Post Bariatric Male Chest Re-Shaping Using L-Shaped Excision Technique

We read with great interest the article titled ‘‘Post Bariatric Male Chest Re-shaping Using L-Shaped Excision Technique’’ by Ibrahiem et al.[1] Post-bariatric gynecomastia patients represent a sensitive challenge in chest reshaping due to excess parenchyma and fat tissue with a severe grade of ptosis often involving the lateral thoracic wall. The presence of prominent axillary rolls in massive weight loss patients often requires extensive scaring that involves the dorsum. We appreciated the Author’s efforts in presenting their surgical treatment of gynecomastia in male chest contouring in overweight patients with the aim to limit the extension of scaring. In the article, a significant cohort of patients is reported with a long-lasting follow-up. We appreciate the Author’s proposal of their interesting surgical technique, but we have some elements to discuss. In order to restore a more masculine thoracic appearance according to the most standard attractive male chest, the thorax should maximize an extreme chest definition, requiring thinning of the adipo-cutaneous flap as much as possible. Although nipple–areola complex (NAC) sensitivity should be considered, the presence of a pedicled flap could cause inferior bulging in overweight patients, resembling a feminine chest appearance, interfering with the main purposes of the procedure and, therefore, limiting patient satisfaction.[2, 3] Since the optimization of male chest recontouring represents the main purpose in the treatment of gynecomastia disorder, and although NAC graft could represent a risk in NAC survival, it should be considered to obtain the principal objective of this type of surgery.[4–6] Were the two patients who underwent secondary outpatient liposuction procedure to correct central fullness contour abnormalities due to the inferior-based NAC pedicle bulging? In the article, the Authors reported surgical drains usually up to 14 days post-operatively. Why did the Author’s maintain such a long time-period for the surgical drains? The drains could represent both severe patient discomfort including pain, and an increased risk of complications, such as infection. Although the vacuum drains can reduce the presence of dead spaces between the skin and pectoralis fascia, do the Authors retain that quilting stitches may reduce the time of drainage maintenance? [7] Although the clinical cases stated in article reported interesting results, do the Authors retain that smaller areolas should be considered in order to achieve a more masculine chest appearance? Since scaring represents one of the most common reasons for patient disclaim, did the vertical scar cause retraction limiting arm movement?