Transaxillary suspension endoscopic-assisted subcutaneous gland excision: clinical outcomes and significance in gynecomastia management

Introduction

Background

Gynecomastia (GM) is the most common male breast disease, accounting for approximately 80% to 90% of all male breast conditions. This disease typically manifests as progressive, painless enlargement of one or both breasts or a painful mass in the subareolar region. Over 30% of adolescent males experience GM, and more than 60% of males over the age of 60 years are affected (1,2). Although GM is generally not life-threatening, its psychological impact is profound, often resulting in depression, low self-esteem, and anxiety, significantly impairing quality of life.

Treatment for GM is usually guided by clinical staging. According to the Simon classification, pharmacological treatments may be suitable for patients with GM of grade IIb or lower, whereas surgery is often required for those with grade IIb or higher due to limited efficacy of pharmacological agents. Traditional subcutaneous mastectomy through midaxillary line has been widely applied attributed to the concealed incision. However, the distance between the incision and inner quadrant surgical sites can compromise hemostasis, increasing the risk of postoperative bleeding. In contrast, endoscopic-assisted subcutaneous mastectomy is equipped with superior advantages such as reduced skin flap necrosis, minimal bleeding, faster recovery, and smaller scars, making it widely applied in clinical practice (3-5).

Rationale and knowledge gap

Traditional endoscopic-assisted surgery requires pneumoperitoneum which is unstable to create a working space, possibly causing complications such as subcutaneous emphysema, gas embolism, and hypercarbia. These risks are particularly pronounced in elderly patients or those with comorbidities, leading to issues such as venous return obstruction, shoulder pain, nausea, and vomiting (6-8). Additionally, axillary midline or axillary anterior incisions for the Trocar can result in unfavorable postoperative appearance, particularly in individuals prone to keloids.

To address these issues, we proposed a novel approach, transaxillary suspension endoscopic-assisted subcutaneous mastectomy. This technique eliminates the need for pneumoperitoneum, reducing physiological risks, and improves cosmetic outcomes by employing a more favorable axillary incision.

Objective

The aim of this study was to evaluate the safety, perioperative outcomes, complication rates, and aesthetic and psychological effects of lipolysis-free suspension endoscopic-assisted subcutaneous mastectomy (observation group) compared to conventional subcutaneous mastectomy via midaxillary incision (control group) in male patients with GM. By employing a consistent surgical protocol and standardized outcome assessment, this retrospective cohort study aims to generate evidence supporting the clinical feasibility and advantages of a novel gasless endoscopic technique in reducing surgical trauma and enhancing patient satisfaction, thereby informing future prospective investigations and clinical practice guidelines for GM management. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-344/rc).

Methods

Patients

This retrospective cohort study was conducted at Zibo Central Hospital and included 103 male patients with GM who underwent surgical treatment between January 1, 2021 and March 1, 2024, under the care of a consistent surgical team. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Zibo Central Hospital (No. 202101007), and individual consent for this retrospective analysis was waived.

Patients were eligible for inclusion if they had a unilateral diagnosis of GM confirmed by Doppler ultrasound, were classified as Simon’s grade IIb or higher, presented with clinical symptoms, exhibited a strong desire for surgical correction due to significant psychological burden, and had either failed medical therapy or were deemed unsuitable for conservative treatment. Patients with Simon’s grade < IIb who had previously failed pharmacological treatment were also considered. A total of five such patients were included under this criterion, having persistent GM despite medical therapy. Patients were excluded if they had severe chronic systemic diseases such as uncontrolled hypertension or diabetes, cognitive or psychiatric disorders impairing decision-making capacity, secondary GM due to identifiable etiologies such as testicular tumors, congenital testicular dysplasia, hyperthyroidism, cirrhosis, or primary hypogonadism, or if Doppler ultrasound revealed coexisting breast nodules. The severity of GM was graded according to the Simon classification system (9).

