Gynecomastia classification: Difference between revisions

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{{CMG}}; {{AE}} {{HS}}, {{DAMI}}
{{CMG}}; {{AE}} {{HS}}, {{DAMI}}
==Overview==
==Overview==
Gynecomastia has been classified by various systems mainly based on [[Surgery|surgical]] management, the severity of gynecomastia, physical appearance, and [[etiology]]. [[Breast]] size and [[ptosis]] are the most commonly included features.
Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology.


==Classification==
==Classification==
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=== Surgical classification of gynecomastia ===
=== Surgical classification of gynecomastia ===
{| class="wikitable"
{| class="wikitable"
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Author}}
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF| Classification system}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF| Year}}
! colspan="2" style="background: #4479BA;" |{{fontcolor|#FFF|Criteria}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Method of classification}}
! rowspan="2" style="background: #4479BA;" | {{fontcolor|#FFF|Description}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Classification system}}
|-
|-
|Nydick
! style="background: #4479BA;" |{{fontcolor|#FFF|Physical}}
|1961
! style="background: #4479BA;" |{{fontcolor|#FFF|Tissue type}}
|-
|Nydick's
|
|Physical  
|Physical  
|
|
*Gland limited to the [[Areolar|retro areolar region]]; it does not reach the edge of the areola
*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]]
*Gland extends as far as the edge of the [[areola]]
*The increase in [[gland]] volume extends beyond the edge of the [[areola]]
*The increase in [[gland]] volume extends beyond the edge of the [[areola]]
|-
|-
|Tanner
|Tanner's
|1971
|
|Physical  
|Physical  
|
|
*Stage 1: [[Nipple]] prominence
*Stage 1: [[Nipple]] prominence
*Stage 2: [[Mammillary body|Mammillary]] button stage; the [[breast]] and the areola-nipple are slightly swollen and the diameter of the [[areola]] increases  
*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 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 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
*Stage 5: There is protrusion of the [[nipple]] only after retraction of the [[areola]] from the [[breast]] surface
|-
|-
|Simon
|Simon's
|1973
|
|Physical  
|Physical  
|
|
* GRADE 1: Small visible [[breast]] enlargement, no skin redundancy  
* Grade 1: Small visible [[breast]] enlargement and no skin redundancy  
* GRADE 2a: Moderate [[breast]] enlargement without skin redundancy  
* Grade 2a: Moderate [[breast]] enlargement without skin redundancy  
* GRADE 2b: Moderate [[breast]] enlargement with skin redundancy  
* Grade 2b: Moderate [[breast]] enlargement with skin redundancy  
* GRADE 3: Marked [[breast]] enlargement with marked skin redundancy
* Grade 3: Marked [[breast]] enlargement with marked skin redundancy
|-
|-
|Deutinger and Freilinger  
|Deutinger's and Freilinger's
|1986
|
|Physical  
|Physical  
|
|
*Grade 1: [[Thoracic wall]] poor in the flesh; [[mammary tissue]] localized behind and around the [[nipple]]; no skin excess  
*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; widespread alterations; [[breast]]s similar to feminine ones during puberty
*Grade 2: [[Adipose]] thoracic wall with widespread alterations and [[breast]]s similar to feminine ones during puberty
*Grade 3: Widespread alterations; excess [[adipose]] tissue, skin redundancy, inframammary fold and [[ptosis]]
*Grade 3: Widespread alterations with excess [[adipose]] tissue, skin redundancy and inframammary fold and [[ptosis]]
|-
|-
|Cohen  
|Cohen's
|1987
|
|Physical  
|Physical  
|
|
*Group 1: [[Glandular]] gynecomastia
*Group 1: [[Glandular]] gynecomastia
*Group 2: [[Glandular]] gynecomastia with [[ptosis]]
*Group 2: [[Glandular]] gynecomastia with [[ptosis]]
*Group 2: [[Glandular]] gynecomastia with [[ptosis]]
*Group 3: [[Adipose]] gynecomastia
*Group 3: [[Adipose]] gynecomastia
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*Group:4 [[Adipose]] gynecomastia with a slight [[glandular]] component
*Group:4 [[Adipose]] gynecomastia with a slight [[glandular]] component
|-
|-
|Rohrich  
|Rohrich's
|2003
|
|Physical/Tissue type
|Physical/Tissue type
|
|
* GRADE 1: Minimal [[hypertrophy]], (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 2 or 3 ptosis [[glandular]] or [[fibrous]]
|-
|-
|Gusenoff
|Gusenoff's
|2008
|
|Physical
|Physical
|
|
* GRADE 1: Minimal excess skin and fat, minimal alteration of nipple-areola complex (NAC),  inframammary fold (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  
** 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 nipple-areola complex (NAC) above the inframammary fold (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 inframammary fold (IM)
* 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)
* 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 is  <0.3


