Comment on: “Surgical Masculinization of the Breast: Clinical Classification and Surgical Procedures”

Dear Sir, We read with great interest the article entitled: ‘‘Surgical masculinization of the breast: clinical classification and surgical procedures’’ by Cardenas-Camarena et al. [1]. Based on three different anatomical characteristics (amount of fatty tissue, gland tissue and excess of skin), the authors proposed a new clinical classification system and relative surgical procedure for each gland type. We fully agree with the authors that to obtain a masculine breast shape, regardless of patient gender, is the main objective in gynecomastia treatment, and a careful pre-operative physical examination is essential to select the most appropriate surgical technique, but we have some elements to discuss. Recently, we conducted a study to investigate different expectations in a large gynecomastia population [2–5]. Because dissatisfaction with the results represents a common reason for claims, management of patients’ expectations is the key element to achieve a high level of approval as the leading measure of treatment success. Considering patients’ physical appearance is mandatory to maximize postoperative satisfaction. Three different categories can be identified: athletic physiques (high muscle mass and body fat9%, and aBMI); normal physiques (not particularly muscular BMI); and overweight subjects (BMI[25). The concept of an ideal chest is dissimilar among these different categories of subjects; it is influenced by the age, personal preference, lifestyle, and different body structure. High-muscle-mass patients want better definition of the pectoralis area that cannot be obtained by simple physical training. Their chest is more scrutinized, especially in body builders; the low percentage of fat tissue renders the gland even more pronounced. They are the most distressed by gynecomastia and are very sensitive to the problem, showing high expectations that can only be satisfied by minimizing the adipo-glandular layer covering the muscle. Normal-body-type patients, as well as females affected by gender dysphoria, suffer from female appearance revealing social limitations, so they require a more masculine chest aspect. Overweight patients feel that gynecomastia is a weight disorder, so they require a slimmer appearance. BMI, representing a crucial feature in treatment of gynecomastia disorder and should be meticulously considered during pre-operative planning, varying between different physical body types and expectations.