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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

GradeProcedureDescriptionInfiltrationTreatment plan
1aPuffy NippleNo obvious problem is visible except stretched areola. Button type feel below50 ml each side along with the glandExcision in LA from the infraareolar incision
1bMinor chest enlargement (< 100 ml fat, gland +)The chest is a visibly bigger, but limited fat, usually higher amount of fibro-glandular tissue200 ml each sideSuction and gland excision in LA from infraareolar incision and stab incision in the inframammary area
1cMinor chest enlargement (100-250 gm fat)The chest is visibly larger. Assessed fat component is between 100 to 250 gm300 ml each sideSuction and gland excision In GA from infraareolar incision and stab incision in the axillary area
2aModerate chest enlargementThe chest is moderately enlarged. The fat component is between 250-500 gm. No skin looseness expected500 ml each sideSuction – stab incision in axillary area, and gland excision In GA from the infraareolar incision
2bModerate chest enlargement with skin loosenessThe 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 needed500 ml each sideSuction from stab incision in axillary area, and gland excision + U skin lift from supra areolar approach In GA
3aBig chest with side rolls without skin loosenessThe chest is severely enlarged. The fat component is between 500+ gm. Fat in breast rolls+. No skin looseness expected750 ml each side and axillaSuction – stab incision in axillary area, axilla from infra areolar, and gland excision In GA from the infraareolar incision
3bBig chest with side rolls with skin looseness expectedThe chest is severely enlarged, fat component +, axilla rolls +, skin looseness expected750 ml each side and axillaSuction from stab incision in axillary area, and gland excision + U skin lift from supra areolar approach In GA
4aBig chest with very large skin laxityThe chest is severely enlarged, fat component +, axilla rolls + large skin looseness expected750 ml + each sideStage procedure. 1st stage sams as 3b. 2nd stage, o- lift procedure
4bSevere weight loss conditionThe chest is hanging, not much fat excess expected, gland +, skin excess ++200-250 each sideMastopexy, 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
  • 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 
  • 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
  • Fat over entire breast – check with Pectoralis muscle contraction 
  • Gland usually present 
  • 250 – 500 ml fat
  • No skin laxity 
  • No breast rolls 
  • No axillary breast 
  • Patient will probably need to be operated in general anesthesia
  • 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 
  • Excess fat ( mroe than 500 ml fat  , less than 1000 ml fat)
  • Typical female small breast look 
  • Gland usually present 
  • No skin laxity 
  • No breast rolls 
  • No axillary breast 
  • Patient with need GA 
  • As in grade 3a , with breast rolls , and skin laxity needing a u lift
  • Breast rolls + 
  • Axillary breast may or may not, but usually is 
  • No  significant skin laxity  
  • Large amount of fat  ( > 1000 ml )
  • Gland usually present 

Advantages of this new classification

  • No need for ultrasound examination
  • Teachable
  • Standard Treatment Protocols
  • Predictable Results
  • Several clinical situations not discussed previously included

Photography in Gynecomastia

The pictures need to be 

  • From front  – 3 feet away from the patient – assess the grade 
  • From side – exactly 90 degrees – both sides – assess sde roles
  • Angle – 45 degrees from both sides
Correct ways of taking pics in gynecomastia
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