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Zoning in on gynecomastia

Article-Zoning in on gynecomastia

Man with enlarged breasts

A newly proposed gynecomastia zone classification is a simple, objective way to describe gynecomastia and guide treatment, according to a paper published October 2018 in Plastic and Reconstructive Surgery.

But it’s not ideal for all gynecomastia patients, according to the author of an accompanying discussion.

Robert C. Caridi, M.D., a plastic surgeon in Austin, Texas, saw a consistent pattern of contour variations in 635 gynecomastia patients and developed a zone classification for the male chest. He writes that plastic surgeons haven’t universally embraced gynecomastia classification despite the availability of many such systems. And just how these classifications impact gynecomastia diagnoses or treatment isn’t clear.

Dr. Caridi’s system includes five zones:

  • Zone 0 is just under the nipple-areola complex and is often where “puffy nipples” have their origin.
  • Zone 1, surrounding zone 0 and overlying the pectoralis major muscle, is where the most common gynecomastia presentation of fullness likely occurs.
  • Zone 2 is lateral to the pectoralis muscle.
  • Zone 3 runs along the pectoral muscle’s upper lateral border and is adjacent to the axillary crease.
  • Zone 4 is the typically oblong area inferior to the pectoralis, caudal to the inframammary fold, according to the paper.

“… surgeons should examine all areas of the upper chest for appropriate treatment and not focus on the frontal chest exclusively,” Dr. Caridi writes.

A 4-Step Approach

The plastic surgeon author used a uniform approach — a four-step process — to treat the patient cohort. Dr. Caridi first infiltrated zones with tumescence; then treated with ultrasound liposuction, followed by standard liposuction; then removed residual tissue with a gland excision under the nipple.

The classification system appropriately targets therapy to the chest, offering several potential benefits, including better doctor-patient communication, better directed treatment and documentation, and more of a focus on global aesthetic chest contouring, according to the paper.

The zone distribution, he writes, is optimally integrated with modern gynecomastia treatment.

Dr. Caridi’s classification system and described technique are good for typical gynecomastia cases, where patients have a slight excess of gland or fatty tissue of the chest, according to Jeffrey Gusenoff, M.D., professor of Plastic Surgery, and co-director, of the Life After Weight Loss Program, University of Pittsburgh School of Medicine. Dr. Gusenoff coauthored the discussion in Plastic and Reconstructive Surgery.

“You need to be able to assess the chest wall in its entirety to come up with a good plan to get a good cosmetic result. So, he has come up with a nice system of zones, where you can look at the chest and come up with a plan based on assessing where there’s excess and where you need to address it,” Dr. Gusenoff tells The Aesthetic Channel.

The classification helps determine, for example, if treatment needs to be directly primarily behind the nipple in zone zero; along the pectoralis muscle in zone 1; out to the side of the chest in the axilla; or in the area below the inframammary fold, according to Dr. Gusenoff.

“Dr. Caridi gives you a way to think about it, which I think is very helpful for the plastic surgeon that’s seeing your typical gynecomastia case,” he says.

Zone Limitations

The classification system and treatment, however, have limitations for the patient who needs a more aggressive technique.

“He doesn’t really advocate that if you have this type of deformity in this zone then this is a specific treatment for it. He has one treatment that he uses for everything,” Dr. Gusenoff says. “If you have a patient that comes in with massive weight loss and has a lot of excess skin, the technique that he offers is not going to be a good solution for that person. The patient is going to have recurrent skin laxity and want another operation with more aggressive scars and to get rid of that loose skin.”

The zones in the classification are not as helpful when patients’ chest deformities extend to the upper abdomen, back and into the axilla, the authors of the discussion write.

Another example is the patient with gynecoid distribution of chest skin and fat that is so severe it appears woman-like, with extreme ptosis of chest tissue that positions the nipple below the inframammary fold, according to the discussion.

Dr. Gusenoff says achieving optimal outcomes with gynecomastia involves looking at all the chest areas that Dr. Caridi describes. Whether patients are massive weight loss patients or not, it’s important that plastic surgeons look at the nipple, assess for gland behind it, as well as look at the area over the pectoralis, the lateral chest wall and the area below.

“Really looking at all the surrounding areas is key to achieving an optimal chest contour,” Dr. Gusenoff says.