The Pull-Through Technique — Minimal Scar, Careful Selection
The pull-through technique (Morselli, 1996) is a minimally invasive gynecomastia approach that combines liposuction with gland delivery through the same small port — avoiding the formal periareolar incision. Typically suited to Simon Grade I–IIa cases with mixed glandular-fatty composition where the gland is not too dense. The aim: a flatter chest contour without a periareolar scar — only 3–4 mm puncture sites, which typically fade within months. Individual results vary.
The pull-through technique is a minimally invasive approach to gynecomastia that removes the glandular component through the same small port used for liposuction — avoiding the classical inferior periareolar incision while still addressing the tissue that liposuction alone cannot reach. For selected Simon Grade I–IIa patients, it allows gland removal without a periareolar scar. Whether you are one of those patients is decided by examination — see liposuction vs. gland excision for how tissue type is assessed, and the Simon classification for grading.
Key principle: the pull-through technique is elegant and effective — but it is not universal. A gland that is too dense, too adherent, or too large cannot be safely delivered through a small port. Knowing when the pull-through is indicated and when it is not is the clinical skill; blindly attempting it in the wrong anatomy produces incomplete gland removal and recurrence.
How the technique works — step by step
- Marking and anaesthesia. The patient is marked standing. General anaesthesia is typical; local + sedation is possible in lean patients with small resections
- Tumescent infiltration. Lidocaine-epinephrine solution is infiltrated into the entire operative field for haemostasis and hydrodissection
- Aggressive subcutaneous liposuction. Using 3–4 mm cannulas through a single lateral or axillary 4 mm incision. The fat component is removed in full; the gland remains because it resists cannula action
- Gland mobilisation. A slightly more aggressive pass of liposuction around — but not through — the gland disrupts the surrounding adherent fat, leaving the gland semi-free in the cavity
- Pull-through. Through the same 4 mm port, a small Allis or tenaculum forceps is introduced, grasps the gland, and delivers it in one or several pieces without enlarging the incision. A dedicated "gynecomastia retractor" may be used
- Cavity verification. Finger palpation through the port confirms that no residual firm tissue remains. Any retained fragment is removed with further liposuction or additional forceps passes
- Closure. The 4 mm port is closed with a single subcuticular suture. No visible periareolar scar
Ideal candidates
- Simon Grade I–IIa with mixed glandular-fatty composition
- Moderate gland size — typically 15–40 g per side
- Semi-fibrous gland, not dense or heavily calcified
- Young, elastic skin that will retract without surgical tightening
- Younger patients (under 40) tend to respond more predictably due to skin elasticity
When the pull-through is NOT the right choice
- Dense fibrous gland that cannot be safely mobilised — requires direct excision
- Large gland volumes (>50–60 g) that would require enlarging the port defeating the purpose
- Simon Grade IIb with skin laxity — even a perfect gland removal won't produce a good result without addressing skin
- Revision cases where scar tissue from prior surgery prevents clean mobilisation
- Suspected calcification on examination or imaging
Advantages over classical periareolar excision
The classical approach involves a ≈5 cm periareolar arc incision, direct visualisation, and formal gland excision. It remains the gold standard for larger glands and Grade IIb cases. The pull-through's advantages over it, in appropriately selected patients: no visible scar, shorter operative time, faster recovery, less post-operative bruising, and often less swelling. Its disadvantages: reduced tactile control of resection margins and inability to handle very large or very dense tissue.
