Historically Significant: Mastectomy for Gynecomastia Through Semicircular Intra-Areolar Incision, Webster (1946) 

Written in 1946 by Dr. Jerome P. Webster, Mastectomy for Gynecomastia Through a Semicircular Intra-Areolar Incision describes a forward-thinking surgical technique for treating gynaecomastia using a minimally invasive approach. 

First introduced in 1934, the Webster procedure holds particular historical significance as one of the first surgical approaches specifically designed to address male breast tissue enlargement. The procedure, involving a semicircular incision at the edge of the areola, allows for effective tissue removal with minimal scarring.

While modern techniques have largely supplanted this method, the procedure has several notable advantages, especially within the context of its time, and has been recognized for its effectiveness, satisfactory outcomes, and low complication rates. ​

Key Aspects of the Webster Technique

1. Precise incision placement to reduce visible scarring.
2. Dissection under the areola to remove excess breast tissue while leaving enough fat for a smooth chest contour.
3. Meticulous suturing to maintain pleasing aesthetic outcomes and symmetry.
4. Avoiding adhesion of the nipple to underlying muscle, ensuring natural results.

Three Classes Of Permanent Benign Hypertrophy

Presented before The New York Surgical Society and The Philadelphia Academy of Surgery, February 14, 1945, this study, which  involved 32 breasts, does not deal with the surgical treatment of the malignant type of male breast hypertrophy, nor does it involve pubescent cases which generally resolve on their own.

According to Webster, there are three classes of permanent or persistent benign hypertrophy for which surgical intervention may be the advised protocol.

1. Periductal Connective Tissue Hypertrophy without Adipose Tissue 

Characteristics

• No male breast cancer evident.
• Mammary gland is hypertrophied, forming a firm discrete nodule beneath the areola and adjacent tissue .
• A well-defined white fibrous tissue is also present, while microscopic examination reveals elongated ducts and ductules surrounded by a mass of connective tissue and a complete absence of adipose tissue within the nodule. 
• The intra-ductal epithelium may be hypertrophied forming projections into the lumens of the ducts.
• No true acini are found as in the female mammary gland, although terminal Ductules may exhibit similarities. 
• Onset commonly occurs during puberty.

Treatment

The treatment for periductal connective tissue hypertrophy without adipose tissue, according to Webster, involves a surgical approach tailored to address the dense fibrous tissue concentrated around the ducts. The key aspects of his treatment approach are:

The treatment for periductal connective tissue hypertrophy without adipose tissue, according to Webster, involves a surgical approach tailored to address the dense fibrous tissue concentrated around the ducts. The key aspects of his treatment approach are:

1. Direct Excision

• Webster advocated for a subareolar incision through the areola to access and excise the periductal fibrous tissue.
• An approach that targets the hypertrophic connective tissue while preserving the surrounding normal tissues, direct excision ensures a flat chest contour.

2. Preservation of Normal Tissue

• Webster’s technique emphasizes removing only the hypertrophic tissue without disturbing the nipples, skin, or areolar structures to ensure aesthetic integrity.

3. Minimal Liposuction

• In an absence of adipose tissue, liposuction is typically unnecessary. However, Webster allowed for adjunctive liposuction if minor fatty tissue is present.

4. Focus on Functional and Aesthetic Outcomes

• For aesthetic outcomes, the focus was achieving a natural, masculine chest contour while minimizing scarring and disruption to the nipple-areola complex.

2. Increase in Hypertrophy and Adipose Tissue

Characteristics

• Connective tissue elements exist only in small amounts in the region beneath the areola with the remainder of excess tissue composed of adipose tissue. 
• The body appears feminine (eunuchoid) or masculine. 
• Genitalia may be normal or underdeveloped.
• One or both breasts may be involved.
• Commonly occurs at puberty.

Treatment

For cases involving increased hypertrophy of periductal connective tissue along with adipose tissue, Webster’s approach combines techniques to address both fibrous and fatty components. Webster’s method focuses on excision and contouring for a natural chest appearance. Here’s an overview:

1. Combination of Excision and Liposuction

• A subareolar incision directly removes the dense, hypertrophic connective tissue surrounding the ducts, an essential step because liposuction alone cannot adequately address the fibrous component. Suction-assisted liposuction is employed to remove excess tissue and contour the chest.

