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Plastic & Reconstructive Surgery

Pseudogynecomastia

ICD-10 Code
E65_2

Advanced Plastic & Reconstructive Criteria for Pseudogynecomastia.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with concerns regarding bilateral breast enlargement and contour deformity. Denies nipple discharge, tenderness, or palpable retroareolar masses. No history of hormonal therapy, anabolic steroid use, or significant weight fluctuations. Patient reports stable adiposity in the pectoral region, consistent with generalized obesity or localized lipodystrophy.

Clinical Examination Findings

Physical examination reveals bilateral, soft, non-tender, diffuse enlargement of the pectoral regions. Absence of firm, subareolar glandular tissue or retroareolar cord-like structures upon palpation. Skin envelope is redundant with no signs of inflammation or skin changes. Pectoral contour is consistent with adipose tissue accumulation. No axillary lymphadenopathy.

Treatment Protocol

Recommended management includes lifestyle modification (diet and exercise) for weight reduction. Surgical intervention options discussed: Liposuction of the pectoral region to address adipose hypertrophy, potentially combined with skin excision if significant laxity is present. Risks, benefits, and alternatives explained. Patient understands that this is a cosmetic/reconstructive procedure for adiposity, not glandular excision.

Detailed clinical guide coming soon.