Background <p>Endoscopic mastectomy has gradually become an important surgical modality for the treatment of breast diseases, and is the preferred procedure for gynecomastia. However, endoscopic mastectomy presents challenges such as a steep learning curve, prolonged surgical duration, increased hospitalization costs, and high technical difficulty. This study aimed to evaluate the clinical efficacy and patient satisfaction of endoscopic mastectomy using a single axillary incision versus a triple lateral chest wall incision for gynecomastia.</p> Methods <p>Patients were stratified into a single-port group and a three-port group based on the surgical approach. Propensity score matching was used for the nearest neighbor matching, adjusting baseline data differences at a 1:1 ratio, with a caliper value set at 0.2 to ensure comparability between the two groups. Clinical efficacy and patient satisfaction were compared after propensity score matching.</p> Results <p>A total of 36 pairs of patients were successfully matched after propensity score matching, with no differences in baseline characteristics (<i>P</i> &gt; 0.05). Notably, the three-port group experienced longer surgical durations compared to the single-port group, alongside higher hospitalization costs (<i>P</i> &lt; 0.05). There were no differences in surgical bleeding volume, postoperative drainage volume, extubation time, postoperative hospitalization time , surgical complications, visual analog scale pain scores, and recurrence rate (<i>P</i> &gt; 0.05). After a 6-month follow-up, the vancouver scar scale assessment showed no differences in scar color, thickness, vascularity, softness, and total score (<i>P</i> &gt; 0.05). Based on the BODY-Q questionnaire chest module scores, the single-port group showed better overall satisfaction in appearance (<i>P</i> = 0.038), especially in the smoothness of the chest wall, with significantly higher scores than the three-port group (<i>P</i> = 0.001). No differences were found in nipple symmetry, nipple sensation, and skin redundancy (<i>P</i> &gt; 0.05).</p> Conclusion <p>The single axillary incision endoscopic mastectomy demonstrated advantages in shorter surgical duration and lower hospitalization costs, while providing a smoother chest wall appearance, thereby enhancing overall patient satisfaction. Consequently, this surgical approach may arise as one of the preferred procedures for gynecomastia.</p> Level of Evidence II <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="https://www.springer.com/00266">www.springer.com/00266</a>.</p>