liposuction of gynecomastia

1. )‫ل‬ ‫سبحانك‬ ‫قالوا‬)‫ل‬ ‫سبحانك‬ ‫قالوا‬
‫ما‬ ‫إل‬ ‫لنا‬ ‫علم‬‫ما‬ ‫إل‬ ‫لنا‬ ‫علم‬
‫أنت‬ ‫إنك‬ ‫علمتنا‬‫أنت‬ ‫إنك‬ ‫علمتنا‬
(‫الحكيم‬ ‫العليم‬(‫الحكيم‬ ‫العليم‬

2. M.B.B.Ch., Faculty of Medicine,M.B.B.Ch., Faculty of Medicine,
Resident of Plastic Surgery in Mansoura General HospitalResident of Plastic Surgery in Mansoura General Hospital
ByBy

3. Prof. Dr.
Mohamed Mohamed Salah
Awad
Prof of Plastic Surgery
Faculty of Medicine
Zagazig University
Prof. Dr.
Adel Mohamed Said Tolba
Assistant Prof of Plastic Surgery
Faculty of Medicine
Zagazig University
Prof. Dr.
Mohmmed Ali Nasr
Prof of Plastic Surgery
Faculty of Medicine
Zagazig University

4. Prof. Dr.
Mohamed Mohamed Salah
Awad
Prof of Plastic Surgery
Faculty of Medicine
Zagazig University
Prof. Dr.
Mamdouh Mahmoud
Badawy
Prof of plastic surgery
Prof. Dr.
Mohamed Hassan Abd El
Aal
Prof of Plastic Surgery
Faculty of Medicine
Zagazig University

6. IntroductionIntroduction
Gynacomastia is a benign enlargement of the
male breast occurs at all ages.
Gynacomastia has several classifications.
Classified according to the nature of the content in
two types :
1- True Gynacomastia ( glandular )is proliferation
of ducts and peri-ductal tissues caused by some
form of endocrine imbalance : increased estrogen,
decreased androgen, receptor defects, or an
change sensitivity of the breast to estrogen
2- Pseudo-gynecomastia (fatty ) is due to
deposition of adipose tissue with the presence of
an excessive amount of skin

7. IntroductionIntroduction
Gynecomastia classified according to the
size of breast and degree of skin redundancy,
Simon classification is commonly used, which
Grade [1]; is minor visible enlargement
without skin redundancy.
Grade [2A]; is moderate breast enlargement
without skin redundancy.
Grade [2B]; is moderate breast enlargement
with minor skin redundancy .
Grade [3]; is gross breast enlargement with
redundancy that a pendulous female breast

8. IntroductionIntroduction
Morphological Classification depend onMorphological Classification depend on NAC&IFNAC&IF

9. IntroductionIntroduction
A Grad I Grad II A Grad II BA Grad I Grad II A Grad II B

10. IntroductionIntroduction
Grad IIIGrad III

11. IntroductionIntroduction
The causes of Gynacomastia may be physiological,
pathological, pharmacological and Idiopathic.
The complaints are embarrassment concern about
outward appearance (body image). With physical
symptoms as breast enlargement, asymmetry, nipple
discharge, pain, and tenderness.
The treatment may be
Medical aims to block estrogen effects in the breast tissue
or give androgens to counteract the effects of estrogens.
Surgical aims to restore the normal male chest contours
by many surgical techniques as liposuction ,subcutaneous
mastectomy and breast reduction.

12. IntroductionIntroduction
Liposuction of Gynacomastia .
The first surgical procedures used to treat
Gynacomastia were excisional in nature. Temourian
and Perlman 1982 introduced the liposuction
technique as a tool in the treatment of Gynacomastia .