2. Contouring

• Liposuction is extended to the surrounding chest areas to eliminate any uneven fat distribution and ensure a smooth transition. This step minimises the risk of postoperative complications.

3. Skin Retraction and Redundancy

• In cases significant tissue removal is needed, Webster emphasised evaluating the skin’s elasticity to predict its ability to retract.
• Skin tightening procedures or direct excision of redundant skin may be performed to achieve optimal results when necessary.

4. Aesthetics

• Special care is taken to maintain the integrity of the nipple-areola complex and ensure minimal scarring by concealing the incision within the natural areolar boundary.

5. Postoperative Care

• Compression garments are used to support skin retraction, reduce swelling, and promote proper healing. Webster stressed the importance of this step for maintaining contour and minimising complications.

Combining excision and liposuction, Webster addresses both hypertrophic connective tissue and adipose tissue, ensuring functional and aesthetic outcomes tailored to the patient’s body shape, this treatment remains a cornerstone for treating complex gynecomastia cases.

3. Adipose Tissue Hypertrophy

Characteristics

• Increase in size of the breast is due entirely to excessive adipose tissue with no mammary gland hypertrophy. 
• The body is generally underdeveloped and may be of the Froehlich type. Also known as adiposogenital dystrophy, Froehlich syndrome is a group of endocrine abnormalities believed to result from damage to the hypothalamus, a part of the brain that links the nervous system to the endocrine system via the pituitary gland.  
• Bi-lateral.
• Appears in the first decade of life, but usually does not cause issues until the age of puberty. 
• No nodule palpable beneath the areola.

Treatments

Webster’s treatment for adipose tissue hypertrophy (predominantly involving excess fat without significant glandular or fibrous tissue enlargement) primarily focused on removing the fat deposits and contouring the chest for a natural appearance. Here’s a breakdown of his approach:

1. Liposuction as the Primary Treatment

Suction-assisted liposuction is the first-line treatment for adipose tissue hypertrophy because the primary issue is fat accumulation, liposuction effectively reduces volume and reshapes the chest without the need for extensive glandular excision.

• Cannula Insertion: Small incisions made in inconspicuous areas
• Fat Removal: Suction used to selectively remove excess fat while preserving overall chest structure.

2. Assessment of Skin Elasticity

• Skin Retraction: If the skin has good elasticity, it can naturally contract after liposuction, negating the need for additional skin-tightening procedures.
• Management of Loose Skin: In cases of poor skin elasticity (e.g., older patients or significant weight loss), Webster noted the potential need for additional procedures to address skin redundancy, though these were less common in adipose-dominant cases.

3. Minimal Incisions and Aesthetic Considerations

• Scarring: The liposuction incisions are minimal and strategically placed to ensure they are as inconspicuous as possible.
• Contour Smoothness: Careful liposuction technique is employed to avoid irregularities and achieve a symmetric, masculine chest contour.
• Rare Need for Glandular Excision
• Since adipose tissue hypertrophy lacks significant glandular or fibrous tissue, glandular excision is typically unnecessary unless there is a mixed presentation.

4. Postoperative Care

• Compression Garments: These are essential to support skin retraction, reduce swelling, and enhance contouring during recovery.
• Follow-Up: Monitoring for any residual irregularities or asymmetry, which could be corrected with touch-up liposuction.

Surgical Indications

In the early 20th century, widely accepted treatment for gynaecomastia included radiotherapy, endocrine therapy, and surgery. According to Webster, radiotherapy and other non-surgical techniques were ineffective, however, with surgical removal of the excess tissue offering the best method for correcting enlarged male breasts. 

1. Malignancy

Though quite rare, mammary hypertrophy carcinoma (male breast cancer) develops late in life.

2. Breast Pain Relief

Pain or tenderness was a complaint in some of the men. Though painful gynecomastia was reported as a complaint, however, the true cause was the unwelcome shape of the breast.

3. Preventing Psychic Trauma  

The psychic trauma caused by enlarged breast development and a feminine appearance due to oestrogen levels is the main reason for surgical interference for non-malignant gynaecomastia. 

