Discussion on “Reduction of the Areolar Diameter After Ultrasound-Assisted Liposuction for Gynecomastia”

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Dear Editor,
We read with great interest the article titled “Reduction of the Areolar Diameter After Ultrasound-Assisted Liposuction for Gynecomastia” by Keskin et al.1 Gynecomastia generates considerable embarrassment, even in minor forms, creating distressing and low self-esteem that induces men to require surgical correction. We believe that Keskin et al1 discussed a very sensitive issue, namely, the diameter of nipple-areolar complex (NAC) after gynecomastia correction. To the best of our knowledge, this is the first study to consider the dimension of the NAC as a crucial element for patients affected by gynecomastia. In our experience, patients perceive a large areola as a very feminine feature, resulting in a reduction of self-confidence even after recontouring of the thorax. To achieve a more masculine appearance, patients required small areola. Recently, we conducted a study to investigate different expectations, needs, and surgical outcomes in a large gynecomastia population.2 Patients were grouped in 3 different categories according to their physical appearance and lifestyle. In high muscle mass subjects [body mass index (BMI), <25; body fat, <9%), gynecomastia created greater distress. The low percentage of fat tissue rendered the gland even more pronounced, and the special attention given by these subjects to their physical appearance made them very sensitive to the problem. They required the higher definition of the pectoralis area that cannot be achieved by physical training, so their expectations could be satisfied only by minimizing the adipo-glandular layer covering the muscle. In normal muscular subjects (BMI, <25), gynecomastia revealed social limitations owing to their female appearance, seeking for more masculine aspect. Overweight subjects (BMI, >25) viewed gynecomastia as a weight disorder requiring a slimmer appearance. We fully agree with the authors that, when skin elasticity is optimal, areola reduction may be obtained through an aggressive thinning of the subdermal tissue that usually makes it shrink almost instantly so that the need of full circle incision is less frequent.3–5 Obviously, the respect of the dermal plexus is mandatory to avoid necrosis. This procedure also decreased modification of the areola in terms of widening and shrinking related to the temperature variation. Because dissatisfaction with the results represents a common reason for claims, pleasant outcomes minimizing extension of skin incision, reducing the risk of unpleasant scars, can be the key element to achieve high level of approval as the leading measure of treatment success. Postoperative scars represent a very sensitive issue for patients, causing permanent embarrassment to the patients that may negatively influence the perception of the final result. Unlike Keskin et al,1 we performed surgical correction of gynecomastia under local anesthesia in form of subcutaneous mastectomy. Liposuction was routinely used to smooth the profile of the adjacent area. Furthermore, undermining large skin flaps in the area surrounding the breast allows a better re-adaptation of the skin over the pectoralis. The redundant skin in fact can be redistributed through quilting stitches onto a wider area, reducing the recurrence to extra areola scars. In conclusion, final NAC appearance must be considered in surgical planning to maximize aesthetic results and patients' satisfaction.

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