Algorithm for clinical evaluation and surgical treatment of gynaecomastia☆

Article Outline

• Summary
• Morphological classification of gynaecomastia
  • Cases review
• Surgical treatment
  • Grade I gynaecomastia
  • Grade II gynaecomastia
  • Grade III gynaecomastia
  • Grade IV gynaecomastia
• Conclusions
• References
• Copyright

Summary 

Background

Gynaecomastia can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifications of gynaecomastia currently made often use subjective parameters and qualifying adjectives. In this paper the authors propose a scheme for morphological classification of gynaecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations.

Methods

A retrospective analysis was made of 121 cases of gynaecomastia operated on in the last 5 years. The extent of the clinical picture, the technique employed, the complications and the need to re-operate were observed and related.

Results

On the basis of this review the authors observed that when the nipple-areola complex is above the inframammary fold (grade I and grade II gynaecomastia), complete flattening of the thorax can be achieved by means of suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. When the nipple-areola complex is at the same height as, or at most 1cm below the fold (grade III gynaecomastia), skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is more than 1cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes necessary, with upper repositioning of the nipple-areola complex; in these cases central pedicle techniques make it possible to limit scarring in the periareolar areas.

Conclusions

In the preoperative phase this simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.

Keywords: Gynecomastia, Classification, Cutaneous ptosis, Skin-sparing techniques

Gynaecomastia is a deformity of the male thorax with multifactorial aetiology. Independently of the pathogenesis, in most cases it requires surgical treatment. Spontaneous regression and an effective nonsurgical treatment are only theoretically possible in types of gynaecomastia with recent proliferation that have not produced any ptosis of the mammary skin.

The histopathological aspect of gynaecomastia is determined not only by the pathogenesis but also by its persistence. In types which have persisted for over a year, the loose peri-ductal tissue and the surrounding stroma undergo an irreversible process of fibrosis and hyalinisation, which explains why once glandular hypertrophy has set in it cannot regress.¹

Gynaecomastia shows a gradation of clinical types going from simple areolar protrusion to breasts with a female appearance (female pendulous breast).

At all events, any feminising deformity of the male thorax requires attention, especially in adolescent subjects, in whom it may alter self-perception, especially in the sexual sphere.²

Gynaecomastia is an epiphenomenon that can be linked to more or less well-known pathogenetic factors and can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology, morphology.

In this article there will be no discussion of pathogenetic classifications³, ⁴, ⁵ and histopathologic ones,⁶, ⁷ as they are simply lists referring, respectively, to pathogenetic factors and histopathologic aspects, susceptible to being modified as medical knowledge progresses.

Instead, attention will be focused on a scheme for morphological classification which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations.

The clinical aspects characterising gynaecomastia are:

Association of these deforming aspects makes it possible to identify various types of gynaecomastia marked by differing grades of severity.

The current morphological classifications of gynaecomastia fail to focus anatomically on the entity of the defect and generally make use of subjective parameters⁵, ⁸, ⁹, ¹⁰, ¹¹, ¹² and qualifying adjectives like ‘minimal’, ‘moderate’ and ‘severe’.¹⁰

Quantitative evaluation of the excess tissue⁵ may also be useful in retrospective analysis, but cannot be applied to the preoperative phase, since it is not easy to predict the weight ratio between adipose tissue and glandular tissue which, as is well known, have different specific weights (Table 1).¹³

Table 1. Classifications of gynaecomastia

Authors	Classification
Nydick 1961	-gland limited to the retroareolar 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	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	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 (pendulous female breast)
Deutinger and Freilinger 1986	Grade 1.– thoracic wall poor in flesh; mammary tissue localised 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	Group 1.– glandular gynaecomastia;
	Group 2.– glandular gynaecomastia with ptosis;
	Group 3.– adipose gynaecomastia;
	Group 4.– adipose gynaecomastia with slight glandular component.
Rohrich 2003	Grade I.– minimal hypertrophy (< 250g of breast tissue) without ptosis; IA:primarily glandular; IB:primarily fibrous;
	Grade II.– moderate hypertrophy (200–500g of breast tissue) without ptosis; IIA: primarily glandular; IIB: primarily fibrous;
	Grade III.– severe hypertrophy (>500g of breast tissue) with grade I ptosis glandular or fibrous;
	Grade IV.– severe hypertrophy with grade II or III ptosis glandular or fibrous

Nowadays surgical treatment of gynaecomastia can make use of different techniques like suction-assisted lipoplasty¹⁴ or ultrasound-assisted lipoplasty,⁵ round-block suture,¹⁵ and the endoscopic approach¹⁶ which have already proved their worth in cosmetic surgery and in female breast surgery.

