Comment to: The Scar-Hidden Surgery on Gynecomastia: Experiences from a Single-Institutional Large Case Series

We read with great interest the article titled ‘‘The Scar- Hidden Surgery on Gynecomastia: Experiences from a Single-Institutional Large Case Series’’ by Luo et al. [1] The Authors described a very interesting technique reporting a short operation time, low incidence of complications and very good outcomes. We congratulate with the Authors for their very large case series including 1082 patients suffering from gynecomastia, underwent mastoscopic subcutaneous mastectomy, but we have some elements to discuss. Gynecomastia is a common disorder representing, causing decreased self-esteem, social embarrassment, and discomfort. As reported, hormonal imbalance, in favor of estrogen, is one of the main causes. Nowadays, the diet of refined foods and the prevalence of diets rich in fats contribute to increasing the problem. Therefore, an increasing demand for surgical correction is observed. The Authors present a very interesting surgical technique named mastoscopic subcutaneous mastectomy, highlighting how in this study this technique is used even for patients with severe degree of gynecomastia, according to II b or above types, following Simon classification system. According to Simon’s classification system, patients suffered from grade II B and III show redundant skin including a ptotic breast appearances, with downward dislocation of the nipple-areola complex (NAC). In this type of patients, the endoscopic approach could limit the management of the extra-skin. Do the Authors used quilting stitches to redistribute the redundant skin onto the new thorax profile [2, 3]? In the presence of large and feminine ptotic NAC, frequently present in the most severe case of gynecomastia disorder, how do the Authors manage this unpleasant condition without circumareolar incision? Is the natural retraction of the extra skin after mastoscopic removal of the gland sufficient to correct the aesthetic aspect [4]? How Do the Authors investigate the skin quality preoperatively to avoid a post-op crescent appearances of the redundant skin? Since scarring represents one of the major concerns for claims, the method reported in the paper is very interesting in specific cases without extra skin, reporting a satisfactory elastic skin quality. Even if endoscopic approach should be present in a plastic surgeon’s toolbox, a brief surgical incision, located in the inferior edge of areola, represents a very comfortable operating theater, often resulting in a poor visible scarring because of the localization at the border of the NAC, where a color transition zone is already present. A surgical circumareolar approach permits also NAC transposition in a more cranial and in a more appropriate localization according an ideal masculine chest appearance [5]. Moreover, general anesthesia, and endoscopic instruments represent a conspicuous increment of costs, requiring a more complex learning curve for the operators [6–9]. The proposed