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Received: 26 September 2018    Revised: 27 March 2019    Accepted: 28 March 2019

DOI: 10.1111/tbj.13424

ORIGINAL ARTICLE

Comparison of curative effects between mammotome‐assisted

minimally invasive resection (MAMIR) and traditional open
surgery for gynecomastia in Chinese patients: A prospective
clinical study

Yu Wang MS1 | Jiyan Wang MB2 | Lin Liu MS2 | Wenlong Liang MS2 |

Youyou Qin MS2 | Zihao Zheng MS2 | Shifang Zou MS2 | Yuting Xu MS3 |
Cuicui Chen MS4 | Zhenchu Feng MB2 | Jianguo Zhang MD2 | Lin Tao MS5 | Xi Chen MD2

1
Department of Head Neck Thyroid and
Mammary Surgery, Tumor Hospital of Abstract
Mudanjiang City, Mudanjiang, Heilongjiang, To analyze and compare prospectively the curative effects between mammotome‐
China
2 assisted minimally invasive resection (MAMIR) and traditional open surgery (TOS) for
Department of Mammary Surgery, The
Second Affiliated Hospital of Harbin Medical gynecomastia in Chinese male patients, a total of 60 patients suffering from grade
University, Harbin, Heilongjiang, China
I and II gynecomastia, evaluated by automated whole‐breast ultrasound (AWBU),
3
Department of Mammary
Surgery, Affiliated Cancer Hospital of Harbin
were recruited and randomly divided into TOS and MAMIR groups (each n = 30). The
Medical University, Harbin, Heilongjiang, postoperative scar size, healing time, patient hospital stay, postoperative satisfac‐
China
4
tion, postoperative pain, and complications including edema and bruising were ana‐
Campus Direct Outpatient
Department, Harbin Medical University, lyzed. The participants were followed up for 1 week, 1 month, 6 months, and 1 year
Harbin, Heilongjiang, China after surgery. Compared with patients who received TOS, patients in the MAMIR
5
Inpatient Department of
group had significantly smaller scar sizes (0.40 ± 0.08 cm vs 5.34 ± 0.38 cm, P < 0.01),
Ultrasound, Second Affiliated Hospital
of Harbin Medical University, Harbin, shorter healing times (3.67  ±  0.71  days vs 7.90  ±  0.92  days, P  <  0.01), and hospi‐
Heilongjiang, China
talization (2.60 ± 0.62 vs 7.17 ± 0.83 days, P < 0.01), as well as higher postoperative
Correspondence satisfaction (4.70  ±  0.60 vs 3.20  ±  0.55 scores, P  <  0.01), respectively. Patients in
Xi Chen, Department of Mammary Surgery,
the MAMIR group experienced postoperative mild pain significantly more often than
the Second Affiliated Hospital of Harbin
Medical University, Harbin, Heilongjiang those in the TOS group (6.70 ± 1.06 vs 4.13 ± 0.78 scores, P < 0.01, respectively), but
150081, China.
with significantly less postoperative severe pain (53.33% vs 0.00%, P < 0.000). While
Email: 13804517666@163.com
the incidence rate of edema and bruises was significantly higher in the MAMIR group
Funding information
This study was supported by the China compared with the TOS group (47% vs 17%, P = 0.013 and 54% vs 20%, P = 0.007,
Youth Innovation Fund of the Second respectively). MAMIR had advantages for curative effects compared with traditional
Affiliated Hospital of Harbin Medical
University (Grant no. CX2016‐14). open surgery. However, the recurrence rate in patients needs to be further studied.

KEYWORDS
automated whole‐breast ultrasound, gynecomastia, mammotome, minimally invasive
resection, traditional open surgery

Yu Wang and Jiyan Wang are contributed equally.

