Dr. Mordcai Blau – Gynecomastia Surgery Blog

Anatomy Relevant to the Surgical Correction of Gynecomastia by Dr. Mordcai Blau

The blood supply to the cutaneous tissue in the anterior chest area, including the NAC (nipple-areola complex), is from the anterior perforators arising from the internal thoracic artery, and the  musculocutaneous perforators arising from pectoral branch of thoracoacromial axis.  The cutaneous tissue located laterally, to lateral cephalic of the NAC,  is supplied by the superficial thoracic artery. Lateral cephalic from the superficial thoracic artery cutaneous supply, the cutaneous tissue located on the ventral portion of the axilla continuing to the medial, proximal portion of the biceps brachii, is supplied by the anterior circumflex humeral artery.  Located inferiorly to the clavicle, on the lateral portion of the upper pectoralis area, the cutaneous tissue is supplied from the direct cutaneous branch arising from the thoracoacromial axis.

Figure 1. Anterior aspect of the anatomical territories of cutaneous blood vessels on the anterior trunk. (Adapted from) (1)

The fascia relevant to gynecomastia surgery are the superficial fascia, and the deep fascia.  The superficial fascia, consist of adipose tissue loosely attached to the skin.  Small blood vessels and nerves perforate the superficial fascia to supply the skin. (2)  The gynecomastia fibroglandular tissue is found within the superficial fascia, as is true with the female breast.  The deep fascia is a tough and fibrous membrane that allows some movement of the structures over one another. (2) The deep fascia investing the pectoralis major muscle is relatively thin, but polar, stronger and more distinct in the upper pole of the muscle. (2)

Figure 2. Anatomical diagram of the left anterior chest. (3)

The male NAC, like females, is susceptible to hypertrophic scarring as a result of the high tensile forces present. (2) The NAC is more susceptible to hypo and hyperpigmentation, onset by surgical wound, than the thin hirsute skin that covers most of the body.  This is due to the greater degree of melanization in the NAC. (4) Physical examination is performed to evaluate the breast for any dominant masses, nipple discharge, or lymphadenopathy. (2)  Patients with gynecomastia were found to have an increased incidence of testicular tumors (5), warranting examination of the testacies.  Factors influencing which operative procedure a patient will require are, skin redundancy, the amount of adipose tissue present, the amount of glandular tissue present, and the diameter of the NAC. Mild cases of gynecomastia can be corrected by intraareolar incisions (infraareolar, cresentareolar), circumareolar, endoscopic approaches, and transaxillary approaches. (6)  Moderate cases of gynecomastia can be addressed with the donut mastopexy. (2,7,8)  Extreme cases of gynecomastia can be corrected with a vertical scar mastopexy, wise pattern mastopexy, or IMF approach (9,10).  Gynecomastia operations need to be designed specifically to address the amount of skin excess, glandular breast tissue, fatty tissue, degree of breast ptosis, and the size of the NAC. (2)  Each component should be considered separately to optimize the outcome.(2) An example of a single component to consider when planning a surgical approach is the NAC size.  The diameter of the NAC will decrease after the removal of the glandular tissue, as a result of contraction, in absence of pressure from underlying tissue volume.  Excessively large NACs sometimes require a circumareolar excision, to achieve a reduction in nipple diameter. Based on Dr. Mordcai Blau’s observations, this method comes at the expense of aesthetics, as there is a greater potential for more apparent scarring.  An extensive knowledge and understanding of the anatomy relevant to gynecomastia facilitates better aesthetics in procedural outcomes.

Figure 3. A lateral, inferior infraareolar incision of the NAC. The view is parallel to the coronal plane.

Figure 4. Diagram of the NAC innervation. An infraareolar incision is labeled in black. This incision is most often appropriate for grades I and IIa, IIb (grades defined by Simon et al.). (5)

References

1. Cormack, GC and Lamberty, BGH. The Arterial Anatomy of Skin Flaps. 2nd Edition. Edinburgh : Churchill Livingstone, 1994.
2. Bahman, Guyuron, Eriksson, Elof and Persing, John A. PLASTIC SURGERY INDICATIONS AND PRACTICE. [ed.] Kevin C Chung, et al. s.l. : Elsevier Inc., 2009. Vol. I and II.
3. Gray, Henry. Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.
4. Standring, Susan. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.
5. Testicular tumours presenting as gynaecomastia. Daniels, IR and Layer, GT. 29, 2003, Eur J Surg Oncol, pp. 437-439.
6. A transaxillary incision for gynecomastia. Balch, CR. 61, 1978, Plast Reconstruct Surg, Vol. 1, pp. 13-16.
7. Concentric circle operation for massive gynecomastia to excise the redundant skin. Davidson, BA. 63, 1979, Plast Reconstruct Surg , Vol. 3, pp. 350-354.
8. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. Smoot, EC 3rd. 41, 1998, Ann Plast Surg, Vol. 4, pp. 378-383.
9. Correction of gynecomastia with an inframammary incision and subsequent scar. Beraka, GJ. 96, 1995, Plast Reconstruct Surg, Vol. 7, pp. 1753-1754.
10. Correction of extreme gynaecomastia. Wray, RC Jr, Hoopes, JE and Davis, GM. 27, 1974, Brit J Plast Surg, Vol. 1, pp. 39-41.
11. Classification and surgical correction of gynecomastia. Simon, BE, Hoffman, S and Kahn, S. 1973, Plast Reconstr Surg, Vol. 51, pp. 48-52.

Figure 5. Bilateral fibro-sclerotic glandular tissue excised through an infraareolar incision. Glands were released by sharp dissection. Visual inspection elucidates a small percent of adipose tissue present. Lipoplasty was not applied for the purpose of evening the contour of the chest periareolar-NAC area, due to the patients low percent body fat.(11)