Keywords
gynecomastia - gynecomastia classification - puffy nipple - male breast enlargement.
Introduction
Gynecomastia is a common aesthetic problem encountered[1] and is the most common benign condition to occur in the male breast.[2] A study showed that 36% of adult young men and 57% of older men have some form of
gynecomastia[3]; therefore, this implies it to be as common as one in every three adult men and
one in every two elderly men.[3] In our practice, we consult close to 200 patients every month, and speak to almost
1,000 patients monthly via telephonic consultation.
The definition does not include the size, volume measurement of the gland, or the
amount of fat. Patients can have more than 1 L of fat in each breast and less than
100 g of gland tissue or 500 mL of fat and 400 g of gland tissue. Thus, the definition
does not have a correlation with the composition of the male breast. Therefore, enlargement
of the breast, whether it is due to fat or gland, that gives the appearance of a female
breast is sufficient to call it a gynecomastia. Histopathology of gynecomastia specimens
show fat and glandular elements in varying proportions.[4]
[5]
Classifications like Simon's classification[6] do not mention about puffy nipples, which are only glands, whereas Rohrich's classification[7] includes ptosis in higher grades only. Hence, we believe that these classifications
are incomplete and need to be more detailed to cater to the Indian population and
possibly worldwide as well. A new classification should encompass the entire spectrum
of the problem so that apt managements can be done for them all.
Materials and Methods
The authors conducted this study at their Aesthetic Surgery Center in India over a
period of 24 months from May 2020 to May 2022, and included 1,571 patients whose age
ranged from 15 to 56 years. All patients were classified with the existing most commonly
used Rohrich's[7] classification along with our proposed classification. Similarities were noted in
different cases with the same proposed grade. Some parameters were used to iterate
the new classification:
-
Patient demographics were recorded and divided into various age groups and subsequent
grades as per the proposed classification.
-
Infiltration volumes were recorded in each grade in the first 500 cases, and then
a proposal to infiltrate calculated “X” amount of fluid for each stage was made.
-
Volume of lipoaspirate was recorded in each case in the first 500 cases to authenticate
the predicted lipoaspirate in each grade.
-
The skin lift procedure was assessed for its efficacy in reducing postoperative sagging
and healing delay. This was done in the first 25 cases of skin lift and then it became
a standard practice for grades IIb, IIIb, and IVb. Skin lift was also used to correct
minor asymmetries. The procedure involved marking the new position of the areola,
de-epithelizing the skin from the marked segment, removing the gland from there, and
re-suturing the areola in its elevated position in two layers.
We assessed the classification on the following parameters: ability to correctly predict
the infiltration amount for each grade, the predictability of results, how much lipoaspirate
can be expected in each grade, and the ability to predict the need for skin ptosis
correction with the “U lift” procedure.
While classifying the patients and analyzing data, the following lacunae were noted:
-
A peculiar subset comprising nearly 8 to 10% of gynecomastia patients presented with,
what they call, a puffy nipple, which is areolar enlargement without any major breast
enlargement, which gives them the perception of gynecomastia. They have enlarged glands
that cause an outward projection of the nipple areola complex. Such patients are commonly
advised by the family/doctors to exercise expecting spontaneous reduction. However,
there is a severe psychological impact on these patients due to their clinical condition,
resulting in low self-esteem. This needs to be addressed in classification for gynecomastia.
One article defined gynecomastia as the presence of greater than 2 cm of palpable,
firm, subareolar gland and ductal breast tissue.[8] This definition is controversial in our view, since in many patients, the palpable
firmness may be less than 1 cm and sometimes none at all.
-
Patients with skin laxity/ptosis need to be addressed, even if the breast enlargement
is not very severe. As per current classifications, these are categorized as grade
III, where it is taken for granted that they have a large amount of fat and gland.
This may not be true, and often grade II patients have severe laxity that needs surgical
correction.
-
As per current classifications, grade II patients cannot have ptosis, but this is
not true. We have a large subset of patients who have less than 500 g of fat/gland,
yet have reasonable ptosis to warrant intervention and correction.
