Gynaecomastia Surgery Patient 2021-7001

*Results vary

Patient History

• Male patient, 25 years old.
• Longstanding history of gynaecomastia (benign enlargement of male breast tissue), first noted during adolescence.
• Clinical examination identified:
  • Fibroglandular tissue beneath the nipple-areolar complex (NAC).
  • A larger component of pseudo-gynaecomastia (adipose tissue hypertrophy of the chest wall).

Classification

• Condition classified using Dr Beldholm’s internal grading system: Grade BB 2b.
• Recommended management: ultrasound-assisted suction lipectomy (VASER liposuction).
• Due to the presence of a small amount of fibroglandular breast tissue beneath the areola, sub-areolar excision (direct glandular excision) was also performed.

Operation Performed

• Bilateral ultrasound-assisted suction lipectomy (VASER liposuction) performed on the anterior chest and lateral chest wall.
• Peri-areolar incisions were made bilaterally to allow removal of glandular breast tissue.
• A 10 French Belovac drain was placed on each side, removed the following day.

Histopathology Report

Macroscopic findings

• Right breast specimen: Fibroadipose breast tissue, 9g, 77×25×15mm. Cut surface: uniform fibrofatty tissue. No discrete macroscopic lesions.
• Left breast specimen: Fibroadipose breast tissue, 10g, 64×35×12mm. Cut surface: uniform fibrofatty tissue. No discrete macroscopic lesions.

Microscopic findings

• Right breast specimen: Fibrofatty breast tissue with occasional ducts showing columnar cell change without cytological atypia. Apocrine metaplasia present. No in situ or invasive malignancy. No microcalcifications.
• Left breast specimen: Fibrofatty breast tissue with unremarkable ducts and densely fibrous stroma. Features may represent late-stage gynaecomastia. No in situ or invasive malignancy. No microcalcifications.

Final Diagnosis

• Findings consistent with gynaecomastia (benign enlargement of male breast tissue).

Images:

3 months after the operation