The male chest can be one of the most desirable(and desired) parts of the idealized physique, garnering lots of attention in art, on the beach, at the gym, and just about anywhere that men’s chests are on display.  But if you’ve been afflicted with “gynecomastia,” known commonly as “man-boobs,” or in the gym crowd as “bitch-tits,” you may feel cheated by all of that attention.  Perhaps you’re one of those young men who never took your t-shirt off in gym class, at the beach, in front of your family members.  You dreaded any game of “shirts and skin,” for fear that your puffy nipples—or worse yet, your full chest—would be scrutinized by teammates, exposing you to teasing and bullying.  

The scenario is common enough that most of us, even if we never had an issue with this problem, are familiar with it.  And that’s because gynecomastia is remarkably common.  Studies have shown that the condition develops in anywhere from 30 to 70% of all men.  There are three periods in life when this may occur:

1) during the newborn period as a result of maternal circulating estrogens;
2) during adolescence when hormones are all over the place;
3) in older men who are experiencing dropping testosterone levels. 

Each of these situations represents a “normal” phase in development, and at least in the first two instances, the condition resolves most of the time, whereas in older men, testosterone supplementation
(or estrogen management) would be required for resolution.  In the case of adolescent gynecomastia, certainly the most common scenario, 95% of cases resolve within three years of onset.  Unfortunately, those which don’t go away on their own result in the scenarios I described in the opening sentences,
and in most of these cases, surgical correction is the only recourse.  

In evaluating patients with gynecomastia, several issues should be addressed.  First off, the cause needs to be considered.  Gynecomastia, which occurs outside of the “normal” physiologic periods—and in most cases, this refers to the condition arising outside of puberty—should compel a work-up of the endocrine system looking at hormone levels.  Tumors in the pituitary gland or the testes, as examples, might be responsible and should be ruled out before dealing with the gynecomastia, since these could
be life threatening.  Alternatively, certain medications and supplements can cause gynecomastia.  Common among these are anabolic steroids, used for athletic performance enhancement, and the irony is that in such cases of “hypermasculinity,” the end result is a more feminine appearance to the
breasts.  Other sports supplements, particularly the “pro-hormones,” such as androstenedione and other pre-testosterone derivatives can lead to gynecomastia, and since many of these supplements are used by less sophisticated athletes, they are frequently caught off guard when lumps begin to develop under their nipples.  There are a number of medications with which gynecomastia is associated, and Propecia is perhaps one of the more commonly encountered in recent years.  In many instances, if the
medication or supplement is stopped promptly after recognition of the problem,  and hormonal levels allowed to return to normal, the condition may resolve over a six month period.  If it doesn’t improve on its own, surgery may be required. 

The procedure to correct gynecomastia in most cases involves a combination of liposuction along with direct excision of tissue under the nipple.  This can be accomplished with a minimum of scarring with the end result a relatively normal appearing chest.  This is typically an outpatient procedure, and it can be done under general anesthesia or using sedation along with local anesthetic, referred to as “tumescent
anesthesia,” which involves infiltration of a dilute local anesthetic into the entire chest area.  The need for liposuction or for excision is in large part based on the composition of the gynecomastia, and those surgeons who do a lot of this surgery (myself included) will generally use both techniques in order to achieve a normal chest contour.  If liposuction manages to remove all of the tissue responsible for the abnormal appearance, then it may not be necessary to make an incision along the edge of the areola and excise tissue under the nipple.  In such cases, where fat alone is responsible for the condition,  this approach can be effective.  In most patients, however, the combination is superior for a good outcome.  On some occasions, in patients who have lost a lot of weight, for example, skin excision might also be required, and this is a more challenging situation, though one that can be effectively managed with a good outcome, albeit with more scarring than less severe cases. 

Following surgery, some limitation on activity is  required, along with compression, either using a vest or a compression shirt of some sort, typically for four to six weeks.  I am fairly aggressive with my patients as far as activity, and especially fitness and weight training, as many of my patients come to me through fitness and bodybuilding.  I allow them to resume cardio, such as a stationary bike or other low-impact training, after a week, and they can resume weight training in two weeks, protecting the chest for a month.  By six to eight weeks post-operatively, the chest looks good, and patients are nearly back to normal with their exercise regimen.  Because there’s some time required for recovery and a compression garment, the ideal time to have the procedure is during cooler months, when there is less compulsion to go shirtless.  Recurrence is unusual, although some tissue must be left under the nipple-areola to support it and protect its blood supply, and that tissue is sensitive to stimuli such as steroids or medication. In such cases, medication might be used to block the estrogenic proliferative effect on the remaining breast tissue, but ideally, avoiding the stimulus is the best option. 

