Comment to: “Operative management of gynecomastia and pseudogynecomastia in ambulatory surgery setting from 2016 to 2019”

We have read with great interest the paper entitled “Operative management of gynecomastia and pseudogynecomastia in ambulatory surgery setting from 2016 to 2019” by Rishub K. Das, BA.1 This article pointed out how the most common surgical approach to gynecomastia in the United States was mastectomy being also more easily covered by private national health insurance, while procedures such as liposuction have costs that are mostly covered in a private setting by the single individual. The authors performed an interesting investigation in gyneco- and pseudo-gynecomastia population, focusing on the feasibility of an insurance coverage and costs of the surgical procedures performed over a 3-years span of time in USA, but we have some elements to discuss. Obesity is becoming a huge issue in Europe as well; this was demonstrated by an increasing trend in gynecomastia incidence over the years. Obese men have an increased estrogen to androgen ratio as testosterone is aromatized to estradiol in fatty tissue, which may manifest as gynecomastia. Although nowadays the economic issues represent a very sensitive issue worldwide, male breast enlargement is becoming a very common disorder which includes patients that suffered from obesity. It can be related to the presence of glandular, adipose tissue or both. Preoperative assessment is essential to plan the most appropriate surgical approach which should be strictly related to the type of disorder. The presence of glandular tissue requires mastectomy, also to reduce the incidence of recurrences, as well as histopathological investigation to exclude malignancy.2, 3, 4, 5 The surgical strategy to correct gynecomastia should depend on the type and severity of gynecomastia. How did the authors stratified the enrolled patients in terms of surgical procedure performed and gynecomastia severity? Gynecomastia procedure can easily be performed under local anesthesia, but what did the authors mean in terms of ambulatory setting procedures? It would have been interesting to extract from the national USA database used patients’ data on gynecomastia severity by a standardized score to understand if a trend in the surgical procedure was severity-driven or if it is driven by the insurance coverage. In the paper, the authors raise a very complex debated topic represented by the economic aspect, but the interference between the surgical strategy, costs and the available insurance coverage could become a sensitive issue.