[Medical Column] Gynecomastia Simon Classification: Myths and Facts
Does the Simon Classification determine the severity of gynecomastia based on the size of the glandular tissue?
No. The Simon Classification primarily evaluates the degree of breast enlargement and skin excess or sagging.
The absolute size or thickness of the glandular tissue is not a criterion used to determine the Simon grade.
Written by Dr. Jihoon Moon, Lesarts Plastic Surgery
This medical column was written directly by the attending surgeon.
※ Unauthorized reproduction, editing, or redistribution is prohibited. ※
One of the questions I hear most often during consultations is:
“Doctor, another clinic told me my gynecomastia was Grade 2a.
Why is it classified as Grade 2b here?”
Another common question is:
“I was told that my glandular tissue is quite large.
Does that automatically mean I have Grade 3 gynecomastia?”
When searching for information about gynecomastia online,
one of the most commonly encountered systems is the Simon Classification.
However, most blogs and clinic websites simply list the basic definitions
from Grade 1 through Grade 3 without clearly explaining how this classification is actually applied in clinical practice
or what limitations the system may have.
In this article, we will take a closer look at the straightforward structure of the Simon Classification,
which is widely used as a standard system for evaluating gynecomastia,
as well as several important facts that patients commonly misunderstand.
1. The Simon Classification: A Simple and Intuitive Three-Grade System
First introduced by Simon and colleagues in 1973,
this classification system remains one of the most widely used guidelines
in breast surgery and plastic surgery worldwide, even more than half a century later.
The structure itself is relatively simple.
It classifies the appearance of the chest into different grades
based on the degree of breast enlargement
and whether excess or sagging skin is present.
• Grade 1: Mild enlargement limited mainly to the nipple and areola,
with no excess or sagging skin.
• Grade 2a: Moderate breast enlargement is present,
but there is no noticeable excess or sagging of the chest skin.
• Grade 2b: Moderate breast enlargement is accompanied by early signs
of excess skin or downward sagging.
• Grade 3: Severe breast enlargement is accompanied by significant excess skin
and pronounced sagging, creating a more female-like breast appearance.
One of the greatest advantages of the Simon Classification
is its intuitive and straightforward nature.
Through visual examination and palpation,
physicians can quickly assess the overall shape of the chest
and determine which grade most closely describes the patient’s condition.
2. Why Can the Same Chest Be Classified Differently at Different Clinics?
If the Simon Classification is relatively simple,
why might a patient receive different grades at different clinics?
The reason lies in the subjective nature
of the Simon Classification.
The Simon Classification does not use objective numerical measurements,
such as a specific number of millimeters of sagging, to determine each grade.
The distinction between Grade 2a and Grade 2b
is particularly likely to cause confusion.
When the chest is moderately enlarged with only slight skin sagging,
one physician may classify it as Grade 2a, considering the appearance to be related to the patient’s natural body shape
without significant skin excess.
Another physician may interpret the same condition as Grade 2b,
considering it an early sign of breast ptosis or skin laxity.
Therefore, receiving slightly different grades at different clinics
does not necessarily indicate a lack of experience on the part of the physician.
Rather, it reflects an inherent characteristic
of a classification system based partly on subjective morphological assessment.
More important than the grade itself is how the physician interprets the patient’s skin elasticity and degree of sagging
and incorporates those findings into the surgical plan,
including the extent of liposuction and the amount of correction required.
3. One of the Most Common Misconceptions: Glandular Tissue Size Does Not Determine the Simon Grade
Many patients ask:
“My ultrasound showed that my glandular tissue is 3 cm.
Does that mean I automatically have severe, Grade 3 gynecomastia?”
However, this is one of the most common misconceptions
about the Simon Classification.
Confirming the presence of glandular tissue, such as through an ultrasound examination,
is an essential part of diagnosing gynecomastia.
