Gynecomastia classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2], Omodamola Aje B.Sc, M.D. [3]

Overview

Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology.

Classification

Different gynecomastia classification systems are:[1][2][3][4][5][6]

Surgical classification of gynecomastia

Classification system Criteria Description
Physical Tissue type
Nydick's Physical
  • Gland limited to the retro areolar region and it does not reach the edge of the areola
  • Gland extends as far as the edge of the areola
  • The increase in gland volume extends beyond the edge of the areola
Tanner's Physical
  • Stage 1: Nipple prominence
  • Stage 2: Mammillary button stage. The breast and the nipple-areola complex are slightly swollen and diameter of the areola increases
  • Stage 3: Further swelling of the breast and areola without separation of their edges
  • Stage 4: Areola and nipple become protrusive and form a secondary protrusion above the breast
  • Stage 5: There is protrusion of the nipple only after retraction of the areola from the breast surface
Simon's Physical
  • Grade 1: Small visible breast enlargement and no skin redundancy
  • Grade 2a: Moderate breast enlargement without skin redundancy
  • Grade 2b: Moderate breast enlargement with skin redundancy
  • Grade 3: Marked breast enlargement with marked skin redundancy
Deutinger's and Freilinger's Physical
  • Grade 1: Thoracic wall poor in the flesh with mammary tissue localized behind and around the nipple without skin excess
  • Grade 2: Adipose thoracic wall with widespread alterations and breasts similar to feminine ones during puberty
  • Grade 3: Widespread alterations with excess adipose tissue, skin redundancy and inframammary fold and ptosis
Cohen's Physical
Rohrich's Physical/Tissue type
Gusenoff's Physical
  • Grade 1: Minimal excess skin and fat with minimal alteration of nipple-areola complex (NAC) and inframammary fold (IMF)
    • 1a: No lateral skin roll
    • 1b: Lateral skin roll
  • Grade 2: Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and minimal upper abdominal laxity
  • Grade 3: Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and significant upper abdominal laxity
Barros's Physical
  • Grade I: Increased diameter and slight protrusion limited to the areola region
  • Grade II: Moderate hypertrophy of the breast with the nipple-areola complex (NAC) above the inframammary fold (IMF)
  • Grade III: Major hypertrophy of the breast with glandular ptosis and the NAC situated at the same height as or as much as 1 cm below the inframammary fold (IM)
  • Grade IV: Major breast hypertrophy with skin redundancy, severe ptosis, and the NAC positioned ≥1 cm below the inframammary fold (IMF)
Çi̇l's Imaging (computed tomography)
  • Gynecomastic adipose tissue/total gynecomastic tissue is <0.3
  • Gynecomastic adipose tissue/total gynecomastic tissue is 0.3–0.5
  • Gynecomastic adipose tissue/total gynecomastic tissue is >0.6
Cordova's Physical
  • Grade I: Increase in diameter and protrusion limited to the areolar region
  • Grade II: Hypertrophy of all the structural components of the breast and the nipple-areola complex (NAC) is above the inframammary fold (IMF)
  • Grade III: Hypertrophy of all the structural components with nipple-areola complex (NAC) at the same height as or approximately 1 cm below the inframammary fold (IMF). In this group we can also include male tuberous breast
  • Grade IV: Hypertrophy of all the structural components with nipple-areola complex (NAC) >1 cm below theinframammary fold (IMF)
Fruhstorfer's Physical
  • Small-to-moderate gynecomastia
  • Moderate-to-large gynecomastia
Mladick's Physical
  • No sagging
  • Slight sagging
  • Moderate sagging
  • Extensive sagging
Monarca's Physical/tissue type
  • Grade I: Minimal hypertrophy (<250 g)
    • IA: Primarily fatty breast tissue
    • IB: Primarily fibrous breast tissue
    • IC: Nipple malposition (upright)
    • ID: Gynoid (rounded) shape of the chest
    • IE: Absence of sternal notch II: Moderate hypertrophy (250–500 g)
  • Grade IIA: Primarily fatty breast tissue
    • IIB: Primarily fibrous breast tissue with peripheral fat
    • IIC: Nipple malposition (upright or upward)
    • IID: Moderate gynoid shape of the chest
    • IIE: Absence of sternal notch
  • Grade III: Severe hypertrophy with grade I ptosis (>500 g)
    • IIIA: Fatty and fibrous tissue with ptosis of grade I
    • IIIB: Nipple malposition (upright or upward)
    • IIIC: Severe gynoid shape of the chest
    • IIID: Absence of sternal notch
  • Grade IV: Severe hypertrophy with grade II or III ptosis (>500–700 g)
    • IVA: Fatty and fibrous tissue with ptosis of grade II
    • IVB: Fatty and fibrous tissue with ptosis of with nipple reorientation grade III
    • IVC: Nipple malposition (upright or upward)
    • IVD: Severe gynoid shape of the chest
    • IVE: Absence of sternal notch
Ratnam's Physical
  • Type 1: Enlarged breasts with elastic skin and no fold
  • Type 2: Enlarged breasts with elastic skin and an inframammory fold (IMF)
  • Type 3: Ptotic breasts with inelastic skin
Webster's Tissue type

*NAC, nipple-areola complex; IMF, inframammary fold

Classification based on severity

Gynecomastia can be classified on the basis of severity as:

  • Grade I: Minor enlargement with no skin excess
  • Grade II: Moderate enlargement with no skin excess
  • Grade III: Moderate enlargement with skin excess
  • Grade IV: Marked enlargement with skin excess

Classifcation based on etiology

References

  1. Waltho D, Hatchell A, Thoma A (2017). "Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System". Plast Reconstr Surg. 139 (3): 638e–648e. doi:10.1097/PRS.0000000000003059. PMID 28234829.
  2. Monarca C, Rizzo MI (2013). "Gynecomastia: tips and tricks-classification and surgical approach". Plast Reconstr Surg. 131 (5): 863e–5e. doi:10.1097/PRS.0b013e318287a18f. PMID 23629140.
  3. Rohrich RJ, Ha RY, Kenkel JM, Adams WP (2003). "Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction". Plast Reconstr Surg. 111 (2): 909–23, discussion 924-5. doi:10.1097/01.PRS.0000042146.40379.25. PMID 12560721.
  4. Wollina, U; Goldman, A (June 2011). "Minimally invasive esthetic procedures of the male breast". Journal of cosmetic dermatology. 10 (2): 150–155. doi:10.1111/j.1473-2165.2011.00548.x. PMID 21649820.
  5. Simon BE, Hoffman S, Kahn S (1973). "Classification and surgical correction of gynecomastia". Plast. Reconstr. Surg. 51 (1): 48–52. PMID 4687568.
  6. Gikas P, Mokbel K (2007). "Management of gynaecomastia: an update". Int J Clin Pract. 61 (7): 1209–15. doi:10.1111/j.1742-1241.2006.01095.x. PMID 17362482.



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