Divine Classification of Gynecomastia

Practically relevant classification that helps in management

Grade 1a – Puffy nipple
Grade 1b – small amount of fat limited to lower half + puffy nipple . fat less than 250 ml
Grade 2a – fat over entire breast, no axillary fat or breast rolls
Grade 2b – fat over entire breast, no axillary fat or breast rolls , loose skin , saggy skin with the need for skin lift ( < 500 ml fat)

Grade 3a – large amount of fat with visible female breast look, with or without breast rolls ( > 500 ml to 1000 ml)
Grade 3b – large amount of fat with visible female type breast and breast rolls
Grade 4a – very large breast, not in shape with the body at all, looseness of skin. Breast rolls present ( more than 1000 ml fat)
Grade 4b – very large breast, not in shape with chest at all , with skin looseness due to weight loss. The problem is loose saggy skin and not much fat . Breast rolls present

Divine Clinical Classification Of Gynecomastia

Grade	Procedure	Description	Infiltration	Treatment plan
1a	Puffy Nipple	No obvious problem is visible except stretched areola. Button type feel below	50 ml each side along with the gland	Excision in LA from the infraareolar incision
1b	Minor chest enlargement (< 100 ml fat, gland +)	The chest is a visibly bigger, but limited fat, usually higher amount of fibro-glandular tissue	200 ml each side	Suction and gland excision in LA from infraareolar incision and stab incision in the inframammary area
1c	Minor chest enlargement (100-250 gm fat)	The chest is visibly larger. Assessed fat component is between 100 to 250 gm	300 ml each side	Suction and gland excision In GA from infraareolar incision and stab incision in the axillary area
2a	Moderate chest enlargement	The chest is moderately enlarged. The fat component is between 250-500 gm. No skin looseness expected	500 ml each side	Suction – stab incision in axillary area, and gland excision In GA from the infraareolar incision
2b	Moderate chest enlargement with skin looseness	The chest is moderately enlarged. The fat component is between 250-500 gm.. large gland component in the form of a conical chest. Excision is likely to leave loose skin. U lift needed	500 ml each side	Suction from stab incision in axillary area, and gland excision + U skin lift from supra areolar approach In GA
3a	Big chest with side rolls without skin looseness	The chest is severely enlarged. The fat component is between 500+ gm. Fat in breast rolls+. No skin looseness expected	750 ml each side and axilla	Suction – stab incision in axillary area, axilla from infra areolar, and gland excision In GA from the infraareolar incision
3b	Big chest with side rolls with skin looseness expected	The chest is severely enlarged, fat component +, axilla rolls +, skin looseness expected	750 ml each side and axilla	Suction from stab incision in axillary area, and gland excision + U skin lift from supra areolar approach In GA
4a	Big chest with very large skin laxity	The chest is severely enlarged, fat component +, axilla rolls + large skin looseness expected	750 ml + each side	Stage procedure. 1st stage sams as 3b. 2nd stage, o- lift procedure
4b	Severe weight loss condition	The chest is hanging, not much fat excess expected, gland +, skin excess ++	200-250 each side	Mastopexy, chest lift type of procedure

Why is it necessary to have a new classification for gynecomastia?

The previous classifications have taken a very simplistic view of gynecomastia, this condition occurs in myriad forms and have specific treatment planning for each grade.

This classification clearly defines what is possible in local anesthesia and what is recommended under general anesthesia.
It talks of managing potential complications and gives a separate grade to it
Asymmetric gynecomastia has not been discussed previously since the treatment can be remarkably different for both the sides

Unilateral gynecomastia has not been discussed previously
Severe skin laxity has not been discussed in any classification
Post weight loss gynecomastia correction has been included
Puffiness of nipple has not been identified as a separate grade. It is important since the treatment is absolutely different compared to all other grades

Grade 1A - Puffy Nipple

Only projecting nipple and areola
No fat
No breast rolls
No axillary breast
No skin laxity
Is sometimes painful
Amenable to be performed under local anesthesia

Grade 1b - small amount of fat limited to lower half, no loose skin

Fat is limited to just under the areola and lower quadrant of the breast – check by Pectoralis muscle contraction
Gland is usually present
No skin laxity
No breast rolls
Less than 250 ml fat
No axillary breast
Amenable to be performed under local anesthesia with liposuction and gland removal