The Tumescent Technique By Jeffrey A. Klein MD
The male breast is one of the four areas most requested for liposuction in men. An excessive amount of adipose tissue in the male breast, together with a normal amount of glandular breast tissue, is known as pseudogynecomastia.
Most enlarged male breasts are usually the result of excessive fat. Occasionally, however, a patient may have excessive glandular breast tissue.
Pseudogynecomastia is typically an idiopathic condition. Specific causes of gynecomastia include hypogonadism and alcoholism. Drugs associated with bilaterally enlarged male breasts include thyroid hormones, anabolic steroids, marijuana, estrogens, spironolactone, digitalis, diazepam, phenytoin, and clomiphene. Paraneoplastic syndromes that produce gynecomastia include testicular and adrenocorticosteroidsecreting tumors.
Unilateral breast enlargement in a male requires that a primary breast tumor be ruled out. Any significant asymmetry of the male breasts, especially with recent onset of asymmetric growth, should prompt the surgeon to consider a mammogram (Figure 37-1).
Tumescent liposuction of the male breast is quite successful. The goals are basic liposuction strategies: (1) remove as much fat as possible, (2) maximize the natural appearance of the result, and (3) avoid damage to the skin or subjacent muscles.
Although microcannular tumescent liposuction is satisfactory for most cases of gynecomastia, some patients may require a direct excision of the glandular breast tissue. This possibility must be discussed with patients before surgery.
Gross Anatomy of Subcutaneous Fat
Breast tissue has increased vascularity compared with the flanks, abdomen, and submental area, which are the other areas for which men frequently request liposuction. The tendency for bleeding with breast liposuction is greatly attenuated by the tumescent technique.
The proximity of the subjacent pectoralis muscle, its variable size, and its mobility make this muscle vulnerable to trauma during breast liposuction. Even a small muscle laceration can result in bleeding and a hematoma. Avoiding inadvertent penetration of pectoralis muscle during either infiltration or liposuction requires conscientious attention to the subtleties of the local anatomy. Before beginning infiltration the breast must be carefully palpated, with specific attention to locating the breast tissue–pectoralis muscle interface.
Normal male breast adipose tissue is relatively more fibrous than other areas in the male. The fibrousness of the male breast makes it one of the most challenging areas for liposuction.
In true gynecomastia, excess glandular breast tissue is present along with fat. This glandular tissue is extremely fibrous. Although liposuction of true gynecomastia using Capistrano microcannulas is usually successful, liposuction results can never be guaranteed. Prospective patients should understand that it is sometimes difficult to assess the amount of glandular tissue in a male breast before surgery.
True breast tissue in males is typically located immediately subjacent to the nipple-areolar complex. It is often distinctly more firm to palpation than the surrounding fatty tissue. A routine mammogram may facilitate a preoperative assessment of male breasts regarding the amount of fibrous glandular tissue versus adipose tissue.
Two simple maneuvers can help the surgeon distinguish between subcutaneous adipose tissue and subjacent deeper pectoralis muscle, as follows:
- With the patient supine and arms at his side, he contracts the pectoralis muscles. When the pectoralis muscle is tightened, the surgeon can appreciate the palpable interface between the soft compressible fat and the firm muscle.
- With the patient supine and ipsilateral arm raised, he places his hands behind his head. The pectoralis muscle is stretched and facilitates palpation of the softer, overlying fatty breast tissue.
The size of male pseudogynecomastia increases with both age and the degree of obesity. Obesity in early childhood is associated with pseudogynecomastia. Obesity is not an indication for liposuction. If there is a limited area where liposuction could provide some aesthetic improvement, however, liposuction should be considered. In an obese male patient, breast reduction by tumescent liposuction can provide gratifying cosmetic results.
In most males the extent of the excessive breast tissue is obvious to both patient and surgeon. With increasing obesity, fat may be augmented along the axillary chest wall. This lateral chest wall fat often blends into the breast area without a demarcation between the two areas. Technically the areas are distinct, but cosmetically it is difficult to achieve satisfactory results without treating both areas.
The surgeon must discuss and document the extent of the proposed “breast” surgery. All confusion about treatment areas must be eliminated before surgery. During the initial consultation, it is helpful to draw on the patient to define the boundaries of the proposed surgery.
At the time of surgery the contour mappings should be drawn carefully, with the innermost concentric circle designating the deepest area of subcutaneous fat. The area of deepest fat does not always coincide with the location of the nipple-areolar complex. In some males, satisfactory liposuction of the breasts may require liposuction of fat at the periphery of the breast, such as along the anterior axillary area and on the lateral chest wall (Figure 37-2).
Patient position during breast surgery is a matter of convenience for the surgeon. In one preferred position the patient is supine, with a small pillow or a folded towel placed beneath his ipsilateral scapular back. This slight elevation of the chest wall allows the arm to rest at the patient’s side and along the lateral chest wall. This posterior displacement of the arm improves the surgical access to the breast’s lateral aspect. This position also stretches the pectoralis muscle and facilitates palpation to distinguish breast fat from deeper muscle.
