CLEVELAND, OHIO --Pop culture has had its fun with "man boobs."

For many, introduction to this condition, sometimes also called "moobs" but clinically known as gynecomastia, was probably through comedy treatment on shows such as "Glee" and "Hot in Cleveland," and in the iconic "Seinfeld" episode that added the word "mansier," or "brassiere for men," to the cultural lexicon.

But for men and boys who have the condition, it isn't funny at all. It can be a source of mortification -- and a reason many men never take their shirts off in front of anyone.

Two decades ago, breast reduction surgery to address gynecomastia was rarely heard of, or done. Last year, it was the fourth most popular surgical procedure among male patients in the United States.

Of course, the number of men having all kinds of plastic surgery has been rapidly growing each year. In 2009, 10 percent of people getting cosmetic surgery were men. A year later, it was 13 percent.

2010 U.S. Top 5 male cosmetic surgeries

1) Lipoplasty (liposuction) 37,183

2) Rhinoplasty (nose job) 30,099

3) Blepharoplasty (cosmetic eyelid surgery) 20,675

4) Gynecomastia (male breast reduction) 18,256

5) Otoplasty (ear reshaping) 10,849

Source: American Society for Aesthetic Plastic Surgery

Doctors say part of the reason for the increase is cultural acceptance. Also, men can easily, and privately, do research online and see the results of what surgery can do. Surgeons say men also tell them that to compete with younger men in the workplace, or in the dating arena, they can't afford to look old or tired.

Beverly Hills cosmetic surgeon Dr. Gabriel Chiu -- who did some of his residency training at Robinson Memorial Hospital in Ravenna -- says men now make up more than 20 percent of his patients. He attributes the exceptionally high percentage at his practice, Beverly Hills Plastic Surgery, to the general body-conscious culture in Los Angeles, and specifically to the high percentage of gay men who live in nearby West Hollywood.

"In beach communities, and in gay communities, there's a particular interest in maintaining the body and looking good," Chiu says.

Not that such interest is confined to body-baring climates.

True, in cold-weather cities like Cleveland, it's easier to cover up a condition like gynecomastia. Yet it turns out that 32 percent of all these procedures are done in the Northeast United States, particularly in the Boston area. Doctors attribute this to an educated population of patients and medical professionals who know what the condition is, and that the way to treat it is surgically.

Nationally, the surgery ranks in the top five of cosmetic-surgery procedures that men get. Last year, 18,256 gynecomastia surgeries were performed in the U.S. (just a couple of thousand fewer than the number of eye tucks done on men). The surgery is almost never covered by insurance, and while costs vary by doctor and location, it generally ranges from $5,000 to $7,000.

At Cleveland's MetroHealth Medical Center, cosmetic surgeon Dr. Daniel Medalie is a specialist in male breast reduction. He says there are two separate categories of candidates -- those for whom breasts are related to overall obesity, and those for whom the condition is inconsistent with the rest of the body.

For the first group, fatty tissue produces more estrogen in males, so obesity itself can result in male breast development.

Male patients in the second group might have a hormonal imbalance (possibly caused by certain medications, steroid use or chemotherapy). Long-term use of marijuana is another cause of the condition, doctors say, because it seems to interrupt the endocrine (hormonal) balance in the body.

Often, though, there is no obvious reason for gynecomastia.

But weight-loss surgery or dramatic weight loss from other factors can also result in "drapey" extra tissue that looks breastlike because of gravity.

"In that case, you had extra fatty tissue, and now you just have extra skin," Medalie says. "But some men have had this since they were 16 or so, and it's not related to skin and fat. That is true gynecomastia, which means breast development, not just of skin and fat, but of glandular tissue."

Sometimes, treatment can be as simple as using liposuction to remove extra fat, Medalie says. Or, it might require more complex ultrasonic liposuction, which breaks up fat behind fibrous breast tissue, allowing it to be aspirated through a tube.

Those are the easiest cases. More likely is that surgical cutting and contouring is required. In extreme cases, the surgery is, in essence, a mastectomy.

Medalie explains that breast tissue often will sprout for boys during adolescence, because it is a time of glandular-tissue development. Up to 25 percent of boys might have an issue with breast growth.

