Gynecomastia classification: Difference between revisions

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{{Gynecomastia}}
{{Gynecomastia}}


{{CMG}}
{{CMG}}; {{AE}} {{HS}}, {{DAMI}}
==Overview==
Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology.


===Classification===
==Classification==
The spectrum of gynecomastia severity has been categorized into a grading system:<ref name="Minimal">{{cite journal|last1=Wollina | first1=U|last2=Goldman|first2=A| title=Minimally invasive esthetic procedures of the male breast|journal=Journal of cosmetic dermatology|date=June 2011| volume=10| issue=2| pages=150–155|pmid=21649820|doi=10.1111/j.1473-2165.2011.00548.x}}</ref><ref name="pmid4687568">{{cite journal| author=Simon BE, Hoffman S, Kahn S| title=Classification and surgical correction of gynecomastia. | journal=Plast Reconstr Surg | year= 1973 | volume= 51 | issue= 1 | pages= 48-52 | pmid=4687568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4687568 }} </ref>
Different gynecomastia classification systems are:<ref name="pmid28234829">{{cite journal| author=Waltho D, Hatchell A, Thoma A| title=Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System. | journal=Plast Reconstr Surg | year= 2017 | volume= 139 | issue= 3 | pages= 638e-648e | pmid=28234829 | doi=10.1097/PRS.0000000000003059 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28234829  }} </ref><ref name="pmid23629140">{{cite journal| author=Monarca C, Rizzo MI| title=Gynecomastia: tips and tricks-classification and surgical approach. | journal=Plast Reconstr Surg | year= 2013 | volume= 131 | issue= 5 | pages= 863e-5e | pmid=23629140 | doi=10.1097/PRS.0b013e318287a18f | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23629140  }} </ref><ref name="pmid12560721">{{cite journal| author=Rohrich RJ, Ha RY, Kenkel JM, Adams WP| title=Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. | journal=Plast Reconstr Surg | year= 2003 | volume= 111 | issue= 2 | pages= 909-23; discussion 924-5 | pmid=12560721 | doi=10.1097/01.PRS.0000042146.40379.25 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12560721  }} </ref><ref name="Minimal">{{cite journal|last1=Wollina | first1=U|last2=Goldman|first2=A| title=Minimally invasive esthetic procedures of the male breast|journal=Journal of cosmetic dermatology|date=June 2011| volume=10| issue=2| pages=150–155|pmid=21649820|doi=10.1111/j.1473-2165.2011.00548.x}}</ref><ref name="pmid4687568">{{cite journal |vauthors=Simon BE, Hoffman S, Kahn S |title=Classification and surgical correction of gynecomastia |journal=Plast. Reconstr. Surg. |volume=51 |issue=1 |pages=48–52 |year=1973 |pmid=4687568 |doi= |url=}}</ref><ref name="pmid17362482">{{cite journal| author=Gikas P, Mokbel K| title=Management of gynaecomastia: an update. | journal=Int J Clin Pract | year= 2007 | volume= 61 | issue= 7 | pages= 1209-15 | pmid=17362482 | doi=10.1111/j.1742-1241.2006.01095.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17362482 }} </ref>  
* Grade I: Minor enlargement, no skin excess
=== Surgical classification of gynecomastia ===
* Grade II: Moderate enlargement, no skin excess
{| class="wikitable"
* Grade III: Moderate enlargement, skin excess
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF| Classification system}}
* Grade IV: Marked enlargement, skin excess
! colspan="2" style="background: #4479BA;" |{{fontcolor|#FFF|Criteria}}
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF|Description}}
|-
! style="background: #4479BA;" |{{fontcolor|#FFF|Physical}}
! style="background: #4479BA;" |{{fontcolor|#FFF|Tissue type}}
|-
|Nydick's
|
|Physical
|
*Gland limited to the [[Areolar|retro areolar region]] and 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's
|
|Physical
|
*Stage 1: [[Nipple]] prominence
*Stage 2: [[Mammillary body|Mammillary]] button stage. The [[breast]] and the nipple-areola complex are slightly swollen and 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's
|
|Physical
|
* Grade 1: Small visible [[breast]] enlargement and 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
|-
|Deutinger's and Freilinger's
|
|Physical
|
*Grade 1: [[Thoracic wall]] poor in the flesh with [[mammary tissue]] localized behind and around the [[nipple]] without skin excess
*Grade 2: [[Adipose]] thoracic wall with widespread alterations and [[breast]]s similar to feminine ones during puberty
*Grade 3: Widespread alterations with excess [[adipose]] tissue, skin redundancy and inframammary fold and [[ptosis]]
|-
|Cohen's
|
|Physical
|
*Group 1: [[Glandular]] gynecomastia
*Group 2: [[Glandular]] gynecomastia with [[ptosis]]
*Group 3: [[Adipose]] gynecomastia
 
