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Gynecomastia Type 5

Type 5 Gynecomastia - Significant Breast Roll

1. Overview

  • Average cost: $13,000 – $16,000
  • Recovery3 days sedentary work, 4-6 weeks heavy labor

2. Cruise Classification

  • Accurate assessment is critical to achieve your goals

3. Anatomy of Type 5

  • Firm, white, glandular tissue located almost exclusively underneath the nipple/areola

4. Optimal Results

  • The 8 components that define a masculine chest

5. Surgical Treatment

  • Best treatment options:Best treatment options: Chest Tightening

6. Recovery Timeline

  • Everything you need to know at a glance with progression pictures

7. Before & After Images

  • Type 4 before and after photos of Dr. Cruise’s patients

8. For Spouses & Parents

  • Eye opening insights of the unseen pain from those who have gone through it

Overview

Type 5 Overview

Significant Breast Roll

Definition

  • Breast tissue –Breast tissue – extends into axilla
  • Nipple position – ≥ 2 cm below chest fold
  • Chest fold shape – significant skin excess, breast roll extends to back of arm pit
  • Most common demographic: overweight, massive weight loss
Characterized by droopy breasts with extra skin that extends into the armpit. A significant breast roll is usually present.

Surgery Information

  • Anesthesia: Varies. Can be performed under local anesthesia in the office or general anesthesia in an accredited outpatient facility. A recommendation will be made by Dr. Cruise during the consultation.
  • Cost: Average cost $13,000 – $16,000. Cost will vary if combined w/ other procedures or performed under general anesthesia.
  • Consultation fee: Charged upon scheduling a consultation.
  • Recovery: 3 days for sedentary work, 4-6 weeks if job requires heavy labor.

Cruise Classification System

Based on over 2500 gynecomastia surgeries, Dr. Cruise has classified gynecomastia into 6 different types. Each type is unique in its own way and must be treated differently. The purpose of the Cruise Classification System is to:
  • 1. Classify gynecomastia type
  • 2. Define patient goals
  • 3. Outline optimal treatment plan

A classification system is only useful if it outlines a treatment plan.

Dr. Cruise

Cruise Classification System – 6 Types of Gynecomastia

Notice the progressive increase in skin laxity. This excess skin will change the type of surgery necessary to properly correct the problem.

Breast tissue – under nipple/areola only

Nipple position – above border of pec. muscle

Lateral chest fold – tight, straight

Breast tissue – extends over chest fold

Nipple position – above border of pec. muscle

Lateral chest fold – tight, rounded

Breast tissue – extends over chest fold

Nipple position – 0 to 2 cm. below border of pec. muscle

Lateral chest fold – mild laxity, horizontal

Breast tissue – extends into axilla

Nipple position – >1.5 cm below border of pec. muscle

Lateral chest fold – small breast roll in front of arm pit

Breast tissue – extends into axilla

Nipple position – ≥ 2 cm below border of pec. muscle

Lateral chest fold – breast roll extends to the back of arm pit

Breast tissue – extends into axilla

Nipple position – ≥ 2cm below border of pec. muscle

Lateral chest fold – breast roll extends around to back

What is Type 5 Gynecomastia?

Type 5 gynecomastia, by definition, has significant excess skin that creates a breast roll that goes beyond chest wall to the back of arm pit. Proper assessment requires taking into account skin deflation from removal of gynecomastia/fatty tissue. However, the major difference between types 4 and 5 is goes much deeper. Type 5 will have excess skin in “two directions.” This means that in addition to excess skin in up and down direction, it also has excess skin in side to side direction. Tightening skin in both directions in addition to removing fat and sculpting arm pit is often required to achieve optimal long term, masculine chest results.

