Comparison of efficacy between the gasless and the gas-insufflation single-port transaxillary access subcutaneous mammectomy in the treatment of gynecomastia

Comparison of efficacy between the gasless and the gas-insufflation single-port transaxillary access subcutaneous mammectomy in the treatment of gynecomastia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of efficacy between the gasless and the gas-insufflation single-port transaxillary access subcutaneous mammectomy in the treatment of gynecomastia Yuqing Zhang, Huiling Wang, Jie He, Yaqin Wu, Rui Liu, Xiangyuqin Xiao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5247768/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To evaluate the clinical efficacy of gasless transaxillary versus single-port gas-insufflation transaxillary approaches in subcutaneous mammectomies for treating gynecomastia. Methods This study enrolled 46 patients diagnosed with gynecomastia from May 2022 to October 2023. Of these, 20 underwent subcutaneous mammectomy using the single-port gas-insufflation transaxillary approach (gas-insufflation group), while 26 received the same procedure through the gasless transaxillary approach (gasless group). We compared the two groups in terms of operation time, intraoperative bleeding, volume of postoperative drainage, timing of drainage tube removal, short-term postoperative complications, length of postoperative hospital stay, and medical costs. Results All 46 patients successfully completed the operation without conversion to open surgery, and pathology confirmed gynecomastia in each case. The surgical time for the gasless group was significantly shorter, averaging 38.20 ± 10.773 minutes, compared to 62.96 ± 15.311 minutes for the gas-insufflation group (P 0.05), postoperative drainage volume from one side, drain retention time, length of postoperative hospital stay, or postoperative cosmetic outcomes (P > 0.05). Conclusion This study supports the clinical feasibility of using the gasless transaxillary approach for subcutaneous mammectomy in treating gynecomastia. gynecomastia subcutaneous mammectomy endoscopic Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32–65%, depending on the age and the criteria used for definition. [ 1 ] . It arises from both physiological and non-physiological factors and is characterized by unique clinical, histological, and radiological features. Physiological gynecomastia frequently occurs in neonates, adolescents, and older men, affecting up to 70% of adolescent males [ 2 ] . Non-physiological causes include chronic diseases such as cirrhosis, hypogonadism, renal insufficiency; drug use; and rare tumors [ 3 ] . While gynecomastia is often self-limiting and asymptomatic cases typically require no specific intervention, treatment may be necessary if symptoms persist beyond one year and involve severe pain, tenderness, or psychological distress [ 4 ] . Treatment options include medication and surgery, though medication tends to be ineffective for conditions lasting over 12 months, thus necessitating surgical intervention [ 5 ] . Recently, gasless axillary access laparoscopic surgery has gained popularity in thyroidectomy due to its safety and aesthetic outcomes [ 6 , 7 ] . However, its use in treating gynecomastia remains unreported. This study aims to evaluate the effectiveness of the gasless transaxillary approach compared to the gas-insufflation single-port transaxillary approach for subcutaneous mammectomy in treating gynecomastia. 2. Patients and methods 2.1Patients In our study, patients with gynecomastia were enrolled from May 2022 to October 2023 and were assigned to either the gas-insufflation group or the gasless group according to their wishes. All procedures were performed by the same surgical team. 2.2Surgical steps Gasless Group (Underwent Gasless Transaxillary Approach Subcutaneous Mammectomy) Following successful general anesthesia, the patient was positioned supine with the operative side near the operating table's edge and the shoulders elevated. The arm on the operative side was abducted at 90 degrees, aligning with the hand tray's lower edge. A lipolytic solution of 400 ml was prepared, consisting of 200 ml saline, 200 ml distilled water, 0.2 mg epinephrine hydrochloride injection, and 10 ml of 2% lidocaine. The operation field was routinely sterilized, and a sterile towel sheet was placed. Under ultrasound guidance, 100 to 150 ml of lipolytic solution was injected into the surface of the mammary glands and retromammary space, with a 15-minute wait thereafter. A 4 cm incision was made along the transverse axillary line, about 4 cm from the axilla's top. Liposuction was performed in the retromammary space and on the subcutaneous glandular surface using a metal lateral orifice aspirator. A long-handled scalpel was utilized along the pectoral major muscle surface to free the retromammary space, followed by the insertion of a luminal pull hook and luminal mirror. The ultrasonic scalpel and electrocoagulation hook was then used to release the retromammary space and subcutaneous glandular layer, aided by the luminal mirror. The nipple and areola were carefully freed using long-handled tissue scissors, retaining a small amount of glandular tissue at the nipple's back. Hemostasis was achieved, followed by saline flushing. With no significant bleeding observed under the luminal microscope, a drainage tube was placed. The wound was sutured intermittently with a 3 − 0 absorbable suture