Patients
Between January 1st 2002 and October 31st 2021,a total of 2035 breasts of 1082 male patientswith gynecomastia, of which 129 patients withoneside, were underwent mastopscopic subcutaneous mastectomy. Informed consent was obtained from the participating patients. The protocol was approved by the institutional review board committees of all institutions in compliance with the Declaration of Helsinki and guidelines for good clinical practice. The patients’ age ranged from 17-79 years, average of d 37.6± 10.2 years. The disease history was from 2 - 34 years, average of7.8± 4.1 years. Preoperative physical examinationand color-ultrasound both indicatedthe glandular hyperplasia. The inclusioncriteria were: (1) Simon IIB level and above; (2) lastingat least 24 months; (3) affecting physical and mental health; (4)strongly demanding the surgery.The study was approved by the institutional ethics of researchcommittee and written consent was obtained from each patient.
Surgical Procedure
The liposuction range was marked in the standing position beforesurgery(Figures 1). Under general anesthesia, the patient was placed in the supine position with the ipsilateral arm abducted to 90°. The patient's forearm was hung to the head frame of the bed to the level of the nose head. Excessive lifting will tighten the chest skin and affect the operative space(Figures 2). A monitor was placed on the contralateral side of the upper side of the patient's head. For example, while operating the breast on the left side, the surgeon will watch the monitor in front of the patient's head on the upper right.
Alipolysis liquid (saline 200 ml, distilled water 200 ml, lidocaine 400 mg, adrenaline 0.5 mg) was prepared for each breast injection(Figures 3), according to the method reported previously.10–14
Injection of lipolysis liquid: (1)50ml syringe is easy to be used. (2) The Long needle is convenient for injecting the liquid to the distant place of the breast. (3) The injection sequence was important. The breast rear (the front of the pectoralis major fascia) should be injected first so that the injection needle can be placed easily into the breast rear by grasping the breast. If the liquid is injected first into the front of the breast (subcutaneous tissue), the whole breast will become full. Then the breast can't be easily grasped, which increases the difficulty of injectingthe lipolysis liquid into the breast rear. Subsequently, the breast is grasped from the outside. The liquid is injected successively into the outside, the front, the head side, the tail side, and finally, the inside of the breast.
Liposuction: (1) Liposuction started 10 minutes after the injection of lipolysis liquid. (2) Suction incision was made below the axilla, at the junction of the mid-axillary line and the upper margin of the breast. This incision was also the trocar hole for the mastoscopy subsequently. (3) Suction hole was first cut to7~8mm long. During sucking, this hole will be distended a little. If a 1cm incision is made at the beginning, the repeated sucking action will expand the hole. The gas will release around the loose 10mm trocar for mastoscopy, which affects the mastoscopy operation. (4) The No. 8 suction head used for artificial abortion was convenient. It is economical, affordable, durable, and, more importantly, fast. (5) Suction range should cover all the previously marked regions of the breast and the deep part of the breast. (6) When sucking behind the breast, it is advisable to grab the breast. The suction head cannot be inserted too deep to avoid entering the pectoralis major muscle. (7) After the suction is estimated to end, the liposuction effect should be checked by sweeping or slightly swinging the suction head from side to side, especially in the rear of the breast, to confirm that the suction has been perfect.
Trocar location: The liposuction hole is a camera hole. The twooperating holes are respectively located at the junction of the nipple with the mid-axillary line and the lower border of the breast with the mid-axillary line. Scissors and forceps are placed into each other, which can exchange at any time according to operative needs.
Air cavity pressure control: Steady gas pressure in axillary space is essential in assuring the operation smoothly. Excessively high gas pressure may increase the possibility of postoperative subcutaneous emphysema and affect the large blood vessels in the upper part ofthe thoracic cage. On the other hand, a lack of sufficient gas pressure could result in contraction or expansion of the operative space as the patient breathes, making the procedure more difficult. 8~9mmHg gas pressure is generally suitable.
"Nine-step method" of operation process: The mastoscopic scar-hidden surgery for gynecomastia was turned into a process by us. The overall operation follows a "spatial sequence" of "from outside to inside" and "three-dimensional outflanking." (1) thelateral side of the breast gland.(2)the front part of the gland, namely Cooper's ligament. (3) theouter-upper part. (4) the rear. (5) theinner-upper. (6) theouter-lower.(7) the inner-lower. (8) beneath the nipple. (9) themedial. At this point, thebreast gland has been entirely dissociated. The breast gland was taken out from the 10mm trocar hole under the axilla.
Managing the bleeding: After the glands were taken out, the 10mm trocar was reinserted and inflated. The bleeding should be completely managed under the endoscopy. At last, the wound was washedwith saline.
Flattening the front chest wall: The relative collapse in the central part and the slight uplift in the outer periphery of the breast will appear after the taken-out of the breast gland. It is necessary to perform sucking in the outer periphery of the breast, which makes the front chest wall more smooth-going and avoids the "volcanic crater" phenomenon. The aesthetic appearance enhances further.
Observation of symmetry: The bilateral front chest should be compared. If necessary, the protruding area can be equated by additional lipolysis.
Flattening breast skin: For those with large breasts and more skin, the skin should be distributed evenly on the chest to avoid skin folding.
Drainage and bandaging: High negative pressure drainage was placed from the 10mm trocar hole, and the trocar incision was sutured intracutaneously with 4-0 absorbable thread. Lastly, the chest and axilla were bandaged.