madman
Super Moderator
Abstract
Background Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on an individual basis to all types of patients.
Materials and Method A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision.
Results No recurrence of the deformity was observed as well as major complications such as necrosis, and a high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days.
Conclusion Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed.
Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Introduction
Gynecomastia is a benign enlargement of the mammary region, commonly diffused among men, showing peculiar hallmarks according to the body shapes of the patients affected by the disorder [1]. Considering the wide range of population [2, 3], a sensitive discrepancy among expectations is observed, posing a great challenge in aesthetic correction. Its incidence ranges widely in the world population, ranging from 32 to 65 percent [4]. The etiology of gynecomastia is heterogeneous. Although several secondary forms of gynecomastia have been identified, more than 80% of the disorders are idiopathic and therefore related to a hypersensitivity of the glandular estrogen receptors present in the breast parenchyma [5, 6]. Gynecomastia is considered a psychological threat to normal self-esteem and sexual identity and often patients feel ashamed of their bodies during normal social activities [7, 8]. Focusing on breast hypertrophy and the presence of redundant skin, several classifications have been proposed in the literature to address gynecomastia and many surgical techniques have been described for its correction [9, 10]. However, gynecomastia affects patients with different body shapes: muscular subjects, average physique, and overweight patients. In each of these subgroups, peculiar hallmarks, reflecting patients’ expectations, can be observed. Since the physical status is strictly related to the clinical features of the disorder, a reconstructive comprehensive algorithm, including the rarest forms of gynecomastia, aids in the identification of all hallmarks of the clinical status of the deformity and to establish the most appropriate treatment strategy. In this paper, the authors propose a classification system that has enabled the formulation of a surgical plan tailored on an individual basis to all types of patients for correction of gynecomastia.
Classification Schema
*Following parameters have been included to investigate gynecomastia hallmarks: overall physical status (including BMI and muscular trophism), hypertrophy of the mammary region, gland and skin cover consistency and nipple-areola disorder. A four-tier classification system has been used to facilitate the qualification of the severity of the deformity.
GROUP I
It includes subjects with an athletic physique, defined muscular body mass, BMI \ 25, and body fat \ 9%. Usually, the deformity consists only of a very circumscribed glandular bulk behind the areola covered by a very elastic skin. Among group I, two subgroups are identified: Ia and Ib, showing, respectively, small and large areola
GROUP II
It includes patients with average physique and BMI from 18 to 25. This group presents the most heterogeneous spectrum of clinical degrees but commonly showing a well-defined inframammary fold and the absence of breast ptosis. Two subgroups are identified: IIa and IIb, showing, respectively, firm gland with elastic skin cover and mobile gland with inelastic skin cover. Even if these subjects are not related to high BMI, fat deposits may also be present especially in sub- and supra-axillary zones.
GROUP III
It includes overweight patients (BMI[25); being related to obesity, in this group fat component, is prevalent over the gland. The well-defined inframammary fold, ptosis, and a women-like areola are distinctive hallmarks in this group. Three subgroups are identified:
• Group IIIa: NAC above the inframammary fold
• Group IIIb: NAC below the inframammary fold, moderate breast hypertrophy
• Group IIIc: NAC below the inframammary fold, severe breast hypertrophy
GROUP IV
Includes gynecomastia with tuberous breast hallmarks: stenotic breast constricted by a fibrous ring at the mammary base, a high inframammary fold, and a large areola [12–16].
*Surgical Technique
-GROUP I
-GROUP II
-GROUP III
-GROUP IV
Conclusion
Because dissatisfaction with the result represents one of the most common reasons for claims, management of patients’ expectation is the key element to achieve a high level of approval as the leading measure of treatment success [64, 65]. Nomenclature classification and a reconstructive algorithm is important in the preoperative identification of every single element to assess the entity of gynecomastia, to assist in achieving more consistent results.
Background Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on an individual basis to all types of patients.
Materials and Method A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision.
Results No recurrence of the deformity was observed as well as major complications such as necrosis, and a high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days.
Conclusion Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed.
Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Introduction
Gynecomastia is a benign enlargement of the mammary region, commonly diffused among men, showing peculiar hallmarks according to the body shapes of the patients affected by the disorder [1]. Considering the wide range of population [2, 3], a sensitive discrepancy among expectations is observed, posing a great challenge in aesthetic correction. Its incidence ranges widely in the world population, ranging from 32 to 65 percent [4]. The etiology of gynecomastia is heterogeneous. Although several secondary forms of gynecomastia have been identified, more than 80% of the disorders are idiopathic and therefore related to a hypersensitivity of the glandular estrogen receptors present in the breast parenchyma [5, 6]. Gynecomastia is considered a psychological threat to normal self-esteem and sexual identity and often patients feel ashamed of their bodies during normal social activities [7, 8]. Focusing on breast hypertrophy and the presence of redundant skin, several classifications have been proposed in the literature to address gynecomastia and many surgical techniques have been described for its correction [9, 10]. However, gynecomastia affects patients with different body shapes: muscular subjects, average physique, and overweight patients. In each of these subgroups, peculiar hallmarks, reflecting patients’ expectations, can be observed. Since the physical status is strictly related to the clinical features of the disorder, a reconstructive comprehensive algorithm, including the rarest forms of gynecomastia, aids in the identification of all hallmarks of the clinical status of the deformity and to establish the most appropriate treatment strategy. In this paper, the authors propose a classification system that has enabled the formulation of a surgical plan tailored on an individual basis to all types of patients for correction of gynecomastia.
Classification Schema
*Following parameters have been included to investigate gynecomastia hallmarks: overall physical status (including BMI and muscular trophism), hypertrophy of the mammary region, gland and skin cover consistency and nipple-areola disorder. A four-tier classification system has been used to facilitate the qualification of the severity of the deformity.
GROUP I
It includes subjects with an athletic physique, defined muscular body mass, BMI \ 25, and body fat \ 9%. Usually, the deformity consists only of a very circumscribed glandular bulk behind the areola covered by a very elastic skin. Among group I, two subgroups are identified: Ia and Ib, showing, respectively, small and large areola
GROUP II
It includes patients with average physique and BMI from 18 to 25. This group presents the most heterogeneous spectrum of clinical degrees but commonly showing a well-defined inframammary fold and the absence of breast ptosis. Two subgroups are identified: IIa and IIb, showing, respectively, firm gland with elastic skin cover and mobile gland with inelastic skin cover. Even if these subjects are not related to high BMI, fat deposits may also be present especially in sub- and supra-axillary zones.
GROUP III
It includes overweight patients (BMI[25); being related to obesity, in this group fat component, is prevalent over the gland. The well-defined inframammary fold, ptosis, and a women-like areola are distinctive hallmarks in this group. Three subgroups are identified:
• Group IIIa: NAC above the inframammary fold
• Group IIIb: NAC below the inframammary fold, moderate breast hypertrophy
• Group IIIc: NAC below the inframammary fold, severe breast hypertrophy
GROUP IV
Includes gynecomastia with tuberous breast hallmarks: stenotic breast constricted by a fibrous ring at the mammary base, a high inframammary fold, and a large areola [12–16].
*Surgical Technique
-GROUP I
-GROUP II
-GROUP III
-GROUP IV
Conclusion
Because dissatisfaction with the result represents one of the most common reasons for claims, management of patients’ expectation is the key element to achieve a high level of approval as the leading measure of treatment success [64, 65]. Nomenclature classification and a reconstructive algorithm is important in the preoperative identification of every single element to assess the entity of gynecomastia, to assist in achieving more consistent results.
