Discussion: Surgical Management of Gynecomastia—Subcutaneous Mastectomy and Liposuction

We have read with great interest the paper entitled ‘‘Surgical Management of Gynecomastia: Subcutaneous Mastectomy and Liposuction’’ by Kim et al. [1]. The authors tried to determine the best management approach by comparing outcomes of two groups of patients with gynecomastia who received subcutaneous mastectomy combined with liposuction (Group B) and liposuction only (Group A). Congratulations on the excellent results achieved by the authors and we would like to expose elements for a discussion. In 2016, we published a paper about our experience in the treatment of gynecomastia in 312 consecutive cases [2]. Unlike Kim et al. in all our cases, an excision of the gland was performed (using a periareolar approach in the great majority). No patient underwent liposuction alone. In fact, in our experience the periareolar access offers good visibility and allows us to get an adipocutaneous flap able to offer a good shape and contour of the pectoral region. If necessary, liposuction of the peripheral fatty tissue was usually performed using the contralateral periareolar incision. However, the cannula, even without uction, was used to undermine a larger flap to obtain a better contouring of the skin to the chest profile as described in various areas of the body [3]. After then, we use to fix the flap to the deep surface with few quilting stitches thus to provide a better distribution of the adipocutaneous flap and to reduce the dead space and to decrease the risk of postoperative seroma or hematoma. An important element in favor of subcutaneous mastectomy is evident rom the paper under discussion. Satisfaction regarding size was significantly higher in group B, and satisfaction regarding scarring was significantly higher in group A. So we agreed to support the best outcomes with the addition subcutaneous mastectomy, because the residual periareolar scars are almost invisible; we believe that it is worth using this surgical approach devoid of significant risks of pathological scars [4]. Also in the paper of Korean authors, all procedures were performed under general anesthesia. In our series, we conducted 309 procedures under local anesthesia with intravenous sedation if necessary. The choice to conduct surgery under local anesthesia has allowed us to reduce hospitalization costs in addition to reduce the anesthetic risk. We think that in selected patients the choice to conduct local anesthesia procedures is an important advantage.