Breast J. 2019;00:1–6. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/tbj  
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2       WANG et al.
1 |  I NTRO D U C TI O N
Gynecomastia is a clinical disease in males characterized by ab‐
normal breast tissue development and breast connective tissue
proliferation caused by an alteration in the estrogen/androgen bal‐
1
ance or other organic diseases. 2 Clinical manifestations of gyne‐
comastia include enlarged or feminized development of unilateral
or bilateral male breasts, with or without secreting milk‐like liquid.
Gynecomastia occurs in about 38% of the young male population
3 2.1 | Participants
and accounts for about 60%‐80% of male breast disorders,4 with
an increasing prevalence in recent years.5 Transient gynecomastia,
such as secondary and drug‐induced male breast development, can
gradually resolve on its own after the primary disease is cured or
6
after drug withdrawal. Persistent enlarged breasts have a serious
impact on male appearance, and physical stress may occur. Surgical
treatment is recommended for those with persistent gynecomastia,
and unnormalized breast development in secondary or drug‐induced
gynecomastia after the primary disease has been cured or drugs
have been withdrawn for 1‐2 years.7,8
Gynecomastia is categorized into four grades according to the
Rohrich grading system: grade I (minimal hypertrophy with ˂250 g),
grade II (moderate hypertrophy of 250‐500 g without ptosis), grade
III (severe hypertrophy of ˃500  g with light ptosis), and grade IV
(severe hypertrophy with severe ptosis). Grades I and II have been
subtyped into A‐type (gland hyperplasia) and B‐type (fibroplasia), re‐
spectively. Although grades III and IV have indications for open sur‐
gery, it is difficult to precisely measure the weight of the mammary
gland before an operation. In contrast, automated whole‐breast
ultrasound (AWBU) 3D data sets of the whole breast are acquired
and consecutive B‐mode pictures used to construct a composite
image.9 It can render multi‐faceted anatomy of the breast through
transverse, sagittal, and coronal planes, thereby reconstructing the
volume, basal diameter, and protrusion of the entire breast.
Open surgery under general anesthesia is the traditional treatment
for gynecomastia, requiring preoperative fasting and water depriva‐
tion for 8 hours, postoperative bed rest for 24 hours and placement
of drainage tubes for 5 ~ 7 days. In addition, the scars left after the
operations are present for life and can have a great negative impact
on the physical and psychological health of patients. Mammotome
is a novel ultrasound‐guided vacuum‐assisted biopsy device, which
is extensively used in Japan, Europe, and America as a minimally in‐
vasive approach in breast puncture for qualitative diagnosis before
breast cancer surgery,10,11 evaluation of breast microcalcification,12
and papillary lesions.13 In addition as a diagnostic tool, mammotome
has also been widely applied to assist therapeutic excision of benign
14
breast lesions. Compared with traditional open surgery to treat
breast lesions, mammotome‐assisted minimally invasive resection
(MAMIR) has advantages in several respects such as a shorter hospi‐
tal stay, operation time, smaller postoperative scar, and better healing
conditions.15-19 Although the application of mammotome in resect‐
ing male mammary hypertrophy has been reported, 20 there have
been few studies which compared the curative effect between novel
MAMIR and traditional open surgery for gynecomastia.
In this prospective study, we first evaluated and graded gyneco‐
mastia patients using AWBU imaging, and then compared curative
effects such as postoperative scar size, healing time, length of hospi‐
tal stay, postoperative satisfaction, postoperative pain, and compli‐
cations of treatment with MAMIR vs traditional open surgery.
2 | PATI E NT S A N D M E TH O DS
This prospective study was designed and conducted in the
Department of Mammary Surgery of the Second Affiliated Hospital,
Harbin Medical Sciences University from September 2015 to
September 2016. Gynecomastia patients diagnosed by clinical and
imaging features were examined with routine ultrasonography and
AWBU (ACUSON S2000, Siemens, Berlin, Germany) before opera‐
tion. According to the breast volume and content of the mammary
gland evaluated by AWBU imaging (Figure S1), patients were graded
as AWBU grade I (gland volume ˂100  cm3 with obvious protrud‐
ing breast), II (gland volume of 100‐200 cm3), and III (gland volume
˃200  cm3). Based on evaluation of AWBU images, first created in
our department by experienced ultrasound physicians with an op‐
eration certification of AWBU, and comprehensive preoperative
assessment, patients with AWBU grades I or II were selected as can‐
didates for MAMIR. All patients met the following inclusion criteria:
(a) with psychological pressure and a strong willingness to undergo
therapeutic surgery; (b) aged from 12 to 48 years; and (c) voluntar‐
ily participated in the study and provided written informed consent.
Patients were excluded if they met any of the following criteria: (a)
AWBU grade III; (b) a history of breast cancer; (c) combined serious
dysfunctions in other organ systems or conscious disturbances; (d)
malignant tumor history in other organ systems or cachectic appear‐
ance; and (e) poor general physical condition, incapable of undergo‐
ing an operation. As a result, a total of 60 gynecomastia patients
that met the inclusion criteria were recruited and divided into A and
B groups (each n = 30) who received either traditional open surgery
or MAMIR. The ethical committee of the Second Affiliated Hospital
of Harbin Medical Sciences University approved the study and writ‐
ten informed consent was obtained from all patients and/or their
guardians.
2.2 | Surgical procedures
The patients were placed in a supine position. For patients receiving
MAMIR, the surgical margin was determined according to the ultra‐
sound localized position and the thickness of the gland and fat. The
operation procedure was performed under local anesthesia with 1%
lidocaine and adrenaline (4‐5 drops in 10 mL). The cutting head of the
mammotome was used to puncture the skin at the lower exterior mar‐
gin of the breast and penetrate into the interlayer between the mam‐
mary gland and pectoralis fascia under the guidance of ultrasound.
Concentric resection, guided by ultrasound, was started from the sur‐
rounding area of the glands (Figure S2A). The entire mammary gland
WANG et al. |
      3

