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Gynaecomastia Revisited


Treatment of gynaecomastia has been described by several methods. Here the author describes his own modification to achieve better cosmetic results.


Gynaecomastia is one of the commonest male cosmetic surgery that aesthetic surgeons are called upon to perform.

In medical terms it signifies benign enlargement of male breast. Obviously it is customary to differentiate true gynaecomastia (proliferation of mammary ducts and periductal tissues) from pseudo-gynaecomastia (either by deposition of fat or skin might be lax as result of weight loss after obesity).

The imbalance in growth  may be neonatal, pubertal or involutional which are physiological causes of gynaecomastia. Endogenous endocrine imbalance due to hypogonadism, adrenocortical tumours, hyperthyroidism, cromophobe adenoma and drugs and hormones.

While pseudogynaecomastia due to excess fat can be effectively treated by liposuction , and excess skin can be treated by excision, true gynaecomastia though easy to treat surgically is difficult to get contour right.

While  numerous operations have been described to correct true gynaecomastia  ranging from semicircular infra-areolar  or lateral areolar incisions  of Webster, to transnipple-transareolar incisions of Pitanguy18, to radical incision of Eade7, or superior semicircular incisions of Letterman 11,15 and Schurter, or intra-areolar Z incision  of Sinder , to  inferior semicircular intra-areolar incision of Barsky, Simon, Hoffman9  or subcutaneous mastectomy incisions of Gillard Thomas or extra-areolar incisions of Campos . Modifications have been proposed by Malbec, Kurtzahns and Iglesiaas.

The shear volume of techniques involved show that all the techniques are less than perfect. While most techniques emphasise better cosmetic appearance by placement of scars art different positions very few highlight methods of getting the contour right.

The author here proposes Davidson's30 modification to obtain an aesthetic good contour.


The amount of breast tissue to be excised is drawn out .A circumareolar incision 1 to 1.5cm width away from areolar margin is drawn parallel to areolar margin as per Davidson. Further parallel circles are drawn to mark the chamfering edges. Local anaesthesia with adrenaline injected by a spinal needle.   

 Superior pedicle is de-epithelised. Through the inferior half  dissection s carried through breast keeping significant fat on inferior flap to sub-mammary fold. Breast is lifted up in the breast augmentation plane, i.e. between breast and pectoral fascia . Excision is carried out from posterior surface  upto the margins previously marked gauging the thickness of skin and fat  by bimanual palpation. Excision is carried out until the correct thickness  is reached, i.e. thickness of chest wall fat.

After inserting drains closure is affected by 5/0 Vikryl and 6/0 Prolene.


The advantage of this method of posterior dissection is two-fold:

1. It prevents saucerisation which seems to be the commonest problem in cosmetic correction of gynaecomastia.

2. The operator can accurately gauge the thickness of chest wall (skin callipers may be used, if needed) thereby preventing  undue indentation.


This technique is a further improvement  to Davidson's technique.  For very large breasts  the areolar diameter  is brought to the standard size by a subcuticular 4/0 Maxalon.

The advantage of this technique is that since thickness of remnant breast tissue is felt by bimanual palpation (rather than guessing) chances of error are less. Moreover slight amount of unevenness on posterior breast is masked by breast tissue lying over it and is less noticeable.


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Figure 1: Circumareolar incision and de-epithelize d superior pedicle



Figure 2:  Surgical approach plane and elevation




Figure 3:  Breast Tissue removed keeping superifical layer of fat