1. Dr Venkataram Mysore-Dr Jayashree Venkataram Venkat Charmalaya-centre for advanced dermatology Bangalore www.bangaloreliposuction.com www.bangalorehairtransplant.com

2. Gynaecomastia is a common condition causing psychological disturbance and social embarrassment

3.  Puberty  Steroid abuse  Obesity  Tumours  Genetic disorders  Chronic liver disease  Side effects of many medications  Castration  Klinefelter Syndrome  Gilbert's Syndrome  Aging

4.  In most cases, underlying cause cannot be found  Tamoxifen, Danazol has been found to be useful for oestrogen sensitive gynaecomastia  However, treatment of the condition is usually by surgery

5.  Liposuction, surgical resection are suggested as the surgical techniques

6.  Studies have suggested that liposuction or suction lipectomy alone is an excellent treatment

7.  In Indian culture, dress code for men demands that, during religious occasions, visit to temples, marriages, breast area is exposed  Limitation of outdoor activities such as swimming, while playing sports, Gymnasium  Limitation in wearing tight shirts  Source of embarrassment for students in hostels with common baths Gynaecomastia-Situation in India

8.  There are very few centres in India performing tumescent liposuction alone.  655 liposuction surgeries from 2004-2013  MALE vs FEMALE: 333:322 WOMEN were more than MEN; marginally Our Experience Our Experience

9.  BREAST  ABDOMEN  Flanks  Thighs  Buttocks  Arms  CHIN MALE breast was the most common indication

10.  Mild( with prominence of central part of breast and nipple areas only)  Moderate( prominence of entire breast region without skin hanging)  Severe( prominences of entire breast area with hanging resembling female breast).

11.  Mild  Moderate  Severe

12.  Most patients were in the age group of 15-30 years.  Four patients below 20 years  Youngest was 15 years in age (was counseled with parents )  Oldest patient was 60 years-

13.  Routine blood investigations such as blood counts, Coagulation profile, LFT, Blood sugar, HbS Ag, HIV - and ECG, Ultrasound in moderate & severe male breasts  Advice to stop smoking  Avoidance of oral NSAIDs  Preoperative tranquillizer such as diazepam or lorazepam on the night before surgery  Injection Vitamin K to minimize postoperative bruising

14.  Preoperative evaluation by ultrasound was performed in all the moderate and severe cases of gynaecomastia  Most cases had an admixture of fat and glandular tissue  Severe cases had predominant glandular tissue

15.  a) Preoperative antibiotic such as cephalexin  b) Preoperative tranquillizer such as oral lorazepam 1 mg  c) Oral Clonidine 0.1 mg to prevent epinephrine induced tachycardia and as an adjuvant anxiolytic drug.

16.  Surgical cleaning of the area with povidone iodine  The area for liposuction is topographically marked, with marker ink of different colours to delineate the bulges and asymmetry

17. Monitoring-we have a standby anesthetist for emergencies

18.  NUMBER : 1-2 on each side  SIZE : 2 to-2.5mm  PLACEMENT: We avoid upper medial quadrant in breast as this area is seen when shirt is not buttoned as it is more prone for Keloid

20.  Infiltration microcannulae have diameter of 0.5-1 mm  Aspiration microcannulas have an outside diameter upto 2.8 mm.  Cause less bleeding as they are small and hence safer

21.  We use power Assisted Liposuction-Microair, Euromi machines are available  No thermal component  We have found that it reduces surgeons strain and fatigue  Cuts short Surgery time

22.  We use Nd yag laser for lipolysis for additional benefit.  Laser can access difficult areas  Laser also helps reduce fat and induce tightening of skin to prevent hanging

23.  Amount of fat aspirated was between 1 - 4 liters, with an average of 2.5 liters  Duration of surgery was between 2 -4 hours

24.  In patients with severe gynaecomastia, an additional larger adit of 6 mms was placed, just adjacent to areola and the fibrofattyglandular tissue was extracted and excised.  This greatly reduced the subareloar lump

25. Severe gynaecomastia-result after liposuction and extraction

27.  No suturing of adits in most cases  In severe cases, which need manual extraction, we put an infraareolar incision which is sutured  This facilitates drainage of fluid  Tight pressure bandages are essential to ensure proper drainage of the tumescent fluid.  Pt goes home the same day

28.  ANTIBIOTIc  PARACETAMOL  PROXYVON

29.  Patient is advised to come for follow up for dressing daily for two days.  More than 50% of results will be seen on day 2  Further improvements happen gradually due to breakdown and absorption of fat  Final result is seen after 4-6 weeks

30. Clinical Results

40.  All patients had uneventful recovery with out any serious side effects.  Post operative pain and tenderness were mild in all patients.  Adit sites healed well in all patients

41.  No sagging was seen except in patients  Even in severe cases, there was no obvious hanging and the resultwas mild and was acceptable to patients.

42.  Tumescent liposuction is a very safe and effective surgery for gynaecomastia  Thorough tumescence and use of microcannulae are important for safety  Most cases can be treated effectively, without the need for more aggressive and expensive surgery  Severe Gynaecomastia needs additional extraction through a juxtaareolar adit  Skin hanging is not a significant problem except in the severe cases

45.  Dr venkataram MD DNB DipRCPAth(Lond)- Consultant Dermatosurgeon. Past President of Assn of Cutaneus Surgeons India  Dr Jayashree Venkataram MRCOG Liposuction Surgoen trained with Dr Jeffrey Klein