Pectoral etching in early grades gynecomastia Pectoral etching in early grades gynecomastia

Background: Nowadays there is a great introduction of 3D,4D and high-definition body contouring. Applicability and evaluation of such techniques in gynecomastia surgery needs more investigation. Aim of the study: The aim of our study was to assess high definition liposculpture to get masculinized appearance of the chest for treatment of early grades gynecomastia. Patients and Methods: 30 patients with grade I&II gynecomastia were selected with age group between 18 and 50 years old with mean 24.73 ± 2.62. It was a prospective observational cohort study to assess the applicability of pectoral etching in early grades gynecomastia. The study was conducted at Al-Azhar university hospitals. Results: Age group ranged from 18 to 50 with a mean on 24.73 ± 2.62. The subjective results for all patients at 6 months assessment point. Seventeen patients scored very satisfied, nine stated satisfied, three patients not satisfied, one patient Neither satisfied nor dissatisfied. The average sternal notch to nipple length pre and six months postoperative were respectively 21.08cm and 18.6cm. Conclusion: Satisfaction for the patient and the surgeon is high in our technique. Fat survival is confirmed by MRI. Surgical Excision of glandular tissue by semicircular trans-areolar incision also adds other advantages to the maneuver as the trans-areolar incision made the scar not well defined as it become camouflaged by the color change between normal skin and the areola.


INTRODUCTION
Gynecomastia in spite of its benign nature; it may lead to severe psychological problems. 1 Traditional surgical interventions although, it defeminizes the shape of gynecomastic chest however they aren't masculinized. Moreover, the traditional techniques leave the chest flat, under projected, and depressed. 2 To date, global debulking of the chest was desired by patients to eliminate the feminine and overweight appearance. Successful contouring for gynecomastia surgery required removal of glandular component, adipose tissue and excess skin. 3 To enhance the masculine contour of male chest and get rid of gynecomastia, selective liposuction and fat grafting to the pectoralis major may be considered. 4 Aim of the present work was to assess high definition liposculpture to get masculinized appearance of the chest for treatment of early grades gynecomastia

PATIENTS AND METHODS
In this study, 30 patients with grade I, II gynecomastia were selected with age group between 18 and 50 years old with mean 24.73 ± 2.62, 30 patients were idiopathic and the 30 cases were bilateral. It was a prospective observational cohort study to assess the effectiveness of pectoral etching, 25 cases underwent surgical gland excision while 5 cases didn't need to. The study was conducted at Al-Azhar university hospitals Inclusion criteria: Age group from 18 to 50 years old with grade I&II gynecomastia Simon`s classification, patients whose weight is stable for at least 6 months, and BMI >18 & <30.
Exclusion Criteria: Age group below18 or above50 years old, patients with ongoing weight loss or post bariatric surgery patients, BMI > 30, patient with excess skin requiring surgical removal or any hindering comorbid diseases.

Disclosure:
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
Authorship: All authors have a substantial contribution to the article.

