The blood supply to the cutaneous tissue in the anterior chest area, including the NAC (nipple-areola complex), is from the anterior perforators arising from the internal thoracic artery, and the musculocutaneous perforators arising from pectoral branch of thoracoacromial axis. The cutaneous tissue located laterally, to lateral cephalic of the NAC, is supplied by the superficial thoracic artery. Lateral cephalic from the superficial thoracic artery cutaneous supply, the cutaneous tissue located on the ventral portion of the axilla continuing to the medial, proximal portion of the biceps brachii, is supplied by the anterior circumflex humeral artery. Located inferiorly to the clavicle, on the lateral portion of the upper pectoralis area, the cutaneous tissue is supplied from the direct cutaneous branch arising from the thoracoacromial axis.
Figure 1. Anterior aspect of the anatomical territories of cutaneous blood vessels on the anterior trunk. (Adapted from) (1)
The fascia relevant to gynecomastia surgery are the superficial fascia, and the deep fascia. The superficial fascia, consist of adipose tissue loosely attached to the skin. Small blood vessels and nerves perforate the superficial fascia to supply the skin. (2) The gynecomastia fibroglandular tissue is found within the superficial fascia, as is true with the female breast. The deep fascia is a tough and fibrous membrane that allows some movement of the structures over one another. (2) The deep fascia investing the pectoralis major muscle is relatively thin, but polar, stronger and more distinct in the upper pole of the muscle. (2)
Figure 2. Anatomical diagram of the left anterior chest. (3)
The male NAC, like females, is susceptible to hypertrophic scarring as a result of the high tensile forces present. (2) The NAC is more susceptible to hypo and hyperpigmentation, onset by surgical wound, than the thin hirsute skin that covers most of the body. This is due to the greater degree of melanization in the NAC. (4) Physical examination is performed to evaluate the breast for any dominant masses, nipple discharge, or lymphadenopathy. (2) Patients with gynecomastia were found to have an increased incidence of testicular tumors (5), warranting examination of the testacies. Factors influencing which operative procedure a patient will require are, skin redundancy, the amount of adipose tissue present, the amount of glandular tissue present, and the diameter of the NAC. Mild cases of gynecomastia can be corrected by intraareolar incisions (infraareolar, cresentareolar), circumareolar, endoscopic approaches, and transaxillary approaches. (6) Moderate cases of gynecomastia can be addressed with the donut mastopexy. (2,7,8) Extreme cases of gynecomastia can be corrected with a vertical scar mastopexy, wise pattern mastopexy, or IMF approach (9,10). Gynecomastia operations need to be designed specifically to address the amount of skin excess, glandular breast tissue, fatty tissue, degree of breast ptosis, and the size of the NAC. (2) Each component should be considered separately to optimize the outcome.(2) An example of a single component to consider when planning a surgical approach is the NAC size. The diameter of the NAC will decrease after the removal of the glandular tissue, as a result of contraction, in absence of pressure from underlying tissue volume. Excessively large NACs sometimes require a circumareolar excision, to achieve a reduction in nipple diameter. Based on Dr. Mordcai Blau’s observations, this method comes at the expense of aesthetics, as there is a greater potential for more apparent scarring. An extensive knowledge and understanding of the anatomy relevant to gynecomastia facilitates better aesthetics in procedural outcomes.
Figure 3. A lateral, inferior infraareolar incision of the NAC. The view is parallel to the coronal plane.
Figure 4. Diagram of the NAC innervation. An infraareolar incision is labeled in black. This incision is most often appropriate for grades I and IIa, IIb (grades defined by Simon et al.). (5)
References
1. Cormack, GC and Lamberty, BGH. The Arterial Anatomy of Skin Flaps. 2nd Edition. Edinburgh : Churchill Livingstone, 1994.
2. Bahman, Guyuron, Eriksson, Elof and Persing, John A. PLASTIC SURGERY INDICATIONS AND PRACTICE. [ed.] Kevin C Chung, et al. s.l. : Elsevier Inc., 2009. Vol. I and II.
3. Gray, Henry. Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.
4. Standring, Susan. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.
5. Testicular tumours presenting as gynaecomastia. Daniels, IR and Layer, GT. 29, 2003, Eur J Surg Oncol, pp. 437-439.
6. A transaxillary incision for gynecomastia. Balch, CR. 61, 1978, Plast Reconstruct Surg, Vol. 1, pp. 13-16.
7. Concentric circle operation for massive gynecomastia to excise the redundant skin. Davidson, BA. 63, 1979, Plast Reconstruct Surg , Vol. 3, pp. 350-354.
8. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. Smoot, EC 3rd. 41, 1998, Ann Plast Surg, Vol. 4, pp. 378-383.
9. Correction of gynecomastia with an inframammary incision and subsequent scar. Beraka, GJ. 96, 1995, Plast Reconstruct Surg, Vol. 7, pp. 1753-1754.