Research methods

This study employed a single-center, non-randomized, retrospective comparative design to evaluate the clinical outcomes and patient satisfaction of two surgical approaches for the treatment of GM. Patients were not randomly assigned to surgical approaches; instead, the procedure for each patient was determined based on the operating surgeon’s recommendation and the patient’s preference after discussing the available options. No formal stratification by disease severity or other patient characteristics was performed.

The patients who underwent GM surgery, facilitated by the same team of physicians, were meticulously tracked and followed for comprehensive analysis. The surgical room nurses meticulously recorded the duration of surgeries and the volume of intraoperative bleeding for both groups. Additionally, nurses specializing in breast and thyroid surgeries documented the daily postoperative subcutaneous drainage for each group. Extubation time, set with a criterion of drainage volume <10 mL, and the incidence rates of postoperative bleeding, identified by notable fluid flow (>5 mL per minute) in the drainage tube, and occurrences of nipple-areola flap necrosis were diligently documented by attending physicians.

A 180-day postoperative follow-up assessment was administered through an electronic survey questionnaire, focusing on evaluating patient satisfaction and psychological improvement. The evaluation encompassed diverse aspects: overall self-satisfaction, skin satisfaction in the surgical area, bilateral breast symmetry satisfaction, and nipple sensation satisfaction, rated on a scale of 0 to 10 points. Scores were stratified into dissatisfaction [0–3], good [4–7], and satisfaction [8–10].

Psychological assessment was conducted using a structured questionnaire based on the Symptom Checklist-90 (SCL-90), which included domains of interpersonal sensitivity, obsessive tendencies, depression, and anxiety. Each domain was rated on a 0–10 scale. Ratings were classified as no symptoms or mild [0–3], moderate [4–7]—impacting daily life but manageable through attention diversion or medication, and severe [8–10]—significantly disrupting daily life and unmanageable by any means. Higher scores indicated more severe symptoms and poorer psychological conditions.

Surgical procedure

Observation group

Preoperative marking of the surgical area was made with patients based on ultrasound examination and palpation (Figure 1). The procedure was performed under general anesthesia in a supine position. The surgical area was routinely disinfected, and sterile drapes were applied. An incision measuring approximately 4–5 cm was in the axilla (Figure 2). The skin and subcutaneous fat were incised sequentially to expose the lateral border of the pectoralis major muscle. The space between the breast gland and part of the pectoralis major muscle was carefully dissected under direct vision. The breast tissue and skin were then suspended, allowing for the insertion of endoscope equipped with an electrocautery tool to continue the dissection of the remaining breast tissue in the space between the gland and the pectoralis major muscle. Once the dissection was completed, the suspension device was used to hang the breast surface and skin (Figure 3). Hemostasis was achieved by multiple subcutaneous injections of hemostatic fluid (0.9% saline with 1 amp of adrenaline) via the axillary incision. Under direct vision, blunt dissection was used to separate the breast tissue from the subcutaneous fat, and the breast tissue was completely excised within the marked boundaries using the endoscope. Thorough hemostasis was performed, and the wound was irrigated repeatedly. A drainage tube was placed on the surgical side, and the incision was sutured (Figures 4,5).

Figure 1 Preoperative marking of the surgical area based on ultrasound examination and palpation, delineating the boundaries of glandular tissue requiring excision.

Figure 2 Intraoperative anatomy demonstrating dissection of the lateral border of the pectoralis major muscle through the axillary incision, providing access to the retroglandular plane.

Figure 3 Suspension of the skin using a no-insufflation retractor system, enabling optimal visualization and surgical manipulation during endoscopic glandular excision without gas insufflation.

Figure 4 Lateral view of the left chest wall 10 days postoperatively after dressing change, demonstrating excellent wound healing and minimal scarring at the axillary incision site.

Figure 5 Frontal view of the left chest wall 10 days postoperatively after dressing change, showing symmetric chest contour and satisfactory aesthetic outcome with concealed surgical access.

