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    Gynecomastia Type 1 – Puffy Nipple

    Definition

    Breast tissue 
    Located primarily beneath nipple/areola

    Nipple position 
    At or above pectoralis border

    Skin excess 
    Tight skin – straight chest fold (no rounding)

    Commonly referred to as “Puffy Nipple.”

    Examples of Gynecomastia Type 1

    Type 1 – Puffy Nipple
    Characterized by a bulging, shiny areola and an over projecting nipple.

    Most common age group: 15-25

    Puffy nipple is caused by swelling of this excess breast tissue. This swollen tissue causes the areola to bulge, enlarge and become shiny. The nipple projects outward causing the characteristic “puffy nipple” appearance.  It may be painful which means that the gynecomastia tissue is actively inflamed. Puffy nipple occurs primarily when the patient is hot or emotional. Patients often describe how it goes away when they get cold, pinch their nipple, or when they come out of a pool. It is caused by the swelling of excess breast tissue located directly below the nipple. This swollen breast tissue makes wearing a tight T-shirt almost impossible and going shirtless embarrassing. For body builders, it disrupts the masculine, defined look they work so hard to achieve. 

    Type 1’s have tight chest skin and are usually young and thin. It is often seen in body builders. Surgical results are predictably excellent because of the patient’s tight skin and lean body type. Incisions are limited to the areola which fade away quickly and are not noticeable. The biggest challenge is to know exactly how much breast tissue to remove to prevent recurrence.

    Psyche:
    Type 1’s gynecomastia effect everyone differently depending on personality type. Teenagers are often most severely effected. They become withdrawn. Avoids normal shirtless activities common for this age group. They become uncomfortable with their body during this critical formative period. A period when everyone questions their body image and peers have no filter when it comes to pointing it out. Emotional issues associated with gynecomastia go far beyond other imperfections such as obesity, pimples, bad hair, etc. It brings the whole question of masculinity into the mindset. 
    Body builders are a unique subset that we often see. They typically have greater self esteem and simply are frustrated with a problem that is “self inflicted” and ruins the results they are trying to achieve.

    Cruise Classification System

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

    Based on over 2500 gynecomastia surgeries, Dr. Cruise has classified gynecomastia into is 6 different types. Each type is different in many ways and must be treated differently. The purpose of the Cruise Classification System is:

    • Easily identifies what type you are
    • Defines the goals of surgery
    • Describes the critical steps in achieving optimal results

    Cruise Classification System – 6 Types of Gynecomastia

    angle-classification-6-Types

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

    Type 1 gynecomastia will have tight skin. This allows the skin to wrap around the pectoralis border in a straight line because there is little or no breast tissue blurring the muscle definition. Type 2 does have breast tissue extending over muscle border. This causes chest fold rounding.


    Type 1




    Breast tissue
    Located primarily beneath nipple/areola. Aka – Puffy Nipple.

    Nipple position 
    At or above pectoralis muscle border

    Skin excess
    Tight skin – straight chest fold (no rounding)


    Type 2




    Breast tissue 
    Extends over pectoralis muscle border

    Nipple position 
    At or above pectoralis border

    Skin excess 
    Tight skin – rounded chest fold


    Type 3




    Breast tissue 
    Extends over pectoralis muscle border

    Nipple position 
    0 to 2 cm. below pectoralis border

    Skin excess
    Moderate skin excess – creates horizontal chest fold (not rounded)


    Type 4




    Breast tissue 
    Extends into arm pit

    Nipple position 
    ≥ 2 cm below pectoralis border

    Skin excess
    Breast roll in front of arm pit


    Type 5




    Breast tissue 
    Extends into axilla

    Nipple position
    ≥ 2 cm below pectoralis border

    Skin excess
    Breast roll extends to the back of arm pit


    Type 6




    Breast tissue
    Extends into arm pit

    Nipple position
    ≥ 2cm below pectoralis border

    Skin excess
    Breast roll extends around to back

     

    What is Type 1 Gynecomastia?