Subjected to bullying, men with enlarged breast tissue whose bare chest is exposed on a regular basis— such as in the military, locker rooms, and pools—may exhibit changes in behaviour patterns— such as hesitating to undress for the gym or the beach and refrain from swimming or wearing thin clothing, may exhibit psychotic disturbances.

Surgical Techniques

There was a time when surgeons advocated removing the entire areola together as there is no indication that the resulting scars cause as much embarrassment as the original condition, especially when the scars are bilateral and symmetrical.  As such, this operation which was devised by the author and first performed in 1934, resulted in satisfactory outcomes.  

Using general anesthesia, the surgery proceeded as follows:

• To improve the mammary appearance, the removal of the excess tissue through a single submammary lunar incision was the preferred treatment. 
• If the condition was bilateral, two operative teams were used simultaneously to reduce the length of the operative time. Care was taken so the procedures used by each operator were similar and that the tissue remaining on each side was symmetric.
• The areola was distended by pressure exerted downwards about the breast by the encircling hands of the assistant. 
• A semicircular incision was made just within the margin of the pigmented area of the areola. It may either extend over the lower, or caudad, half of the areola, or be placed more laterally, leaving  fine inconspicuous scars. 
• Dissection beneath the areola with division of the ducts was made early to facilitate operation.
• Excision was aided by traction upwards with Kocher clamps on the divided ductal stump or on the mass of tissue that has been freed. 
• Enough adipose tissue was left to be drawn together eventually beneath the nipple.
• If the areola was small in comparison with the amount of tissue to be re-moved through the incision, the tissue was halved or quartered and removed in separate portions.
• Sufficient fat was left over the pectoral fascia to obtain a smooth, even surface when the remaining tissues are replaced. 
• Reduction of the adipose tissue was sufficient to overcome the similarity to the female breast, with the remaining amount remaining proportionate to the rest of the body.

Case Analysis

The results of this procedure on 17 subjects and 32 breasts were uniformly successful, for the most part. Excellent results were achieved on all patients with the exception of two, one which resulted in insufficient reduction in the size of the breasts; and one experiencing nipple deformity as the result of  necrosis.

The final appearance in all cases was favorably compared to other procedures, according to Webster. The absence of noticeable scars, together with the reduction of breast size and contour, lessened the patient’s psychological disturbance.

Advantages of Mastectomy through a Semicircular Intra-areolar Incision for the Correction of Gynecomastia

1. Direct Glandular Removal

• The Webster procedure is effective at removing dense glandular tissue, which can be challenging to eliminate with liposuction alone.
• This makes it particularly useful for patients with firm, fibrous gynecomastia that is resistant to other interventions.

2. Relatively Simple

• The procedure involves an inframammary incision, allowing direct access to the glandular tissue.
• To treat gynecomastia, this straightforward approach requires fewer specialized tools compared to modern liposuction techniques, making it accessible for surgeons.

3. Predictable Outcomes

• Since the tissue is excised directly, the procedure provides a high degree of certainty in removing the gland, reducing the risk of recurrence due to incomplete tissue removal.

4. No Reliance on Advanced Technology

• Unlike modern methods that often involve ultrasound- or laser-assisted liposuction, the Webster procedure does not require advanced or expensive equipment, making it more practical in resource-limited settings.

5. Foundation for Modern Techniques

• The Webster procedure served as an essential starting point for understanding gynecomastia and refining surgical techniques. Many modern approaches, which combine glandular excision and liposuction, are built on principles first formalized by Webster.

6. Reliable for Severe Cases

• In cases of severe gynecomastia with significant glandular tissue, the direct excision offered by the Webster procedure ensures comprehensive removal, which might not be achievable with liposuction alone.

7. Low Risk of Incomplete Gland Removal

• Modern liposuction-based techniques sometimes fail to remove all glandular tissue, requiring follow-up surgery. The Webster procedure eliminates this concern by prioritizing complete excision.

While the Webster procedure is largely outdated today due to advancements in minimally invasive techniques that address scarring, contouring, and recovery time, it remains a significant milestone in the surgical treatment of gynecomastia and is still relevant in specific, limited scenarios.

