http://www.nytimes.com/2007/06/14/fashion/14reduction.html?ex=1182484800&en=4805ecbd54672c59&ei=5070&emc=eta1NY Times
June 14, 2007
http://www.nytimes.com/2007/06/14/fashion/14reduction.html?_r=1&8dpc&oref=sloginA Sense of Anxiety a Shirt Won't Cover
By ALEX KUCZYNSKI
ON a recent afternoon, Dr. Michelle Copeland, a plastic surgeon whose offices face the Metropolitan Museum of Art, clicked her computer's mouse as images of young men's torsos flickered across the screen. Unlike the ancient Greek statues of Herakles or the bronze discus throwers in the newly renovated galleries across the street, the young men in Dr. Copeland's digital images were a bit different: Rather than bearing the broad, flat chests of Greek athletes, their pectoral areas assumed a fuller, more feminine shape.
The patients were found to have enlarged male breasts, a condition known as gynecomastia. While it is not a new disorder, more men are seeking treatment for it, and new statistics from the American Society of Plastic Surgeons show that the majority are adolescent boys.
In 2006, according to the group, nearly 14,000 boys age 13 to 19 underwent surgery to reduce the size of their breasts. That represents 70 percent of all the male patients who had such surgery last year, and an increase of 21 percent over the previous year for that age group.
In a culture that increasingly encourages young boys to be body conscious, demand for chiseled torsos and sculpted pecs is rising, so much so that the number of boys ages 13 to 19 who had breast reduction surgery last year is equal to the total number of all men who had the procedure just two years earlier, in 2004.
The foremost reason is the rise in obesity, according to several plastic surgeons who were interviewed. At the same time, there is a new willingness among pediatricians and plastic surgeons to surgically treat enlarged male breasts.
Often, enlarged breasts are simply part of adolescence, most commonly caused by the hormonal fluctuation of puberty, according to the National Institutes of Health . But in a society that values chiseled abs and Rafael Nadal biceps, adolescent boys are willing to resort to surgery to fix problems their bodies might resolve later on their own.
David Zinczenko, the editor in chief of Men's Health, said that many of his magazine's readers are concerned about having enlarged breasts.
"The sad thing is that it's a fairly common problem among young teenagers, which is usually resolved by the latter stages of the testosterone rush that finishes off adolescence," he wrote in an e-mail message. "But add some fat in there, and a cut-happy approach to body oddities, and you've got teens under the cosmetic knife."
Dr. Roxanne Guy, a plastic surgeon in Melbourne, Fla., and the president of the American Society of Plastic Surgeons, said that the statistics don't pick up all the nuances of why the numbers have increased, but she was sure on one point. "It is certain that teenage obesity is a huge issue," she said. "And awareness of plastic surgical procedures is much greater than it used to be. I find that men in general, and particularly young men, find it acceptable to have cosmetic surgery."
Adolescent boys also no longer have the patience to outgrow a little breast puffiness. "Boys these days are much more in tune with trying to look good, to try to look like the models on the covers of the fitness magazines," Dr. Guy said. "Be that good or bad, sometimes they can go overboard, and in this sense they are beginning to resemble teenage girls."
The shame can be intense. One of Dr. Copeland's patients, now 17, had breast reduction surgery at 15. His problem was not one of obesity but of glandular overgrowth. He was given anonymity, after saying he was still too embarrassed to speak publicly about the issue.
"I took my shirt off once, and a couple of kids laughed at me, and I never took my shirt off again," he said. His pediatrician was opposed to the surgery, but the young man, a student at a Manhattan private school, had the support of his parents.
"It sounds cliché and kind of lame, but it just comes down to a point of embarrassment," he said. "You don't think you look like you should. If I was fat, I could have lost weight. If was weak, I could have exercised. But this was simply genetic, and there was nothing I could do about it."
Indeed, the condition is a punch line in sitcoms and movies. In a now-famous episode of "Seinfeld," Kramer invented "the Bro," a bra for men with breast development. (Frank Costanza, Kramer's partner, wanted to call the garment "the Mansiere.") In the movie "Knocked Up," the actor Seth Rogen is referred to by the actress Leslie Mann as "the one with the man boobs."
A British Web site, Manboobs.co.uk, welcomes readers with the slogan, "Welcome to Man Boobs. The site that says, 'we're fat and we're proud,' and then quickly puts it T-shirt back on." And several Web sites, such as gc2compression.com and makemeheal.com, sell compression garments that purport to reduce the visibility of enlarged male breasts.
