Gynaecomastia is a benign clinical condition that can occur in men of all ages, attributed by the proliferation of glandular tissue. Most patients are asymptomatic while symptoms ranging from mild discomfort to severe pain can present in patients with gynaecomastia. In addition to these, this condition may affect the psychological well-being of patients leading to a need for further treatment. Medical treatment of primary gynaecomastia in the form of anti-oestrogen therapy has not been proven to be effective and there is no consensus regarding the drug of choice or optimal duration of treatment. Surgical treatment is usually the standard treatment in primary gynaecomastia. There have been various techniques described in the literature with the aim of restoring a pleasant chest shape with limited scar on incision. Most of the techniques however involve the use of a peri-areolar or a Wise pattern incision, which can be obvious, especially in patients with a tendency to scar badly. The authors describe a novel approach, whereby a single-port endoscopic subcutaneous mastectomy using the three-dimensional endoscopic system with incision placed along the anterior axillary line was performed for a patient with gynaecomastia and thereby conferring excellent aesthetic outcomes.
Surgical techniques in gynaecomastia treatment have evolved over the years towards less invasive approaches such as liposuction[
Preoperative markings were performed with the patient in standing and sitting position [
Preoperative front views showing preoperative markings and right gynaecomastia. Extent of planned dissection was marked out (as shown by red markings)
Preoperative lateral views showing preoperative markings and right gynaecomastia. Extent of planned dissection was marked out (as shown by red markings)
On-table view showing the planned incision
Methylene blue gel was used to mark the extent of dissection to aid in identification during subsequent endoscopic dissection. A saline solution containing lignocaine 0.05% and epinephrine 1:1,000,000 was injected subcutaneously into the whole breast to minimise bleeding.
Following that, a 3-cm incision was made over the extra-mammary region near the anterior axillary line at the level of nipple areolar complex (NAC). A working space of 4-5 cm was created by dissecting the subcutaneous flap under direct vision to allow subsequent placement of the single port. After creation of working space, subcutaneous tunnelling/blunt dissection of the anterior skin flap with Metzenbaum scissors was performed to aid in subsequent skin flap dissection. Following that, posterior dissection of breast parenchyma off pectoralis major fascia was performed under endoscopic guidance with endoscopic vein harvester
Endoscopic view showing the dissection of breast parenchyma off pectoralis major fascia
On-table view demonstrating placement of single port and instruments before commencement of endoscopic subcutaneous mastectomy
Endoscopic dissection commenced from superficial skin flaps in all quadrants with the septa between skin flap and parenchyma dissected using laparoscopic Metzenbaum scissors [
Endoscopic view after CO2 insufflation demonstrating fibrous septa between skin flap and breast parenchyma
Skin flap dissection with fibrous septa taken down using laparoscopic curved scissors
Thicker tissue beneath nipple areolar complex preserved to avoid nipple retraction and nipple areolar complex necrosis
Blood vessel supplying nipple areolar complex can be clearly seen under three-dimensional view
Extent of peripheral dissection guided by blue dye gel
Patient was discharged the next day and drain subsequently removed on Postoperative Day 5. Following the surgery, the patient was seen a month after surgery with excellent aesthetic outcomes
One-month postoperative front views showing excellent symmetry and aesthetic outcomes
One-month postoperative lateral view showing hidden incision
One-month postoperative front and lateral views (dressed) showing excellent symmetry and aesthetic outcomes
Single-port 3D endoscopic subcutaneous mastectomy is a novel and aesthetically superior approach for the treatment of gynaecomastia if compared to conventional methods.
Conception and design of the study: Mok CW, Hing JXJ
Drafting of manuscript: Mok CW
Revision and final manuscript: Mok CW, Hing JXJ, Tan SM
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None.
All authors declared that there are no conflicts of interest.
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Written informed consent for publication was obtained as appropriate.
© The Author(s) 2019.