The surgical procedure began with securing the modular base to the edge of the operating table, followed by adjusting the vertical support rod and locking the stabilizing frame. A transverse beam equipped with multiple hooks formed the suspension platform, which was connected to an L-shaped retractor via chains. This configuration allowed for mechanical elevation of the skin and superficial fascia, thereby creating a stable endoscopic working space without the need for carbon dioxide insufflation.

Based on the preoperative breast markings delineating the glandular boundaries, three suspension needles were inserted perpendicular to the direction of operation in most cases. The first needle was placed on both sides of the nipple-areolar complex, while the remaining two were inserted between the incision and the nipple–areolar complex, and between the lateral border of the sternum and the midpoint of the nipple, respectively. After securing the suspension needle clips into the corresponding slots, the skin was elevated using chains until further lifting was not possible, and then fixed to the suspension frame to ensure an adequate operative field and workspace. No skin injury occurred throughout the procedure.

Control group

An incision approximately 5 cm in length was made along the midaxillary line. The skin and subcutaneous fat were sequentially incised. Using electrocautery, the breast tissue was dissected along the preoperatively marked boundaries based on ultrasound localization and completely excised. Thorough hemostasis was achieved, and the wound was irrigated repeatedly. A drainage tube was placed on the surgical side. Postoperative care included regular dressing changes, and sutures were removed 20 days after the operation.

Statistical analysis

All data were analyzed using SPSS 27.0 software. Kolmogorov-Smirnov single-sample test was performed to check whether the data conformed a normal distribution. Continuous variables with normal distribution are presented as mean ± standard deviation and compared using independent-sample t-tests; non-normally distributed data are expressed as median [interquartile range (IQR)] and compared using the Mann-Whitney U test. Categorical variables (if any) would be analyzed using the Chi-squared or Fisher’s exact test. A P value <0.05 was considered statistically significant.

Results

Of the 103 patients included in the study, 43 underwent lipolysis-free suspension endoscopic-assisted subcutaneous mastectomy (observation group), while 60 received conventional subcutaneous mastectomy via a mid-axillary incision (control group). Baseline characteristics, including age, body surface area (BSA), height, weight, and body mass index (BMI), were comparable between groups (all P>0.05). Specifically, the median age was 34.00 years in both groups (IQR, 27.50–44.00 in the observation group vs. 28.00–43.25 in the control group; P=0.92), and mean BMI values were similar (29.01±3.82 vs. 28.80±3.72 kg/m², P=0.78) (Table 1). Additionally, GM severity (Simon grade) was similar between the cohorts. The observation group included 25 patients (58%) with Simon grade IIb and 16 (37%) with Simon grade III, along with 2 patients (5%) who were grade < IIb (these cases were included after failed medical therapy). The control group included 32 patients (53%) with grade IIb and 25 (42%) with grade III, plus 3 patients (5%) with grade < IIb. Notably, these five grade < IIb cases (two in the observation arm and three in the control arm) represented only about 5% of each group. There was no significant difference in the distribution of Simon grades between the observation and control groups.

Intraoperative blood loss was significantly reduced in the observation group compared with the control group [median (IQR): 32.00 (27.00–43.00) vs. 57.00 (41.00–65.00) mL; P<0.001]. However, the operative time was notably longer in the observation group [123.00 (109.00–135.00) vs. 35.00 (32.00–37.00) minutes; P<0.001], likely reflecting the technical complexity of the endoscopic approach. Notably, no patients in the observation group required conversion to an open procedure.

Postoperative recovery indicators were more favorable in the observation group. The median postoperative drainage retention time was significantly shorter [3.00 (3.00–3.00) vs. 4.00 (4.00–5.00) days; P<0.001], and the average postoperative daily drainage volume was also lower [27.00 (24.50–30.00) vs. 35.12 (33.00–37.50) mL; P<0.001], suggesting a faster recovery profile associated with the endoscopic technique (Table 2).

