Enhancing Masculine Features After Massive Weight Loss (WARNING GRAPHIC CONTENT)

[madman]

Abstract

Background Whereas body contouring surgery after massive weight loss in women emphasizes sculptured adipose and broader lower torso, little attention has been devoted to accentuating the male physique.

Objective To determine if boomerang excision pattern correction of gynecomastia with J torsoplasty combined with abdominoplasty with oblique excisions directly over bulging flanks provide effective and safe optimizing of muscle visibility and upper torso dominance.

Methods A description of comprehensive body contouring through abdominoplasty and a series of obliquely oriented ellipses of the male torso is followed by a review of 19 consecutive patients.

Results Seventeen patients were performed in a single stage. Nine of the last ten cases included J torsoplasty and oblique excision extensions over the flanks. Of the 17 patients responding to a ten-question survey, 15 were satisfied with chest improvement. One of the first eight patients with a transverse lower body lift was satisfied with the flank bulges. All of the last eight cases with direct oblique flank excisions were satisfied with their lower body. Five patients (26 %), having a total of 74 operative procedures, had significant complications of chest hematoma, persistent hip and buttock seromas, superior NAC edge necrosis, and distal necrosis of the fleur de lis abdominoplasty. One boomerang correction underwent minor revisions. One transverse lower body lift underwent major revision. No complications occurred in the last ten patients, having oblique flank excisions instead of transverse lower body lifts.

Conclusion Comprehensive excisional body contouring surgery of a central high tension abdominoplasty with a series of obliquely oriented ellipses throughout the torso appears to provide low risk improved body contour for the muscular male.



Introduction

After massive weight loss (MWL), men seek body contouring surgery for the removal of excess skin and fat followed by tightening and suspension of residual lax tissues. Men generally have a correction of pseudo gynecomastia and an abdominoplasty extending into a lower body lift [1].

Since many men are obsessed with muscle show and upper torso dominance and are considering plastic surgery to achieve those goals [2], plastic surgeons should be prepared to accentuate those features. This is a preliminary
report of total body lift (TBL) [3] surgery that seeks that transformation through abdominoplasty and a crisscross pattern of elliptical excisions across the torso (Fig. 1) [4]. By removal of most horizontal and vertical excess skin and fat, uniformly tight skin across the torso leaves upper body dominance, muscular show, and two sets of long zigzag scars (Fig. 2). This comprehensive surgery is presented and then followed by a review of 19 consecutive patients (Table 1).

The indication for this male TBL is sagging pseudo gynecomastia with moderate to severe skin laxity of the abdomen and flanks 1 year after stable MWL. The ideal patient is muscular, healthy, and frustrated that rigorous bodybuilding fails to reveal visible results. He desires a harmonious muscularity throughout the torso with the upper dominating the lower. Less sinewy and older men, seeking more muscular show, are also considered. Lengthy operations and scars throughout their torso must be accepted. All patients understand that the boomerang pattern originated with this author and that combining that operation with abdominoplasty and posterior excisions is an exceptionally lengthy surgery. The operations are staged for BMI over 34, excessive skin resections, chronic illness, or patient concern. Patients agreed to be reported anonymously with consent obtained for photograph presentation.







Conclusion

Boomerang excision pattern correction of gynecomastia and J torsoplasty is combined with abdominoplasty with oblique excisions directly over bulging flanks for effective and safe optimizing of muscularity and upper torso dominance in the MWL male. The further clinical study will determine the reliability and safety of this approach. More cases and technical details are forthcoming [20].

 

[madman]

Fig. 1 Frontal and right side artist rendering of male TBL consisting of boomerang pattern correction of gynecomastia, J torsoplasty upper body lift, abdominoplasty extended with elliptical oblique excisions of bulging flanks, and a picture frame monsplasty continuation of a vertical medial thighplasty. Red lines indicate incisions. Yellow fill represents full-thickness skin and subcutaneous tissue resections.

 

[madman]

Fig. 2 Frontal and right side artist drawings of the ideal muscular male after TBL surgery. Faint lines indicate unobtrusive curvilinear scars. The upper torso dominates with skin tightly wrapping about superficial muscles. Defined pectoralis and latissimus dorsi muscles drape from broad shoulders. With arms slightly elevated, the pectoralis muscle is stretched and thinned, completely emptying fullness deep and inferior to nipples. Raised arms reveal the recess of intercostal and serratus muscles rippling between the prominent lateral borders of the pectoralis and latissimus dorsi muscles. The inferior and lateral borders of the pectoralis muscles are defined about the fourth rib. A flat rectus abdominus muscle, depressed by two transverse inscription sets, extends from the costal margin to the mons pubis. The rectus muscles are further contoured by narrow depressions along the midline linea alba and obliquely oriented lateral rectus border. As the narrow waist approaches the hip, the external oblique muscle smoothly swells above the prominent iliac crest. The lateral border of the latissimus dorsi muscle extends to nearly the hips. The buttocks are rounded and narrow.

