Gynecomastia is the benign proliferation of male breast glandular tissue and is usually driven by a relative excess of oestrogenic stimulation, reduced androgenic effect, or altered tissue responsiveness. The clinical spectrum is broad. Some men have a small, painless subareolar disc, while others develop conspicuous enlargement, tenderness, skin excess, or asymmetry that becomes difficult to conceal. Persistent disease is not merely an aesthetic concern, because it can prompt anxiety about malignancy and may impair social confidence, clothing choices, exercise, and intimate relationships.[1] The biological basis of the condition is equally varied. Physiological change during puberty, obesity-related aromatisation, medication exposure, hypogonadism, liver or renal disease, and endocrine tumours may all alter the oestrogen-androgen balance. A careful history and examination therefore come before operative planning. True glandular enlargement must be separated from pseudogynecomastia, and suspicious unilateral or eccentric masses require further assessment.[2] Surgery is generally considered when enlargement persists, causes pain or psychosocial distress, or contains a fibrotic component unlikely to respond to conservative treatment. Preoperative assessment is intended to identify reversible causes, define the relative proportions of fat and gland, assess skin redundancy, and align the chosen operation with the patient's expectations.[3] This step has particular practical value in Indian public hospitals, where late presentation, variable access to endocrine evaluation, and cost-sensitive follow-up can shape both treatment selection and postoperative care.[4] The psychosocial burden can be marked even when physical severity appears modest. A prospective case-control study in adolescents found impairment in social functioning, mental health, and self-esteem, supporting the view that treatment decisions should not be based on breast size alone.[5] Once surgery is chosen, the operative strategy is usually guided by breast volume, skin excess, tissue consistency, nipple-areola position, and scar tolerance. Simon and colleagues classified gynecomastia according to enlargement and skin redundancy, creating a practical framework that remains widely used in surgical reporting.[6] Liposuction is attractive in fat-predominant disease because it uses small incisions and allows broad contouring. Direct subcutaneous mastectomy, by contrast, provides reliable access to a dense retroareolar gland, although wider dissection may increase pain, haematoma risk, or contour irregularity. Modern algorithms increasingly treat these operations as complementary rather than mutually exclusive.[7] Direct comparative evidence remains limited, and outcomes are often reported with different definitions of success. The present study compared liposuction and subcutaneous mastectomy in terms of breast size reduction, postoperative pain, recovery, complications, and patient satisfaction among men treated for grade II or III gynecomastia.

Study design and setting A prospective comparative observational study was conducted in the Department of General Surgery in collaboration with the Department of Plastic Surgery at Government Medical College and Hospital, Cuddalore. The institution functions as a tertiary-care teaching and referral centre for surrounding rural and urban populations. The study period was 18 months and covered recruitment, preoperative assessment, surgery, and postoperative follow-up. Study population and sample Men aged 18 years or older with clinically diagnosed gynecomastia who sought operative treatment were screened. An initial sample estimate of 43 was obtained using a single-proportion approach. During the study period, 40 eligible participants completed enrolment and were included in the comparative analysis, with 20 patients in each treatment group. Eligibility criteria Patients were included when the diagnosis was clinically established, they were fit to undergo anaesthesia and surgery, they consented to operative management, and they were able to attend scheduled follow-up. Exclusion criteria were grade I gynecomastia, secondary gynecomastia related to endocrine disease, liver disease, renal failure, or medication exposure, previous chest surgery, traumatic chest deformity, major cardiopulmonary comorbidity, coagulation disorder, suspected malignancy, unwillingness to participate, or inability to comply with follow-up. Preoperative assessment and allocation A structured history recorded duration of enlargement, symptoms, relevant medication use, systemic illness, and psychosocial effects. General and local examinations assessed breast enlargement, tissue consistency, skin redundancy, symmetry, and nipple-areola position. Complete blood count, renal and liver function tests, coagulation profile, and clinically indicated imaging were obtained to establish surgical fitness and exclude secondary pathology. Gynecomastia was graded using Simon classification. Participants were allocated equally to liposuction or subcutaneous mastectomy. Operative procedures In the liposuction group, tumescent solution was infiltrated into the subcutaneous plane. Suction-assisted lipectomy was then performed through small access incisions with standard cannulas. Fat removal was distributed across the enlarged breast and adjacent chest contour, with repeated assessment of symmetry and surface smoothness. In the subcutaneous mastectomy group, glandular tissue was approached through a periareolar or transareolar incision. The hypertrophied tissue was