History of surgical treatment

The surgical course of restoring gynecomastia began long ago when Paulus Aeginita in 625 described the removal of the male breast through an submammary incision or through two parallel crescent sections. In 1933 Menville believed that the male nipple does not play an important role and by using an elliptical incision, including the nipple and the areola he removed the breast. Webster in 1946, revolutionized by suggesting a semicircular intra-areolar incision, while Pitangui used horizontally split incision through the nipple to gain access to the breast.

Letterman and Schurter in 1969 used an upper crescent-shaped incision to remove the skin so that to lift the nipple. Many techniques were also developed the majority of which used external incisions to treat gynecomastia, such as the one by C. M. Ward et al 1989.

Davidson in 1979 describes a way to calculate skin fall in cases of type IIb and III gynecomastia by using two concentric circles. This approach was really good but it had two disadvantages.

1. It could result in a doughnut shortage if the horizontal diameter was bigger than the vertical one and
2. He did not use purse-string sutures therefore the closure could result in skin folds and diameter increase of the areola postoperatively.

Saad (1984) in treating gynecomastia described a circumareolar incision without, however, specifying either how the skin should be removed or the use of purse-string sutures, while E. C. Smoot III (1998) talked about an eccentric skin resection along with subcutaneous mastectomy using the eccentric circle at the south pole of the areola resulting in a closure with multiple folds postoperatively.

We believe that any operation aiming to restore gynecomastia, should take into serious consideration:

1. The proper oncological removal of the gynecomastia mass
2. The aesthetically acceptable image of the complex nipple - areola.

Preoperatively, the course of action in removing the excess skin is calculated by defining two points, one 5 cm from the submammary line and the other in relation to the new position of the nipple.

We believe that despite all these, and especially in older people, it is difficult to say with certainty how much skin will shrink postoperatively and it is particularly risky in type III (female breasts) gynecomastia to confirm the removal of the excess skin using circular accesses.

We tie the purse-string suture to the point set by the areola diameter to avoid expanding its diameter postoperatively though some reactionary pigmentation is inevitable.

In conclusion we believe that the circular mazopexy applies to all classes of gynecomastia even where the Webster technique cannot be applied such as to classes I and IA (with very narrow nipple areola). There are some reservations concerning gynecomastia type III (female breast) where one should seriously consider whether to proceed with the surgical breast amputation with free transfer of the nipple-areola (breast amputation with free nipple-areola graft transplantation).