True Gynecomastia vs. Pseudogynecomastia: Which Surgery Do You Need?

A question came in that the person worried was a dumb one. It's not a dumb question at all. It's actually a fantastic question:

Here's how I evaluate it, and what to ask at your consultation.

Whenever I evaluate a patient with gynecomastia, the first thing I consider is what's actually making the area enlarged.

With true gynecomastia, there's actual hypertrophy, or enlargement, of the glandular tissue.

When I examine a patient, I feel a firm little nodule of tissue under the areola. It can be very small, like the size of an almond, or it can be very large. I've seen it up to the size of a tennis ball.

And depending on the overall size and shape of your chest, even a very small area of hypertrophy can be very noticeable.

With pseudogynecomastia, it's usually a fatty tissue issue. The fatty tissue in the area is hypertrophied, more than it should be.

On exam, fatty tissue is very soft. You won't have that firm nodule of tissue underneath the areola.

The treatment for these two things is very different, so this distinction drives everything else. (For teenagers, the approach is different again. Here's why we usually wait on gynecomastia in adolescent boys.)

Glandular tissue is firm, so it's not something you can really remove well with liposuction. If you have an area of glandular hypertrophy, there are two ways to remove it:

1. Surgical excision. We make a small incision and cut the area out.
2. A minimally invasive option. A small probe goes in through a tiny incision, and under ultrasound guidance, its little rotating "chomper" chomps up the area of hypertrophy and removes it.

Since pseudogynecomastia is fatty tissue, you treat it the way we always treat fatty tissue: with liposuction, not direct excision. The goal is to make a little incision and liposuction that extra fatty tissue out.

The fatty tissue in the chest tends to be more fibrous than fat elsewhere. So my personal preference is ultrasound-assisted liposuction. I like the brand VASER, and I think it's the better option for that area. (More on the different liposuction options here.)

Even with true gynecomastia, where you're removing glandular tissue, most patients get a better cosmetic result if you also do some liposuction to smooth the area and get the contour right.

Even if a patient doesn't have a lot of extra fat, smoothing the area for contour is really helpful.

The last thing to consider if you're having gynecomastia surgery is what your skin looks like.

Some people have very tight, good-quality skin, and it shrinks up really nicely with whatever we do, liposuction or excision. Other people start out with looser or lower-quality skin, and the skin is going to hang. (Skin quality is the same deciding factor in liposuction vs. a tummy tuck.)

So it's important to talk with your doctor about your options for skin tightening.

Surgical skin tightening on a man's chest leaves scars that can be pathognomonic, meaning they basically tell people what you had done.

So for most patients, we like to wait and see what the skin does, just like we do with other procedures, such as liposuction or implant removal. In a lot of patients, the skin shrinks up enough that no surgical skin tightening is needed.

The other option is non-invasive skin tightening, which can be really useful in a lot of patients, especially if you do the recommended number of treatments and keep up with it.

In the right circumstances, you can get 20 to 30% tightening, and that can really make the area look good. How well it works depends on how loose your skin is and how well you respond to the treatments.

If you have an experienced surgeon, you really shouldn't have to ask them to take out the gland. They should do that.

Some surgeons always start with liposuction to see if they can make the area look better, and only go back for the gland if it's needed. That's not necessarily wrong. But most of us who do a lot of this type of surgery can tell when we examine you whether the gland needs to come out at the same time.

So at your consultation, ask your surgeon:

1. What do you think the problem is?
2. Do I have true gynecomastia, or pseudogynecomastia?
3. If it's true gynecomastia, what's your plan to remove the gland?

(Here are a few more tips for getting the most out of a consultation.)

• True gynecomastia is gland: a firm nodule under the areola, anywhere from almond-sized to tennis-ball-sized. It has to be cut out, through a small incision or with a minimally invasive probe under ultrasound
• Pseudogynecomastia is fat: soft on exam, and treated with liposuction. I prefer ultrasound-assisted liposuction (VASER) because chest fat is fibrous
• Most patients do best with both, because liposuction smooths the contour even when the gland is the main problem
• Loose skin: usually wait and see first, because surgical tightening scars on a man's chest are telling. Non-invasive tightening can get 20 to 30% in the right patient
• At your consult, ask what the problem is, whether it's true or pseudogynecomastia, and what the plan is for the gland. An experienced surgeon should plan for one surgery, not two