multiple symmetric lipomatosis ( msl ) is a very rare lipid metabolism disorder characterized by the accumulation of multiple , symmetric , nonencapsulated lipomatous masses on the face , neck , shoulders , and upper arms . madelung then reported the cases of 33 patients in 1888 , and launois and bensaude provided the standard description of msl in 1898 . thus , msl is also known as madelung 's disease or launois - bensaude syndrome . the cause of the condition is unknown , but a number of theories have been proposed . the incidence rate is higher in men than in women , and the average age of incidence is approximately 60 years ; the condition is known to be linked to alcoholism . herein , we report a case of msl in a 66-year - old man and review the current literature on the condition . his breasts had slowly become enlarged over a number of years and this had led to huge breast bulging ; the patient reported that he was ashamed of his breast disfigurement when in public baths and swimming pools . he had undergone an excisional biopsy of a mass in the central upper back region 1 year earlier , which revealed a lipoma . he reported more than 25 years of alcohol abuse , and confirmed that he consumed alcohol 5 times a week . furthermore , he had a history of cigarette use , but had stopped smoking 4 years previously . the patient 's father had a history of multiple large disfiguring masses in the neck and upper body . physical examination of the patient revealed multiple large , disfiguring masses in the occipital region as well as on the breasts , upper arms , shoulders , neck , and upper trunk . palpation revealed that the masses had an elastic consistency , could be moved without causing the patient any pain , and had no definite margins ( figure 1a ) . laboratory examinations revealed normal liver and thyroid function , and a hormone assay confirmed that the results were within the normal ranges . a mammography was performed which revealed that the patient 's breasts were comprised almost entirely of fat . breast ultrasonography revealed excessively fatty breasts without any definite glandular tissue ( figure 1b ) . computed tomography and magnetic resonance imaging showed diffuse and marked fatty deposits in the superficial soft tissue layers of the neck , chest , abdomen , and shoulder wall with marked bulging contours of both breasts ( figure 2 ) . pathology revealed soft tissue lipomas measuring 30175 cm and 27165 cm , and both lipomas were homogenous without hemorrhage and necrosis ( figures 3 , 4 ) . the condition is more common in men , especially those aged 30 to 60 years ; the male to female ratio is approximately 15:1 to 30:1 . the etiology of msl remains unknown , however , several theories have been suggested , such as mitochondrial disorder related to genetic dysfunction , defective embryogenic brown adipose tissue , and a lack of adrenergic - induced lipolysis . msl presents as large painless growing adipose masses with little circumscription that are usually located in the neck region , on the shoulders and upper extremities , and in the upper trunk region . pathologically , msl shows characteristics of normal adipose tissue and accumulation of fat in the brown adipose tissue . sporadic cases are more frequently observed and are strongly related to alcoholic abuse and tobacco smoking . in the case type i is horse collar lipoma , which presents as circumscribed protruding masses in the neck area as well as the clavicular and deltoid regions . in severe cases , type ii is characterized by a pseudoathletic appearance with diffuse involvements of the trunk and the proximal end of the extremities , resembling obesity . donhauser et al .   added gynecoid type to the categories of the disease and classified msl as follows : type i , horse collar lipoma ; type ii , pseudoathletic appearance ; and type iii , gynecoid type . the presenting symptom of msl is somewhat different according to gender ; men who presented with condition usually present with a submental mass . however , the patient in our case presented mainly with large bilateral breast masses . due to this extraordinary clinical presentation , we first had to exclude simple gynecomastia by taking a through medical history and performing a physical examination . malignant degeneration of fatty tissue into liposarcoma has only been reported in two cases . despite the benign nature of msl , it can present a serious clinical scenario . in the early period of the disease , it grows rapidly and thereafter , shows slow progression or remains stable for a long period of time . the long - term deposition of lipomatous tissue often results in a cosmetic problem , and more seriously it can cause obstructive symptoms such as dysphagia , dysphonia , or dyspnea . in some cases , neurological symptoms , which are related to mitochondrial defect , maybe present . differential diagnoses of msl are simple obesity , cushing syndrome , angiolipoma , neurofibromatosis , salivary gland diseases , conditions with a neck mass such as thyroid goiter , frohlich 's syndrome , dercum 's disease , and lipomatosis in human immunodeficiency virus . for the accurate diagnosis of msl , taking the clinical history of patients and performing physical examinations are very important . in the case presented here , the patient presented with large bilateral breast masses , which had slowly become enlarged over a number of years . he also had a history of a lipomatous mass on his central upper back and 25 years of alcohol abuse . physical examination revealed multiple large , disfiguring masses in the occipital region , upper arms , shoulders , and upper trunk . we were able to exclude the possibility of simple gynecomastia and diagnose msl through careful history taking and physical examination . alcohol withdrawal and weight reduction are recommended , however , these can not reverse or stop the course of the disease . ultrasound - guided liposuction can also achieve good effects . however , liposuction is of limited effectiveness with large masses . the overall recurrence rate following surgery is approximately 63% , open surgery results in a recurrence rate of 51% compared to a recurrence rate of 95% with liposuction . in conclusion , msl can present as gynecomastia . increasing awareness of the clinical characteristics of msl , especially among breast surgeons , could facilitate its recognition . in addition , because msl is a genetic disorder , family members should be followed up to allow for early detection and appropriate surgical treatment , thus avoiding a delayed diagnosis and subsequent unsatisfactory treatment outcome accompanying a series of further operations .
multiple symmetric lipomatosis ( msl ) , or madelung 's disease , is a rare disease of unknown etiology . 
 it is characterized by the presence of loose adipose tissue deposits localized in the cervical region and upper body . 
 msl presenting as bilateral huge gynecomastia is an extremely rare phenomenon . 
 the present report describes a case of msl in a 66-year - old man . 
 the patients presented with bilateral breast bulging . 
 he had a history of cigarette and alcohol use . 
 his condition was treated with a bilateral nipple - sparing mastectomy . 
 msl can present as a form of gynecomastia , for its accurate diagnosis and proper treatment of msl , increasing awareness of the clinical characteristics of the disease is required , especially amongst breast surgeons . 
 herein , we review the literature and discuss the clinical characteristics , pathology , and surgical treatment of msl .