Gynecomastia Management With Local Anaethesia

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com Gynecomastia Management with Local Anesthesia Dr. Mohamed Ahmed Sayed Mostafa El-Rouby, MD * Lecturer of Plastic Surgery – Ain Shams University.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com The surgical treatment for gynecomastia has had  variations since 1538, as Paulus Aegineta discribed the first surgical treatment. Since then, various incisions on and under the breast  had been used. Before the 1980’s, “Webster technique” Subcutaneous  mastectomy was the most commonly used method. It is performed with an infra-areolar approach and if necessary extended laterally.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com It has also been thought that when gynecomastia  is severe, the excess skin should be removed along with the gland and fat.  These procedures had a relatively high complication rate due to haematomas and seromas (10 %), and the results are often disappointing for patients and surgeons (52 %), because of frequent contour irregularities, disfigured scars and reduced nipple sensibility.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com In addition, any significant medical problems,  such as heart disease, lung disease, or diabetes, must be excluded before the procedure is performed for risks of General Anesthesia.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com The introduction of liposuction in cosmetic  surgery has resulted in a new treatment modality, as non-scarring modality that can be performed under local anesthesia on an outpatient basis.  However, this technique was applied only in minor grades of gynecomastia with no glandular hypertrophy nor skin excess.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com THE PURPOSE OF THE PRESENT WORK  has been to evaluate surgical treatment of all degrees of gynecomastia performed by “Pull-Through Technique Combined With Liposuction” under Local Anesthesia.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com COPELAND AND GESCHIKTER, 1943 According to etiological and parenchymal disturbances  classify the breast enlargement to four types: Type 1 or diffused hypertrophic form: (adolescence, with  feminine characteristics for the male breast). Type 2 or fibroadenomastosa form: (nodules of either  glandular or fibrous tissue spread in the breast) Type 3 or true gynecomastia: (glandular and adipose tissue,  resembling the female breast in size and shape) Type 4 or pseudogynecomastia or adipose form: ( adipose  tissue without compromise of the glandular tissue, adult man)

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com SIMON ET AL, 1973 According to morphological deformities “i.e. the breast  volume and the skin redundancy”, classify gynecomastia into four grades: Grade 1: minor but visible breast enlargement without skin  redundancy. Grade 2A: moderate breast enlargement without skin  redundancy. Grade 2B: moderate breast enlargement with minor skin  redundancy. Grade 3: gross breast enlargement with skin redundancy (as  pendulous ♀ breast)

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com KLEIN JA, 2000 According to histopathological composition into:  True gynecomastia is the increase in size of male  breasts due to glandular tissue proliferation. Pseudogynecomastia is defined as an excessive  amount of adipose tissue in the male breast, along with a normal amount of glandular breast tissue. A mixed variety combines excessive fatty and glandular  tissue.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com Local Anesthetics and Surgical Considerations For Gynecomastia Management local anesthetic for body contouring procedures  can be summarized on three levels.  First,establish preemptive analgesia and adequate vasoconstriction at all incision sites.  Second, provide both anesthesia and vasoconstriction in all planes of dissection and manipulation.  Third, facilitate vasoconstriction to all vascular beds supplying the surgical planes of dissection.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com SURGICAL 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. The nipple and areolar complex are  always supplied by sensory nerves were seen through the depths the glandular tissue and not by superficial nerves

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com SURGICAL ANATOMY 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. This rudimentary structure becomes enlarged in  gynecomastia with prevalence of either glandular or adipose tissue regarding the etiology of the gynecomastia.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com NERVE SUPPLY OF BREAST The glandular tissue  receives its sensory innervation from: the lateral mammary  rami of the third through sixth intercostal nerves and medial mammary  rami of the second through sixth intercostal nerves Intercostobrachial nerve 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com DOMINANT VASCULAR SUPPLY THE BREAST Although there is no  dominant vascular supply to the breast (Maliniak, 1943), the main contributors are: perforators from the  internal mammary artery, the lateral thoracic  artery, and intercostal vessels 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com PATIENTS 42 cases,  41 patients were treated bilaterally, and one case  unilaterally. Mean age was 29 years (range 23–55 years).  In 85.7 % of patients (36/42) gynecomastia was  idiopathic. Past history of intake of anabolic steroids was the cause of gynecomastia in 6 patients. 39 out of 42 patients (93 %) were seeking treatment  because of cosmetic and psychological problems. Local pain was the reason in 3 patients (7 %).

