LAUSR

Dear Editor, W e readwith great interest the article titled “Reduction of the Areolar Diameter After Ultrasound-Assisted Liposuction for Gynecomastia” by Keskin et al. Gynecomastia generates considerable embarrassment, even in minor forms, creating distressing and low selfesteem that induces men to require surgical correction. We believe that Keskin et al 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. 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 adipoglandular 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. Obviously, the respect of the dermal plexus is