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Shaping up

shapingup2Shaping up

Dr Dennis Hurwitz describes his combination body lift for men, to treat gynaecomastia and tighten the skin, using a boomerang correction, J torsoplasty, abdominoplasty and oblique extensions

Most men like to think of themselves as muscular­—they have large upper body skeletons with broad, superficial muscles that are best exposed by the surrounding skin tightness and adherences.

To reveal these muscles, we can get skin tightness by excising horizontally and vertically with oblique excisions of the excess skin, or criss-crossing. There will be a generalised tensional closure which is best treated—although not exclusively—by the total body lift.  The procedure will maximise the natural adherences to the skin, depending on how well-developed the muscles are.

Once they’ve had this treatment, many men start working out and weightlifting again, because they can see the change.  While I do see some bodybuilders who compete, most of these men don’t want to be stronger, they want to look stronger.

We tend to be female-focused surgeons and technicians. However, when we’re treating men, we have to think differently—we don’t want to leave an inframammary fold and we want to reduce the hip adiposity.

Body lift

A total body lift targets all areas we want to treat, involving a boomerang gynaecomastia correction which is extended by a J torsoplasty.  We want to obliterate the inframammary fold that can lie well below the adherences of the pectoralis muscle.

We can then perform an abdominoplasty with high central tension, using oblique excisions of the flanks—not transverse low ones, as they don’t tend to work as well as we’d like. We can get a great transformation, particularly if the men continue to work out following surgery.

The ideal male chest has nipples in the proper position which moves with muscular contracture. The nipple lies just above the adherences of the pectoralis muscle, and this is where it should be positioned. There are subtle skin adherences, not deep markations like the inframammary fold, which results from breast tissue.

Focusing on the upper body, there is a vertical and transverse excess in gynaecomastia. In weight loss patients, gynaecomastia doesn’t tend to be particularly severe—it’s worse than it looks and is actually quite loose.  Conceptually, we should excise ellipses in each direction.  But a more favourable approach is an oblique direction. An even better technique uses double opposing oblique excisions, criss-crossing over the nipple areola complex.

One patient I treated almost ten years ago received the double ellipsis extending across—it resembles a boomerang as it hugs over the nipple areola complex. The complex breaks the scar, so there isn’t one long scar across the body, creating a visual break.

On some patients, I start the operation with a lower body lift. The upper body lift is far enough away to get a tight excision closure from the scapulas across to the hips. But not too tight—that’s our job as plastic surgeons, to figure that out.

We can perform some liposuction of the base of the pedicle to remove the inframammary fold.  Ultrasound-assisted liposuction can remove the excess tissue. If there is a failure, it’s related to not getting enough fat.

In smaller patients, the gynaecomastia is less severe. However, the main problem concerns the loose skin of the chest. Using an extending boomerang pattern in a lateral transverse upper body lift will give a skin-hugging approach. It’s important to note that if you leave any residual gynaecomastia in the contracting male, it’s quite obvious.  You have to be aggressive in that area.

When evaluating gynaecomastia pictures, patients having their arms to the side will allow for the most relaxation of the chest skin.  The pre-op appears worse when the arm is down to the side.

shapingbeforeLower body

I used to have problems with low transverse, which looked a little skewed and asymmetrical—I couldn’t figure out how to get around it. I once treated a wrestler who ended up with an excellent result in the upper body—his opponents were actually pulling on his breasts to help pull him down.  However it was difficult thinning out along the hips and there was some residual bulging as I dove underneath the flank excision.

About five years ago, I bit the bullet and decided to target those flanks directly.  You can see the inframammary fold more distinctly while the patient raises his arms, showing what we have to obliterate.

Use direct excisions. Don’t go too far down the body—leave the buttocks alone. To excise the area, to get as narrow a hip as possible, a huge amount moves to the flanks. I find it easier, and creates a more symmetric results, to put patients prone through this.

For speed and security, I use a two-layer bar suture which gives improved wound healing and reduced complications, usually using a quill.

After that’s done, we can adjust the boomerang excision. At the end, when they’re supine, they’re tight from the clavicles to the groin. Remember not to make it excessively tight, and use discontinuous undermining with a dissector.

Following surgery, the obliquity of the posterior pull will make a difference to the patient and allow him to show off his latissimus muscles and have a narrow waist. Results come from a combination of a boomerang correction, J torsoplasty, abdominoplasty and oblique extensions.

Weight loss

One patient came to me after a 100-pound weight loss, but he was still not an ideal weight for the procedure.  I put him on the HCG (human chorionic gonadotropin) diet, which involves injections of HCG in combination with a low calorie diet to lose weight. Every plastic surgeon should have the availability to provide this or have a nutritionist to advise.
The patient lost another 40 pounds, which produced excess tissue in areas where I could excise it.  It ends up being thin where I want it to be—in the lower abdomen, the flanks and the breast.

shapingafterI used the same combination of procedures, including a vertical thighplasty with the posterior oblique position going directly over the flanks.  I no longer struggle targeting the flank now.  I didn’t always do it when I went low.  Sometimes it worked; sometimes it didn’t.  For men in particular, you can dissect right down to the external oblique and latissimus muscles and remove the fat.

Look for the reflection of the inferior border of the pectoralis muscle and raise the nipple up.  There will be some pull down, because it’s not a perfect anchor support.  You also want the nipple to be three or four centimetres above the inframammary fold.  Use multiple elliptical excisions to get it transverse and horizontal.

We don’t often see before and after photographs of the patient leaning over—if the area sags, he will not be happy. If you perform a one direction excision, you will have laxity in the opposite direction. So we need to get this area right.

