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What is Gynecomastia

Gynecomastia Progression - Summary

  • Gynecomastia is classically defined as excess breast tissue in the male chest.
  • Pseudo-gynecomastia
Gynecomastia is not a disease that stays the same over time. Instead, It is a progressive process. It is caused by excess breast tissue which puts a weight burden on the chest skin. Over time, the support structures of the chest weaken allowing the chest fold to drop and the skin to stretch. The progression is quite predictable.
The optimal time to treat Gynecomastia is early in the Type 1 or 2 phase. At this point, there is not much skin stretching and the skin is likely to snap back. The treatment is less complex and is done via a small, hard-to-see incision.

Pre-pubescent patients with gynecomastia are correctly told that there is a strong likelihood of their gynecomastia going away without any treatment. However, after puberty, breast tissue that is present for more than 18 months it is not likely to resolve on its own.

As a general rule, If BT is large enough to bother you, it usually has enough weight to weaken support systems and advance to next type over time.
Once the skin stretches and begins to “bounce” when running, the skin excess becomes more challenging to treat. Removing breast tissue weight early is just beneficial to improving chest appearance immediately; it has the additional benefit of preventing chest sag later in life
Type 1
Puffy Nipple
Type 2
Chest rounding
Type 3
Excess Skin
Type 4
Chest Sag

Leprachaun Gif

Unfortunately, the progression will often continue. The breast tissue weight will continue to stretch the skin, turning the type 2 into a type 3. Progressing to type 3 has considerable implications. It means that treatment needs to be more complex than type 1 and 2 because now, there is too much skin to get it all to lay flat. You can think of it as putting a 14 foot rug in a 10 foot room. No matter how hard you try, whenever you stomp down one wrinkle another one will pop up. Patient satisfaction is still high but not that of type 1 and 2. Fortunately, the skin excess has not progressed to the point of requiring the long incision underneath the chest. This is where type 4 comes in

Gynecomastia Type Classification - Summary

Type 1
Puffy Nipple
Type 2
Chest rounding
Type 3
Excess Skin
Type 4
Chest Sag
Type 5
Arm-pit Sag
Type 6
Upper Body Sag
  • The natural history of Gynecomastia is a progressive weakening of chest fold and skin due to the weight of breast tissue; thus, making early removal very important as a preventative measure.
  • Types 1 and 2 are “True Gynecomastia”. Type 3 is a hybrid of gynecomastia and skin excess. Whereas, type 4, 5 and 6 are primarily excess skin.
  • Most reliable measurement is Chest Fold angle with arms relaxed.
  • Type 1 – Excess breast tissue located underneath Nipple. Puffy Nipple.
  • Type 2 – Breast tissue has weakened chest fold and fallen below chest causing chest rounding but skin is still tight.
  • Type 3 – Breast tissue over time has stretched skin causing chest looseness.
  • Type 4 – Continued breast tissue stretching causing chest sag.
  • Type 5 – Both chest sag and arm-pit sag.
  • Type 6 – Entire upper body sag. Often seen in massive weight loss patients.

Type 1

Gynecomastia Progression Overview – H5

Type 1 – Teens / early 20’s
Gynecomastia typically presents itself in the teenage years just after puberty as Puffy Nipple. Puffy Nipple occurs when the enlarging breast tissue pushes forward through the nipple / areola. It can’t push downward because the youthful skin is simply too strong.
The strong skin holds everything together like a compression garment. This forces the breast tissue to expand forward causing Puffy Nipple characteristic of Type 1 gynecomastia.
Type 2 – Late 20’s / 30’s
However, by late 20’s the constant weight weakens the chest fold opening it up like a trap door. This chest fold descent is what causes the chest rounding which defines Type 2 gynecomastia.
40’s & 50’s – Type 3
Once the breast tissue falls to the next level of support it can not fall any further due to 7th rib support ligament. Now, the breast tissue is forced forward again stretching the skin and causing loose chest and skin excess. Here the Skin has stretched beyond the point of being able to be put back on the chest without rumpling. Think of placing a 14 foot rug in a 10 foot room. Every time you step on one rumple another pops up.

Fortunately, Dr. Cruise is able to implement several other types of incisions that do not leave the patient with a long chest fold incision seen in type 4 incision. However, type 3 patients should be warned that their chest will not be tight. There will still be skin laxity. They should expect to have a 2nd, smaller skin tightening procedure several months later to either raise the nipple back on top of the Pec. Muscle or to tighten the skin further. This skin tightening procedure can be thought of as an anti-aging procedure as it is not really treating gynecomastia, rather, it is treating loose skin.

See Type 3 procedure details for better explanation
Type 4
Type 4 Gynecomastia occurs when the breast tissue weight of a Type 3 patient is great enough or if the skin quality is simply not capable of resisting the weight. Either way, the breast tissue will cause the lower chest skin to stretch further where it sags downward.
With type 4’s there is no way to limit the incision within the nipple / areola because there is simply too much skin to remove. There is no way to get the chest skin to lay flat against the chest wall without considerable contour irregularities and a “deflated” look.
Trying to perform a type 3 procedure on a type 4 to limit the incision is fraught with problems and must be carefully thought through given the fact that residual skin laxity will persist. There simply is no way to significantly tighten a saggy chest using only a small incision around the areola. This is a conversation that requires deep knowledge of the Gynecomastia surgeon as will as full understanding of expectations by the patient.
Types 5 and 6
Type 5’s and 6’s can be thought of as Type 4’s except that the excess skin is not limited to the chest.
Type 5 can be thought of as having “arm pit sag” as the entire armpit sags creating a breast roll crease that extends onto the back.
Type 6 can be thought of as “upper body sag” where the skin excess is comply circumferential. This is demonstrated by having upper and/or mid back creases that can only be corrected by doing a complete upper body lift.

Gyne Types and Treatment in Detail

10 essential measurements Reasons
1) CF angle
Gyne type
2) CF sag
CF suture
3) PN
PN management
4) Areola size
Areola management
5) Nipple location
Incisions / 2nd stage
6) Pec size
Vol. preservation
7) BT size
Vol. preservation
8) Vertical excess / Pencil text
Response to CF suture / 2nd stage
9) Horizontal excess
V to Y
10) Pec origin
Vol. preservation, nipple elevation
6) Pec size
6) Pec size
  • Progression within Type 1
  • Generally what is happening within Type 1
    1. BT growing, support structures holding, forcing BT to push through least resistance which is areola.
    2. Gravity takes over in Type 3 max decreasing PN but increasing lower chest fullness, support structure still holding
  • Resulting look- 1 Min – growth under nipple, often painful, Minimal PN, can feel but can not see unless hot or emotional