| BackgroundGynecomastia is a common endocrine disorder,caused by a few physiological and pathological factors and characterized by benign enlargement of breast tissue in males.It was estimated that about 30-70%of males were affected to different extents by gynecomastia,and especially in the following three different age populations:newborns,adolescents,and men older than 50 years of age.Gynecomastia in adolescence is about 70%,and 1/3 to 2/3 adults male can be touched obvious breast tissues.Gynecomastia cases frequently present social and psychological difficulties such as low self-esteem or shame for the appearance.A study showed that over 80%of patients who chose to undergo surgery were worried about self confidence and emotional distress.Treatment for gynecomastia includes medical therapy,radiation therapy and surgical therapy.Medical therapy of gynaecomastia will probably be ineffective.Owing to the increased risk of breast cancer related to radiation exposure,radiation treatment of the breast tissue has been less tried.Mastectomy by surgery including conventional subcutaneous mastectomy(CSM)and endoscopic subcutaneous mastectomy(ESM)is the main strategy and always the final choice for most gynecomastia.Conventional surgery causes obvious scar and complications,and poor cosmetic outcome always leads to unsatisfaction,leaving an obvious large scar and causing a series of physiologic and psychologic impact that could be worse than the original deformity.Moreover,reoperation and nipple-areolar necrosis were often observed or reported.Since first introduced in 1992,ESM has been performed in an increasing number of institutions as a safe,appropriate approach to treating this problem.ESM resulted in better cosmetic effects and good clinical outcomes for gynecomastia.Because of the limited surgical space,ESM is a relatively more technically complex procedure,especially for unskilled surgeons,which leads to clashing instruments,sometimes called "sword fighting".Currently,whether ESM can replace CSM is lack of research support,and there is no research to confirm the relationship between learning and efficiency in ESM for gynecomastia.Therefore,we tried to analyze the clinical data of gynecomastia in our hospital,comparing the ESM and CSM,evaluating the safety and efficacy of ESM.And we we conducted a single-center case-control study evaluate ESM by its learning curve and identifying the risk factors related to the surgical outcomes.Obejects:1.Evaluate the safety and efficacy of ESM by comparing the ESM and CSM2.Prospective analysis of learning curve for ESM3.Explore the factors of learning curve for ESM.Method:1.PatientsFrom April 2005 to June 2016,patients diagnosed as gynecomastia underwent surgery at the Second Hospital of Shandong University(Jinan,China).All patients meeting the following inclusion criteria were included in our study:(1)Preoperative ultrasonography showed evident glandular component within the breast.(2)There was no obvious scar on the chest.(3)Patients accepted operation were finally included in this study.Exclusion criteria were(1)Presence of contraindications for conventional surgery(e.g.,severe arrhythmia,heart functional disturbance,hemorrhagic tendency).(2)Pseudogynecomastia and breast cancer confirmed by pathology examination.(3)Patients refused surgery were excluded.2.Data collectionThe following clinical records were documented and collected from the consecutive patients:age,nationality,body mass index(BMI),major axis of the breast,breast width,breast height,unilateral operative time,unilateral drainage volume,unilateral extubation time,hospital stay,nipple-areola complex postoperative appearance,pictures and video,financial records,pathology,long-term follow-up information.The information of patients after December 2013 is prospectively collected,while the information of patients before December 2013 is retrospectively collected.ESM is developed in December 2013 in our hospital,so the information of patients is totally prospectively collected.3.Operative procedure and techniqueIn the ESM group,operations were carried out under general anesthesia.Operation was divided into 3 consecutive steps:lipolysis and liposuction,excision of Cooper ligaments and removal of excised breast tissues.In the CSM group,operation was divided into 3 consecutive steps:crescent-shaped incision in periareolar superior area of the breast,excision of the glandular tissue,excision of post nipple-areolar area.4.Statistical