Restoring confidence and self-esteem

Rather than choose between drawing attention to himself by wearing a shirt to swim or going bare-chested, Gregory Bentley, 23, Cohoes, N.Y., opted to simply avoid the lakes near his home altogether. His abnormally enlarged breasts had become a source of embarrassment, and rather than risk public ridicule, Bentley literally kept his secret under wraps as he looked for a solution.

After researching his condition online, Bentley learned that he had gynecomastia, a condition involving enlarged breast glands in men. He also found its possible causes, corrective options and plastic surgeons who could help. In late May, Bentley underwent a procedure performed by ASPS member Mordcai Blau, MD, White Plains, N.Y.

Bentley is among a growing number of men who undergo gynecomastia procedures each year. There were 16,275 procedures performed by board certified plastic surgeons in 2005, a 17 percent increase over the 2004 level, according to ASPS procedural statistics.

Dr. Blau says that roughly 40 percent of his practice is now gynecomastia patients, and the number of cases he sees has shown a marked increase over the last decade in particular. Whereas in the early 1980s he performed five or six gynecomastia procedures per year, he says he now averages more than 150 per year; over the last five years he has performed more than 1,000 gynecomastia procedures.

Statistics indicate a slight increase in the nationwide incidence of gynecomastia, though plastic surgeons interviewed for this article suggest the rise is not statistically significant. They attribute the marked increase in procedures to correct the condition, however, to the news media's interest in plastic surgery, the specialty's public education efforts, reality television shows that have elevated the visibility of procedures for males - all which have led to a growing acceptance of plastic surgery among men. They also agree that the vast amount of related information available on the Internet has helped many men gain relief from the problem.

Possible causes

Any rise in the incidence of gynecomastia, however small, can be attributed to several factors in varying degrees. One of the more prevalent conditions among men in general is obesity, which leads to what Dr. Blau calls "pseudo-gynecomastia" and what ASPS Public Education Committee Chair Walter Erhardt Jr., MD, Albany, Ga., calls "fatty gynecomastia."

This condition of enlarged breasts mimics and is often called gynecomastia, but it's not true gynecomastia since the breast gland is not the culprit in the enlargement. Either way, there's no question that a growing number of Americans are obese - and many men are undergoing liposuction to improve the appearance of their chests.

There also are several prescription and over-the-counter drugs, medications and supplements that are reported to have gynecomastia as a side effect. These include Effexor®, Motrin®, Pepcid® and digitalis purpurea, also known as foxglove. Heavy marijuana use has also been linked to gynecomastia.

In 2005, the Sunday Times of London printed an article suggesting that hormones introduced into the environment were also partly to blame for an increase in gynecomastia in the United Kingdom. The article quoted an endocrine surgeon from London saying that in a study of tissue samples removed from men's breasts he found tissue typically found only in women. "I can only speculate as to the causes, but I would suspect that the use of oestrogen in the food chain is a factor," he said, referring to hormones used to promote growth in farm animals in the United Kingdom.

Dennis Hammond, MD, Grand Rapids, Mich., the author of several articles on gynecomastia for the Plastic and Reconstructive Surgery journal, says there may be another, more serious cause. He recommends that anyone who presents with gynecomastia undergo a testicular exam. "You need to look in all age groups for a hormone-secreting tumor," he says. "There's a small chance that you would find a tumor, but it's important to check for it."

Further, bodybuilders who use steroids or such supplements as prohormone - an over-the-counter substance designed to convert into active hormones - are prime candidates for gynecomastia. Prohormones can increase the amount of estrogen in the body which, in males, would cause the breast gland to become overactive and thus increase a man's breast size.

At 5 feet 8 inches tall and 165 pounds, Bentley is not obese, but he says his gynecomastia likely resulted from a muscle mass supplement purchased at a health store and from infrequent steroid use.

Weightlifting enthusiast Christopher Villalba, 22, of Hawthorne, N.Y., says his use of a prohormone "was probably the main cause" of his gynecomastia. "To pinpoint the exact cause is difficult, but I guarantee that taking the prohormone definitely added to me getting it as badly as I did," he says. Villalba says he looks forward to beginning his rigorous workouts again, but he won't be taking anything to build bulk. "No more supplements," he says.

For many, however, gynecomastia, which can develop early in life - in some cases, before age 13 - is a genetic condition that is related solely to the activity of the breast gland. Some estimates put the percentage of gynecomastia among teenage boys at 65 percent, but most conditions resolve themselves in this age group by age 17.

Information = procedures

Anecdotal evidence suggests that the availability of information on gynecomastia - and plastic surgery in general - has played a key role in the increase in gynecomastia procedures, however.

Dr. Erhardt says with the heightened awareness of plastic surgery has come increased acceptance of plastic surgery procedures among men. In the case of gynecomastia, more men are becoming comfortable with a surgical solution to enlarged breasts.

"Before the recent onslaught of reality television shows - good, bad or indifferent, and as bad as some of these shows were - most of the information that was disseminated to the public was in women's magazines," Dr. Erhardt says. "Men don't read those, so awareness has come from reality television, whether we like it or not, and the media in general; men are being exposed to the fact that something can be done about gynecomastia.

"This goes hand in hand with the greater general acceptance of plastic surgery," he adds. "Men in the past might say, 'I'd never have this or that procedure done.' That's changing. If someone has a significant problem like gynecomastia, they're far and away more likely to do something that, a few years ago, they wouldn't have done. The changing perception by society of men having plastic surgery has helped men in general."