    Type 1 Gynecomastia Visualized

    Puffy Nipple

    Type 1 Appearance.

    Characterized by Puffy Nipple. Patients are typically young, thin with a straight, well defined pectoralis muscle.

    Type-1

    What is going on underneath? 

    Notice the firm, white, glandular tissue located almost exclusively underneath the nipple/areola. This tissue is what creates
    Puffy Nipple.

    Optimal Results for Type 1

    Unfortunately, the clinical definition for optimal results for gynecomastia is virtually non-existent; even in plastic surgery literature. Type 1 does not necessary mean easiest. In fact, Type 1 patients are very particular and do not tolerate complications such as persistent Puffy Nipple, cratering, contour irregularities, etc. Type 1 patients are typically in very good physical shape to begin. Their Puffy Nipple is the often only thing that bothers them. However, there are many variations of Type 1 gynecomastia. Achieving optimal results and avoiding complications requires both expertise and a plan.

    The most common cause of poor outcomes is not having this plan. Unfortunately, gynecomastia treatment has never been given the same attention that most other plastic surgery procedures. This over-sight is the reason Dr. Cruise has created this site. To create the infrastructure for both patients and surgeons to advance gynecomastia treatment.

     

    A plan is like using Google maps. First you have to know where you are. Then, where you want to go; only then can you determine the best way to go. The Cruise Classification system describes where you are,  result you are looking for.

    Masculine Chest Visualized

    Ideal-obliqe

    External view of masculine chest

    Ideal

    Internal view of masculine chest

    What defines “Optimal Results?”

    The answer is actually very difficult to find. Compared to other medical conditions, clinically relevant information is not available. This ignorance is unacceptable particularly because it has such significant impact on so many men’s lives. Even plastic surgeons are often vague as to what is the best way to evaluate and treat. To simplify this, Dr. Cruise outlines the 8 areas of the upper body that need to be considered to provide a surgical road map that will predictably achieve your optimal results. As a patient, you do not need to know all the nuances but you do need to make sure that you and your gyncomastia surgeon know in detail what your goals are and make sure both of you are on the same page.

    This is the purpose of this gynecomastia “Wikipedia” approach. Gynecomastia treatment has not been given the same attention as other procedures despite the tremendous burden associated with it.

    The silver lining is that the patient satisfaction from properly performed gynecomastia surgery is beyond what words can describe. It is the reason Dr. Cruise has dedicated his career to advancing its cause. The only requirements are dedication and meticulous planning. With this in mind, please ignore the information that is beyond what you are interested in. Just know that there is a bigger, common purpose; to provide a platform solely designed to achieve optimal results to a problem that has lived in darkness.

    1. Nipple position

    Ideally, the nipple should be 1-2 cm above the pec. border (pectoralis major muscle). However, it is perfectly acceptable even if it is located directly on the border as long as it sits on a convex (not concave) surface. This is particularly true with body builders or men with large pec. muscles as it gives the low lying nipple a bigger base to sit on. However, when it sits below the pec. border it begins to face downward or worse it falls into the chest fold which is concave. Sitting in the chest fold often gives the appearance of “cratering.” 

    2. 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.

    3. Chest shape

    Overall, a masculine chest is full and powerful. While muscle definition is important, it is best to 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 create a V shape from both the back and front view. 

    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. They blur pec., arm pit and lat. definition and disrupts V shape 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. 

    Optimal results – Insights from Dr. Cruise

    Accurate classification and accurate assessment of patient goals 
    This is, by far, the most important pieces of information you absolutely need to know. For example, body builders often have different goals than say the high school teenager.   

