Doughnut (concentric) excision for Simonʼs grade 3

gynaecomastia
Hisham H.Ahmed,MD , Ayman M. Abdelmofeed, MD

General Surgery department , Benha University, Benha, Egypt

Abstract.

Purpose
The aim of the study was to evaluate the surgical outcome of doughnut excision
for grade 3 gynaecomastia and its impact on quality of life (QOL) of these patients
before and after surgery.
Patients and methods
Thirty male patients with bilateral gynaecomastia grade 3 were included in this
study in the period from January 2012 to June 2014 in benha university hospital, all
patients operated upon by doing doughnut (concentric) excision for their Simonʼs
grade 3 gynaecomastia.
Results
There was significant difference between patients satisfaction before and after
surgery without major offending operative or postoperative complications.
Conclusion
Although there are some possible complications associated with surgery, our case
series demonstrates that with careful planning and shrewd patient selection, outcomes
of operative correction can be favourable and yield high levels of satisfaction from
both patient and surgeon

Key words.
Gynaecomastia - doughnut – Simon – concentric excision

Introduction:
Gynaecomastia is a benign enlargement of the male breast. It is a common
condition, with an incidence in young patients as high as 38%.[1]
Gynaecomastia presents physiologically in two thirds of normal males at puberty
and may persist into adolescence, this transient breast enlargement usually subsides
spontaneously, but it may persist in adolescence or adulthood due to a real
hypertrophy of breast tissue, fat excess, or a combination of both. [2]
Gynaecomastia is divided according to Webester into true gynaecomastia which is
due to proliferation of ducts and periductal tissues and pseudogynaecomastia which is
due to deposition of adipose tissue and combined cases. [3].
Morphologically and according to the degree of skin redundancy, Simon et al,
1973 classified gynaecomastia into 3 grades:
* Grade-I: Small visible breast enlargement and no skin redundancy.
* Grade-IIA: Moderate breast enlargement without skin redundancy.
* Grade- IIB: Moderate breast enlargement with skin redundancy.
* Grade- III: Severe breast enlargement with marked skin redundancy (pendulous
female breast) [4].

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 Based on the different structural components of the breast(skin, nipple-areola
complex, inframammary fold, glandular tissue) and the relations between these
various components and in particular between the inframammary fold and nipple
areola complex, Adriana et al, 2008 proposed a new four grades gynaecomastia
classification of increasing severity from I to IV as follows: * Grade –I: Increase in
male breast diameter and protrusion but still limited to the areolar region. * Grade- II:
Hypertrophy of all the structural components of the breast beyond the areola region
but still the nipple areola complex is above the inframammary fold. * Grade-III:
Hypertrophy of all the structural components of the breast with the nipple areola
complex at the same height as or about 1 cm below the inframammary fold. * Grade-
IV: Hypertrophy of all the structural components of the breast with the nipple areola
complex more than 1 cm below the inframammary fold. [5]
True gynaecomastia is due to some form of endocrine imbalance [6]. This may be
attributable to increased estrogen, decreased androgen, receptor defects, or an altered
sensitivity of the breast to estrogen [7].
The endocrine imbalance may occur first as a physiological condition which may
become evident during various periods of a man’s life: Neonatal, pubertal, or
involutional. It is unlikely that neonatal gynaecomastia would be treated surgically. If
pubertal gynaecomastia is transient, there are no surgical implications. The permanent
form is well known. Involutional imbalance is a medical problem, and surgery is
rarely indicated,The second endocrine imbalance is endogenous this condition may
result from congenital or acquired hormonal abnormalities as Klinefelter’s syndrome,
male hypogonadism, testicular neoplasm,, mumps , testicular atrophy, adrenal cortex
neoplasm, adrenal cortex hyperplasia, thyrotoxicosis, and pituitary tumour. Lastly the
third endocrine imbalance is exogenous this situation may result from the
administration of hormones, drugs whose molecular structure is similar to that of
estrogen, or drugs that antagonise androgen[6].
The most common symptom of the patient with gynaecomastia is being self-
conscious about the appearance of his enlarged breasts , and occasionally
tenderness or even pain [7].
Most patients request treatment for psychological reasons. The goal in treating
these patients is resection of the abnormal tissue that restores the normal male breast
contour and minimizes scarring or residual deformity of the breast and nipple areola
complex [8].
Determination of site and size of nipple areola complex in males according to
Beckenstein et al. was approximately 20 cm from the sternal notch and 18 cm from
the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average
areolar diameter is 2.8 cm. [9]
In 1990, Spear et al. [10] described three rules to mark the patient having
concentric mastopexy that seemed to produce more predictable aesthetic results
(Fig.1). The three rules are as follows:
1. The outer circle diameter must be drawn not to exceed the original areola diameter
by more than the difference between the original areola diameter and the inner
concentric circle (normal) diameter.
2. The diameter of the outer circle should never be more than twice the diameter of
the inner circle.
3. The final areola size should be an average of the inner and outer concentric circle.

