Gynecomastia classification: Difference between revisions

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{{Gynecomastia}}
{{Gynecomastia}}


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


==Classification==
==Classification==
*There is no established system for the classification of [disease name].
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>
OR
=== Surgical classification of gynecomastia ===
*[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
OR
*[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
*[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
OR
*Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
OR
*If the staging system involves specific and characteristic findings and features:
*According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
OR
*The staging of [malignancy name] is based on the [staging system].
OR
*There is no established system for the staging of [malignancy name].
 
{| class="wikitable"
{| class="wikitable"
!Author
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF| Classification system}}
!Year
! colspan="2" style="background: #4479BA;" |{{fontcolor|#FFF|Criteria}}
!Method of classification
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF|Description}}
!Classification system
|-
! 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]]
|-
|-
|Simon
|Cohen's
|1973
|
|Physical
|Physical  
|
|
* GRADE 1: Small visible breast enlargement, no skin redundancy
*Group 1: [[Glandular]] gynecomastia
* GRADE 2a: Moderate breast enlargement without skin redundancy
*Group 2: [[Glandular]] gynecomastia with [[ptosis]]
* GRADE 2b: Moderate breast enlargement with skin redundancy
*Group 3: [[Adipose]] gynecomastia
* GRADE 3: Marked breast enlargement with marked skin redundancy
 
*Group:4 [[Adipose]] gynecomastia with a slight [[glandular]] component
|-
|-
|Rohrich
|Rohrich's
|2003
|
|Physical/Tissue type
|Physical/Tissue type
|
|
* GRADE 1 : Minimal hyperteophy, (less than 250g of tissue) without ptosis
* Grade 1: Minimal [[hypertrophy]], (less than 250g of tissue) without [[ptosis]]
** 1a : Primary glandular
** 1a: Primarily [[glandular]]
 
** 1b: Primarily [[fibrous]]
** 1b : Primarily fibrous
* Grade 2: moderate [[hypertrophy]] (250-500g of breast tissue) without [[ptosis]]
* GRADE 2 : moderate hypertrophy (250-500g of breast tissue) without ptosis
** 2a: Primarily [[glandular]]
** 2a : Primarily glandular
** 2b: Primarily [[fibrous]]
** 2b : primarily fibrous
* Grade 3: Severe [[hypertrophy]] (>500g of breast tissue with grade 1 ptosis [[glandular]] or [[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]]
* GRADE 4 : Severe hypertrophy with grade 1 or 3 ptosis glandular or fibrous
|-
|-
|Gusenoff
|Gusenoff's
|2008
|
|Physical
|Physical
|
|
* GRADE 1: Minimal excess skin and fat, minimal alteration of NAC, normal IMF  
* Grade 1: Minimal excess skin and fat with minimal alteration of nipple-areola complex (NAC) and inframammary fold (IMF)
 
** 1a: No lateral skin roll  
** 1a: No lateral skin roll  
** 1b: Lateral skin roll Grade
** 1b: Lateral skin roll
** 2: NAC and IMF below the ideal IMF, lateral chest roll, minimal upper abdominal laxity  
 
