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Body Treatment

Gynecomastia Surgery in Singapore


Gynecomastia (pronounced guy-neh-co-mastia) is Greek for "women's breasts". The term was first coined by Galen, a second-century AD physician. It describes excess glandular and/or fatty breast tissues in man.

Also known as man boobs, gynecomastia is a benign enlargement of the male breast. Defined as the presence of abnormal proliferation of breast tissues (glands & fats) in males, gyno may cause discomfort, pain and severe distress emotionally and physically. This medical condition is the most common male breast deformity, affecting over 65 percent of young and adult men globally.

True Gynecomastia

Defined clinically by the presence of firm mass (glandular tissue) that extends concentrically from the nipples.

Mixed Gynecomastia

When both fat and firm mass (glandular tissue) are the cause.


It should be differentiated from gynecomastia, as it is characterised by ONLY fat deposition WITHOUT the involvement of enlarged glandular tissue.


Physical signs of gynecomastia include:

  • Male breasts resembling female breasts
  • Oversized nipple-areola complex (puffy nipples)
  • Feminine appearance when wearing form-fitting clothing

Additional symptoms may involve:

  • Swelling
  • Pain
  • Occasional nipple discharge
  • Soreness

How to do a self-check on gynecomastia at home?

A self-check method is to gently pinch the nipple with your fingers.  If you can feel a tender, firm and mobile disc-like mound of tissue when pressure is applied, you might be suffering from gynecomastia. Gynecomastia can occur unilaterally (one-sided) or bilaterally (both sides). If you have man boobs, take a few moments to answer these questions sincerely and note your emotions as you think about your answers:

  • Does the thought of your others staring at your chest make you cringe, anxious and even angry?
  • Do you feel that there is a possibility of being made fun of by your peers for having a female-like chest?
  • How does removing your shirt in front of others make you feel?

What are the psychological effects of gynecomastia?

Body dissatisfaction has resulted in a high percentage of males with extremely low self-confidence, anti-social behaviour and poor mental health and wellbeing. As men are more clammed up about their feelings and insecurities, they tend to take matters into their own hands.

Studies have shown the profound psychological impact that gynecomastia has on male sufferers. It may cause embarrassment, self-consciousness and a decline in self-esteem, leading to social anxiety and body image issues. 

"Male patients who suffer from gynecomastia avoid removing their shirt in the public setting, such as swimming or going to the gym, to avoid judgement or ridicule. In particular, adolescents with this medical condition experience increased psychological distress, as it coincides with heightened self-awareness and peer scrutiny," shares Dr Ivan Puah.


Typically, hormonal imbalance triggers the onset and development of gynecomastia.

Gynecomastia Surgery

Natural hormone changes

Gynecomastia is triggered by hormonal imbalance, where there is a decrease in testosterone compared with estrogen.

The hormones testosterone and estrogen not only control the development but it is a maintenance of sex characteristics in both men and women. Testosterone takes control of male traits, such as muscle mass and body hair, while estrogen takes control of female characteristics, including the growth of breasts. Most people associate estrogen as an exclusively female hormone, but the truth is, men also produce it — though generally in small quantities.

However, when male estrogen levels are too high or are out of balance with testosterone levels, this can cause gynecomastia.

Adolescent gynecomastia, which is caused by hormone changes during puberty) is common. Adult gynecomastia is prevalent amongst men ages 50 and above.

other factors that can upset the hormone balance

Health conditions that can lead to development of gynecomastia

These include:

  • Klinefelter's syndrome

  • Klinefelter syndrome is one the most common genetic conditions, where a male is born with an extra X chromosome that affects about one in every 550 males.

  • Conditions that interferes with T production

  • Any conditions that interfere with normal testosterone production, such as pituitary insufficiency, can be associated with gynecomastia.

  • Tumours

  • Some tumours, such as those involving the testes, adrenal glands or pituitary glands, can produce hormones that alter the male-female hormone balance.

  • Kidney Failure

  • About half the people treated with regular hemodialysis experience gynecomastia due to hormonal changes.

  • Liver Failure And Cirrhosis

  • Hormonal fluctuations related to liver problems and medications taken for cirrhosis are associated with gynecomastia.

  • Malnutrition And Starvation

  • When your body is deprived of adequate nutrition, testosterone levels drop while estrogen levels remain constant. As such, this causes a hormonal imbalance. Unfortunately, Gynecomastia may persist despite resuming normal nutrition.