These techniques, which have gradually replaced traditional surgical dermo-lipectomy, have made it possible to reduce the invasiveness of the operation, improving the final result and reducing scars.

On the basis of a chart review of their cases, the authors propose a morphological classification of gynaecomastia prevalently based on evaluation of the relationship between the nipple-areola complex and the inframammary fold, which makes it possible to establish an algorithm for the choice of the most suitable technique.

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Morphological classification of gynaecomastia 

On the basis of a chart review of 121 patients affected by gynaecomastia and operated on over a period of 5 years, a classification of gynaecomastia was made that takes into account the different structural components of the breast (skin, nipple-areola complex, inframammary fold, glandular tissue, adipose tissue) and the relations between these various components and, in particular, the relationship between the inframammary fold and the nipple-areola complex, which is the watershed between mild types and serious types.

All types of gynaecomastia can be classified into four grades of increasing severity from I to IV (Fig. 1), as follows:

Grade III, hypertrophy of all the structural components, nipple-areola complex at the same height as or about 1cm below the inframammary fold; in this group we can also include male tuberous breast;

Grade IV, hypertrophy of all the structural components, nipple-areola complex more than 1cm below the inframammary fold.

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• Figure 1 

  Classification of gynaecomastia. Grade I, increase in diameter and protrusion limited to the areolar region; Grade II, areola-nipple complex above the inframammary fold (I.F.); Grade III, areola-nipple complex at the same height as or about 1cm below the I.F.; Grade IV, areola-nipple complex more than 1cm below the I.F.

This classification, which is very simple and stringent, makes it possible in the preoperative phase to divide patients affected by gynaecomastia into four groups, corresponding to different surgical choices.

Cases review 

Before undergoing surgery, patients underwent a different clinical workup depending on their age.

The workup protocol used so far includes for all patients: thyroid function tests (fT3 (free Triiodothyronine), fT4 (free Thyroxine),TSH (Thyroid Stimulating Hormone)), extradiol, FSH (Follicle Stimulating Hormone), LH (Luteinizing Hormone), total and free testosterone, prolactine, beta-hCG (human Chorionic Gonadotropin), liver function tests, kidney function tests, mammary bilateral ultrasonography. In patients aged 12 to 18 right hand and wrist X-rays are requested in order to evaluate the bone age. Mammography, turcic sella X-rays, testicular ultrasonography and chromosomal mapping are performed only if a specific indication is present depending on the patient history, the physical exam and hormonal tests.

In our review of 123 patients, of which 121 underwent a surgical operation, we were able to establish an aetiopathogenic relationship with the gynaecomastia onset in only 21 cases.

In 21 cases, of which 13 were considered to be grade II, four were grade III and four were grade IV, the persistance of a pre-puberal hormonal setting was found, with increased extrogens levels and reduced total and free testosterone levels.

In one case of grade II gynaecomastia, a diagnosis of Klinefelter's syndrome was made.

In one case, clinically considered as a group II gynaecomastia, the onset of the disease was related to the recreational use of marijuana.

In one case, grade II, altered levels of extrogens lead to the diagnosis of a Leydig cells testicular cancer. This patient was not operated on for his gynaecomastia.

In one grade I case associated with increased levels of prolactine, a pituitary microadenoma was diagnosed. This patient was also not operated on and both these patients were removed from the study.

In 102 cases no hormonal dysfunction was found, nor was there found an aetiopathogenic, pathological, pharmacological or comportmental correlation. Thus, in this cases review 83% of gynaecomastia cases are considered to be idiopathic.

The main morphological aspects relating to the 121 cases we operated on are summarised in Table 2. Monolateral types account for 20% of the cases studied (25 cases) and are all classifiable as grade I and II. Bilateral types account for about 80% of the cases studied (96 cases), 64 cases of which (67%) can be classified as grade II. Bilateral cases were considered as symmetric when, though with some volumetric difference, both breasts can be included in the same grade and treated with the same surgical approach.

Table 2. Patients' distribution according to our classification and number of complications and re-operations

There were such serious asymmetrical differences between the two breasts that we were led to consider different surgical procedures for each breast (i.e. cutaneous resections on one side and skin-sparing on the other).

The most frequent complication was haematoma, which occurred in six cases (5%), all falling into grade II gynaecomastia. No haematomas were seen in the six cases with the most severe form of gynaecomastia (grade IV). The incidence of haematomas was indeed greater in grade II, for the following reasons:

In all cases included in grade IV (female pendulous breast) and in seven cases included in grade III, it was necessary to re-operate to correct the scars. In these cases, re-operating has not to be considered as a complication but part of the surgical programme presented to patients in the preoperative phase. Second operations were always performed as day surgery and under local anaesthesia, after at least 3 months. In two cases of grade IV gynaecomastia two operations under local anaesthesia to correct periareolar scars were needed.

