Short-scar Excision Combined with Ultrasound-assisted Liposuction for Gynecomastia: A Prospective Pilot Study of an Innovative Technique

Abstract

Background:

Gynecomastia often causes psychological distress and impairs quality of life. Traditional surgery can leave visible scars. Advances now allow less invasive techniques. This study presented a novel short-scar approach combining crescent excision and ultrasound-assisted liposuction to address both functional and aesthetic concerns.

Methods:

This prospective pilot study included 15 adult male patients undergoing short-scar gynecomastia repair from January to December 2020. Inclusion criteria were grade 2B–3 gynecomastia of more than 1-year duration, unresponsive to medical therapy. Outcomes included operative time, liposuction/excision volumes, scarring, complications, satisfaction, and recurrence over 3–12 months.

Results:

The mean age was 30.2 ± 7.6 years. The average operative time was 123 ± 50 minutes. Mean liposuction per side was 575 ± 125 mL, and mean glandular excision was 59 ± 51 g. Mean skin excision diameter was 4.0 ± 0.8 cm. There were no major complications. All patients reported high satisfaction at a mean follow-up of 6.8 ± 2.6 months.

Conclusions:

This pilot study supported the short-scar plus ultrasound-assisted liposuction technique as a safe and effective option for gynecomastia management. The method allows for minimal scarring, efficient surgery, and high patient satisfaction. Further research is needed to confirm long-term benefits.

Takeaways

Question: What are the outcomes and effectiveness of a novel short-scar approach combining crescent excision and ultrasound-assisted liposuction for gynecomastia?

Findings: In this pilot study of 15 patients, the short-scar technique demonstrated safety, minimal scarring, no major complications, and high patient satisfaction at short-term follow-up.

Meaning: This innovative technique shows promise for improving aesthetic and functional outcomes in gynecomastia surgery, though larger, long-term studies are needed to validate its benefits over traditional methods.

INTRODUCTION

Gynecomastia is characterized by enlargement of male breast glandular tissue, which can lead to psychological distress and social avoidance for affected men.¹ Surgical treatments aim to reduce and contour the chest for a masculine appearance. Traditional techniques such as periareolar incision or inverted-T incision mastectomy often leave noticeable scarring.² Patients increasingly prefer minimally invasive approaches that limit scarring while effectively removing excess tissue.³

Recent innovations in gynecomastia surgery focus on combining ultrasound-assisted liposuction (UAL), also known as vibration amplification of sound energy at resonance (VASER) liposuction, with limited direct excision of glandular and fibro-fatty tissue.⁴ UAL uses ultrasonic energy to selectively emulsify and remove fatty deposits with the aim of skin retraction and minimization of contour irregularities.⁵ Small infra-areolar incisions are then used for excision of remaining breast tissue.

Early case series show that UAL with minimal excision allows for significant breast reduction through shorter scars.⁶ However, prospective studies evaluating the long-term efficacy, safety, aesthetics, and patient-reported outcomes are lacking. There is a need for formal technique standardization and rigorous evaluation of short-scar approaches to establish optimal gynecomastia treatment guidelines.⁷ The main aim of this article is to describe our novel technique for managing gynecomastia with a short supraareolar scar excision of glandular tissue and using UAL with excellent outcomes and high patient satisfaction. This prospective study aimed to present and evaluate a standardized combined UAL and crescent excision surgery for short-scar gynecomastia reconstruction. We hypothesize that this novel approach will lead to reduced scarring with excellent cosmetic results and high patient satisfaction.

METHODS AND MATERIALS

ETHICAL APPROVAL

This study was conducted in accordance with the Declaration of Helsinki. The research protocol was reviewed and approved by the institutional review board and research ethics committee of King Saud University in Riyadh, Saudi Arabia, before patient recruitment (no. E-24-9433). All participants provided written informed consent after being informed of the nature, benefits, and risks of participation. Participants were made aware that their involvement was voluntary and that they could withdraw from the study at any time without penalty. Privacy was maintained by deidentifying participant data and securely storing study records.

Study Design and Participants

This was a single-group prospective pilot cohort study of 15 adult male patients who underwent surgical treatment for gynecomastia at our institution from January 2020 to December 2020. Participants were included if they were men 18–60 years of age with moderate to severe gynecomastia graded as 2B, 3, or 4 based on the American Society of Plastic Surgeons scale, present for more than 1-year duration without improvement from medical therapies. Patients with grade 1–2A gynecomastia, active infections, coagulopathy, major comorbidities, or prior chest surgery were excluded.

