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)قالوا سبحانك ال )قالوا سبحانك ال علم لنا إال ما علم لنا إال ما

علمتنا إنك أنت علمتنا إنك أنت العليم الحكيم(العليم الحكيم(صدق الله العظيمصدق الله العظيم

االية) البقرة االية) سورة البقرة ((۳۳٢٢سورة

M.B.B.Ch., Faculty of Medicine,M.B.B.Ch., Faculty of Medicine,Resident of Plastic Surgery in Mansoura General HospitalResident of Plastic Surgery in Mansoura General Hospital

ByBy

Prof. Dr.Mohamed Mohamed

Salah AwadProf of Plastic Surgery

Faculty of MedicineZagazig UniversityProf. Dr.

Adel Mohamed Said Tolba

Assistant Prof of Plastic SurgeryFaculty of MedicineZagazig UniversityProf. Dr.

Mohmmed Ali NasrProf of Plastic Surgery

Faculty of MedicineZagazig University

Prof. Dr.Mohamed Mohamed

Salah AwadProf of Plastic Surgery


Prof. Dr.Mamdouh Mahmoud

BadawyProf of plastic surgery

Faculty of MedicineElMansoura University

Prof. Dr.Mohamed Hassan

Abd El Aal Prof of Plastic Surgery


IntroductionIntroductionGynacomastia is a benign enlargement of the male breast occurs at all ages. Gynacomastia has several classifications.Classified according to the nature of the content in two types :

1- True Gynacomastia ) glandular (is proliferation of ducts and peri-ductal tissues caused by some form of endocrine imbalance : increased estrogen, decreased androgen, receptor defects, or an change sensitivity of the breast to estrogen

2- Pseudo-gynecomastia )fatty ) is due to deposition of adipose tissue with the presence of an excessive amount of skin

IntroductionIntroductionGynecomastia classified according to the size of breast and degree of skin redundancy, Simon classification is commonly used, which Grade [1]; is minor visible enlargement without skin redundancy. Grade [2A]; is moderate breast enlargement without skin redundancy. Grade [2B]; is moderate breast enlargement with minor skin redundancy .Grade [3]; is gross breast enlargement with redundancy that a pendulous female breast

IntroductionIntroduction

Morphological Classification depend on Morphological Classification depend on NAC&IF NAC&IF


A Grad I Grad II A Grad II B A Grad I Grad II A Grad II B


Grad III Grad III


The causes of Gynacomastia may be physiological, pathological, pharmacological and Idiopathic.The complaints are embarrassment concern about outward appearance )body image(. With physical symptoms as breast enlargement, asymmetry, nipple discharge, pain, and tenderness.The treatment may be Medical aims to block estrogen effects in the breast tissue or give androgens to counteract the effects of estrogens. Surgical aims to restore the normal male chest contours by many surgical techniques as liposuction ,subcutaneous mastectomy and breast reduction.


Liposuction of Gynacomastia .

The first surgical procedures used to treat

Gynacomastia were excisional in nature. Temourian

and Perlman 1982 introduced the liposuction

technique as a tool in the treatment of Gynacomastia .


GynacomastiaGynacomastia Mechanism of Mechanism of liposuctionliposuction

Superficial liposuctionSuperficial liposuction : : ByBy, 3mm cannula. , 3mm cannula. ActionAction, ,

dissection of breast parenchyma from the skin so dissection of breast parenchyma from the skin so promote skin contraction.promote skin contraction.

Deep liposuctionDeep liposuction: : ByBy 4mm cannula. 4mm cannula. ActionAction, , dissection of glandular tissue from pectoral fascia .dissection of glandular tissue from pectoral fascia .

Injected tumescentInjected tumescent: has roles : has roles 1) Dissecting effect by volume of the saline1) Dissecting effect by volume of the saline2) Hemostatic effect by adrenalin.2) Hemostatic effect by adrenalin.3)Analgasic effect by zylocain.3)Analgasic effect by zylocain.4)Lipolytece effect help the dissolving fat cell4)Lipolytece effect help the dissolving fat cell


Tumescent liposuction

Technique for liposuction solution in which a large volume of the fluid ( 3-4 ml of estimated milliliter of expected aspirate) is injected in to the breast fat raising

the breast area to become turgid and firm .

The advantages: The blood loss is approximately 1% of the aspirated

volume . Provides local anesthesia to large volumes of subcutaneous fat and thus permits liposuction totally by local anesthesia..


Techniques of liposuction can be used in Techniques of liposuction can be used in

management of gynecomastiamanagement of gynecomastia

Suction Assisted Liposuction (SAL).Suction Assisted Liposuction (SAL).