A persistent alteration of the nipple-areola complex was signalled in two cases, one classified as grade III that underwent a wide skin resection with the removal of an abundant glandular mass, and one case classified as grade IV. In both cases the decrease in sensibility was unilateral and involved the nipple-areola left complex.

In general the surgical procedure for gynaecomastias is followed by an elevated patient satisfaction rate which is greater in patients with initially bigger defects and in patients with inconspicuous scarring.

Three patients considered among the most severe cases (grade IV) stated that they felt more comfortable even with their chest exposed; three patients instead felt uncomfortable with their chest exposed. However, all these patients felt more comfortable with their clothes on and wearing tailored clothing.

It is indeed true that patients affected by more severe gynaecomastias, which is usually associated with a certain level of obesity and a feminine body type (round abdomen and wide hips, slim upper limbs), rarely happen to be satisfied with their figure and require psychological support.

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Surgical treatment 

The objectives of surgical treatment are:

On the basis of our experience the presence or absence of cutaneous ptosis is decisive in the choice of the specific form of surgical treatment. The grade of ptosis is evaluated by observing the position of the nipple-areola complex with respect to the fold.

In all cases of grade I and grade II gynaecomastia, where the nipple-areola complex is above the fold, it is possible to apply skin-sparing techniques requiring a single surgical phase and involving minimum scarring.

In grade II gynaecomastia, whether more surgical time is devoted to adenectomy or to suction-assisted lipoplasty depends on the prevalence of glandular tissue or adipose tissue. A thorough physical examination of the thoracic region, and a thorough palpation, backed up by ultrasonography, makes it possible to distinguish forms with a prevalently glandular or prevalently adipose component.

Leaving aside grade I gynaecomastia, which is caused by pure glandular hypertrophy, there are no other forms of exclusively glandular or adipose gynaecomastia. The pathogenetic factors giving rise to glandular proliferation are the same as those that cause an accumulation of adipose tissue in the male breast, though with a different gradation.¹⁷, ¹⁸ Hence it would be more correct to refer to gynaecomastia with a prevalent glandular component or a prevalent adipose component than to speak of glandular gynaecomastia and pseudogynaecomastia. The term pseudogynaecomastia should be reserved solely for thoracic adiposity in very obese subjects.

In grade III and grade IV gynaecomastia, in addition to an accumulation of adipose/glandular tissue, there is redundant skin which will have to be removed in order to achieve satisfactory flattening, even though this leads to bigger scars.

Grade I gynaecomastia 

Grade I gynaecomastia can be monolateral or bilateral. It affects young people, often thin ones, and involves an increase in the diameter and protrusion of the areola; there is no inframammary fold, adipose accumulation or excess skin. This is the only type of pure glandular gynaecomastia.

Treatment of this type of gynaecomastia simply involves minimally invasive adenectomy, which can be carried out by means of lower semicircular periareolar incision¹⁹ or endoscopy.¹⁶ In grade I gynaecomastia liposuction is not required (Fig. 2).

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• Figure 2 

  Grade I gynaecomastia. (a) Protrusion and increase in the diameter of the areola; (b) intraoperative view; grade I is the only form of pure glandular gynaecomastia; (c) final result after 1 year.

Grade II gynaecomastia 

In grade II gynaecomastia we can include all cases of gynaecomastia in which the nipple-areola complex is above the inframammary fold, independently of the increase in the mammary volume. Most of the cases of gynaecomastia we treated can be included in this group.

In the preoperative phase it is possible to ascertain the prevalence of glandular or adipose tissue. However, surgery must certainly act on both components, glandular and adipose, and on the fold, making sure that the skin loses the memory thanks to thorough detachment.

Usually it is not necessary to act on the areolar diameter, even when it has increased, since retraction of the skin involves a corresponding retraction of the areola, taking it back to an acceptable size (the effect is that of a drawing on a balloon: when the balloon deflates, the drawing decreases in size). In our experience, even in the case of voluminous breasts with a female appearance, if the nipple-areola complex is above the fold, skin-sparing surgical techniques can be used successfully.

In skin-sparing techniques, there is a first phase of vacuum or ultrasound-assisted lipoplasty, followed by minimally invasive adenectomy, which can be carried out by means of semicircular periareolar, intraareolar, pull-through or endoscopic incision.¹⁷

At all events, whatever technique is chosen for adenectomy, the residual scars are minimal. Vacuum or ultrasound-assisted lipoplasty is a fundamental phase in surgery for gynaecomastia in achieving homogeneous flattening of the thoracic wall and the reduction of scarring and postoperative complications, but, in most cases of grade II gynaecomastia, liposuction by itself it is not sufficient to achieve satisfactory flattening, due to the constant presence of fibro-glandular residues that persist in the retro-areola which need to be removed by means of surgical adenectomy (Fig. 3).