*Group:4 [[Adipose]] gynecomastia with a slight [[glandular]] component
|-
|Rohrich's
|
|Physical/Tissue type
|
* Grade 1: Minimal [[hypertrophy]], (less than 250g of tissue) without [[ptosis]]
** 1a: Primarily [[glandular]]
** 1b: Primarily [[fibrous]]
* Grade 2: moderate [[hypertrophy]] (250-500g of breast tissue) without [[ptosis]]
** 2a: Primarily [[glandular]]
** 2b: Primarily [[fibrous]]
* Grade 3: Severe [[hypertrophy]] (>500g of breast tissue with grade 1 ptosis [[glandular]] or [[fibrous]]
* Grade 4: Severe [[hypertrophy]] with grade 2 or 3 ptosis [[glandular]] or [[fibrous]]
|-
|Gusenoff's
|
|Physical
|
* Grade 1: Minimal excess skin and fat with minimal alteration of nipple-areola complex (NAC) and inframammary fold (IMF)
 
** 1a: No lateral skin roll
** 1b: Lateral skin roll
 
* Grade 2:  Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and minimal upper abdominal laxity
 
* Grade 3:  Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and significant upper abdominal laxity
|-
|Barros's
|
|Physical
|
* Grade I: Increased diameter and slight protrusion limited to the [[areola]] region
* Grade II: Moderate [[hypertrophy]] of the [[breast]] with the nipple-areola complex (NAC) above the inframammary fold (IMF)
* Grade III: Major [[hypertrophy]] of the [[breast]] with [[glandular]] [[ptosis]] and the NAC situated at the same height as or as much as 1 cm below the inframammary fold (IM)
* Grade IV: Major [[breast]] [[hypertrophy]] with skin redundancy, severe [[ptosis]], and the NAC positioned ≥1 cm below the inframammary fold (IMF)
|-
|Çi̇l's
|
|Imaging (computed tomography)
|
* Gynecomastic [[adipose]] tissue/total gynecomastic tissue is  <0.3
 
* Gynecomastic [[adipose]] tissue/total gynecomastic tissue is 0.3–0.5
 
* Gynecomastic [[adipose]] tissue/total gynecomastic tissue is >0.6
|-
|Cordova's
|
|Physical
|
* Grade I: Increase in diameter and protrusion limited to the [[areolar]] region
* Grade II: [[Hypertrophy]] of all the structural components of the breast and the nipple-areola complex (NAC) is above the inframammary fold (IMF)
* Grade III: [[Hypertrophy]] of all the structural components with  nipple-areola complex (NAC) at the same height as or approximately 1 cm below the inframammary fold (IMF). In this group we can also include male [[tuberous breast]]
* Grade IV: [[Hypertrophy]] of all the structural components with nipple-areola complex (NAC) >1 cm below theinframammary fold (IMF)
|-
|Fruhstorfer's
|
|Physical
|
* Small-to-moderate gynecomastia
* Moderate-to-large gynecomastia
|-
|Mladick's
|
|Physical
|
* No sagging
 