Anatomy of Type 5 Gynecomastia

The most obvious difference between Type 5 from Type 4 is the length of the breast roll. With Type 5, the breast roll goes all the way to the back of the arm pit. Type 5’s, however, are more complex in that the excess skin is not just up and down, it is also side to side. Proper skin tightening requires removing skin in both directions in order to obtain a masculine, V shaped back as well as a defined, sculpted arm pit.
Type 5’s often will have significantly more fat pocket accummulations as shown above. The 3 main pockets are in front of the arm pit, in the arm pit and the breast roll. Optimal results require removing these fat pockets followed by proper skin tightening.
Type 5 patients who do not have fat pockets usually are men who have lost a significant amount of weight. Essentially, they have melted their fat away. Unfortunately, the skin has been stretch beyond its limits of snapping back.

Optimal Results for Type 5

Unfortunately, the clinical definition for optimal results is virtually non-existent; even in plastic surgery literature. This is why it was essential for Dr. Cruise to include it as part of the Cruise Classification System. A classification system is only useful if it identifies where you are and where you need to go.
The first part of the classification system identifies 6 basic types based on where you are. This next part of the system identifies where you need to go. It is true, different men have different goals. This is particularly true with Type 4 gynecomastia. However, Dr. Cruise’s has identified eight fundamental aspects of the male upper chest that need to be evaluated in order to achieve a masculine chest. They are outlined below.
Optimal results for Type 5 patients require critical evaluation of all 8 components. By definition, component 8 (back rolls) do not need to be treated but they still need to be evaluated. By the time you get to Type 5 gynecomastia, minimizing incisions is usually way down the list on your objectives. However, with Dr. Cruise it still is very important. As hard as it may be to believe, the goal is still to allow you to comfortably take your shirt off in public. Incisions get better every day but skin sag only keeps getting worse. With this in mind, chest shape and tight skin is critical. This makes components 4-7 particularly important. It has been a long time since you can remember even having a sculpted arm pit or even seeing the border of your pec. major and lat. dorsi. This, however, is what the art of gynecomastia surgery is all about. Meticulously evaluating and addressing these components is what separates you from over-sized to fitted shirts.

“Achieving optimal results and avoiding complications requires both expertise and a plan”

Dr. Cruise

Anatomy of a Masculine Chest

External view of masculine chest
Inside view of masculine chest

What defines “Optimal Results?”

The Cruise classification accurately defines “where you are”. Now, we need to clearly define in surgical terms “where you want to go.”
With this is mind, we asked Dr. Cruise to outline the most important aspects that need to be addressed when surgically treating gynecomastia and what they should ideally look like.

Eight Components

While most gynecomastia patients are looking for a “flat” chest what they really mean is they want a masculine chest. There is a difference. Overall, a masculine chest is flat with a defined pec. major muscle. The upper chest should remain full and powerful. The goal is to create a sculpted look by getting the nipple to lay flat against the pec. major muscle and by getting the the skin to wrap around the border of the muscle into a sculpted axilla.
The areola is the dark, pigmented skin around the nipple. Areola size is proportionate to chest size. Ideally, it should 25-35 mm and lay flush with the surrounding skin. However, slight elevation is common. Most people do not consciously realize it but areolas are usually wider than they are tall. A perfectly round areola is not ideal and an areola that is taller than it is wide may even appear unusual or “surgical”. This is particularly relevant with Types 4, 5 and 6 which usually require reducing and re-positioning the nipple with a free nipple graft. A protruding nipple is common with puffy nipple due to the pressure from the swollen breast tissue below. However, there are situations where the nipple is simply enlarged. Fortunately, reducing the nipple by excision is straight forward, low cost, little down time and very effective.
Overall, a masculine chest is full and powerful above the nipple but ripped and defined below. The key is to create muscle definition, flatten the nipple, yet keep the chest area above the areola normal thickness. Thinning too much will create a “fragile” appearance and worse, may create contour irregularities. The goal is to flatten the chest so that you can confidently wear tight white T-shirts and to create a V shape from both the back and front view.
Ideally, the pectoralis major muscle should be defined and straight with the skin wrapping around it into a well defined chest fold and then into a defined arm pit hollow. Excess breast tissue, fat and/or saggy skin will blur this border and create a round, feminine appearance.
Should have sculpted appearance with a well define hollow at its apex. The borders of the pec. major in front and the latissimus dorsi in back should be well defined giving a V shape to the upper body. Excess fat/saggy skin can fill the arm pit creating an uncomfortable fullness in armpit and a saggy breast roll just below. For types 5 and 6’s, this is often as big of a concern as the chest. Creating a sculpted axilla and a V shape appearance to the upper body is one of the most rewarding parts of gynecomastia surgery yet it is usually overlooked as not being part of the gynecomastia. It is important for your surgeon to understand that the goal of surgery is to create a V shaped, masculine chest and not just to remove breast tissue. While this is true for all types it is particularly relevant for types 4,5 and 6. I can not tell you have powerful the results are when you create a sculpted pec., lat. and arm pit. It is truly life changing.

