What causes gynecomastia or man boobs?
Gyno, as it is called among people who talk openly about it, is a real physiological condition – a proliferation of breast tissue, not just an awkward distribution of fat – caused by an excess of estrogen relative to testosterone. Millions of men have gyno – at least 30 per cent of males will be affected in their lifetime – but it’s impossible to get much more specific than that, because most people who have it don’t discuss it, let alone do anything about it. For some men, gyno can be painful, making the breasts tender to the touch. For most men suffering from it, the real damage is emotional. Alan managed to talk to a few friends about it over the years, and they always recommended chest exercises. Do more flies. Bench more. Drop and do pushups whenever possible. He took their advice and started working out obsessively in his 20s.
“But it actually made it worse,” he says now. “The boobs were more pronounced.” So he went the other way and gained weight on purpose to try to even things out in his midsection. He ballooned up to 118kg. It was no way to live.
How can you get rid of man boobs?
Alan knew male breasts could be removed through surgery – his sister, who’s a nurse, had given him a brochure – but he’d seen some scary pictures online of botched results and he couldn’t afford the out-of-pocket expense anyway ($US 4000).
After getting a new job as a maintenance technician at a pharmaceutical warehouse, however, he was able to save a little more money. He began doing some additional research online, and that’s when Google led him to the website of Dr Robert Caridi, a plastic surgeon in Texas who performs gynecomastia removal surgery. The site touted Caridi’s thousands of gyno patients from all over the world. There were videos from inside the operating room, before and after photos, images of raw breast tissue just pulled from men’s chests. Alan couldn’t look away. There was a button that said free online consultation. Ten minutes after discovering Caridi’s Austin Gynecomastia Center, Alan had Rebecca take pictures of his chest in the bathroom. It was about 10:30 on a Sunday morning when he sent in his photos and some details.
“I have been living with this for around 27 years,” he wrote in an email that reads like a primal scream. “Only a couple of people in my entire life have ever seen me with my shirt off. I’m convinced this is the main reason for my insecurities and social anxiety, ruined relationships, jobs, etc . . . Basically controlled my life as long as I can remember . . . Just pure misery with these breasts, and I’m sick of it.”
Thirty minutes later, Caridi got back to him. Three weeks later, Alan was in Austin for surgery and a day after that, he tells me his story. We’re in an exam room in Caridi’s office suite in the posh suburb of Westlake. Rebecca sits across the room, smiling sweetly. As we talk, Alan stands a few feet away from me – a complete stranger – with his shirt off. His chest is bruised purple from the procedure, but where he once had a pair of C-cups, he now has typical pecs. He doesn’t even seem to notice that he’s shirtless, and he absentmindedly pats his chest during our conversation. For the first time in nearly three decades, Alan Ash feels comfortable in his own skin.
What does gynecomastia surgery involve?
The words come like bullets. “Look at this one. Rohan. He’s from Bangladesh. Here’s one in Sweden. Or look at this one. This guy, he says, ‘I’m going to be in Austin soon – I need you to check me out because I’m freaking out.’ He’s 71.” It’s a little after 8am and Caridi (or Doctor C, as he’s known to patients and employees, including not one but two nurses named Lacy) is wearing scrubs and scrolling through online consult requests that came in overnight. Email after email tells variations of Alan Ash’s story. Humiliation. Years or decades of quiet suffering. Elaborate cover-up rituals.
Sixty years old, trim and intense, with a rapid-fire Brooklyn-tinged accent that he has never fully shed since leaving New York at age 20, Doctor C is arguably one of the world’s most in-demand gynecomastia surgeons, and one of the few doctors anywhere who’s considered a gyno expert. He’s done nearly 3000 of these surgeries in the past couple of decades and today averages 250 to 300 per year, about 70 per cent of which, he says, are patients who travelled from other states or countries to see him. On the day I spend in his office, he does three gyno removals and sees two post-op patients he treated the day before. “Most plastic surgeons do maybe a dozen in a year,” he says. “Or less. If they do it at all.”