Disadvantages of Mastectomy through a Semicircular Intra-areolar Incision for the Correction of Gynecomastia

The Webster procedure, developed in 1946 by  Frederick S. Webster, is one of the earliest techniques for addressing gynecomastia. While it has historical significance, it is not commonly used in modern practice due to several disadvantages compared to contemporary surgical techniques. Disadvantages include:

1. Scarring

• The procedure involves an inframammary incision (under the breast), which can result in visible and sometimes prominent scars, particularly if the patient has poor wound healing or keloid tendencies.

2. Limited Contouring Ability

• The Webster procedure is primarily designed to remove glandular tissue but does not address fatty tissue or skin excess effectively.
• It lacks the precision of modern liposuction-assisted techniques for contouring the chest to achieve a more natural appearance.

3. Skin Laxity

• In cases of significant gynecomastia or when there is excess skin, the Webster procedure does not address skin tightening, often leaving the chest with residual sagging or irregular contours.

4. Higher Risk of Asymmetry

• The direct excision method may lead to uneven tissue removal, resulting in chest asymmetry or unnatural contours.

5. Limited Application

• This technique is less effective for pseudo-gynecomastia (enlarged male breasts caused by fat rather than glandular tissue), which is common in many patients.

6. Prolonged Recovery Time

• The surgery and the recovery period can be more invasive compared to minimally invasive methods that include liposuction.

7. Potential for Nipple Distortion

• Improper technique or excessive tissue removal could lead to complications like nipple flattening, inversion, or poor positioning.

8. Outdated Technique

• Modern procedures such as ultrasound-assisted liposuction, VASER liposuction, or a combination of liposuction with glandular excision are preferred. These newer methods minimize scarring, improve contouring, and often have shorter recovery times.

Final Thoughts

In the context of modern medicine, Webster’s treatments for gynecomastia remain foundational and continue to influence current surgical practices. His emphasis on tailoring interventions to the underlying tissue composition provides a structured approach that balances aesthetic outcomes with patient-specific anatomy. Advances in liposuction techniques, such as ultrasonic or power-assisted liposuction, have further enhanced precision and efficacy, especially in cases involving adipose tissue hypertrophy.

Webster’s legacy lies in his commitment to both functional correction and aesthetic refinement, making his techniques as relevant today as they were when first introduced, particularly in the era of patient-centered, minimally invasive approaches to gynecomastia treatment.

While the Webster procedure for gynecomastia holds historical importance as one of the first surgical approaches designed to specifically address male breast tissue enlargement due to chronic gynecomastia, pubertal gynecomastia, or idiopathic gynecomastia (of unclear cause), and played an essential role in the evolution of gynecomastia surgery, advancements in treatments and technology have made it largely obsolete.

While modern techniques have largely supplanted Webster, the procedures do have notable advantages, especially within the context of the time period.

Since the normal appearance of the male pectoral region is achieved with almost no evidence of operative interference, the patient can return to normal activities and expose his chest without the fear of ridicule. 

To learn more about the surgery, whether you’re a candidate for the procedure, and the overall process in my article, Essential Insights on Gynaecomastia Surgery for Men, or book a consultation to learn if gynaecomastia surgery is right for you.

After performing a thorough examination and asking questions about your goals, concerns, expectations, and medical history, I will tell you about the benefits, risks, downtime,  cost associated with the surgery, and address all of your questions and concerns. This informative consultation takes place in a discreet, professional office environment, convenient to most localities.

