Gynecomastia: Ultrasound-Confirmed Classification Pertainent to Surgical Correction


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Gynecomastia is the most common form of breast alteration in men, due to the proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drug suspension), surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture.

Materials and Methods A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles.

Results The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients’ and surgeons’ satisfaction were performed, showing excellent feedbacks regarding the results accomplished.

Conclusions The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients satisfaction.

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


Gynecomastia represents the most common pathology of male breast and is characterized by a symmetrical or asymmetrical volumetric enlargement of the breast, supported by a benign proliferation of glandular and stromal tissue.

The term gynecomastia was introduced by Galen in the second century A.D. as an unnatural increase in breast fat in males.

The first description of the surgical treatment of gynecomastia was attributed to Paulus Aegineta (625–690 A.D.).

Historically, surgical treatment has been subcutaneous mastectomy with or without direct skin incision, which was very successful at removing the subareolar fibrous disk but often left unacceptable scars.
Common incision patterns include circumareolar, partly circumareolar with transverse extension (Webster technique), and inframammary [1–4]; in certain cases, an adenectomy is performed with transposition of the nipple-areola complex, free nipple grafting, or with a transverse elliptical incision pattern [5, 6]. In the 1980s, Courtiss advocated extensive removal of the fat with suction lipectomy and used a knife or scissors to remove the subareolar breast bud [7].

Multiple classification systems have been published throughout the years to classify different forms of gynecomastia, depending on the type of alteration, position of the nipple-areola complex (NAC), the position of the inframammary fold (IMF), skin excess/ptosis, and breast volume.
Tanner [8, 9] first proposed an anatomical/clinical classification, mainly focused on the stages of breast development. Simon [10], in 1973, proposed one of the most renowned classification systems, considering both the breast volume and the skin redundancy. Rohrich [11], in 2003, proposed an excellent classification based on breast volume (expressed in grams) and breast ptosis, which also included correlated surgical treatments. Cordova [12], in 2008, introduced another classification system, which included the breast volume and the position of the NAC compared to the IMF.

*Histologically, gynecomastia is characterized by a benign proliferation of subareolar ducts and periductal stroma, with the elongation and branching of lactiferous ducts; ducts epithelium becomes pluristratified. Connective tissue becomes hyperplastic, thicker, and hypercellular [7, 13].

The etiology of gynecomastia contains a wide range of spectrum including physiologic, endocrinologic, metabolic, neoplastic, and drug-induced causes
. Although the prevalence ranges from 90% in neonates to 50–70% in adolescents and elderly men, people requiring a surgical correction for cosmetic purposes are mainly adolescents and adults [14–17].

In recent years, gynecomastia has become increasingly common and clinically important.

There are many studies in the literature related to the etiology, the prevalence, and the physiopathology of gynecomastia; nevertheless, major gaps in knowledge regarding its modern epidemiology exist.

In our clinical practice, we noticed an increasing number of requests for gynecomastia correction, although no real increase in cases has been demonstrated. Nonetheless, over recent decades, there have been substantial increases in the use of anabolic steroids and food contamination with xenoestrogens or estrogen-like substances that, at least theoretically, can stimulate glandular proliferation of the male breast [18, 19].

A myriad of medical treatment options (testosterone, dihydrotestosterone, danazol, clomiphene citrate, testolactone, and tamoxifen) are available; in other cases, it is important to stop taking drugs, but if gynecomastia persists, surgery is the best option for cosmetic improvement [20, 21].

Ultrasound-Confirmed Classification System

The attention of the authors is focused on performing an accurate preoperative examination, supported by breast ultrasound.

Although gynecomastia is a clinical diagnosis, ultrasound is a documented modality of choice in the evaluation of male breast enlargement; for this reason, we always require a bilateral breast sonography to all the patients before undergoing surgery.
Sonographic examinations are performed with a linear transducer in a standard supine position with an arm above the head. This examination is useful not only to identify possible abnormal findings (i.e., suspect nodules) but to confirm the clinical findings (fat or glandular tissue prevalence) and classify the patient with our new classification system.

Classification is based on the tissue quality of gynecomastia related to skin excess and ptosis of the breast.

It is directly related to surgical indications (Fig. 1)

Surgical Technique Gynecomastia

• Type 1A
• Type 1B
• Type 2A
• Type 2B
• Type 3A
• Type 3B

*The main limitation of our study is that our classification system cannot be used on the totality of the gynecomastia cases. Indeed, this new classification system does not fit severe forms of gynecomastia, with severe ptosis and skin excess (i.e., after massive weight loss, post-bariatric surgery). In these situations, liposuction alone is not enough, and skin reducing techniques need to be employed (such as vertical, L or T incision, or lateral/axillary scars). However, we consider the classification system as a great tool since it is an excellent guide to planning the best surgical procedure for most of our patients.


The simple ultrasound-confirmed classification we proposed is useful to guide the treatment, avoiding insufficient or invasive surgical approach and undesirable scars, and synthetically includes all types of clinical presentation.

Moreover, the presence of cutaneous ptosis, the amount of excess skin, and a high inframammary fold as a tuberous breast is decisive in guiding the choice between surgical treatment methods and in using a special surgical approach (mastopexy, round-block suture, and disruption of inframammary fold).

Especially in the tuberous breast, the key is the transection of the stenotic fibrous ring of the footprint, the NAC centralization, and the release of the inframammary fold.

Finally, following the patients through a long follow-up, we can manage patients over time and treat the possible sequelae to reach high patients satisfaction.


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Fig. 1 New ultrasound confirmed classification system for gynecomastia and suggested the surgical algorithm, based on the most represented component in gynecomastia (fat tissue, glandular tissue, or both) and the presence of ptosis
Screenshot (4476).png


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Fig. 2 (Left) Preoperative oblique view of an 18-year-old patient presenting with a bilateral tuberous true gynecomastia (Type 1B, according to our classification system). (Right) Postoperative view 6 months after glandular resection through periareolar access, areolar diameter reduction, and correction of the ptosis with skin excision
Screenshot (4478).png


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Fig. 3 (Left) Preoperative frontal view of a 21-year-old patient presenting with mixed bilateral gynecomastia (Type 3A, according to our classification system). (Right) Postoperative view 6 months after inferior periareolar glandular resection and liposuction
Screenshot (4477).png


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Table 2 Number of complications after surgery for each new classification category; most of the complications (14) were observed in patients who underwent glandular resection. We report in the table also recurrence case (both monolateral and bilateral) and data of reversible nipple hypoesthesia
Screenshot (4480).png

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