13. IntroductionIntroduction
GynacomastiaGynacomastia Mechanism ofMechanism of
liposuctionliposuction
Superficial liposuctionSuperficial liposuction :: ByBy, 3mm cannula., 3mm cannula. ActionAction,,
dissection of breast parenchyma from the skin sodissection of breast parenchyma from the skin so
promote skin contraction.promote skin contraction.
Deep liposuctionDeep liposuction:: ByBy 4mm cannula.4mm cannula. ActionAction,,
dissection of glandular tissue from pectoral fascia .dissection of glandular tissue from pectoral fascia .
Injected tumescentInjected tumescent: has roles: has roles
1) Dissecting effect by volume of the saline1) Dissecting effect by volume of the saline
2) Hemostatic effect by adrenalin.2) Hemostatic effect by adrenalin.
3)Analgasic effect by zylocain.3)Analgasic effect by zylocain.
4)Lipolytece effect help the dissolving fat cell4)Lipolytece effect help the dissolving fat cell

14. IntroductionIntroduction
Tumescent liposuction
Technique for liposuction solution in which a large
volume of the fluid ( 3-4 ml of estimated milliliter of
expected aspirate) is injected in to the breast fat raising
the breast area to become turgid and firm.
The advantages:
The blood loss is approximately 1% of the aspirated
volume.
Provides local anesthesia to large volumes of
subcutaneous fat and thus permits liposuction totally
by local anesthesia..

15. IntroductionIntroduction
Techniques of liposuction can be used inTechniques of liposuction can be used in
management of gynecomastiamanagement of gynecomastia
Suction Assisted Liposuction (SAL).Suction Assisted Liposuction (SAL).
Ultra sound Assisted liposuction (UAL)Ultra sound Assisted liposuction (UAL)
Power Assisted Liposuction (PAL)Power Assisted Liposuction (PAL)
Laser Assisted liposuction (LAL)Laser Assisted liposuction (LAL)
Radiofrequency-assisted liposuction (RFAL)Radiofrequency-assisted liposuction (RFAL)

16. IntroductionIntroduction
Suction Assisted liposuction
Done by infiltration the tumescent and a suction
cannula was inserted through the same incision,
electrical suction connects with suction cannula.
Advantage :effective in young patients with soft
breast tissue enlargement. leads to acceptable
degree of satisfaction.
Disadvantage : not all types of gynecomastia can
be treated with conventional liposuction. The most
common complication is a residual lump. it is not
associated with a significant disadvantage .

17. IntroductionIntroduction
Ultra sound Assisted liposuction
Ultrasonic energy is generated from electrical energy
through a piezoelectric crystal. Applied to adipose
tissue, this energy creates a cavitation phenomenon
that causes the cellular destruction of the adipocytes.
Advantages :
No early postoperative complications. less traumatic.
Effective in all grades .
Facilitate the removal of dense fibrotic parenchymal
tissue, Allowing for skin retraction, and less physical
effort is needed
DisadvantagesDisadvantages :: Need prolonged operative timeNeed prolonged operative time

18. IntroductionIntroduction
PowerPower Assisted liposuction
Removal of breast tissue by using vibrating micro-
cannulas travel between 2000 and 4000 cycles/min .
Advantages :
The ductal and stromal tissue can be removed using
tumescent PAL (not limited to the removal of fat only
but applied to remove enlarged glands in
Gynacomastia )
Decrease surgeons physical effort a ‘‘no sweat’’
technique.
Disadvantages: still provides the feel of manual
liposuction

19. IntroductionIntroduction
LaserLaser Assisted liposuction
Laser energy delivered through a small cannula that
aids in the coagulate thermal destruction of adipose
and glandular tissue and stimulates collagen
contraction.
Advantages:
Hemostatic effect for vessel coagulation. Photo-
thermal disruption of fat cell. Stimulating skin
tightening through thermal collagen contraction
Disadvantages : Much heat to the surrounding
tissues cause swelling, bruising, burns and
numbness

