Grade 4 Gynecomastia: Why Horizontal Scars Often Give More Reliable Results

In my practice, grade 4 gynecomastia refers to cases with significant excess breast skin, where the nipple–areola complex is ptotic and lies below the inframammary crease.

For grade 4 gynecomastia, surgical correction typically requires skin excision with nipple-areola complex relocation, rather than gland excision alone.

The core issue usually isn’t only tissue volume. It’s that the skin envelope is too large and too low, with the nipple-areola complex sitting below the inframammary crease (fold). A circumareolar incision can remove tissue, sure, but it’s limited in how much reliable skin reduction and repositioning it can achieve without creating distortions or circulation issue.

Benefits of the horizontal (inframammary) approach

A horizontal approach offers more control of contour. It allows true skin excision, produces a flatter and more masculine chest contour, and addresses the lower pole and lateral chest better, where grade 4 skin excess and laxity commonly extends. In advanced cases, this predictability is why I often rely on this approach to achieve the most natural results for my patients.

Limitations of circumareolar-only approaches in grade 4 gynecomastia

Although periareolar/circuareolar scars can be well concealed, and I use them in most of my nipple areola lift cases, this procedure is not suitable for most grade 4 cases because of potential drawbacks if used for the wrong patient. These include areolar widening (the “donut scar” expands over time), puckering, a flattened or puffy areola, residual lower-pole laxity, and limited ability to remove skin where it is most needed. For this reason, I often avoid relying solely on a circumareolar lift in grade 4 gynecomastia.

Why larger scars can heal better

Counterintuitively, longer incisions may heal more predictably because tension is distributed over a broader area. Circumareolar techniques concentrate tension at the edge of the areola, increasing the risk of distortion and scar widening.

The patient’s choice with grade 4 gynecomastia surgery

Scarring has real psychological and social implications, and patient preference matters. Some patients prefer to avoid a visible horizontal scar, even though this may come with residual laxity, a higher likelihood of areolar widening, and a less aggressive contour correction.

However there are many patients who are happy to accept a horizontal scar line in exchange for maximising contour and lift, achieving a more natural male chest appearance.

Disclaimer:

Not medical advice. This reflects my clinical experience and explains why, in my practice, I often prefer a horizontal / inframammary scar for grade 4 gynecomasti

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