It’s not that gynecomastia surgery is all that complicated. We’re not talking brain surgery here. It starts with liposuction, to address the gynecomastia tissue, along with the fat around the breast. Then residual tissue is removed through a small incision at the bottom of the nipple and it ends with some careful sewing to ensure minimal scarring. In the most complex cases, such as when a patient is particularly large or has lost a lot of weight, the last step might also involve removing the excess skin. In these cases, Doctor C removes the chest skin and repositions the nipple. As plastic surgery goes, it’s pretty basic. Most operations are done in less than an hour. Doctor C doesn’t pretend he’s a surgical genius – more like a sculptor who’s mastered the male form.
“I think that most surgeons are adeptly qualified to do it,” he says. “But I will tell you this: there’s nothing that beats experience. You do 100, okay, you start to get the idea. Do 300, you’re really kind of figuring it out. Do 1000? Okay, now we’re talking.”
His experience with performing the actual procedure is part of what sends all those patients through his doors, for sure, but it’s not the main reason.
The physiological impact of gynecomastia
After seeing so many men like Alan, after hearing so many of their stories, Doctor C began to grasp how crushing it was to them mentally.
“The more I’ve delved into it, the more I’ve realised they all have just been jacked by this. They don’t have sex. They don’t take their kids to the pool. It affects their relationships. This isn’t a small bother; it’s a big deal.”
And he started to realise how he could broadcast that understanding so that men would find him and know that he was the doc who got it. Doctor C’s awakening happened about 10 years ago. His practice back then was, like that of most plastic surgeons, focused 80 or 90 per cent on women: face-lifts, breast augmentations and revisions, nose jobs. At the time, those kinds of procedures were common in pop culture.
How the Internet is helping sufferers
Throughout the ’00s , a parade of reality-TV series such as Extreme Makeover helped bring cosmetic surgery out into the open, and 79 per cent of the cosmetic surgery patients surveyed had been influenced by these shows, according to a 2007 study in the academic journal Plastic and Reconstructive Surgery. Seeing the surgeries and watching patients’ journeys made people more comfortable with the idea of going under the knife themselves. A few Internet-savvy doctors took note, posting videos of their surgeries on YouTube. Why bother with a TV deal when they could potentially reap the same benefits more easily online, reaching prospective customers directly and controlling their own messages and images? Some, like a South Floridian named Dr Michael Salzhauer (aka Dr. Miami), became celebrities because of their social-media videos. Doctor C, who has never been shy in front of cameras (he got married on Good Morning America in 1990), decided to try his hand at it too – with a twist. Rather than concentrate on female boob jobs, as others were doing, he put out a gynecomastia video in 2010.
“You have to understand, at the time, gynecomastia – no one even knew how to pronounce the word. It was not talked about.” The term actually dates back to the second century a.d. – it means female (gynec) breast (mastos) – and the first surgical treatments came a few hundred years later. It wasn’t until the 1970s that liposuction entered the picture, and the procedure has become less invasive since then. A doctor in White Plains, New York, named Mordcai Blau, is considered the modern trailblazer in the field for men. But despite Blau’s decades of success, the condition was still largely under the radar.
“I could see this shit was prime time for someone to blow it out,” Doctor C continues. “So we videoed one. My wife was like, ‘No, don’t put it out, because it’s just so disgusting’. ” He did it anyway. “And the floodgates opened. Totally opened.” In the years since, Doctor C has posted nearly 100 gynecomastia videos on YouTube, which have racked up millions of views. He started experimenting with Snapchat, Periscope and other forms of social media a few years ago, yet it was the online consultation form, which he added to his website in 2016, that brought in customers from all corners of the globe. They were finding him on YouTube or Reddit, but before the online consultation, prospective patients still had to clear the mental hurdle of reaching out. A phone call or Skype session might be embarrassing. A trip to Austin for a simple exam would be expensive. Taking off their shirt would be mortifying. But snapping a few selfies and shooting an email? It was like discovering a lifeline.
Now Doctor C says gynecomastia accounts for about 70 per cent of his practice. It’s one of the top plastic-surgery procedures for men, according to the American Society of Plastic Surgeons. Between 2013 and 2018, the number of such surgeries grew by 30 per cent – and Doctor C is the tip of the spear, or scalpel, as it were.
What a consultation involves
“Feel it, go ahead. Feel it. Yeah, right there, go, do it. That’s the gland. That’s it. That’s gyno. That’s the mass.”
