Though the clinical diagnosis of gynecomastia is straight forward, there are some issues that may make this seemingly simple issue a little tricky. These diagnoses that mimic a certain other disorder are called differential diagnoses.
One such common differential diagnosis is pseudo gynecomastia. As the name suggests it refers to ‘false male breast’ meaning fat that masquerades as breast tissue. It is especially common in men who are overweight or obese. However, in my opinion, the term pseudo gynecomastia is overused and over-diagnosed. There have been instances in mine and my colleagues’ practices where a patient is referred to us as pseudo gynecomastia and the patient is expecting liposuction as the sole treatment.
Some surgeons have even gone ahead and done liposuction to this apparently pseudo gynecomastia only for them to realize that there is, in fact, a large amount of breast tissue left. Now, this complicates the issue.
One, the patient has not been told that he requires a gland excision and a bigger skin cut is needed to do the same. Now either the surgeon has to explain the patient’s friends or relatives who have accompanied the patient that the surgical plan has changed as he has now noticed breast tissue or he has to end the procedure there and plan breast tissue removal later on. In either of these scenarios, the surgeon does not come off with flying colors. More importantly, the patient is put through a procedure that he is ill-prepared for.
If the surgeon takes relatives into confidence and goes ahead and operates and removes the breast tissue, it is left to him to explain it to the patient when he comes out of anesthesia. The matter is easier said than done as it depends entirely on how the patient takes the news. If the surgeon chooses the second option and ends the surgery without removing the gland, he needs to explain that to the patient who may not be happy hearing that he needs another procedure to sort out his chest. I have seen patients who underwent only liposuction for ‘pseudo gynecomastia’ and coming to me complaining that their surgeon has left a lot of hard fat under the nipple. I have had explain to such patients that only fat was removed and the breast tissue was left behind and indeed the diagnosis may be wrong. Now imagine the patient’s conundrum at this phase. An issue that could have been easily sorted in the first procedure has now dragged on not only needing another procedure but also making the patient invest a disproportionate amount of time to sort out the one issue at hand.
This is especially true if the patient following liposuction gets fitter and loses more weight only to notice his breast tissue getting more prominent. Before the surgery and his weight loss, the overall smooth contour due to fat might have camouflaged the breast tissue better than when he gets the liposuction or loses weight. All these issues are readily avoided if one is careful while diagnosing pseudo gynecomastia. If the diagnosis is correct then liposuction should suffice.
This diagnosis is especially important as pseudo gynecomastia does not require surgery in many cases as diet and exercise my dissolve the fat. Gynecomastia, however, requires surgery to treat it and exercise or diet will never suffice!
So one should be very careful while diagnosing pseudo gynecomastia!