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Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 41e49

Algorithm for clinical evaluation and surgical


treatment of gynaecomastia*
Adriana Cordova*, Francesco Moschella

Dipartimento di Discipline Chirurgiche ed Oncologiche, Cattedra di Chirurgia Plastica e Ricostruttiva,


Università degli Studi di Palermo, Palermo, Italy

Received 18 August 2006; accepted 25 September 2007

KEYWORDS Summary Background: Gynaecomastia can be classified on the basis of the main character-
Gynecomastia; ising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifica-
Classification; tions of gynaecomastia currently made often use subjective parameters and qualifying
Cutaneous ptosis; adjectives. In this paper the authors propose a scheme for morphological classification of gy-
Skin-sparing naecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis
techniques 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
1 cm 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 peri-
areolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is
more than 1 cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes nec-
essary, 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.
ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and
Aesthetic Surgeons.

*
Presented at the 53rd Congresso della Società Italiana di Chirurgia Plastica Ricostruttiva ed Estetica, Pisa, Italy, 16e18 September 2004.
* Corresponding author. Address: C. da Bagliuso, 90049, Terrasini, Palermo, Italy. Tel./fax: þ39 091 6553705.
E-mail address: adriana.cordova@excite.com (A. Cordova).

1748-6815/$ - see front matter ª 2007 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
doi:10.1016/j.bjps.2007.09.033
42 A. Cordova, F. Moschella

Gynaecomastia is a deformity of the male thorax with the endoscopic approach16 which have already proved their
multifactorial aetiology. Independently of the pathogene- worth in cosmetic surgery and in female breast surgery.
sis, in most cases it requires surgical treatment. Spontane- These techniques, which have gradually replaced tradi-
ous regression and an effective nonsurgical treatment are tional surgical dermo-lipectomy, have made it possible to
only theoretically possible in types of gynaecomastia with reduce the invasiveness of the operation, improving the
recent proliferation that have not produced any ptosis of final result and reducing scars.
the mammary skin. On the basis of a chart review of their cases, the authors
The histopathological aspect of gynaecomastia is de- propose a morphological classification of gynaecomastia
termined not only by the pathogenesis but also by its prevalently based on evaluation of the relationship be-
persistence. In types which have persisted for over a year, tween the nipple-areola complex and the inframammary
the loose peri-ductal tissue and the surrounding stroma fold, which makes it possible to establish an algorithm for
undergo an irreversible process of fibrosis and hyalinisation, the choice of the most suitable technique.
which explains why once glandular hypertrophy has set in it
cannot regress.1
Gynaecomastia shows a gradation of clinical types going Morphological classification of gynaecomastia
from simple areolar protrusion to breasts with a female
appearance (female pendulous breast). On the basis of a chart review of 121 patients affected by
At all events, any feminising deformity of the male gynaecomastia and operated on over a period of 5 years,
thorax requires attention, especially in adolescent sub- a classification of gynaecomastia was made that takes into
jects, in whom it may alter self-perception, especially in account the different structural components of the breast
the sexual sphere.2 MPH (skin, nipple-areola complex, inframammary fold, glandu-
Gynaecomastia is an epiphenomenon that can be linked lar tissue, adipose tissue) and the relations between these
to more or less well-known pathogenetic factors and can be various components and, in particular, the relationship
classified on the basis of the main characterising factors, between the inframammary fold and the nipple-areola
i.e. pathogenesis, histopathology, morphology. complex, which is the watershed between mild types and
In this article there will be no discussion of pathogenetic serious types.
classifications3e5 and histopathologic ones,6,7 as they are All types of gynaecomastia can be classified into four
simply lists referring, respectively, to pathogenetic factors grades of increasing severity from I to IV (Fig. 1), as follows:
and histopathologic aspects, susceptible to being modified
as medical knowledge progresses. Grade I, increase in diameter and protrusion limited to
Instead, attention will be focused on a scheme for the areolar region;
morphological classification which can serve as a guide for Grade II, hypertrophy of all the structural components of
choosing the surgical technique, once the diagnosis of the breast. The nipple-areola complex is above the in-
gynaecomastia as a benign pathology has been confirmed framammary fold;
by preoperative examinations. Grade III, hypertrophy of all the structural components,
The clinical aspects characterising gynaecomastia are: nipple-areola complex at the same height as or about
1 cm below the inframammary fold; in this group we
 an increase in the areolar diameter; can also include male tuberous breast;
 breast swelling, altering the profile of the male thorax; Grade IV, hypertrophy of all the structural components,
 anomalous presence of an inframammary fold; nipple-areola complex more than 1 cm below the infra-
 cutaneous ptosis with the nipple-areola complex sliding mammary fold.
down to the height of the fold or even below it;
 asymmetry. This classification, which is very simple and stringent,
makes it possible in the preoperative phase to divide
Association of these deforming aspects makes it possible patients affected by gynaecomastia into four groups,
to identify various types of gynaecomastia marked by corresponding to different surgical choices.
differing grades of severity.
The current morphological classifications of gynaeco-
mastia fail to focus anatomically on the entity of the defect Cases review
and generally make use of subjective parameters5,8e12
and qualifying adjectives like ‘minimal’, ‘moderate’ and Before undergoing surgery, patients underwent a different
‘severe’.10 clinical workup depending on their age.
Quantitative evaluation of the excess tissue5 may also be The workup protocol used so far includes for all patients:
useful in retrospective analysis, but cannot be applied to thyroid function tests (fT3 (free Triiodothyronine), fT4
the preoperative phase, since it is not easy to predict the (free Thyroxine),TSH (Thyroid Stimulating Hormone)), ex-
weight ratio between adipose tissue and glandular tissue tradiol, FSH (Follicle Stimulating Hormone), LH (Luteinizing
which, as is well known, have different specific weights Hormone), total and free testosterone, prolactine, beta-
(Table 1).13 hCG (human Chorionic Gonadotropin), liver function tests,
Nowadays surgical treatment of gynaecomastia can make kidney function tests, mammary bilateral ultrasonography.
use of different techniques like suction-assisted lipoplasty14 In patients aged 12 to 18 right hand and wrist X-rays are re-
or ultrasound-assisted lipoplasty,5 round-block suture,15 and quested in order to evaluate the bone age. Mammography,
Algorithm for treatment of gynaecomastia 43

