Comment to: “Correction of Gynecomastia with Combination of Ultrasonic Liposuction (VASER) and Gland Excision through a Minimal Scar Incision: A Multi-Center Experience”

We have read with great interest the article ‘‘Correction of Gynecomastia with Combination of Ultrasonic Liposuction (VASER) and Gland Excision through a Minimal Scar Incision: A Multi-Center Experience’’ by Dr Hasab Ali [1]. The Author shares a very large report of 960 patients affected by different grades of gynecomastia undergoing VASER-assisted liposuction combined to subcutaneous mastectomy. We congratulate the Author for the extended cohort, excellent results, and we appreciate the effort to propose a minimally invasive 3 to 4 mm incision, but we have some elements to discuss. Gynecomastia is a benign enlargement of the mammary region in the male thorax. It consists in a prevalence of adipose or glandular tissue, but frequently a combination of them. Different subjects with different body-types, lifestyles, and different expectations can be affected by gynecomastia. The Author documented a very large cohort of patients belonging to all grades of gynecomastia according to Simon classification system, including patients with reported evident extra skin redundancy. The extra skin recontouring onto the new thorax profile represents one of the most relevant aims in male thorax remodeling. The VASER system helps the surgeon in this field but, especially in the presence of inelastic extra skin, the ultrasound device might be unable to produce suitable retractions of the redundant skin. Breast consistency, skin quality, and elasticity are predictors clinical features of postoperative skin retraction and therefore should be strongly considered. Although a minimal incision is very attractive for both patients and surgeons, a 1,5 cm surgical approach at the areolar border permits satisfactory vision on the surgical theater, comfortable hemostasis control during subcutaneous mastectomy, reducing the risk of complications. Through this approach, quilting stitches can be easily applied, guiding a suitable recontouring of the extra skin onto the new chest profile and reducing the risk of unsatisfactory skin retraction and unaesthetic folds as shown in Fig. 12 [2–5].