Gynecomastia may be treated surgically by direct excision (removal) of breast tissue, liposuction, and in some cases by removal of breast skin, when indicated. The majority of patients have at least some degree of glandular tissue proliferation immediately behind the nipple and areola, which is usually removed through an incision placed at the inferior border of the areola. The incision can be limited, in many cases, from about the 4 o'clock to the 8 o'clock position of the areola. The color difference between areolar skin and chest skin serves to conceal this incision nicely for most patients.
Some patients have proliferation of primarily fatty breast tissue over the pectoralis major muscle, which can be effectively reduced by liposuction. In many of these cases there is actually little glandular breast tissue present, and this situation is sometimes referred to as "pseudogynecomastia". For the majority of liposuction procedures, whether involving the chest/breast area or other sites, I perform power-assisted liposuction. The surgical device involves an electrically-driven handpiece that pistons a modified liposuction cannula several thousand times per minute, enhancing the efficiency of fat removal. I have recently started using Vaser Liposelection for gynecomastia patients and I am very pleased with the results. The Vaser helps to tighten skin and in some cases eliminate the need for skin excision, minimizing scarring significantly.
The power-assist handpiece turns an 'elbow grease' operation into a sculpting and finesse operation. For patients with densely fibrous breast tissue, and for planned 'second stage' liposuction procedures for gynecomastia, I generally prefer to use an ultrasonic liposuction device. Ultrasonic liposuction uses heat energy to emulsify (liquefy) fat, allowing removal of fatty tissue that may not be extractable by suction alone, and is also highly effective in assisting the passage of the cannula through densely fibrous areas.