    Shorter incision vs optimal chest shape
    The epic battle between youthful, well defined chest shape vs minimal incisions. This is such an important topic, Dr. Cruise devotes a good portion of his consultation time going over your options. Fortunately, for type 1’s, incision visibility is not usually a significant concern. However, some incisions are better than others. This is most applicable to  body builders with very low set nipples. In these cases, it is important to fully understand patient goals both short and long term. With rare exception, experience has overwhelming shown that optimal chest shape and definition are more important than incisions almost every time. Dr. Cruise recognized this early in his career. The key, then, became “How do I make the incisions so good that, with time, they become a non-issue”; which is exactly what he has dedicated his career to. 

    When performed correctly, incisions fade over time. Low hanging nipples, however, continue to drop lower and lower with time. It is important to consider how you will look not only in 2-3 years but also in 2-3 decades. It is usually better to have time on your side.

    “With time, incisions fade while saggy skin gets worse”

    Having said that, there are criteria that may change which procedure is best one way or another. 

    Reasons to consider shorter incision

    1. History of true keloids
    2. Youth
    3. Darker skin tone
    4. Models/actors and men who can not tolerate the necessary 1 year healing time
    5. Men who are willing to live with some skin laxity and/or are OK with a second procedure in the future.
    6. Men with perfect skin and no chest hair.

    Reasons to consider longer incision

    1. Patients who haven’t taken their shirt off publicly in years anyways
    2. Older skin/poor skin quality
    3. Lighter skin tone
    4. Men with a hairy chest
    5. Just about everyone who is willing to accept the 1 year healing process.

    Surgical treatment options

    Pros and Cons of each:
    Incision visibility is less of an issue with type 1 gynecomastia compared to the other types. This is because even the most aggressive incision (the superior crescent) still remains within the “forgiving” areola compared to the less forgiving non-areola skin.

    Type 1 Incision Options

    Inferior incision

    Inferior crescent excision

    Superior incision

    Superior crescent excision

    Inferior incision

    Inferior linear incision

     

    1. Inferior crescent – most common type 1 incision with Dr. Cruise. Inferior crescent excision means that a 1/4″ to 1/2″  crescent shaped piece of skin is removed just below the areola. This does several good things beyond tightening the chest skin. More importantly, it pulls the areola tight similar to getting the wrinkles out of a bed sheet. This little maneuver has a large impact in getting rid of excess skin that has been stretched over time. It also flattens the lower chest skin mildly so that it better wraps around the pec. border improving definition. The incision is located low on the areola where it is very hard to see even early on. Crescent incisions, however, create skin margins that do not line up exactly. The side toward the areola will always be shorter than its counterpart. When sutured together this length mismatch will create mild bunching that takes a little longer to fade away than a linear incision. However, it is certainly worth it.
    2. Superior crescent – useful when the nipple is near the pec. border and you need a small elevation to make sure the nipple stays on the convex pec. border and does not migrate downward into the concave chest fold when the breast tissue is removed. If this occurs and it could create a “crater” appearance. This is rare with type 1 puffy nipples unless the skin is lax and/or of poor quality. The downside is that superior incisions are always more visible and widen more than inferior. Superior incisions pull the nipple upward slightly. While this is a good thing from a position standpoint, the slight additional tension means it will take longer to fade. Overall, it is a good way to go for low hanging type 1 nipples. However, young body builders with flawless, darker toned skin and no chest hair should avoid this incision if possible. 
    3. Inferior linear – most common type 1 incision world-wide. Because there is no skin removal at all, the incision lines up exactly and fades away the quickest. However, it does not tighten the areola which means that the areola must tighten on it own. If it is unable to tighten it may puff out which is a major reason for the surgery in the first place. Dr. Cruise does not use this incision because slight skin tightening provides optimal nipple/areola flatness.
       

    Recovery – Everything you need to know

    Type 1 – Puffy nipple

    View timeline

    Before and Afters

     Sub-optimal results

    Perhaps, the best way to demonstrate what are the most important concerns to focus on with type 1 is to give an overview of its most common complications . As a recognized authority in gynecomastia surgery, patients often come to Dr. Cruise for revision surgery. Fortunately (or unfortunately – depending on how you look at it), this has given Dr. Cruise the unique opportunity to assess, analyze and prioritize the most common things that can go wrong.