-
The differentiation of grade III and IV solely based on ptosis is not justified. There
are patients who have 500 g of tissue and have severe ptosis, and there are patients
with more than 1,500 g of tissue and yet have negligible ptosis. These patients do
not need any special treatment for this ptosis. We have created a complete subclassification
to address ptosis along with tissue proposed to be removed in an easy-to-follow manner.
In our classification, we have clearly divided grade III into two parts: grade IIIa
without a need to address ptosis and grade IIIb with a need for ptosis correction
with the U lift procedure (supra-areolar skin lift).
-
Grade IV as per current classification is severe hypertrophy, with grade II or III
ptosis This implies that ptosis can only occur in grade III or IV. We have seen severe
ptosis in lower grades of gynecomastia and minimal or no ptosis in higher grades.
Therefore, grade IV is redundant in its definition.
-
In the classifications, emphasis is laid on the weight of tissue. But is it fat or
gland? Has the fat been weighed? How much decantation or fat preparation was carried
out to measure liposuctioned fat in grams? Or are the authors referring only to glands?
In such a scenario, is the volume of fat not important in the classification? We have
observed that defining the classification with the volume of fat is far easier and
better quantifiable since in 80% of patients, the gland amount removed is usually
less than 100 g. Only in patients with severe or moderate ptosis does the amount of
gland exceed 200 g, and is rarely more than 750 g each side. In the last 2 years,
during the study period, we have had only three patients who have had more than 500 g
of gland apart from the huge amount of fat aspirated. We believe that the amount of
gland in grams has no relevance except possibly an indicator of degree of ptosis.
-
Difference between the breast and chest: In a large majority of grade III and IV cases,
there is the presence of breast rolls or fat in the form of rolls below the axilla.
There is no mention of this fact in any of the previous classifications. We believe
that unless the side rolls are tackled with liposuction, the patient does not get
a complete look, and in fact the chest appears broad when the breast has been liposuctioned.
That is why the differentiation between volume of lipoaspirate and weight of tissue
becomes more important.
-
What is a small, moderate, or marked gland enlargement in terms of volume? Subjectivity
was noted depending upon who classified the patient. Thus, we set out to correct this
anomaly.
We included not only breast tissue but also side rolls, ptosis, skin laxity, and puffy
nipple for classification as we are treating the chest and not the breasts alone.
This is the main basis of our new clinical classification for gynecomastia ([Table 1]).
Table 1
New proposed gynecomastia classification
|
Grade
|
Description of grade
|
Explanation
|
Infiltration volume + treatment plan
|
|
1a
|
Puffy nipple
|
No obvious problem visible except stretched areola with a button type feel
|
50 mL + excision in LA from infra-areolar incision
|
|
1b
|
Minor breast enlargement
|
The breast is visibly bigger, limited fat, 250 mL with higher amount of fibroglandular
tissue
|
200 mL + suction and gland excision in LA from infra-areolar incision and stab in
the inframammary area
|
|
2a
|
Moderate breast enlargement
|
The fat component is between 250 and 500g. No ptosis expected
|
500 mL + suction and stab incision in the axillary area and gland excision in GA from
the infra-areolar incision
|
|
2b
|
Moderate breast enlargement with ptosis
|
The fat component is between 250 and 500 g. Large gland components in the form of
a conical breast U lift needed for ptosis
|
500 mL + suction from stab incision in the axillary area and gland excision + U skin
lift from the supra-areolar approach in GA
|
|
3a
|
Large chest enlargement with side rolls without ptosis
|
Chest is enlarged. Fat component is 500–750 g. Fat in breast rolls. No ptosis expected
|
1,000 mL (each side and axilla) + suction from stab incision in the axillary area
and gland excision in GA
|
|
3b
|
Large severe chest enlargement with side rolls with ptosis expected
|
Chest is enlarged, fat component + axilla rolls + ptosis expected/present
|
1,000 mL (each side and axilla) + suction from stab incision in the axillary area
and gland excision + U skin lift from the supra-areolar approach in GA
|
|
4a
|
Severe chest enlargement without significant ptosis
|
Chest is severely enlarged, >750 g fat component + axilla rolls without significant
ptosis. No need for skin lift
|
1,500 mL (each side and axilla) + suction from stab incision in the axillary area
and gland excision in GA
|
|
4b
|
Severe chest enlargement with significant ptosis. May need second stage for tackling
excess skin or same stage axillary roles excision
|
Chest is very big, large breast rolls, significant ptosis requiring skin lift procedure
|
1,500 mL (each side and axilla) + suction from stab incision in axillary area and
gland excision + U skin lift from the supra-areolar approach in GA. Second stage O
lift (circumferential skin mastopexy) may be needed
|
Abbreviations: LA, local anesthesia; GA, general anesthesia.
