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 [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. Breast size and ptosis are the most commonly included features.

Classification

Different gynecomastia classification systems are:

Surgical classification of gynecomastia

Author	Year	Method of classification	Classification system
Nydick	1961	Physical	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	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	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	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	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 2 or 3 ptosis glandular or fibrous
Gusenoff	2008	Physical	GRADE 1: Minimal excess skin and fat, minimal alteration of nipple-areola complex (NAC), inframammary fold (IMF) 1a: No 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
Barros	2012	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	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

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

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
  • The physiological gynecomastia is seen due to hormonal changes and most commonly seen in newborns, adolescents and in the elderly.
• Pathological
  • The pathological gynecomastia is seen due to excess unopposed estrogen to androgen ratio.
• Pharmacological
  • The pharmacological agents commonly causing