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com PATIENTS SELECTION Patient’s desire for the type of anesthesia used for  gynecomastia. Medical conditions that would be at risk.  Patient comfort, particularly in the case of adolescents.  The severity of gynecomastia and the rule of the surgery  required to achieve the best results. “When the case is serious, it may be more likely to have  local anesthesia and sedation”.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com METHODOLOGY Clinical examination revealed that 81 % (34/42) of patients had  considerable fat deposition combined with glandular hypertrophy, while the remaining 19 % (8/42) had predominantly glandular hypertrophy with modest fat deposition. Preoperatively, treated areas were marked with the patient in upright  position. Local anesthesia infiltration:  At incisions sites  1% lidocaine with epinephrine (1:100,000) and 100–200  ml of ringer lactate.  + 1 cm within inframammary crease (lateral at anterior axillary line or medially at parasternal line)  + tip of axillary tail of the breast  + lower hemi-areolar incison Breast tissue infiltration  Tumescent infiltrates depending of the size of the  breast (50 cc of 1% lidocaine plus 1mg of epinephrine per liter of normal saline or Lactated Ringers solution).

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com METHODOLOGY Local anesthesia infiltration:  At incisions sites  1% lidocaine with  epinephrine (1:100,000) and 100–200 ml of ringer lactate.  + 1 cm within inframammary crease (lateral at anterior axillary line or medially at parasternal line)  + tip of axillary tail of the breast  + lower hemi-areolar incision. At main nerve trunks  Breast tissue infiltration  Tumescent  infiltrates depending of the size of the breast (50 cc of 1% lidocaine plus 1mg of epinephrine per liter of normal saline or Lactated Ringers solution).

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com TECHNIQUE Anesthesia:   Local + sedation  (Diprivan (propofol) by continuous infusion is recommended. Rate should be adjusted according to required depth of sedation 0.3 - 4.0 mg/kg/hr). Surgical Procedure:   Liposuction  Pull-ThroughTechnique + areola reduction.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com METHODOLOGY liposuction was performed with 6 mm  and 3 mm cannulas. After liposuction glandular tissue was  removed through the same incisions. We preserved approximately 1 cm of  glandular tissue under the areola in order to avoid inversion postoperatively.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com METHODOLOGY In 4 cases patients  complained of large diameter of the areolae (> 3 cm) and concentric deepithelization of areolae were done. The incisions were sutured  and covered with a tightened bandage for two weeks, and patients were advised to wear pressure vest for 3 months.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com METHODOLOGY Operative time, suction volume, postoperative average hospital  stay, pain, edema, hematoma and infection were recorded. Patients were followed up at 2 weeks, 3 months and 6 months.  At 3rd month follow-up, patients filled up the questionary where  they were asked about: experience with the operation under local anesthesia  the type of anesthesia they would prefer next time if they were in the  same situation. At 6th month follow-up they filled up questionary about:  satisfaction with the cosmetic result of the operation  compare nipple sensation of operated side with non operated or before  the operation.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com SPECIAL CONSIDERATIONS: For proper analgesia as well as vasoconstriction at the  incision sites, Authors prefer the use of 1% lidocaine + epinephrine (1:100,000) + bupivcaine (for postoperative pain management, however, its prolonged vasodilatation effect seems to outlast the effects of the epinephrine). Any rent in the fascia either sharply with scissors or with  electrocautery, or stimulation of the fascia and underlying muscle produces significant increases in postoperative pain and should be avoided.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com FACTORS THAT MUST BE MONITORED 1.the starting hematocrit of the patient, if a lidocaine-epinephrine solution is injected in the amount of 15–30 cc per 100 cm2 of the area to be treated, the hematocrit will fall approximately 1% for every 150 cc of fat aspirated. (Hetter, 1989). 2.the volume of tumescent fluid infiltrated, 3.volume of fat aspirated, (A one-to-one volume of fluid is injected equal to the amount of lipo- aspirate) 4.volume of crystalloid administered through the IV, 5.the amount of lidocaine used. (up to 35 mg/kg)