"Testosterone and estrogen are closely related," he says. "When you have hormones circulating at high levels, as at puberty, you can get breast development. And when puberty settles down, it usually goes away.

"But these are prime years in a young man's life, and he might not want to wait until his early to mid-20s for that to happen."

For about 5 percent of those boys, the breast tissue or sub-nipple engorgement won't ever go away by itself. The breasts will continue to feel more marblelike and dense than normal tissue.

That was the case with Bill L., 27, of Chardon. Unfortunately, getting rid of the breast tissue became an unfortunate odyssey for him.

"I'd had the growth since I was 10, including a lot of physical sensitivity," he says. And he was self-conscious. "I never wore tight shirts."

When he was 20, he went to see a surgeon in Mentor, who recommended liposuction. Bill told the surgeon that he didn't think that would do the job, "because I knew it was glandular tissue, not fat -- I could feel it. And the thinner I got, the worse it looked."

But the surgeon went ahead with the lipo. As Bill had predicted, it was to no avail. His breast tissue remained prominent. Then the surgeon persuaded him that using an ultrasonic device would do the trick, so he had another procedure -- again, with no results.

Finally, he turned to Medalie. "I found him online, on YouTube," says Bill. "I saw that he did transgender surgery, too, and I thought if he could make a girl's chest look like a guy's, he could do this."

Medalie performed the gynecomastia surgery five weeks ago, and Bill says his chest finally looks normal. He rues having spent nearly $10,000 on the surgeon who botched the job and who left bigger scars on him from the lipo incisions than Medalie did by surgically removing the glandular tissue.

Paul G., 46, a retired Los Angeles-area police officer, is also a trim, fit male who had Chiu perform the surgery last October.

Paul was lifting weights regularly in his early 20s when he noticed what he at first thought was extra fatty tissue around his breasts. But it never went away.

"I was self-conscious about it, so I always stayed covered up at the pool or at the beach," he said in a phone interview. The women he dated didn't seem bothered by it, he said, but his appearance concerned him.

Eventually, he learned there was surgery available for his condition, "but my life was so busy, I didn't have the downtime until I retired last year."

He had the surgery, with Chiu excising fibrous tissue and recontouring the breast/chest area. "I couldn't believe there was no pain afterward, just some soreness, like someone punched you hard," said Paul, noting he didn't even need to take painkillers.

He wore a compression vest, designed to ease swelling and support tissue while it is healing, for a little more than a month. He said the small scars are barely visible now.

Having had gynecomastia, he's noticed other boys and men who have it, too.

"I can tell -- those are the guys who wear bigger shirts," he said. "I know everyone can't afford it, but if a kid has this, I think parents should help him possibly get the surgery -- not forcing it, of course.

"But having the condition? It can really affect your self-esteem."

If a man decides to proceed with surgery, it's important to see a surgeon experienced at the procedure, doctors say.

Chiu says many of the surgeries he performs are revisions of surgery poorly done by an inexperienced surgeon.

"Sometimes the scar tissue from the first surgery is hard to manage," he says. "I like to say the most expensive surgery is the one done wrong the first time. The revisionary rate for gynecomastia surgery is pretty high -- nearly 40 percent -- because you have surgeons doing it who aren't that experienced with it."

He and Medalie suggest doing research to find surgeons who have performed a lot of the surgeries. Check out their websites, ask to see photos that have not been retouched (making sure it's not someone else's work); or get a referral from another doctor you respect.

Medalie notes that gynecomastia has been around for a long time. "I just worked on a guy who is 55, and had it most of his life. And it was pretty severe," Medalie says. "I asked him, 'What took you so long?'

"He said he never had the time or money before."

These days, men are more aware than ever that surgery is an option to the embarrassment they feel -- or the comments they're subject to.

"My wife still remembers how back in high school, years ago, girls and boys would make fun of a boy who had it and say, 'You need a bra,' " Medalie says.

"I think for males the self-esteem and embarrassment factor can be more intense than for females.

"So if you have something like this? Know that taking care of it has become a common surgical procedure that can really be worthwhile."