and most of the fat were isolated and removed (Figure S2B). Excessive TA B L E 1   Comparison of baseline information, rate of recovery,
resection should be avoided when removing the gland below the are‐ and recurrence between the open surgery and MAMIR groups
ola to prevent ischemic necrosis due to an insufficient blood supply. Open surgery Mammotome resec‐
Hemostatic materials could be implanted inside the needle sleeve if group tion group
an obvious bleeding point was detected during the operation and the
  (n, %) (n, %) P‐value
congestion removed completely by vacuum pumping. After pressing
the affected bleeding area for 10 minutes and no further bleeding was Gender 30 (100%) 30 (100%)  

confirmed, the incision was adhered with histoacryl, and covered with Age (y)

a sterile dressing and compression bandage.21 In contrast to MAMIR, 12‐25 19 (63%) 17 (57%) 0.598
traditional open surgery was performed under general anesthesia. A 26‐48 11 (37%) 13 (43%)  
5‐mm arc of incision was made below the nipple, and negative pressure AWBU grade
drainage tubes were placed on both sides. The extra mammary gland I 18 (60%) 20 (67%) 0.592
and fatty tissue were removed. II 12 (40%) 10 (33%)  
Unilateral 6 (20%) 6 (20%) 1.000

2.3 | Measurement of follow‐up data and Bilateral 24 (80%) 24 (80%) 1.000

statistical analysis
All participants were followed up and had repeated ultrasonic exam‐
inations at 1 week, 1 month, 6 months, and 1 year intervals after the
operation. Information recorded at follow‐ups included postopera‐
tive scar size, length of stay in hospital, healing time, postoperative
satisfaction, postoperative pain scores, and complications, such as
edema and bruising. A questionnaire was used to measure postoper‐
ative satisfaction (score range 0‐5) including postoperative recovery
and comprehensive factors affecting the physical and mental health
of each patient (Table S1). Postoperative pain was assessed using the
visual analog scale (VAS) with a score range from 0 to 10 (0 reflecting
no pain and 10 unbearable pain).
Measurement data are reported as the mean  ±  standard devi‐
ation (x̄   ±  s), and normally distributed data were analyzed using a
t‐test. Categorical data are shown as percentages and were analyzed
using a chi‐squared test. SPSS software (version 19.0, SPSS) was
used for all data analysis, and a P‐value <0.05 was considered to be
statistically significant.
7.90 ± 0.92 days, P < 0.01, respectively). We also found the recovery
condition at 1 week, 1 month, 6 months, and 1 year after the oper‐
ation of a representative patient in the MAMIR group was almost
no operation scar (Figure 1B), while the recovery condition of open
surgery (Figure 1A) still had obvious scars remaining at the opera‐
tion site (Figure 1A). MAMIR had a better cosmetic outcome com‐
pared with open surgery. In addition, pain levels after operations in
the MAMIR group were significantly lower than in the open surgery
group (4.13  ±  0.78 scores vs 6.70  ±  1.06 scores, P  <  0.01), result‐
ing in significantly enhanced patient satisfaction scores (4.70 ± 0.60
vs 3.20  ±  0.55, P  <  0.01, respectively). Postoperative complica‐
