LAUSR

Gynecomastia is a benign enlargement of the male breast secondary to gland proliferation, and it occurs in up to 65% of adolescents and adult men [1]. There is a spontaneous correction in most cases, but a high incidence of 32–36% remains in adulthood [2, 3] Gynecomastia has been classified by Webster on the basis of the predominant type of tissue into glandular, fatty, and mixed types [4]. Based on clinical appearance, gynecomastia was classified by Simon et al. in 1973 into three grades: Grade I: minor visible enlargement with no redundant skin; Grade II: moderate breast enlargement with no redundant skin (IIA) or some redundant skin (IIB); and Grade III: gross enlargement with excess skin, mimicking female breast ptosis [5]. When gynecomastia remains for more than 12 months, surgery is needed for an effective correction. Even in teenagers, surgery can be indicated to alleviate psychological problems [6]. Traditional surgery has been the technique pioneered by Webster [4] through the areola. However, areola distortions and unevenness are not unusual with this approach. The most important thing to prevent this problem is to provide a good cushion to the areola. Even Webster [4] recommended reconstructing the adipose layer under the areola to avoid sinking and distortions of the NAC complex. Over the years and as the authors of this paper point out [7], several ‘‘minimally invasive’’ approaches have been described to prevent the use of the areolar approach and its potential sequelae (quoting them, ultrasound-assisted lipectomy (UAL), suction-assisted cartilage shaver technique (SACST), microdebrider excision and liposuction technique (MELT), endoscopic subcutaneous mastectomy (ESCM), and vacuum-assisted biopsy (VAB)). I would add as well the minimal areolar incision [8] and the pullthrough technique [9]. De Prado [10] described the use of a shaver to remove the gland in gynecomastia. Since then, I have been using liposuction plus a shaver to treat Grade II and III gynecomastia patients. In my experience [11], Grade I patients are not suitable for this technique because of the risk of dermal injury and hyperpigmentation. For these patients, I prefer the traditional (areolar) or transaxillary approach. In most cases, the periareolar approach leaves an inconspicuous scar (Fig. 1). Adipose tissue can be mobilized from the surrounding tissue and advanced under the areola to reconstruct the deep layer. The transaxillary approach is only for Grade I patients who do not want a scar on their chest (Fig. 2). Of course, the use of a shaver requires a learning curve. However, combined with liposuction, extremely good results can be achieved in patients with Grade II and III gynecomastia, and the safety in terms of complications is similar to that of other techniques (Fig. 3). & Jesús Benito-Ruiz [email protected]