INTRODUCTION: Gynecomastia is a relatively common aesthetic deformity which will be exacerbated by the current epidemic of obesity in the United States. Depending on patient age, historical incidence of gynecomastia ranged from 7.7 to 30%. An increase in these numbers is predicted. Additionally, as male patients demand more cosmetic procedures, techniques for management of gynecomastia must based on grade, desired cosmetic effect, and patient characteristics including skin laxity and body habitus. METHODS: For patients presenting with gynecomastia to a university teaching facility the following surgical approaches were used: Grade 1 – Periareolar or transaxillary/endoscopically-assisted resection (depending on patient preference); Grade 2 – transaxillary/endoscopically-assisted resection +/- ultrasound assisted liposuction; Grade 3 – horizontal scar resection with ultrasound assisted liposuction. Case examples are provided. RESULTS: Overall aesthetic improvement has been noted. Incision placement, paucity of concentric nipple scarring, and avoidance of Wise pattern scars have been viewed favorably. CONCLUSIONS: This algorithmic approach for management of gynecomastia reviews some commonly utilized procedures. Additionally, the widely forgotten technique of horizontal scar resection is revisited. Additionally, utilization of ultrasound assisted liposuction for improved chest wall aesthetics is emphasized. Results from these minimal scar techniques have been viewed positively suggesting an attractive surgical algorithm.