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Gynecomastia Type 4

Type 4 Gynecomastia - Moderate Breast Roll

1. Overview

Average cost: $11,500 – $13,400
Recovery: 2 -3 days sedentary work, 4-6 weeks heavy labor

2. Cruise Classification

Accurate assessment is critical to achieve your goals

3. Anatomy of Type 4

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: 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

Type 4 Overview

Moderate Breast Roll


Breast tissue – extends into the axilla (armpit area)

Nipple position – > 2 cm below the chest fold

Chest fold shape – significant skin excess – creates a small breast roll

Most common demographic: 40 – 60 years old, aging male, married or married with children.

Type 4 is characterized by the breast drooping and nipple falling 2 cm or more below the chest fold. There is usually a breast roll present. 

Surgery Information

Anesthesia: Varies. Local anesthesia in the office or general anesthesia performed at an accredited outpatient facility.

Cost: Average cost $11,500 – $13,400 depending on whether surgery is performed under local or general anesthesia. Cost will also increase if combined w/ other procedures.

Consultation fee: Charged upon scheduling a consultation.

Recovery: 2 – 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.

  • Type 1

    Breast tissue – under nipple/areola only

    Nipple position – above border of pec. muscle

    Lateral chest fold – tight, straight

  • Type 2

    Breast tissue – extends over chest fold

    Nipple position – above border of pec. muscle

    Lateral chest fold – tight, rounded

  • Type 3

    Breast tissue – extends over chest fold

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

    Lateral chest fold – mild laxity, horizontal

  • Type 4

    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

  • Type 5

    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

  • Type 6

    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 4 Gynecomastia?

Type 4 Gynecomastia has breast tissue that extends into arm pit region similar to type 3. The major difference is that there is significant excess skin that causes the horizontal chest fold to extend into arm pit creating a breast roll. Proper assessment requires that you take into consideration that removing the gynecomastia tissue will cause “deflation”. Evaluation requires knowing how much skin will be present after tissue removal. Tightening this skin is often required to achieve long term, masculine chest results.

Anatomy of Type 4 Gynecomastia

  • Typical appearance

    The most obvious difference between Type 4 and Type 3 is the breast roll. In type 3, the breast roll is minimal if any. With Type 4, the breast roll is clearly present particularly when you consider the sag/deflation that will occur when the breast tissue is removed. Unlike Type 5's, skin excess is primarily one directional. It can easily be tightened by simply grabbing the skin along the pectoralis border and pinching together - simulating what would happen with surgical tightening.

  • What's going on underneath

    Like Type 3, the breast tissue drapes over the pectoralis muscle into the arm pit. The tissue is usually more fatty and saggy. The sag is primarily from the skin no longer being able to hold it in place.

Optimal Results for Type 4

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 optimal results. Page down to see the eight components that define a masculine chest.

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    Optimal results for Type 4 patients require critical evaluation of the first 6 components. Determining your goals while addressing these components is what determines your surgical road map. This is particularly true for Type 4 as excess skin is becoming more significant with the need for more dramatic treatment. The upside to this is dramatically improved results.

Masculine Chest Visualized

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

  • 1. Chest shape - masculine, flat and defined

    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.

  • 2. Nipple position

    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.

  • 3. Areola size, projection and shape

    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.

  • 4. Pec. border definition

    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.

  • 5. Arm pit

    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.

  • 6. Three Fat pockets – pre-axillary, axillary and breast roll

    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.
  • 7. Breast rolls

    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.

  • 8. Back rolls

    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

See below for Dr. Cruise’s preferred incision options for treating Type 4 Gynecomastia.

Shorter Incision vs Masculine Chest Shape

Type 4 Gynecomastia patients are often in good physical shape but have significant excess chest and arm pit skin laxity. This physical condition allows them the opportunity for a youthful, masculine chest that they can be proud of.

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.

Type 4 Gynecomastia Chest Tightening Incisions

Chest Tightening with One of the Following:

  1. Nipple Repositioning (Pedicle), or
  2. Free nipple graft

This technique is also referred to as Pedicle Gynecomastia. It is the most predictable way to create a truly youthful chest that will last virtually forever.

It involves removing excess skin by leaving a well hidden incision directly in the chest fold. The nipple never leaves the body, maintaining its own blood and nerve supply. This makes for a much easier recovery. Its biggest limitation is with significant amounts of glandular tissue.

The best option for Type 4 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 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, patient are more than happy to wait wearing fitted shirt, tight tank tops, or white T-shirts.

A free nipple graft means that the nipple and areola are re positioned as a skin graft. This requires 2 weeks of wearing a vest 24/7.

Watch a Pedicle Gynecomastia Surgery

Recovery Timeline

Click the image below to view a complete timeline of the recovery process following Type 4 Gynecomastia surgery. Gaining a better understanding of what to expect will help you prepare, plan, and reduce stress.

Everything you need to know about your recovery

Gynecomastia Before & After Photos

View our gallery of before and after photos to see the results from Type 4 Gynecomastia surgery. Remember each patient is unique and results will vary from person to person.


Type 4 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.

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    Unfortunately, because of the stigma associated with it, it is not always readily apparent what your loved one may be experiencing. In fact, the men or more commonly pubescent teenagers, who are most deeply affected go to great lengths to suffer alone. The Internet becomes the only one they can talk to. 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 4 Gynecomastia:

  • Having lived with gynecomastia for quite some time, it appears much worse now.
  • More self-conscious about his chest then signs of aging showing on his face.
  • Feels hopeless.
  • Likely knows about “gynecomastia,” but has avoided pursing options for getting rid of it. Frustration with the changes in his chest due to aging are a big reason for considering doing something now.
  • Behavior:
    • Hunched neck and shoulders
    • Hands on hip, always pulling shirt off chest
    • Downward gazing head/eyes.
    • Uncomfortable with eye contact
    • Will not take his shirt off in public
    • Depressed, hopeless.
    • Avoids interaction with young children
    • Wears baggy, old-man clothing

Spouse/Significant Other Perspective – signs of concern

  1. Observe. Are the behaviors above becoming worse?
  2. Have activities become almost non-existent?
  3. Is working out or dieting a thing of the past?
  4. Has he purchased compression garments to wear under his shirts hoping to hide his chest?
  5. Is he embarrassed when you see him without his shirt on?
  6. Does he avoid hugging?
  7. Is your sex life declining?
  8. Does he act hopeless, depressed or moody?

A loved one’s perspective

Schedule a Consultation

Gynecomastia surgery is a surgery that many men undergo to rid themselves of their man boobs. If you are interested in learning more about the surgical process or want to schedule a consultation with Dr. Cruise, please fill out our online contact form or call our office at (949) 644-4808.