Comment to: Liposuction Assisted Gynecomastia Surgery with Minimal Periareolar Incision: a Systematic Review

We read with great interest the article entitled “Liposuction assisted gynecomastia surgery with minimal periareolar incision: a systematic review” by Prasetyono TOH et al. [1]. In this systematic review, the Authors aimed to analyze the efficacy of liposuction assisted procedure performed trough a minimal incision for gynecomastia surgery, taking into account the final patients’ personal satisfaction. We appreciate Authors’ effort in reviewing a considerable number of studies reported in the present literature, but we have some elements to discuss. Gynecomastia represents a very common problem in male, causing diminishing of a self-esteem, social embarrassment and sensitive distress. Therefore, a growing demand of surgical correction is increasingly observed. 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. Although Authors’ review can result useful to the surgeons in apply the most suitable surgical technique, as reported by the same Authors, it could be affected from several bias. In fact, patients’ expectations should be strongly considered as a sensitive influenced factors of satisfactions for a more accurate evaluation on patients’ perception of the result. Patients’ physical characteristics could strongly interfere with their perception of quality of the final outcome. Although the image of the ideal male thorax is nowadays clearly identified in the collective imagination, gynecomastia populations include male with different range of physical appearance; schematically three different categories of male could be identified: athletic, normal and overweight subjects, and considering every single expectation is mandatory to maximize postoperative satisfaction. The concept of an ideal chest is dissimilar among these different categories of subjects affected from gynecomastia. 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 preoperative planning, varying between different physical body types and expectations. [2,3,4,5,6,7,8,9,10] Moreover, although the systematic review reported by Prasetyono as produced valuable result in support of liposuction assisted gynecomastia surgery with minimal periareolar incision, histopathological investigations in gynecomastia patients, should be always considered in supporting of combined technique.