Gynecomastia classification

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

Overview

Gynecomastia has been classified by various systems mainly based on surgical management, the severity of gynecomastia, physical appearance, and etiology. Breast size and ptosis are the most commonly included features.

Classification

Common features included in different gynecomastia classification systems included:

• Breast size
• Skin redundancy
• Breast ptosis
• Tissue predominance
• Upper abdominal laxity
• Breast tuberosity
• Nipple malposition
• Chest shape
• Absence of sternal notch
• Breast skin elasticity

Classification based on different systems

Author	Year	Method of classification	Classification system
Nydick	1961	Physical appearance	Gland limited to the retro areolar region; 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	1971	Physical appearance	Stage 1: Nipple prominence. Stage 2: Mammillary button stage; the breast and the areola- nipple are slightly swollen and the 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	1973	Physical appearance	GRADE 1: Small visible breast enlargement, 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 and Freilinger	1986	Physical appearance	Grade 1: Thoracic wall poor in the flesh; mammary tissue localized behind and around the nipple; no skin excess. Grade 2: Adipose thoracic wall; widespread alterations; breasts similar to feminine ones during puberty. Grade 3: Widespread alterations; excess adipose tissue, skin redundancy, inframammary fold and ptosis.
Cohen	1987	Physical appearance	Group 1: Glandular gynecomastia. Group 2: Glandular gynecomastia with ptosis. Group 2: Glandular gynecomastia with ptosis. Group 3: Adipose gynecomastia. Group:4 Adipose gynecomastia with a slight glandular component.
Rohrich	2003	Physical/Tissue type	GRADE 1: Minimal hypertrophy, (less than 250g of tissue) without ptosis 1a: Primary 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 1 or 3 ptosis glandular or fibrous
Gusenoff	2008	Physical	GRADE 1: Minimal excess skin and fat, minimal alteration of NAC, normal IMF 1a: No lateral skin roll 1b: Lateral skin roll Grade 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.
Barros	2012	Physical	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 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
Çi̇l	2012	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
Cordova	2008	Physical	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 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 IV: Hypertrophy of all the structural components, NAC >1 cm below the IMF
Fruhstorfer	2003	Physical	Small-to-moderate Moderate-to-large
Mladick	2004	Physical	No sagging Slight sagging Moderate sagging Extensive sagging
Monarca	2013	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	2009	Physical	Type 1: Enlarged breasts with elastic skin and no fold Type 2: Enlarged breasts with elastic skin and an IMF Type 3: Ptotic breasts with inelastic skin
Webster	1946	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

Classification based on severity

Gynecomastia can be graded on the basis of severity as:

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

Classifcation based on pathogenesis

• Physiological
• Pathological
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