It’s a tad awkward. We’re in an exam room and Doctor C is directing me to squeeze the nipple of a patient I’ve just met: Max, a 22-year-old Texas A&M Corps of Cadets senior with sleeve tattoos and an impressively built upper body that looks pretty much ideal – except for the puffy nipples, stretched-out areolas, and small, cone-shaped breasts, as if somebody had stuffed little birthday-party hats in there. The doc then produces a marker and starts drawing circles around the breasts to define the area that he’ll reduce, all the while talking in a machine-gun rap. One of the things patients like about Doctor C is his directness, his refusal to coddle their self consciousness. It’s not that he ignores their sensitivity but that he acknowledges it by charging right at it – to “cut through the crap”, as he describes it. “Bam. Brooklyn. Let’s go. ‘Take your shirt off.’ Grab their boobs. They don’t have a choice. Walls come crashing down. Let’s just take care of business.”
"Open up your shoulders, Max,” he barks, pressing one hand into the young man’s back and pulling his shoulders with the other. He gives Max’s shoulders a pat and looks over at me. “He’s got good muscles. The reason I asked you to feel it, his gyno’s mostly puffy stuff.” Puffy nipples are a common, telltale sign of gyno among bodybuilders. He looks back at Max. “Did you take some kind of prohormones?” “I took SARMs,” Max admits. Selective androgen receptor modulators, that is, a category of steroid alternative that has become popular among athletes in recent years; they work like anabolic steroids but target androgen receptors specifically in skeletal muscles, in theory sparing other tissues from typical steroid side effects. Max hopes to be an Army infantry officer one day and fitness is a big part of his preparation for that life, he explains.
About two years ago, in his second year at uni, he was in the best shape of his life – “88kg with a really low body-fat percentage” –and SARMs helped him get there. That’s when he first noticed the puffy nipples and so-called “post-cycle therapy” to counteract the SARM regimen didn’t make them go away. His third year at uni, he landed in the hospital with a bad case of both mononucleosis and pneumonia. He lost 10kg in a week and the doctors prescribed him some steroids. About four weeks after that, he had full gynecomastia. Doctor C has heard all this before.
Real life experiences with gynecomastia
There are three groups of people who make up the vast majority of gynecomastia cases he sees, he’d explained to me earlier in the day. First are those like Alan Ash, for whom the problem began in puberty and never went away. Many boys develop small masses behind their nipples in their teens, when a surge in hormones creates an imbalance between the levels of testosterone and estrogen. In most cases, things rebalance naturally in a matter of months, but for some men that never happens. Second are guys who have used anabolic steroids or steroid alternatives such as prohormones and SARMs. Then there’s a third category of gyno patients: men past their mid-40s, when testosterone levels can dip and result in a hormonal imbalance. This can cause the pecs to soften and flesh to sag, with as many as one in four men experiencing this problem as they age.
Of the patients I met in the doctor’s office, three had used performance-enhancing drugs, and three had suffered since puberty. One patient, 37-year-old David, played football at a midwestern Division II college. He wanted to level up to a D1 school, so he started using steroids the summer after his freshman year. Boom, gyno, within weeks. He’s now married and has a three-year-old son he couldn’t wait to take to the water park this summer for the first time after having avoided all swimsuit-related activities for most of his adult life. Matthew, 30, is a former patient and competitive men’s physique bodybuilder who stopped in for a visit today. He once took a 12-week round of steroids. Boom, puffy nipples. Soft-spoken 39-year-old Jose, a veteran of the wars in Iraq and Afghanistan, has had gyno since puberty. So has 22-year-old Tawsif, a software engineer who found Doctor C on Reddit. Not that everyone with pronounced masses in their breast area actually has gynecomastia. It’s rare but possible for men to get breast cancer, so if you develop a breast lump or thickening or notice any type of change in the skin or nipple, have it checked out.