tions mainly included edema and bruising. Although patients in the
MAMIR group had a significantly higher incidence of edema and
bruising compared with the traditional open surgery group (47% vs
17%, P = 0.013 and 54% vs 20%, P = 0.007, respectively), the com‐
plications were generally mild in both groups. Individual patients in
the MAMIR group had severe edema and bruising but had effectively
recovered to normal 2 weeks after resection (Figure 2).

3 | R E S U LT S
3.1 | Comparison of baseline information, clinical
effects, and recurrence rate between the open
surgery and mammotome resection groups
The demographic information, postoperative clinical effect, and re‐
currence rate at 1‐year follow‐up are shown in Table 1. No significant
differences were found in the baseline characteristics including age,
AWBU grade or a hypertrophic side between the study and control
groups. All participants recovered, and there was no relapse during
follow‐ups for 12 months.
As shown in Table 2, the surgical curative effect of gynecomastia
was compared between the open surgery and the MAMIR groups.
Compared with the open surgery group, the MAMIR group had signifi‐
cantly smaller scar sizes left after the operation, and shorter hospital
stays and healing times (0.40 ± 0.08 cm vs 5.34 ± 0.38 cm, P < 0.01;
2.60 ± 0.62 days vs 7.17 ± 0.83 days, P < 0.01 and 3.67 ± 0.71 days vs
4 | D I S CU S S I O N
Gynecomastia or male breast hyperplasia can occur on one or both
sides of the male breast. Basically, enlargement of the male breast
has no affect on patient health and requires no treatment unless
gynecomastia patients suffer from an embarrassing appearance
and psychological distress. Although medication is effective for
breast hyperplasia at the initial stage, 22 surgical intervention is con‐
sidered to be necessary for persistent male breast hypertrophy and
to obtain a better cosmetic outcome. The present prospective clini‐
cal study was designed to compare the curative effects of MAMIR
with traditional open surgery for the treatment of gynecomastia.
We first applied AWBU to measure precisely the volume of
male hypertrophic breast tissue and categorized it into AWBU
grades I ~ III. Gynecomastia patients of AWBU grade I and II were
deemed to be suitable for receiving MAMIR in the absence of special
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4       WANG et al.

TA B L E 2   Comparison of the curative effect between the open surgery and MAMIR groups

  Open surgery group MAMIR group P‐value

Postoperative scar size (cm) 5.34 ± 0.38 0.40 ± 0.08 P < 0.01

Hospital stay (d) 7.17 ± 0.83 2.60 ± 0.62 P < 0.01
Healing time (d) 7.90 ± 0.92 3.67 ± 0.71 P < 0.01
Postoperative pain level (no pain to unbearable pain 6.70 ± 1.06 4.13 ± 0.78 P < 0.01
‐ range 0‐10)
Pain grade (n, %)
0 0 (0.00) 0 (0.00) –
1 ≤ mild ≤3 0 (0.00) 5 (16.7) 0.020
4 ≤ moderate ≤6 14 (46.7) 25 (83.3) 0.003
7 ≤ severe ≤10 16 (53.3) 0 (0.00) <0.000
Patient satisfaction (low to high score range 0‐5) 3.20 ± 0.55 4.70 ± 0.60 P < 0.01
Edema (n, %) 5 (17) 14 (47) 0.013
Bruise (n, %) 6 (20) 16 (54) 0.007