20. IntroductionIntroduction
Radio-frequencyRadio-frequency Assisted liposuction
The delivery of a controlled amount of RF energy
through breast tissue resulting in fat liquefaction,
sub-dermal contraction and hemostasis.
Advantages: Strong coagulation, liquefaction and
aspiration of glandular tissue, Strong soft tissue
contraction
Disadvantages: Higher lidocaine concentrations are
required for effective analgesia when performing this
procedure due to the delivery of higher energy by the
device to the tissues

21. IntroductionIntroduction
Classification of The Role of liposuction in
idiopathic Gynecomastia
Liposuction alone: indicated in Psudo-gynecomastia
GI,II.
Liposuction combined with surgical approaches
indicated in :
A- True (glandular in nature) &Mixed GI, II gynecomastia .
By Liposuction with surgical excision of the residual glandular
tissue.
B- Grad III gynecomastia . By liposuction with Surgical
resection of excess skin (Breast reduction).

22. IntroductionIntroduction
Examples for Surgical excision&Examples for Surgical excision&
Resection approachesResection approaches
For glandular excisionFor glandular excision :Pre areola ,hemi:Pre areola ,hemi
circular ,pre dermal incision . pull throughcircular ,pre dermal incision . pull through
tech, Arthroscopic shaver technique.tech, Arthroscopic shaver technique.
for skin excess resectionfor skin excess resection::
( Banally tech): complete circume areola( Banally tech): complete circume areola
decortications +purse string suture .decortications +purse string suture .
keyhole design .Free areola and nipple graftkeyhole design .Free areola and nipple graft
Inferior pedicel reduction mammoplasty .Inferior pedicel reduction mammoplasty .

23. IntroductionIntroduction
Complication of liposuction Gynacomastia
No early sever post liposuction complication.
Show minor and short-term complications that
resolve on their own or with little additional treatment
include small hematomas, seromas, minor contour
irregularities, hyperesthesia, parenthesis, edema,
ecchymosis, bruising and infection all usually
resolve quickly.
Anesthetic complications of general and regional
anesthesia as lidocain toxicity.
Allergic reactions to the components of tumescent

25. Aim of the WorkAim of the Work
- This descriptive study is designed to evaluate
the role of liposuction in management of
idiopathic Gynacomastia by the assessments of:
The frequency of the complication of liposuction in
management of Gynacomastia.
The efficacy of liposuction in giving cosmetically
result in management of gynecomastia .

27. The present studyThe present study is Non experimental
(observational ) :Descriptive Study done in plastic surgery
Unit in General Surgery Department Of Zagazig University
.
According to CI , the total number of the cases with
inclusion Criteria are (18 ) patients with idiopathic
Gynacomastia were operated upon as sample size in our
study in the period between January 2015 & July 2015.
Our patients classified in to two groups according to
Simons classification: according to breast size and skin
excess.
Group I : Patient with Simon grade I .
Group II : Patient with Simon grade II (IIA---IIB ) .
Patients and MethodsPatients and Methods

28. Inclusion criteriaInclusion criteria :
1- Idiopathic Gynacomastia .
2- The age rang in between (15 -40) years.
3- Developed by the age or Wight gain.
4- Developed by failure of medical treatment.
Exclusion criteria:
1-Chronic pulmonary, liver, renal diseases .
2-Drug administrated, Neoplasm, Hormonal
imbalance,physiological, pharmacological,
metabolic causes
Patients and MethodsPatients and Methods

29. Exclusion criteriaExclusion criteria
Patients excluded from this study were patients withPatients excluded from this study were patients with
hepatocellular carcinoma, liver transplant patients ,hepatocellular carcinoma, liver transplant patients ,
kidney transplant patients and history of other renalkidney transplant patients and history of other renal
troubles.troubles.
Patients and MethodsPatients and Methods

30. A) History takng
All subjects in the study will be subjected to:All subjects in the study will be subjected to:
Patients and MethodsPatients and Methods

