Background: The treatment of certain types of gynecomastias employs the use of direct excision. Direct excision may be combined with liposuction but the dense tissue of some gynecomastias does not respond well to liposuction alone. Unlike liposuction, however, directly cutting out male breast tissue underneath the nipple can easily be overdone and too much can be removed. There is an experience and art form to know just what is the right amount to remove to have a good result but not enough to cause a secondary contour deformity.
Over resection of gynecomastia is often not immediately apparent and only appears when the swelling has gone down. As healing sets in, the nipple may be pulled downward with scar contracture. This results not only in nipple inversion but the nipple may be distorted with certain arm movements due to the scar bands between the nipple and the deeper tissues.
Revision of over resected gynecomastia is different than underresected gynecomastia. It illustrates that it is always easier to remove tissue than it is to add tissue. Nipple inversion from gynecomastia requires a release and tissue fill. The question is what material is best to fill in the defect.
Case: This is a 28 year-old male who previously had a nipple gynecomastia removed by direct excision through a lower nipple incision by a general surgeon. Postoperatively he developed a severe nipple and chest contour deformity on the right side that was treated by the placement of a multiple layers of Gore-tex sheeting. While this provided some contour restoration, it soon became hard and contracted. The photos here do not do justice to how hard and abnormal it felt. The nipple, while better, still had a contracture deformity to it.
The best tissue fill for many soft tissue contour problems, including gynecomastia, is a dermal-fat graft. It is soft, supple and is composed of one’s own natural fat tissue. Its only negative is that it requires a harvest site with associated temporary pain and a scar. He underwent a revision procedure consisting of an initial removal of the synthetic grafts through his old nipple incision. Then a dermal-fat graft was harvested from his lower buttock crease which matched the dimensions of the synthetic grafts removed. The dermal-fat graft was sutured to the muscle from underlying the nipple upward to the top of the defect. No drain was used. He only had to wear a chest wrap for 10 days. While there was no discomfort from the chest site, the harvest site had predictable discomfort.
He went on heal without any problems and was seen back three months later. His nipple contour was much improved and his chest felt soft without any deforming scar contractures. There was a slight hint of the graft contour externally but that will disappear as the fat graft continues to heal and settle down.
Case Highlights:
1) Over resection of gynecomastia causes a chest wall deformity consisting of nipple inversion and scar contracture.
2) Revision of a gynecomastia inverted deformity requires some form of tissue fill. This is best done with a dermal-fat graft or an allogeneic dermal graft. Synthetic materials, while having initial good results, will ultimately develop contracture and unnatural hardness.
3) Dermal-fat grafts can be harvested from most abdominal scar sites or along the lower buttock crease.
Dr. Barry Eppley
Indianapolis Indiana