This is because it is important to distinguish pseudogynecomastia, which consists primarily of fatty tissue,
from true gynecomastia, in which actual glandular tissue has developed,
as this distinction can affect whether surgery is appropriate and how it should be performed.
Key Point: The absolute size or thickness of the glandular tissue
is not included as a criterion in the Simon Classification.
In other words, even if the glandular tissue measures less than 2 cm on ultrasound,
a patient with significant skin sagging may still be classified as Grade 3.
Conversely, even if the glandular tissue is relatively large at 3–4 cm or more,
a patient may still be classified as Grade 2a
if the overall chest contour is firm and there is no significant skin sagging.
It is important to remember that the Simon Classification is primarily a tool
for evaluating the external appearance of the chest, including the degree of enlargement and skin sagging,
rather than a system for measuring the size or volume of the internal glandular tissue.
4. The Simon Grade Can Change with Weight Fluctuations
A gynecomastia grade is not a fixed classification
that necessarily remains the same throughout a patient’s life.
Changes in body weight, as well as changes in skin elasticity with age,
can alter the appearance of the chest
and may result in a different Simon grade over time.
• When Weight Increases
As fat accumulates around the glandular tissue,
the overall volume of the chest may increase.
If the increased volume stretches the skin,
a chest previously classified as Grade 1
may progress to Grade 2a or Grade 2b.
• When Weight Is Lost Through Diet
As body fat decreases,
the overall volume of the chest may also become smaller.
However, previously stretched skin may not fully contract
and can remain loose even after the underlying volume has decreased.
In this situation, the chest may become smaller in volume
while skin sagging becomes more noticeable,
making a previous Grade 2a appearance resemble Grade 2b.
Therefore, when planning gynecomastia surgery,
it is important to consider more than the patient’s current Simon grade.
A comprehensive assessment should also include the patient’s history of weight fluctuations,
future weight-loss plans, and the skin’s ability to contract and recover.
View More Lesarts Gynecomastia Surgery Cases
Conclusion: An Accurate Diagnosis Is the Foundation of a Successful Surgical Outcome
The Simon Classification remains a useful guideline
for understanding gynecomastia and determining the general direction of surgical treatment.
However, it is only the first step in evaluating the overall contour of a patient’s chest
and should not be considered a complete guide that provides every answer needed for surgery.
In actual surgical planning, many factors must be assessed together
in addition to the patient’s external appearance according to the Simon Classification.
These include the density and distribution of glandular tissue identified through ultrasound,
the thickness of the fat layer in the central and lateral chest,
the size of the areola, and the elasticity of the skin.
This is why there is no need to become overly concerned
or make assumptions about your condition simply by comparing your chest
with Simon grades found through an online search.
If you are concerned about the shape of your chest,
we recommend undergoing a one-on-one ultrasound examination and consultation
with an experienced physician who has a detailed understanding of breast anatomy.
A thorough evaluation can help determine
a surgical plan tailored to your individual chest structure and condition.
FAQ
Q1. What is the Simon Classification for gynecomastia?
The Simon Classification is a system used to categorize gynecomastia
based mainly on the degree of breast enlargement and the presence of excess or sagging skin.
Q2. What is the difference between Simon Grade 2a and Grade 2b?
Grade 2a involves moderate breast enlargement without significant skin excess,
while Grade 2b includes moderate enlargement with signs of skin laxity or sagging.
Q3. Can different clinics assign different Simon grades to the same patient?
Yes. The Simon Classification does not rely on specific numerical measurements for skin sagging,
so borderline cases may be interpreted differently depending on the physician’s assessment.
Q4. Does larger glandular tissue mean a higher Simon grade?
No. Glandular tissue size itself does not determine the Simon grade.
A patient with large glandular tissue but little skin sagging may still be classified as Grade 2a.
Q5. Can a patient’s Simon grade change after weight gain or weight loss?
Yes. Changes in body weight can alter chest volume and skin laxity,
which may change how the chest is classified under the Simon system.
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