Ideally, there should not be any fat pockets. There are three common fat pockets that need to be evaluated and removed if present:

  1. Pre-axillary fat – located just in front of the armpit.
  2. Axillary fat – located within the arm pit itself and
  3. Breast roll fat – located just below the arm pit and creates a fullness or breast roll. It blurs pec., arm pit and lateral definition and disrupts V shape and the upper body that defines masculinity.
Should not be present. Lateral chest/arm pit skin should be tight enough to prevent breast rolls, create a defined pec. border and lat. border with a sculpted arm pit in between. Breast rolls represent saggy skin under the arm pit. Flattening the chest and not correcting breast rolls actually makes the breast rolls more noticeable and creates a disproportionate look to the upper body.
Should not be present. They represent saggy skin that goes all the way around to the back. Optimal surgical treatment requires removing all the excess skin in a 360 degree fashion. Often seen with massive weight loss patients.

Surgical Treatment Options

The diagram below outlines Dr. Cruise’s preferred incision method for treating Type 5 Gynecomastia. A detailed description about this method follows.

Shorter Incision vs Masculine Chest Shape

The chest should have a sculpted appearance with a well defined hollow at its apex. The borders of the pec. major in front and the latissimus dorsi in back should be well defined giving a V shape to the upper body. Excess fat/saggy skin can fill the arm pit creating an uncomfortable fullness in armpit and a saggy breast roll just below. For types 5 and 6’s, this is often as big of a concern as the chest. Creating a sculpted axilla and a V shape appearance to the upper body is one of the most rewarding parts of gynecomastia surgery yet it is usually overlooked as not being part of the gynecomastia. It is important for your surgeon to understand that the goal of surgery is to create a V shaped, masculine chest and not just to remove breast tissue. While this is true for all types it is particularly relevant for types 4,5 and 6. The results are powerful when a sculpted pec., lat. and arm pit are created. It is truly life changing.

Type 5 Gynecomastia Incisions – Extended Chest Tightening

Chest Tightening with either:
Nipple Re-positioning (Pedicle) or Free Nipple Graft with Axillary Pleat.
Incisions look the same. The procedure is different.

Also referred to as Pedicle Gynecomastia. This is the most predictable way to create a youthful chest that will last virtually forever.
It involves removing the excess skin by leaving a well-hidden incision directly in the chest fold Distinctive from FNG the nipple never leaves the body. It maintains its own blood supply and nerve supply and is a much easier recovery. Its biggest limitation is if there is a significant amount of glandular tissue.
The Axillary pleat incision is very well hidden within the armpit region.

Advantages of the Extended Chest Lift with Axillary pleat compared to the Standard Chest lift:

