Comprehensive Surgical Management of Grade III and IV Gynecomastia: Our Approach and Experience

Abstract

Background: Gynecomastia, the benign proliferation of male breast glandular tissue, is often associated with adiposity and skin redundancy. Surgical intervention for advanced grades (III and IV) remains challenging due to significant skin excess, glandular ptosis, and descent of the nipple-areolar complex (NAC). Objective: To present our experience and novel techniques in the management of Grade III and IV gynecomastia over a one-year period. Methods: Seventy-three patients with gynecomastia, treated between February 2024 and 15 May 2025, were prospectively evaluated. Patients were categorized using Simon’s classification. Data collected included demographic information, comorbidities, and surgical outcomes. Surgical techniques varied by grade, with a unique approach employed for Grades III and IV involving quilting sutures and bipedicle NAC flaps. Postoperative outcomes and satisfaction levels were assessed over a follow-up period of 3 - 12 months. Results: Of the 73 patients, the mean age was 27.5 years (range: 18 - 51) and BMI ranged from 21 to 35. High satisfaction rates were reported by patients (95%) and surgeons (91%). Complications were minimal, and scars were generally well-tolerated and faded away after few weeks, particularly in patients with chest hair. Conclusion: To our best knowledge, this is the first paper that reports one-stage surgery for grade 4 Gynecomastia. Our one-stage surgical technique offers a reliable, aesthetically pleasing solution for advanced gynecomastia. The use of quilting sutures (has been reported few in other surgeries and not in Gynecomastia) and bipedicle flaps for NAC repositioning effectively addresses drooping excess skin and glandular ptosis while minimizing visible scarring.