excised under direct vision until a flatter chest contour was obtained, and haemostasis was secured. Adjunctive liposuction was used in selected excision cases when additional contour refinement was considered necessary. Postoperative care and follow-up Postoperative management included analgesics, antibiotics, and a compression garment. Drains were used when required and removed according to output. Patients were reviewed during the immediate postoperative period and at scheduled visits thereafter. Assessments included wound healing, postoperative pain, return to normal activity, haematoma, seroma, infection, contour irregularity, breast contour, and patient satisfaction. Follow-up was directed towards early and short-term postoperative outcomes; long-term recurrence was not included as an analysed endpoint. Outcome measures The principal effectiveness measure was reduction in breast size. Other outcomes were postoperative pain measured on a visual analogue scale, number of days required to resume normal activities, presence of postoperative complications, and cosmetic satisfaction measured on a 10-point scale. The relationship between postoperative pain and satisfaction was also examined. Statistical analysis Data were entered in Microsoft Excel and analysed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as mean±standard deviation, while categorical variables were summarised as frequency and percentage. One-way analysis of variance was used for continuous comparisons between the two groups, and the chi-square test was used for categorical comparisons. Pearson correlation assessed the association between pain and satisfaction. A two-sided p value below 0.05 was considered statistically significant. Ethical considerations Written informed consent was obtained from all participants before enrolment and surgery

Forty men were analysed, 20 after liposuction and 20 after subcutaneous mastectomy. Age ranged from 18 to 40 years. The mean age was 26.8±4.9 years in the liposuction group and 27.6±5.3 years in the subcutaneous mastectomy group, without a significant difference (F=0.27, p=0.60). Mean preoperative breast size was also comparable, 6.7±1.1 cm and 6.9±1.2 cm, respectively (F=0.32, p=0.57). Grade distribution was balanced: Simon grade IIa was present in 8 and 7 patients, grade IIb in 7 and 8 patients, and grade III in 5 patients in each group (chi-square=0.82, p=0.66). These baseline findings are summarised in Table 1, while the overall grade composition is shown in Figure 1. Table 1. Baseline demographic and clinical characteristics Characteristic Liposuction (n=20) Subcutaneous mastectomy (n=20) Test statistic p value Age (years), mean±SD 26.8±4.9 27.6±5.3 F=0.27 0.60 Preoperative breast size (cm), mean±SD 6.7±1.1 6.9±1.2 F=0.32 0.57 Simon grade IIa, n (%) 8 (40.0) 7 (35.0) Simon grade IIb, n (%) 7 (35.0) 8 (40.0) chi-square=0.82 0.66 Simon grade III, n (%) 5 (25.0) 5 (25.0) SD: standard deviation. Percentages are calculated within each treatment group The donut chart presents the combined grade distribution for all 40 participants; counts and percentages are displayed within segments. Both operations produced substantial reduction in breast size. Mean reduction was 4.3±0.9 cm following liposuction and 3.9±1.0 cm following subcutaneous mastectomy; the difference did not reach statistical significance (F=1.89, p=0.17). Postoperative experience differed more clearly. Mean VAS pain score was 3.1±0.8 after liposuction and 5.2±1.1 after subcutaneous mastectomy (F=42.6, p<0.001). Patients returned to normal activity after 6.4±1.2 days and 10.1±1.5 days, respectively (F=68.5, p<0.001). Satisfaction was higher following liposuction, with mean scores of 8.9±0.9 compared with 7.1±1.2 after subcutaneous mastectomy (F=30.4, p<0.001). Table 2 presents these comparisons. Figure 2 contrasts postoperative pain and satisfaction on their common 0-10 scale, and Figure 3 depicts the difference in recovery time. Table 2. Comparative postoperative outcomes Outcome Liposuction Mean±SD Subcutaneous mastectomy Mean±SD F value p value Breast size reduction (cm) 4.3±0.9 3.9±1.0 1.89 0.17 Postoperative pain (VAS) 3.1±0.8 5.2±1.1 42.6 <0.001 Days to resume normal activities 6.4±1.2 10.1±1.5 68.5 <0.001 Patient satisfaction (0-10) 8.9±0.9 7.1±1.2 30.4 <0.001 VAS: visual analogue scale; SD: standard deviation. One-way analysis of variance was used for group comparisons. Horizontal bars show mean recovery time, with standard-deviation error bars and bold mean values. Postoperative complications were recorded in 2 patients (10%) in the liposuction group and 5 patients (25%) in the subcutaneous mastectomy group. Although the absolute frequency was lower after liposuction, the difference was not statistically significant (chi-square=1.67, p=0.19). The distribution of complication status is presented in Table 3 and Figure 4. Across the full cohort, postoperative pain showed a strong inverse correlation with satisfaction (r=-0.71, p<0.001), indicating that higher pain scores were associated with less favourable patient-rated outcomes (Table 3). Table 3. Postoperative complications and pain-satisfaction correlation Analysis Liposuction (n=20) Subcutaneous mastectomy (n=20) Statistic p value Any postoperative complication, n (%) 2 (10.0) 5 (25.0) chi-square=1.67 0.19 No postoperative complication, n (%) 18 (90.0) 15 (75.0) - - Pain score vs patient satisfaction Overall cohort Overall cohort r=-0.71 <0.001 The categorical comparison used the chi-square test. The association between pain and satisfaction was assessed using Pearson correlation.