for the subcutaneous tissue and dermis and closed with a continuous intradermal tissue suture using a 4 − 0 absorbable suture. The procedure concluded with the application of an external negative pressure drainage bulb, sterile dressing, and pressure bandage. Gas-Insufflation Group Underwent Gas-Insufflation Single-Port Transaxillary Approach Subcutaneous Mammectomy After inducing general anesthesia, the patient was similarly positioned supine with the operative side close to the edge of the operating table and shoulders elevated. The upper limb on the operative side was abducted at 90 degrees to lie flat against the hand tray. A lipolytic solution of 400 ml (200 ml saline, 200 ml distilled water, 0.2 mg epinephrine hydrochloride, and 10 ml 2% lidocaine) was prepared. The surgical field was sterilized, and a sterile towel was laid down. A curved incision of about 4 cm was made at the anterior axillary line and mammary gland edge intersection, where 150 to 200 ml of lipolytic solution was injected into the mammary gland's subcutaneous tissue and retromammary space, followed by a 15-minute wait. A non-invasive dissection stick was used to separate the breast flap up to the breast margin marking line, and the fat solution was aspirated. A disposable multi-channel single-port laparoscopic trocar was inserted and carbon dioxide gas was introduced to maintain an 8–10 mmHg pressure, creating an operating space. The nipple was suspended to assist in maneuvering. The breast tissue was separated from the pectoralis major muscle using an electrocoagulation hook, ultrasonic scalpel, and dissecting scissors, fully freeing and excising the breast glandular tissue and some fat tissue. The specimen was placed in a bag and removed through the port. After achieving hemostasis and saline flushing, with no significant oozing detected under the luminal microscope, a drainage tube was placed. The wound was sutured with a 3 − 0 absorbable suture intermittently for the subcutaneous tissue and dermis and closed using a continuous intradermal tissue suture with a 4 − 0 absorbable suture. The surgery concluded with the placement of an external negative pressure drainage bulb, sterile dressing, and pressure bandage. 2.3Questionnaire We developed a simple questionnaire to assess patient satisfaction following surgery. We employed the Visual Analog Scoring (VAS) method, which involved a 10 cm straight line representing scores from 0 to 10. Patients marked points on the line based on their postoperative satisfaction. These marks were then quantified into scores, where a higher score indicated greater satisfaction. 2.4Data analysis SPSS 27.0 software was used to analyze the data statistically. Measurement data were analyzed by t-test expressed as x ± s, and count data were analyzed by χ2 test or Fisher's exact probability method test, and count data were tested by χ2 test, and the difference was regarded as statistically significant at P < 0.05. 3. Results Comparison of the operation indexes of the two groups of patients, the patients in the gas-insufflation group took less operation time than the gas-insufflation group (P 0.05)(Table 1 ). There was no significant difference in the comparison of unilateral postoperative drainage volume(ml), length of drain retention(d), length of hospital stay (d), and postoperative cosmetic satisfaction༈points༉ between the two groups (p > 0.05) (Table 2 ). Table 1 Comparison of surgical indicators (x ± s) Groups Operative time (min) Incision length (cm) Intraoperative blood loss(ml) the gasless group 38.20 ± 10.773 4.25 ± 0.716 16.50 ± 4.323 the gas-insufflation group 62.96 ± 15.311 4.08 ± 0.560 14.81 ± 4.792 t -6.149 0.891 1.238 p < 0.01 0.379 0.222 Table 2 Comparison of postoperative recovery and outcome (x ± s) Groups Unilateral postoperative drainage volume(ml) Length of drain retention(d) Length of hospital stay(d) Postoperative cosmetic satisfaction(points) the gasless group 47.70 ± 11.631 2.25 ± 0.444 2.70 ± 0.470 8.85 ± 0.671 the gas-insufflation group 44.00 ± 12.538 2.35 ± 0.485 2.69 ± 0.471 8.77 ± 0.587 t 1.023 -0.691 0.055 0.435 p 0.312 0.493 0.956 0.666 4. Discussion Gynecomastia is usually asymptomatic, although some patients may experience pain and tenderness in the breasts [ 8 ] . Simon et al. classified gynecomastia into the following categories based on breast size and skin redundancy: I - small visible breast enlargement without skin redundancy; IIa - moderate breast enlargement without skin redundancy; IIb - moderate breast enlargement with skin redundancy; and III - marked breast enlargement with skin redundancy resembling a pendulous female breast, typically seen in obese patients [ 9 ] . The condition primarily arises from an imbalance between estrogen and androgen levels and is idiopathic and physiologic in over 95% of cases [ 10 ] . In adolescents, 75%—90% of gynecomastia cases are self-limiting and resolve within 1–3 years. Most patients do not require treatment, except for those with severe gynecomastia or those experiencing significant psychological distress, who may benefit from pharmacological and surgical interventions. Medical treatments aim to correct the hormonal imbalance but are often ineffective and associated with side effects. Surgical intervention is usually recommended for patients who need treatment. Surgical management of pubertal gynecomastia should be considered for nonobese male adolescents with persistent breast enlargement after a minimum 12-month observation