Other possible causes and factors that may cause hormonal imbalance

  • Obesity

  • Obesity lowers testosterone levels, thus causing havoc to your muscle-to-fat and estrogen-to-androgen ratio [4]. The male hormone androgen will convert into estrogen in the subcutaneous fat. Excessive fat in obese men may worsen the appearance of man boobs.

  • Smoking

  • A study published in the American Journal of Epidemiology found that smokers who smoke more than 36.5 packs a year "show a faster age-related decline in testosterone than non-smokers" [5].

  • Alcohol abuse

  • Alcohol abuse affects the liver's ability to get rid of excess estrogen, and when it can't function effectively, it may also start converting androgens into estrogens. Smoking also causes hormone imbalance [6].

  • Anabolic steroid abuse

  • Anabolic steroid or even legal steroids contain aromatase, an enzyme that converts androgens into estrogens [7].

  • Cannabis abuse

  • The direct relationship between cannabis abuse and gynecomastia has been successfully proven. Cannabis abuse encourages hyperprolactinemia and low serum testosterone levels [8]. In Singapore, cannabis use, in any form, is illegal.


Gynecomastia (True and Mixed) is universally classified under Gynecomastia Scale under Grade I, II, III and IV, according to the severity of breast tissue enlargement.

Gynecomastia grade 1

Grade I

Small breast enlargement with a localised button of tissue that is concentrated around the areola. At this stage, it is generally less noticeable with clothing but can be evident when undressed.

Gynecomastia grade 2

Grade II

Grade II gynecomastia is most commonly seen; it involves moderate male breast enlargement, which expands up to the width of the chest. Depending on the individual's condition, loose skin may or may not be present clinically.

Gynecomastia grade 3

Grade III

Grade III will see a moderate to significant enlargement in the breast tissue. This physical change lends an appearance that resembles a woman's breasts and is often noticeable.

Gynecomastia grade 4

Grade IV

Grade IV gynecomastia is a significant breast enlargement further aggravated with substantial excess skin. This grade is severe and highly visible, giving the appearance of a feminine breast.


Gynecomastia may happen at different phases of their lives. Causes may vary, and the treatment to be recommended is also dependent on their age.

Gynecomastia can look different in men of different ages, and its appearance can vary based on various factors such as the severity, cause, and duration of the condition. 

Gynecomastia in adolescents

According to statistics collected by the National Institutes of Health (NIH) statistics Singapore, about 50 to 60 percent of adolescent males experience gynecomastia.

Symptoms in adolescent males who suffer from gynecomastia are usually caused by male hormonal changes, resulting from the effect of an altered estrogen/androgen balance on the breast tissues or, it can also result from an increased sensitivity of breast tissue to normal estrogen level.  

Although it is not unusual for the condition to regress over time, this is unfortunately not always the case for some.

Gynecomastia in adult men

Gynecomastia is even more common among adult men.  Nearly 65 percent of men between 27 and 92 years old had some kind of gynecomastia. Although the symptoms may be similar, the causes of gynecomastia in adolescents and adults are very different. Adult gynecomastia is usually associated with increasing age due to progressive testicular hypofunction and increased weight and body fat.  

The prevalence of this condition peaks again between the ages of 50 and 69, with at least 1 in 4 men in this age group being affected.


While at a glance, gynecomastia and pseudogynecomastia may appear similar, they have distinct causes and characteristics.

What are the different treatment options for gynecomastia and pseudogynecomastia? 



It has little effect on those suffering from gynecomastia besides helping to get rid of excess fat. Exercise has no effect on the glandular tissue, which is a concern of gynecomastia patients. For pseudogynecomastia patients, exercise and a healthy diet may help to improve their condition.

Non-Invasive Fat Reduction Treatment, fat freezing

Non-invasive Fat Reduction Treatment

The pills or lotions that promise to reduce the size of your gynecomastia that you found online are nothing but a gimmick. Nothing you do, eat or apply can reverse the enlargement of your breast glands; neither can fat freezing or low-energy laser, except for surgical intervention, in the form of gynecomastia surgery.



