Surgical management of gynecomastia by four-plane tumescent subcutaneous mastectomy (TSM)

Introduction: Gynecomastia or the enlargement of breast tissue in men is one of the most common problems. Surgical management includes surgical excision or liposuction or both based on the grade. Surgical excision by Subcutaneous mastectomy(SM) is the criterion standard for the management of gynecomastia with only glandular hypertrophy without skin excess. We have evaluated the ease, safety and pitfalls of SM with tumescent technique. Aims and objectives: To describe our technique of tumescent subcutaneous mastectomy (TSM), its operative ease, post-operative analgesia, and complications. Patients and methods: The study was conducted in the department of plastic surgery of a tertiary care hospital from 2018 August to 2021 July. 53 SM without liposuction were included in the study. Operative procedure: Infiltration solution consisted of Ringer Lactate - 500ml + 2% Lignocaine (12.5ml) + 1:1000 Adrenaline (0.5ml) + 0.5% Bupivacaine (12.5ml). 200-250 ml of tumescent solution was used per side using four-plane technique (Sub glandular, glandular, supra glandular and subdermal). SM was done using a standard technique. Operative time, ease of surgery, duration of post-operative analgesia and post-operative complications were recorded on a preformed questionnaire. Results: 80% operating surgeons reported very good visualization of tissue planes and 79.2% reported dissection was very easy. 85% of the excisions were performed using 2 or less gauze pieces. Post-operative analgesia was achieved for 4-6 hours in more than 75%. Complications like seroma (7.5%), epidermal loss (3.8%), contour abnormality (1.9%) and nipple flattening (3.8%) were noted. Discussion: The effects of tumescent components like hydro-dissection, vasoconstriction and analgesia added to the benefits of this technique. The complications noted were like or less compared to standard SM. Conclusion: TSM being safe and easy, with an additional benefit of post-operative analgesia, is a worthy option in the management of gynecomastia with glandular hypertrophy without skin excess.