Gynecomastia classification for surgical management: A systematic review and novel classification system

Sir: We read with interest the article entitled “Gynecomastia Classification for Surgical Management: A Systematic Review and Novel Classification System” by Waltho et al.1 The authors offer a good systematic review of the gynecomastia classification systems present in the literature and propose an “ideal classification” (McMaster classification of gynecomastia). We agree completely with the authors about an “ideal classification” that is universal, includes all causes of gynecomastia, and consisting of patient-related features (e.g., breast size, tissue predominance). In the classification systems reviewed in the article, none has considered the body mass index as a “patient characteristic.” Again, we agree with the authors that the body mass index be considered essential, as it allows a more appropriate surgical algorithm to be obtained. In this regard, we cite an article published in 2016 entitled “Management of Gynecomastia in Patients with Different Body Types.”2 In our experience, we divide patients into three categories: Group A: subjects with athletic physique, body mass index less than 25 kg/m2, high muscle mass, and body fat less than 9 percent. Group B: subjects with normal physique, not particularly muscular, and a body mass index less than 25 kg/m2. Group C: overweight subjects with a body mass index greater than 25 kg/m2. For us, it is important to divide patients according to their physical characteristics, in particular, the body mass index. In fact, the requests and the needs of patients were different in the three categories; thus, the surgical approach needed in the different groups was different.For example, the low percentage of fat tissue in high-muscle-mass patients renders the gland even more pronounced and thus these patients seek surgical consultation to ensure a better definition of the pectoralis area that cannot be obtained by simple physical training. In these patients, the definition of the pectoralis muscle is important; thus, to respect this standard, we perform a subcutaneous mastectomy where the adipocutaneous flap must be as thin as possible to achieve the maximum contouring of the pectoralis area even if the low percentage of fatty tissue leaves any postoperative irregularities more visible and, consequently, more frequent in groups A and B rather than in overweight patients. Thicker flaps were performed in normal (group B) and overweight (group C) patients to obtain a more suitable contouring according to the patient’s chest profile. We conclude by pointing out that it is desirable that a classification system includes all causes of gynecomastia, and that body mass index is an essential element in the evaluation of the causes and the determining factor in the choice of surgical procedures.