With the music of rapper Jay-Z blaring in the background, Marwan Khalifeh, a Washington-area cosmetic surgeon, vigorously plunged a strawlike metal probe back and forth through the breasts of a patient lying on an operating table, as if he were playing a cello.
The goal was to reduce the size of his patient's breasts, an increasingly common procedure for women who decide to change their lifestyle or address a medical condition. And Khalifeh's surgical room on the 17th floor of a medical arts building in Friendship Heights is arrayed with state-of-the-art equipment, including a laser machine called the Smartlipo MPX that emulsifies unwanted fat.
But in this case, Khalifeh was using his surgical talents to shrink the breasts of a 32-year-old man who has suffered the indignities of having a feminine shape most of his life.
David, a government contracting consultant and self-described physical fitness zealot, had spent years trying to hide the size of his breasts with loosefitting or dark-colored shirts and by avoiding beaches or locker rooms where he might have to bare his chest. He long complained that his oversize breasts — a small B cup of breast tissue — had frustrated his bodybuilding efforts and made it harder to lose weight.
David (who agreed to be interviewed for this article on the condition that his last name be withheld to guard his privacy) says he was emotionally scarred growing up in Texas when buddies made fun of his breasts.
"When you're hot-dogging with friends and they're doing titty-twisters, you laugh it off, but it hurts," David said as he was being prepped for the surgery one afternoon in mid-December. "People want to be happy with what they see in the mirror every day, and I wasn't happy with what I saw."
The scientific word for enlarged male breasts is gynecomastia, from the Greek for "womanlike breasts." Although you don't hear much about this condition, experts say it is quite common and may affect as many as 50 to 70 percent of men to varying degrees throughout their lives.
The abnormality typically is caused by a hormonal imbalance beginning in puberty, but it also can be triggered by certain prescription drugs or excessive smoking of marijuana, according to experts.
Americans long ago grew nonchalant about women's efforts to improve on nature with breast implants or reductions. In 2016, more than 310,400 women underwent surgery in the United States to enlarge their breasts with plastic implants, according to the American Society of Aesthetic Plastic Surgery. At the same time, 43,181 women had their breast implants removed.
Men, by contrast, have shied away from cosmetic surgery — especially for something as potentially embarrassing as oversize breasts. Women are roughly three times as likely as men to say they have undergone cosmetic surgery, regardless of age, according to the Pew Research Center.
Fearing the stigma of gynecomastia, some men have gone to such extremes as flattening their chests with duct tape or wearing shirts that compress their chests and necks — often leaving unsightly scars, according to some cosmetic surgeons.
Now, however, cosmetic surgery for men is winning wider acceptance. What's more, men like David are tired of compromising on their lifestyle and denying themselves even the simplest pleasures of life, such as swimming and going shirtless outdoors.
During 2016, 27,760 men underwent breast-reduction surgery, according to the American Society of Plastic Surgeons. That marked a 36 percent increase since 2000.
Some plastic surgeons say they have seen as much as a doubling or tripling of business over the past three years, despite the fairly hefty fees they charge — $4,500 to $8,000, costs that are generally not covered by health insurance.
"They want to migrate toward what's considered the ideal male figure, which does not include overdeveloped breasts," Khalifeh said.
Paul G. Ruff IV, another Washington cosmetic surgeon who specializes in treating men with enlarged breasts, said, "The fact is there are really good, probably high-impact, relatively low downtime, minimally invasive ways to deal with this now that we haven't had in the past."
One of Ruff's former patients — a 61-year-old technology sales representative from suburban Maryland — recalls years of trying to hide his enlarged breasts at the expense of enjoyment of life and athletic activities.
No matter how hard he worked out — including bench pressing as much as 350 pounds — he couldn't get rid of his large breasts.
"I don't know that I had people making fun of me, but I knew people would look at it and see it," he said during a recent interview. And when he and his wife separated several years ago and he began going out with other women, "they certainly noticed it, too."
Last May, after years of soul-searching and online research, Martin — who also spoke on condition that his last name be withheld — underwent surgery that removed gobs of fat and glandular tissue from his breasts. "It made such a big difference," he said. "It was like night and day. I mean, I go out with someone now and they don't even know I had this operation."
There are still a lot of unknowns about the causes of gynecomastia, but scientists mostly cite hormonal imbalances. Unlike the enlarged breasts on overweight or obese men that contain large deposits of fat, gynecomastia can affect boys going through puberty, middle-aged men and the elderly, regardless of the general condition of their bodies or how much they weigh.
Men with gynecomastia suffer from a buildup of glandular tissue that nature designed to secrete substances, such as milk or hormones, through a network of ducts. Men are born with a combination of male and female hormones, yet androgens such as testosterone that control male traits like muscle mass and body hair far outweigh traces of female estrogen that dictate the size of breasts.
Gynecomastia can occur when the hormonal balance dramatically shifts, resulting in either an increase in estrogen or a decrease in androgen, as research physicians and endocrinologists Glenn D. Braunstein and Bradly D. Anawalt noted in a study updated last year.
Gynecomastia can also be triggered by an adverse reaction to antibiotics, certain other drugs, anabolic steroids and herbal products. And here's bad news for marijuana users: The most common reason for gynecomastia among 18-to-35-year-olds is frequent use of pot, according to Ruff. Marijuana is an estrogen stimulator, so it increases the relative effect that estrogen has on those tissues.
For gynecomastia sufferers who can't be helped by a change in a drug prescription, diet or exercise, breast surgery has become a more attractive alternative. Because improved technology allows patients to forgo general anesthesia, the surgery in most cases can be performed on an outpatient basis and the recovery time has been slashed considerably, so that men can get back to work within a day or two.
Traditionally, surgeons used a scalpel and fairly primitive liposuction to remove fat and glandular tissue from the breasts. In some cases, the surgeon also removed excess skin, to create a flatter, firmer chest.
But that procedure had its drawbacks. It frequently resulted in infections, skin injuries and excessive bleeding. Patients complained about numbness in the breast that sometimes lasted as long as a year. And the surgery often left thick, noticeable scars and permanently altered pigment around the breast or nipple.
The technology and techniques have improved in the past decade, however, especially after the introduction of the Vaser liposuction system, which uses ultrasound to break up and liquefy unwanted fat and then expel it with an aspirator.
Khalifeh prefers an alternate laser technique — using the Smartlipo MPX machine — that does a better job of shrinking loose skin around the chest.
The procedure takes about two hours and is not the prettiest thing to watch.
In operating on David, Khalifeh used his scalpel to make incisions below both of the nipples and through both armpits to make way for the thin metal probes that were used first to anesthetize the chest and then to break up the fat and tissue in the breasts.
Once the fat was emulsified, the reddish fluid was sucked out and drained through a rubber tube into a plastic container near the operating table. Khalifeh and an assistant then surgically removed the unwanted breast tissue and the two rubbery breast glands before sewing David back up.
Khalifeh, 43, a graduate of the Vanderbilt medical school who did his residency at Johns Hopkins, was affable and reassuring throughout the surgery. Still, David was clearly surprised by the initial pain of all the probing.
"Oh, my god," he yelled at one point. "This is truly painful!"
But after the anesthesia fully kicked in, the rest of the surgery went smoothly, and Khalifeh declared it a provisional success, pending a follow-up exam later in the week and assuming there were no unforeseen complications such as bleeding.
"A big success is when the patient is happy in two weeks," Khalifeh said cautiously.