period, intractable pain, or significant psychosocial distress. Various classification systems based on clinical features may guide surgical decisions [ 11 – 12 ] . Current surgical options include:1.Traditional subcutaneous mastectomy via an inframammary approach, which allows for complete gland excision but may lead to significant scarring and emotional distress.2.Transareolar excision, which provides more concealed wounds but is unsuitable for large or deep lumps far from the areola [ 13 ] . This method has the highest rate of nipple-areola complex necrosis (18.1%) [ 14 ] .3.Mammotome-assisted minimally invasive resection (MAMIR), a new technique reported for treating gynecomastia. Although it avoids the use of drainage tubes, it increases the risk of edema, bruising, and ischemic necrosis in the nipple-areola region if improperly performed [ 15 – 16 ] . It is not recommended for patients with breast masses larger than 6 cm in diameter or located close to the skin surface or directly beneath the areola [ 2 ] . For those patients with grade 3 gynecomastia, redundant skin may need to be corrected. However, MAMIR was not able to correct skin sagging [ 17 ] .4.Endoscope-assisted subcutaneous mastectomy, which can be performed with or without CO2 insufflation. This technique involves hidden incisions, high postoperative cosmetic satisfaction, and minimal damage to the nipple-areola complex. It is performed through a single-hole axillary approach, leaving the only scar concealed in the axillary area, thus maximizing the cosmetic effect (Figs. 1, 3, and 4). It also offers the advantages of not being limited by the size or location of the lump and significantly reduces the rates of nipple areola inversion and necrosis. Additionally, excess skin tissue can be removed, alleviating sagging caused by skin redundancy after surgery. The study results showed that there was no significant difference (P > 0.05) between the two groups of patients in terms of surgical incision length, intraoperative bleeding volume, unilateral postoperative drainage volume, duration of drainage tube retention, length of hospital stay and postoperative beauty; However, patients in the gasless group used less surgical time than those in the gas-insufflation group (P < 0.05); The reason for this is that the gasless group eliminates the steps of inserting and inflating a single hole sleeve, and can also use open instruments, while the inflation method uses endoscopic instruments. The gripping force of open instruments is greater, and the free and shear speeds are relatively faster, which reduces the difficulty of surgical operations and further accelerates the surgical speed. Compared to the gas-insufflation group, the gasless group doesnt require CO2 gas to be injected during the surgical process, avoiding the risks of hypercapnia and gas embolism that may be caused by CO2. Continuous negative pressure suction can maintain a clear surgical cavity without smoke, significantly reducing the risk of contamination of the field of view and nerve thermal damage caused by ultrasound knife mist, and a clearer field of view also increases surgical safety [ 18 ] ; Applying a dedicated spatial construction system to maintain good vertical and horizontal space, freeing assistants, reducing labor costs, and maintaining stable space [ 19 ] ; Furthermore, the gasless group doesnt require the use of a disposable multi-channel laparoscopic surgery single hole puncture device soft instrument sheath, saving patients a total cost of 500–3000 yuan compared to the gas-insufflation group, while minimizing the economic cost of patients while ensuring their postoperative beauty. In recent years, our department has used gasless single-port transaxillary access subcutaneous mammectomy to treat gynecomastia with good results. This study has a short follow-up period and small sample size, and the author will further extend the follow-up period and expand the sample size to conduct an in-depth evaluation of the safety, efficacy, and cosmetic outcome of gasless single-port transaxillary access subcutaneous mammectomy for gynecomastia. In conclusion, the gasless single-port transaxillary access subcutaneous mammectomy for gynecomastia minimizes operation time and cost, proving to be effective, safe, and satisfying patients' cosmetic needs. Its promotion in clinical settings, following strict adherence to surgical indications, is recommended. Declarations Acknowledgments Funding The study was supported by the Hunan Provincial Department of Education. (Project No. 20C1170). Compliance with ethical standards The authors take responsibility for all aspects of the work and ensure that issues relating to the accuracy or completeness of any part of the work are properly investigated and resolved. The study was conducted by the Declaration of Helsinki (revised 2013) and was approved by the Ethics Committee of Hunan Provincial People's Hospital (approval number: 2024-010). Individual consent was not required for this retrospective analysis.Clinical trial number: not applicable Conflict of interest The authors declare that they have no conflict of interest. References Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines gynecomastia evaluation and Management. Andrology, 2019, 7(6): 778-793. Lazala C, Saenger P. Pubertal gynecomastia. J Pediatr Endocrinol Metab. 2002;15(5):553-560. Ladizinski B, Lee KC, Nutan FN, Higgins HW 2nd, Federman DG. Gynecomastia: etiologies, clinical presentations, diagnosis, and management. South Med J. 2014;107(1):44-49. Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. 2011;96(1):15-21. Waltho D, Hatchell A, Thoma A. Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System. Plastic and Reconstructive Surgery. 2017;139(3): 638e–648e. Alzahrani HA, Mohsin K, Ali DB, Murad F, Kandil E. Gasless trans-axillary robotic thyroidectomy: the technique and evidence. Gland Surg. 2017;6(3):236-242. Lewis CM，Chung WY，Holsinger FC. Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO(2) in-sufflation.Head Neck，2010，32（1）：121-126. Baumann K. Gynecomastia - Conservative and Surgical Management. Breast Care, 2018, 13(6): 419–424. Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51(1):48-52. Derkacz M, Chmiel-Perzyńska I, Nowakowski A. Gynecomastia a difficult diagnostic problem. Endokrynol Pol. 2011, 62(2): 190202. Berger O, Landau Z, Talisman R. Gynecomastia: A systematic review of pharmacological Treatments. Frontiers in Pediatrics. 2022, 10: 978311. Lemaine V, Cayci C, Simmons PS, Petty P. Gynecomastia in adolescent males. Semin Plast Surg. 2013;27(1):56-61. Lu YQ, Song YG, Sun AJ. Clinical application of circumareolar incision in the excision of benign breast masses. Chin J Gen Surg, 2011, 20(10): 1154-1155. Daar DA, Abdou SA, Rosario L, et al. Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019;143(5):906e-919e. Wang Y, Wang J, Liu L, et al. Comparison of curative effects between mammotome‐assisted minimally invasive resection (MAMIR) and traditional open surgery for gynecomastia in Chinese patients: A prospective clinical Study. The Breast Journal, 2019, 25(6): 1084-1089. Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and Management. Andrology, 2019, 7(6): 778–793. Qu S, Zhang W, Li S, et al. The Vacuum-Assisted Breast Biopsy System is an Effective Strategy for the Treatment of Gynecomastia. Aesthetic Plastic Surgery, 2021, 45(2): 404-410. Yangfeng X, Chuanming Z, Minghua G E. Preliminary evaluation of the endoscopic thyroidectomy using gasless postauricular crease and occipital hairline approach. China Oncology, 2019, 29(6): 434-438. Chuanming Z, Jiajie X, JIANG Liehao, et al. Endoscopic thyroid lobectomy by a gasless unilateral axillary approach: Ge & Zheng's seven-step method[in Chinese]. Chin J Gen Surg, 2019, 28(11): 1336-1341. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5247768","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":369119304,"identity":"4b527254-7000-4183-ae58-ade1729c574e","order_by":0,"name":"Yuqing Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuqing","middleName":"","lastName":"Zhang","suffix":""},{"id":369119305,"identity":"6023189e-86ba-4d99-af5e-d2365d9618b1","order_by":1,"name":"Huiling 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17:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5247768/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5247768/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67371082,"identity":"82b47d14-e235-4b48-beb7-9acf808b5d6d","added_by":"auto","created_at":"2024-10-24 07:55:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":491982,"visible":true,"origin":"","legend":"\u003cp\u003eAfter completion of surgery\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5247768/v1/2fe742597533c0bd5e5748e4.png"},{"id":67369254,"identity":"15765177-4a7c-4aa9-bc85-e123c6d758ed","added_by":"auto","created_at":"2024-10-24 07:47:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128775,"visible":true,"origin":"","legend":"\u003cp\u003eCompletely resected glandular tissue.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5247768/v1/f2063034ade904f3d501adde.png"},{"id":67369252,"identity":"5470e777-79ad-4f9b-94f0-5083173bba36","added_by":"auto","created_at":"2024-10-24 07:47:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":91270,"visible":true,"origin":"","legend":"\u003cp\u003eThe day after surgery\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5247768/v1/0bbd293e4fbefdb25436802f.png"},{"id":67369255,"identity":"560f595c-8b66-480c-85d4-d7ba54128e35","added_by":"auto","created_at":"2024-10-24 07:47:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":131298,"visible":true,"origin":"","legend":"\u003cp\u003eThree months after the operation\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-5247768/v1/b3e3ebd2f291e349c7730c3c.png"},{"id":74463761,"identity":"bdfd7ac1-bf0b-464b-a383-d9b6168419f3","added_by":"auto","created_at":"2025-01-22 14:02:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1799001,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5247768/v1/a19fef5c-2326-4bdd-bca0-c415e4d3c338.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of efficacy between the gasless and the gas-insufflation single-port transaxillary access subcutaneous mammectomy in the treatment of gynecomastia","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32\u0026ndash;65%, depending on the age and the criteria used for definition. