Cordova and Moschella 2008 Gynecomastia Classification System

Gynecomastia is a common aesthetic issue frequently encountered by surgeons. Most male patients with this condition undergo surgery to regain their masculine contour and flat chest with as few scars as possible.

Developed by Adriana Cordova and Francesco Moschella, a study was conducted to review the older classification methods of grading Gynecomastia treatments and patient presentation. They developed a new classification system that included a scheme for morphological classification of gynaecomastia, which could serve as a guide for choosing the surgical technique.

An analysis was made of 121 gynaecomastia cases over 5 years examining the extent of the techniques employed, complications, and the need to re-operate.

On the basis of this review, the authors voiced the following opinion:

• When the nipple-areola complex is above the inframammary fold, complete flattening of the thorax can be achieved with suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. 
• When the nipple-areola complex is at the same height as, or at most 1 cm below the fold, skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. 
• When significant ptosis is present and the nipple-areola complex is more than 1 cm below the fold,  reduction mastoplasty becomes necessary. 

In response, the authors developed a new classification system.

Cordova and Moschella Gynecomastia Classification System

The Cordova and Moschella Gynecomastia Grading System was developed to provide a more detailed classification of gynecomastia, based on both clinical and anatomical features. This grading system arose from the need to offer a more comprehensive and practical approach to evaluate the severity and characteristics of gynecomastia, which would help guide treatment options, particularly for surgical interventions.

How the System Came to be:

1. Observational Basis: Cordova and Moschella based their system on a detailed clinical examination of patients with gynecomastia. They observed that the condition manifests with various degrees of breast tissue enlargement, skin excess, and the presence of fatty tissue.
2. Need for Precision: Prior to this, other systems existed but lacked precision in addressing the variability in tissue types (glandular, fat, or both) and the presence of skin excess. The new classification aimed to categorise gynecomastia in a way that directly influenced the choice of surgical or non-surgical treatment.
3. Differentiation of Glandular and Fat Components: The Cordova and Moschella system distinguishes between the glandular and fatty components of gynecomastia. It also factors in the degree of ptosis (sagging) and skin redundancy, which previous systems did not emphasise enough.
4. Comprehensive Grading: This system introduced a more detailed grading scale to better inform surgical planning, whether the patient needs liposuction, excision of glandular tissue, skin reduction, or a combination of procedures.
5. Influence on Treatment: By classifying gynecomastia into different grades based on tissue composition and skin excess, the system helps surgeons select the most appropriate technique for each patient. Lower grades may involve simple excision or liposuction, while higher grades may require more complex surgeries, including skin tightening procedures.

Cordova and Moschella Gynecomastia Grading System 

Grade I

Presentation:

• Increased diameter and protrusion limited to aolar region.

Treatment:

• Subcutaneous mastectomy through an infra-areolar incision.
• Liposuction not required.

Grade II

Presentation:

• Hypertrophy of all structural components of the breast.
• NAC (Nipple Areolar Complex)  is above the IMF (Inframammary Fold) 

Treatment:

• Ultrasound-assisted liposuction
• Subcutaneous mastectomy through an infra-areolar incision.

Grade III

Presentation: 

• Hypertrophy of all structural components of the breast.
• NAC (Nipple Areolar Complex) at the same height or 1 cm below the  IMF (Inframammary Fold) 
• Includes Male Tuberous Breast

Treatment:

• Ultrasound-assisted liposuction
• Subcutaneous mastectomy through an infra-areolar incision.
• Circular removal of skin around he NAC with round block structure

Grade IV

Presentation: 

• Hypertrophy of all structural components of the breast.
• NAC (Nipple Areolar Complex) at the same height or 1 cm below the  IMF (Inframammary Fold) 

Treatment:

• Central pedicle reduction mastectomy techniques
• No liposuction required

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Advantages of the The Cordova and Moschella System 

The Cordova and Moschella Classification System for gynecomastia offers several advantages that have made it a valuable tool for both surgeons and patients. A precise focus on anatomical features and flexibility in guiding surgical treatments are key strengths. 

These are the advantages:

Holistic, Multi-Dimensional Approach

Though the system addresses the size of the breast tissue, it also takes factors such as skin excess, glandular and fatty tissue composition, and the degree of sagging (ptosis) into account.  