David Sarwer, PhD, of the Center for Human Appearance at the University of Pennsylvania (Philadelphia) School of Medicine, agrees the media has altered the norm of acceptability with regard to men and plastic surgery, particularly where gynecomastia is involved. "Reality-based cosmetic surgery television shows likely have put the idea of cosmetic surgery on the minds of millions of Americans," says Dr. Sarwer.

Asked how the gender implications of gynecomastia - which lends a female appearance to a male body part - affects men's self-image, Dr. Sarwer says: "Numerous studies have shown that if you show people pictures of very attractive models, their dissatisfaction with the own appearance increases."

Because of wider acceptance of plastic surgery, gynecomastia patients are willing to undergo corrective surgery "probably more than ever before," he adds.

Silver screen, TV screen, monitor

When stars reveal that they've struggled with certain problems - or have undergone certain surgical procedures, including plastic surgery - the public often follows.

Case in point: In early 2005, professional wrestler and movie star Dwayne Johnson, also known as The Rock, revealed that he had undergone gynecomastia correction. His revelation was quickly followed by articles in the same vein by multiple print media outlets and discussed on various radio and television talk shows. In the days and weeks that followed that media exposure, Dr. Blau says he experienced a "significant" increase in the number of calls to his office seeking information on the procedure.

Dr. Blau says the Internet has worked as an effective informational tool, becoming a source of fact and aid to most of those to whom he's provided consultations, regardless of whether they undergo a corrective procedure. "I've gotten e-mails from boys ages 12-13 who've researched this on the Internet," he says. "Many have come in with their parents, of course, but they've done the homework themselves online and are, in many cases, up-to-speed on their condition and options.

"Many men who didn't know anything could be done about their gynecomastia have gone online and learned about their options," Dr. Blau says. "The Internet really has been an effective tool."

Villalba agrees with the assessment. "The Internet was extremely helpful to me," he says. "Before I met or spoke with a plastic surgeon, I read many articles online and I was really helped by the sites I found where people posted their experiences with gynecomastia procedures, guys who had gone through the same things I was going through. One Web site in particular featured only people with gynecomastia writing about their experiences. I was able to communicate with them, and they were very helpful with my decision-making."

Information gleaned online also helped Bentley make his decision to proceed with surgery.

Bentley says he compiled information online that he otherwise would have found difficult to locate at all and which probably would have been incomplete for his purposes - such as others who had undergone the procedure. "I knew through the Internet of professional bodybuilders who had it done," he says. "I was able to find information on the procedure and general costs. The Internet really simplified the process for me."

Dr. Erhardt agrees that the Internet has been a welcome source of assistance for men with gynecomastia. "It's made a big, big difference," he says. "Men in the privacy of their own homes can research information regarding one option or another, what's involved from start to finish and the costs involved. "They're able to gain education in relative privacy and, therefore, they are availing themselves of the procedures that are offered."

A recent Internet search with gynecomastia as the keyword returned approximately 266,000 references. Although many related to advertising and scholastic pieces, the vast majority were in fact news items and other informational pieces.

Awareness or external factors?

In addition to explaining why gynecomastia can appear and the increase in the popularity of corrective procedures, the plastic surgeons also provided several pieces of information they felt needed to be considered.

Dr. Blau says plastic surgeons who take on gynecomastia patients should keep several points in mind:

• Liposuction alone will not usually fully correct a significant proportion of gynecomastia cases.
• For men, scar location is very important. Therefore, the periareola is the best place for the incision because of the resulting scar.
• The recurrence rate is significantly higher when the breast gland is not resected.
• Bodybuilders usually bleed at a greater rate than non-bodybuilders, which is likely attributable to steroids and certain supplements.

Scott Spear, MD, Washington, D.C., chair of the Georgetown University Plastic Surgery Department, says bodybuilders, who make up between 5-10 percent of his gynecomastia cases, possess several qualities that make them unique.

"They usually don't have a great amount of breast tissue, but since they have so little body fat, it's easier to see, which makes them dissatisfied with the look of their chests," Dr. Spear says. "You might not be able to see the gynecomastia, but they can - and they're looking at themselves all the time. They are a more critical group, and they are going to be more critical afterward. That makes them a bit tricky."

Dr. Blau says his 20 years' experience with bodybuilder gynecomastia enabled him to eventually negotiate that minefield. "They're wonderful patients," he says.

Dr. Hammond says his greatest source of satisfaction in gynecomastia patients results from his ability to help the most emotionally vulnerable sufferers. "This condition can be tremendously emotionally disturbing to the adolescents," he says. "They will have begun to associate with their peer groups, and such breast development at this time in their lives is a very unfortunate confluence.

"They are excellent candidates for gynecomastia excisions, and there's absolutely no reason not to do one. Some say you should wait until the gynecomastia is fully mature before you excise it, but I don't agree at all. As soon as it becomes an issue, it should be addressed so these boys can develop normally."

Perhaps unlike any other aesthetic procedure, gynecomastia removes the stigma that results from a man having a physical characteristic normally found in women. Surgically eliminating the problem improves the state of mind of those who suffer from from it, Bentley says.

This may be especially true in the schoolyard. Navigating the often awkward teen years can be difficult for anyone, but for the many young men and boys who suffer with gynecomastia, procedures to correct the condition allow them to feel more comfortable in their own skin. This often translates to greater confidence and self-esteem. Correcting gynecomastia, like many plastic surgical procedures, does more than fix a physical problem - it can also have a profound impact on the patients' happiness and quality of life.