Comment on “The combination of endoscopic subcutaneous mastectomy and liposuction (Liu and Shang’s 2-hole 7-step method) as the treatment of gynecomastia”

We read with great interest the article “The combination of Endoscopic Subcutaneous Mastectomy and Liposuction (Liu and Shang’s 2-hole 7-step method) as the Treatment of Gynecomastia” by Fangjian et al. The authors present a novel surgical multistep method combining endoscopy and liposuction in gynecomastia surgical management.1 We congratulate the authors on their excellent aesthetic results and the number of enrolled patients in the cohort, but we have some elements to discuss. The surgical procedure proposed by the authors is articulated by several steps, including general anesthesia. Hydrodissection by infiltration of local anesthetics, besides preparing the surgical plane, could allow the procedure only under local anesthesia, in particular, the combination of lidocaine with a long-lasting anesthetic such as ropivacaine (Naropin), to maximize postoperative comfort, simplifying the surgical procedure and recovery time. Moreover, we completely agree with the use of hemocoagulase to decrease intraoperative bleeding and the risk of postoperative hematoma. Postmastectomy redundant skin represents one of the most sensitive issues in the management of the most severe form of gynecomastia. Quilting stitches reduce dead spaces and the incidence of hematomas/seromas and facilitate extra-skin distribution, reducing the incidence of a postoperative sagging appearance.2e5 How did the authors manage exuberant skin in the most severe grades of the disorder? Based on our experience, inferior circumareolar scarring, representing a color-changing area, leads to a less visible scar, especially on a hairy chest, rather than 2 poking holes enter-points scars in a more visible hairless area such as the lateral part of the chest. A 2.5 cm inferior edge periareolar incision, being placed in a colortransition area, permits a broad view of the surgical field, an easy mastectomy, and hemostasis, avoiding an extra-areolar scar. On the contrary, endoscopy certainly could represent a valid tool, but it could elongate the surgical procedure, especially in younger, inexperienced surgeons, representing major costs and a longer learning curve. Gynecomastia generates embarrassment and low self-esteem, especially in very young patients. It is a frequent disorder; the incidence varies widely in the world population, but very young patients, still in puberty, could not gain a sufficient rate of selfpsychophysical awareness. We strongly believe that gynecomastia requires a radical resection of the gland with a subcutaneous mastectomy. Although endoscopy should be taken into consideration, subcutaneous mastectomy and liposuction performed under local anesthesia using a short surgical incision located in the inferior border of the areola allow for an easier surgical procedure, reducing the incidence of recurrences, which permits minimal scar visibility and, consequently, high patient satisfaction with the short recovery time and lower costs.