* Slight sagging
 
* Moderate sagging
 
* Extensive sagging
|-
|Monarca's
|
|Physical/tissue type
|
* Grade I: Minimal [[hypertrophy]] (<250 g)
** IA: Primarily fatty [[breast]] tissue
** IB: Primarily fibrous [[breast]] tissue
** IC: [[Nipple]] malposition (upright)
** ID: Gynoid (rounded) shape of the chest
** IE: Absence of sternal notch II: Moderate [[hypertrophy]] (250–500 g)
* Grade IIA: Primarily fatty [[breast]] tissue
** IIB: Primarily fibrous [[breast]] tissue with peripheral fat
** IIC: [[Nipple]] malposition (upright or upward)
** IID: Moderate gynoid shape of the chest
** IIE: Absence of sternal notch
* Grade III: Severe [[hypertrophy]] with grade I [[ptosi]]s (>500 g)
** IIIA: Fatty and [[fibrous tissue]] with ptosis of grade I
** IIIB: Nipple malposition (upright or upward)
** IIIC: Severe gynoid shape of the chest
** IIID: Absence of sternal notch
* Grade IV: Severe [[hypertrophy]] with grade II or III ptosis (>500–700 g)
** IVA: Fatty and fibrous tissue with [[ptosis]] of grade II
** IVB: Fatty and fibrous tissue with [[ptosis]] of with [[nipple]] reorientation grade III
** IVC: [[Nipple]] malposition (upright or upward)
** IVD: Severe gynoid shape of the chest
** IVE: Absence of sternal notch
|-
|Ratnam's
|
|Physical
|
* Type 1: Enlarged [[breasts]] with elastic skin and no fold
 
* Type 2: Enlarged [[breasts]] with elastic skin and an inframammory fold (IMF)
 
* Type 3: Ptotic [[breasts]] with inelastic skin
|-
|Webster's
|
|Tissue type
|
* Class 1: Periductal connective  tissue [[hypertrophy]] without [[adipose]] tissue change
* Class 2: Increase in the amount of both connective and [[adipose]] tissue
* Class 3: [[Adipose]] tissue [[hypertrophy]] alone
|}
<nowiki>*</nowiki>NAC, nipple-areola complex; IMF, inframammary fold
 
===Classification based on severity===
Gynecomastia can be classified on the basis of severity as:
* Grade I: Minor enlargement with no skin excess
* Grade II: Moderate enlargement with no skin excess
* Grade III: Moderate enlargement with skin excess
* Grade IV: Marked enlargement with skin excess
 
=== Classifcation based on etiology ===
*[[Gynecomastia causes|Physiological]]
*[[Gynecomastia causes|Pathological]]
*[[Gynecomastia causes|Pharmacological]]
*[[Gynecomastia causes|Idiopathic]]


==References==
==References==
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[[Category:Needs content]]
[[Category:Disease]]
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Latest revision as of 21:31, 9 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2], Omodamola Aje B.Sc, M.D. [3]

Overview

Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology.

Classification

Different gynecomastia classification systems are:[1][2][3][4][5][6]

