Percutaneous Intradermal Purse-String Closure for Correction of Male Tuberous Nipple-Areola Complex Deformity

Dear Sir, We read with interest the article titled ‘‘Percutaneous Intradermal Purse-String closure for Correction of Male Tuberous Nipple-Areola Complex Deformity’’ by Carvajal et al. [1]. We congratulate the authors for their nice result and for the innovative approach in the surgical approach for the correction of a rare variant of gynecomastia, with the effort to reduce the visibility of surgical scars. The proposed technique and the final outcome are interesting, but we have some elements to discuss. Gynecomastia is particularly distressing in adolescence, causing embarrassment and low self-esteem also in adults, even in the minor forms. Male tuberous breast (MTB) is a rare form of gynecomastia characterized by the presence of a fibrous constriction that clearly imprints the base of the male breast with a sub-mammary fold above which projects a breast with a very feminine appearance [2]. This sulcus can be sometimes very challenging to correct as it tends to conserve its memory. It can also complicate the distribution of the extra skin (remaining after glandular removal) onto a wider area on the chest; moreover, it may produce extra scarring. In patients with elastic skin coverage, areolar shrinking can be obtained by combining liposuction with surgical mastectomy through an aggressive thinning of the sub-dermal tissue during dissection of the outer surface of the gland from the overlying skin [3]. Usually, it makes the areola shrink almost instantly, reducing the recurrence to circumareolar incision when strictly necessary [4]. In the proposed case the technique, even if extremely interesting and well described, the removal of only inferior redundant areolar skin did not permit a homogeneous redistribution of the tension forces and the nipple appears to not be centered resulting in an irregular areolar diameter. Although the proposed method appears valid, it would be interesting to investigate the described technique with a larger cohort of patients. Furthermore, 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. Several questionnaires can be used in order to prove the final satisfaction with the results, helping surgeons in understanding the efficacy of the proposed surgical correction [5]. The satisfaction of the single proposed case was not objectively analyzed, and therefore, we retain that it would be interesting to evaluate the long-term satisfaction with the results in a larger cohort of patients.