Ultra sound Assisted liposuction (UAL)Ultra sound Assisted liposuction (UAL)

Power Assisted Liposuction (PAL)Power Assisted Liposuction (PAL)

Laser Assisted liposuction (LAL)Laser Assisted liposuction (LAL)

Radiofrequency-assisted liposuction (RFAL)Radiofrequency-assisted liposuction (RFAL)


Suction Assisted liposuction Done by infiltration the tumescent and a suction

cannula was inserted through the same incision, electrical suction connects with suction cannula.Advantage :effective in young patients with soft

breast tissue enlargement. leads to acceptable degree of satisfaction.Disadvantage : not all types of gynecomastia can

be treated with conventional liposuction. The most common complication is a residual lump. it is not associated with a significant disadvantage .


Ultra sound Assisted liposuctionUltrasonic energy is generated from electrical energy through a piezoelectric crystal. Applied to adipose tissue, this energy creates a cavitation phenomenon that causes the cellular destruction of the adipocytes.Advantages :No early postoperative complications. less traumatic.Effective in all grades .Facilitate the removal of dense fibrotic parenchymal tissue, Allowing for skin retraction, and less physical effort is needed Disadvantages Disadvantages : : Need prolonged operative time Need prolonged operative time


Power Power Assisted liposuction Removal of breast tissue by using vibrating micro-cannulas travel between 2000 and 4000 cycles/min .

Advantages : The ductal and stromal tissue can be removed using tumescent PAL (not limited to the removal of fat only but applied to remove enlarged glands in Gynacomastia ) Decrease surgeons physical effort a ‘‘no sweat’’ technique.

Disadvantages: still provides the feel of manual liposuction


Laser Laser Assisted liposuction Laser energy delivered through a small cannula that

aids in the coagulate thermal destruction of adipose and glandular tissue and stimulates collagen contraction.Advantages:

Hemostatic effect for vessel coagulation. Photo-thermal disruption of fat cell. Stimulating skin tightening through thermal collagen contraction Disadvantages : Much heat to the surrounding

tissues cause swelling, bruising, burns and numbness


Radio-frequency Radio-frequency Assisted liposuction The delivery of a controlled amount of RF energy through breast tissue resulting in fat liquefaction, sub-dermal contraction and hemostasis.Advantages: Strong coagulation, liquefaction and

aspiration of glandular tissue, Strong soft tissue contractionDisadvantages: Higher lidocaine concentrations are

required for effective analgesia when performing this procedure due to the delivery of higher energy by the device to the tissues


Classification of The Role of liposuction in idiopathic Gynecomastia

Liposuction alone: indicated in Psudo-gynecomastia GI,II.

Liposuction combined with surgical approaches indicated in : A- True (glandular in nature) &Mixed GI, II gynecomastia . By Liposuction with surgical excision of the residual glandular tissue.

B- Grad III gynecomastia . By liposuction with Surgical resection of excess skin (Breast reduction).


Examples for Surgical excision& Examples for Surgical excision& Resection approachesResection approaches

For glandular excision For glandular excision :Pre areola ,hemi :Pre areola ,hemi circular ,pre dermal incision . pull through circular ,pre dermal incision . pull through tech, Arthroscopic shaver technique.tech, Arthroscopic shaver technique.

for skin excess resectionfor skin excess resection::( Banally tech): complete circume areola ( Banally tech): complete circume areola decortications +purse string suture .decortications +purse string suture .keyhole design .Free areola and nipple graft keyhole design .Free areola and nipple graft Inferior pedicel reduction mammoplasty .Inferior pedicel reduction mammoplasty .


Complication of liposuction GynacomastiaNo early sever post liposuction complication.Show minor and short-term complications that

resolve on their own or with little additional treatment include small hematomas, seromas, minor contour irregularities, hyperesthesia, parenthesis, edema, ecchymosis, bruising and infection all usually resolve quickly.

Anesthetic complications of general and regional anesthesia as lidocain toxicity.

Allergic reactions to the components of tumescent

Aim of the WorkAim of the Work

- This descriptive study is designed to evaluate the role of liposuction in management of idiopathic Gynacomastia by the assessments of: The frequency of the complication of liposuction in management of Gynacomastia. The efficacy of liposuction in giving cosmetically result in management of gynecomastia .

The present study The present study is Non experimental (observational ) :Descriptive Study done in plastic surgery Unit in General Surgery Department Of Zagazig University .

According to CI , the total number of the cases with inclusion Criteria are (18 ) patients with idiopathic Gynacomastia were operated upon as sample size in our study in the period between January 2015 & July 2015.

Our patients classified in to two groups according to Simons classification: according to breast size and skin excess.

Group I : Patient with Simon grade I .

Group II : Patient with Simon grade II (IIA---IIB ) .

performed in the period from October 2014 to march 2015 in Intensive Care performed in the period from October 2014 to march 2015 in Intensive Care

Unit of Internal Medicine in Zagazig University Hosptials . Subjects included in Unit of Internal Medicine in Zagazig University Hosptials . Subjects included in

this study were divided into three main groups patients with hepatorenal this study were divided into three main groups patients with hepatorenal

syndrome (n=20), cirrhotic patients with normal kidney function (n=10) and syndrome (n=20), cirrhotic patients with normal kidney function (n=10) and

control group (n=10).control group (n=10).

