Gynecomastia is a clinical condition in which male breast tissue develops abnormally and the connective tissue of the breast proliferates abnormally. It usually manifests as painless, progressive enlargement of the breast unilaterally or bilaterally or as a painful mass in the subareolar area, accounting for about 60% of adolescent and adult males, and is the most common among male breast diseases. As the standard of living has improved in recent years, the incidence of this disease has gradually increased, especially in the urban population, where young male patients who come to the clinic for improved appearance are particularly common. From March 2007 to August 2008, we treated 28 cases of gynecomastia using fat aspiration plus small incisions in the areola, with a total of 56 sides, and all achieved satisfactory results, which are reported as follows: 1. Clinical data There were 28 male patients in this group, aged 22 to 35 years old, with an average age of 28 years. All patients had abnormal bilateral glandular hyperplasia with prominent breasts and normal nipple and areola development. The patient was asked to tense the bilateral pectoralis major muscles for palpation, and the tougher breast tissue under the skin of the breast was palpable, and no nodules or pressure pain were found. All breasts were mildly or moderately enlarged without significant ptosis. Extensive diffuse breast glandular hypertrophy or marked ptosis was not included in this group. There was no mass on palpation of the testicles. Mammography showed a disc-shaped homogeneous opacified area under the nipple; abdominal CT scan showed no occupancy in the adrenal parenchyma. Laboratory tests showed normal estrogen and androgen levels. 2. Surgical method 2.1. Line drawing and marking Before surgery, the patient was placed in a standing position with both hands hanging down naturally, and the area of breast hypertrophy was marked with methylene blue, and the curved incision line was marked along the medial edge of the areola in a lying position with both upper limbs abducted at 90°. The length of the incision is approximately 1/3 to 1/2 of the entire circumference of the areola, (do not exceed 1/2). The incision is fixed with tincture of iodine. 2.2. Preparation of swelling anesthetic solution 2% lidocaine 40 ml + 0.1% epinephrine 1.0 ml + 5% NaHCO 325 ml + saline 1000 ml [2] concentration of about 0.08%; incision anesthetic solution: 2% lidocaine 2.5 ml + saline 7.5 ml concentration of 0.5%. 2.3. Fat aspiration Select one side (left or right) with 500 ml of swelling solution for infiltrative swelling anesthetic injection under the skin of the hypertrophic breast area. After infiltrating the skin with 0.5% anesthetic solution, cut the skin with a sharp knife for 0.5 cm and use a blunt liposuction tube with a diameter of 2.5-3 mm and a length of 25 cm, connected to an electric negative pressure suction device with a suction force of 0.08×106～0.09×106 Pa, avoiding the nipple and areola. Avoiding the nipple and areola, the fat and breast tissue in the breast area are suctioned back and forth to reach a satisfactory thickness, noting that the subcutaneous fat suction should not be too thin, leaving a thickness of about 0.5 to 1 cm. After fat aspiration, the residual breast tissue is seen to be elevated. 2.4. Excision of the glandular body After the onset of anesthesia, the skin, subcutaneous tissue and breast tissue are cut along the areolar incision marker line, leaving about 0.5~1cm thickness of breast tissue below the areola. After aspiration, the glandular tissue below the nipple and areola is loosely connected to the surrounding and deep surface tissues in a reticular pattern with clear boundaries. If the gland is large, the gland can be divided and removed in batches before removal. 2.5 Postoperative treatment After mastectomy, the wound cavity is carefully hemostatic, and the wound cavity is flushed with gentamicin and saline, and a negative pressure drainage tube is placed and fixed from the liposuction incision. When suturing the areolar incision, the 0.5~1 cm thick breast tissue flap below the areola is first fixed to the medial pectoralis major muscle fascia by slightly pulling and suturing to position and fix the areolar area, so that the skin of the areolar area can be “flattened” after fixation. Intermittent suturing of the subcutaneous and skin. Before dressing, 2 to 3 small pieces of gauze are overlapped and a small hole of the same size as the nipple is cut in the center, and the nipple is led out from the small hole to avoid direct pressure and then wrapped and fixed with dry gauze, cotton pad and elastic chest bandage. The drainage tube was removed within 24 to 48 hours after surgery, and the stitches could be removed in 7 to 10 days. 3. Results All 28 patients achieved one-stage healing of the incision. The incision scars were not obvious, no hematoma or seroma occurred, and the breasts were flat and natural with no unevenness. There was good skin sensation and no blood flow disorder in nipple and areola. 3 patients had postoperative loss of nipple and areola skin sensation on 4 sides, and all patients had no loss of nipple and areola sensation. After follow-up from 3 months to 18 months, sensation was restored. 4 , Discussion 4.1, male breast enlargement, the cause of its pathogenesis is not clear. It may be related to various factors such as disturbance of sex hormone levels in the blood, abnormal tissue response to hormones, and obesity. Gynecomastia is generally divided into two categories: primary and secondary, with the former being more common. Primary gynecomastia is common in adolescent (12-17 years old) and old age (50-70 years old) males; secondary gynecomastia is common in certain diseases such as male hypogonadism, impaired liver function, after hemodialysis treatment, and adrenal tumors. Exogenous drug treatment causes gynecomastia in 10-25% of them. Therefore, patients should be carefully examined before treatment, using auxiliary examinations such as mammography, ultrasound and MRI, in addition to physical examination, in order to detect the primary disease in time, especially to differentiate it from malignant tumors. From the morbidity characteristics of the disease, adolescence is the peak period of breast proliferation, and most of them are able to return to the normal state by themselves within 1 to 2 years. Therefore, adolescent patients can be left untreated for the time being, while treatment should be actively considered for patients whose breast development still cannot regress back to normal after adulthood, affecting the appearance or even causing some degree of psychological disorder [6]. Gynecomastia can be classified into three categories and four levels according to the size of the breast and the degree of excess skin, with the following criteria: category I, mild breast enlargement without excess skin; category IIA. Moderate breast enlargement without excess skin; Class IIB, moderate breast enlargement with excess skin; Class III, significant breast enlargement with significant excess skin, similar to a sagging female breast. 