Liposuction (also known as lipoplasty) is a body contouring and fat removal surgery to correct disproportionate body shape and remove excess stubborn fat resistant to exercise and diet. It is useful in treating pseudogynecomastia. However, in true gynecomastia and mixed gynecomastia cases, the patient will require BOTH liposuction and glandular tissue removal surgery.


Understanding the anatomy of the gynecomastia gland guides a gynecomastia doctor to perform a more thorough and sufficient gland excision.

Ideally, the male chest should be flat with the pectoralis muscle accentuated. In the gynecomastia patient, the male breasts possess a more pyramidal shape with feminine features. 

Gynecomastia anatomyGynecomastia anatomyGynecomastia anatomy

Anatomy of gynecomastia

The enlarged male breast tissue appears to have a unifying shape of a head, body, and tail. The head is semicircular in shape and is located more medially toward the sternum. 

Most glandular tissue consists of a body found immediately deep into the nipple-areolar complex. The tail appears to taper off the body more laterally and toward the insertion of the pectoralis major muscle onto the humerus.

Image source [9]: A specimen collected after surgical excision of gynecomastia from a bodybuilder. The specimen demonstrates the high glandular content of the tissue with its distinct shape of a head, body, and tail. 


Gynecomastia can cause physical discomfort and pain both in adolescence and adulthood. This is more so when the breast enlarges and becomes significant in size, where a slight contact can cause considerable discomfort.

Teenagers may be uncomfortable discussing the issue and therefore may keep it from their parents and family members. This can lead to long-term adverse effects such as low-self esteem, depression, and lack of body confidence.

Your child needs to understand that the issue can be resolved, and seeking a doctor's consultation is the best way to assess and establish if it is indeed gynecomastia.

diagnosING adolescent gynecomastia

Generally, to diagnose adolescent gynecomastia, hormone lab tests may be excluded to establish the presence of gynecomastia.  History taking and physical examination such as pinch test is the key to diagnosing adolescent gynecomastia.

Gynecomastia diagnostic

Diagnostic Tests by Dr Ivan Puah

  • Pinch and touch test to identify fibrous and firm tissue
  • Assessment of skin laxity and excess chest fat
  • Comprehensive medical history and family background evaluation

What happens during gynecomastia consultation
at Amaris B. Clinic?

We believe a detailed clinical consultation and physical examination play an integral part in diagnosing your condition and planning a tailored treatment for you. During the consultation, Dr Ivan Puah will conduct a series of physical assessments and questions while establishing a full report on your concerns.

What is the pre-surgery blood investigation?

History and physical examinations are crucial elements when considering gynecomastia diagnosis [1]. Longstanding stable cases in an adult do not require blood tests other than those that would be necessary for gynecomastia surgery. Blood work may include liver function tests and assays for:

  • Follicle-stimulating hormone
  • Luteinising hormone
  • Thyroxine
  • Estrogen
  • Estradiol
  • Testosterone level

Questions that Dr Ivan Puah may ask

  • Medical History
  • When and how long you've started noticing the signs of abnormal chest enlargement
  • Any pain or discomfort accompanying the physical changes?
  • Medications that you have taken or are currently taking
  • Your diet, lifestyle, and activity history
  • Any surgery performed, injuries, or any other health concerns that need to be taken note of
  • Does the condition affect you while you continue your daily activities and life?


Endoscopic-line incisions not bigger than 4mm are made strategically on the target area to allow infiltration of anaesthetic fluid.  

Through the small incision, a 360° glandular tissue dissection is performed carefully following the physiological disposition of the glandular tissues. Not only can the affected tissues be removed effectively, but scarring is also minimal, and the risks of haematoma are significantly reduced.

Patients treated with 360°GTD® do not require suction drainage, which typically leaves ugly scars and increases the risks of infection post-op.

For those patients whose gynecomastia also comprises excess chest fat, Dr Ivan Puah will perform modern liposuction with his MDC-Sculpt®️ Lipo Technique. He carefully removes stubborn fat with a specialised cannula, further contouring and sculpting the area for a more defined chest contour.

4D Chest Remodelling By Dr Ivan Puah

4D Chest Remodelling developed by Dr Ivan Puah is a customised, more complex treatment modality especially planned for those whose objective is to achieve a flat, sculpted chest with tightened skin and improved nipple appearance.

It involves Dr Ivan Puah performing the high-definition chest sculpting on the patient and 360°GTD® to remove the glandular tissues, further sculpting the chest and correcting disproportionately shaped nipples.