Plastic surgeons in the United States suggested that the rise in popularity of professional golf may have also contributed to public awareness of gynecomastia; several prominent popular players have slightly enlarged chests.
But in most adolescents who are not obese, the condition will resolve itself spontaneously as the boy progresses through adolescence and produces more testosterone, said Dr. Brenda Kohn, an associate professor of pediatrics who specializes in pediatric endocrinology at New York University School of Medicine.
As such, she said, "It is very important that one not operate on a child who is still in puberty." If surgery is done too early, she said, the hormones that caused the initial breast enlargement may still be active and cause ongoing breast development after surgery.
While gynecomastia in young men is most often associated with hormonal fluctuations or obesity, many surgeons are also beginning to link it with increased abuse of steroids . "They have hopped up their testosterone levels, and so when they get off the stuff, there is a change in the hormonal milieu," said Dr. Guy, the Florida plastic surgeon. "It can reset itself, but many times if they have abused steroids, you have to send them to an endocrinologist to address the problem." If that doesn't work, she said, they come back to her for surgery
Surgeons who are referred a young patient by a pediatrician often will first call for a complete endocrinological workup to make sure that the breast enlargement isn't a transient hormonal fluctuation. Other causes include decreased testosterone production, kidney failure, testicular tumors and liver disease. The condition can be addressed with hormone treatments such as testosterone patches or even Tamoxifen, an estrogen-inhibiting drug that is best known for its use in the treatment of breast cancer in women. "You have to rule out any other cause before surgery," Dr. Copeland said. (This reporter was until four years ago a cosmetic surgery patient of Dr. Copeland.)
The reduction procedure depends on the size and composition of the breast. Some surgeons simply use liposuction to remove fatty deposits. If the breasts are enlarged with not only fat but also extra glandular tissue, the surgeon must remove the fat and excise the glandular tissue.
Occasionally, in extreme cases, a surgeon must remove fat, glandular tissue, excess skin and reposition the nipple, in which case the patient will have some scarring. The procedure does not require general anesthesia , but it typically requires several days of bed rest and wearing a compression garment for a month.
The price range is $4,000 to $10,000, depending on the complexity of the procedure. The issue of expense, as well as the acceptability of gynecomastia as a medical disorder, was recently addressed in New York when a Long Island man fought Group Health Inc., seeking coverage for his son's breast reduction surgery. In April, the appellate division of the State Supreme Court ruled that the insurance company must pay the family $5,000 toward the $7,500 surgery. But the majority of patients pay for the procedure themselves.
Nathan Johnson, a 31-year-old actor in Manhattan, had the surgery when he was in his early 20s.
"I was definitely a morbidly obese child," Mr. Nathan said. In his late teens, he lost weight, but was left with a sagging chest. "I had these big pockets, little pointy sagginess that looked like pointy breasts. No matter how much I dieted or worked out, I couldn't get rid of them."
Dr. Guy performed the surgery, but Mr. Johnson remained nervous about removing his shirt until a year later. "People love my body now," he said. "And I take great care of myself now."
DR. FOAD NAHAI, a plastic surgeon in Atlanta and the president of the American Society for Aesthetic Plastic Surgery, said that he was "personally amazed" to see that the number of male breast reduction procedures had for the first time risen above those for male facelift procedures.
"Some of these boys are just heavy everywhere," he said. "They are told if you lose weight the problem will go away. And with some of them, having the procedure is an inducement to lose weight. Perhaps if the chest looks good, they will go ahead and start working out and paying a bit more attention to diet and exercise."
Medical ethicists have even come around to see gynecomastia as a disorder worthy of surgical risk. Dr. Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania , and typically a critic of cosmetic surgery, said that gynecomastia that does not resolve itself after adolescence should be addressed.
"Growing out of something is a strategy you might take with shyness or awkwardness, but when it's breasts in a boy, or something like acne, I don't know that I'd want to make the patient wait to grow out of it," he said.
Dr. Robert Kotler, a plastic surgeon in Beverly Hills, Calif., said that his nephew, who is now in his 20s, had breast reduction surgery when he was a teenager.
"My nephew wouldn't take his shirt off in public," Dr. Kotler said. "He wouldn't go to the beach, which in California is a pretty big deal.
"In the past, doctors said, 'Oh, he'll grow out of it.' He decided not to grow out of it, but to have the procedure." The result was astonishing, Dr. Kotler said.
"Here was the shyest, most introverted kid you could ever meet," he said. "And now, well, he's the polar opposite of the shy kid. Guess what he does now? He's a Hollywood agent."
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