A pictorial representation with front and side views are also added ([Figs. 1],[2],[3],[4]).
Fig. 1 (a) Grade 1a - anterior view showing only subareolar fullness i.e., puffy nipple,
pre and postoperative view. (b) Grade 1b - lateral and anterior pre and post operative
view with minor breast enlargement.
Fig. 2 (a) Grade 2a - lateral and anterior pre and post operative views of moderate breast
enlargement. (b) Grade 2b - lateral and anterior pre and post operative views of moderate
breast enlargement with ptosis.
Fig. 3 (a) Grade 3a - lateral and anterior pre and post operative views of large chest enlargement.
(b) Grade 3b - lateral and anterior pre and post operative views of large chest enlargement
with ptosis.
Fig. 4 (a) Grade 4a - lateral and anterior views of pre and post operative severe chest
enlargement. (b) Grade 4b - lateral and anterior views of pre and post operative severe
chest enlargement with ptosis.
Results
The age range of the 1,571 patients who were included for data collection was 15 to
56 years. They were segregated into the following groups per their age: 15 to 18 years
(adolescent), 19 to 40 years (young), and 41 to 60 years(older). The majority of the
patients were in the young age group.
With the use of the proposed classification, the volume of infiltrate and lipoaspirate
was correctly predicted, with all values having up to 95% positive prediction. A standardization
was developed for all grades of gynecomastia and as the chest was treated and not
the breast, patient satisfaction was high as all problem areas were taken care of
and the outcome that was explained to them preoperatively was clearly visible postoperatively.
Discussion
A widely used classification is Simon's classification system,[6] which uses the physical criteria for classification. The classification is based
on the amount of tissue and skin redundancy. In 1973, they identified four grades
of gynecomastia:
-
Grade I: small enlargement without skin excess.
-
Grade IIa: moderate enlargement without skin excess.
-
Grade IIb: moderate enlargement with minor skin excess.
-
Grade III: marked enlargement with excess skin and mimicking female breast ptosis.
Clinically, it has several grades that range from simple areolar protrusion to breasts
with a feminine appearance.
The classification by Rohrich[7] is based on tissue hypertrophy and nature of tissue, i.e., glandular or fibrous.
They have proposed a similar classification of gynecomastia with four grades of severity:
-
Grade I: minimal hypertrophy (<250 g) without ptosis.
-
Grade II: moderate hypertrophy (250–500 g) without ptosis.
-
Grade III: severe hypertrophy (>500 g) with grade I ptosis.
-
Grade IV: severe hypertrophy with grade II or III ptosis.
Similarly, Ratnam[1] proposed a classification based on skin elasticity and ptosis. Various classifications
such as Cohen's, Barros's,[9] Gusenoff's,[10] etc., take into account the amount of tissue, volume of tissue, presence of lateral
rolls, relationship with the nipple areola complex and inframammary crease, etc. Their
approach is rather simplistic, and they do not address the myriad forms of gynecomastia
that can exist in different patients or even the same patient.
Puffy nipples were treated with a simple local anesthesia procedure to only remove
glandular tissue. As the majority of patients attempt weight loss to cure themselves
of gynecomastia, there is reduction of their grade, and also results in variable amounts
of sagging. Contrary to common belief, skin does not retract well in these situations,
and they may be left with some sagging. U lift helps tighten the skin in these situations
and further raise the level of the nipple–areola complex. We have further noticed
a reduction in the redundancy of skin in the inframammary fold in such patients, as
is very commonly observed in gynecomastia in weight loss patients.