Technical pitfalls
| Pitfall | Consequence | Avoidance |
|---|---|---|
| Over-aggressive retroareolar liposuction | Crater deformity | Preserve 5–8 mm retroareolar disc |
| Incomplete gland removal | Early recurrence | Finger palpation check at end of procedure |
| Forced pull-through of dense gland | Extended port, visible scar | Convert to open if required |
| Nipple devascularisation | Partial necrosis | Preserve subdermal vascular plexus at areola |
| Ignoring skin laxity | Underwhelming contour | Re-grade to IIb if needed, change plan |
Outcomes & recovery
Compared with classical periareolar excision:
- Operative time: 45–90 min (vs 90–120 min)
- Return to desk work: 3–5 days (vs 5–7 days)
- Return to full upper-body training: same — 6 weeks
- Scar: 4 mm puncture (vs ≈5 cm periareolar)
- Outcome: closely tied to case selection — usually satisfactory in appropriate candidates, disappointing if the technique is forced in the wrong anatomy. Individual results vary
The recovery stages themselves — compression, swelling, return to travel — follow the same course as other gynecomastia procedures and are described in the recovery protocol, the week-by-week recovery guide and the compression vest guide.
When the plan changes in theatre: conversion to open excision
A pull-through is planned on the basis of examination, but the true density of a gland is only fully known once it is being mobilised. If the gland proves too dense or too adherent to deliver through the 4 mm port, forcing it risks an extended port and a visible scar — and leaving it behind risks early recurrence. The safer course is to convert to formal excision through a periareolar incision, the approach described in liposuction vs. gland excision.
For this reason, the possibility of conversion is part of the consent discussion for a pull-through. It is raised before surgery so that a periareolar scar, if it becomes necessary, is an expected outcome rather than a surprise. The aim is complete gland removal; the smallest possible scar comes second.
Risks to discuss before choosing a pull-through
No surgery is risk-free. A smaller incision does not change the main risks of gynecomastia surgery, which are discussed individually before any decision:
- Contour irregularity and crater deformity — from over-resection directly behind the nipple; see crater deformity after gynecomastia surgery
- Residual gland — if a fragment is left behind, which is why cavity verification by finger palpation is part of the procedure; see can gynecomastia come back?
- Fluid collection and bleeding — seroma and haematoma; see seroma and drains
- Nipple sensation change — most often transient; see nipple sensation after surgery
Key references
- Morselli PG. "Pull-through": a new technique for breast reduction in gynecomastia. Plast Reconstr Surg 1996;97:450-454.
- Gheita A. Gynecomastia: the horizontal ellipse method for its correction. Aesthet Plast Surg 2008;32:795-801.
- Rosenberg GJ. Gynecomastia: suction-lipectomy as a contemporary solution. Plast Reconstr Surg 1987;80:379-386.
- Rohrich RJ et al. Classification and management of gynecomastia. Plast Reconstr Surg 2003;111:909-923.
Am I a pull-through candidate?
Send standing photos on WhatsApp — Dr. Erdal will assess whether the pull-through is likely to give you an optimal result or whether a different technique is indicated.
WhatsApp Dr. ErdalFrequently asked questions
The pull-through technique is a minimally invasive approach in which the surgeon performs aggressive subcutaneous liposuction first, then grasps the remaining fibrous gland with forceps through the small liposuction port and delivers (pulls through) the gland without enlarging the incision. This avoids the formal periareolar scar of classical gland excision while still removing the glandular component.
The pull-through technique was described by Morselli in 1996 as an evolution of standard gynecomastia liposuction. The technique has since been refined by multiple surgeons internationally. It is now a mainstream approach for Simon Grade I–IIa gynecomastia, especially in patients prioritising minimal scarring.
No. Pull-through is generally suited to Simon Grade I–IIa with mixed glandular-fatty composition. It is less suitable for very dense fibrous glands (where the tissue cannot be effectively pulled through the small port), Simon Grade IIb–III with significant skin excess (which requires formal excision and skin tightening), and revision cases. The right technique depends on individual anatomy.
Yes — significantly. The pull-through technique uses only 3–4 mm puncture sites at the inframammary border or lateral chest, similar to liposuction-only. There is no periareolar incision and therefore no periareolar scar. The puncture sites typically fade within months and are usually difficult to see once mature, although healing varies between individuals.