Algorithm for clinical evaluation and surgical treatment of gynaecomastia

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.

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. (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. (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.

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.