For those who suffer from gynecomastia, correction can be life-changing.  Many men, tormented by this condition from puberty, will typically express the wish that they’d undergone treatment long ago, but because this is rarely covered by insurance, many young men are not in a financial position to have the surgery in their teens or early twenties.  While cost may be a factor in pursuing a surgeon to correct the condition, it’s best to find someone who has a lot of experience with gynecomastia correction, since the best option to get the best outcome is with the first procedure.  In cases where a contour deformity or a significant scar results from the primary procedure, correction can be achieved over time, but it can be much more challenging than performing an uncomplicated primary operation.  An excellent on-line resource to find surgeons in your area who have a particular interest in gynecomastia can be found at 

YOUR LDL CHOLESTEROL NUMBER DOESN'T MEAN MUCH  At least not as a stand-alone stat.  That's because it doesn't take your "good" HDL cholesterol, which may counteract the bad kind, into account.  A better gauge of heart-disease risk:  your ratio of total to HDL cholesterol, a notion confirmed by a 2001 study in the Archives of Internal Medicine.  



By: Dr. Rick Silverman, Fuerte Men Medical Correspondent 


fitness  physique  strength


Plastic Surgery Insights
By: Dr. Rick Silverman, Fuerte Men Medical Correspondent 

First off, fillers are different from neurotoxins in that they replace lost volume or provide additional volume to areas where this is lacking—they don’t cause paralysis to the muscles. As a result, motion will continue in the face of filler use, and a crease, which is softened or even obliterated, will gradually reappear or deepen over time as the filler dissipates.
While permanent fillers are available, most of the fillers used currently provide a temporary augmentation of the soft tissue, which must be repeated every so often, depending on the product used and the area treated. Other than autologous fat—that means taking some of your own fat from one spot and injecting it into another area, such as lips or cheeks—most of the conventional fillers used last from three months to a year or even longer.

The most commonly used fillers are the hyaluronic acid based products, including Restylane, Perlane and Juvederm, among others. These have replaced collagen as the work-horse in dermal fillers, since they are safe, effective and reasonably priced, and can be used without doing any allergy testing as was required with collagen. Hyaluronic acid is present naturally in the skin, where it binds to water, and when injected into the skin, it provides volume while softening and hydrating the skin. These products differ in the size of the molecule, the source of the material, and the degree of cross-linking. These factors will impact the handling and duration of action, which are considerations in deciding which products to use in any given area. The most common areas of treatment with these fillers are the lips, nasolabial folds and marionette lines around the mouth. They last from six months to a year, in most cases, with little to no permanent long-term change.

Sculptra is product, which was initially approved by the FDA for treatment of HIV-associated lipoatrophy, and has more recently gained approval for cosmetic correction of skin folds, such as the nasolabial folds. This product is made of poly-L-lactic acid (a material found in suture material—“stitches”), which is an inert polymer believed to stimulate collagen production. The product is injected into a given area, and initially, very little change is noted. Over four to six weeks, with stimulation of collagen production, there is gradual filling of the area leading to softening of skin folds and some smoothing of fine wrinkles. This product usually requires several sessions to achieve desired correction, which is then maintained for at least two years based on scientific studies. The correction is gradual, which may be desired by those looking for improvement that is more subtle, rather than a huge change in one session.

Radiesse, which is composed of calcium hydroxyapatite beads in a carrier gel, is a second unique product, which was initially approved for treatment of HIV-associated lipoatrophy as well, and was approved in 2009 for treatment of cosmetic signs of facial aging. Radiesse is very effective for larger volume replacement, particularly in treating nasolabial folds, atrophic cheeks, and hollows in the temporal area. Initial treatment will give immediate improvement, which dissipates as the gel carrier goes away. A second treatment six weeks to several months after the first is usually required to maintain the result. The calcium hydroxyapatite may stimulate new collagen production, leading to some long-lasting effect, and results are typically maintained for at least a year if not longer.

These are the products that I use in my practice, having only recently added Sculptra. Each has potential benefits and drawbacks. When considering your options, you should make your goals clear, and understand that results vary from person to person, including how long the results persist. Based on individual factors, the practitioner will likely recommend one or another filler, and he or she should be able to provide a rationale for their use. The more you understand about the fillers and what they can do, the more likely you are to be satisfied with the results.

It’s important to remember that treatment with fillers will typically result in some bruising and swelling, meaning that you may want a few days without social commitments to allow time for resolution. While some anesthetic (Lidocaine) is often used with these products during the injection, there is still some pain associated with their use, and this can be significant, especially with areas such as the lips. Most patients, however, feel that the benefits outweigh the drawback of pain. Other problems, such as nodules, discoloration, or other undesired effects may occur, and it takes time and sometimes intervention for most of these issues to resolve. Nonetheless, in good hands, the results can be very satisfying.

​This brief discussion is only an overview, so be sure to do your research!