Gynecomastia is the most common condition affecting the male breast. It affects 32%–65% of all men. Gynecomastia can be physically and psychologically harmful to the patient and hence surgical correction is needed in many circumstances. Many grading classification systems and surgical approaches exist including the one by Dr. Sreekar Harinatha that was published in the Brazilian Journal of Plastic Surgery

Methods of surgical treatment of grade I gynecomastia vary and include gland removal only, gland removal in combination with liposuction, etc. Most authors agree that skin resection is not indicated for patients with grade I gynecomastia.

Gland removal can be done using various techniques, including a traditional, larger, 2-cm infra-areolar incision for direct excision, or a small 6–8 mm infra-areolar or inferolateral quadrant incision for “pull through” or “orange peel” techniques for direct excision. Both techniques include grasping of the breast tissue through a small incision with removal of the breast tissue from surrounding structures under direct visualization.

A large variety of surgical approaches was also noted for the treatment of grade II gynecomastia like in Grade I.

An even wider variety of surgical techniques exists for grade III gynecomastia, including gland isolation with central subdermal plexus pedicle, with posteroinferior subdermal plexus pedicle, liposuction + gland removal, breast amputation through inframammary fold (IMF) approach with free nipple graft, etc. Several of these surgical approaches have been previously detailed in this report for the treatment of grades I and II gynecomastia.

No definitive, universally accepted algorithm exists regarding the ideal surgical approach for the treatment of gynecomastia based on severity. Each patient must be considered individually, and the treatment decided upon should be tailored as such. Given the wide variety of acceptable surgical techniques available regardless of patient severity, several factors should be considered. These include patient scarring/tendency for poor scarring, patient comfort with the possibility of revision, patient comfort with the presence of skin redundancy, and other specific circumstances such as the presence of tuberous breast deformity, size of the nipple, and large nipple-to-IMF (Infra-mammary fold) distances, as seen in massive weight loss patients.

Based on the published literature and personal experience, Dr. Sreekar Harinatha provides the following surgical algorithm based on the Simon grading system to assist the plastic surgeon in determining the most appropriate surgical approach for each individual patient.

The first step in the determination of appropriate surgical treatment should be the grading of the patient’s gynecomastia based on Simon’s grade. For patients with grade I gynecomastia, the patient’s previous scars should be examined. If the patient is known to form hypertrophic scars or keloids, excision of glandular tissue should be avoided as an unsightly periareolar scar may cause distress to the patient. In this case, liposuction alone should be chosen as the modality treatment of choice. Conversely, if that patient does not scar poorly, liposuction in addition to SSPM may be chosen.

For patients with grade II gynecomastia, the question regarding the presence of excess skin should be considered. If that patient does not have excess skin but does have an enlarged NAC, gland removal ± liposuction may be utilized. If the patient does not have excess skin and NAC is not enlarged, we advocate for the use of gland removal+ liposuction. If significant excess skin exists regardless of NAC size, we advocate for the use of secondary skin tightening.

Finally, for patients with grade III gynecomastia, the primary question we consider pertains to the nipple-to-IMF distance. If that distance is >10 cm, we advocate for the use of simple mastectomy via the IMF approach with free nipple grafting, as the amount of resection necessary to achieve an acceptable contour would likely revascularize the NAC. If the nipple-to-IMF distance is <10 cm, we advocate for the use of gland removal ± liposuction.