Chest Wall Contouring for Gynecomastia


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    • Dr. David A. Gilbert's Corner
    Chest Wall Contouring for Gynecomastia

    Male patients for the treatment of breast growth [gynecomastia] often request chest wall contouring. Enlarged breasts – usually hormonally related, can afflict both teen-age boys and mature men. However, gynecomastia may also be a side effect of prescribed medications or, infrequently, a primary breast tumor. Surgical techniques are designed to reduce the breast size and contour the breast – no attempt is made to remove all of the breast tissue.

    In contrast to female breast augmentation, the goal of chest wall contouring is to distract attention from the chest’s pre-operative appearance and attendant post-operative scars. The ideal goal of successful chest wall contouring is a patient who is comfortable enough to expose himself publicly and not be restricted to exposing his chest in his doctor’s exam room.

    There are four goals in considering chest wall contouring. First, the solution to contouring is to establish what the normal male chest dimensions are. Interestingly, although men are, on average, 4 inches taller and 30 pounds heavier than women are, the supra-sternal notch-to-nipple length is the same in both sexes [Fig1]. Second, male hormones increase muscle development, fibro-fatty thickness, body hair growth, and weight gain. Third, surgical scars on the chest wall are unpredictable and therefore located judiciously. Even then, chest scars are a leap of faith. Fourth, the surgeon must have a selection of surgical options to address the wide range gynecomastia presentations. As surgeons, we have very little control over the first three factors. However, we do have some control over the surgical technique and location of the incision sites.

    For the past 10 years, I have employed three different surgical options for chest wall contouring based on pre-operative size, shape, asymmetry and underlying muscle development.

    For small chest wall gynecomastia, elderly patients, and men with overriding comorbid problems [diabetes, bleeding problems, high blood pressure, liver problems], liposuction alone is often effective.



    Fig. 1

    However, liposuction is ineffective in removing breast tissue per se, which is “liposuction unfriendly”. Therefore, I plan open surgery with all liposuction cases.

    Chest wall contouring in the medium-sized breast is usually best managed by a concentric mastopexy [nipple “lift”] and “purse-string” closure with liposuction. Following initial de-epithialization and liposuction, direct surgical excision removes peripheral breast and fibro-fatty tissue and obliterates the infra-mammary fold [the female fold] while preserving the nipple complex on a central pedicle. The mobilization of skin and subcutaneous tissue allows contouring of the chest wall, obliterating of the infra-mammary fold, and reestablishment of the nipple position. Surgical excision focuses on the lateral and inferior quadrants to define the pectoral muscle. The circum-nipple incision provides access to the lateral and inferior quadrant dissection that is necessary to release the infra-mammary fold. A “purse-string” suture closes the incision around the nipple to minimize a crenulated appearance at the skin-nipple interface. This is an example of a concentric mastopexy and liposuction to masculinize the chest wall. {Figure 2., 3., 4., 5., Case 1 and Case 2.]


    Fig. 2
    Fig. 3

    Fig. 4
    Fig. 5

     

    Case 1

     

    Case 2

     

    Large ptotic and asymmetric chests are more difficult to contour due to the laxity of the skin following chest/breast tissue excision. For these contours, the procedure of choice is a composite resection and free nipple grafting. This procedure adequately reduces the chest wall size and contours the chest wall but carries the potential for chest wall scars and the vagaries of free nipple grafting. [Figure 6., Case 3.]


    Figure 6
    Case 3

    In conclusion, the goal of predicable chest wall contouring remains challenging but increasingly achievable. Only by utilizing scientific methods and understanding chest wall aesthetics will we advance this important surgery.

    David A. Gilbert, Md