analysisWhen carrying on the difference analysis of hospitalization cost,we used the consumer price index(CPI,Health Care and Personal Articles)which was from National Bureau of Statistics of China to discount and converted it into a unified value before comparing them.The learning curve was analyzed by the moving average method,with a 10-case moving average introduced,which could make the change shift smoothly.The cases were classified into a learning stage(LS)group and a master stage(MS)group,based on the point at which the curve reached its platform level.Univariate logistic regressions were performed to identify the risk factors related to clinical outcomes.The odds ratios(OR)and 95%confidence interval(95%CI)were calculated to estimate the associated risk factors.For categorical and continuous parametric variables,the ?2 and t tests,respectively,were used to compare the differences between groups.All analyses were performed with SPSS version 21.0 software.A value of P<0.05 was considered to indicate statistical significance.Results1.Detailed characteristics of the patientsBetween April 2005 and June 2016,a total of 154 patients with 244 breasts were included,among which 68 patients(120 breasts)underwent CSM and 86 patients(124 breasts)underwent ESM.2.Clinical outcomes between ESM and CSM 2.1 Detailed characteristics of the patients Compared with CSM,the mean age of ESM was smaller(36.17±18.41 vs.26.18±10.50,p<0.05).The mean of breast major axis by physical examination and by ultrasonograpy in the ESM group was longer,respectively(6.54±4.13 vs.8.10±2.85,p<0.05;4.02±2.33 vs.4.98±2.45,p<0.05).2.2 Operative information of the patientsIn our study,the duration of unilateral operation of ESM was longer than that of CSM(68.63±28.74 min vs.110.37±28.80min,p<0.05).No statistical difference was observed between the two groups,in the aspects of unilateral postoperative drainage time,unilateral drainage volume,postoperative hospital stay and hospital stay.2.3 Details of postoperative appearance results Significant differences of the complications(p<0.05)and nipple-areolar complex appearance(p<0.05)were observed between ESM and CSM groups.No complication such as postoperative bleeding,postoperative infection and cracking of incision occurred in the ESM group.The rate of nipple-areolar complex ischemia was higher in ESM group than CSM groups(25.8%vs.14.5%).2.4 Details of follow-up resultsPatients from ESM group reported significantly higher overall satisfaction score,satisfaction score of postoperative mammary appearance and self-esteem score than those from CSM group,with a mean score of 9.21 vs.8.37(p<0.05),9.128 vs.8.11(p<0.05)and 9.21 vs.8.52(p>0.05)respectively.2.5 Details of hospitalization cost resultsMedicine fees,treatment fees,material fees and total charge among patients between ESM and CSM had not statistical significance.Operation fees among patients from ESM were higher than those from CSM(3790.00±355.21 ? vs.3192.54±657.59 ?,p<0.05).3.Learning curve and the factors of learning curve in ESM3.1 Detailed characteristics and surgical outcomes between LS and MS The overall learning curve reached its platform level at the 10th operation,at which point we divided the cases into two stages:the LS group(the first 1-10 breasts)and the MS group(the next 11-120 breasts).There were significant differences between the two groups regarding the unilateral operation duration(168.75±59.41 vs.105.07±16.52 min,p<0.05).3.2 Detailed characteristics and surgical outcomes between a prolonged-duration group and a shorter-duration group in MSThe drainage volume and extubation time among patients in the prolonged-duration group were longer than those in the shorter-duration group:117.02±60.43 vs.148.20±66.93 ml(p<0.05)and 5.15±1.31 vs.5.76±1.51 days(p<0.05),respectively.3.3 Univariate logistic regression of the prolonged-duration group in MS Overweight/obesity(BM1>25 kg/m2)was the only factor associated with a prolonged duration:OR 2.45;95%Cl 1.08-5.57(p=0.032).Conclusion1.In our study,compared to CSM,ESM is an effective,safe approach to treating gynecomastia.2.ESM provided satisfactory cosmetic effects and good clinical outcome3.An obvious learning curve was observed for surgeons performing ESM.ESM seemed simpler and easier to master.But overweight/obesity was associated with a prolonged unilateral operation period.4.ESM may become one of alternative treatment to treat gynecomastia. |
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