F I G U R E 1   Comparison of the recovery condition of representative patients at preoperation, 1 wk, 1 mo, 6 mo, and 1 y postoperation
between the open surgery and MAMIR groups. A, open surgery group, B, MAMIR group

F I G U R E 2   The severe edema and bruising shown in individual patients on day 1 after resection had recovered to normal 15 d
after resection A, Day 1 postoperation, B, Day 15 postoperation with significant swelling and bruising

contraindications. Compared with measuring the weight of breast Traditional open surgery can remove most glandular and fatty
glandular tissue, volume measurement of breast mammary gland is tissues of the developed breast; however, it usually leaves an in‐
easier to implement. cision scar of 5‐10  cm, which causes patient dissatisfaction due
WANG et al.
to an unimproved psychological load. In comparison, introduction
of the vacuum‐assisted mammotome biopsy device in the diag‐
14,23
nosis and treatment of benign and early breast cancerous
24
lesions has the advantages of minimal invasiveness, is carried
out under local anesthesia and produces cosmetic results, with an
incision as small as 4 mm being required and no implantation of
drainage tubes. Iwagwu et al succeeded in treating gynecomas‐
25,26
tia and fibroadenoma using the mammotome technique
achieved considerable cost savings, excellent cosmesis and high
patient satisfaction. 20 Similar to the previous studies of Iwuagwu,
treatment of gynecomastia with MAMIR demonstrated a signifi‐
cantly smaller postoperative scar size, shorter hospitalization and
healing times, lower postoperative pain levels, and higher patient
satisfaction.
However, although liposuction is mainly used for the removal of
glandular and fatty‐glandular breast tissue, 27 it has the disadvantage
of a high recurrence rate, which led to the approach of combining
liposuction with subsequent sharp glandular tissue excision through
the incision cannula of liposuction. 28 In future studies, we also will
consider this approach, especially in patients with lipomatous gyne‐
comastia, since the recurrence rate is particularly high in this patient
29
group.
The reason for the higher incidence of complications such as
edema and bruising in MAMIR is probably due to the absence of
a drainage tube. The incision was adhered with histoacryl, and
the hematocele and exudate induced during the operation could
not directly move outside the breast and needed to be slowly
absorbed. On the other hand, the remnants of hematocele and
exudate might lead to a better and natural postoperative breast
appearance. A study with a larger cohort of patients and longer
follow‐ups for long‐term cosmetic effect and recurrence evalua‐
tions is underway.
In conclusion, compared with traditional open breast surgery,
MAMIR showed significant advantages in the cosmetic outcome,
which greatly helped resolve the psychological stress of gynecomas‐
tia patients. MAMIR is recommended for gynecomastia patients of
AWBU grade I ~ II.
AC K N OW L E D G E M E N T S
Not applicable.
C O N FL I C T O F I N T E R E S T
The authors declare that they have no competing interests.
AU T H O R C O N T R I B U T I O N S
YW, JW, LL, WL, YQ, JZ, LT, and XC were responsible for the con‐
ception and design of the study. All the authors were responsible
for acquisition and analysis of data; furthermore, YW and JW were
in charge of statistical analysis. YW and JW drafted the manuscript;
|
      5
YW, JW, LL, WL, YQ, JZ, LT, and XC revised and commented on the
draft, and YW, JW, and XC approved the final version.
E T H I C A L A P P R OVA L
The ethical committee of the Second Affiliated Hospital of Harbin
Medical Sciences University approved the study and written informed
and consent was obtained from all participants and/or their guardians.
DATA AC C E S S I B I L I T Y
All data generated or analyzed during this study are included in this
published article.
C O N S E N T FO R P U B L I C AT I O N
Consent for publication was obtained from all patients.
ORCID
Xi Chen  https://orcid.org/0000-0002-6333-6754
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article. 
How to cite this article: 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. Breast J. 2019;00:1–6. https​://doi.
org/10.1111/tbj.13424​