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 Rule 1 D. outside ≤ D.( original - D.inside)
Rule 2 D. outside ≤ D. (2 × D.inside)
Rule 3 D. final = D. (original - D.inside)

Fig.1: Spear rules. Illusterative markings of the three concentric circles for the spear
rules in mastopexy design . D refers to the diameter of labeled circles.

The aim of the study was to evaluate the surgical outcome of doughnut excision for
grade 3 gynaecomastia and its impact on quality of life (QOL) of these patients before
and after surgery .

Patients and methods:

Thirty male patients with bilateral gynaecomastia grade 3 were included in this
study in the period from January 2012 to December 2014 in Benha university
hospital, after approval of the study by the local ethical committee and obtaining
written fully informed consent from the patients. the age of the patients ranged
between 20 and 44 years with the mean age of 26 years, all patients underwent a
preoperative evaluation in the form of medical history, general and local examination
, routine laboratory and endocrinal assessment to exclude cases with secondary
gynaecomastia, so any case due to hormonal imbalance , drug therapy , liver diseases
or any other cause were excluded and only the idiopathic cases were included in this
study, breast mammography was done to exclude any calcifications .
Based on the size of the breast and the degree of skin redundancy in Simonʼs
classification the severe degree (grade 3) only included in this study either true
gynaecomastia cases (firm ,localized, discoid mass) , pseudo-gynaecomastia cases
(soft and diffused mass) or mixed cases confirmed by mammography. A consent for
photographing was taken from all patients preoperatively.
Surgical technique.
Markings were drawn on the patient in upright position included midline of the
chest, inframammary fold, breast meridian (from midclavicular point to the nipple
normally= 18 cm ), then while the patient lying down the concentric circles were drawn in the form of 3 circles
centered at the nipple, (fig. 2)
1- original areolar circle in the middle
2- normal sized areolar circle about (2.8 cm in diameter) internally
3- circle of de epithelialization outside, Its radius was determined by subtraction normal meridian (18 cm)
from the actual meridian .

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Fig.(2) :The three concentric circles.