In another position the supine patient places his ipsilateral hand behind his head (Figure 37-3).
Routine blood pressure monitoring using a traditional cuff on the arm can be a problem when doing liposuction of the breast, lateral chest, or arms. Because of the physical location of the blood pressure cuff on the proximal arm, the cuff can be contaminated with blood-borne pathogens. Also, the cuff can interfere with surgical access to the treatment area. These problems can often be eliminated by placing a pediatric blood pressure cuff on the wrist over the radial artery.
Successful and painless liposuction of the male breast totally by local anesthesia requires the following (Figure 37-4):
- Adequate concentrations of lidocaine (1250 to 1500 mg/L) and epinephrine (1 to 1.5 mg/L)
- Careful infiltration technique
- Use of microcannulas
Both male and female breast tissue has a high degree of antitypy (resistance to penetration). Infiltration of the male breast requires special care and attention to detail. The glandular breast tissue can be so dense that infiltration requires extra effort.
Infiltration should be initiated with a 25-gauge needle, either a 5-cm (2-inch) hypodermic needle or a 25-gauge pediatric spinal needle. The 25-gauge needles cause little discomfort and provide enough local anesthesia to allow painless, more complete infiltration using a 20-gauge spinal needle. After the glandular nipple tissue has been made somewhat tumescent, a larger (20-gauge) spinal needle can be more easily passed through the otherwise dense and resistant tissue.
Multiple 2-mm to 3-mm incisions or 1.5-mm adits (punch biopsy excisions) are made in convenient areas. Some are placed along the inframammary crease and others at the periphery or within the targeted area. The incisions are not closed with sutures. I have yet to encounter a hypertrophic or keloid postoperative scar on the chest that was caused by a liposuction incision. To minimize the risk of keloid formation on the chest, the surgeon should avoid placing incisions over the xyphoid area.
Tumescence of the subareolar glandular breast tissue decreases the tissue density and the resistance to penetration by a microcannula. Thus tumescence facilitates passage of a short (5-cm) and thus relatively inflexible 16-gauge Capistrano microcannula. Having created an initial crisscross pattern of 16-gauge cannula tunnels through the adipose and glandular tissue, the surgeon can then use a larger, more efficient 14-gauge Capistrano microcannula. The 14-gauge cannula is efficient, with small incisions; a larger cannula is rarely necessary. The use of 12-gauge cannulas is unusual except in the largest breasts.
Adipose tissue in the male breast is more fibrous than in most other areas treated by liposuction. Microcannulas can penetrate the tissue with greater accuracy and less discomfort than larger cannulas. The preferred Capistrano microcannulas include 16-gauge cannulas that are 5 cm (2 inches), 7.5 cm (3 inches), and 12 cm (4.75 inches) in length; 14-gauge cannulas; and 12-gauge cannulas that are 15 cm (6 inches) in length.
Capistrano microcannulas remove fibrous fat from within dense fibrous connective tissue by gentle rasping from multiple tiny apertures with simultaneous suction. Even glandular breast tissue can be raspirated. With careful, assiduous surgical effort, this technique will remove both adipose and normal subareolar glandular tissue.
The smaller the cannula diameter, the easier it can penetrate the dense tissues. Short (5-cm) 16-gauge cannulas are ideal for initiating liposuction within the dense subareolar male breast. This requires minuscule adit incisions beyond the periphery of the areola. Adit incisions disappear quickly without scarring or dyschromia if care is taken not to traumatize the epidermis.
Excess fatty tissue in the male breast is often seen in older patients (Case Report 37-1).
Liposuction of the male breast is a well-recognized procedure, but the technique and instrumentation have not been standardized. Some surgeons use larger cannulas with an outside diameter (OD) of at least 4 mm. I prefer microcannulas having an inside diameter (ID) ranging from 1.2 mm (16 gauge), to 1.8 mm (14 gauge), to 2.2 mm (12 gauge).
Some surgeons have advocated sharp cutting cannulas to facilitate liposuction of male breast glandular tissue. Others advocate excisional male breast mammoplasty, despite the risk of scarring and disfigurement. I have found that smaller cannulas facilitate liposuction of male breast glandular tissue and permit consistently excellent results (Figure 37-5).
Prominent subareolar breast tissue can be reduced by careful tumescent liposuction using a delicate infiltration technique and short (5-cm and 7.5-cm) 16-gauge Capistrano cannulas.
Optimal postoperative recovery with minimal bruising and swelling requires open drainage (no sutures) and bimodal compression provided by a breast-torso garment and a 6-inch-wide elastic binder. This combination of devices allows adjustable compression that can be applied precisely over the entire liposuction area. Adequate compression during the first 18 to 24 hours after surgery is necessary to prevent hematomas. Most commercially available postoperative compression vests may not provide enough compression, and the degree of compression is not adjustable.
The breast-torso garment is a spandex garment with a pair of Velcro strips (hooks) sewn onto the front and extending from the shoulders to the midabdomen (Figure 37-6). This garment is not required to provide compression but has the following advantages:
- The spandex garment holds the postoperative superabsorbent pads securely in place over the treated areas.