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 e nipple prominence;


Stage 2 e mammillary button stage; the breast and the areola- nipple are slightly swollen and
the diameter of the areola increases;
Stage 3 e further swelling of the breast and areola without separation of their edges;
Stage 4 e areola and nipple become protrusive and form a secondary protrusion above the breast;
Stage 5 e there is protrusion of the nipple only after retraction of the areola from the breast surface.

Simon 1973 Grade 1 e small visible breast enlargement; no skin redundancy;


Grade 2A e moderate breast enlargement without skin redundancy;
Grade 2B e moderate breast enlargement with skin redundancy;
Grade 3 e marked breast enlargement with marked skin redundancy (pendulous female breast)

Deutinger and Grade 1 e thoracic wall poor in flesh; mammary tissue localised behind and around the nipple;
Freilinger 1986 no skin excess;
Grade 2 e adipose thoracic wall; widespread alterations; breasts similar to feminine
ones during puberty;
Grade 3 e widespread alterations; excess adipose tissue, skin redundancy, inframammary
fold and ptosis.

Cohen 1987 Group 1 e glandular gynaecomastia;


Group 2 e glandular gynaecomastia with ptosis;
Group 3 e adipose gynaecomastia;
Group 4 e adipose gynaecomastia with slight glandular component.

Rohrich 2003 Grade I e minimal hypertrophy (< 250 g of breast tissue) without ptosis; IA:primarily glandular;
IB:primarily fibrous;
Grade II e moderate hypertrophy (200e500 g of breast tissue) without ptosis; IIA: primarily
glandular; IIB: primarily fibrous;
Grade III e severe hypertrophy (>500 g of breast tissue) with grade I ptosis glandular or fibrous;
Grade IV e severe hypertrophy with grade II or III ptosis glandular or fibrous

turcic sella X-rays, testicular ultrasonography and chromo- In our review of 123 patients, of which 121 underwent
somal mapping are performed only if a specific indication is a surgical operation, we were able to establish an aetiopa-
present depending on the patient history, the physical thogenic relationship with the gynaecomastia onset in only
exam and hormonal tests. 21 cases.

