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Letter to the Editor - Year2018 - Volume33 - Issue 1

Dear Sir,

We read with great interest the article titled, "Periareolar zigzag incision as treatment for gynecomastia"1, under the Ideas and Innovations section in your reputed journal. We must congratulate the authors for their innovative idea of incorporating the basic principle of avoiding a long straight line by breaking the line as in W-plasty2, Z-plasty, or geometric broken line closure.

A similar incision was described by Tu et al3. Of the various approaches described, including periareolar, transareolar, circumareolar, inframammary, and axillary, the periareolar seems to be one of the most commonly used approaches. The periareolar approach (superior, inferior, or medial) gives direct access to all the segments. Glandular excision can be performed under direct vision and promotes good hemostasis. However, the NAC aesthetic unit scar, which is sometimes hypopigmented and can be adherent, are the drawbacks of this approach.

Although the authors presented excellent aesthetic postoperative results, we find that the incision from the 3 o’clock to the 9 o’clock direction to be excessively longer than the 6- to 8-mm incision that we described earlier4. The innovative and novel idea of breaking the straight line by a zigzag incision is commendable, but we feel that it takes longer time to mark and execute the symmetrical incision. The three-layer closure seems to be tedious and consumes additional time and cost of operation theater charges and sutures; it also entails additional visits and procedures for suture removal. In our experience, a smaller incision left open seems to save time and cost, and to help prevent seromas while providing better aesthetic results.

The authors leave approximately 1 cm of the glandular tissue beneath the NAC, whereas we leave only approximately 0.5 cm of the gland. We strongly believe that pressure garments for longer periods provide better contouring; thus, we suggest using them continuously for 10 days and intermittently for 3 months. We feel that the use of a scar assessment scale and including a larger number of patients with longer follow-up would make the assessment more objective and allow for analysis of long-term results of this innovative approach.


1. Pazio ALB, Krieger JGC, Itikawa WM, Balbinot P, Ascenço ASK, Freitas RS, et al. Periareolar zigzag incision as treatment for gynecomastia. Rev Bras Cir Plást. 2017;32(4):579-82. DOI:

2. Borges AF. W-plasty. Ann Plast Surg. 1979;3(2):153-9. PMID: 543648 DOI:

3. Tu LC, Tung KY, Chen HC, Huang WC, Hsiao HT. Eccentric mastectomy and zigzag periareolar incision for gynecomastia. Aesthetic Plast Surg. 2009;33(4):549-54. PMID: 19205793 DOI:

4. Shirol SS. Orange Peel Excision of Gland: A Novel Surgical Technique for Treatment of Gynecomastia. Ann Plast Surg. 2016;77(6):615-9. DOI:

Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Institution: Karnataka Institute of Medical Sciences, Hubli, Karnataka, India.

*Corresponding author:
Shirol S S
Vidyanagar - Club Road
Hubli, Karnataka, India - Zip Code 580032

Article received: January 17, 2018.
Article accepted: January 26, 2018.

Conflicts of interest: none.


André Luiz Bilieri Pazio

Dear Sir,

Thank you for your comments and interest in reading our article.

The aim of the zigzag incision for gynecomastia treatment is to camouflage the scar in the transition between normal skin and the areola-papillary complex. It is well known that techniques that break up or make the scar line more irregular provide greater camouflage and cosmetic acceptability1.

Regarding the length of the incision, in our experience, extending the incision from the 3 o´clock to the 9 o’ clock points makes it easier to resect the glandular tissue that is underneath the areola-papillary complex and allows stopping of the bleeding securely and safely.

In our opinion, the three-layer closure is important to obtain a smooth aspect while avoiding a secondary deformity after resection of the glandular tissue (dinner-plate deformity). In addition, closing the incision in layers decreases the tension in the suture of the skin, which helps avoid complications such as hypertrophic scar and skin necrosis.

Once again, thank for your comments, and congratulations on your previous paper.


1. Graf R, Ascenço ASK, Maluf Junior I, Lopes MC, Nasser IJG, Balbinot P, et al. Incisão periareolar em zigue-zague modificada: técnica alternativa para mastoplastia de aumento. Rev Bras Cir Plást. 2013;28(2):297-300. DOI:

1. Universidade Federal do Paraná, Curitiba, PR, Brazil


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