After anaesthesia and drapping, filtration of the subcutaneous tissue with tumescent
solution composed of 250 – 350 ml mixture of normal saline 1000 ml , lidocaine 2%
25ml and 1 ml adrenaline 1: 1000, then deepithelialization of the area between the
inner and the outer circles was done after that a hemicircular incision done at the
lower edge of the large circle then all the gynaecomastia tissue were dissected from
the nipple and areola superficially leaving 10-15 mm thickness of tissue on the under
surface of the nipple and areola and to the pectoral fascia deeply without insulting it
then haemostasis and negative suction drain was inserted, the wound was closed with
the aid of a burse string proline suture through the large circle to became at the size of
the small circle then deep dermal interrupted sutures followed by skin stitches,the
excised tissue was sent for histopathological examination.
An elastic compression garment was applied for 48 hours before exposure of the
wound.
Post operative the patient was discharged from hospital in the same day, broad
spectrum antibiotic was given for one week, sutures were removed after 5-7 days, and
the drain was removed 5-7 days when drain outcome less than 20 cc per day and the
garment was applied for 3 months.
Post operative visits at 2 weeks, 4 weeks and 12 weeks were scheduled for follow up
and photographing .
No validated outcome assessment questionnaire exists specifically for
gynaecomastia correction. We, therefore, created a three-item questionnaire, which
was sent to all patients who underwent surgery to ascertain their satisfaction with the
procedure. A similar proforma was used by Ridha et al.[11] The proforma asked
patients to rank their satisfaction levels with their surgery in relation to three factors.
The first question related to patients’ comfort with their breast/chest in different
settings (intimate, social and professional). The second question related to the degree
of comfort with their breast/chest appearance. The third question asked patients to
rank the satisfaction level for themselves and their partner/family. (1 = very
dissatisfied; 2 = dissatisfied; 3 = neither; 4 = satisfied; 5 = very satisfied) preoperative
and postoperative.

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 To achieve some level of objective assessment a topographic scale was used to
evaluate pre and postoperative results, Each patient underwent a photographic
assessment before and after surgery at each visit,The photos of before and after were
assessed by three surgeons who were not involved with the patients, surgeon-assessed
result was evaluated in a visual analog scale (VAS) (scale 0 – 10 where 0 is worst
outcome and 10 is the best). The VAS considered symmetry, scarring and natural
appearance. Data provided by surgeons were grouped (12).

Statistical Analysis
A nonparametric test (Wilcoxon test) was used to compare the results of the
questionnaire of self-esteem in two separate stages. The Mann-Whitney test was used
to analyze the importance of the subjective evaluation of the photographs. Differences
were considered significant if the probability was less than 0.05.

Results
Thirty patients with gynaecomastia were included in the study 18 (60 %) cases
with true gynaecomastia and 12 (40 %) cases with pseudogynaecomastia , the age of
the patients ranged between 20 and 44 years,with the mean age (26),there were 2
cases obese patients , 8 cases over weight, 5 cases type 2 diabetis mellitus , one case
hypertensive , the remaining 17 cases were free of co- morbidity, all patients with
bilateral idiopathic gynaecomastia ,all enrolled data shown in tables (1,2).

Table (1) type of gynaecomastia

Total True gynaecomastia pseudogynaecomastia

30 18 (60%) 12 (40%)

Table (2) co-morbidity with the cases

Obese 2 6.7 %
Over weight 8 26.7 %
diabetes 2 6.7 %
hypertension 1 3.3 %
free 17 56.6 %

All patients received general anaesthesia and local tumescent solution and operated
up on by doing doughnut (concentric) excision after which the patients were advised
to wear elastic garment and followed up at 2 ,4, 12 weeks.
Collected data included duration of surgery , amount of blood loss , need for blood
transfusion , post operative hospital stay , frequency of complications and the impact
on the patient quality of life preoperative and 3 months postoperative.

Complications looked for such as early (haematoma , seroma , skin necrosis ,

bruises and infection ) and late complications as (hyposthesia , ugly scar , nipple
inversion , residual lump and skin redundancy )

All surgeries passed smooth without intraoperative complications with a mean

operative time of 90±31 minutes. All patients passed a smooth uneventful
postoperative course , Complications were classified into two types: early, when
occurring within the first 15 days, and late if happening after this period. The early

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complications were 2 patients (6.6%) developed seroma collections after removal of
the drains and was treated by aspiration .
One patient (3.3%) developed haematoma and was treated medically. Six patients
(20%) developed bruises in the surgical field early postoperative and passed smoothly
without trouble . Two patients (6.6%) developed infections in the suture line with
partial dehescene, one patient passed conservatively the other required secondary
sutures. No cases of skin , nipple or areola slouphing or necrosis .