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
1 cm below the I.F.; Grade IV, areola-nipple complex more than 1 cm below the I.F.
44 A. Cordova, F. Moschella

In 21 cases, of which 13 were considered to be grade II, four is prevalent), the glandular component is prevalent and
were grade III and four were grade IV, the persistance of a its bleeding makes haematoma more likely during the
pre-puberal hormonal setting was found, with increased postoperative period. In fact, in all cases complicated
extrogens levels and reduced total and free testosterone by haematomas, the glandular component outnum-
levels. bered the adipose component.
In one case of grade II gynaecomastia, a diagnosis of  In conclusion, grade II gynaecomastias account for the
Klinefelter’s syndrome was made. majority of our cases (96 cases of grade II gynaecomas-
In one case, clinically considered as a group II gynaeco- tia versus 15 cases that include grade III and IV) thus it
mastia, the onset of the disease was related to the recrea- is also predictable that the greater incidence of compli-
tional use of marijuana. cations happens in the numerically bigger group.
In one case, grade II, altered levels of extrogens lead to
the diagnosis of a Leydig cells testicular cancer. This In all cases included in grade IV (female pendulous
patient was not operated on for his gynaecomastia. breast) and in seven cases included in grade III, it was
In one grade I case associated with increased levels of necessary to re-operate to correct the scars. In these cases,
prolactine, a pituitary microadenoma was diagnosed. This re-operating has not to be considered as a complication but
patient was also not operated on and both these patients part of the surgical programme presented to patients in the
were removed from the study. preoperative phase. Second operations were always per-
In 102 cases no hormonal dysfunction was found, nor was formed as day surgery and under local anaesthesia, after at
there found an aetiopathogenic, pathological, pharmacolog- least 3 months. In two cases of grade IV gynaecomastia two
ical or comportmental correlation. Thus, in this cases review operations under local anaesthesia to correct periareolar
83% of gynaecomastia cases are considered to be idiopathic. scars were needed.
The main morphological aspects relating to the 121 cases A persistent alteration of the nipple-areola complex was
we operated on are summarised in Table 2. Monolateral signalled in two cases, one classified as grade III that
types account for 20% of the cases studied (25 cases) and underwent a wide skin resection with the removal of an
are all classifiable as grade I and II. Bilateral types account abundant glandular mass, and one case classified as grade
for about 80% of the cases studied (96 cases), 64 cases of IV. In both cases the decrease in sensibility was unilateral
which (67%) can be classified as grade II. Bilateral cases and involved the nipple-areola left complex.
were considered as symmetric when, though with some In general the surgical procedure for gynaecomastias is
volumetric difference, both breasts can be included in the followed by an elevated patient satisfaction rate which is
same grade and treated with the same surgical approach. greater in patients with initially bigger defects and in
There were such serious asymmetrical differences be- patients with inconspicuous scarring.
tween the two breasts that we were led to consider Three patients considered among the most severe cases
different surgical procedures for each breast (i.e. cutane- (grade IV) stated that they felt more comfortable even with
ous resections on one side and skin-sparing on the other). their chest exposed; three patients instead felt uncomfort-
The most frequent complication was haematoma, which able with their chest exposed. However, all these patients
occurred in six cases (5%), all falling into grade II gynaeco- felt more comfortable with their clothes on and wearing
mastia. No haematomas were seen in the six cases with the tailored clothing.
most severe form of gynaecomastia (grade IV). The in- It is indeed true that patients affected by more severe
cidence of haematomas was indeed greater in grade II, for gynaecomastias, which is usually associated with a certain
the following reasons: level of obesity and a feminine body type (round abdomen
and wide hips, slim upper limbs), rarely happen to be
 The surgical treatment of grade II gynaecomastia re- satisfied with their figure and require psychological support.
quires access through minimal skin incisions, therefore
the haemostasis is realised partially by postoperative Surgical treatment
compression. In grade III and IV the amplitude of the
skin incisions allows a careful direct haemostasis which The objectives of surgical treatment are:
reduces the incidence of postoperative haematomas.
 In grade II gynaecomastia (more frequently than in  flattening of the thoracic region;
grade IV gynaecomastia in which the adipose component  elimination of the inframammary fold;

