Introduction <p>Gynecomastia is a benign development of male breast tissue accompanied by fat tissue. This condition is increasing due to a sedentary lifestyle and poor diet. This study compared patient satisfaction and outcomes between traditional elliptic excision and posteroinferior pedicle methods for treating Grade III gynecomastia by analyzing 20 years of data.</p> Materials and Methods <p>A retrospective analysis was conducted on patients treated from 2003 to 2023 at a single center at the University Hospital of Dijon, France, with 318 patients included. The BODY-Q chest module was used to evaluate patient satisfaction.</p> Results <p>There were significant differences in patient satisfaction, with the flap technique (Group 2) reporting higher scores across various domains, including scars, psychological function, and body image, than the elliptic excision technique (Group 1), with p values all less than 0.001. The flap technique also demonstrated advantages in preserving nipple sensation, with only 5.4% reporting nipple sensation trouble in Group 2 versus 23% in Group 1 (<i>p</i>=0.002) and minimizing visible scarring. The surgical time was slightly longer, at 96 min in the flap group versus 84 min (<i>p</i>&lt;0.001) for the elliptic excision group, due to more extensive dissection.</p> Discussion <p>The results of this study were in line with the findings in the scientific literature. Notably, this research stands out as one with the most participants over 20 years. This study supports the use of the dermoglandular posteroinferior flap technique as the preferred method for treating Grade III gynecomastia, which significantly improved patient satisfaction and surgical outcomes.</p> Level of Evidence IV <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a></p>