Gusenoff Gynecomastia Classification System (2008)

Developed by Jeffrey A. Gusenoff to classify gynecomastia based on the severity of breast tissue enlargement, skin excess, and the degree of ptosis (sagging), the Gusenoff Gynecomastia Classification System is particularly focused on guiding surgical treatment for patients, providing a clear framework for surgeons to choose the appropriate technique based on the severity of the condition.

This section covers one of the numerous classification systems for gynecomastia, originally developed by Gusenoff to give a precise understanding of this grading approach. However, Dr. Beldholm uses a unique grading system in his practice, which he believes provides improved assessment and treatment recommendations. For a full overview of available gynecomastia grading systems, refer to Dr. Bernard Beldholm’s article: Dr. Bernard Beldholm’s Comprehensive Summary of Gynecomastia Surgery Grading Systems.

Key Elements of the Gusenoff Gynecomastia Classification System

1. Breast Volume: Enlarged breast tissue (glandular or fatty) 
2. Skin Excess: Degree of redundant skin
3. Ptosis (Nipple Position): Degree of sagging based on the nipple’s position relative to the IMF (inframammary fold).

Gusenoff Gynaecomastia Classification System

The Gusenoff Gynecomastia Classification Grading System is divided into four grades, which consider both the glandular tissue hypertrophy and the degree of skin laxity (ptosis) associated with gynecomastia, allowing for better matching of surgical techniques to the patient presentation.

Grade 1a of the Gusenoff Gynaecomastia Classification System

• No excess skin roll laterally
• Minimal excess skin and fat on the chest 
• Minimal alteration in nipple location in one or both breasts
• Minimal descent of the inframammary fold

Grade 1b Gusenoff Gynaecomastia Classification System

• Lateral chest skin roll on one or both breasts
• Minimal excess skin and fat on the chest 
• Minimal alteration in nipple location
• Minimal descent of the inframammary fold

Grade 2 Gusenoff Gynaecomastia Classification System

• Nipple-areola complex (NAC) and inframammary fold below the ideal inframammary fold
• Lateral chest roll on one or both breasts
• Abdominal laxity

Grade 3 Gusenoff Gynaecomastia Classification System

• Nipple-areola complex (NAC) and inframammary fold below the ideal inframammary fold
• Lateral chest roll
• Significant abdominal laxity

Gusenoff Treatment Considerations

Treatment for gynecomastia varies depending on the grade according to the Gusenoff 2008 Gynecomastia Classification System. Here’s a breakdown of potential treatments for each grade:

Gusenoff Treatment Considerations Grade 1A

Involving only minor breast enlargement without excess skin or sagging, Grade IA is often treated with liposuction alone to remove excess fatty tissue or glandular excision if glandular tissue is present. Treatment includes ultrasonic and suction-assisted lipectomy followed by secondary excisional techniques if results are not satisfactory. 

Gusenoff Treatment Considerations Grade 1B

Disclaimer: Operation performed by Dr Bernard Beldholm. Adult content, surgery has risks; individual results vary, seek 2nd opinion. Please see the full disclaimer.

Treatment for this grade, which includes moderate enlargement with skin excess, is liposuction or glandular excision combined with skin tightening procedures to reduce sagging. Minor skin excision techniques (such as periareolar incisions) may be used to avoid extensive scarring. Treatment includes ultrasonic and suction-assisted lipectomy along with direct excision of the lateral chest roll as well as secondary excisional techniques for residual deformity. 

Gusenoff Treatment Considerations Grade 2 

Grade 2 pseudogynecomastia was treated with a dermoglandular pedicled reconstruction. The authors  advocated an elliptical excision of chest skin with the preservation of the nipple on a thinned, broadbased dermal pedicle.

Gusenoff Treatment Considerations Grade 3 

Disclaimer: Operation performed by Dr Bernard Beldholm. Adult content, surgery has risks; individual results vary, seek 2nd opinion. Please see the full disclaimer.

Due to the extent of resection, grade 3 pseudogynecomastia is treated with free-nipple grafting. The superior incision line is determined by downward retraction of the chest tissues to the desired location of the final scar. The inferior margin of resection is estimated by a pinch test conducted when the patient is standing preoperatively. The entire region is resected, including the chest deformity, lateral chest roll, and upper abdominal excess.

Download our free guide: “Do I have Gynecomastia? Find out in 3 Easy Steps”

Advantages of the Gusenoff Classification System

Surgical Focus

The classification is particularly helpful for surgeons in deciding the appropriate surgical technique based on the extent of gynecomastia and skin laxity.

Emphasis on Ptosis

One of the key features of this system is its emphasis on ptosis, which is critical in guiding the extent of skin excision and nipple repositioning.

Improves Surgical Outcomes

By categorizing patients into distinct grades, the system ensures more tailored surgical planning, reducing the risk of over- or under-treatment.

Disadvantages of the Gusenoff Classification System

Focused on Severe Cases

The system is primarily surgical in nature and may not be as useful for non-surgical management of early-stage gynecomastia or patients seeking less invasive options.

Complex Procedures for Higher Grades

For patients with Grade III or IV gynecomastia, the surgical procedures can be complex and may require advanced techniques for optimal outcomes.

Limited Differentiation

The Gusenoff system may lack granularity for differentiating between various tissue compositions (fat versus glandular tissue). Gynecomastia cases often present unique tissue distributions, which can affect treatment approaches. The system’s focus primarily on skin excess and ptosis (sagging) may overlook other anatomical nuances, limiting its precision in guiding surgical planning.

Subjectivity in Classification

Like many grading systems, the Gusenoff system can introduce subjective interpretation among surgeons. Variations in individual assessment of tissue laxity and skin quality can lead to inconsistent classifications across practitioners, potentially impacting treatment consistency and outcomes.

Focus on Severe Cases

The Gusenoff system is more useful in cases with significant ptosis or skin redundancy but may offer limited guidance for mild gynecomastia. As the system is primarily surgical in nature, it is not useful for non-surgical management of early-stage gynecomastia or patients seeking less invasive options.

Limited Guidance for Post-Weight Loss Patients

The classification was developed to address traditional gynecomastia and may not adequately account for the complex presentation of gynecomastia in massive weight-loss patients. These patients often have unique challenges with extensive skin laxity and variable tissue composition, which the Gusenoff system does not fully address.

Dr Beldholm’s Opinion of Gusenoff Grading System

• Though varying from patient-to-patient, most post-weight loss patients have limited benefit from non-invasive treatments such as liposuction as their skin is generally inelastic and will not pull back to the new shape.
• The pedicle technique leaves too much excess tissue and has a tendency to leave the male chest with a round, less-than-masculine appearance.
• The study was not large enough to reach many new conclusions.

Final Thoughts

The Gusenoff 2008 Gynecomastia Classification System is a practical and surgeon-oriented grading tool, particularly useful in evaluating and planning surgical treatments for patients with moderate to severe gynecomastia. Its emphasis on both breast volume and ptosis allows for a more personalized approach to treatment, ensuring that the surgical intervention matches the severity of the condition. However, its utility is more limited in non-surgical management or milder cases of gynecomastia.

An increasing number of male patients are presenting for treatment of male chest deformity after massive weight loss. The authors prefer to preserve the nipple-areola complex on a dermoglandular pedicle. They sought to identify detectability of technique, assess patient satisfaction, and outline a treatment algorithm for this population.

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