الفهرس 
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Abstract
Background: Gynecomastia is a benign condition refers to enlargement of the male breast either due to proliferation of ductal, stromal or fatty tissue. It affects about 30-60 % of newborn infants and about 30-65 % of adolescents and old age. It occurs due to imbalance between serum levels of estrogens and androgens in the form of increasing levels of estrogens or decreasing levels of androgens. Also, it may be due to a defect in androgen receptors that become insensitive to normal levels of circulating androgens. The causes may be idiopathic, congenital, physiological, drug induced, oncological and systemic diseases.
Objective: The study is to compare between circumareolar approach and inverted-T pattern aiming to reach the most effective, reliable and recommended technique in surgical management of high grades gynaecomastia.
Methods: There are several classifications for gynecomastia that have been used but the most commonly used is Simon classification: Grade 1: Small visible breast enlargement without skin redundancy. Grade 2A: Moderate breast enlargement without skin redundancy. Grade 2B: Moderate breast enlargement with skin redundancy. Grade 3: Marked breast enlargement with marked skin redundancy. Proper diagnosis of gynecomastia is achieved by adequate history taking, general, local examination and laboratory investigations. Treatment is divided into reassurance and follow up, treatment of the cause, pharmacotherapy and surgical therapy. Pharmacotherapy includes androgens like Danazol, antiestrogens like Tamoxifen and aromatase inhibitors like Anastrozole. They have some effect in treatment of gynecomastia. Surgical management is considered if gynecomastia persists more than two years without spontaneous regression or not responds to medical treatment. It is either liposuction alone, subcutaneous mastectomy with or without skin excision and a combination of liposuction and surgical excision. There are many methods of liposuction as conventional, power assisted, ultrasound assisted and laser assisted liposuction.
Results: Subcutaneous mastectomy may be with or without skin excision. Approaches of mastectomy without skin excision may be periareolar, circumareolar, perithelial, intra-areolar, inframammary and axillary. Approaches of skin excision may be circumareolar, inverted-T, le jour mastopexy and free nipple areolar graft. The surgical management of high grades gynecomastia is considered a problematic issue as liposuction and conventional subcutaneous mastectomy without skin excision are not sufficient in most cases and need another session for redundant skin excision. In our study, statistics shows to some extent the preference of circumareolar approach over inverted-T pattern due to significant lower rates of hematoma and nipple areola complex complications. However, there is no significant difference between the two approaches in incidence of seroma, patient satisfaction and the need for secondary operation.
Conclusion: Surgical management of high grades gynecomastia is a big challenge and there is no single approach is recommended between surgeons.