This prospective comparison found that liposuction and subcutaneous mastectomy achieved similar reductions in breast size, yet the postoperative course was not equivalent. Liposuction was followed by substantially lower pain, earlier resumption of routine activity, and higher satisfaction. Complications were numerically less frequent after liposuction, although the study was too small to establish a statistically reliable difference. These findings are clinically plausible because suction-assisted treatment uses smaller access incisions and avoids the broader tissue dissection required for direct gland excision. Baseline comparability supports the interpretation that the observed differences were not simply a reflection of age or clinical grade. Both groups had a mean age close to 27 years, similar preoperative breast size, and nearly identical proportions of Simon grades IIa, IIb, and III. Fruhstorfer and Malata similarly emphasised that breast size, consistency, skin excess, and skin quality must be considered together, rather than allowing grade alone to determine the operation.[8] The present cohort reflects that practical middle range of disease in which either suction or excision may be technically feasible. The comparable breast size reduction is important. It suggests that, over the follow-up assessed, both approaches corrected the principal physical deformity. A 10-year surgical analysis by Handschin and colleagues also showed that several operative strategies can achieve satisfactory correction when selected according to tissue characteristics and severity.[9] Thus, volumetric reduction by itself may be an incomplete marker of success. A patient may obtain a flatter chest after either procedure but experience a very different burden of pain, scarring, stiffness, and recovery. Pain was the clearest differentiating outcome. The mean VAS score after liposuction was lower by more than two points, a difference that is likely to be perceptible to patients even without a formal minimal clinically important difference being defined for this setting. Colombo-Benkmann and colleagues reported that postoperative results are shaped by the indication for surgery and the selected operative method, reinforcing the need to match technical aggressiveness to the actual glandular component.[10] Limited dissection may explain the lower pain observed after liposuction, whereas periareolar or transareolar excision inevitably creates a wider operative field. Recovery followed the same pattern. Patients treated with liposuction resumed normal activity about four days earlier on average. For young adults, this interval has practical consequences. Time away from college, work, exercise, and family duties can influence whether a technically successful operation is experienced as worthwhile. Courtiss's classic series placed suction lipectomy at the centre of treatment for fat-predominant enlargement, while retaining direct excision for parenchymal hypertrophy that suction cannot remove.[11] The present results support that distinction: liposuction has a recovery advantage when the anatomy permits it, but it should not be extended to dense glandular disease merely to avoid an incision. Patient satisfaction was also higher after liposuction. Small scars, smoother contour transitions, reduced pain, and quicker social reintegration probably contribute together. Petty and colleagues described an evolving treatment paradigm in which surgical technique is selected and combined to improve contour while limiting visible morbidity.[12] This is relevant because aesthetic satisfaction is not determined only by the amount of tissue removed. Residual subareolar prominence, a saucer deformity from excessive excision, asymmetry, scars, and prolonged tenderness can each outweigh an otherwise adequate reduction. The role of hybrid treatment deserves attention. In selected patients within the excision group, adjunctive liposuction was used for contour refinement. Lista and Ahmad reported favourable outcomes with power-assisted liposuction combined with a pull-through excision technique, illustrating how fat removal and gland extraction can be integrated through limited access.[13] Such combined procedures are particularly useful when the breast contains both diffuse adipose excess and a firm retroareolar component. They also make a simple binary comparison between liposuction and mastectomy less representative of contemporary practice. Complications occurred in 10% of liposuction patients and 25% of subcutaneous mastectomy patients, but the difference was not statistically significant. With only seven total events, the estimate is imprecise and should not be interpreted as proof of superior safety. Patient-reported outcomes can also be less uniformly favourable than surgeons expect. Ridha and colleagues found that satisfaction after gynecomastia reduction was not universally high, underscoring the importance of preoperative counselling, realistic expectations, and structured postoperative review.