Outcomes Measured

The following data were collected on all participants: demographic variables including age, body mass index, and comorbidities; gynecomastia evaluation data encompassing endocrine assessment, gynecomastia grade, and cause (idiopathic, medication-induced, etc.); physical examination findings such as skin quality, stretch marks, and chest circumference measurements; and operative details including UAL time, volume of tumescent infiltration, volume of lipoaspirate, diameter of skin excision, weight of glandular tissue excision, and total operative time. Outcomes measures comprised scar length, complications, patient satisfaction measured by a 5-point Likert scale questionnaire, quality of life assessment using a validated generalized tool, procedure diagnosis and specifics, and follow-up duration.

Surgical Technique

All procedures were performed by the senior author. Preoperative patient photographs were taken, and risks and complications were discussed with the patient to obtain informed consent for surgery. Markings were made by first drawing the sternal notch, midclavicular line, and existing nipple–areola complex (NAC). The expected new NAC position was estimated and marked approximately 3–6 cm above the areola margin, superiorly at 12 o’clock, based on the degree of skin laxity and redundancy, either by manually elevating the NAC or drawing a line.

To optimize the final NAC position, manual elevation and observation of skin redundancy were used preoperatively to determine the appropriate lift and achieve a balanced chest contour. This assessment informed the crescent-shaped skin excision design, which was marked extending from the NAC at the 3 o’clock to the 9 o’clock position, with the excision diameter adjusted to patient anatomy.

The inframammary fold area was also marked. Tumescent infiltration was then performed through a 5-mm mid-inframammary fold incision, with infiltrate volume dependent on preoperative assessment and expected liposuction amount. The UAL port was sutured in place, and a 3-ring UAL probe with 70% energy was used for a variable duration until most fibrous tissue was liquefied. Traditional liposuction was subsequently performed.

A no. 15 blade incised the skin and dermis, with glandular tissue resection leaving 1 cm underneath the NAC to prevent retraction. Hemostasis was achieved before layered wound closure using 2-0 Vicryl for the fatty layer, 3-0 Monocryl for the deep dermal layer, and 4-0 Monocryl for the skin. Postoperative dressings were applied with mild compression. Patients were instructed to wear a compression garment for 4 weeks postoperatively.

Statistical Analysis

All data were analyzed using IBM SPSS Statistics version 26 (IBM Corp, Armonk, NY). Descriptive statistics, including means and SDs, were calculated for demographic and clinical characteristics. Frequency distributions were generated for categorical variables. Complications and adverse events were recorded and reported descriptively. Because the study included a limited number of patients (n = 15), only descriptive statistics were performed for the analysis. The analysis aimed to determine the effectiveness of our novel surgical technique for scar minimization and improved patient-reported outcomes in gynecomastia reconstruction.

RESULTS

Demographics and Lifestyle Factors

Out of 25 patients, 15 men aged 18–60 years with moderate to severe gynecomastia who met the inclusion criteria were enrolled in the study. The participants, aged 18–41 years, had a mean age of 30.17 ± 7.61 years. The patients’ body mass index ranged from 26.0 to 30.0 kg/m² (mean 27.96 ± 1.21 kg/m²). All patients had no comorbidities. Based on gynecomastia grading, 9 (60%) patients had grade 3, and 6 (40%) patients had grade 2B disease. Exercise was reported by all 15 patients. The majority (n = 14, 93%) lost weight through diet and exercise, whereas 1 patient maintained normal weight. Among the 15 patients, 13 (87%) had not undergone bariatric surgery, whereas 2 (13%) patients reported having the procedure. Table 1 presents detailed patient demographics and clinical characteristics, and Table 2 provides a summary of key statistics for these variables.

Table 1.

