Redefining Revision After Gynaecomastia Surgery

Background: Gynaecomastia ranges from localised fibroglandular enlargement to marked ptotic hypertrophy. Surgical management may involve liposuction, glandular excision, combined excision and liposuction, energy-assisted skin tightening, periareolar mastopexy, or reduction mammaplasty with pedicled NAC transposition or free NAC grafting. We combined a random-effects meta-analysis with findings from our own consecutive 300-patient single-practice cohort to examine stratified complication and reoperation risk according to grade, operative complexity, and the use of adjunctive procedures. Methods: We conducted a two-part study: a random-effects re-analysis of aggregate data from the largest published systematic review of complications after gynaecomastia surgery, comprising 7,294 patients, and a retrospective cohort study of 300 consecutive patients treated in our unit between 1 January and 30 June 2025. Each of the 17 published technique strata served as the unit of analysis. Using random-effects pooling, subgroup analysis, meta-regression and prediction intervals, we generated reference estimates overall and strati- fied by surgical technique, adjunctive procedure, indirectly assigned Simon grade and operative complexity. Because only aggregate data were available, within-stratum heterogeneity could not be estimated, risk of bias could not be assessed, and individual case mix could not be evaluated or adjusted for. The pooled estimates therefore served as reference benchmarks rather than as direct measures of the com- parative effectiveness of surgical modalities. Outcomes in the 300-patient cohort were assessed over a 365-day observation period and compared with pooled and technique-standardised estimates. Subsequent procedures were classified as elective refinement, residual- tissue re-excision, unplanned reoperation, or true glandular recurrence. Results: The pooled complication rate was 14.44% (95% CI 9.04–20.73) with a 95% prediction interval of 0.11–44.88%. The wide pre- diction interval reflects extreme between-study heterogeneity (I2 = 96.9%), likely arising from differences in severity, surgical technique, adjunctive procedures, follow-up period, and outcome and/or revision definitions. Grade was inferred from technique, since no study reported outcomes by Simon grade. Complication rates differed significantly across grades (p < 0.001): 14.85% for Grade I–IIa, 10.24% for Grade IIa–IIb, and 32.64% for Grade IIb–III. The excess risk in the highest-grade group likely reflects the greater use of skin- excisional procedures rather than grade alone. Risk likewise did not increase with operative complexity. Interestingly, glandular excision alone had a 2.61-fold higher complication rate than excision with adjunctive liposuction, whereas energy-assisted tightening could not be pooled independently. In the 300-patient cohort, 11 patients had complications (3.67%) and the technique-standardised complication ratio was 0.30, although the rate remained within the prediction interval. Of 36 subsequent procedures, 32 were elective refinements, 3 residual-tissue re-excisions, and 1 an unplanned return to theatre; no true glandular recurrence was documented. Clinically indicated reoperation was 1.33% and complication-related return to theatre 0.33%, against a broad “revision” rate of 12.00%. Conclusions: Complication and reoperation rates should be interpreted as stratified outcomes influenced by gynaecomastia grade, opera- tive complexity, adjunctive procedures, and endpoint definition. Procedures involving formal skin excision formed the highest-risk stra- tum, whereas adjunctive liposuction was associated with lower pooled complication rates. In the 300-patient cohort, most revisions were elective refinements rather than treatment failures, reinforcing concerns raised in the published literature about inconsistent revision defi- nitions and the need to distinguish aesthetic touch-ups from clinically indicated reoperation and true glandular recurrence. These findings support stratified reporting of complications and reoperations by grade, surgical technique, adjunctive procedure, and clinical indication. Without such stratification, comparisons may be confounded and the true rates of complications and clinically indicated reoperations misrepresented.