[14] In this study, the strong inverse correlation between pain and satisfaction suggests that perioperative comfort itself forms part of the cosmetic outcome. The broader evidence base remains methodologically limited. Fagerlund and colleagues found that published studies were predominantly non-randomised and carried a high risk of bias, despite generally favourable surgical results.[15] More recently, a systematic review of complications showed that morbidity varies across aspiration, excision, and combined techniques, and that comparisons are complicated by differences in grade, definitions, and follow-up.[16] The present findings should therefore be viewed as supportive comparative evidence rather than a universal ranking of procedures. Several limitations require acknowledgement. The sample was small, recruitment came from a single tertiary-care centre, and long-term recurrence could not be evaluated. The available results did not permit analysis of individual complication types, operative duration, blood loss, scar quality, or objective postoperative chest measurements. Satisfaction was assessed on a 10-point scale rather than a validated gynecomastia-specific patient-reported outcome measure. In addition, the use of adjunctive liposuction in selected excision cases may have reduced the contrast between treatment groups. Larger multicentre studies with clearly defined allocation, standardised photographs, validated quality-of-life instruments, and longer follow-up would provide more robust guidance. Even with these constraints, the clinical message is straightforward. Liposuction offers meaningful advantages in pain, recovery, and satisfaction when the breast is sufficiently fat-predominant and skin recoil is adequate. Subcutaneous mastectomy remains indispensable for dense, fibrotic, or advanced glandular enlargement. The safest decision is therefore not to declare one operation universally superior, but to select the least invasive technique that can reliably remove the tissue responsible for the deformity.

Liposuction-assisted subcutaneous mastectomy provides an effective and comprehensive approach to the surgical management of gynecomastia by combining effective glandular tissue removal with improved chest contouring. The combined technique offers the advantages of both liposuction and direct excision, resulting in satisfactory aesthetic outcomes, reduced postoperative morbidity, faster recovery, and high patient satisfaction. Therefore, liposuction-assisted subcutaneous mastectomy may be considered a preferred technique in appropriately selected patients with mixed fatty and glandular gynecomastia.

1. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007;357(12):1229-37. doi:10.1056/NEJMcp070677. 2. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009;84(11):1010-5. doi:10.4065/84.11.1010. 3. Narula HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin North Am. 2007;36(2):497-519. doi:10.1016/j.ecl.2007.03.013. 4. Cuhaci N, Polat SB, Evranos B, Ersoy R, Cakir B. Gynecomastia: clinical evaluation and management. Indian J Endocrinol Metab. 2014;18(2):150-8. doi:10.4103/2230-8210.129104. 5. Nuzzi LC, Cerrato FE, Erickson CR, Webb ML, Rosen H, Walsh EM, et al. Psychosocial impact of adolescent gynecomastia: a prospective case-control study. Plast Reconstr Surg. 2013;131(4):890-6. doi:10.1097/PRS.0b013e3182818ea8. 6. Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51(1):48-52. doi:10.1097/00006534-197301000-00009. 7. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909-23; discussion 924-5. doi:10.1097/01.PRS.0000042146.40379.25. 8. Fruhstorfer BH, Malata CM. A systematic approach to the surgical treatment of gynaecomastia. Br J Plast Surg. 2003;56(3):237-46. doi:10.1016/S0007-1226(03)00111-5. 9. Handschin AE, Bietry D, Husler R, Banic A, Constantinescu M. Surgical management of gynecomastia: a 10-year analysis. World J Surg. 2008;32(1):38-44. doi:10.1007/s00268-007-9280-3. 10. Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. 1999;178(1):60-3. doi:10.1016/S0002-9610(99)00108-7. 11. Courtiss EH. Gynecomastia: analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79(5):740-53. doi:10.1097/00006534-198705000-00010. 12. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010;125(5):1301-8. doi:10.1097/PRS.0b013e3181d62962. 13. Lista F, Ahmad J. Power-assisted liposuction and the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2008;121(3):740-7. doi:10.1097/01.PRS.0000299907.04502.2F. 14. Ridha H, Colville RJI, Vesely MJJ. How happy are patients with their gynaecomastia reduction surgery? J Plast Reconstr Aesthet Surg. 2009;62(11):1473-8. doi:10.1016/j.bjps.2008.04.042. 15. Fagerlund A, Lewin R, Rufolo G, Elander A, Santanelli di Pompeo F, Selvaggi G. Gynecomastia: a systematic review. J Plast Surg Hand Surg. 2015;49(6):311-8. doi:10.3109/2000656X.2015.1053398. 16. Innocenti A, Melita D, Dreassi E. Incidence of complications for different approaches in gynecomastia correction: a systematic review of the literature. Aesthetic Plast Surg. 2022;46(3):1025-41. doi:10.1007/s00266-022-02782-1