- The garment protects the patient’s axillary area from the chafing and rubbing of the elastic binder.
- The Velcro strips prevent the elastic binder from shifting or moving out of its proper position directly over the breasts.
- The Velcro strips optimize the positioning of the rib belt so that it can deliver compression to the uppermost (proximal) portion of the breasts, well above the level of the axillary vault (Figure 37-7).
Without the Velcro strips, anterior aspect of the axilla pushes upper edge of the rib belt below the level of the axilla (Figure 37-8). The axilla tends to limit the area of the breast that can be compressed by a rib belt. Ecchymosis and swelling often result wherever adequate compression is not maintained on a liposuctioned area (Figure 37-9).
A second binder is applied on top of the garment’s initial binder and cinched more tightly. The total amount of compression should be tight but easily tolerable. Both male and female breasts seem to be more susceptible to hematomas and therefore require more firm compression during the first 12 to 24 hours than other areas treated by liposuction.
Male breasts are usually susceptible to perioperative hematomas or excessive ecchymoses. This might be explained by the vascularity of the fat and glandular tissue of the breasts. In addition, because the pectoralis muscle can be inadvertently grasped along with the fat when the surgeon grips the breast, the breast is vulnerable to injury from a misdirected thrust of the cannula.
During the first 12 to 24 hours after breast liposuction, firm compression of the breast reduces the degree of early postoperative ecchymosis.
I have seen only three postoperative liposuction-related hematomas. Two occurred in association with breast liposuction patients who had received only mild postoperative compression with an Ace bandage. The other liposuction-related hematoma occurred in an obese male who falsely denied taking aspirin the day of surgery (see Chapters 8 and 38).
Pitfalls and Special Considerations
Men should be given an explicit written estimate of the expected degree of improvement. Patients are typically advised to base their decision on the assumption that they will see no more than a 50% cosmetic improvement. In some cases, patients are told not to expect more than a 30% improvement.
Possible sources of patient dissatisfaction include insufficient amount of tissue aspirated, scarring, asymmetry, skin irregularities, and redundant skin.
Figure 37-1 A, Asymmetric male breasts of longstanding duration in young man who sought liposuction to achieve unilateral breast reduction. Mammogram revealed normal glandular breast tissue with minimal fat. Patient elected not to proceed with liposuction after being told that liposuction might not adequately reduce size of left breast (B).
Figure 37-2 Male breast contour drawings facilitate accurate liposuction despite change of breast shape from tumescent infiltration. A and B, Topographic contour drawings on male breast, extending onto anterior axillary chest area. C and D, Preoperative anterior and lateral views. E and F, Anterior and lateral views after tumescent liposuction using microcannulas.
Figure 37-3 Proper positioning of patient during surgery facilitates access to targeted fatty tissue and minimizes risk of injury to pectoralis muscles.
Figure 37-4 Male breasts after tumescent anesthetic infiltration. Right breast was infiltrated first and therefore exhibits greater vasoconstriction and blanching than left breast.
Figure 37-5 For mild to moderate pseudogynecomastia, tumescent liposuction using microcannulas provides consistently satisfying results. A and B, Preoperative anterior and lateral views of fatty breasts of muscular young man. C and D, Postliposuction anterior and lateral views.
Figure 37-6 Breast-torso garment designed to provide optimal postliposuction compression after male or female breast reduction. Anterior perspectives: A, without elastic torso binder; B, with elastic torso binder in place.
Figure 37-7 Breast-torso garment with two elastic rib belts provides maximal comfortable compression and optimal open drainage and bimodal compression. Patient can adjust compression if it feels too tight. Velcro strips (black) hold binders in place.
Figure 37-8 Without breast-torso garment, rib belt compression alone may fail to provide adequate postliposuction compression above level of axilla. Excess bruising and swelling occur in liposuctioned areas not adequately compressed.
Figure 37-9 A, Cosmetically significant male pseudogynecomastia. B, Topographic contour drawings demonstrating relative depth of subcutaneous fat. C, Postliposuction view 1 day after open drainage but with incomplete compression. Two rib belts failed to compress above axillary level, resulting in bruising and swelling where compression was inadequate. D, Postoperative view several months after microcannular tumescent liposuction.
|CASE REPORT 37-1 Elderly Male and Breast Liposuction|
|My oldest liposuction patient was an 84-year-old gentleman who, because of his large breasts, felt self-conscious and uncomfortable in front of the women at his retirement facility when he went swimming every afternoon. His case is instructive. He was first a patient in the late 1980s, when liposuction was done using a lidocaine concentration in the anesthetic solution of 500 mg/L. The procedure was only partially completed because of patient discomfort.|
|The patient returned again several years later requesting additional liposuction of his breasts. At this second liposuction the lidocaine concentration was 1000 mg/L. He tolerated the procedure without discomfort. The results of the second procedure were excellent.|
|Discussion. Sufficient lidocaine concentration is critical for complete patient comfort. A concentration that is too low produces unnecessary patient discomfort. An excessively high concentration can limit the extent of the areas that can be safely treated in one day.|