Asymmetric gynecomastia treatment can be remarkably different for both sides.
A new classification for gynecomastia ([Table 1]) was devised to make a practically relevant classification that systematically covers
the mentioned lacunae and helps in outlining the management. It also has a suggested
treatment plan for standardization.
Rohrich's classification and the proposed new classification were compared ([Table 2]).
Table 2
Comparison table
|
Grade
|
Rohrich' s classification
|
New proposed classification
|
|
I
|
Minimal hypertrophy (<250 g) without ptosis
|
a: Puffy nipple
b: Minor ranging up to <250 g enlargement
|
|
II
|
Moderate hypertrophy (250–500 g) without ptosis
|
a: 250–500 g without ptosis
b: With ptosis
|
|
III
|
Severe hypertrophy (>500 g) with grade I ptosis
|
a: 500–750 g with side rolls
b: With axilla rolls, side rolls, and ptosis
|
|
IV
|
Severe hypertrophy with grade II or III ptosis
|
a: >750 g with side rolls
b: With ptosis
|
In the study, we were able to demonstrate that while using the proposed classification
correct prediction of infiltration volume and lipoaspirate could be done ([Table 3]). This assisted us in incorporating these values as standard in the classification.
This was seen even when patients were grouped age wise ([Table 4]).
Table 3
Grade-wise correct prediction
|
Grade
|
Correct prediction of infiltration volume (%)
|
Corrected prediction of lipoaspirate volume (%)
|
|
1a
|
94
|
96
|
|
1b
|
95.2
|
96.8
|
|
2a
|
97.1
|
96.9
|
|
2b
|
96.6
|
95.4
|
|
3a
|
91.5
|
95.8
|
|
3b
|
98.2
|
97.3
|
|
4a
|
97.7
|
96.3
|
|
4b
|
97.9
|
95.4
|
Table 4
Age-wise patient correct prediction
|
Age group (y)
|
No. of patients
|
Correct infiltration volume prediction
|
Correct lipoaspirate volume prediction
|
|
15–18
|
45
|
Yes
|
Yes
|
|
19–40
|
1224
|
Yes
|
Yes
|
|
40–56
|
302
|
Yes
|
Yes
|
On using the new classification for gynecomastia, the following advantages were noted:
-
No need for sonography for assessment: Since a description of each grade is present,
there was no need to quantify the gynecomastia volume with ultrasound.
-
It is readily teachable: Communication with surgeons, nursing, and support staff became
clearer and crisp. From preparation of infiltration fluid to plan of anesthesia, instrument
requirements became more streamlined.
-
Standardized protocols: This allowed less wastage of time and resources, as the whole
team was aware of the protocol.
-
Predictable results: After following the new grading system, estimated volume and
aspirated volume of lipoaspirate were comparable. It was noted that the results were
reproducible, predictable for new patients, and could be successfully used for visual
reinforcement for patients' enquiries regarding outcomes.
Patients with ptosis or asymmetrical chests were also included, and predictable results
could be obtained for them.
The only lacunae noted in the new classification, which has not been addressed in
any previous classification as well, are clinical situations where the chest is composed
of predominantly heavy glandular tissue. This is common in patients who take steroids
for bodybuilding.[11] The chest can be very big, and more than 50% of the chest could be due to the gland
element. Currently, we add that volume to the fat aspirated. We are working on incorporation
of this in the classification, in terms of pre- and postsurgical classification of
gynecomastia.
Conclusion
Our new classification for gynecomastia is a simple, straightforward, comprehensive
grading system, the use of which has helped the authors and the team in achieving
precise and predictable results and ensuring patient satisfaction. This classification
allowed us to recommend each step of the procedure, such as quantity of infiltration
according to the grade, expected adipose component, and addressing skin excess. Therefore,
we believe the use of this classification ensures great outcomes and functional ease.