* GRADE 3: NAC and IMF below the ideal IMF, lateral chest roll, significant upper abdominal laxity.
* 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
|Barros's
|2012
|
|Physical
|Physical
|
|
* GRADE I: Increased diameter and slight protrusion limited to the areola region  
* Grade I: Increased diameter and slight protrusion limited to the [[areola]] region  
* GRADE II: Moderate hypertrophy of the breast with the NAC above the IMF  
* 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 IMF Grade IV: Major breast hypertrophy with skin redundancy, severe ptosis, and the NAC positioned ≥1 cm below the 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
|Çi̇l's
|2012
|
|Imaging (computed tomography
|Imaging (computed tomography)
|Gynecomastic adipose tissue/total gynecomastic tissue, <0.3 Gynecomastic adipose tissue/total gynecomastic tissue, 0.3–0.5 Gynecomastic adipose tissue/total gynecomastic tissue, >0.6
|
* 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
|Cordova's
|2008
|
|Physical
|Physical
|
|
* GRADE I: Increase in diameter and protrusion limited to the areolar region  
* Grade I: Increase in diameter and protrusion limited to the [[areolar]] region  
* GRADE II: Hypertrophy of all the structural components of the breast; the NAC is above the IMF  
* 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, NAC at the same height as or approximately 1 cm below the IMF; in this group we can also include male tuberous breast  
* 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, NAC >1 cm below the IMF
* Grade IV: [[Hypertrophy]] of all the structural components with nipple-areola complex (NAC) >1 cm below theinframammary fold (IMF)
|-
|-
|Fruhstorfer
|Fruhstorfer's
|2003
|
|Physical
|Physical
|Small-to-moderate Moderate-to-large
|
* Small-to-moderate gynecomastia
* Moderate-to-large gynecomastia
|-
|-
|Mladick
|Mladick's
|2004
|
|Physical
|Physical
|No sagging Slight sagging Moderate sagging Extensive sagging
|
* No sagging  
 
* Slight sagging  
 
* Moderate sagging  
 
* Extensive sagging
|-
|-
|Monarca
|Monarca's
|2013
|Physical/tis- sue type
|
|
* GRADE I: Minimal hypertrophy (<250 g)  
|Physical/tissue type
** IA: Primarily fatty breast tissue  
|
** IB: Primarily fibrous breast tissue  
* Grade I: Minimal [[hypertrophy]] (<250 g)  
** IC: Nipple malposition (upright)  
** IA: Primarily fatty [[breast]] tissue  
** IB: Primarily fibrous [[breast]] tissue  
** IC: [[Nipple]] malposition (upright)  
** ID: Gynoid (rounded) shape of the chest  
** ID: Gynoid (rounded) shape of the chest  
** IE: Absence of sternal notch II: Moderate hypertrophy (250–500 g)  
** IE: Absence of sternal notch II: Moderate [[hypertrophy]] (250–500 g)  
* GRADE IIA: Primarily fatty breast tissue
* Grade IIA: Primarily fatty [[breast]] tissue
** IIB: Primarily fibrous breast tissue with peripheral fat  
** IIB: Primarily fibrous [[breast]] tissue with peripheral fat  
** IIC: Nipple malposition (upright or upward)  
** IIC: [[Nipple]] malposition (upright or upward)  
** IID: Moderate gynoid shape of the chest  
** IID: Moderate gynoid shape of the chest  
** IIE: Absence of sternal notch  
** IIE: Absence of sternal notch  
* GRADE III: Severe hypertrophy with grade I ptosis (>500 g)  
* Grade III: Severe [[hypertrophy]] with grade I [[ptosi]]s (>500 g)  
** IIIA: Fatty and fibrous tissue with ptosis of grade I
** IIIA: Fatty and [[fibrous tissue]] with ptosis of grade I
** IIIB: Nipple malposition (upright or upward)  
** IIIB: Nipple malposition (upright or upward)  
** IIIC: Severe gynoid shape of the chest  
** IIIC: Severe gynoid shape of the chest  
** IIID: Absence of sternal notch  
** 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  
* Grade IV: Severe [[hypertrophy]] with grade II or III ptosis (>500–700 g)  
** IVB: Fatty and fibrous tissue with ptosis of with nipple reorientation grade III  
** IVA: Fatty and fibrous tissue with [[ptosis]] of grade II
** IVC: Nipple malposition (upright or upward)  
** 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  
** IVD: Severe gynoid shape of the chest  
** IVE: Absence of sternal notch
** 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


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>
=== Classifcation based on etiology ===
* Grade I: Minor enlargement, no skin excess
*[[Gynecomastia causes|Physiological]]
* Grade II: Moderate enlargement, no skin excess
*[[Gynecomastia causes|Pathological]]
* Grade III: Moderate enlargement, skin excess
*[[Gynecomastia causes|Pharmacological]]
* Grade IV: Marked enlargement, skin excess
*[[Gynecomastia causes|Idiopathic]]


==References==
==References==

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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