    Inaccurate classification and/or accurate assessment of patient goals

    This was already outlined in what it takes to create “optimal results” but it also a major reason for sub-optimal results.  

    Persistent puffy nipple

    Undoubtedly, the most prominent concern we see in revision type 1 cases is persistent puffy nipple. This is especially true when liposuction alone was used. This is particularly problematic with body builders who have very low body fat, thus, making even slight puffy nipple look unacceptable. Treatment is not as simple as you may think as the causes are often multi factorial. Complete treatment is beyond the scope of this summary but listed below are the essentials that both you and your surgeon should know.
         Treatment/Prevention:

    1. Make sure the classification is correct.
      Incorrect classification will often lead to incorrect treatment. Your type 1 may actually be a type 2 or type 3. This will cause the nipple to drop below the pec. border which can imitate puffy nipple.
    2. Remove virtually all breast tissue.
      Type 1 glandular breast tissue acts very different than in other gynecomastia types. It is incredibly tenacious. It invades directly into the dermis of the areola like tentacles. Removing precisely the correct amount requires experience.This is not as easy as it may seem. Even small amounts of residual breast tissue can swell significantly causing the nipple to continue to be puffy and patients to be upset.  However, removing too much can cut off blood supply to nipple/areola which can be disastrous. Optimal treatment is a balancing act. 
    3. Tighten the areola skin
      Often, with puffy nipple the areola has been so stretched out that it simply has too much skin to completely snap back. This excess areola skin makes the nipple look puffy even if all the breast tissue has been removed. It is similar to trying to put a 10 foot rug into and 8 foot room – you will never get it to lay flat. Tightening the areola is critical and is the reason Dr. Cruise strongly prefers the crescent excision compared to the traditional linear incision.
    4. Prevent scar tissue formation/reformation under the areola
      If the areola does not heal flat onto the pec. muscle below it will fill with scar tissue. This scar tissue will look puffy – which is very upsetting. Proper treatment requires the following protocol:
      • Remove scar tissue
      • Tighten areola skin
      • Prevent fluid from collecting/scar reformation
      • Apply proper compression for proper time
      • Limit shoulder range of motion based on the science of wound healing

    Enlarged areola

    Enlarged areola are very common with puffy nipple. The most common reason is because the areola is constantly stretched from the swollen breast tissue below. Typically, precisely removing this breast tissue is all that is necessary as the areola usually will shrink back depending on its elasticity. However, in the event that the areola remains enlarged even after tissue removal, a circumferential areola reduction (doughnut lift) would create the desired size. It is strongly recommended to perform a doughnut lift as a second stage procedure. Removing breast tissue aggressively below the areola and then cutting circumstantially around the areola may result in a serious loss in blood supply and possible nipple loss.

    Elongated, protruding (not puffy) nipples

    Typically, protruding nipples are associated with a protruding areola which is treated as a normal type 1 gynecomastia procedure. However, there are times when this is not the case and the problem is simply an elongated nipple without gynecomastia. 

    • Treatment – Is simple excision of anywhere from 20-75% of the nipple projection. This is amazingly effective as it quickly and efficiently eliminates the nipple from popping through tight clothing. Recovery is short and easy.

    Breast tissue fullness just lateral to areola.

    This is a very common area where breast tissue tends to cling onto in type 1’s. It must be addressed similar to breast tissue under the areola. Remove enough to treat the problem but not too much to create contour irregularities.

    Crater deformity.

    Can be seen in other types but is most common in type 1’s. This is because type 1’s are usually thin to begin with and removing the exact amount of tissue is more critical than in other types. Treatment depends on the cause. The easiest treatment is when only the central portion of the breast tissue is removed and leaves a central crater. In this case, proper breast tissue removal and beveling the margins provides good results. More complicated causes include over-resection of tissue – which requires tissue replacement either from surrounding tissue or via fat/soft tissue fillers. Finally, a common cause of cratering is due to low nipple placement. When the breast tissue is removed, the nipple often “sags” into the concavity of the chest fold which patients often refer to as cratering. Treatment requires re-positioning the nipple/areola back on top of the pec. major border where it belongs.