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• Figure 3 

  Grade II gynaecomastia. (a) Frontal view; in the lateral (b) and three-quarters view (c) it is evident that the nipple-areaola complex is above the inframammary fold. Surgical treatment: skin-sparing technique (vacuum liposuction and semicircular periareolar adenectomy). (d, e, f) Results after 1 year.

Grade III gynaecomastia 

The treatment of grade III gynaecomastia is more challenging. It is important to identify these types of gynaecomastia in the preoperative phase and distinguish them from more severe types of grade II gynaecomastia.

In our experience of grade III gynaecomastia using skin-sparing techniques is not sufficient, and in order to achieve good flattening of the thorax it is necessary to eliminate the excess skin by means of periareolar removal of epidermis. We had the best results using this method.

The operation begins with liposuction. Then an adenectomy with semicircular periareolar access follows, and lastly the area to be disepithelialised is marked. In this phase, if necessary, the areolar diameter can be reduced. The periareolar area to be disepithelialised can be marked in various ways, also depending on the operator's own experience. At all events, it must make it possible to position the nipple-areola complex correctly and symmetrically with respect to the contralateral side and to reduce the areolar diameter according to the reference canons for the male thorax.²⁰, ²¹, ²², ²³, ²⁴, ²⁵

Once the removal of the epidermis has been carried out, round-block suturing is performed. Of course, with periareolar removal of epidermis there is a circumferential periareolar scar, sometimes wrinkled, but this can improve spontaneously or with subsequent surgery (Fig. 4).²⁶

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• Figure 4 

  Grade III gynaecomastia. (a) Frontal view; in the three-quarters view (b) it is evident that the nipple-areola complex is at the same height as the inframammary fold. Surgical treatment: vacuum-assisted liposuction, adenectomy, periareolar disepithelialisation. (c, d) Results after 6 months; flattening of the thorax is good but another operation is required to improve periareolar scars.

The rarer cases of male tuberous breast can be included in grade III and treated in the same way: liposuction (if necessary), semicircular periareolar adenectomy and periareolar and areolar skin resections.

Grade IV gynaecomastia 

Grade IV includes the most severe types of gynaecomastia, which are fortunately rare. These are characterised by marked cutaneous ptosis with the nipple-areola complex more than 1cm below the fold. Often patients belonging to this group are formerly obese or at least overweight.

Surgical treatment of grade IV gynaecomastia is often unsatisfactory because of the inevitable residual scars. In these cases, complete flattening of the thorax with elimination of the fold, correct positioning of the nipple-areola complex, with its vascularisation being safeguarded, and resection of the redundant skin, require reduction mastoplasty to be followed by further surgery for scar correction.

We believe that in grade IV gynaecomastia, though it is characteristic of overweight patients, the fulcrum of treatment is not liposuction. As in the case of surgery for very obese and formerly obese patients, the problem to solve is not localised accumulation of adipose tissue but the removal of major skin redundancy and residual scarring.

The techniques described for the treatment of grade IV gynaecomastia are numerous, and include free transplantation of the nipple-areola complex,²¹ transversal or vertical scars.²⁷, ²⁸, ²⁹ We believe it is preferable for the final result that scars be confined to the periareolar area. Contemplating a second stage of scar correction or irregularities in the residual adipose tissue (Fig. 5), in our experience central pedicle reduction mastoplasty techniques³⁰ are the most suitable for achieving good flattening of the breast. In our opinion, the use of a central pedicle makes it easier to gather the redundant skin around the areola.

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• Figure 5 

  Grade IV gynaecomastia. (a, b) Frontal view: the nipple-areola complex is about 3cm below the inframammary fold. Surgical treatment: first stage, under general anaesthesia, central pedicle reduction mammoplasty; second stage, under local anaesthesia, vacuum-assisted liposuction and scar revision. (c, d) Results after 1 year.

Today the acquisition of new techniques common to cosmetic surgery and female breast surgery makes it possible to solve the most severe cases of gynaecomastia with less invasive operations limiting scarring to the nipple-areola junction.

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Conclusions 

In this article a simple morphological classification and an algorithm (Table 3) of the main surgical techniques can help to choose between skin sparing or cutaneous resection techniques³¹ (especially in the most severe grade of gynaecomastia).

Table 3. Algorithm for gynaecomastia treatment

The simple classification into four grades proposed in this paper has the advantage of being based on objective data: the relationship between the nipple-areola complex and the inframammary fold.

This relationship provides clinical data which can be used to establish whether the redundant skin needs to be excised or whether adequate skin retraction can be obtained by means of lipectomy alone.

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