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Tumescent Liposuction in Gynaecomastia. Dr Venkataram Mysore-Dr Jayashree Venkataram Venkat Charmalaya-centre for advanced dermatology Bangalore www.bangaloreliposuction.com www.bangalorehairtransplant.com. Male breasts ( Gynaecomastia).
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Tumescent Liposuctionin Gynaecomastia Dr Venkataram Mysore-Dr Jayashree Venkataram Venkat Charmalaya-centre for advanced dermatology Bangalore www.bangaloreliposuction.com www.bangalorehairtransplant.com
Male breasts ( Gynaecomastia) Gynaecomastia is a common condition causing psychological disturbance and social embarrassment
Causes • Puberty • Steroid abuse • Obesity • Tumours • Genetic disorders • Chronic liver disease • Side effects of many medications • Castration • Klinefelter Syndrome • Gilbert's Syndrome • Aging
Causes • In most cases, underlying cause cannot be found • Tamoxifen, Danazol has been found to be useful for oestrogen sensitive gynaecomastia • However, treatment of the condition is usually by surgery
Surgery • Liposuction, surgical resection are suggested as the surgical techniques
Is liposuction alone adequate? • Studies have suggested that liposuction or suction lipectomy alone is an excellent treatment
Gynaecomastia-Situation in India • In Indian culture, dress code for men demands that, during religious occasions, visit to temples, marriages, breast area is exposed • Limitation of outdoor activities such as swimming, while playing sports, Gymnasium • Limitation in wearing tight shirts • Source of embarrassment for students in hostels with common baths
Indications in Indian patients Our Experience • There are very few centres in India performing tumescent liposuction alone. • 655 liposuction surgeries from 2004-2013 • MALE vs FEMALE: 333:322 WOMEN were more than MEN; marginally
Different Areas In Men • BREAST • ABDOMEN • Flanks • Thighs • Buttocks • Arms • CHIN MALE breast was the most common indication
Simplified classification of Gynaecomastia • Mild( with prominence of central part of breast and nipple areas only) • Moderate( prominence of entire breast region without skin hanging) • Severe( prominences of entire breast area with hanging resembling female breast).
Mild • Moderate • Severe
Male breasts our data • Most patients were in the age group of 15-30 years. • Four patients below 20 years • Youngest was 15 years in age (was counseled with parents ) • Oldest patient was 60 years-
Pre-operative instructions • Routine blood investigations such as blood counts , Coagulation profile, LFT, Blood sugar, HbS Ag, HIV - and ECG, Ultrasound in moderate & severe male breasts • Advice to stop smoking • Avoidance of oral NSAIDs • Preoperative tranquillizer such as diazepam or lorazepam on the night before surgery • Injection Vitamin K to minimize postoperative bruising
Preoperative Ultrasound of Breast • Preoperative evaluation by ultrasound was performed in all the moderate and severe cases of gynaecomastia • Most cases had an admixture of fat and glandular tissue • Severe cases had predominant glandular tissue
Preparation of patient • a) Preoperative antibiotic such as cephalexin • b) Preoperative tranquillizer such as oral lorazepam 1 mg • c) Oral Clonidine 0.1 mg to prevent epinephrine induced tachycardia and as an adjuvant anxiolytic drug.
Preparation of patient • Surgical cleaning of the area with povidone iodine • The area for liposuction is topographically marked, with marker ink of different colours to delineate the bulges and asymmetry
Adits • NUMBER : 1-2 on each side • SIZE : 2 to-2.5mm • PLACEMENT : We avoid upper medial quadrant in breast as this area is seen when shirt is not buttoned as it is more prone for Keloid
Suction apparatus of 1HP power
Instruments -microcannulae • Infiltration microcannulae have diameter of 0.5-1 mm • Aspiration microcannulas have an outside diameter upto 2.8 mm. • Cause less bleeding as they are small and hence safer
Powered liposuction • We use power Assisted Liposuction-Microair, Euromi machines are available • No thermal component • We have found that it reduces surgeons strain and fatigue • Cuts short Surgery time
Laser Lipolysis • We use Ndyag laser for lipolysis for additional benefit. • Laser can access difficult areas • Laser also helps reduce fat and induce tightening of skin to prevent hanging
Aspiration • Amount of fat aspirated was between 1 - 4 liters , with an average of 2.5 liters • Duration of surgery was between 2 -4 hours
Severe gynaecomastia-use of extraction • In patients with severe gynaecomastia, an additional larger adit of 6 mms was placed, just adjacent to areola and the fibrofattyglandular tissue was extracted and excised. • This greatly reduced the subareloar lump
Severe gynaecomastia-result after liposuction and extraction
Severe gynaecomastia-result after liposuction and extraction
Postoperative Dressing and follow up • No suturing of adits in most cases • In severe cases, which need manual extraction, we put an infraareolar incision which is sutured • This facilitates drainage of fluid • Tight pressure bandages are essential to ensure proper drainage of the tumescent fluid. • Pt goes home the same day
Postoperative Drugs • ANTIBIOTIc • PARACETAMOL • PROXYVON
Followup • Patient is advised to come for follow up for dressing daily for two days. • More than 50% of results will be seen on day 2 • Further improvements happen gradually due to breakdown and absorption of fat • Final result is seen after 4-6 weeks
Does it have any complications? • All patients had uneventful recovery with out any serious side effects. • Post operative pain and tenderness were mild in all patients. • Adit sites healed well in all patients
Sagging of skin • No sagging was seen except in patients • Even in severe cases, there was no obvious hanging and the resultwas mild and was acceptable to patients.
Conclusions • Tumescent liposuction is a very safe and effective surgery for gynaecomastia • Thorough tumescence and use of microcannulae are important for safety • Most cases can be treated effectively, without the need for more aggressive and expensive surgery • Severe Gynaecomastia needs additional extraction through a juxtaareolaradit • Skin hanging is not a significant problem except in the severe cases
Our Doctors- experienced team • Dr venkataram MD DNB DipRCPAth(Lond)- Consultant Dermatosurgeon. Past President of Assn of Cutaneus Surgeons India • Dr Jayashree Venkataram MRCOG Liposuction Surgoen trained with Dr Jeffrey Klein