As regard late postoperative complications one (3.3%) patients developed

unilateral hyposthezia in the region of the nipple and areola also 2 (6.6%) patients
developed ugly keloid scars and were treated by serial corticosteroid injections . No
cases of nipple inversion or residual lumps.

Table (3 ) operative data

Data Finding
Operative time (minute) 90 ± 20

Weight of excised tissue 250±30

Grams per side
Hospital stay All one day

Table (4 ) early complications

Number Percentage
-haematoma 1 3.3%
-seroma 2 6.6%
-skin necrosis ---- -----
-bruises 6 20%
-infection 2 6.6%

Table (5 ) day of drain removal

case Day of drain removal Total amount
13 cases 5 th (30-80) cc / day
9 cases 6 th (35-85) cc / day
8 cases 7 th (40-110) cc / day

Table (6 ) total amount of seroma on each side before drain removal.

Number of cases Right side Left side
13 30 cc 50 cc / day
9 35 cc 60 cc / day
8 40 cc 70 cc / day

Table (7 ) seroma after drain removal

number Percentage
Number of cases 2 cases 6.6%

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Table ( 8 ) late complications
Number Percentage

- Hyposthezia 1 3.3%
- Ugly scar 2 6.6%
- Nipple inversion --- ---
- Residual lump ---- ----
- Skin redundancy ---- ------

As regard the patient satisfaction pre and postoperative all the thirty patients were
very dissatisfied preoperatively with their images and postoperative 20 (66.6%)cases
were very satisfied with their images, 5 (16.7%)cases were satisfied and 5(16.7%)
cases were equivocal in their satisfaction with their images.
High satisfaction rates among surgeons. 21 patients (70%) had their outcome
classified as 'excellent' at their second follow up appointment, 5 patients (16.7%) as
'good', 4(13.3%) as 'satisfactory'.

Table ( 9) levels of patients satisfaction

Post-oprative satisfaction No. of patients P value
very dissatisfied 0 (0%)
dissatisfied 0 (%)
equivocal 5 cases (16.7%) 0.05
satisfied 5 cases (16.7%) 0.05
very satisfied 20 cases (66.6%) 0.03

Figure ( 3 ): levels of patients satisfaction

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 Table (10 ) Topographic scale
scale No. of patients P value
Excellent 21(70%) 0.01
Good 5(16.7%) 0.05
Satisfactory 4(13.3%) 0.05
Poor -----

Figure (4 ): Topographic scale

Table (10) visual analog scale

Data score finding

Scaring 8 9 (30%)
9 21 (70%)
Symmetry 7 5 (16.7%)
9 25 (83.3%)
natural appearance 8 10 (33.4%)
9 20 (66.6%)

Analysis revealed a general trend showing increased satisfaction rates as time

from surgery increased.

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Case 1

Preoperative side view Preoperative frontal view

Preoperative markings De -epithelialization between outer and

inner circle

Complete de-epithelialization Gynaecomastia tissue excised

After complete excision with areola flap

- ٩ -Pre-suture burse string of the outer
elevated circle to the size of the inner one
After complete closure Early postoperative side view

Early postoperative frontal view Late postoperative side view

Late postoperative frontal view

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Case 2

Preoperative frontal view Preoperative side view

Preoperative markings De -epithelialization between outer and

inner circle

Complete de-epithelialization After complete excision

After complete excision with areola Pre-suture burse string of the outer
flap elevated circle to the size of the inner one

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Unilateral complete closure bilateral complete closure

Postoperative supine view Postoperative setting view

Discussion

Numerous aesthetic surgical techniques have been described for correction of

gynaecomastia but it is a challenge to fulfil the main objectives of the surgical
treatment of gynaecomastia which are restoration of the male chest shape with good
contour, elimination of the inframammary fold, correction of position of nipple-
areola complex, removal of reduntant skin, symmetrization between the two sides and
the nipple areola complex. [5]