Surgical classification of gynecomastia

Classification system Criteria Description
Physical Tissue type
Nydick's Physical
  • Gland limited to the retro areolar region and 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's Physical
  • Stage 1: Nipple prominence
  • Stage 2: Mammillary button stage. The breast and the nipple-areola complex are slightly swollen and 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's Physical
  • Grade 1: Small visible breast enlargement and 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
Deutinger's and Freilinger's Physical
  • Grade 1: Thoracic wall poor in the flesh with mammary tissue localized behind and around the nipple without skin excess
  • Grade 2: Adipose thoracic wall with widespread alterations and breasts similar to feminine ones during puberty
  • Grade 3: Widespread alterations with excess adipose tissue, skin redundancy and inframammary fold and ptosis
Cohen's Physical
Rohrich's Physical/Tissue type
Gusenoff's Physical
  • Grade 1: Minimal excess skin and fat with minimal alteration of nipple-areola complex (NAC) and inframammary fold (IMF)
    • 1a: No lateral skin roll
    • 1b: Lateral skin roll
  • Grade 2: Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and minimal upper abdominal laxity
  • Grade 3: Nipple-areola complex (NAC) and inframammary fold (IMF) below the ideal IMF with lateral chest roll and significant upper abdominal laxity
Barros's Physical
  • Grade I: Increased diameter and slight protrusion limited to the areola region
  • Grade II: Moderate hypertrophy of the breast with the nipple-areola complex (NAC) above the inframammary fold (IMF)
  • Grade III: Major hypertrophy of the breast with glandular ptosis and the NAC situated at the same height as or as much as 1 cm below the inframammary fold (IM)
  • Grade IV: Major breast hypertrophy with skin redundancy, severe ptosis, and the NAC positioned ≥1 cm below the inframammary fold (IMF)
Çi̇l's Imaging (computed tomography)
  • Gynecomastic adipose tissue/total gynecomastic tissue is <0.3
  • Gynecomastic adipose tissue/total gynecomastic tissue is 0.3–0.5
  • Gynecomastic adipose tissue/total gynecomastic tissue is >0.6
Cordova's Physical
  • Grade I: Increase in diameter and protrusion limited to the areolar region
  • Grade II: Hypertrophy of all the structural components of the breast and the nipple-areola complex (NAC) is above the inframammary fold (IMF)
  • Grade III: Hypertrophy of all the structural components with nipple-areola complex (NAC) at the same height as or approximately 1 cm below the inframammary fold (IMF). In this group we can also include male tuberous breast
  • Grade IV: Hypertrophy of all the structural components with nipple-areola complex (NAC) >1 cm below theinframammary fold (IMF)
Fruhstorfer's Physical
  • Small-to-moderate gynecomastia
  • Moderate-to-large gynecomastia
Mladick's Physical
  • No sagging
  • Slight sagging
  • Moderate sagging
  • Extensive sagging
Monarca's Physical/tissue type
  • Grade I: Minimal hypertrophy (<250 g)
    • IA: Primarily fatty breast tissue
    • IB: Primarily fibrous breast tissue
    • IC: Nipple malposition (upright)
    • ID: Gynoid (rounded) shape of the chest
    • IE: Absence of sternal notch II: Moderate hypertrophy (250–500 g)
  • Grade IIA: Primarily fatty breast tissue
    • IIB: Primarily fibrous breast tissue with peripheral fat
    • IIC: Nipple malposition (upright or upward)
    • IID: Moderate gynoid shape of the chest
    • IIE: Absence of sternal notch
  • Grade III: Severe hypertrophy with grade I ptosis (>500 g)
    • IIIA: Fatty and fibrous tissue with ptosis of grade I
    • IIIB: Nipple malposition (upright or upward)
    • IIIC: Severe gynoid shape of the chest
    • IIID: Absence of sternal notch
  • Grade IV: Severe hypertrophy with grade II or III ptosis (>500–700 g)
    • IVA: Fatty and fibrous tissue with ptosis of grade II
    • IVB: Fatty and fibrous tissue with ptosis of with nipple reorientation grade III
    • IVC: Nipple malposition (upright or upward)
    • IVD: Severe gynoid shape of the chest
    • IVE: Absence of sternal notch
Ratnam's Physical
  • Type 1: Enlarged breasts with elastic skin and no fold
  • Type 2: Enlarged breasts with elastic skin and an inframammory fold (IMF)
  • Type 3: Ptotic breasts with inelastic skin
Webster's Tissue type

*NAC, nipple-areola complex; IMF, inframammary fold

Classification based on severity

Gynecomastia can be classified on the basis of severity as:

  • Grade I: Minor enlargement with no skin excess
  • Grade II: Moderate enlargement with no skin excess
  • Grade III: Moderate enlargement with skin excess
  • Grade IV: Marked enlargement with skin excess

Classifcation based on etiology

References

  1. ↑ Waltho D, Hatchell A, Thoma A (2017). "Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System". Plast Reconstr Surg. 139 (3): 638e–648e. doi:10.1097/PRS.0000000000003059. PMID 28234829.
  2. ↑ Monarca C, Rizzo MI (2013). "Gynecomastia: tips and tricks-classification and surgical approach". Plast Reconstr Surg. 131 (5): 863e–5e. doi:10.1097/PRS.0b013e318287a18f. PMID 23629140.
  3. ↑ Rohrich RJ, Ha RY, Kenkel JM, Adams WP (2003). "Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction". Plast Reconstr Surg. 111 (2): 909–23, discussion 924-5. doi:10.1097/01.PRS.0000042146.40379.25. PMID 12560721.
  4. ↑ Wollina, U; Goldman, A (June 2011). "Minimally invasive esthetic procedures of the male breast". Journal of cosmetic dermatology. 10 (2): 150–155. doi:10.1111/j.1473-2165.2011.00548.x. PMID 21649820.
  5. ↑ Simon BE, Hoffman S, Kahn S (1973). "Classification and surgical correction of gynecomastia". Plast. Reconstr. Surg. 51 (1): 48–52. PMID 4687568.
  6. ↑ Gikas P, Mokbel K (2007). "Management of gynaecomastia: an update". Int J Clin Pract. 61 (7): 1209–15. doi:10.1111/j.1742-1241.2006.01095.x. PMID 17362482.

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