Masculinizing chest wall gender-affirming surgery: Clinical outcomes of 73 subcutaneous mastectomies using the double-incision and semicircular incision techniques

Dear Sir, We read with great interest the article entitled “Masculinizing chest wall gender-affirming surgery: Clinical outcomes of 73 subcutaneous mastectomies using the double-incision and semicircular incision techniques” by Kuruglu et al.1 The Authors aimed to identify the risk factors for major complications and revision surgery related to double-incision and periareolar semicircular approaches for masculinizing top surgery, with and without concomitant liposuction, finding out that there was no statistically significant association between any risk factor and major complications. Furthermore, decrease of revision surgery was observed after concomitant liposuction. We congratulate the Authors on their results and we would like to expose elements for discussion. Double-incision was the most used technique by the Authors (89%), performed in patients with large breast size (> C cup). This approach leads inevitably to visible and extended extra-areolar scars, which represent a sensitive issue for patients. Extra-areolar scarring, especially if placed in hairless areas such as the inferolateral part of the thorax, may negatively influence the perception of the final results inducing patients to complain, especially in case of pathological scars frequently observed in the thorax. Therefore, minimizing the visibility of the scar is recommendable to avoid unpleasant results. In 2016, we published a paper about our experience in the treatment of gynecomastia in 312 consecutive cases, using a circumareolar approach in the great majority, including severe grades of the disorder.2 The circumareolar access offers good visibility and allows to get an adipo-cutaneous flap able to gain a good shape and contour of the pectoral region. Taking into consideration the analogies between the management of gynecomastia and in some cases of chest wall gender-affirming surgery, especially in grade III gynecomastia, we believe that a less visible location for the surgical incision, such as the inferior border of the areola, can be more suitable for patients, reducing their future embarrassment with higher levels of satisfaction, still guaranteeing a good esthetic outcome. Since scarring represents a very sensitive item and one of the most popular issue for patients disclaim, limiting the surgical incision to the areolar area is strictly suggested when it is possible. During mastectomy the association of a wide undermining of the peripheral area could allow the distribution of the extra skin even in the presence of bigger dimension breasts, reducing the recurrence to double-incision even in females. Moreover, the use of quilting stitches can help to gain a satisfactory contour of the redundant flap. In fact, quilting stitches aid to guide adipo- cutaneous flap recontouring and are crucial to avoid dead space, decreasing strongly the incidence of hematomas and post-operative seromas.3, 4, 5 Do the Authors take into consideration the use of these two surgical methods in their practice? Moreover, the characteristics of female breast tissues, thanks to their thin thickness, could facilitate an easier retraction compared to gynecomastia patients reducing the incidence of extra-areolar scars. Taking into consideration these aspects, a greater recruitment of patients affected by gender dysphoria could be candidate to circumareolar approach during female to male surgical procedures.