  1. Skin tightening is much more dramatic and allows for armpit sculpting. A result that will last the rest of your life.
  2. Fat removal is more aggressive and, thus, creates a more defined result
The best option for Type 5 requires a chest lift incision that removes a swath of skin from the medial chest into the armpit. It also re-positions the nipple/areola exactly where you want it with exactly the chest thickness you want. While this may seem like a long incision, it is actually very well hidden with time as it falls into the nature chest fold crease. When placed correctly, the incision replaces the rounded, feminine shape of the chest to one that is straight, well defined, and follows the margin of the pec. major muscle creating a much more masculine look.
Well over 500 cases have shown that there is little regret going with this incision because its dramatic, youthful improvement of chest shape far out-weighs the incision; even in patients that tend to keloid. While on the other hand, patients have regretted going with a smaller procedure and not tightening the skin more.
The three significant advantages of this procedure are:
  1. Dramatic skin tightening that will last the rest of your life,
  2. The incision around the areola is a non-issue. It fades very quickly. Skin sensation and color return very well; to the point where they are not noticeable. Skin sensation usually ranges from 30-90% of normal and, frankly, is never considered a problem.
  3. The incision is within the chest fold which has a strong advantage of being a natural fold. However, it usually does take 1 year or longer to fade away to not being an issue shirtless. After which, it continues to fade away. All this time, however, the patient is more than happy to wait to wear a fitted shirt, tight tank tops, or white T-shirts.
A free nipple graft means that the nipple and areola are repositioned as a skin graft. This requires 2 weeks of wearing a vest 24/7.

Watch a Pedicle Gynecomastia Surgery

Type 5 Gynecomastia has a significant amount of excess skin that extends to the back of the arm pit region and often contains fat pockets. Surgical correction requires a chest lift with with either nipple re-positioning or free nipple graft to tighten the chest skin and re-position the nipple to it’s ideal location. It also requires an extended incision with axillary pleat to tighten the armpit skin in two directions to achieve the desired sculpted masculine look.
While type 5 and 6 patients have significant issues that need to be overcome, Type 4 typically just requires proper nipple placement and a tight skin envelop. As one of the top gynecomastia surgeons in the U.S., Dr. Cruise uses his expertise to create a sculpted arm pit with a well defined hollow at its apex. He then flanks the areas to define borders of the pec. major in front and the latissimus dorsi in back. This not only shapes the chest but gives a powerful, well defined V shape to the upper body. Typically, this can only be achieved with the longer, chest lift incision as opposed to the shorter super extended superior incision. The techniques explained here are likely not practiced by doctors who perform just a few male breast reduction surgeries per year. A great deal of knowledge, skill, and experience is necessary to properly execute this type of surgical plan.

The best option for Type 5 requires a chest lift incision that removes a swath of skin from the medial chest into the arm pit. It also re-positions the nipple/areola exactly where you want it with exactly the chest thickness you want. While this may seem like a long incision, it is actually very well hidden with time as it falls into the nature chest fold crease. When placed correctly, the incision replaces the rounded, feminine shape of the chest to one that is straight, well defined, and follows the margin of the pec. major muscle creating a much more masculine look.

Well over 500 cases has shown that there is little regret going with this incision because its dramatic, youthful improvement of chest shape far out-weighs the incision; even in patients that tend to keloid. While on the other hand, patients have regretted going with a smaller procedure and not tightening the skin more.
The three significant advantages of this procedure is:
Dramatic skin tightening that will last the rest of your life, The incision around the areola is a non issue. It fades very quickly. Skin sensation and color return very well; to the point where they are not noticeable. Skin sensation usually ranges from 30-90% of normal and, frankly, is never considered a problem. The incision is within the chest fold which has a strong advantage of being a natural fold. However, it usually does take 1 year or longer to fade away to not being an issue shirtless. After which, it continues to fade away. All this time, however, patient are more than happy to wait wearing fitted shirt, tight tank tops, or white T-shirts.
Type 5’s have considerably more excess skin and fat in the arm pit region compared to Type 4’s. Beyond this, the excess of skin and fat is more complex and requires more aggressive techniques in order to achieve optimal results. The most radical change in thinking from traditional gynecomastia surgery is the concept of treating the entire upper body. Pertaining to Type 5’s, this requires definition of the pec. major muscle, a sculpted arm pit, and a V shape from the lat. dorsi. muscle.
Skin Excess. Type 5’s have excess skin in two directions; vertical (up/down laxity) as well as horizontal (side to side laxity). Therefore, skin tightening needs to be done in both directions. This requires an axillary “pleat”. The pleat is an amazing addition to the the Type 5 treatment because the incision is completely in the arm pit hair; thus hiding the incision. The most important aspect is the horizontal skin tightening is what causes the skin to wrap around both the pec. major in front and the lat. dorsi behind AND helps sculpt out the arm pit. To non Type 5 people, this concept does not likely register as important. But to those with Type 5 gynecomastia, this is almost impossible to fully grasp. The horizontal incision typically extends to the back of the arm pit. Ideally, it assumes a straight line with a slight angle upward – straight lines are masculine; upward tilts are youthful. These may seem subtle but they do make a big difference.

