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Page 2 of 9 Mok et al. Mini-invasive Surg 2019;3:40 I http://dx.doi.org/10.20517/2574-1225.2019.39

INTRODUCTION
Surgical techniques in gynaecomastia treatment have evolved over the years towards less invasive
[1]
approaches such as liposuction . However, in patients with larger amount of tissue or ptotic breast,
[2]
subcutaneous mastectomy is still more effective in removing excess glandular tissue . The downside
[3]
to subcutaneous mastectomy are the resulting large, long and often unsightly scars . Endoscopic
[4,5]
subcutaneous mastectomy has been described in the literature where it is commonly performed via
three incisions along the mid-axillary line or a single incision in the axilla and the specimen will be
morcellated and suctioned out thereafter. Single-port nipple-sparing mastectomy using three-dimensional
[6]
(3D) endoscopic system in the management of breast cancer was recently reported and the authors
describe the advantage of enhanced 3D visualisation in the conduct of the operation, allowing precise
plane recognition and dissection. In this article, the authors describe the use of single-port 3D endoscopic-
assisted subcutaneous mastectomy in the management of gynaecomastia.

TECHNIQUE
Preoperative markings and positioning
Preoperative markings were performed with the patient in standing and sitting position [Figures 1 and
2]. Extent of dissection was determined with comparison to the contralateral (non-gynaecomastia) side.
Under general anaesthesia, patient was then placed in a supine position with ipsilateral arm abducted at
90° [Figure 3]. The ipsilateral shoulder was then elevated to 30° to facilitate access for the operation.

Tumescent injection
Methylene blue gel was used to mark the extent of dissection to aid in identification during subsequent
endoscopic dissection. A saline solution containing lignocaine 0.05% and epinephrine 1:1,000,000 was
injected subcutaneously into the whole breast to minimise bleeding.

Skin flap dissection
Following that, a 3-cm incision was made over the extra-mammary region near the anterior axillary line
at the level of nipple areolar complex (NAC). A working space of 4-5 cm was created by dissecting the
subcutaneous flap under direct vision to allow subsequent placement of the single port. After creation
of working space, subcutaneous tunnelling/blunt dissection of the anterior skin flap with Metzenbaum
scissors was performed to aid in subsequent skin flap dissection. Following that, posterior dissection of
breast parenchyma off pectoralis major fascia was performed under endoscopic guidance with endoscopic
vein harvester [Figure 4]. Thereafter, the single port was placed with CO insufflation kept at a pressure of
2
8 mmHg. A 30° 10-mm diameter camera TIPCAM 1 S- 3D VIDEO Endoscope (KARL STORZ, Germany),
5-mm laparoscopic Metzenbaum scissors, curved (Applied Medical, USA) and 5-mm laparoscopic grasping
forceps were used to conduct the operation [Figure 5].

Endoscopic subcutaneous mastectomy
Endoscopic dissection commenced from superficial skin flaps in all quadrants with the septa between
skin flap and parenchyma dissected using laparoscopic Metzenbaum scissors [Figures 6 and 7]. During
skin flap dissection, a 30° upward facing 3D endoscope with reverse imaging was used to produce a clear
3D image. The angle and field of vision could be adjusted with upward, downward or reverse motion of
the image by the 3D endoscope when deemed necessary. Tissue beneath the NAC were intentionally left
thicker to prevent nipple retraction as well as preserve the blood supply to NAC, thereby reducing the risk
of NAC necrosis [Figure 8]. With 3D visualisation, blood vessels could be clearly visualised and hence
preserved [Figure 9]. After completion of superficial skin flap dissection, peripheral dissection was carried