Gynecomastia Type 5- Chest Angle Greater than 90° Significant Sag

Definition
Chest angle is greater than 90 degrees. Breast tissue sags below chest fold. Signficant chest sag.

Physical Exam

Type 5 gynecomastia is defined as breast tissue that drops below the chest fold as shown in the two images below. has sagging breast tissue below the chest fold and the bottom of the areola is located above the chest fold. The main surgical difference of a Type 5 from a Type 4 is that a donut lift will not reliably tighten the skin enough to produce an acceptable appearance.

Gynecomastia Type 5

Notice the breast tissue sags slightly below the
chest fold.

If a donut lift were performed on a type 6 one of two things would happen. One, the donut lift would be so big that it would leave significant rippling and a poor scar or, two, the chest would sag.

The image below outlines the 7 types of gynecomastia. Types 1 is Puffy Nipple. Types 2-5 are determined by the chest angle. Types 6 and 7 are determined by the position of the nipple in relation to the chest fold.

Gynecomastia Types

The 7 types of gynecomastia. The horizontal line represents the level of the chest fold. Notice the progressive increase in skin laxity. This excess skin will change the type of surgery necessary to properly correct the problem

The purpose of categorizing gynecomastia is to determine what type of surgery is necessary to correct a given problem. Joseph T Cruise, MD has developed this classification system based on the extensive work he has done with gynecomastia patients. Other surgeons may use other methods.

Here is how the type of surgery changes depending on the gynecomastia type.

Type 1 - Incision at lower margin of areola
Type 2 - Incision at lower margin of areola
Type 3 - Incision at lower margin of areola or donut lift
Type 4 - Donut lift or anchor lift
Type 5 - Anchor lift
Type 6 - Anchor lift or free nipple graft
Type 7 - Free nipple graft

Here is an enlarged view to show the differences between Types 2-5. The reason why these are grouped together is because the differences are relatively close but they are enough to change the type of surgery necessary to obtain a good result.

Skin laxity differences between types 2-5

Notice the progressive skin laxity from type 2-5. This excess skin will change the type of surgery necessary to properly correct the problem.

Diagnosing a Type 2,3,4 and 5 gynecomastia. The major difference between the different types is not so much the volume, but rather the skin excess. As you go up, the amount of skin excess increases. This increase in skin excess changes the procedure necessary to correct it. With increasing skin excess, the chest will sag more. This will result in the Chest Fold Angle (CFA) getting smaller and smaller as shown above. Keep in mind, when the breast volume is removed the chest will deflate causing significantly more chest sag. This will further increase the need for skin removal. Failure to address the skin laxity may make the sagginess worse. Fortunately, for type 2 gynecomastia, the chest will likely "snap back" without any skin removal.

• Type 2    <45 degrees
• Type 3    45-60 degrees
• Type 4    60-90 degrees
• Type 5    >90 degrees

Surgical implications

1. Liposuction
   May or may not be useful to remove breast tissue depending on whether or not it is fatty or glandular. If patient is heavy, it may be used to flatten breast roll or decrease fatty deposits at chest margin.
2. Surgical removal of breast tissue
   Surgical removal of breast tissue is often method of choice to ensure that all necessary breast tissue is removed.

Difference between a donut lift and anchor lift in a Type 5

Before
 
 
 

After
Breast tissue removal with donut liftNotice the contour irregularity at the bottom of the
chest and the rippling around the areola.

After
Breast tissue removal with anchor lift Notice how the skin envelop is much tighter than with the donut lift.

Preferred incision for Type 5

Type 1 - Incision at lower margin of areola
Type 2 - Incision at lower margin of areola
Type 3 - Incision at lower margin of areola or donut lift
Type 4 - Donut lift or anchor lift
Type 5 - Anchor lift
Type 6 - Anchor lift or free nipple graft
Type 7 - Free nipple graft

Incisions for Type 5 gynecomastia

Donut lift

Anchor lift

Type 5 gynecomastia is treated with an anchor lift. Patients with Type 5 have too much excess skin to be treated effectively with a donut lift. If a donut lift were performed on a Type 5 there would be significant rippling as well as persistent saggy breast tissue.