* Gynecomastic [[adipose]] tissue/total gynecomastic tissue, 0.3–0.5  
* Gynecomastic [[adipose]] tissue/total gynecomastic tissue is 0.3–0.5  


* Gynecomastic [[adipose]] tissue/total gynecomastic tissue, >0.6
* 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  
* Small-to-moderate gynecomastia
* Moderate-to-large
* Moderate-to-large gynecomastia
|-
|-
|Mladick
|Mladick's
|2004
|
|Physical
|Physical
|
|
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* Extensive sagging
* Extensive sagging
|-
|-
|Monarca
|Monarca's
|2013
|
|Physical/tissue type
|Physical/tissue type
|
|
* GRADE I: Minimal [[hypertrophy]] (<250 g)  
* Grade I: Minimal [[hypertrophy]] (<250 g)  
** IA: Primarily fatty [[breast]] tissue  
** IA: Primarily fatty [[breast]] tissue  
** IB: Primarily fibrous [[breast]] tissue  
** IB: Primarily fibrous [[breast]] tissue  
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** 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 [[ptosi]]s (>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)  
** IVA: Fatty and fibrous tissue with [[ptosis]] of grade II
** IVB: Fatty and fibrous tissue with [[ptosis]] of with [[nipple]] reorientation grade III  
** IVB: Fatty and fibrous tissue with [[ptosis]] of with [[nipple]] reorientation grade III  
** IVC: [[Nipple]] malposition (upright or upward)  
** IVC: [[Nipple]] malposition (upright or upward)  
Line 157: Line 162:
** IVE: Absence of sternal notch
** IVE: Absence of sternal notch
|-
|-
|Ratnam
|Ratnam's
|2009
|
|Physical
|Physical
|
|
* Type 1: Enlarged [[breasts]] with elastic skin and no fold
* Type 1: Enlarged [[breasts]] with elastic skin and no fold


* Type 2: Enlarged [[breasts]] with elastic skin and an IMF  
* Type 2: Enlarged [[breasts]] with elastic skin and an inframammory fold (IMF)


* Type 3: Ptotic [[breasts]] with inelastic skin
* Type 3: Ptotic [[breasts]] with inelastic skin
|-
|-
|Webster
|Webster's
|1946
|
|Tissue type
|Tissue type
|
|
Line 178: Line 183:


===Classification based on severity===
===Classification based on severity===
Gynecomastia can be graded on the basis of severity as:
Gynecomastia can be classified on the basis of severity as:
* Grade I: Minor enlargement, no skin excess
* Grade I: Minor enlargement with no skin excess
* Grade II: Moderate enlargement, no skin excess
* Grade II: Moderate enlargement with no skin excess
* Grade III: Moderate enlargement, skin excess
* Grade III: Moderate enlargement with skin excess
* Grade IV: Marked enlargement, skin excess
* Grade IV: Marked enlargement with skin excess


=== Classifcation based on pathogenesis ===
=== Classifcation based on etiology ===
*[[Physiological]]
*[[Gynecomastia causes|Physiological]]
*[[Gynecomastia causes|Pathological]]
*[[Gynecomastia causes|Pathological]]
*[[Pharmacological]]
*[[Gynecomastia causes|Pharmacological]]
*Idiopathic
*[[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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