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. Omodamola Aje B.Sc, M.D. [2]

Overview

Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology. Breast size and ptosis are the most commonly included features.

Classification

Common features included in different gynecomastia classification systems included:[1][2][3][4][5][5]

  • Breast size
  • Skin redundancy
  • Breast ptosis
  • Tissue predominance
  • Upper abdominal laxity
  • Breast tuberosity
  • Nipple malposition
  • Chest shape
  • Absence of sternal notch
  • Breast skin elasticity

Classification based on different systems

Author Year Method of classification Classification system
Nydick 1961 Physical
  • Gland limited to the retro areolar region; 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 1971 Physical
  • Stage 1: Nipple prominence
  • Stage 2: Mammillary button stage; the breast and the areola- nipple are slightly swollen and the 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 1973 Physical
  • GRADE 1: Small visible breast enlargement, 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 and Freilinger 1986 Physical
  • Grade 1: Thoracic wall poor in the flesh; mammary tissue localized behind and around the nipple; no skin excess
  • Grade 2: Adipose thoracic wall; widespread alterations; breasts similar to feminine ones during puberty
  • Grade 3: Widespread alterations; excess adipose tissue, skin redundancy, inframammary fold and ptosis
Cohen 1987 Physical
  • Group 1: Glandular gynecomastia
  • Group 2: Glandular gynecomastia with ptosis
  • Group 2: Glandular gynecomastia with ptosis
  • Group 3: Adipose gynecomastia
  • Group:4 Adipose gynecomastia with a slight glandular component
Rohrich 2003 Physical/Tissue type
  • GRADE 1: Minimal hypertrophy, (less than 250g of tissue) without ptosis
    • 1a: Primary glandular
    • 1b: Primarily fibrous
  • GRADE 2: moderate hypertrophy (250-500g of breast tissue) without ptosis
    • 2a: Primarily glandular
    • 2b: primarily fibrous
  • GRADE 3: Severe hypertrophy (>500g of breast tissue with grade 1 ptosis glandular or fibrous
  • GRADE 4: Severe hypertrophy with grade 2 or 3 ptosis glandular or fibrous
Gusenoff 2008 Physical
  • GRADE 1: Minimal excess skin and fat, minimal alteration of nipple-areola complex (NAC), inframammary fold (IMF)
    • 1a: No lateral skin roll
    • 1b: Lateral skin roll
    • 2: NAC and IMF below the ideal IMF, lateral chest roll, minimal upper abdominal laxity
  • GRADE 3: NAC and IMF below the ideal IMF, lateral chest roll, significant upper abdominal laxity
Barros 2012 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 2012 Imaging (computed tomography)
  • Gynecomastic adipose tissue/total gynecomastic tissue, <0.3
  • Gynecomastic adipose tissue/total gynecomastic tissue, 0.3–0.5
  • Gynecomastic adipose tissue/total gynecomastic tissue, >0.6
Cordova 2008 Physical
  • GRADE I: Increase in diameter and protrusion limited to the areolar region
  • GRADE II: Hypertrophy of all the structural components of the breast; the NAC is above the IMF
  • GRADE III: Hypertrophy of all the structural components, NAC at the same height as or approximately 1 cm below the IMF; in this group we can also include male tuberous breast
  • GRADE IV: Hypertrophy of all the structural components, NAC >1 cm below the IMF
Fruhstorfer 2003 Physical
  • Small-to-moderate
  • Moderate-to-large
Mladick 2004 Physical
  • No sagging
  • Slight sagging
  • Moderate sagging
  • Extensive sagging
Monarca 2013 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 2009 Physical
  • Type 1: Enlarged breasts with elastic skin and no fold
  • Type 2: Enlarged breasts with elastic skin and an IMF
  • Type 3: Ptotic breasts with inelastic skin
Webster 1946 Tissue type
  • Class 1: Periductal connective tissue hypertrophy without adipose tissue change
  • Class 2: Increase in the amount of both connective and adipose tissue
  • Class 3: Adipose tissue hypertrophy alone

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

Classification based on severity

Gynecomastia can be graded on the basis of severity as:

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

Classifcation based on pathogenesis

  • Physiological
  • Pathological
    • Due to excess unopposed estrogen to androgen ratio.

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. 5.0 5.1 Simon BE, Hoffman S, Kahn S (1973). "Classification and surgical correction of gynecomastia". Plast. Reconstr. Surg. 51 (1): 48–52. PMID 4687568.

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