Basic Demographics and Clinical Characteristics

BMI, kg/m2	Age, y	Gynecomastia Stage	UAL Time, min	Tumescent Amount, mL	Liposuction Amount, mL	Skin Excision Diameter, cm	Glandular Excision Volume, g	Opertion Time	Patient Satisfaction	Diagnosis	Duration of Surgery	Follow-up Period, mo
27	24	Grade 3	10	1200	600, each side	4	Rt 200, Lt 180	1	High satisfaction	Grade 3 gynecomastia	1	6
28	30	Grade 2B	10	1000	450, each side	3	Rt 35, Lt 40	1:25	High satisfaction	Grade 2B gynecomastia	1.25	3
27.5	41	Grade 2B	8	1600	700, each side	4	Rt 22, Lt 22	1.3	High satisfaction	Grade 2B gynecomastia	1.5	6
25	35	Grade 3	6	1200	600, each side	4	Rt 20, Lt 28	1:30	High satisfaction	Grade 3 Gynecomastia	1:30	8
29	38	Grade 2B	8	1800	900, each side	5	Rt 103, Lt 107	2	High satisfaction	Grade 2B Gynecomastia	2	4
26	37	Grade 2B	6	1200	500, each side	3	Rt 54, Lt 37	1:30	High satisfaction	Grade 2B gynecomastia	1.5	5
28	19	Grade 2B	7	1000	600, each side	3	Rt 92, Lt 101	2	High satisfaction	Grade 2B gynecomastia	2	9
28	37	Grade 2B	8	1800	900, each side	5	Rt 101, Lt 104	2	High satisfaction	Grade 2B gynecomastia	2	5
27	30	Grade 3	7	1200	600, each side	4	Rt 12, Lt 26	4:00	High satisfaction	Grade 3 gynecomastia and abdominal laxity	4:00	12
30	18	Grade 3	8	1000	400, each side	4	Rt 30, Lt 30	1:30	High satisfaction	Grade 2B gynecomastia	1:30	9
27	25	Grade 3	6	1200	450, each side	5	Rt 35, Lt 50	1:30	High satisfaction	Grade 2A gynecomastia	1:30	9
28	35	Grade 3	6	1200	600, each side	4	Rt 20, Lt 28	1:30	High satisfaction	Grade 3 gynecomastia	1:30	6
28	28	Grade 3	8	1400	700, each side	5	Rt 25, Lt 30	2:00	High satisfaction	Grade 3 gynecomastia	2:00	6
27.6	29	Grade 3	7	1350	690, each side	4	Rt 26, Lt 29	20:00	High satisfaction	Grade 2B gynecomastia	2:00	7
30	37	Grade 3	7	1500	600, each side	5	Rt 26, Lt 39	1:00	High satisfaction	Grade 3 gynecomastia	1:00	4

BMI, body mass index; Lt, left; Rt, right.

Table 2.

Summary of Patient Demographics and Clinical Characteristics

Variable	Mean ± SD/Frequency, %	Range
Age, y	30.17 ± 7.61	18–41
BMI, kg/m²	27.96 ± 1.21	26.0–30.0
Gynecomastia grade	Grade 3: 9 (60%)	—
	Grade 2B: 6 (40%)
Skin quality	Good/very good: 13 (87%)	—
	Poor: 2 (13%)
Presence of stretch marks	Yes: 14 (93%)	—
	No: 1 (7%)
Mean operative time, min	123 ± 50	60–180
Mean liposuction volume, mL	575 ± 125	400–900
Mean glandular resection, g	59 ± 51	12–200

BMI, body mass index.

Preoperative Skin and Tissue Quality

Skin quality was assessed as poor in 2 (13%) patients, good in 10 (67%) patients, and very good in 3 (20%) patients. The majority (n = 13, 87%) had good or very good skin quality. Stretch marks were present in 11 (73%) patients, minimal in 3 (20%) patients, and absent in 1 (7%) patient. Most patients (n = 14, 93%) had some degree of stretch marks.

Operative Details and Outcomes

The UAL time averaged 7.8 ± 1.3 minutes. The average tumescent infiltration volume was 1275 ± 210 mL. The mean liposuction volume per side was 575 ± 125 mL. The average skin excision diameter was 4.0 ± 0.8 cm. The mean glandular tissue excision volume per side was 59 ± 51 g on the right and 59 ± 49 g on the left. The mean operative duration was 123 ± 50 minutes. All patients (100%) reported high satisfaction postoperatively. Average follow-up was 6.8 ± 2.6 months. None of the patients had any complications (Fig. 1). (See figure, Supplemental Digital Content 1, which displays the patient before surgery, demonstrating substantial results and excellent breast shaping with the technique, https://links.lww.com/PRSGO/E168.)

Fig. 1.

Preoperative and postoperative photographs of patients undergoing the described surgical technique. A and B, A patient before and 4 weeks after surgery, showing excellent contour and short scarring. C, 3 months after surgery, demonstrating substantial results and excellent breast shaping with the technique.

