Comment to: “Sub-nipple Incision for Gland Resection in Gynecomastia, Combined with High-Definition Liposculpture Principles: Technical Refinements and a Step-by-Step Video Guide”

e have read with great interest the paper by Tamara A. Garsten et al. entitled ‘‘Sub-nipple Incision for Gland Resection in Gynecomastia, Combined with High-Definition Liposculpture Principles: Technical Refinements and a Step-by-Step Video Guide.’’ [1]. The Authors focus on the therapeutic efficacy of powerassisted liposuction (PAL) and a novel, minimally invasive sub-nipple access technique, emphasizing incision size, scar outcomes, and patient satisfaction. The management of patient expectations is essential to achieve high satisfaction. A modern approach to gynecomastia surgery must consider the three-dimensional contour of the ideal male chest wall, which plays a pivotal role in enhancing postoperative outcomes and patient confidence. The Authors propose an innovative approach for Simon grade I and II gynecomastia that reduces the visibility of surgical scarring. However, we believe several aspects merit further discussion. The article does not report detailed patient selection criteria or demographic characteristics of the 16 included cases. Given the wide variability in gynecomastia etiology, BMI, and skin quality even within Simon grade I–II classifications, this information should be considered in the reproducibility and applicability of the technique in broader clinical practice. Were Grade II b patients enrolled in the study? Scarring and the preservation of areolar sensibility remain among the most pressing concerns for patients undergoing gynecomastia surgery. The technique presented by the Authors addresses these issues well in this small preliminary series. However, the method of glandular excision through a limited 7 mm sub-nipple incision raises questions about the completeness and precision of tissue removal, and therefore the control of the regularity of the mastectomy flap in the prevention of the contour. Yet, without wider exposure or enhanced visualization, the ability to perform a meticulous dissection, particularly in cases of dense fibroglandular tissue or anatomical variability, could be compromised. Moreover, an incision, limited to a small portion of the areola edge, allows NAC repositioning (when necessary), good visibility of the surgical field, including hemostasis, allowing the use of quilting stitches to reduce dead space, the incidence of hematoma or seroma, guiding the extra-skin redistribution to the new thorax profile [2–7]. Furthermore, innervation and sensory function are not impacted by this surgical approach which could potentially enhance aesthetic outcomes even in low-grade gynecomastia cases.