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. It arises from both physiological and non-physiological factors and is characterized by unique clinical, histological, and radiological features. Physiological gynecomastia frequently occurs in neonates, adolescents, and older men, affecting up to 70% of adolescent males \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Non-physiological causes include chronic diseases such as cirrhosis, hypogonadism, renal insufficiency; drug use; and rare tumors \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. While gynecomastia is often self-limiting and asymptomatic cases typically require no specific intervention, treatment may be necessary if symptoms persist beyond one year and involve severe pain, tenderness, or psychological distress \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Treatment options include medication and surgery, though medication tends to be ineffective for conditions lasting over 12 months, thus necessitating surgical intervention \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Recently, gasless axillary access laparoscopic surgery has gained popularity in thyroidectomy due to its safety and aesthetic outcomes \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, its use in treating gynecomastia remains unreported. This study aims to evaluate the effectiveness of the gasless transaxillary approach compared to the gas-insufflation single-port transaxillary approach for subcutaneous mammectomy in treating gynecomastia.\u003c/p\u003e"},{"header":"2. Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1Patients\u003c/h2\u003e \u003cp\u003eIn our study, patients with gynecomastia were enrolled from May 2022 to October 2023 and were assigned to either the gas-insufflation group or the gasless group according to their wishes. All procedures were performed by the same surgical team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2Surgical steps\u003c/h2\u003e \u003cp\u003eGasless Group (Underwent Gasless Transaxillary Approach Subcutaneous Mammectomy)\u003c/p\u003e \u003cp\u003eFollowing successful general anesthesia, the patient was positioned supine with the operative side near the operating table's edge and the shoulders elevated. The arm on the operative side was abducted at 90 degrees, aligning with the hand tray's lower edge. A lipolytic solution of 400 ml was prepared, consisting of 200 ml saline, 200 ml distilled water, 0.2 mg epinephrine hydrochloride injection, and 10 ml of 2% lidocaine. The operation field was routinely sterilized, and a sterile towel sheet was placed. Under ultrasound guidance, 100 to 150 ml of lipolytic solution was injected into the surface of the mammary glands and retromammary space, with a 15-minute wait thereafter. A 4 cm incision was made along the transverse axillary line, about 4 cm from the axilla's top. Liposuction was performed in the retromammary space and on the subcutaneous glandular surface using a metal lateral orifice aspirator. A long-handled scalpel was utilized along the pectoral major muscle surface to free the retromammary space, followed by the insertion of a luminal pull hook and luminal mirror. The ultrasonic scalpel and electrocoagulation hook was then used to release the retromammary space and subcutaneous glandular layer, aided by the luminal mirror. The nipple and areola were carefully freed using long-handled tissue scissors, retaining a small amount of glandular tissue at the nipple's back. Hemostasis was achieved, followed by saline flushing. With no significant bleeding observed under the luminal microscope, a drainage tube was placed. The wound was sutured intermittently with a 3\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture for the subcutaneous tissue and dermis and closed with a continuous intradermal tissue suture using a 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture. The procedure concluded with the application of an external negative pressure drainage bulb, sterile dressing, and pressure bandage.\u003c/p\u003e \u003cp\u003eGas-Insufflation Group Underwent Gas-Insufflation Single-Port Transaxillary Approach Subcutaneous Mammectomy\u003c/p\u003e \u003cp\u003eAfter inducing general anesthesia, the patient was similarly positioned supine with the operative side close to the edge of the operating table and shoulders elevated. The upper limb on the operative side was abducted at 90 degrees to lie flat against the hand tray. A lipolytic solution of 400 ml (200 ml saline, 200 ml distilled water, 0.2 mg epinephrine hydrochloride, and 10 ml 2% lidocaine) was prepared. The surgical field was sterilized, and a sterile towel was laid down. A curved incision of about 4 cm was made at the anterior axillary line and mammary gland edge intersection, where 150 to 200 ml of lipolytic solution was injected into the mammary gland's subcutaneous tissue and retromammary space, followed by a 15-minute wait. A non-invasive dissection stick was used to separate the breast flap up to the breast margin marking line, and the fat solution was aspirated. A disposable multi-channel single-port laparoscopic trocar was inserted and carbon dioxide gas was introduced to maintain an 8\u0026ndash;10 mmHg pressure, creating an operating space. The nipple was suspended to assist in maneuvering. The breast tissue was separated from the pectoralis major muscle using an electrocoagulation hook, ultrasonic scalpel, and dissecting scissors, fully freeing and excising the breast glandular tissue and some fat tissue. The specimen was placed in a bag and removed through the port. After achieving hemostasis and saline flushing, with no significant oozing detected under the luminal microscope, a drainage tube was placed. The wound was sutured with a 3\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture intermittently for the subcutaneous tissue and dermis and closed using a continuous intradermal tissue suture with a 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable suture. The surgery concluded with