Combined Use of Ultrasonic Liposuction with the Pull-Through Technique for the Treatment of Gynecomastia; Dennis C. Hammond, M.D., Jame F. Arnold, M.D., Amy M. Simon, M.D., and Philippe A. Capraro, M.D.

Dr. Hammond and colleagues present a novel combination of techniques in the treatment of gynecomastia. Using ultrasoundassisted liposuction and excision of the remaining fibrous breast bud in a periareolar pullthrough fashion, they report effective resolution of male breast hypertrophy. They acknowledge that their technique is a modification of the technique described by Morselli1: (1) ultrasound-assisted liposuction is used instead of suction lipectomy; (2) a periareolar incision is used instead of a combination of axillary and inframammary fold incisions; and (3) excision and ultrasound-assisted liposuction are performed through solitary periareolar incisions. Gynecomastia has traditionally been a treatment of excision, usually leaving visible, often lengthy scars, and with high complication rates.2 The periareolar incision for resection of gynecomastia has long been used as the best excisional approach to minimize scarring.3 Newer modalities including suction lipectomy and ultrasound-assisted liposuction have had the advantages of minimizing scarring and improving contour. A common problem in achieving optimal results has been the residual fibrous subareolar tissue that frequently is resistant to standard liposuction techniques. The authors should be commended for their recognition that combined modalities are often necessary for optimal correction of gynecomastia. The results shown are seen for mild to moderate grades of gynecomastia, which generally have good results with either liposuction or excisional techniques. Results were reported as a retrospective review of patient satisfaction, although they were not quantified on a scale. A more objective photographic review of resolution of breast hypertrophy is warranted. An evaluation of their results using this technique for severe cases of gynecomastia (with ptosis and skin excess) would be useful as well. The authors’ concern regarding “saucer” deformities refers to common sequelae after excision through periareolar incisions. These have been largely avoided with adjunctive or primary liposuction, which reduces or eliminates the need for extensive resection of breast tissue. The reported complications in their series included areolar scar retraction, seroma, ultrasound-assisted liposuction burns, and diminished sensation. All were reported as transient in nature, with no permanent adverse outcome. Of concern, however, is the 18.5 percent overall complication rate (five of 27 breasts). All of these complications could potentially be avoided through a modification of the authors’ technique. Early studies examined the issue of thermal injury and diminished sensation using ultrasound-assisted liposuction.4 It is recommended that radial passes from distant access incisions be used to avoid the damaging thermal effects of ultrasound-assisted liposuction (Fig. 1). The periareolar incision has disadvantages in this regard. Most of the problematic fibrous breast tissue is located in the subareolar region and is difficult to treat with a cannula tip through this incision. It is likely that because of difficulty passing the cannula through short strokes in this region, lengthy ultrasound-assisted liposuction time was required, subjecting the patient to an increased risk for burns and diminished sensation. It would be helpful for readers to have information regarding the wetting solution, the duration of ultrasound-assisted liposuction treatment, and the amount of tissue