If there is one factor that determines the kind of surgery and the outcomes it the grade of gynecomastia. Though there are many different methods of grading gynecomastia, the most commonly followed is Simon’s grading described in 1973. He classified gynecomastia into three grades depending on the amount of breast tissue and loose skin on top of the breast.

• Grade I: Small enlargement without skin excess
• Grade IIa: Moderate enlargement without skin excess
• Grade IIb: Moderate enlargement with minor skin excess
• Grade III: Marked enlargement with a lot of excess skin, resembling a female breast

Rohrich in 2003 proposed another classification into four grades.

• Grade I: Minimal hypertrophy (< 250 g) without ptosis
• Grade II: Moderate hypertrophy (250–500 g) without ptosis
• Grade III: Severe hypertrophy (> 500 g) with grade I ptosis
• Grade IV: Severe hypertrophy with grade II or grade III ptosis
  

Though these two are used worldwide, Simon’s grading is simple and used more widely. One addition I would like to suggest to these gradings is the addition of skin tone factor. To put it simply, while skin excess is the loose skin on top of the breast tissue, skin tone is the inherent capacity of the skin to shrink and contract after the surgery. While skin excess has a linear progression from grades 1 to 3, skin tone can be independent of it. 

The revised grading by Dr. Sreekar Harinatha is as below:

• Grade IT: Small enlargement, No skin excess, Normal skin tone
• Grade 1L: Small enlargement, No skin excess, Poor skin tone
• Grade IIAT: Moderate enlargement, No skin excess, Normal skin tone
• Grade IIAL: Moderate enlargement, No skin excess, Poor skin tone
• Grade IIBT: Moderate enlargement, Minimal Skin excess, Normal skin tone
• Grade IIBL: Moderate enlargement, Minimal Skin excess, Poor skin tone
• Grade IIIT: Marked enlargement, Lot of excess skin, Normal skin tone
• Grade IIIL: Marked enlargement, Lot of excess skin, Poor skin tone

The ‘L’ here would indicate laxity, meaning poor skin tone. This revised grading would also predict the eventual surgical results in terms of skin reshaping in a more accurate way. And once documented into history, it would serve as a reminder about the patient’s original skin tone before the surgery and during follow-up.

Dr. Sreekar Harinatha’s revised grading is now widely accepted and also published in the prestigious Brazilian Journal of Plastic Surgery. Read the article here…

This is very important and is very often understated for reasons I cannot fathom. When two patients with grade IIA come for surgery and get operated by the same technique under the same surgeon, the results may be different. The reason being the difference in skin tone between the two. This should not come as a surprise as such a difference in results follows other surgeries like liposuction too. The lack of skin tone makes a visible difference in the results after any procedure. And patient with loose skin even after seemingly lack of loose skin may need other non-non-surgical procedures or very rarely surgery to tighten the loose skin. This can happen even in Grade IIA gynecomastia.

Meet the experienced gynecomastia surgeon in Bengaluru, Dr Sreekar Harinatha to get your male breast sorted.