Endoscopic Axillary Approach Improves Patient Satisfaction of Gynecomastia Subcutaneous Mastectomy: A Cross-Sectional Study using the BODY-Q Chest Module

Dear editors, We read with great interest the article titled ‘‘Expected Reduction of The Nipple-Areolar Complex over Time after Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone’’ by Peter P. Pfeiler et al. [1]. We congratulate the authors for addressing such a sensitive item like NAC dimensions in men, which is clearly a feminizing feature, and for their interesting results on a large cohort of patients. Gynecomastia is a complex clinical condition characterized by several items including NAC aesthetical appearance. The NAC aspect mostly depends on the patient’s physical body type; in particular, it is related to BMI and physical appearance. Overweight patients generally show larger areolas while patients with good body contour generally show a more masculine areolar appearance. In our experience, areolar dysmorphism is strictly related to preoperative physical conditions and lifestyle. Given the growing demand for gynecomastia correction, recently we have conducted a study regarding patients’ personal satisfaction with gynecomastia correction in patients with different body types [2]. In the paper, the authors reported only nine Simon’s type III patients over 55 (16.36%) treated only by semilunar periareolar incision according to Webster’s technique. In these subjects, patients often present very large and feminine areolas. Since gynecomastia involves patients with different body types, considerations on areola’s diameters should be investigated according to the different physical preoperative appearance. Despite the fact that we really appreciated the authors’ effort, we maintain that the proposed results of postoperative NAC shrinkage and patients’ personal satisfaction with the results should be further related to physical condition. Is this surgical incision, in addition with ultrasound- assisted liposuction (UAL), really sufficient to obtain sensitive reduction of areola’s dimensions? Even if UAL can be definitely considered as an interesting approach, how much did the authors report NAC shrinkage for Simon III patients? In our experience, the circumareolar approach is strictly recommended to obtain a sensitive reduction of NAC diameters and extra-skin redistribution [3]. While we maintain that in high muscle mass patients the thickness of the underside of the NAC is sufficient for a satisfactory postoperative NAC shrinking [4], in the presence of Simon III patients, it is not enough, the semilunar periareola approach with UAL could not be sufficient to obtain satisfactory results [5, 6]. In conclusion, we maintain that UAL could be considered as a valid additional tool in a restricted cohort of patients, as reported in the authors’ paper in which the majority of recruited patients belong to Simon I (31) and Simon IIa (50) over 105 analyzed NACs.