And then there are men who accumulate fat in the chest region – there’s even a medical term for their condition, pseudogynecomastia. This fat could be targeted through exercises such as push-ups, rows and pull-ups. In theory, anyway. “The whole concept of pseudogynecomastia should be banned,” says Doctor C. “The implication is [the breasts] will go away if you lose weight, but that doesn’t happen.” On the surface, that might seem self-serving coming from a surgeon who has every incentive to book more surgeries. But as an article in the peerreviewed journal Mayo Clinic Proceedings put it: “The decision to treat . . . should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction.” In other words, if a guy has boobs and the boobs are bothering him, he should get rid of the boobs. Back in the exam room, Doctor C leaves me alone with Max, who talks with me some more. Despite his physique and tatts, he hasn’t quite grown out of a boyish sweetness. He explains that he has some friends who use anabolic steroids and have developed gyno; they self medicate by trying to adjust their estrogen levels with drugs such as tamoxifen and letrozole (which reduce estrogen production or block its effects and which the FDA has not approved for the treatment of gynecomastia; illegal steroid suppliers usually sell these otherwise prescriptiononly drugs).
Max “almost went down that route,” he says, but decided to do his own research first. On Internet bodybuilding forums, “people swear by [the self-administered drugs]”. But as he dug deeper, he wasn’t so sure. “I think you’re throwing the dice there,” he says. “You can block the estrogen so much that it’ll shut off and something catastrophic can happen.” His Google searches directed him to Doctor C’s online consultation, then to the YouTube videos and finally to his office. “I’m glad I’m here,” he says. “To get rid of it.” At this point, one of the nurses named Lacy comes back in to cut us off. The anesthesiologist is waiting for Max. So is Doctor C’s dedicated videographer, Jonathan Holt. Like every other surgery patient here today, Max has agreed to have his procedure filmed. Maybe the footage will help some other guy with a similar story come out of the shadows. And now it’s showtime.
Real life experiences with gynecomastia surgery
“You can really feel the bass in here!” Jonathan says. The Ariana Grande song “Break Up with Your Girlfriend, I’m Bored” blares through the operating room’s speakers as the videographer enters with his shoulder-mounted camera rig, followed by Doctor C, a nurse named Sarah, the Lacys and me. Max has already been put all the way under and his face is hidden beneath a blue sheet. After making a small incision on the outside of one side of the breast, a cut no wider than a grain of rice, Doctor C inserts a roughly 30cm-long wand into the hole and starts waving it around inside the chest, his arm twisting and jerking this way and that as if he were working a giant socket wrench.
The machine makes a persistent squeaking sound as he does this, and as Doctor C probes every inch of the breast, the far end of the wand pushes up the skin from the inside, somewhat disturbingly like the extraterrestrial bursting from John Hurt’s midsection in Alien. This is the first step of liposuction, which melts the fat in the breast using ultrasound energy. Then the doc switches to a suction tube that vacuums out the melted fat, a viscous, pinkish fluid that sputters through a transparent tube into a collection vessel. Once he’s removed the fat – and narrated every step, and paused for a conversation with the anesthesiologist about the newest Corvette model – he makes a slit just below the areola and manually begins to pull out a mass of harder tissue, the actual breast gland, with a forcefulness that’s a little violent. It’s lumpy, pink and white, and about the size of a small crab cake. He flaps it around once it’s fully dangling out of the hole, asks me to come in close and have a look, makes way for the camera to get a good money shot and then pulls the connecting tissue taut and scissors the gland out of the body. After about 45 minutes, the surgery is over. Two of the fleshy crab cakes sit in a small plastic tub and Doctor C says he always offers patients a chance to see these when they wake up, to stare down a vanquished demon.
“They always want to see it,” one of the Lacys says. “It’s the first question: ‘Did you get out a lot?’ They need to know it’s gone. And they’re like, ‘Show my wife, show my sister, show my mom. This was in there, and it wouldn’t just go away with weight loss’. ” Doctor C cuts in. “You can touch them,” he says to me. “Go ahead, feel it.” I slide on a sterile glove and give one of the masses a quick poke. Yep, it’s firm. “And you see the nipples now? Totally different.” They’re no longer puffy. Half an hour later, having changed from scrubs into a sharp checked blazer and pink shirt, Doctor C is ready to take the team out for happy hour. But first he says a quick hello to his ex-patient Matthew, who’s been hanging out with the nurses. “Hey, Matt, you feel good?” asks Doctor C. Matthew whips off his shirt proudly. “Let me see that,” the doctor says. “Look at you, wow. Beautiful, baby!”