32. ResultsResults
show demographic distribution of patients in threeshow demographic distribution of patients in three
groupsgroups
Pt
Group3
(n=10)
Group2
(n=10)
Group1
(n=20)
5614M
0.50.44
546F
Sex
0.7790.28356.5056.3056.45Age

33. ResultsResults
shows ANOVA study of patient lab distributedshows ANOVA study of patient lab distributed
between three main groupsbetween three main groups

34. ResultsResults
distibution of copeptin and creatinine between threedistibution of copeptin and creatinine between three
main groupsmain groups
PFGroup 3Group 2Group 1
0.000*87.5822.3±0.313.6±0.997.3±1.11
Copeptin
mean (±SD)
0.000*41.0071.03±0.311.11±0.302.13±0.65
Creatinine
mean (±SD)

35. ResultsResults
show post Hoc test to determine the difference in the three main groupsshow post Hoc test to determine the difference in the three main groups
according to different parameters of significant differenceaccording to different parameters of significant difference

36. ResultsResults
box plot of copeptin level distributed between threebox plot of copeptin level distributed between three
main groupsmain groups

37. ResultsResults
Roc curve of copeptin level between group 1&3Roc curve of copeptin level between group 1&3

38. ResultsResults
The ethetic outcome rate:

39. ResultsResults
shows Roc curve of copeptin between group 1&2shows Roc curve of copeptin between group 1&2

40. ResultsResults
there is a positive correlation
between the esthetic outcome rates and
patient satisfaction in general
Ethetic_outcome_Overall_satisfied
40.0038.0036.0034.00
Satisf_Total
10.00
9.80
9.60
9.40
9.20
9.00

41. ResultsResults
correlation between serum copeptin and other parameter in patients withcorrelation between serum copeptin and other parameter in patients with
hepatorenal syndromehepatorenal syndrome

42. ResultsResults
distribution of study subjects as regard Child-Pughdistribution of study subjects as regard Child-Pugh
classification in group 2&3classification in group 2&3
pChild c (n)Child b (n)
119Group 1
64Group 2 0.794
17(57.7%)13(43.3%)Total (%)

44. ConclusionConclusion
 Full clinical examination was done . LaboratoryFull clinical examination was done . Laboratory
investigations: They were done according to theinvestigations: They were done according to the
methods applied in the clinical pathology andmethods applied in the clinical pathology and
laboratories of Zagazig University hospitals andlaboratories of Zagazig University hospitals and
included: complete blood picture, liver functionincluded: complete blood picture, liver function
tests, kidney function tests, coagulation profile (PT,tests, kidney function tests, coagulation profile (PT,
PTT, and INR) and ABG.PTT, and INR) and ABG.

45. ConclusionConclusion
 Specific investigations include serum copeptinSpecific investigations include serum copeptin
level and complete urine analysis. Radiologicallevel and complete urine analysis. Radiological
investigation: pelvi- abdominal ultrasound withinvestigation: pelvi- abdominal ultrasound with
special comment on both kidneys.special comment on both kidneys.

46. ConclusionConclusion

47. ConclusionConclusion
The results showed that:The results showed that:
 Copeptin is significant high in patient withCopeptin is significant high in patient with
hepatorenal syndrome than neither cirrhotic norhepatorenal syndrome than neither cirrhotic nor
healthy individualhealthy individual
 Copeptin is correlated with declining renalCopeptin is correlated with declining renal
function in hepatorenal syndromefunction in hepatorenal syndrome

49. RecommendationsRecommendations
Early detection of hepatorenal syndromeEarly detection of hepatorenal syndrome
help in preventing bad outcome of such case.help in preventing bad outcome of such case.
Further studies will be needed to determineFurther studies will be needed to determine
ability of use copeptin as biomarker of renalability of use copeptin as biomarker of renal
failure in hepatorenal syndrome.failure in hepatorenal syndrome.

50. Graphic@ShowGraphic@Show