Differentiates Between Glandular and Fatty Components

By differentiating between the glandular and fatty components, the system allows for more precise diagnoses and treatment planning.

Guides Surgical Decisions

The classification helps surgeons choose the best approach for each grade. Lower grades may only require liposuction, for example, while higher grades might need excision or more extensive glandular resection.

Predicts Surgical Complexity

By categorising the severity of gynecomastia and ptosis, the system predicts the complexity of the surgery needed. This helps to improve  patient counselling and treatment planning.

Tailored Surgical Approaches

The system encourages personalised treatments based on individual characteristics, leading to better aesthetic outcomes. Because treatment can be more tailored, patients experience better results. 

Standardised Language

The classification provides a standardised way for surgeons to describe gynecomastia, which improves communication between patients and their surgeons.

Accommodates Various Body Types

The system accommodates a range of body types and varying degrees of severity, making it applicable to a wide range of patients.

Addresses Ptosis and Skin Laxity

Many classification systems overlook skin laxity or ptosis (sagging), but Cordova and Moschella incorporate these factors, which are essential for planning skin-tightening procedures.

Anticipates Complications

The system’s grading allows surgeons to anticipate challenges during surgery, which can minimise complications and improve recovery times.

Focus on Aesthetic Outcomes

Because the system classifies according to the amount of excess skin and tissue composition, surgical outcomes are not just functional but also aesthetically pleasing.

Disadvantages of the The Cordova and Moschella Classification System for Gynecomastia

While the Cordova and Moschella Classification System for gynecomastia offers many advantages, it also has certain limitations which can affect its applicability and usefulness in clinical practice.

Complexity in Classification

Because the system incorporates multiple factors and makes it more comprehensive and complex, it is harder for less experienced surgeons to use or understand.

Time-Consuming

Accurately assessing all the factors involved, (e.g., glandular tissue, fat, skin excess, ptosis) can be more time-consuming during evaluations.

Subjectivity in Application

The evaluation of skin excess, ptosis, and tissue composition can be somewhat subjective, leading to variability in surgical planning and outcomes.

Lack of Objective Measurement

The system relies on visual and manual assessments without the use of standardised, objective tools which may lead to inconsistent classifications between providers. 

Geared Only Towards Surgical Interventions 

The system is heavily geared toward guiding surgical interventions and does not offer insight into non-surgical treatment options.

Doesn’t Address Underlying Causes

While it is useful for surgical planning, the classification does not account for the underlying causes of gynecomastia.

Focus on Advanced Cases

The system is useful for more advanced cases of gynecomastia, however, it does not provide significant benefits in guiding treatment for mild or early-stage gynecomastia. 

Limited Global Use

Because the Cordova and Moschella system is not as widely adopted as some other systems, some surgeons still prefer simpler or more widely known grading systems.

Lack of Comparative Studies

Fewer comparative studies validating the superiority of this classification system over others make it difficult to determine whether it offers significant advantages.

Does Not Address Psychological Impact

Gynecomastia often has psychological and emotional implications for patients. This system focuses purely on anatomical features and surgical treatment, with no guidance on addressing psychological aspects.

Summary

The Cordova and Moschella Classification System stands out for its detailed, treatment-oriented approach, its adaptability to various body types, and its ability to guide both surgeons and patients toward the best possible outcomes in gynecomastia treatment. Its tailored, patient-specific approach helps to improve surgical results and overall satisfaction.

The system has limitations in terms of complexity, subjectivity, and its focus on surgical treatment, however, which makes it less applicable for less experienced surgeons, patients with mild cases, or non-surgical management. Additionally, it does not address the underlying causes or psychological aspects of gynecomastia.

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Dr Bernard Beldholm’s Take

Having reviewed and referred to this classification system over the years, Dr Bernard offers these thoughts regarding this method:

• The Cordova and Moschella Gynecomastia Grading System is a useful tool in both clinical practice and research, helping standardise treatment approaches and improving patient outcomes in the management of gynecomastia.
• It takes the position of NAC (Nipple-areola complex) and gland excess into account. 
• It is not very precise, however, as it frames the excess as “hypertrophy” and does not give a good sense of the extent of hypertrophy.
• In grade 4, I would recommend excision of the skin with NAC grafts.

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