Type 4 is characterized by the breast drooping and nipple falling 2 cm or more below the chest fold. There is usually a breast roll present.
Based on over 2500 gynecomastia surgeries, Dr. Cruise has classified gynecomastia into 6 different types.
Each type is unique in its own way and must be treated differently. The purpose of the Cruise Classification System is to:
A classification system is only useful if it outlines a treatment plan.
Dr. Cruise
Notice the progressive increase in skin laxity. This excess skin will change the type of surgery necessary to properly correct the problem.
Type 4 Gynecomastia has breast tissue that extends into arm pit region similar to type 3.
The major difference is that there is significant excess skin that causes the horizontal chest fold to extend into arm pit creating a breast roll. Proper assessment requires that you take into consideration that removing the gynecomastia tissue will cause “deflation”. Evaluation requires knowing how much skin will be present after tissue removal. Tightening this skin is often required to achieve long term, masculine chest results.
The most obvious difference between Type 4 and Type 3 is the breast roll. In type 3, the breast roll is minimal if any. With Type 4, the breast roll is clearly present particularly when you consider the sag/deflation that will occur when the breast tissue is removed. Unlike Type 5’s, skin excess is primarily one directional. It can easily be tightened by simply grabbing the skin along the pectoralis border and pinching together – simulating what would happen with surgical tightening.
Like Type 3, the breast tissue drapes over the pectoralis muscle into the arm pit. The tissue is usually more fatty and saggy. The sag is primarily from the skin no longer being able to hold it in place.
Unfortunately, the clinical definition for optimal results is virtually non-existent; even in plastic surgery literature. This is why it was essential for Dr. Cruise to include it as part of the Cruise Classification System.
A classification system is only useful if it identifies where you are and where you need to go. The first part of the classification system identifies 6 basic types of enlarged breasts based on where you are. This next part of the system identifies where you need to go. It is true, different men have different goals. This is particularly true with Type 4 Gynecomastia. However, Dr. Cruise’s has identified eight fundamental aspects of the male upper chest that need to be evaluated in order to achieve optimal results. Page down to see the eight components that define a masculine chest.
Optimal results for Type 4 patients require critical evaluation of the first 6 components. Determining your goals while addressing these components is what determines your surgical road map. This is particularly true for Type 4 as excess skin is becoming more significant with the need for more dramatic treatment. The upside to this is dramatically improved results.
“Achieving optimal results and avoiding complications requires both expertise and a plan”
Dr. Cruise
External view of masculine chest
Internal view of masculine chest
The Cruise classification accurately defines “where you are”. Now, we need to clearly define in surgical terms “where you want to go.”
With this is mind, we asked Dr. Cruise to outline the most important aspects that need to be addressed when surgically treating gynecomastia and what they should ideally look like.
Overall, a masculine chest is full and powerful above the nipple but ripped and defined below. The key is to create muscle definition, flatten the nipple, yet keep the chest area above the areola normal thickness. Thinning too much will create a “fragile” appearance and worse, may create contour irregularities. The goal is to flatten the chest so that you can confidently wear tight white T-shirts and to create a V shape from both the back and front view.
While most gynecomastia patients are looking for a “flat” chest what they really mean is they want a masculine chest. There is a difference. Overall, a masculine chest is flat with a defined pec. major muscle. The upper chest should remain full and powerful. The goal is to create a sculpted look by getting the nipple to lay flat against the pec. major muscle and by getting the the skin to wrap around the border of the muscle into a sculpted axilla.
The areola is the dark, pigmented skin around the nipple. Areola size is proportionate to chest size. Ideally, it should 25-35 mm and lay flush with the surrounding skin. However, slight elevation is common. Most people do not consciously realize it but areolas are usually wider than they are tall. A perfectly round areola is not ideal and an areola that is taller than it is wide may even appear unusual or “surgical”. This is particularly relevant with Types 4, 5 and 6 which usually require reducing and re-positioning the nipple with a free nipple graft. A protruding nipple is common with puffy nipple due to the pressure from the swollen breast tissue below. However, there are situations where the nipple is simply enlarged. Fortunately, reducing the nipple by excision is straight forward, low cost, little down time and very effective.
Ideally, the pectoralis major muscle should be defined and straight with the skin wrapping around it into a well defined chest fold and then into a defined arm pit hollow. Excess breast tissue, fat and/or saggy skin will blur this border and create a round, feminine appearance.
