What is Pseudogynecomastia

Cosmetic surgery patients are concerned about the appearance of their breasts, not their contents. From an appearance point of view, pseudogynecomastia does not exist. The patients seek flat chests irrespective of whether their breasts contain glands or fat. Some of these patients are dissatisfied by the partial return of enlargement of their breasts after liposuction alone.

The term “pseudogynecomastia” seems to be the culprit that misleads surgeons because it is used almost synonymously with the treatment method of applying liposuction alone. Avoidance of the term “pseudogynecomastia” could be doubly beneficial. On the other hand, the incidence of residual gynecomastia resulting from “liposuction alone for pseudogynecomastia,” could be significantly reduced or even eliminated.

Dr. Ishoo hopes to change the narrative around the diagnoses of pseudogynecomastia and justification of treatment of “pseudogynecomastia” by some surgeons using liposuction alone, and save the resultant unhappy patients because of residual breast gland tissue and true gynecomastia. Dr. Ishoo has for many years attempted to educate and  appeals to the medical community and especially the surgeons treating gynecomastia to consider discouraging usage of the term “pseudogynecomastia,” at least until the causes of residual gynecomastia are elucidated, and measures to prevent residual gynecomastia after liposuction alone are established.

Definition of Pseudogynecomastia

In True Genecomastia, overly large male breasts are only caused by an excess accumulation of glandular breast tissue. This extra tissue buildup usually begins developing during puberty due to hormonal fluctuations, and for many young men, it resolves on its own. In the event there is no underlying medical condition that can be treated and the condition persists (which could take approximately one to two years following the end of puberty), surgical intervention will be necessary for men seeking to reduce the size of their breasts and improve their overall chest contour.

In Pseudogynecomastia, the primary cause of enlarged male breasts is excess weight gain and  buildup of fat that often manifests around, behind, or underneath the nipples. Although certain diets, lifestyle changes and weightlifting techniques and pectoral exercises can help some individuals improve this condition by toning the chest, the actual deformity does not self-correct without surgical intervention.

You may often see that many “experts” claim on their websites that “If male breast enlargement is caused by glandular proliferation, it is defined as gynecomastia. If it is caused by increased fat deposition, it is defined as pseudogynecomastia .” And recommend that “Pseudogynecomastia is an ideal condition for ‘liposuction alone’, whereas gynecomastia can be treated by surgical excision, liposuction, or a combination of both.”

These quotes seem to represent the current beliefs of the medical fraternity about enlarged male breasts. Presumably based on such beliefs, patients are advised to undergo radiologic investigations such as ultrasound scanning, mammography, contrast-enhanced computed tomography (CT scan), and magnetic resonance imaging (MRI) to differentiate pseudogynecomastia from gynecomastia. Moreover, these patients are treated by applying liposuction alone for so called “pseudogynecomastia”.

Causes of  Pseudogynecomastia

Dr. Edwin Ishoo has been  fortunate to have treated thousands of patients in his career spanning more than 30 years. Beyond the physical symptoms of gynecomastia, he does not believe there is much scientific research addressing the true cause of gynecomastia, other than the basic observation that imbalance of sex hormones estrogen and testosterone can lead to the enlargement of breast tissue.

In morbidly obsess men, testosterone levels tend to be lower than average, while estrogen levels are higher. We can measure this in their blood. Theoretically, there is peripheral conversion of testosterone to estrogen that is accelerated in those who are obese. More fat = more conversion of testosterone to estrogen = an imbalance of the “normal” ratio seen in men = ideal environment for the development of gynecomastia.

All men have some breast tissue beneath their nipple-areola complexes. This tissue is unique and unlike normal fatty tissue elsewhere throughout the human body. This tissue is sensitive to changes in the testosterone-estrogen balance. In men, testosterone predominates, and the tissue does not grow. In women, estrogen dominates, and their breast tissue grows, leading to the appearance of fuller breasts. In men, this tissue can grow with exposure to excess estrogen and cause gynecomastia. Not in all men, but in some. Cases due to hormone imbalance can vary, as tissue can have varying degrees of sensitivity to estrogens.

Based on this understanding of how hormones work, you can imagine that as a man accumulates more fat, there is more conversion of testosterone to estrogen and that this can stimulate their chest tissue to grow, in addition to the accumulation of normal fatty tissue in the chest area. Over time, this tissue becomes stable gynecomastia tissue that doesn’t change with weight loss. Imagine that during weight loss the normal fat is lost but the stable gynecomastia tissue remains. This helps explain why thousands of emails that I get from all over the world are from guys who have heard the term pseudogynecomastia and who had lost weight but are perplexed by the remaining chest fullness. In many cases, this makes the gynecomastia appear more pronounced, as it is no longer camouflaged by the fatty tissue elsewhere.

You can certainly make the argument that obesity is a risk factor for developing gynecomastia. Unfortunately, diet, exercise and pills will not make it go away. The only known definitive treatment for gynecomastia is the surgical removal of the offending tissue.

Pseudogynecomastia Treatment

Achieving and maintaining healthy weight and lifestyle are strongly encouraged as the first step for all our patients. However, if the term pseudogynecomastia means a female-looking breast in an overweight man caused by excess fat, why does it not go away after weight loss?Dr. Ishoo believe this is because these patients have also developed an enlarged breast gland which persists.

Some surgeons routinely apply liposuction alone to treat both gynecomastia and pseudogynecomastia patients. However, most of their patients will likely have some residual or partial recurrence of breast enlargement a few months after liposuction . In addition, a close look at published “satisfactory” results of treatment using “liposuction alone” shows some breast enlargement remaining in some patients, irrespective of whether they had pseudogynecomastia or gynecomastia preoperatively.

In reality, the vast majority of men who desire gynecomastia treatment have an excess of both fat and glandular tissue in the breasts. As a result, our Boston Gynecomastia Surgeon, Dr. Edwin Ishoo, often employs a unique, minimally invasive male breast reduction technique that addresses both the fatty and glandular tissue using VASER and Power Assisted Liposuction with minimally invasive PEXsculpt, microdebrider excision method. He then optimizes aftercare with compression garments designed to facilitate skin retraction for optimal results. Following surgery, patients usually experience a considerable boost of self-confidence and esteem as a result of their more masculine-appearing chest.