 

[madman]

Fig. 3 Frontal, right lateral, and posterior views of a typical massive weight loss male, Case 1, seeking comprehensive body contouring surgery to enhance muscular features. There is generalized mild to moderate adiposity with localized bulging and sagging of pseudo gynecomastia, lower abdomen, flanks, mons pubis, and medial thighs

 

[madman]

Fig. 4 Frontal, right lateral, and posterior views after an additional 40-pound weight loss in Case 1 show he transformed into an ideal candidate for single-stage total body lift surgery. There is increased ptosis and definition of his gynecomastia, abdominal pannus, flank bulges, mons pubis, and medial thighs. Now the remaining unresected skin with thin subcutaneous tissue could reveal superficial muscularity and upper body dominance. He has been marked for a boomerang pattern correction of gynecomastia, J torsoplasty upper body lift, and a central high tension abdominoplasty extended with elliptical oblique excisions of his bulging flanks and a picture frame pubic monsplasty extension of a vertical medial thighplasty

 

[madman]

Fig. 5 Case 1 improved contour and upper body dominance is evident 2 years and bodybuilding extra ten pounds later. The shoulders including the deltoid masses are now broader than the waist and hips. A broad rib cage is draped with sheets of contoured muscles that taper to a narrow waist bordered by a flat abdomen and narrowly rounded buttocks. A thin subcutaneous layer and adherent skin distinctly reveal the contour and edges of the pectoralis, latissimus, rectus abdominus, and external oblique muscles. Obliteration of pseudo gynecomastia is combined with tightening of the upper torso skin. Upper body dominance is restored by the effective reduction of lower torso excess

 

[madman]

Fig. 6 Frontal and left oblique swimmers view show that pectoralis major muscle contraction, relaxation, and arm and body position distinctively alter anterior torso surface form. Left Pectoralis muscle contraction bulges superior to the nipple and flattens inferior, even with the arm to the side. The defined inferior limit is the lowest origin of the pectoralis major muscle, not the IMF which is seen closer to the costal margin. Right Generalized even fullness is present behind the nipple with the pectoralis muscle relaxed and the arms to the side

 

[madman]

Fig. 7 Case 2 left anterior oblique views before (a), and after TBL at 3 months (b) and 3.6 years (c). This 26-year-old, 6'10"male requests body contouring surgery. After dieting from 390 to 200 pounds, he is embarrassed by gynecomastia, generalized loose skin, large sagging abdomen, and oversized love handle. a The markings are for boomerang pattern correction of gynecomastia with J torsoplasty extensions and abdominoplasty with oblique excisions over the flanks. b Three months later, the torso exhibits uniformly tight skin with oblique curvilinear scars seemingly interrupted along the superior margin of the NAC’s. The absence of a lower torso bulge restores upper body dominance. c Three and a half years after his TBL, the scars have faded. Despite a 90-pound weight gain, the gynecomastia remains corrected. The abdomen is enlarged without ptosis or flank bulges

 

[madman]

Fig. 8 Case 2 intraoperative views of excisions. Upper After removal of the boomerang pattern, pectoralis muscle fascia is exposed. The inferior pedicle has been defatted and undermined through UAL. After this boomerang cutout is closed, the J torsoplasty pattern will be adjusted and excised to the optimal width of resection. Lower Prone with head to the right. The dissected flank roll hangs from the yet to be resected abdominoplasty. The depth of resection is progressive to the external oblique fascia

 

[madman]

Fig. 9 At the completion of the TBL, Case 2 shows uniform tension and improved contours across the anterior and lateral torso. The even pleating of the outer, longer incision line of the J torsoplasty smooths out over 3 months

 

[madman]

Fig. 10 Case 3 is a 29-year-old with serial ellipses marked for revision surgery. He is 5'11", 200 pounds, after 115-pound dietary weight loss. He is disappointed by gynecomastia, low nipples, and loose chest skin a year after two-stage body contouring elsewhere (a, b). The prior first stage was an abdominoplasty and lower body lift. The second stage was a transverse excision along the inframammary fold, extended to the lateral chest. His IMF remains defined, with no definition of pectoral borders. He was annoyed by anterior chest skin sagging when leaning forward, residual epigastric adiposity, high abdominoplasty scar, and left lower abdominal painful neuroma (X). The revision lines of resection had to be adjusted to include scars left by the original procedures. UAL of the upper torso is marked. c, d Two years following the revision, he has smooth, even contours, tight skin of the anterior torso with the torso appearing longer due to the greater distance between the lower abdominal scar and the raised NAC’s. His raised arms stretch the pectoralis muscles, which flattens inferior to the NAC’s. The oblique extension of his abdominoplasty revision further narrowed his waist. The lateral and inferior borders of the pectoralis major are defined, while the IMF’s are obliterated. The tightness of his chest skin is reflected by the absence of skin sag and prominence of his Pectoralis Major when leaning forward. The scars have faded

 

[madman]

Fig. 11 Case 4 show hypertrophic medial chest scars in a 26-year-old, who lost 210 pounds to a BMI of 23.6. a Right anterior oblique view with preoperative markings for boomerang pattern correction of gynecomastia with J torsoplasty, and abdominoplasty with oblique excisions over the flanks. b Same view nearly 3 years later shows tight skin revealing muscular contours and dominance of the upper torso. Although improved, hypertrophy of the medial chest scars has not resolved