Surgical complication rates

The incidence of nipple and flap necrosis in the observation group was 4.65% (2/43), which was not significantly different from the control group (6.67%, 4/60) (P>0.99). The incidence of postoperative bleeding in the observation group was 2.32% (1/43), which was not significantly different from the control group (6.67%, 4/60) (P=0.40) (Table 3).

Patient satisfaction

Across all domains, the observation group consistently reported higher satisfaction than the control group. Median self-perception scores were significantly higher in the observation group compared with the control group [9.00 (8.00–10.00) vs. 6.00 (6.00–8.00), P<0.001]. Satisfaction with the surgical skin incision was also greater in the observation group [9.00 (8.00–10.00) vs. 7.00 (6.00–8.00), P<0.001], as was perceived bilateral chest wall symmetry [9.00 (8.00–10.00) vs. 7.00 (6.00–9.00), P<0.001].

Notably, nipple sensation scores were modestly but significantly higher in the observation group [8.00 (6.00–9.00) vs. 7.00 (6.00–8.00), P=0.01], suggesting better sensory preservation following endoscopic surgery (Table 4).

Psychological improvement

There were no statistically significant differences in preoperative psychological measures between the observation and control groups. Specifically, preoperative interpersonal sensitivity, obsessive-compulsive symptoms, and depression and anxiety scores were similar across groups (all P>0.05), indicating comparable baseline psychological states.

Postoperatively, patients in the observation group reported significantly lower interpersonal sensitivity scores compared with the control group [median (IQR): 1.00 (1.00–2.00) vs. 3.00 (1.75–4.00); P<0.001], suggesting better psychological adaptation following endoscopic surgery. No statistically significant differences were observed in postoperative obsessive-compulsive symptoms scores [1.00 (0.00–1.00) vs. 1.00 (0.00–2.00); P=0.44] or depression and anxiety scores [2.00 (0.50–3.00) vs. 2.00 (1.00–3.00); P=0.059], although a numerical trend toward improved mood and anxiety symptoms was noted in the observation group (Table 5).

Discussion

Key findings

This study aimed to evaluate the clinical efficacy of transaxillary suspension endoscopic-assisted subcutaneous mastectomy in the surgical management of GM. The findings indicate that this minimally invasive technique enables safe and effective removal of hypertrophic glandular tissue while minimizing surgical trauma. Key outcomes included significantly reduced intraoperative blood loss, accelerated postoperative recovery, and favorable aesthetic results. Patients reported high levels of satisfaction with postoperative chest contour, accompanied by substantial improvements in psychological well-being.

Strengths and limitations

This study introduced and applied an innovative surgical approach that integrates the precision of suspension endoscopy with a cosmetically favorable, concealed transaxillary incision. This technique enables complete resection of glandular tissue while minimizing anterior chest wall scarring, offering substantial aesthetic benefits in the treatment of GM. All procedures were performed by the same surgical team following a standardized protocol, thereby minimizing operator-related variability. The evaluation encompassed both objective surgical metrics (e.g., blood loss, complications) and patient-centered outcomes (e.g., satisfaction, psychological status), allowing for a comprehensive assessment of clinical efficacy.

Nevertheless, several limitations warrant consideration. First, the retrospective, non-randomized, single-center design of this study inherently limits the generalizability of the findings to broader populations. The absence of random allocation introduces a potential for selection bias, as the surgical technique was determined by patient preference and surgeon recommendation. Consequently, the level of evidence is relatively low, and the results should be interpreted with caution. Future prospective studies—ideally multicenter and randomized controlled trials—are warranted to validate these findings and provide higher-quality evidence. Second, some outcomes—particularly aesthetic satisfaction—were primarily based on subjective self-reports; although satisfaction scores were favorable, the use of standardized, validated aesthetic evaluation instruments would strengthen the robustness of the findings. Finally, we fully acknowledge that the 6-month follow-up duration represents a key limitation of this study. Such a relatively short observation period is insufficient to evaluate important long-term outcomes, including the potential for late recurrence of GM, long-term preservation of nipple sensation, and sustained changes in patient satisfaction and quality of life. We have also noted that late recurrences or sensory changes may occur beyond 6 months; therefore, our conclusions regarding these outcomes should be considered preliminary. Future studies with extended follow-up periods of 12, 24 months, or longer are needed to more comprehensively assess the durability of surgical outcomes and patient-reported results.

