserving the nipple,^8,18,19 but some still advocate the use of sub-mammary incisions.²⁰ However, most authors acknowledge that the operation is cosmetic and should, therefore, be performed only by surgeons with the appropriate experience.^1,21-23

We, therefore, urge that patients with this condition should be treated by surgeons with training in aesthetic surgery. Subcutaneous mastectomies through incisions that extend on to the chest wall must be avoided. Many of these patients will develop hypertrophic scarring, resulting in a far worse problem than the original condition.

ACKNOWLEDGEMENTS

Thanks to Michael Frost in The Department of Medical Photography, Addenbrooke's Hospital, Cambridge, for help with the illustrations.

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Paper accepted 9 December 1996

Correspondence: Mr Alan J Park, Registrar, Department of Plastic Surgery, City Hospital, Stoke-on-Trent, UK.

© 1998 The Royal College of Surgeons of Edinburgh, J R. Coll. Surg. Edinb., 43, April, 89-92