How does gynecomastia surgery by Dr Ivan Puah differ from others?

Each gynecomastia case is unique. The surgical approach developed by Dr Ivan Puah considers the degree of the gynecomastia, glandular tissue-to-fat ratio and parenchyma distribution of the patient. He will propose an individualised approach for the patient after carefully assessing the patient's clinical condition and understanding the patient's concerns.

Dr Ivan Puah's aims to remove fibrous and painful glandular tissues and/or fat tissues to restore a natural-looking masculine body shape with the smallest possible incision for his patients.


When dealing with gynecomastia, selecting the right doctor is crucial. While the desire for a quick resolution is understandable, it's essential not to rush into decisions.  

Here are some key considerations when choosing a suitable gynecomastia doctor for your unique condition:


An experienced doctor can not only identify the underlying issues of a condition, but they can also effectively address it safely with satisfying results. Look for a doctor that does the procedure regularly (with proven results) and one who is meticulous and particular about standards and quality.

Before & After Patient Photos

The doctor should be able to show you various grades of gynecomastia cases that they have performed, in the form of "before" and "after" photos. Most often, these are good indicators of the quality, standard and results you can expect.

Good bedside manners

It is essential that a doctor makes you feel comfortable and can answer your concerns and queries.

The Team

The clinic staff should also be exemplary of the quality and care standard of the clinic. They ideally should have decent experience and knowledge in dealing with patients with different issues and needs.

Clear explanation

The doctor should also be able to explain the reason/s a particular procedure is chosen or preferred over another to address your issue.


A doctor should be patient when addressing questions and concerns. He should not overwhelm or pressure a patient into agreeing to treatments that they (the patients) do not understand regarding the purpose of such treatments.

Clarity & Assurance

A doctor should be able to convey his opinions in a manner that is easily understood and assure his patients, particularly in regards to their safety during the procedure.

Positivity right from the start

Your experience from the moment you step into the clinic until you leave should cast a positive imprint and make you feel confident.

What is the success rate of gynecomastia surgery?

Gynecomastia surgery has a high success rate based on years of patient data collected by Dr Ivan Puah. To ensure optimal results and reduce post-surgery complications, it is crucial for the patient to diligently follow the pre-op and post op instructions provided.

Is gynecomastia surgery medisave/insurance claimable?

To know if your condition is claimable by insurance or Medisave, you must first ascertain that your enlarged male breast is a medical condition and is medically necessary to have it removed.

We encourage you to consult with Dr Ivan Puah, who will be able to identify the root cause of your condition. During the consultation, please share with the doctor your complete medical history.  A detailed physical examination and appropriate diagnostic tests will also be carried out for a thorough assessment.


Dr Ivan Puah is an accredited liposuction doctor and Chairman of Lipo Peer Review Committee in Singapore in Singapore with nearly two decades of surgical body contouring experience. He has completed fundamental and advanced Vaser Liposuction body sculpting surgical training under Dr John Milard and Dr Alfredo Hoyos in Argentina and Colorado.

Dr Puah is also trained in laserlipolysis (laser liposuction) in Italy and has received dedicated gynecomastia surgery training in San Francisco.

Dr Ivan Puah

Dr Ivan Puah is known for his aesthetic sense and meticulousness. Effective doctor-patient communication is paramount in the realm of aesthetics and Dr Puah truly takes the time to understand each patient’s unique needs, and goals and tailors his treatment accordingly.

Dr Ivan Puah marries the principles of science and art in liposuction & gynecomastia surgery, delivering natural and optimal body contouring results for his patients.

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Is gynecomastia caused by obesity?

Contrary to popular misconception, being overweight is not the only cause of gynecomastia. It may be caused by genetics  and ageing as some men experience bodily changes as they grow older.

Is gynecomastia caused by genetics?

Gynecomastia is an endocrine system disorder that causes an enlargement in the size of male breast tissue and it can be caused by genetics.

Is gynecomastia an early sign of breast cancer?

Breast cancer is not only subjected to women as men can get them, although it accounts for only 0.2 percent of all malignancies in male patients.  

Gynecomastia, however, is not a sign of developing breast cancer. Also, excessive breast development and breast cancer are not correlated.

Is gynecomastia caused by andropause (male menopause)?