Fat Excess. There are three fat areas within the arm pit region –

  1. Pre-axillary,
  2. Axillary,
  3. Breast roll.

All must be removed to achieve a masculine upper chest. Type 5 patients are almost numb to the feeling of having excess tissue in their arm pit region. I often hear it compared to having a “pair of socks” buried in the arm pit. This fat is different than your normal subcutaneous fat. It is axillary fat and it is located deep in the axilla and sits on top of the serratus anterior muscle. Removing it is complex as there are important structures in this area but it is necessary to achieve that sculpted look. The pre-axillary fat sits in front of the arm pit and the breast roll fat is self explanatory.

Advantages of the Extended Chest Lift with Axillary pleat compared to the Standard Chest lift

  1. Skin tightening is much more dramatic and allows for arm pit sculpting. A result that will last the rest of your life.
  2. Fat removal is more aggressive and, thus, creates a more defined result

Recovery Timeline

Click the image below to view a complete timeline of the recovery process for Type 5 Gynecomastia surgery. Gaining a better understand about what to expect will help you properly prepare, plan, and reduce stress.

Everything you need to know about your recovery

TYPE 5 GYNECOMASTIA

Surgical Recovery Timeline

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Gynecomastia Before & After Photos

View our gallery of before and after photos to see the results possible from Type 5 Gynecomastia surgery. Remember, each person is unique and results will vary from patient to patient.

Type 5 Before & After Examples

Emotional Cost of Gynecomastia

The pain and suffering associated with gynecomastia is unlike any other condition in plastic surgery and perhaps in all of medicine. The range of its impact is stunning. Some men (usually older) can be relatively unaffected while others (usually the younger) can be completely devastated and even suicidal.
Unfortunately, because of the stigma associated with man boobs, it isn’t always apparent what your loved one may be experiencing. In fact, the men who are deeply affected by it, go to great lengths to suffer alone. The Internet becomes the only means for communication with others. This dangerous combination of deep emotional pain and isolation makes them particularly vulnerable to exploitation. Exploitation that takes the form of the literally thousands of “miracle” cures that have no medical merit to the more nefarious types looking to take advantage of the the emotionally weak.

Patient Perspective – common feelings associated with patients who have Type 5 Gynecomastia:

  • Hopeless, beyond frustrated.
  • Feels like it never ends.
  • Trapped in an alien body with no way out. Doesn’t represent who they are inside.
  • Emotional toll prevents making new relationships.
  • Wide spectrum of outward expression from normal to:
    • Hunched neck and shoulders.
    • Downward gazing head/eyes.
    • Worthless, abnormal.
    • Wants to give up.
    • Negative impact on almost all aspects of life; relationships, health/fitness, social life, career motivation, etc.
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Before and Afters
Reviews

Spouse/Significant Other Perspective – signs of concern

  • Is he too embarrassed to take his shirt off in front of you now?
  • Is he becoming more depressed or negative?
  • Is he gaining weight due to inactivity?
  • Does his wardrobe consist of only baggy shirts?
  • Is he uncomfortable with being intimate?

A loved one’s perspective

Schedule a Consultation

Gynecomastia surgery is a next step that many men choose to resolve their gynecomastia (man boobs). Give our office a call at (949) 373-4867 or fill out our online contact form to get more information on gynecomastia surgery. Dr. Cruise also offers consultations to hear about your gynecomastia journey thus far.

CRUISE PLASTIC SURGERY / LAGYNECOMASTIA Main Office

  • Joseph T. Cruise, M.D.
  • 2081 San Joaquin Hills Road
  • Newport Beach, CA 92660

LAGYNECOMASTIA - Administrative Office