the placement of an external negative pressure drainage bulb, sterile dressing, and pressure bandage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3Questionnaire\u003c/h2\u003e \u003cp\u003eWe developed a simple questionnaire to assess patient satisfaction following surgery. We employed the Visual Analog Scoring (VAS) method, which involved a 10 cm straight line representing scores from 0 to 10. Patients marked points on the line based on their postoperative satisfaction. These marks were then quantified into scores, where a higher score indicated greater satisfaction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4Data analysis\u003c/h2\u003e \u003cp\u003eSPSS 27.0 software was used to analyze the data statistically. Measurement data were analyzed by t-test expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s, and count data were analyzed by χ2 test or Fisher's exact probability method test, and count data were tested by χ2 test, and the difference was regarded as statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eComparison of the operation indexes of the two groups of patients, the patients in the gas-insufflation group took less operation time than the gas-insufflation group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); the difference between the two groups in terms of incision length and intraoperative blood loss was not significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There was no significant difference in the comparison of unilateral postoperative drainage volume(ml), length of drain retention(d), length of hospital stay (d), and postoperative cosmetic satisfaction༈points༉ between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of surgical indicators (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncision length (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntraoperative blood loss(ml)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethe gasless group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.20\u0026thinsp;\u0026plusmn;\u0026thinsp;10.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.323\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethe gas-insufflation group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.96\u0026thinsp;\u0026plusmn;\u0026thinsp;15.311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.792\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-6.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative recovery and outcome (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnilateral postoperative drainage volume(ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLength of drain retention(d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLength of hospital stay(d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostoperative cosmetic satisfaction(points)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethe gasless group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.70\u0026thinsp;\u0026plusmn;\u0026thinsp;11.631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;0.470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethe gas-insufflation group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.587\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.666\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eGynecomastia is usually asymptomatic, although some patients may experience pain and tenderness in the breasts \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Simon et al. classified gynecomastia into the following categories based on breast size and skin redundancy: I - small visible breast enlargement without skin redundancy; IIa - moderate breast enlargement without skin redundancy; IIb - moderate breast enlargement with skin redundancy; and III - marked breast enlargement with skin redundancy resembling a pendulous female breast, typically seen in obese patients \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The condition primarily arises from an imbalance between estrogen and androgen levels and is idiopathic and physiologic in over 95% of cases \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In adolescents, 75%\u0026mdash;90% of gynecomastia cases are self-limiting and resolve within 1\u0026ndash;3 years. Most patients do not require treatment, except for those with severe gynecomastia or those experiencing significant psychological distress, who may benefit from pharmacological and surgical interventions. Medical treatments aim to correct the hormonal imbalance but are often ineffective and associated with side effects. Surgical intervention is usually recommended for patients who need treatment. Surgical management of pubertal gynecomastia should be considered for nonobese male adolescents with persistent breast enlargement after a minimum 12-month observation period, intractable pain, or significant psychosocial distress. Various classification systems based on clinical features may guide surgical decisions \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCurrent surgical options include:1.Traditional subcutaneous mastectomy via an inframammary approach, which allows for complete gland excision but may lead to significant scarring and emotional distress.2.Transareolar excision, which provides more concealed wounds but is unsuitable for large or deep lumps far from the areola\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. This method has the highest rate of nipple-areola complex necrosis (18.1%) \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.3.Mammotome-assisted minimally invasive resection (MAMIR), a new technique reported for treating gynecomastia. Although it avoids the use of drainage tubes, it increases the risk of edema, bruising, and ischemic necrosis in the nipple-areola region if improperly performed\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. It is not recommended for patients with breast masses larger than 6 cm in diameter or located close to the skin surface or directly beneath the areola \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. For those patients with grade 3 gynecomastia, redundant skin may need to be corrected. However, MAMIR was not able to correct skin sagging \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.4.Endoscope-assisted subcutaneous mastectomy, which can be performed with or without CO2 insufflation. This technique involves hidden incisions, high postoperative cosmetic satisfaction, and minimal damage to the nipple-areola complex. It is performed through a single-hole axillary approach, leaving the only scar concealed in the axillary area, thus maximizing the cosmetic effect (Figs.\u0026nbsp;1, 3, and 4). It also offers the advantages of not being limited by the size or location of the lump and significantly reduces the rates of nipple areola inversion and necrosis. Additionally, excess skin tissue can be removed, alleviating sagging caused by skin redundancy after surgery.\u003c/p\u003e \u003cp\u003eThe study results showed that there was no significant difference (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) between the two groups of patients in terms of surgical incision length, intraoperative bleeding volume, unilateral postoperative drainage volume, duration of drainage tube retention, length of hospital stay and postoperative beauty; However, patients in the gasless group used less surgical time than those in the gas-insufflation group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); The reason for this is that the gasless group eliminates the steps of inserting and inflating a single hole sleeve, and can also use open instruments, while the inflation method uses endoscopic instruments. The gripping force of open instruments is greater, and the free and shear speeds are relatively faster, which reduces the difficulty of surgical operations and further accelerates the surgical speed. Compared to the gas-insufflation group, the gasless group doesnt require CO2 gas to be injected during the surgical process, avoiding the risks of hypercapnia and gas embolism that may be caused by CO2. Continuous negative pressure suction can maintain a clear surgical cavity without smoke, significantly reducing the risk of contamination of the field of view and nerve thermal damage caused by ultrasound knife mist, and a clearer field of view also increases surgical safety\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e; Applying a dedicated spatial construction system to maintain good vertical and horizontal space, freeing assistants, reducing labor costs, and maintaining stable space\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e; Furthermore, the gasless group doesnt require the use of a disposable multi-channel laparoscopic surgery single hole puncture device soft instrument sheath, saving patients a total cost of 500\u0026ndash;3000 yuan compared to the gas-insufflation group, while minimizing the economic cost of patients while ensuring their postoperative beauty.\u003c/p\u003e \u003cp\u003eIn recent years, our department has used gasless single-port transaxillary access subcutaneous mammectomy to treat gynecomastia with good results.\u003c/p\u003e \u003cp\u003eThis study has a short follow-up period and small sample size, and the author will further extend the follow-up period and expand the sample size to conduct an in-depth evaluation of the safety, efficacy, and cosmetic outcome of gasless single-port transaxillary access subcutaneous mammectomy for gynecomastia.\u003c/p\u003e \u003cp\u003eIn conclusion, the gasless single-port transaxillary access subcutaneous mammectomy for gynecomastia minimizes operation time and cost, proving to be effective, safe, and satisfying patients' cosmetic needs. Its promotion in clinical settings, following strict adherence to surgical indications, is recommended.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The study was supported by the Hunan Provincial Department of Education. (Project No. 20C1170).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors take responsibility for all aspects of the work and ensure that issues relating to the accuracy or completeness of any part of the work are properly investigated and resolved. The study was conducted by the Declaration of Helsinki (revised 2013) and was approved by the Ethics Committee of Hunan Provincial People\u0026apos;s Hospital (approval number: 2024-010). Individual consent was not required for this retrospective analysis.Clinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines gynecomastia evaluation and Management. Andrology, 2019, 7(6): 778-793.\u003c/li\u003e\n\u003cli\u003eLazala C, Saenger P. Pubertal gynecomastia. J Pediatr Endocrinol Metab. 2002;15(5):553-560.\u003c/li\u003e\n\u003cli\u003eLadizinski B, Lee KC, Nutan FN, Higgins HW 2nd, Federman DG. Gynecomastia: etiologies, clinical presentations, diagnosis, and management. South Med J. 2014;107(1):44-49.\u003c/li\u003e\n\u003cli\u003eCarlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. 