4.2. Treatment of gynecomastia includes pharmacological and surgical treatment. Currently, it is believed that if the developed breasts do not disappear within a certain period of time (usually 2 years) with or without medication, surgical treatment is required. The main surgical methods are open glandular excision and simple fat aspiration, as well as a combination of both. Open excision has the disadvantage of greater surgical trauma and unsatisfactory postoperative breast shape. Fat aspiration alone is effective for patients with fatty gynecomastia, but for glandular and glandular fatty types, it has the disadvantage that the gland cannot be completely removed. We use fat aspiration plus small incisions in the areola to treat gynecomastia, and the author has come up with the following experience: 1. Good anesthesia and long duration Using the swelling anesthesia technique, there is enough swelling fluid to swell the tissues in the operating area for anesthesia. Ensure the requirements of a wide range of surgical excision, most of the lidocaine injected in the fat tissue and glandular tissue is discharged with the fat aspiration and glandular excision, so that the absorption of anesthetic into the blood is controlled within a safe range; at the same time, the swelling solution can also be fully free between the breast tissue and the skin, subcutaneous fat and pectoralis major muscle fascia, and the glandular body is clearly bounded with the surrounding tissue after fat aspiration, and then surgery Excision of the gland is suitable for operation with less bleeding and less operational damage. ②2. When removing the glandular tissue, is the operation larger compared to the incision to remove the gland intact and then take it out. Therefore, it is more convenient to remove the glandular tissues sequentially in a zoned and batched manner and then take them out. 3. 0.5Cm thick breast tissues under the areola are preserved, so that the blood flow of the subdermal vascular network of the nipple and areola is not destroyed, thus ensuring the blood flow of the nipple and areola; at the same time, it is beneficial to fix the nipple and areola on the fascia of the pectoralis major muscle at a later stage to prevent their displacement and reduce the damage caused by the glandular tissues. The cavity formed between the skin and the pectoralis major muscle after excision is reduced, and with negative pressure drainage, the occurrence of postoperative hematoma and seroma in the trauma cavity is reduced. It also reduces the tension of the areola skin edge alignment suture.4. The areola skin pigment is deeper, the incision is located at the edge of the areola, the incision scar formed after surgery is more hidden and inconspicuous, the incision of the liposuction pinhole is small, and the scar is also inconspicuous after healing.5. The postoperative chest wound is routinely bandaged with pressure for 2 weeks, especially the first week. Because the trauma area is large and exudates a lot, the pressure bandage can reduce the exudation of the trauma and is an important measure to prevent postoperative hematoma or seroma. The bandage should be strong and should not be displaced; however, it should not interfere with the patient’s respiratory movement of the thorax. If the patient’s breast skin is sagging and sagging significantly after surgery, the patient should be instructed to have an elastic chest band or bandage wrapped and shaped for 3 to 6 months. 4.3. The innervation of the nipple and areola skin is mainly from the lateral cutaneous branch of the 4th intercostal nerve. The lateral cutaneous branch of the 4th intercostal nerve penetrates the intercostal area near the anterior axillary line and is divided into two branches, the deep and superficial. The superficial branch is usually thicker than the deep branch and travels in the superficial fascial fat layer on the surface of the gland, then extends towards the nipple and areola and becomes thin and sends out branches to the subareolar area, where they are distributed as terminal branches in the superficial subdermis; the deep branch enters the inner part of the gland and sends out branches that accompany the ducts to the nipple, while other small branches emerge superficially on the outside of the areola to join the superficial branch and innervate the skin of the nipple areola. By preserving 0.5-1 cm of subcutaneous fat, we can avoid a significant sunken feeling in the chest after surgery, and at the same time avoid damaging the superficial branch of the lateral intercostal nerve that travels in the subcutaneous fatty tissue as much as possible, so as to preserve the sensation of the nipple areola skin to the maximum extent. Three of our patients had postoperative hyperalgesia of the nipple and areola skin. The possible reason was that the superficial branches were damaged by excessive aspiration of subcutaneous fat during fat aspiration in the outer lower quadrant of the breast, and in subsequent surgeries the outer subcutaneous fat layer was consciously preserved to be thicker, and nipple and areola sensory loss never occurred again. 4.4 For patients with fatty deposits in Class I and II patients, if satisfactory therapeutic results can be achieved by aspiration, glandular excision is not possible; however, for patients with mild glandular hyperplasia, mastectomy with fat aspiration and small incisions in the medial areola can result in clear boundaries between the gland and surrounding tissues, less damage during excision, less bleeding, favorable surgical operation, and more definite results; for Class III patients patients with extensive diffuse glandular hyperplasia or gynecomastia with obvious ptosis such as gynecomastia, we do not advocate the use of this method. For the removal of excess skin and better shaping, the method of superior or inferior tip nipple flap should be used to remove the hyperplastic glandular tissue and excess skin.