Resources

1. https://academic.oup.com/asj/article-abstract/38/1/58/4110193?redirectedFrom=fulltext
2. https://docslib.org/doc/7572473/mastectomy-for-gynecomastia-through-a-semicircular-intra-areolar-incision-jerome-p
3. Menville, J. G.: Gynecomastia. Arch. Surg., 26, 1054-1083, 1933.
4. Lisser, H.: Adrenal Cortical Tumor. Endocrinology, 20, 567-569, 1936.
5. Zondek, Hermann: The Diseases of the Endocrine Glands. London, Edward Arnold & Co., 1935.
6. Lewin, Michael L.: Gynecomastia: The Hypertrophy of the Male Breast. J. Clin.
   Endocrinol., 1, 511-514, 1941.
7. Schonfeld, William A.: Management of Male Pubescence. J. A. M. A., 121, 177-
   182, 1943.
8. Schonfeld, William A.: Primary and Secondary Sexual Characteristics: Study of Their Development in Males from Birth through Maturity:
9. With Biometric Study
10. of Penis and Testes. Am. J. Dis. Child., 65, 535-549, 1943.
11. Buirge, Raymond E., Samuels, Leo T., and McCartney, J. S.: Treatment of Puber-
12. tal Bilateral Gynecomastia. Surgery, 17, 397-403, 1945.
13. Menville, J. G.: X-Ray Treatment in Gynecomastia. Radiology, 18, 295-301, 1932.
14. Adair, F. E.: A Consideration of Recent Additions to Clinical and Experimental Knowledge of Breast Conditions. West. J. Surg., 48, 645-661, 1940.
15. 10 Wernicke, H. O.: Gynecomastia. Surgery, 5, 217-225, 1939.
    ” Klinefelter, Harry F., Jr., Reifenstein, Edward C., Jr., and Albright, Fuller: Syndrome Characterized by Gynecomastia, Aspermatogenesis without A-Lydigism, and Increased Excretion of Follicle-stimulating Hormone. J. Clin. Endocrinol., 2, 615-627, 1942.
16. Sullivan, J. M., and Munslow, R. A.: Gynecomastia. A Study of Five Cases.
17. J. A. M. A., 118, 1443-1444, 1942.
18. ” Gooel, Elmer F.: Gynecomastia. Surgery, 15, 938-943, 1944.
19. Bannayan, G. ,A. and Hajdu, S. .I Gynecomastia: Clin- icopathologic study of 351 cases. Am. .J Clin. Pathol. 57: 431, 1972.
20. Jackson, .A W., Muldal, S,. Ockey, .C H,. and O’Connor, P. .J Carcinoma of male breast in association with the Klinefelter syndrome. B.r Med. .J 1: 223, 1965.
21. Beckenstein, M. S,. Windle, B. H,. and Stroup, .R .T Anatomical parameters for nipple position and areo- lar diameter in males. An. Plast. Surg. 36: 3, 1996.
22. Murphy, .T P,. Ehrlichman, R. J.,and Seckel, B. R. Nipple placement in simple mastectomy with free nipple grafting for severe gynecomastia. Plast. Reconstr. Surg. 94: 818, 1994.
23. Gingrass, M. K,. and Kenkel, .J M. Comparing ultra- sound-assisted lipoplasty with suction-assisted lipo- plasty. Clin. Plast. Surg. 26: 283, 1999.
24. Bowers, S. P,. Pearlman, N. W,. Meintyre, R. C., Jr., Fin- layson, C. ,A. and Huerd, S. Cost-effective manage- ment of gynecomastia. Am. J. Surg. 176: 638, 1998.
25. Beck, W,. and Stubbe, P. Endocrinological studies of the hypothalamo-pituitary gonadal axis during dana- zol treatment in pubertal boys with marked gyneco- mastia. Horm. Metabol. Res. 14: 653, 1982.
26. McGrath, M. H. Gynecomastia. In M. .J Jurkiewicz, S. J. Mathes, .T J. Krizek, and .S Ariyan (Eds.), Plastic Sur- geyr: Principles and Practice. St. Louis: Mosby, 1990.
27. Webster, J. P. Mastectomy for gynecomastia through a semi-circular intra-areolar incision. An. Surg. 124: 57, 1946.
28. Barsky, .A,.J Kahn, S,. and Simon, B. E. Principles and Practice of Plastic Surgery, 2nd Ed. New York: McGraw Hill, 1964.
29. Pitanguy, I. Transareolar incision for gynecomastia. Plast. Reconstr. Surg. 38: 414, 1966.
