Thank you for allowing me to respond to the Letter to the Editor from Nanze Yu et al. regarding my gynecomastia zone observations.1 I have not found excess fullness in the typical gynecomastia patient in the upper portion of the chest as the authors have noted. Treatment in this area is performed only if I need to feather the contour of the chest after removal of all the gynecomastia tissue to minimize any saucer depression.
I agree that zone 4 is more commonly seen in patients with a higher body mass index but not always. Treatment of this area is designed to smooth the transition from the chest to the upper abdomen. The incision for treatment of all chest zones as I describe is from two stab incisions—one in the axillary hair-bearing area and the other at the bottom of the areola border. Therefore, there is minimal scarring with nonskin excisional gynecomastia treatment.
For clarification, my gynecomastia zone system is indicated for non–skin removal gynecomastia treatment. It is not readily applicable to those patients who require skin removal and nipple-areola complex grafting/transposition, as the primary issue in these cases is skin excess/ptosis, and this requires a different assessment and approach to treatment.
I have never found the need to use any of the existing gynecomastia classification systems, as the assessment is subjective and treatment is the same for all non–skin removal gynecomastia patients regardless of the metrics assessed (i.e., amount, type of tissue, or ptosis). None of the 635 patients in the patient cohort was a skin removal candidate.
I have learned through experience that the capacity for the chest skin to retract after standard treatment should not be underestimated. I worry more about overtreatment of patients with skin removal and resulting scars rather than undertreatment, as skin removal can always be performed as a secondary procedure. With experience, the surgeon learns who are the best candidates for skin removal.
My general approach to skin removal involves placement of the scar adjacent to the sixth rib where the pectoral muscle originates and to continue the scar into the lateral thorax to manage the skin redundancy/roll. I place the nipple-areola complex just above the scar in the lateral aspect of the pectoral muscle origins. I am grateful for the opportunity to clarify my gynecomastia experience.
The author has no financial interest to declare in relation to the content of this communication.
Robert C. Caridi, M.D.
1. Caridi RC. Defining the aesthetic units of the male chest and how they relate to gynecomastia based on 635 patients. Plast Reconstr Surg. 2018;142:904–907.