Endoscope-Assisted Minimally Invasive Surgery for the Treatment of Glandular Gynecomastia

We read with great interest the article titled “Endoscope-Assisted Minimally Invasive Surgery for the Treatment of Glandular Gynecomastia” by Liu C et al [1]. We appreciated the author’s efforts in presenting a minimally invasive subcutaneous mastectomy and all the described advantages including avoidance of liposuction and maintenance of well-hidden scars. Among the author’s key points, we strongly agree with sending the excised tissue for routine pathological examination. Yet, an en-block excision was not performed, and orientation was lost when the glandular tissue was removed in strip-like pieces. One of the postoperative pathological results was glandular hyperplasia. Although male breast cancer represents an infrequent condition, pathological investigation is highly recommended [2]. In a worst-case scenario, such as pathological tissue, strip-like pieces could represent a bias for the pathological investigation. Since scaring represents one of the most popular claims in aesthetical procedures, the importance of minimizing scar visibility is paramount [3]. In spite of that, the surgical approach proposed by the authors is a 5-mm incision in the lateral part of the thorax, precisely at the intersection between the anterior axillary line and an imaginary horizontal line that passes through the nipple. Do the authors believe this surgical access could represent a visible area in particular in the presence of pathological scars? Although the author’s efforts to reduce scaring are much appreciated, a small incision placed at the inferior boarder of the areola, roughly 2 cm in length, could be less apparent compared to an incision in the lateral portion of the chest, in particular, where bodily hair is absent [4]. Moreover, it allows for direct observation of the surgical field, complete en-block removal of the glandular tissue in a single piece, and, at the same time, more esthetically pleasing and minimally observable scar [5]. Furthermore, endoscopic procedures are more time consuming, technologically more advanced, and require more surgical training. The simultaneous removal of glandular and fatty tissue by an endoscopic approach, avoiding liposuction, is considered to be an advantage by the authors. Why do the authors retain that not performing liposuction is an advantage? In the presence of the fifth-teen breasts classified as Simon’s grade IIB gynecomastia, how did the authors manage the extra skin following adenectomy? Do the authors retain that quilting stiches help to manage the skin redundancy, in particular, in more severe cases of gynecomastia? Do the authors retain that quilting stiches could reduce dead spaces and, therefore, the incidence of seroma, and could prevent postoperative bleeding? Internal quilting is not externally visible, provides a firm connection between the skin flap and pectoralis fascia, may guarantee better recontouring of skin redundancy and, therefore, provides more satisfactory results in the immediate postoperative results [6].