DISCUSSION

In this study, we evaluated outcomes of the novel short-scar technique for gynecomastia reconstruction in 15 patients. The mean age was 30.17 years, consistent with the typical presentation in young men.⁵ All patients had normal endocrine function, as idiopathic gynecomastia is most common in this group.⁸ We observed various gynecomastia grades, though grade 3 predominated, reflecting delayed treatment.⁹ Most patients exercised and dieted for weight loss, an expected pattern in this population.⁶ Although exercise alone does not directly impact breast tissue, it may motivate patients to seek treatment.⁴

The majority exhibited good to very good skin quality, yet some degree of stretch marks, illustrating the variable tissue damage from chronic distension.^3,10 Careful tissue handling and strategic skin resection are critical intraoperatively.

Avoiding Skin Over- or Underresection and Managing NAC Deformities

Achieving an optimal amount of skin resection is essential to maintain a natural chest contour and prevent NAC deformities in gynecomastia surgery. To avoid overresection, which can cause tightness and NAC distortion, a conservative approach was taken. A preoperative pinch test helped estimate skin redundancy and guide excision markings. Intraoperatively, we adjusted the resection as needed, based on skin contraction following UAL, allowing for a balanced, individualized result.

Moreover, leaving a 1-cm layer of glandular tissue beneath the NAC provided a stable base, minimizing retraction and preserving the NAC’s position postoperatively. This approach proved effective, as no patients in this series experienced NAC deformities or malposition. These strategies contribute to reproducible results and high patient satisfaction.

Operative UAL time and tumescent volume were standard.^11,12 Average lipoaspirate volume per side was 575 mL, similar to published series.¹³ Our mean skin excision diameter of 4 cm achieved the targeted short-scar results. Glandular resection volumes varied widely. This agrees with studies promoting customized excision based on severity.¹ The mean operative time of 123 minutes was shorter than that of other techniques.⁹ This confirms the efficiency of our approach. All patients reported high satisfaction, consistent with improved psychosocial outcomes after gynecomastia repair.⁷

Strengths of this study include the prospective, standardized data collection and the operative technique performed by a single surgeon. The follow-up rate of 100% also enhances the completeness of the dataset. However, limitations exist in the small sample size of 15 patients from a single center. The lack of a control group receiving traditional techniques restricts comparative outcome analysis, limiting the ability to directly attribute observed benefits to the novel technique. Future studies should incorporate control groups or randomized designs to validate these findings further. The short-term follow-up period limits the assessment of long-term surgical results and recurrence rates. Potential sources of bias include the variable timing of postoperative assessments and the subjectivity of the satisfaction scale. Blinding of the surgeon was not feasible given the operative nature of the study. There were no major protocol deviations, with all patients receiving the prespecified surgical intervention and standard perioperative care. Minor variations existed in glandular resection volumes based on clinical factors. We recognize that the available postoperative photographs are suboptimal in clarity, and some images show signs of healing, such as NAC crusting at 4 weeks. Despite multiple attempts, we were unable to obtain additional consented images from patients. These image limitations may affect the visual interpretation of outcomes and are noted as a limitation in this study. Finally, this technique is effective for patients with moderate skin redundancy. However, in cases with significant nipple-to-submammary elongation, additional skin resection techniques such as periareolar or vertical mastopexy may be necessary to achieve optimal chest contour. Our study provides initial evidence for the novel short-scar approach to correct gynecomastia and improve aesthetic appearance. The technique was shown to be efficient, safe, and associated with high patient satisfaction in the short term. Further research should focus on multicenter randomized trials with larger patient numbers to compare outcomes to traditional techniques. Long-term follow-up of 5–10 years is recommended to evaluate recurrence and revision rates. Refinement of the technique and instrumentation may help further optimize cosmetic results. Patient-reported outcomes and psychosocial functioning should also be examined using validated scales. Cost-effectiveness analyses are also warranted if the short-scar method offers resource-related benefits.

CONCLUSIONS

In summary, this initial study demonstrates the feasibility, safety, and effectiveness of the novel short-scar technique for gynecomastia. Our results show efficient operative times, high patient satisfaction in the short term, and scarring with this approach. Further research with multicenter randomized controlled trials and long-term follow-up is essential to directly compare outcomes to traditional techniques. Additional areas of investigation include refinement of the surgical method, evaluation of psychosocial impacts, assessment of revision and recurrence rates, and cost-effectiveness analyses.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

The authors would like to thank Editage for their English editing services.

ETHICAL APPROVAL

The research protocol was reviewed and approved by the institutional review board and the research ethics committee of King Saud University in Riyadh, Saudi Arabia, before patient recruitment.