Comparison with similar research

The findings of this study align with a growing body of literature supporting minimally invasive surgical approaches for the management of GM. As early as 1998, Ohyama et al. first demonstrated the feasibility of endoscopic subcutaneous mastectomy via a transaxillary approach, laying the foundation for scar-reducing techniques in male breast surgery (10). In 2009, Fan et al. reported a series of 65 successful cases of endoscopic subtotal mastectomy, confirming the safety and efficacy of endoscopic resection in achieving satisfactory chest contour without the need for skin excision (11). More recently, several novel minimally invasive techniques have demonstrated similarly promising results. For example, Sim et al. utilized the microsurgical excision with liposuction technique (MELT) technique—microsurgical excision with liposuction via ultra-small incisions—and achieved glandular clearance rates comparable to open surgery with high patient satisfaction (12). Similarly, Wang et al. reported the use of the Mammotome-assisted minimally invasive resection (MAMIR) technique for GM, which significantly reduced postoperative scarring without compromising therapeutic efficacy (13). Our findings further support previous reports on the advantages of single-port transaxillary endoscopic surgery. Studies by Lee et al. and Yang et al. showed that transaxillary single-port endoscopy combined with liposuction allowed effective glandular removal without visible chest scarring, achieving favorable cosmetic outcomes (5,14). Notably, Yang et al. observed that patients with smaller-volume (Simon grade I) GM achieved significantly higher cosmetic scores postoperatively compared to those with more advanced grades, suggesting that endoscopic techniques are especially advantageous in selected patients (5). Chen et al. demonstrated superior patient satisfaction and aesthetic chest contouring in the single-port endoscopy plus liposuction group, compared to conventional periareolar open excision (15). Although the open group had shorter operative times, it also exhibited a higher rate of postoperative seroma, and lower aesthetic satisfaction scores overall. In parallel, a randomized controlled trial by Diao et al. found that endoscopic-assisted surgery significantly reduced intraoperative blood loss, lowered complication rates, and accelerated postoperative recovery without increasing long-term recurrence risk (16). At 1-year follow-up, patients in the endoscopic group reported superior scar quality and chest appearance, consistent with our own observations of high cosmetic satisfaction (16). Additionally, the gasless suspension technique employed in our study is supported by the findings of Zhang et al., who reported that gasless transaxillary endoscopic mastectomy achieved comparable outcomes to CO₂-insufflation methods, while shortening operative time and simplifying surgical steps without compromising postoperative results (17). These findings suggest that eliminating pneumoperitoneum—consistent with our suspension-based cavity creation—can enhance surgical efficiency while preserving therapeutic outcomes. Additionally, recent innovations have focused on reducing anesthesia-related invasiveness. Tettamanzi et al. reported performing GM surgery under tumescent local anesthesia (avoiding general anesthesia) with safe and effective results (18). Such anesthesia-sparing approaches further expand the minimally invasive options for GM management.

Taken together, current evidence consistently supports the surgical benefits observed in our study. Across a range of minimally invasive techniques, patients experience reduced surgical trauma, minimized scarring, and high satisfaction rates. Importantly, there is increasing recognition of the psychosocial benefits following GM surgery. A prospective study by Kasielska-Trojan et al. demonstrated significant improvements in self-esteem and social confidence after surgery, underscoring the psychological value of timely and effective intervention (19). Our findings build on this perspective by demonstrating that transaxillary endoscopic surgery not only addresses the physical manifestations of GM but also minimizes the shortcomings of open approaches, offering a well-tolerated and psychologically beneficial treatment pathway.