2011;96(1):15-21.\u003c/li\u003e\n\u003cli\u003eWaltho D, Hatchell A, Thoma A. Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System. Plastic and Reconstructive Surgery. 2017;139(3): 638e\u0026ndash;648e.\u003c/li\u003e\n\u003cli\u003eAlzahrani HA, Mohsin K, Ali DB, Murad F, Kandil E. Gasless trans-axillary robotic thyroidectomy: the technique and evidence. Gland Surg. 2017;6(3):236-242.\u003c/li\u003e\n\u003cli\u003eLewis CM，Chung WY，Holsinger FC. Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO(2) in-sufflation.Head Neck，2010，32（1）：121-126.\u003c/li\u003e\n\u003cli\u003eBaumann K. Gynecomastia - Conservative and Surgical Management. Breast Care, 2018, 13(6): 419\u0026ndash;424.\u003c/li\u003e\n\u003cli\u003eSimon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51(1):48-52.\u003c/li\u003e\n\u003cli\u003eDerkacz M, Chmiel-Perzyńska I, Nowakowski A. Gynecomastia a difficult diagnostic problem. Endokrynol Pol. 2011, 62(2): 190202.\u003c/li\u003e\n\u003cli\u003eBerger O, Landau Z, Talisman R. Gynecomastia: A systematic review of pharmacological Treatments. Frontiers in Pediatrics. 2022, 10: 978311.\u003c/li\u003e\n\u003cli\u003eLemaine V, Cayci C, Simmons PS, Petty P. Gynecomastia in adolescent males. Semin Plast Surg. 2013;27(1):56-61. \u003c/li\u003e\n\u003cli\u003eLu YQ, Song YG, Sun AJ. Clinical application of circumareolar incision in the excision of benign breast masses. Chin J Gen Surg, 2011, 20(10): 1154-1155. \u003c/li\u003e\n\u003cli\u003eDaar DA, Abdou SA, Rosario L, et al. Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019;143(5):906e-919e.\u003c/li\u003e\n\u003cli\u003eWang Y, Wang J, Liu L, et al. Comparison of curative effects between mammotome‐assisted minimally invasive resection (MAMIR) and traditional open surgery for gynecomastia in Chinese patients: A prospective clinical Study. The Breast Journal, 2019, 25(6): 1084-1089.\u003c/li\u003e\n\u003cli\u003eKanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and Management. Andrology, 2019, 7(6): 778\u0026ndash;793.\u003c/li\u003e\n\u003cli\u003eQu S, Zhang W, Li S, et al. The Vacuum-Assisted Breast Biopsy System is an Effective Strategy for the Treatment of Gynecomastia. Aesthetic Plastic Surgery, 2021, 45(2): 404-410. \u003c/li\u003e\n\u003cli\u003eYangfeng X, Chuanming Z, Minghua G E. Preliminary evaluation of the endoscopic thyroidectomy using gasless postauricular crease and occipital hairline approach. China Oncology, 2019, 29(6): 434-438.\u003c/li\u003e\n\u003cli\u003eChuanming Z, Jiajie X, JIANG Liehao, et al. Endoscopic thyroid lobectomy by a gasless unilateral axillary approach: Ge \u0026amp; Zheng\u0026apos;s seven-step method[in Chinese]. Chin J Gen Surg, 2019, 28(11): 1336-1341.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"gynecomastia, subcutaneous mammectomy, endoscopic","lastPublishedDoi":"10.21203/rs.3.rs-5247768/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5247768/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the clinical efficacy of gasless transaxillary versus single-port gas-insufflation transaxillary approaches in subcutaneous mammectomies for treating gynecomastia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study enrolled 46 patients diagnosed with gynecomastia from May 2022 to October 2023. Of these, 20 underwent subcutaneous mammectomy using the single-port gas-insufflation transaxillary approach (gas-insufflation group), while 26 received the same procedure through the gasless transaxillary approach (gasless group). We compared the two groups in terms of operation time, intraoperative bleeding, volume of postoperative drainage, timing of drainage tube removal, short-term postoperative complications, length of postoperative hospital stay, and medical costs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll 46 patients successfully completed the operation without conversion to open surgery, and pathology confirmed gynecomastia in each case. The surgical time for the gasless group was significantly shorter, averaging 38.20\u0026thinsp;\u0026plusmn;\u0026thinsp;10.773 minutes, compared to 62.96\u0026thinsp;\u0026plusmn;\u0026thinsp;15.311 minutes for the gas-insufflation group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There were no significant differences between the groups in terms of incision length, intraoperative bleeding (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), postoperative drainage volume from one side, drain retention time, length of postoperative hospital stay, or postoperative cosmetic outcomes (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study supports the clinical feasibility of using the gasless transaxillary approach for subcutaneous mammectomy in treating gynecomastia.\u003c/p\u003e","manuscriptTitle":"Comparison of efficacy between the gasless and the gas-insufflation single-port transaxillary access subcutaneous mammectomy in the treatment of gynecomastia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-24 07:47:20","doi":"10.21203/rs.3.rs-5247768/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9536b65f-fd8f-4eff-a92d-fdbd61da4d12","owner":[],"postedDate":"October 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-22T13:53:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-24 07:47:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5247768","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5247768","identity":"rs-5247768","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}