We would like to congratulate Dr. Petty and his colleagues on a well-written article1 that makes a significant contribution to the literature on the surgical management of gynecomastia. In particular, it establishes the place of minimally invasive arthroscopic excision of firm to moderately firm and large gynecomastia using remote incisions. What is especially appealing about this technique, unlike ultrasonic liposuction, is the ubiquity of the arthroscopic shaver in almost any general hospital (which performs orthopedic surgery). Its remote incisions cause less scarring than open excisions and can also be combined with liposuction. It is easy to use and easily learned. Most plastic surgery residents have rotated through orthopedics and know how to use an arthroscopic shaver. The precautions that have to be taken (e.g., cutting edge not facing the skin, pinching the tissues to avoid damage to the pectoralis muscle, low oscillation rate) are minimal compared with those of first-generation ultrasonic liposuction machines. In addition, it is not as labor intensive as ultrasonic liposuction and uses much less expensive equipment.
However, we would like to point out the omission of what we consider a key reference in the evolving paradigm of gynecomastia surgery over the past 20 years. Fruhstorfer and Malata2 in 2003 published the first attempt at rationalizing the various treatment options in their article entitled “A Systematic Approach to the Surgical Treatment of Gynaecomastia.” Their algorithm for the first time provided a useful means of navigation through the different modalities available to the plastic surgeon today. Despite Dr. Petty's article being a multisurgeon article and therefore introducing interoperator variability, it further validates the role of ultrasonic liposuction3,4 as an effective treatment modality of gynecomastia. This is particularly important as, before the above reports, all of the studies of gynecomastia ultrasonic liposuction came from one unit.5
Dr. Petty's algorithm is well formulated, but it is not the first algorithm on the surgical management of gynecomastia and, as the main thrust of their article is an attempt to rationalize surgical treatment modalities, we believe that they should have made reference to our 2003 article.2 It might interest readers that this article has to date been cited 51 times by others on Google Scholar and, as such, is not esoteric, and we consider it to be a key reference in this field.
In conclusion, we would like to draw the attention of Dr. Petty and colleagues to a significant omission on their part regarding the contribution of others to this field. They should, however, be congratulated on their excellent work.
Adesola Adekunle, M.R.C.S.
Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital
Charles M. Malata, M.R.C.S., F.R.C.S.(Glasg.), F.R.C.S.(Plast.)
Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, and, Cambridge Breast Unit, Cambridge, United Kingdom
1. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: Evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2011;125:1301–1308.
2. Fruhstorfer BH, Malata CM. A systematic approach to the surgical treatment of gynaecomastia. Br J Plast Surg. 2003;56:237–246.
3. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classification and management of gynecomastia: Defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111:909–923; discussion 923–924.
4. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg. 2005;116:646–653; discussion 654–655.
5. Maxwell GP, Gingrass MK. Ultrasound assisted lipoplasty: A clinical study of 250 consecutive patients. Plast Reconstr Surg. 1998;101:189–202; discussion 203–204.
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