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Dear Editors,

We read with great interest the article titled “The characteristics and short-term surgical outcomes of Adolescent gynecomastia” by Choi et al. [1]. We really appreciated the authors’ effort to establish how surgical management of gynecomastia can be correctly addressed in adolescents. We congratulate them for the excellent results, but we have some elements to discuss. Although gynecomastia can be particularly distressing and cause embarrassment with low self-esteem even in the minor forms, we maintain that the surgery should be performed when the patients are older than 16 years to let patients achieve a total self-awareness and so that growth of the thorax is complete. The ideal chest appearance is dissimilar among different subjects and may be influenced by age. Patients’ expectations vary according to personal preferences, lifestyle and different physiques. Surgical planning should be carefully tailored to patients therefore, even if earlier surgical correction of the deformity may avoid psychological distress in adolescents; older patients achieved a more adequate psychosomatic development. Recently, we conducted a study to investigate different expectations and needs in a large gynecomastia population, ranging from 18 to 52 years old with different body types, including overweight patients affected by the severe form of the disorder [2]. Choi and colleagues selected 71 adolescents who underwent subcutaneous mastectomy under general anesthesia. The authors’ study reported a shorter postoperative hospital stay compared to the current literature, but their gynecomastia population is not evenly distributed, because most patients had a normal body type and excluded the most severe forms of gynecomastia according to the Simon classification system. Therefore, skin removal was not performed because marked skin redundancy was not observed in any patient. In our patient cohort, longer hospitalization was reported, mostly for overweight patients affected by severe forms of gynecomastia.

We fully agree with the authors that subcutaneous mastectomy, performed through an inferior emiperiareolar access, represents the best surgical approach to the disorder to avoid recurrence [3, 4]. The combination of subcutaneous mastectomy with liposuction, causing skin retraction, may reduce the need for additional scarring in case of skin redundancy [5], limiting future embarrassment due to unpleasant or extended scars and optimizing the cosmetic results.

BMI, representing a crucial feature of gynecomastia, should be meticulously considered. Surgery can be performed in young adolescents, but we retain that patients should be carefully selected and informed of the need for losing weight, if obese, prior to surgery.