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com RESULTS The mean Operative time was 64 minutes (30 – 110 minutes).  Grade 2A (11 cases, 26%), Grade 2B (23 cases, 55%),  Grade 3 (8 cases, 19%). Treatment was able to be performed by liposuction alone  in 25 of 83 breasts (30 %) while in the remaining 58 breasts (70 %) excision of glandular tissue was done as well. One patient developed a haematoma that needed  reoperative surgery. He was treated by a combination of liposuction and gland excision. The Average Hospital stay was 3 hours (1 hour – 12 hours). 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com RESULTS Mean Liposuction volume was 265ml per breast  (100 - 750 ml). The volume of tissue removed by liposuction  correlated with the breast size and technique was easier in fatty type gynecomastia. Five patients of 42 (12 %) expressed postoperative pain  that was managed by NSAID drugs within 3 days. No infection is recorded in all cases. 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com RESULTS In 3rd month follow-up questionary;  Five patients of 42 (12 %) expressed discomfort,  Three patients (7 %) would choose general anesthesia if they  had been offered the possibility. At 6 month follow-up questionary:  95 % (40/42) of patients found the cosmetic result good or  excellent. 2 patients (5 %) had a recurrence of gynecomastia (they had  bad compliance to wear pressure garment for 3 months). There were no cases of inverted nipple or disfigured scars.  Nipple sensation was found to be normal in all patients. 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com ADVANTAGES OF THIS TECHNQUE: Safe surgery at outpatient bases  minimal scarring  good contour  flaps with adequate blood supply  nipple in the normal anatomical position with no postoperative inversion.  Nipple sensation is preserved.  Decreased opioid requirement is likely related to lesser tissue trauma. 

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com COMPLICATIONS OF EXCISIONAL MANAGEMENT THAT VANISHED IN THIS TECHNIQUE X Hematoma (most common) X Breast asymmetry X Contour deformity X Nipple or areola necrosis X Nipple or areola inversion X Infection X Sensory changes X Painful scar X Conspicuous scar X Prolonged Hospital Stay

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com DISCUSSION: Preoperative injection of local anesthetics with adrenalin  ensures compression of the tissue and vasoconstriction which substantially reduces the blood loss. The combination of liposuction with surgical excision of the  glandular tissue offers various advantages compared to surgical excision alone: liposuction causes an increase of coagulative factors in the  treated area, which plays an important role in spontaneous hemostasis and implies minimal bleeding in additional surgery. Liposuction leaves connections between skin and fascia  undisturbed. That is presumably the reason why the sensibility of the region is much less affected compared to surgical excision.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com DISCUSSION: CONTINUE: Tissue bridges seem to enhance the contractibility of the  skin postoperatively, which superfluous skin excision and nipple lift in larger gynecomastia. Suction alone is not sufficient to remove the glandular  tissue. When followed by sharp resection, it reduces the recurrence rate substantially. Liposuction before glandular tissue excision facilitates  the resection of the glandular tissue. The operation is performed through a shorter incision,  and liposuction ensures accurate contouring of the periphery. This contributes to achievement of a better cosmetic result using a minimally invasive technique.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com CONCLUSION It is our impression that liposuction combined  with excision of the gland by pull-through technique under local anesthesia on an outpatient basis was followed by higher patient satisfaction, fewer complications and better cosmesis compared to traditional surgical excision, but a final conclusion can only be achieved after conduction of a randomized trial.

Gynecomastia Management with Local Anesthesia http://www.elroubyegypt.com THANK YOU

Gynecomastia Management With Local Anaethesia

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