    Loose chest skin

    Typically, this means that you were not a type 1 gynecomastia. Some type of precise skin excision is necessary to achieve optimal results. However, it is possible that skin re-draping can redistribute the skin and make it appear flatter. Chest skin laxity is similar to areola skin laxity; it has to be tight and/or elastic to snap back. Making the same analogy – It is like trying to fit a 10 foot rug into an 8 foot room – no matter what you do there will always be some bumpiness. Patients will always assume that this laxity is breast tissue.

    • Treatment
      Reclassify and consider a strategic skin tightening procedure.

    Poorly defined pec. major muscle

    With type 1 this is almost always due to some “spilling” over of breast tissue from on top of the chest to into the concavity of the chest fold. See the image of the skin cutaway showing how this occurs. With type 1, there is not as much breast tissue but enough to frustrate a body builder or someone really trying for chest definition.

    • Treatment
      Go back in and remove the remaining breast tissue. Liposuction will not work effectively as type 1 glandular breast tissue is extremely tenacious and has to be directly cut out.

    Poor scarring

    Sub-optimal incisions widen from the constant stretching movement of the shoulder. However, when performed strategically, tension is reduced and the incisions fade extremely well. Areola incisions routinely heal fantastic as early as 3 months. Skin incisions, however, take longer. While it may be shorter, Dr. Cruise tells his patients that it will take at least a year to fade to the point that they can comfortably take their shirt off in public. Having said that, the sad reality is that many men with gynecomastia don’t feel comfortable taking their shirt off the way they are. Therefore, waiting a year is not an issue. The up side is that even during the waiting period you will be able to where any shirt you could possibly dream of. Even the dreaded tight white T-shirt. To many, this does not even seem possible and has sent goose bumps down your spine. With body builders it is the holy grail of physique.

     Patient Perspective – common feelings associated with patients who have Type 1 gynecomastia:

    • Trapped and alone during critical formation of self-worth period.
    • Feels as if he is only one with problem.
    • Unaware condition has a name: Gynecomastia. (However, internet is changing this).
    • May or may not discuss concerns with parents.
    • High school is emotionally difficult enough; gynecomastia can be anywhere from uncomfortable to unbearable.
    • Wide spectrum of outward expression from normal to:
      • Hunched neck and shoulders.
      • Downward gazing head/eyes.
      • Uncomfortable with eye contact
      • Becoming more and more reclusive for no obvious reason.
      • PE class is torture.
      • Feeling depressed
      • Poor self-image
      • Giving up
      • Negative impact on other aspects of life including school, family, friends.

    Parent Perspective – what can parents do to help?

    1. Observe. Is your son avoiding outdoor/shirtless activities he use to love?
    2. Does he wear shirt at pool/beach?
    3. Is he more reclusive/negative?
    4. Does he decline in academics?
    5. Does he come up with excuses to avoid PE?
    6. More obvious – is he being ridiculed by schoolmates and even friends, being called titty twister, or being a subject of “man boobs” jokes, etc?
    7. Does he wear over-sized clothing? Routine tugging of shirt over chest?

    Spouse/Significant Other Perspective – what can you do to help?

    1. Observe. Is your son avoiding outdoor/shirtless activities he use to love?
    2. Does he wear shirt at pool/beach?
    3. Is he more reclusive/negative?
    4. Does he decline in academics?
    5. Does he come up with excuses to avoid PE?
    6. More obvious – is he being ridiculed by schoolmates and even friends, being called titty twister, or being a subject of “man boobs” jokes, etc?
    7. Does he wear over-sized clothing? Routine tugging of shirt over chest?
    ‹‹ Types of Gynecomastia Type 2 Gynecomastia ››

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