According to statistics, male menopause or andropause happens when testosterone production drops in men aged 50 or older. Testosterone fuels changes during puberty and affects a man's mental and physical energy. It also regulates other vital evolutionary features.

As the levels of testosterone drop, it causes a hormonal imbalance, which may eventually lead to the development of gynecomastia.

I am overweight. How do I lose the fat and excess breast tissue?

For those who are overweight, it is assumed that they can lose the extra fat prevalent in the chest area with dieting and exercise, only to worsen the situation, causing the unflattering chest to appear more noticeable.

Maintaining a healthy weight and body is always recommended. If being overweight is an issue, do try to lose the extra weight. If you think you're suffering from gynecomastia, seek a qualified doctor's advice as soon as possible to safely and effectively address the issue.

Can I exercise or diet gynecomastia away?

Unfortunately, it is impossible to get rid of gynecomastia with exercise because the majority of the time, the problem is excess glandular tissue that no amount of exercise or healthy eating will eradicate.

In fact, many men have reported that as they lose weight, the gynecomastia looks worse because the fatty tissue around the gland shrinks and the gland subsequently stands out more, making the condition more prominent.

Can only overweight men get male boobs?

The more fat tissues you carry, the higher your chance of developing gynecomastia, so the problem is prevalent among overweight men. However, men in great shape also suffer from the condition because it is caused primarily by a hormone imbalance.

Can doing more chest exercise reduce the swollen man boobs?

Gynecomastia is caused by hormone imbalance, so while exercising is good, it does not resolve the underlying issue at all.

Can gynecomastia be treated?

Yes, the predominant treatment to deal with gynecomastia is surgical - gynecomastia surgery.

Are there any natural remedies for gynecomastia?

Despite what's being purported, there is no scientific evidence to prove that topical creams, fat freezing machines, fat reduction machines, or massage techniques can solve the condition permanently. Gynecomastia surgery is the option for surgical correction of gynecomastia.

Can food containing soy beans cause gynecomastia?

Soy contains isoflavones, a class of phytoestrogens which may mildly mimic the hormone estrogen. The effects of soy isoflavones on estrogen levels are complex, but in general, soy is safe to be consumed in moderation. Eggs, milk and other food products that contain hormones are safe for consumption when taken in moderation.

Can beer give you male boobs?

Hoppy beers like IPA (Indian Pale Ale) contain phytoestrogen, a plant-based estrogen hormone. The common myth is that drinking too much of them will cause estrogen levels to skyrocket. The phytoestrogen levels are too low to create any hormone imbalance. But still, consuming beers or any alcohol excessively can be detrimental to your overall health.

Am I a suitable candidate for gynecomastia?

Gynecomastia surgery is recommended for those whose gynecomastia has persisted for more than one year and those whose gynecomastia does not resolve independently or with other means of management.

The objective of gynecomastia surgery is to reconstruct the male chest contour, obtain a histological clarification of the suspicious breasts lesions, and to relieve the symptoms such as pain and discomfort due to the distention from the hypertrophied breasts.  Gynecomastia surgery can treat males with bilateral or unilateral gynecomastia, with protruding and prominent areolas.

Can gynecomastia surgery be performed at the same time with another procedure?

Yes, full male body contouring is sought after by male patients, and they usually request for fat reduction of the face, abdomen and waists at the same time as their male breast reduction surgery.

What types of medications cause gynecomastia?

Following are some of the medications that can cause gynecomastia:

  • Anti-androgens that are used to treat prostate cancer or enlarged prostate
  • Androgens to treat hormone deficiencies
  • HIV medications
  • ADHD medications
  • Anti-anxiety medications
  • Heart medications
  • The use of recreational/illicit drugs, anabolic steroids, excessive alcohol intake, and certain supplements can also cause gynecomastia

What should I expect after my procedure?

Most patients return to work within 2 to 3 days. A compression vest will be prescribed, and the patient will need to diligently use it for at least 6 to 8 weeks, as it will help to reduce the post-tissue swelling and hasten the recovery process. Soreness, discomfort and bruises (if any) are expected and will gradually improve over 1 to 2 weeks.

There is minimal disruption to daily activities. However, please avoid water activities and heavy gym workouts, especially exercises involving the chest and upper body). Dr Ivan Puah will advise you accordingly on the resumption of such activities.

How much does a gynecomastia surgery cost in Singapore?