10. Correction of extreme gynaecomastia. Wray, RC Jr, Hoopes, JE and Davis, GM. 27, 1974, Brit J Plast Surg, Vol. 1, pp. 39-41.
11. Classification and surgical correction of gynecomastia. Simon, BE, Hoffman, S and Kahn, S. 1973, Plast Reconstr Surg, Vol. 51, pp. 48-52.
Figure 5. Bilateral fibro-sclerotic glandular tissue excised through an infraareolar incision. Glands were released by sharp dissection. Visual inspection elucidates a small percent of adipose tissue present. Lipoplasty was not applied for the purpose of evening the contour of the chest periareolar-NAC area, due to the patients low percent body fat.(11)
The nose is a primary factor in determining facial aesthetics.The central location combined with the visual prominence on the sagittal, coronal, and transverse planes supports this observation.Rhinoplasty is an aesthetic procedure requiring great precession.Rhinoplasty is divided into two main procedures, closed or open.The main difference between closed and open rhinoplasty is the incision used and the exposure of the nasal framework. (1)The closed technique is a fast and efficient method for addressing certain anatomic nasal deformities, specifically those requiring reduction procedures. (1)The open technique offers advantages in terms of direct visualization and control.These advantages make the open technique superior for the correction of tip under projection and severely deviated noses. (1)
The surgeon will give a thorough physical evaluation, which facilitates surgical planning.Key steps in this evaluation are evaluating the entire face for shape, size, symmetry, and proportion.The nasal tip will be evaluated for size, shape, position of the tip defining points, skin quality, and skin thickness.The septum, turbinates, internal and external valves will be examined.The surgeon will use diagnostic and analytical techniques including anatomic, functional, photographic, and computer imaging. (1)Standard photographic procedure is to take a front view, worms eye (inferior aspect (2)), three-quarter (right and left) views, and a profile view (in repose and smiling).
Figure 1. Face Profile – sagittal plane
Tip projection is defined as the distance from the tip of the nose to the most posterior point of the nose-cheek junction. (1)
Figure 2.Nose profile – sagittal plane
The preoperative exam should include a thorough evaluation of the shape, size, location and inherent strength of the medial, middle and lateral crura of the alar cartilages. (1)
Figure 3.Anterior aspect nose, coronal plane
The arterial supply of the nose comes from two sources:1.dorsal nasal artery (anterior ethmoidal), which is a branch of the ophthalmic artery and supplies the proximal nose and subdermal plexus of the tip; 2.two branches of the facial artery, the angular artery and superior labial artery, both of which supply the nasal tip area.
Figure 4. Gray’s Anatomy Figure 514 (3)
Figure 5. Grey’s Anatomy Figure 508 (3)
Based on Dr. Mordcai Blau’s recommendation, a cold compress should be applied for 48 hours postoperatively, to minimize bruising and swelling.The head should remain elevated while resting and during sleep.The patient should sleep on their back.Heavy exercise and sexual intercourse should not be performed for three weeks postoperatively.Alcohol, and consumption of NSAIDs (non-steroidal anti-inflammatory), vitamin E, is prohibited for one week.Pain medication is usual prescribed for a transient period.
Figure 6.Projecting tip reduced, dorsal lowering
Figure 7.Dorsal lowering, reduced tip projection, shortening of the caudal septum, correction of cranial, lateral asymmetry
Figure 8. Dorsal lowering, removal of a dorsal hump
References
1. Aston, Sherrell J, Steinbrech, Douglas S and Walden, Jennifer L.Aesthetic Plastic Surgery. s.l. : Elsevier Limited, 2009. ISBN: 978-0-7020-3168-7.
2. Standring, Susan.Gray’s Anatomy The Anatomical Basis of Clinical Practice. 40. s.l. : Churchill Livingstone ELSEVIER, 2008. p. xxiii. 978-0-443-06684-9.
3. Gray, Henry.Gray’s Anatomy. 15th Edition. New York : Barns & Novle Books, 1901, 1995.
Liposuction surgery (lipoplasty), is performed to remove unwanted localized fat deposits. The ideal candidates for this procedure are patients with localized fat accumulation who have been unable to reduce these areas through diet and exercise. The reduction of adipocyte (fat cell) volume can be accomplished by diet (energy intake restriction) and exercise (directly – through work performed,indirectly – through increased BMR). These methods work by inducing a prolonged catabolic state that promotes lipolosis, and gluconeogenesis. One can lose a significant amount of body fat, through mobilizing the 9 kcal/g energy store in adipose tissue but still have a significant local accumulation specific to a body part or area. Contrary to the common misconception, exercises targeted to a specific muscle group or body area will not reduce thebody fat local to the specific area. Lipoplasty removes adipose cells present as opposed toreducing individual cell volume, like is seen with a negative energy balance. It is for this reason, lipoplasty applied specific adipose stores may offer aesthetically pleasing results.
