Invited Discussion on: The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone

Abstract

The request for gynecomastia surgery is increasing worldwide and so the different surgical approaches personalized for each patient. The manuscript ‘‘Expected reduction of the nipple-areolar complex over time after treatment of gynecomastia with ultrasound-assisted liposuction mastectomy compared to subcutaneous mastectomy alone’’ [1] is very interesting, not only because it focuses on a very current issue, but also because there are still different types of surgical treatment, that should be precisely applied to correct different anatomical defects. The main objectives of gynecomastia correction are: flattening of the thoracic region; reduction/elimination of the infra-mammary fold; areola reduction; anatomical repositioning of the nipple–areola complex; removal of redundant skin; symmetrization between the two hemithoraxes and the two areolas; and containment of scars [2]. Proposed surgical techniques can be summarized into four general approaches: (1) excision of breast tissue, (2) suction-assisted liposuction, (3) skin resection, or (4) any combination of the above-mentioned procedures (Fig. 1) [3–5]. Liposuction alone can limit scars and remove excess adipose tissue but is unable to remove the glandular/fibrous breast tissue seen in many patients with gynecomastia and to reduce the diameter of the areola. The combination of liposuction and excision of the breast is usually insufficient to obtaining a good skin retraction (Fig. 2) or could leave unpleasant scars in more challenging cases (Fig. 3). The consolidated use of ultrasound-assisted liposuction (UAL) has dramatically improved the results of traditional liposuction allowing the efficient and safe removal even of the most dense and fibrotic lipodystrophies, as usually found in the male breast and thorax, meanwhile obtaining an artistic and three-dimensional interpretation of the anatomic areas. UAL, if properly used, allows a safe approach to the superficial plans thanks to its tissue specificity which is able to destroy adipocytes preserving nervous and vascular structures [6, 7]. Moreover, UE can induce a controlled thermic effect that stimulates collagen fiber retraction and consequent skin redistribution and redraping over the new volumes (Fig. 4). Whenever the removal of still redundant skin and/or persistent breast tissue is required after UAL, a second-stage touch-up surgery could be planned; in this case, it is suggested to wait at least 9/12 months to allow a maximal skin retraction that minimize the magnitude of the eventual skin excision [8–10]. These clinical effects perfectly fit together with the conclusion of the authors: Subcutaneous mastectomy with UAL showed a larger reduction over time of the nipple–areola complex compared to the subcutaneous mastectomy independent from the stage of gynecomastia. UAL shows relevant advantages in the surgery of gynecomastia. UAL breaks up the dense fibro-connective tissue of the male breast more efficiently than suction-assisted lipectomy, and at higher energy settings, UAL has also the capacity to dissolve and remove the dense parenchymal tissue that suction-assisted liposuction leaves behind [4]. Additionally, UAL performed in & Michele L. Zocchi [email protected]