Response to Letter: Adjustments to the round-the-clock technique for correction of gynecomastia

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Arch Plast Surg. 2019;46(6):608-609
Publication date (electronic) : 2019 November 15
doi :
Department of Plastic and Reconstructive Surgery, Sapienza University, Rome, Italy
Correspondence: Giuseppe Di Taranto Department of Plastic and Reconstructive Surgery, Sapienza University, Via dei Latini 33, Rome 00185, Italy Tel: +39-328-3869334, Fax: +39-6-49970205, E-mail:
Received 2019 August 7; Revised 2019 August 31; Accepted 2019 August 31.

We would like to thank the authors (SH and NR) for appreciating our work and suggesting adjustments to improve our technique [1]. We warmly welcome experience-sharing and discussions of surgical practices.

We read with interest that the authors prefer to perform liposuction before mastectomy, conversely to what we described. As we treated patients with true gynecomastia, we used superficial liposuction in the final step of surgery, in order to smooth the contour and reduce any unpleasant remaining irregularity. We acknowledge that performing liposuction first can assist in haemostasis and enhance the dissection, but our main concern is overcorrection of the chest, especially in thin patients. We believe that in cases of true gynecomastia, only after complete resection of the glandular tissue can the surgeon properly assess the residual adipose tissue to be removed and carefully reshape the final appearance. Nonetheless, patients with pseudogynecomastia can benefit from traditional liposuction, which can also be performed at the beginning of the procedure.

Furthermore, the authors reported their experience with a similar technique for grade 3 gynecomastia [1]. They stated that the treatment of patients with large and widely spread-out glands is challenging through a small incision. In our experience, we use the round-the-clock technique only for the correction of grade I–II gynecomastia. In patients with more severe conditions, we prefer to apply a hemiperiareolar incision at the inferior half of the areola. This has a 2-fold purpose: it provides wider access to the glandular tissue, and also accommodates the subsequent skin resection, which is usually mandatory in the treatment of grade III gynecomastia. One appealing trick suggested by the authors is the use of small illuminated retractors. We agree that using such retractors can notably expedite the procedure, helping to better visualize the plane between the gland and the subcutaneous layer, especially in areas difficult to access [1]. We look forward to applying this manoeuvre to our next challenging cases. However, an endoscope can be too bulky for this procedure, hindering a minimal-incision approach for the correction of gynecomastia.

Again, we would like to express our appreciation to the authors for their suggestions and pertinent comments on our article. We all agree that both our reports will help stimulate interest in developing new techniques with minimal incisions, aiming to reduce the complication rate and morbidity in patients undergoing surgical correction of gynecomastia.


No potential conflict of interest relevant to this article was reported.


1. Tarallo M, Di Taranto G, Fallico N, et al. The round-the-clock technique for correction of gynecomastia. Arch Plast Surg 2019;46:221–7.

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