Patterns of Intraoperative Bleeding in Gynecomastia Surgery: Lessons from a Large Consecutive Series

Abstract Background Gynecomastia surgery, first described by Paulus Aegineta, has evolved considerably; however, intraoperative bleeding and postoperative hematoma remain the most common complications. Objectives To characterise the consistent intraoperative bleeding patterns in a large consecutive series of gynecomastia procedures and to describe an anatomy-based hemostatic protocol intended to reduce hematoma and re-exploration rates. Methods Intraoperative bleeding-site and operative data were collected prospectively for 4560 consecutive patients undergoing gynecomastia correction between 2015 and 2025; pre- and post-protocol cohorts were then compared retrospectively. Intraoperative bleeding sites were systematically documented. A stepwise hemostatic protocol was implemented, incorporating sequential cauterization of predictable perforators, internal quilting sutures, local and intravenous tranexamic acid, and immediate postoperative compression. Postoperative complications and re-exploration rates were analyzed. Results Reproducible bleeding hotspots were identified beneath the nipple–areolar complex (78%), along the lower border of pectoralis major (63%), lateral border (54%), superolateral region (41%), and medial parasternal area (38%). These corresponded to perforators from the internal mammary, intercostal, lateral thoracic, and thoracoacromial systems. The overall hematoma rate was 0.9% and seroma rate 2%.Re-exploration decreased significantly from 0.54% to 0.05% following protocol implementation (p = 0.002), with an overall rate of 0.31%. The hematoma rate showed a trend toward reduction, from 1.17% to 0.60% (p = 0.058) Conclusions Intraoperative bleeding during gynecomastia surgery arises from consistent perforator anatomy. A structured, anatomy-driven sequence of dissection and hemostasis can significantly reduce hematoma and re-exploration rates, enhancing surgical safety.