How important is "pseudogynecomastia"?

“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 [1].” “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 pseudogynecomastia and surgical excision for gynecomastia.

Some surgeons routinely apply liposuction alone to treat both gynecomastia and pseudogynecomastia patients. However, they likely have encountered some patients who have a partial recurrence of breast enlargement a few months after liposuction [2-4]. 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.

Liposuction alone, indeed, is a simple procedure for the treatment of enlarged male breasts. However, some breast enlargement is known to return after the procedure for some patients. Neither the cause nor the prevention of this recurrence is known [4].

Excisional surgery for both pseudogynecomastia and gynecomastia, with or without added liposuction for contouring of the chest and upper abdomen, ensures flat chests and no partial return of breast enlargement [5]. Liposuction alone, however, can be applied for those patients with pseudogynecomastia or gynecomastia who are willing either to accept the possibility of some enlargement returning in their breasts after surgery or to undergo “touch-up” operations at a later date.

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 one hand, radiologic investigations to differentiate pseudogynecomastia from gynecomastia could be drastically reduced [6, 7]. On the other hand, the incidence of residual gynecomastia resulting from “liposuction alone for pseudogynecomastia,” could be significantly reduced or even eliminated.

The author has no intention to ignite a controversy but fondly hopes to block or break the chain of unnecessary radiologic investigations, diagnoses of pseudogynecomastia based on these investigations, treatment of pseudogynecomastia with liposuction alone, and the risk for resultant unhappy patients because of residual gynecomastia. The author humbly appeals to the medical fraternity 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.