Table 2 Patients’ distribution according to our classification and number of complications and re-operations
Gynaecomastia grade Mono-lateral Bi-lateral Haematoma Re-operation Evident scars
Grade I 5 11 0 0 0
Grade II 20 64 6 1 0
Grade III 0 12 0 4 0
Grade IV 0 6 0 8 6
Serious asymmetries
Grade II and III 0 2 0 2 0
Grade III and IV 0 1 0 0 1
Algorithm for treatment of gynaecomastia 45

 correct positioning of the nipple-areola complex; adipose, and on the fold, making sure that the skin loses
 removal of redundant skin; the memory thanks to thorough detachment.
 symmetrisation between the two hemithoraxes and the Usually it is not necessary to act on the areolar
two areolas; diameter, even when it has increased, since retraction of
 containment of scars. the skin involves a corresponding retraction of the areola,
taking it back to an acceptable size (the effect is that of
On the basis of our experience the presence or absence a drawing on a balloon: when the balloon deflates, the
of cutaneous ptosis is decisive in the choice of the specific drawing decreases in size). In our experience, even in the
form of surgical treatment. The grade of ptosis is evaluated case of voluminous breasts with a female appearance, if
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 ultraso-
nography, 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 path-
ogenetic 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 grada-
tion.17,18 Hence it would be more correct to refer to gynae-
comastia with a prevalent glandular component or
a prevalent adipose component than to speak of glandular
gynaecomastia and pseudogynaecomastia. The term pseu-
dogynaecomastia 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).

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. Figure 2 Grade I gynaecomastia. (a) Protrusion and increase
In the preoperative phase it is possible to ascertain the in the diameter of the areola; (b) intraoperative view; grade I
prevalence of glandular or adipose tissue. However, surgery is the only form of pure glandular gynaecomastia; (c) final re-
must certainly act on both components, glandular and sult after 1 year.
46 A. Cordova, F. Moschella

the nipple-areola complex is above the fold, skin-sparing postoperative complications, but, in most cases of grade
surgical techniques can be used successfully. II gynaecomastia, liposuction by itself it is not sufficient to
In skin-sparing techniques, there is a first phase of achieve satisfactory flattening, due to the constant pres-
vacuum or ultrasound-assisted lipoplasty, followed by ence of fibro-glandular residues that persist in the retro-
minimally invasive adenectomy, which can be carried out areola which need to be removed by means of surgical
by means of semicircular periareolar, intraareolar, pull- adenectomy (Fig. 3).
through or endoscopic incision.17
At all events, whatever technique is chosen for adenec-
tomy, the residual scars are minimal. Vacuum or ultra- Grade III gynaecomastia
sound-assisted lipoplasty is a fundamental phase in surgery
for gynaecomastia in achieving homogeneous flattening of The treatment of grade III gynaecomastia is more challeng-
the thoracic wall and the reduction of scarring and ing. It is important to identify these types of gynaecomastia

