Gynecomastia at a Glance

Gynecomastia (“여유증”) enlargement of male breast tissue is far more common than most men realize, affecting up to 65 % of adolescent boys at some point and roughly one in four adult men. While it is medically benign in most cases, the physical change can erode body image and even deter men from exercise or intimacy. Understanding what the condition is (and is not) is the first step toward choosing the right remedy.

True vs. Pseudo-Gynecomastia: Why the Distinction Matters

Term	Main Tissue Involved	Typical Feel	First-line Fix
True gynecomastia (“진성 여유증”)	Proliferation of glandular breast tissue	Firm, rubbery disk under the nipple	Hormonal work-up → medical therapy or surgical excision
Pseudogynecomastia (lipomastia) (“가성 여유증”)	Excess sub-areolar fat with no gland overgrowth	Soft, compressible fat	Weight loss ± liposuction

True gynecomastia reflects a testosterone-to-estrogen imbalance testosterone falls, estrogen or estrogen sensitivity rises, or both. Pseudogynecomastia is essentially localized fat it can disappear with sustained weight loss, but stubborn cases often need liposuction. On ultrasound, glandular tissue appears hypoechoic and nodular, whereas pure fat shows homogeneous hyperechoic lobules.

Root Causes: From Hormones to Habits

• Physiologic surges: newborns (maternal estrogen), puberty, and andropause.
• Medications : finasteride, spironolactone, anabolic steroids, certain antiretrovirals, tricyclic antidepressants.
• Endocrine & systemic disease : hyperthyroidism, Klinefelter syndrome, prolactin-secreting tumors, testicular failure, liver or kidney disease.
• Lifestyle factors : excess alcohol, cannabis, and of course obesity (which increases peripheral aromatization of androgens).

How Doctors Grade Severity

Plastic and endocrine specialists use the Simon classification because it correlates well with surgical planning:

Grade	Presentation	Typical Surgical Plan
I	Small enlargement, no skin excess	Sub-areolar excision
IIa	Moderate enlargement, no skin excess	Excision ± liposuction
IIb	Moderate enlargement with mild skin excess	Excision + liposuction, possible skin tightening
III	Marked enlargement with significant skin excess & ptosis	Excision, liposuction, skin-reducing mastopexy

Some centers now extend the scale to Grades IV–V for >500 g tissue or severe ptosis, but the Simon system remains the benchmark for Korean insurance review.

Diagnostic Work-Up

1. Focused history & exam : drug list, endocrine symptoms, testicular palpation.
2. Laboratory panel : total & free testosterone, estradiol, LH/FSH, prolactin, TSH.
3. Imaging – breast ultrasound : mammography if a discrete mass, unilateral presentation, or malignancy risk factors.
4. Biopsy : only when imaging is inconclusive or malignancy can’t be ruled out.

In adolescents, observation is reasonable for 6–12 months because two-thirds of pubertal cases regress spontaneously.

Scenario	Preferred First Step	Escalation
Pubertal gynecomastia <12 mo	Watchful waiting	SERMs (tamoxifen 10–20 mg/day) for pain or social distress
True gynecomastia ≥12 mo, no regression	SERMs or aromatase inhibitors (anastrozole)	Surgical removal if persistent
Pseudogynecomastia	Caloric deficit & resistance training	Ultrasound-assisted liposuction
Grade IIb–III with ptosis	Combined sub-cutaneous mastectomy + liposuction, ± skin excision	N/A

Meta-analyses show SERMs shrink tissue by ~40 % in three months; however, surgery remains the gold standard for long-standing or fibrotic cases, with satisfaction rates >90 %. Common surgical risks—hematoma, nipple hypoesthesia, contour irregularity—occur in <5 % of well-selected patients.

Insurance Coverage in South Korea (NHIS)

Because you’re in South Korea, the National Health Insurance Service (NHIS) rules are pivotal:

• Covered:
  • Simon Grade IIa or higher and ultrasound/biopsy confirmation of ≥2 cm glandular proliferation.
  • Glandular excision portion of the surgery (code N7132).
• Not covered:
  • Pure liposuction for pseudogynecomastia.
  • Grade I “puffy nipple” cases judged cosmetic.
• Patient cost share: Roughly 30 % of the NHIS fee schedule; typical out-of-pocket 700 000–1 100 000 KRW for qualified cases.
• Private indemnity insurance (실손) may top up uncovered items but depends on your policy; pre-approval and detailed operative notes are mandatory.

Key Takeaways

• Differentiate first : Is it gland (true) or fat (pseudo)? Treatment hinges on that answer.
• Check the grade : Grade IIa or above not only guides surgical design but also determines Korean NHIS eligibility.
• Address hormones : Rule out reversible endocrine triggers before heading to the OR.
• Pick the right tool : Weight control or liposuction for fat; excision ± lipo for gland; combine with skin tightening for high-grade cases.
• Budget wisely : NHIS can significantly offset costs when medical necessity is documented, but purely cosmetic revisions remain self-pay.

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