Another case involved a man who was unhappy with a body lift performed elsewhere. He had residual gynaecomastia, with loose skin, a high abdominal scar, persistent flank rolls and the hips thinned down.  When we documented him leaning over, it was very telling.  He said: “When I go to the beach and lean over, it’s like nothing was ever done.”

The previous surgeon had tried to do an oblique excision, and actually pulled the area down—the distance between the nipple and the scar here was quite short, and he ended up with depressions.

I performed the same operation, but obviously there were already some excisions. I used the boomerang pattern with the J torsoplasty as well as a little liposuction in the epigastrium. I also tried to lower his abdominal scar in the centre and raise it obliquely.

You have to be careful performing liposuction next to an excision area, as the patient can end up with seromas and skin necrosis. In this case, we undertreated the—I don’t generally recommend doing that but it was the best we could do.

At the end of the operation, he was skin-tight from clavicles to groins, and from the axilla down past the thigh. A year later, the nipples were up where they belong relating to the pectoralis muscle. The improvement in distance elongated his torso.

If you photograph the patient leaning over, you can see a defining difference from excising the excess chest skin in the vertical and inferior area. It’s important to remember that if you don’t try to obliterate the inframammary fold, they will still have it. Many articles about gynaecomastia mention putting a scar right in the inframammary fold, but that’s the last place you want it.

I have treated 13 men with body lifts, and six with the oblique flank excisions. I have only seen complications with the body lifts—one haematoma and two issues with the nipple area.
If the gynaecomastia is very extensive, this operation is difficult to perform, as the area is a little boxed in. There have been a few nipple distortions and I had to do some secondary work. I also saw one seroma from a buttock flap.

Dr Dennis Hurwitz is a clinical professor of plastic surgery at the Universiy of Pittsburgh and the director of the Hurwitz Center for Plastic Surgery

CASE STUDY

The patient has some reasonable pectoral development when contracted. The patient wants the breast lifted and the loose skin removed from the epigastrium. We can treat him with a combined boomerang correction of the gynaecomastia, which includes the upper body lift with a J torsoplasty.

He would like the nipple area as high as reasonably possible. To figure this out, we can get the patient to contract the muscle. Feel for the lower border of the pectoral muscle and go about an inch higher. Get the patient to relax and see if the nipples seem to be on the right line. Draw a meridian line there, the same on the other side and a mid line on the pectus carinatum. We’ll make a horseshoe opening.

We want an oblique ellipse and we’ll see what it takes to efface his upper body roll. Get the patient to turn on his side, take your left arm and pull the skin on the back towards you. You will then see the back clear of loose skin and folds. Roughly estimate how much of the lateral torsoplasty we need to remove to efface. Continue a line all the way from the apex axilla around—this can go right into a brachioplasty if needed.

By pinching the skin, you can see how the dynamics of every excision works to tighten the skin. Make sure most of the gynaecomastia fullness is within the excision pattern and less above on the pectoralis muscle. Have equal distances from the sternum and from the midline marking. With pushing together, the gynaecomastia and the upper body lift is corrected at the same time.

After this, we can complete the J torsoplasty, bearing in mind that there will be some lateral pull, leaving some wiggle room for the nipple to move slightly laterally from its current position.

Surgery

The patient is supine and induced under general anaesthesia. The saline has been infused with epinephrine and Xylocaine to give a vasoconstrictor effect. You can see the blanching of the skin. He will receive an upper body lift at the same time as the gynaecomastia correction, having inferior pedicle on the nipple areolar complex. The thickness of the tissue is uniform throughout. Most of the gynaecomastia bulk is within the area of resection. We can perform a linear incision of a lower body lift/gynecomastia combination, following the outside line all the way around, and then raising the lower flap.

Go through Scarpa’s fascia with the knife and stop the haemostasis. Undermine the J torsoplasty flap down to the latissimus muscle. Take it off the latissimus muscle a short distance so that it can be mobilised forward. Complete the inferior incision, leaving an inferior pedicle to the nipple areolar complex, carefully circumscribing the superior two-thirds of the nipple areolar complex and releasing the apex of the male breast, taking it down.

To preserve the perforators, use a blunt dissector and take it over the costal margin. All the vessels are preserved. Elevate the perforator and test the advancement to the marks.

Stay with the preoperative markings unless there’s a reason not to. Do the cut-out as planned, with an assistant working on the opposite side, beginning with the inferior cut and working about 15 minutes behind to follow surgical actions and move forward.

The cut is made all the way around to the point of the J torsoplasty, stop and continue this cut later. Keep it perpendicular to get the volume out. Go with the knife, because of the epinephrine infusion, and cut down the pectoralis fascia—a relatively bloodless cut.

The boomerang is now cut out and extended with the J torsoplasty, leaving extra tissue from the gynaecomastia out of the superior pull. You can see pectoralis muscle below and some glandular tissue from the gynecomastia. Cut out the excision over the pectoralis fascia

Complete the first layer closure of the boomerang excision with the upper body lift. Make sure the markings are right and proceed with the J torsoplasty. Once the boomerang has been excised and the J torsoplasty performed, the back is pulled up to the chest. Hair is back where it belongs and the nipple is along the meridian. The skin is tight from the costal margin to the clavicle, from sternum to the mid-back, tightly adherent to the chest wall.

Post-surgery

Three days since the boomerang pattern correction of his gynecomastia, the patient has virtually no pain. The dressings and elastic binder are off, and the tissue is healing well and in place. The patient is particularly pleased how, in a reverse abdominoplasty, the excess skin has been removed from the upper abdomen and lower chest.

Author: bodylanguage

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