Should have sculpted appearance with a well define hollow at its apex. The borders of the pec. major in front and the latissimus dorsi in back should be well defined giving a V shape to the upper body. Excess fat/saggy skin can fill the arm pit creating an uncomfortable fullness in armpit and a saggy breast roll just below. For types 5 and 6’s, this is often as big of a concern as the chest. Creating a sculpted axilla and a V shape appearance to the upper body is one of the most rewarding parts of gynecomastia surgery yet it is usually overlooked as not being part of the gynecomastia. It is important for your surgeon to understand that the goal of surgery is to create a V shaped, masculine chest and not just to remove breast tissue. While this is true for all types it is particularly relevant for types 4,5 and 6. I can not tell you have powerful the results are when you create a sculpted pec., lat. and arm pit. It is truly life changing.
Ideally, there should not be any fat pockets. There are three common fat pockets that need to be evaluated and removed if present:
Should not be present. Lateral chest/arm pit skin should be tight enough to prevent breast rolls, create a defined pec. border and lat. border with a sculpted arm pit in between. Breast rolls represent saggy skin under the arm pit. Flattening the chest and not correcting breast rolls actually makes the breast rolls more noticeable and creates a disproportionate look to the upper body.
Should not be present. They represent saggy skin that goes all the way around to the back. Optimal surgical treatment requires removing all the excess skin in a 360 degree fashion. Often seen with massive weight loss patients.
See below for Dr. Cruise’s preferred incision options for treating Type 4 Gynecomastia.
Type 4 Gynecomastia patients are often in good physical shape but have significant excess chest and arm pit skin laxity. This physical condition allows them the opportunity for a youthful, masculine chest that they can be proud of.
While type 5 and 6 patients have significant issues that need to be overcome, Type 4 typically just requires proper nipple placement and a tight skin envelop. As one of the top gynecomastia surgeons in the U.S., Dr. Cruise uses his expertise to create a sculpted arm pit with a well defined hollow at its apex. He then flanks the areas to define borders of the pec. major in front and the latissimus dorsi in back. This not only shapes the chest but gives a powerful, well defined V shape to the upper body. Typically, this can only be achieved with the longer, chest lift incision as opposed to the shorter super extended superior incision. The techniques explained here are likely not practiced by doctors who perform just a few male breast reduction surgeries per year. A great deal of knowledge, skill, and experience is necessary to properly execute this type of surgical plan.
Chest Tightening with One of the Following:
This technique is also referred to as Pedicle Gynecomastia. It is the most predictable way to create a truly youthful chest that will last virtually forever.
It involves removing excess skin by leaving a well hidden incision directly in the chest fold. The nipple never leaves the body, maintaining its own blood and nerve supply. This makes for a much easier recovery. Its biggest limitation is with significant amounts of glandular tissue.
The best option for Type 4 requires a chest lift incision that removes a swath of skin from the medial chest into the arm pit. It also re-positions the nipple/areola exactly where you want it with exactly the chest thickness you want. While this may seem like a long incision, it is actually very well hidden with time as it falls into the nature chest fold crease. When placed correctly, the incision replaces the rounded, feminine shape of the chest to one that is straight, well defined, and follows the margin of the pec. major muscle creating a much more masculine look.
Well over 500 cases has shown that there is little regret going with this incision because its dramatic, youthful improvement of chest shape far out-weighs the incision; even in patients that tend to keloid. While on the other hand, patients have regretted going with a smaller procedure and not tightening the skin more.
The three significant advantages of this procedure are:
A free nipple graft means that the nipple and areola are re positioned as a skin graft. This requires 2 weeks of wearing a vest 24/7.
Pedicle Gynecomastia Surgery
"80% of results is done during surgery, 20% of your results is aftercare"
View our gallery of gynecomastia before and after photos to see the results from Type 4 Gynecomastia surgery. Remember each patient is unique and results will vary from person to person.
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The pain and suffering associated with gynecomastia is unlike any other condition in plastic surgery and perhaps in all of medicine. The range of its impact is stunning. Some men (usually older) can be relatively unaffected while others (usually the younger) can be completely devastated and even suicidal.
Unfortunately, because of the stigma associated with it, it is not always readily apparent what your loved one may be experiencing. In fact, the men or more commonly pubescent teenagers, who are most deeply affected go to great lengths to suffer alone. The Internet becomes the only one they can talk to. This dangerous combination of deep emotional pain and isolation makes them particularly vulnerable to exploitation. Exploitation that takes the form of the literally thousands of “miracle” cures that have no medical merit to the more nefarious types looking to take advantage of the the emotionally weak.
Behavior:
Gynecomastia surgery is a tangible next step to resolve your man boobs. Dr. Cruise has performed over 5,000 gynecomastia surgeries and is ready to see you for a consultation. Call us at 949-644-4808 or fill out our online contact form and you will be contacted with the next steps!
Gynecomastia surgery is a tangible next step to resolve your man boobs. Dr. Cruise has performed over 5,000 gynecomastia surgeries and is ready to see you for a consultation. Call us at 949-644-4808 or fill out our online contact form and you will be contacted with the next steps!