Plastic Surgery and Burn
All the patients in the study were candidates for Preoperative: Clinical assessment: Careful history taking and history of drug intake, general condition, local breast examination and genital examination, measurement of chest circumference, measuring nipple's positions from sternum to nipples length and measuring NAC distance from lateral border of pectoralis muscle.
Investigation: Routine preoperative investigations plus hormonal analysis.
Intraoperative and postoperatively: The markings were performed in an upright position. General anesthesia is administered while Patient was placed in supine position with arms abducted at 90 degrees. PECS block was used in some cases. The breast was infiltrated with Tumescent by small incision with 15 blades inside the lower area of the areola and another one along the anterior axillary line near the muscle's insertion. Incision is made in the umbilicus or the inner thigh if fat is taken from these areas followed by infiltration by tumescent solution.
Liposuction begun at the donor areas of fat in the deep and middle layer of fat, the amount of fat to be lipsuctioned is determined by how much augmentation of the muscle is needed usually 150-400 is lipsuctioned in a sterile container and left for sedimentation. Fat was prepared by decantation method which allow fat to separate into layers.
In the chest area liposuction begun from the interareolar incision by deep and superficial liposuction of lower and medial negative areas, followed by deep liposuction from the anterior axillar incision of the upper negative areas and latissimus pectoralis triangle. Liposuction is done by size 4 and 5 Mercedes or TriPort style blunt cannulas. After liposuction is done, the breast is examined for remaining glandular tissue, if present it was removed through the areola by a pull-through technique. The prepared fat is then transferred to 5 cc Luer-Lock syringe. Size 3 single port blunt cannulas is used for grafting (straight and curved cannulas). Insertion of the cannula is done from the axillary incision into the muscle which allow the cannula to run parallel to the muscle fibers. Palpation of the cannula was a must to make sure it was intramuscular or submuscular. Fat injection was done in a retrograde manner.
After injection is done closure of the incisions is done by 4-0 proline. No need for a drain. The Epifoam is cut into pieces to cover the negative areas removed at day 5. Compression garment is worn intra-operatively and for 6 weeks continuously. Postoperative lymphatic massage is a must to relieve edema. Stretch exercise for the muscle after 1 week of the surgery is a must to avoid any contracture. Heavy weightlifting not before 1 month at least. Follow up to 6 months as most patients will not attain their final contour for at least 6 months.
Statistical analysis: Data was analyzed by Microsoft office (Excel) and Statistical Package for Social Science (SPSS). Parametric data will be expressed as mean +-SD and non-parametric data will be expressed as number and percentage of the total Ethical considerations: All patients recruited in this study will give written informed consent before entering the study and the study protocol will be approved by Local Ethical Committee of Faculty of Medicine, Al-Azhar University.

RESULTS
Age group ranged from 18 to 50 with a mean on 24.73 ± 2.62 (Table 1).

Subjective evaluation:
Patient satisfaction assessment.
According to the results, the surgery was a success both in terms of aesthetics and anatomical remodeling of the pectoral muscles. At 6 months. 17 patients said they were "very satisified" with the outcome. 17 patients scored the result as "very satisfied". 9 patients as "satisfied". 3 patients as "not satisfied". 1 patient as "neither satisfied nor dissatisfied". 0 as " Somewhat dissatisfied". 0 as "very dissatisfied" ( Table 2).

Objective evaluation
Sternal notch to nipple length The average SSN to nipple length pre and six months postoperative were respectively 21.08 cm and 18.6 cm (Table 3).

Chest circumference
Mean chest circumference pre and postoperative which were respectively 108.36 cm and 98.77 cm (Table 4).

Postoperative results:
According to postoperative complications, it was found that twelve patients out of thirty patients have shown excessive skin ecchymosis that resolved within two weeks before, and five cases developed nipple retraction (16.6%). two case developed hematoma which needed aspiration. Four patients developed seroma that resolved spontaneously. No infection was detected (Table 5)..    A.mowlavi agrees with our results as regard patient satisfaction through fat grafting surgeons are able to achieve the pentagonal shape achieving a welldefined masculine chest although his mean age was 37.5 on 38 patients. 10 Regarding our study we were able to achieve masculine appearance using fat grafting. In our study 2 patients developed hematoma, 4 patients seroma and 1 patient contour irregularity. regarding patient satisfaction 23 % scored satisfied and 77% scored very satisfied

SN-Nipple length
Our overall success rate is easily explained by several factors. Liposuction combined with pectoral etching improves the esthetic outcome because of muscle augmentation and skin contraction. pectoral augmentation improves the masculine appearance of male chest known as gladiator chest.
Surgical excision by semicircular periareolar incision also adds other advantages to the maneuver, the glandular tissue is removed completely which prevents under correction present in suction-only procedures. The periareolar incision makes the scar not well defined as it becomes camouflaged by the color change between normal skin and the areola.

CONCLUSION
To achieve masculine appearance of the male chest is the ultimate goal of male breast surgery, however, patients' expectations must meet with surgeons' expectation. High-definition gynecomastia surgery brings high satisfaction to the surgeon, but patient selection is a must for this kind of surgery to maintain long term results. The patient must understand the details of the procedure and realize he has to keep up with a healthy lifestyle including sport and diet to keep these results.