Explanations of findings

The clinical benefits observed in this study can be attributed to the minimally invasive nature and refined technical execution of the transaxillary endoscopic approach. The procedure requires only a small incision concealed within the axilla and is performed under direct endoscopic visualization, minimizing disruption to surrounding normal tissues compared to traditional open surgery. This reduced surgical trauma directly accounts for the minimal intraoperative blood loss and limited postoperative pain. Unlike open excision, which necessitates wider tissue dissection, endoscopic resection involves more localized cutting and electrocautery, thereby preserving adjacent structures. For example, preserving a more localized plane of dissection likely spared the small nerve branches that innervate the nipple-areola complex, which may explain the slightly superior postoperative nipple sensation observed in the observation group. The decrease in tissue injury also explains the accelerated recovery observed in patients—manifested by earlier ambulation, shorter hospital stay (patients in the observation group were discharged on postoperative days 3–4, whereas those in the control group were discharged around postoperative days 4–5), and fewer complications—findings that are consistent with prior reports on enhanced recovery following endoscopic interventions (16). In addition, although we did not formally measure postoperative pain or time to return to daily activities, patients in the endoscopic group generally experienced less discomfort and a quicker resumption of normal activities than those in the open group, based on clinical observations. Another critical advantage lies in the absence of visible anterior chest incisions. Because the surgical access is entirely transaxillary, there are virtually no scars on the chest wall, leading to markedly improved cosmetic satisfaction. This contrasts with traditional periareolar or inframammary approaches, which often leave noticeable scars that can impact body image and self-esteem (15). In our cohort, patients exhibited a flat chest contour, preserved nipple-areola complex, and no prominent scarring, significantly enhancing their physical appearance and self-perception.

Furthermore, the technique enables complete excision of hypertrophic glandular tissue, a determinant of both anatomical correction and therapeutic efficacy. Endoscopic magnification facilitates precise dissection and thorough removal of the gland, thereby effectively normalizing chest morphology. This physical transformation, in turn, contributes to substantial psychological relief. Many patients reported increased self-confidence postoperatively, with diminished anxiety and social discomfort. Thus, the procedure addresses both the physical deformity and psychological distress associated with GM, offering a dual therapeutic impact.

The convergence of low blood loss, rapid recovery, superior aesthetics, and psychological improvement can be traced to the core features of the technique—minimal invasiveness paired with effective glandular clearance. By confining the surgical impact while fully resolving the pathological substrate, this approach maximizes therapeutic gain while minimizing iatrogenic burden, as reflected in our clinical outcomes.

Regarding the higher intraoperative blood loss observed in the control group (open surgery), we believe the main reason is the limited surgical field of the open approach, which makes precise hemostasis more difficult. In contrast, the endoscopic procedure allows for more accurate electrocautery under direct visualization. Additionally, the observation group routinely received infiltration with an epinephrine-containing tumescent solution to reduce bleeding, whereas this measure was not used in the control group, which may also have contributed to the greater blood loss.

One notable drawback of the suspension endoscopic approach is that the operative time is longer than that of the conventional open technique. This difference can be partly attributed to the learning curve associated with adopting a new endoscopic technique. Based on our experience, as the surgical team became more proficient, operative times progressively decreased, with later cases being completed much faster than the initial ones. This improvement indicates that the efficiency of the endoscopic technique increases significantly with accumulated experience. Although a longer operative time entails a longer duration of anesthesia, we observed no anesthesia-related complications. Moreover, the advantages of reduced blood loss and faster recovery suggest that the additional operative time may be acceptable for appropriately selected patients.