Costs for gynecomastia surgery in Singapore will vary between practices, and the following factors will determine the costs. In general, the doctor’s fee is based on their experience and the complexity of the case.

Other charges will include the type of anaesthesia used, hospital or surgical facility costs, medical tests such as blood tests, scans, post-surgical compression vests, pre and post-medication, histology (biopsy), etc.

While costs are one of the variables you need to consider, the doctor’s experience, the variety of gynecomastia cases he has treated, and your comfort level with the doctor and his team are just as necessary as the final costs of the surgery. Ensure that the doctor you choose performs the procedure in an accredited surgical facility with a team of anaesthetists and well-trained surgical and medical support staff.

Dr Ivan Puah tailors the approach for the surgery to your clinical condition, considering the gland size, fat layers and skin laxity. He also performs corrective surgeries on patients with botched jobs or unsatisfactory results from other local or overseas practices.

Does Amaris B. provide aftercare treatments?

At Amaris B. Clinic, aftercare significantly assists you with faster recovery and ensures optimum results. We have curated a bespoke aftercare program designed to help you with the healing process, such as manual lymphatic drainage massages, skin firming and many others.

Is recurrence of gynecomastia common after gynecomastia surgery?

Although rare, 10 percent of patients who have had surgery may experience a recurrence of gynecomastia. Ageing, hormonal changes, alcohol, opioids, and certain medications and drugs are usually associated with the onset of gynecomastia.

Is gynecomastia surgery a complicated procedure? How long does the surgery take?

Depending on the clinical condition of the individual, the gynecomastia surgery may take 1.5 - 2.5 hours. It will be performed in our accredited Day Surgery and the patient will be taken care of by trained surgical and medical personnels.  

The patient is discharged on the same day for rest. Most patients can resume work within a day or two.

Can gynecomastia surgery only be performed by plastic surgeons?

No. As gynecomastia surgery involves liposuction and breast tissue removal, all doctors offering this service, including plastic surgeons alike, must meet the stringent criteria set by the board and be liposuction accredited by the Ministry Of Health Singapore. Dr Ivan Puah is one of the doctors to receive the accreditation.


[1] https://emedicine.medscape.com/article/1273437-overview

[2] Toorians AW, Bovee TF, De Rooy J, Stolker LA, Hoogenboom RL. Gynaecomastia linked to the intake of a herbal supplement fortified with diethylstilbestrol. Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2010 Jul;27(7):917-25. doi: 10.1080/19440041003660869. PMID: 20432093.

[3] Henley, D. V., Lipson, N., Korach, K. S., & Bloch, C. A. (2007). Prepubertal gynecomastia linked to lavender and tea tree oils. New England Journal of Medicine, 356(5), 479-485.

[4] Mathur R & Braunstein GD 1997 Gynecomastia: pathomechanisms and treatment strategies. Hormone Research 48 95-102.

[5] Svartberg J, Jorde R. Endogenous testosterone levels and smoking in men. The fifth Tromsø study. Int J Androl. 2007 Jun;30(3):137-43. doi: 10.1111/j.1365-2605.2006.00720.x. Epub 2006 Nov 27. PMID: 17163954.

[6] Rachdaoui N, Sarkar DK. Effects of alcohol on the endocrine system. Endocrinol Metab Clin North Am. 2013 Sep;42(3):593-615. doi: 10.1016/j.ecl.2013.05.008. PMID: 24011889; PMCID: PMC3767933.

[7] de Ronde W, de Jong FH. Aromatase inhibitors in men: effects and therapeutic options. Reprod Biol Endocrinol. 2011 June 21;9:93. doi: 10.1186/1477-7827-9-93. PMID: 21693046; PMCID: PMC3143915.

[8] Duca Y, Aversa A, Condorelli RA, Calogero AE, La Vignera S. Substance Abuse and Male Hypogonadism. J Clin Med. 2019 May 22;8(5):732. doi: 10.3390/jcm8050732. PMID: 31121993; PMCID: PMC6571549.

[9] Blau M, Hazani R, Hekmat D. Anatomy of the Gynecomastia Tissue and Its Clinical Significance. Plastic and Reconstructive surgery. Global Open. 2016 Aug;4(8):e854. DOI: 10.1097/gox.0000000000000844. PMID: 27622122; PMCID: PMC5010345.


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