Patients and MethodsPatients and Methods

Inclusion criteria Inclusion criteria :1- Idiopathic Gynacomastia .

2- The age rang in between (15 -40) years.3- Developed by the age or Wight gain.

4- Developed by failure of medical treatment.

Exclusion criteria:

1-Chronic pulmonary, liver, renal diseases .2-Drug administrated, Neoplasm, Hormonal

imbalance,physiological, pharmacological, metabolic causes


Exclusion criteriaExclusion criteria

Patients excluded from this study were patients with Patients excluded from this study were patients with

hepatocellular carcinoma, liver transplant patients , hepatocellular carcinoma, liver transplant patients ,

kidney transplant patients and history of other renal kidney transplant patients and history of other renal

troubles.troubles.


A( History takng

All subjects in the study will be subjected to:All subjects in the study will be subjected to:


ResultsResults

show demographic distribution of patients in show demographic distribution of patients in three groupsthree groups

P t Group3

(n=10)

Group2

(n=10)

Group1

(n=20)

5 6 14 M 0.5 0.44

5 4 6 F

Sex

0.779 0.283 56.50 56.30 56.45 Age

ResultsResultsshows ANOVA study of patient lab distributed shows ANOVA study of patient lab distributed

between three main groupsbetween three main groups

ResultsResults

distibution of copeptin and creatinine distibution of copeptin and creatinine between three main groupsbetween three main groups

P F Group 3 Group 2 Group 1

0.000* 87.582 2.3±0.31 3.6±0.99 7.3±1.11 Copeptin

mean (±SD)

0.000* 41.007 1.03±0.31 1.11±0.30 2.13±0.65 Creatinine

mean (±SD)

ResultsResultsshow post Hoc test to determine the difference in the three main show post Hoc test to determine the difference in the three main groups according to different parameters of significant differencegroups according to different parameters of significant difference

ResultsResults

box plot of copeptin level distributed between three box plot of copeptin level distributed between three main groupsmain groups

ResultsResults

Roc curve of copeptin level between group 1&3Roc curve of copeptin level between group 1&3

ResultsResults

The ethetic outcome rate:

ResultsResults

shows Roc curve of copeptin between group 1&2shows Roc curve of copeptin between group 1&2

ResultsResults there is a positive correlation between the esthetic outcome

rates and patient satisfaction in general

Ethetic_outcome_Overall_satisfied40.0038.0036.0034.00

Satis

f_To

tal

10.00

9.80

9.60

9.40

9.20

9.00

ResultsResults

correlation between serum copeptin and other parameter in correlation between serum copeptin and other parameter in patients with hepatorenal syndromepatients with hepatorenal syndrome

ResultsResults

distribution of study subjects as regard Child-distribution of study subjects as regard Child-Pugh classification in group 2&3Pugh classification in group 2&3

p Child c (n) Child b (n)

11 9 Group 1

6 4 Group 2 0.794

17(57.7%) 13(43.3%) Total (%)

ConclusionConclusion

Full clinical examination was done . Laboratory Full clinical examination was done . Laboratory

investigations: They were done according to the investigations: They were done according to the

methods applied in the clinical pathology and methods applied in the clinical pathology and

laboratories of Zagazig University hospitals and laboratories of Zagazig University hospitals and

included: complete blood picture, liver function included: complete blood picture, liver function

tests, kidney function tests, coagulation profile (PT, tests, kidney function tests, coagulation profile (PT,

PTT, and INR) and ABG.PTT, and INR) and ABG.


Specific investigations include serum copeptin Specific investigations include serum copeptin

level and complete urine analysis. Radiological level and complete urine analysis. Radiological

investigation: pelvi- abdominal ultrasound with investigation: pelvi- abdominal ultrasound with

special comment on both kidneys.special comment on both kidneys.



The results showed that:The results showed that:

Copeptin is significant high in patient with Copeptin is significant high in patient with

hepatorenal syndrome than neither cirrhotic nor hepatorenal syndrome than neither cirrhotic nor

healthy individual healthy individual

Copeptin is correlated with declining renal Copeptin is correlated with declining renal

function in hepatorenal syndrome function in hepatorenal syndrome

RecommendationsRecommendations

Early detection of hepatorenal syndrome Early detection of hepatorenal syndrome

help in preventing bad outcome of such case.help in preventing bad outcome of such case.

Further studies will be needed to determine Further studies will be needed to determine

ability of use copeptin as biomarker of renal ability of use copeptin as biomarker of renal

failure in hepatorenal syndrome.failure in hepatorenal syndrome.

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