Mild grades of gynaecomastia (Simon 1&2) of pseudogynaecomastia type are

amenable to liposuction , but in severe grades (Simon 3) open surgery should be done
alone or in compination with liposuction. [13]

Surgery is the mainstay of treatment for gynaecomastia. Although a wide range of

surgical techniques have been described as infra-areola excetion of breast tissue ,
concentric mastopexy , formal breast reduction as in female breast reduction with
superiorly or inferiorly based pedicled flaps or breast amputation with free nipple
areola graft, surgeons often find it is difficult to choose the technique that will achieve
the best results for a given patient.[14]
The surgical management of high-grade gynaecomastia (Simon’s grade III) has
remained problematic because both liposuction and conventional subcutaneous
mastectomy (without skin excision) have frequently resulted in significant residual
skin redundancy, requiring a second operation for skin resection [15].

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 In an attempt to minimize scarring, Balch [16]introduced the trans-axillary
approach for glandular excision, The technique is effective in removal of glandular
tissue but still it can not be used in Simon grade II and III with much fat and skin
excess, but in the present study the circum areolar technique helped us to hide the scar
around the areola also helped to wide the range of access to excise all gynaecomastia
tissues without the aid of liposuction and to excise the redundant skin all around the
areola .

As regard complications only 2 patients were developed seroma after drain

removal and were treated by aspiration.

As regard late complications only 2 patients developed keloid scar treated by

corticosteroid injections, and one patient developed unilateral hyposthesia in the
region of nipple and areola.
Celebioglu et al.[7] found that The main disadvantage of free areola nipple graft
technique was long transverse scar and loss of sensation in nipple graft also in pedicle
nipple areola flap in conventional breast reduction the main disadvantage was the
inverted T scar.
The most common complication in study by (B.H. Fruhstorfer and C.M.
Malata )[14] was a residual lump in patients treated by conventional liposuction
alone, which was often associated with a degree of discomfort. In these cases, some
patients were not satisfied with the result, but in our study we excised the redundant
skin and the wide circle allowed us a wider plane for fat excision.

Outcome studies of gynaecomastia correction have shown varying levels of

satisfaction with the results of surgery with Fruhstorfer et al.[14] showing high
levels of satisfaction while Ridha et al .[11] showed much lower levels. Our series
demonstrated generally high satisfaction rates amongst both patients and surgeons.
Twenty one patients (70%) had their outcome classified as 'excellent' (p ₌ 0.01) at
their second follow up appointment by the operating surgeon, 5 patients (16.7%) as
'good', 4(13.3%) as 'satisfactory' with no poor outcome among patients and surgeons.

Patients were generally 'satisfied' with their outcome as regards comfort and
appearance. patients who underwent excision were generally very satisfied, obtaining
the highest overall scores for satisfaction, chest shape and self-confidence levels. The
peri-areolar scar was well accepted and faded with time and this was in accordance
with the study Anna Kasiels et al.[17] which revealed that gynaecomastia causes
considerable emotional discomfort and limitation of every day activity in young
men, and thus it constitutes a psychosocial problem and surgical treatment of
gynaecomastia significantly contributes to an increase in social activity and an
improvement of social acceptance and emotional comfort, and thus significantly
improves satisfaction from personal life in the men who underwent this intervention.

In conclusion the reason for adopting this procedure is that: it is simple and
straight- forward procedure that result in flat chest compared to other breast reduction
techniques that carry the risk of more complications as cone like breast contour, less
skin excision with marked skin redundancy, time consuming and ugly scar.
Although there are some possible complications associated with surgery, our case
series demonstrates that with careful planning and shrewd patient selection, outcomes

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of operative correction can be favourable and yield high levels of satisfaction from
both patient and surgeon.

References
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