30. Letterman, G,. and Schurter, M. The surgical correc- tion of gynecomastia. Am. Surg: 35: 322, 1969.
31. Letterman, G,. and Schurter, M. Surgical correction of massive gynecomastia. Plast. Reconstr. Surg. 49: 259, 1972.
32. Pers, M,. and Bretteville-Jensen, G. Reduction mamma-plasty based on the vertical vascular bipedicle and “tennis ball” assembly. Scand. .J Plast. Reconstr. Surg. 6: 61, 1972.
33. Simon, B. E., Hoffman, S,. and Kahn, .S Classification and surgical correction of gynecomastia. Plast. Recon- str. Surg. 51: 48, 1973.
34. Eade, G. G. The radial incision for gynecomastia exci-sions. Plast. Reconstr. Surg. 54: 495, 1974.
35. Wray, .R ,C. J,.r Hoopes, .J ,E. and Davis, G. M. Cor- rection of extreme gynaecomastia. Br. .J Plast. Surg. 27: 39, 1974.
36. Balch, .C R. Atransaxillary incision for gynecomastia. Plast. Reconstr. Surg. 61: 13, 1978.
37. Artz, ,S. and Lehman, .J ,A. J.r Surgical correction of massive gynecomastia. Arch. Surg. 113: 199, 1978.
38. Davidson, B. .A Concentric circle operation for massive gynecomastia to excise the redundant skin. Plast. R-e constr. Surg. 63: 350, 1979.
39. Fara, M,. and Hrivnakova, .J Reduction mammaplasty in serious gynaecomastias using a single superiorly based flap. Acat Chir. Plast. 23: 159, 1981.
40. Huang, T. ,T. Hidalgo, J.,E. and Lewis, .S R. Acircum- areolar approach in surgical management of gynecomastia. Plast. Reconstr. Surg. 69: 35, 1982.
41. Plast. Surg. 16: 220, 1986. Samdal, F., Kleppe, G,. Amland, P. F,. and Abyholm, F. Surgical treatment of gynaecomastia. Scand. .J Plast. Reconstr. Surg. Hand Surg. 28: 123, 1994.
42. Abramo, .A.C Axilary approach for gynecomastia -liposuction. Aesthetic Plast. Surg. 18: 265, 1994.
43. Smoot, E. C. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. An. Plast. Surg. 41: 378, 1998.
44. Ohyama, T., Takada, ,A. Fujikawa, M,. and Hosokawa, K Endoscope-assisted transaxillary removal of glandular tissue in gynecomastia. An. Plast. Sugr. 40: 62, 1998.
45. Botta, S. .A Alternatives for the surgical correction of severe gynecomastia. Aesthetic Plast. Surg. 2: 65, 1998.
46. Chiu, D. ,T. and Siegel, H. W. The pinwheel technique: An adjunct to the periareolar approach ingynecomastia resection. An. Plast. Surg. 42: 465, 1999.
47. Gingrass, M. K,. and Shermak, M. .A The treatment of gynecomastia with ultrasound-assisted lipoplasty. Perspect. Plast. Surg. 12: 101, 1999.
48. Zocchi, M. L. Ultrasonic-assisted lipoplasty: Technical refinements and clinical evaluations. Clin. Plast. Surg. 23: 575, 1996.
49. Rohrich, R. J.,Raniere, J.,J,.r Beran, S. J., and Kenkel
50. Rohrich, R. J., Beran, .S J., Kenkel, .J M,. Adams, W. P,. and DiSpaltro, F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuc- tion. Plast. Reconstr. Surg: 101: 1090, 198.
51. Rohrich, R. ,.J Beran, .S J., and Fodor, P. B. The role of subcutaneous infiltration in suction-assisted lipoplasty: Plast. Reconstr. Surg. 99: 514, 1997.
52. 53. Rohrich, R. J., and Beran, .S J. Cosmetic introduction: Is liposuction safe? Plast. Reconstr. Surg. 104: 819, 1999.
53. Kenkel, .J M,. Gingrass, M. K,. and Rohrich, R. J. U1- trasound-assisted lipoplasty: Basic science and clinical research. Clin. Plast. Surg. 26: 21, 1999.
54. Kenkel, .J M,. Robinson, J.B,. J,.r Beran, .S J.,et .al The tissue effects of ultrasound-assisted lipoplasty. Plast. Reconstr. Surg. 102: 213, 1998.
55. Colombo-Benkmann, M,. Buse, B,. Stern, ,.J and He1999.