Comment to: “A Three-Dimensional Approach to Male Chest Enhancement: A Surgical Algorithm Based on 300 Cases”

We have read with great interest the paper entitled ‘‘A Three-Dimensional Approach To Male Chest Enhancement: A Surgical Algorithm Based On 300 Cases‘‘ by Tambasco D et al [1]. The authors focus on a very innovative and important issue in gynecomastia surgery: the three-dimensionality appearance of the male thorax, following surgical correction of the disorder. The management of patients’ expectations is important to achieve a high level of satisfaction. A modern approach in gynecomastia surgery couldn’t take into account the tridimensionality conformation of the ideal chest wall, which becomes a very important aspect to achieve high grade of patient’s satisfaction. The authors propose a very interesting algorithm including all the different types of gynecomastia disorder, including minor forms; however, we have some elements to discuss. In the presence of the most severe conditions of gynecomastia, scored as group IV by the authors, patients, as the case reported in Figure 4, show frequently a ptotic breast appearance rather than a real gynecomastia, due to skin laxity after huge weight loss. Since scarring and the preservation of the sensibility of the areola represent nowadays the most focused issues by patients, a circumareolar approach could be useful to obtain a most appropriate relocation of the areola. This allows the preservation of its innervation and areola’s sensibility. This approach might avoid also a large scarring in a visible hair-less area in the inframammary fold, limiting to the lateral part of the thorax the surgical incision, to manage the extra skin, reducing the visibility of the stigmate of the procedure in a more hidden area, decreasing future embarrassment [2–5]. Fat grafting may represent a very simple method and interesting solution to recontour a satisfactory projection of the pectoralis area, but unpredictable results. The presence of several perforator vessels in the anterior and lateral part of the thorax should be considered to use the extra tissue in the lower breast pole as auto-prosthesis to define a threedimensional appearance of the pectoral area. This method can ensure more predictable results, reducing the incidence of multistep lipofilling procedures and the risk of oil cysts development.