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.
Algorithm for treatment of gynaecomastia 47

in the preoperative phase and distinguish them from more necessary), semicircular periareolar adenectomy and peri-
severe types of grade II gynaecomastia. areolar and areolar skin resections.
In our experience of grade III gynaecomastia using skin-
sparing techniques is not sufficient, and in order to achieve Grade IV gynaecomastia
good flattening of the thorax it is necessary to eliminate the
excess skin by means of periareolar removal of epidermis. Grade IV includes the most severe types of gynaecomastia,
We had the best results using this method. which are fortunately rare. These are characterised by
The operation begins with liposuction. Then an adenec- marked cutaneous ptosis with the nipple-areola complex
tomy with semicircular periareolar access follows, and more than 1 cm below the fold. Often patients belonging to
lastly the area to be disepithelialised is marked. In this this group are formerly obese or at least overweight.
phase, if necessary, the areolar diameter can be reduced. Surgical treatment of grade IV gynaecomastia is often
The periareolar area to be disepithelialised can be marked unsatisfactory because of the inevitable residual scars. In
in various ways, also depending on the operator’s own these cases, complete flattening of the thorax with elim-
experience. At all events, it must make it possible to ination of the fold, correct positioning of the nipple-areola
position the nipple-areola complex correctly and symmet- complex, with its vascularisation being safeguarded, and
rically with respect to the contralateral side and to reduce resection of the redundant skin, require reduction masto-
the areolar diameter according to the reference canons for plasty to be followed by further surgery for scar correction.
the male thorax.20e25 We believe that in grade IV gynaecomastia, though it is
Once the removal of the epidermis has been carried out, characteristic of overweight patients, the fulcrum of
round-block suturing is performed. Of course, with periar- treatment is not liposuction. As in the case of surgery for
eolar removal of epidermis there is a circumferential very obese and formerly obese patients, the problem to
periareolar scar, sometimes wrinkled, but this can improve solve is not localised accumulation of adipose tissue but the
spontaneously or with subsequent surgery (Fig. 4).26 removal of major skin redundancy and residual scarring.
The rarer cases of male tuberous breast can be included The techniques described for the treatment of grade IV
in grade III and treated in the same way: liposuction (if gynaecomastia are numerous, and include free transplantation

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 disepithe-
lialisation. (c, d) Results after 6 months; flattening of the thorax is good but another operation is required to improve periareolar
scars.
48 A. Cordova, F. Moschella

Figure 5 Grade IV gynaecomastia. (a, b) Frontal view: the nipple-areola complex is about 3 cm 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.

of the nipple-areola complex,21 transversal or vertical


scars.27e29 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 resid-
Table 3 Algorithm for gynaecomastia treatment
ual adipose tissue (Fig. 5), in our experience central pedicle
reduction mastoplasty techniques30 are the most suitable for GYNAECOMASTIA
achieving good flattening of the breast. In our opinion, the
use of a central pedicle makes it easier to gather the redun-
dant skin around the areola.
Today the acquisition of new techniques common to
cosmetic surgery and female breast surgery makes it Grade I Grade II Grade III Grade IV
possible to solve the most severe cases of gynaecomastia No a
N.A.C. above N.A.C. same N.A.C. under
with less invasive operations limiting scarring to the nipple- submammary
the fold level as fold the fold
fold
areola junction.

S.SP.A.b S.SP.A. P.S.R.A.c REDUCTION


Conclusions + +
LIPOPLASTY LIPOPLASTY MASTOPLASTY
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 SKIN SPARING SKIN RESECTION
techniques31 (especially in the most severe grade of
gynaecomastia). a
N.A.C., nipple-areola complex.
b
The simple classification into four grades proposed in S.SP.A., skin-sparing adenectomy.
c
P.S.R.A., periareolar reduction adenectomy.
this paper has the advantage of being based on objective
Algorithm for treatment of gynaecomastia 49

data: the relationship between the nipple-areola complex 16. Ohyama T, Takada A, Fujikawa M, et al. Endoscope assisted
and the inframammary fold. transaxillary removal of glandular tissue in gynecomastia.
This relationship provides clinical data which can be used Ann Plast Surg 1998;40:62.
to establish whether the redundant skin needs to be excised 17. Hammond D, Arnold JA, Simon AM, et al. Combined use of ul-
trasonic liposuction with the pull-through technique for the
or whether adequate skin retraction can be obtained by
treatment of gynecomastia. Plast Reconstr Surg 2003;112:
means of lipectomy alone. 891. Discussion by Rorich R., Ha R.Y.
18. Hemsell D, Edman C, Marks J, et al. Massive extraglandular aro-
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