From a surgical standpoint, the two techniques differ in execution and present distinct challenges. The gasless suspension endoscopic method requires additional setup and careful coordination, as the surgeon operates in a narrower field with elongated instruments and relies on a magnified endoscopic view. Early in our series, a key challenge was maintaining orientation and exposure while working through the single axillary incision with the suspension device in place. We found that certain strategies facilitate the endoscopic procedure: for example, thorough preoperative ultrasound mapping of the glandular tissue, strategic placement of the suspension sutures at the gland or skin edges to maximize exposure, and slow, meticulous electrocautery dissection to control bleeding in the confined space. In contrast, the conventional open subcutaneous mastectomy via a midaxillary incision is more straightforward and much faster, since it allows direct manual access to the gland. However, the open approach offers limited visualization of deeper tissue planes and can result in greater bleeding if hemostasis is not meticulous (in our practice, we now routinely infiltrate dilute epinephrine even in open cases to improve hemostasis). The open technique relies heavily on manual retraction and tactile feedback, whereas the endoscopic technique provides enhanced visual feedback but demands advanced instrument-handling skills. Overall, with adequate training and experience, we found that the suspension endoscopic technique can be performed safely and reproducibly, but new adopters should anticipate an initial learning curve. It may be advisable to begin using the endoscopic approach on moderate-grade GM cases and gain familiarity with the equipment and anatomy before attempting it in patients with very extensive glandular enlargement or significant excess skin.

Implications and actions needed

The findings of this study underscore the clinical value of transaxillary endoscopic-assisted surgery as a therapeutic modality for GM. This technique demonstrated a favorable safety and efficacy profile while simultaneously addressing both the physical and psychosocial concerns of patients. By offering aesthetically acceptable outcomes in conjunction with definitive glandular excision, it holds the potential to increase treatment acceptance among men with GM who might otherwise forgo surgery due to cosmetic concerns.

Several avenues are necessary to facilitate broader clinical translation of these findings. First, larger multicenter studies and randomized controlled trials are required to validate the reproducibility and generalizability of our single-center observations. Second, longer-term follow-up is essential to assess the durability of outcomes. Extended postoperative monitoring will clarify the potential for glandular recurrence and determine whether high levels of patient satisfaction are maintained over time—insights that are critical for understanding the long-term impact of this approach.

Third, efforts should be directed toward the dissemination and standardization of this surgical technique. Incorporating transaxillary endoscopic surgery into continuing surgical education through structured training programs and dedicated workshops may reduce the learning curve and facilitate safe, consistent adoption across institutions. The development of detailed procedural guidelines or standardized protocols would further support its clinical implementation and ensure uniform surgical quality.

With the accumulation of supportive evidence, this minimally invasive strategy may evolve from a novel intervention into a preferred component of routine clinical management for GM. Through ongoing research and educational outreach, transaxillary endoscopic surgery has the potential to become a widely accepted and impactful technique, elevating the overall standard of care for this condition.

Conclusions

In this retrospective comparative study, transaxillary suspension endoscopic-assisted subcutaneous mastectomy demonstrated significant advantages over conventional subcutaneous mastectomy via midaxillary incision in the surgical management of GM. The suspension technique—characterized by a gasless approach and stable operative field—achieved markedly lower intraoperative blood loss, reduced postoperative drainage, and accelerated drain removal, without increasing complication rates. Beyond technical efficacy, the procedure conferred superior patient-reported satisfaction in terms of chest contour, scar concealment, and nipple-areolar symmetry, alongside measurable improvements in postoperative interpersonal sensitivity. These findings highlight the clinical utility of a gasless suspension strategy as a safe, minimally invasive alternative that addresses both surgical and psychosocial dimensions of GM. Wider adoption and prospective validation of this approach are warranted to support its integration into routine surgical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-344/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-344/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-344/prf

Funding: This study was supported by the Zibo Medical and Health Research Project (No. 20240401045, to J.C.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-344/coif). J.C. declared that this study was supported by the Zibo Medical and Health Research Project (No. 20240401045). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Zibo Central Hospital (No. 202101007), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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