title: Role of Combined Circumareolar Skin Excision and Liposuction in Management of High grade Gynaecomastia.
abstract: BACKGROUND
  High-grade gynaecomastia (Simon IIb and III) has tissue excess (skin excess, enlarged areola, and displaced nipple), which is best managed surgically; however, results of conventional breast reduction surgeries and liposuction is not very good. Aim of our study was to describe a combined technique to manage these problems to produce a good result.
  
  
  METHODS
  This was a 2-year study among 12 patients of high grade gynaecomastia. Clinical and laboratory findings were normal. Pre-operatively in standing position, diameter of breast and areola, position of nipple, and amount of skin excess were marked. Under general anaesthesia, tumescent infiltration, circumareolar de-epithelisation of skin excess, and liposuction was completed. Redundant portion of the breast was sharply dissected and pulled out. Areola was fixed over pectoralis fascia at mid humerus level, just medial to the mid-clavicular line. Outer borders of the de-epithelised area were apposed by the purse-string effect of a subdermal suture, and further apposed by few half buried horizontal mattress sutures. Drains for 24 hour and compressive dressings for 6 weeks were used.
  
  
  RESULTS
  Mean age of presentation was 25.8 year; emotional discomfort was the chief complaint. Among 12 patients, 10 patients had bilateral gynaecomastia and 8 patients had enlarged and displaced nipple-areola complex. Average hospital stay was 2.41 days and recoveries were usually uneventful.
  
  
  CONCLUSIONS
  The problem of tissue excess and tissue displacement in high grade gynaecomastia can be well managed by this combined circumareolar skin reduction and liposuction technique to achieve a scar-less flat male chest.
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Arindam
authors.initials: A
authors.lastname: Sarkar
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Jayanta
authors.initials: J
authors.lastname: Bain
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Debtanu
authors.initials: D
authors.lastname: Bhattacharya
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Raghavendra
authors.initials: R
authors.lastname: Sawarappa
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Kinkar
authors.initials: K
authors.lastname: Munian
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Gouranga
authors.initials: G
authors.lastname: Dutta
authors.affiliation: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.
authors.forename: Ghulam Jeelani
authors.initials: GJ
authors.lastname: Naiyer
authors.affiliation: Department Preventive and Social Medicine, PGIMSR & ESIC Medical College, Kolkata, West Bengal, India.
authors.forename: Shamshad
authors.initials: S
authors.lastname: Ahmad
keywords: Areola; breast; gynaecomastia; liposuction; nipple; tumescent