Lipoplasty procedures including LVL (large volume lipoplasty), are not substitutes for diet and exercise, as research and primary literature have shown that lipoplasty does not reduce themetabolic risk factors for coronary heart disease, or improve insulin sensitivity.
Fat excess or deficiency can have adverse effects on endocrine function. Since significant adipose tissue removal can be achieved through lipoplasty, the procedure should be taken seriously. Adipose tissue is integrally involved in coordinating a variety of biological processes including energy metabolism, neuroendocrine function, and immune function. Adipose tissue is a major site for metabolism of sex steroids and is active in both efferent and afferent signaling. Two major efferent signals produced by adipose tissue are adipsin, and leptin (endocrine factors). Adipose tissue is known to express and secrete a variety of bioactive peptides (adipokines), which act at both the local (autocrine/paracrine) and systemic (endocrine) level. Adipose tissue expresses numerous receptors that allow it to respond to afferent signals from traditional hormone systems as well as the (CNS).
Tumescent liposuction consists of injection of fluid into a specific area as preparation for liposuction surgery. This procedure sometimes helps to reduce the bleeding and facilitate the liposuction surgery.A common method of preparing tumescent solution involves the use of a 3 L bag of lactated Ringer’s solution to which 2% lidocaine 75 ml is added yielding a concentration of 0.05% lidocaine. Next, 1:1000 epinephrine 3 mL is added, resulting in a 1:1,000,000 concentration of epinephrine. The Ringer’s lactate contains 28 mEq/L of bicarbonate ion and has a resultant pH of approximately 6.5.The system is pressurized to approximately 200mm Hg. A suction tube is inserted through a small incision. The surgeon minimizes the incision scar visibility, whenever possible, by placing the incision within and parallel to skin creases on the body.
Multiple modalities for the removal of adipose tissue exist in lipoplasty. SL (syringe lipoplasty), SAL (suction assisted lipoplasty), PAL (power assisted lipoplasty), and UAL (ultrasound assisted lipoplasty), are such modalities. Limitations of traditional lipoplasty (SL / SAL), when performed on fibrotic areas, such as the back, flanks, and gynecomastia, or in secondary or LVL procedures, encouraged the development of energy-efficient devices that allow greater precision and require less physical effort to use. The introduction of UAL, PAL, VAL (Vaser-assisted lipoplasty) resulted in less trauma to the patient, as evidenced by decreased ecchymoses. According to Dr. Mordcai Blau, the surgeon will select the appropriate method, or combination thereof, as appropriate for the anatomy of the area and the tissue removal quantity required.
Areas where the liposuction procedure can be beneficial are the neck, arms, abdomen, waist, back, thighs and knees.
Figure. Lipoplasty preformed on the waist and thighs.This patient is an example of an ideal candidate, in whom, diet and exercise were not adequate to markedly reduce the size of the adipose tissue, heavily distributed in the waist and thighs.
Figure. Lipoplasty of the waist and back. A significant reduction in waist size was achieved by removing adipocyte stores in the waist and lower back.The “love handles” as patients sometimes refer to the adipose tissue located superficial to the external abdominal oblique, internal abdominal oblique, gluteus medius, and tensor fasciae latae muscles.
Figure. A Profile view of a young female, with an adipose tissue store located superficial to the digastric, mylohyoid, and stylohyoid muscles. The postoperative view taken at 1-years time, displays a feminine neck contour, with no skin redundancy. The patients skin elasticity was excellent, which enabled the skin to adjust to the new neck contour after the appropriate volume of adipose tissue was removed.
Gynecomastia Surgery: A Closer Look Gynecomastia is an unacceptable condition when it comes to bodybuilders. Gynecomastia can develop in bodybuilders for many reasons. Some hormones affecting growth and differentiation of breast tissue are growth hormone, estrogen, androgens, and progesterone. A myriad of other peptides both endogenous and exogenously introduced can contribute to developing this condition. Whatever the cause, the development is analogous to female breast development and the results are devastating. It is unacceptable for a bodybuilder who invests the most time, energy, and money per day of life than any other sport or form of human competition to be hindered by breast tissue development.
Drug based therapy is not a viable solution for gynecomastia in the bodybuilder. Surgery is the only effective means of treating this condition. It is important to note that of the general public gynecomastia patients, 50% are not satisfied with the post-operative outcome, as their aesthetic expectations have not been meet. That being said, what the bodybuilder considers aesthetically acceptable is drastically more demanding than a general patient according to Dr. Mordcai Blau who frequently works with this community. One can deduce from this, bodybuilders who do not extensively research for an exceptional, experienced surgeon will likely be disappointed with the results.
Gynecomastia is unacceptable to athletes, recreational bodybuilders, and especially competitive bodybuilders. The staple poses of the competitor are the: quarter turn, front double bicep, front lat spread, abs and thigh, side chest, side tricep, rear double bicep, rear lat spread, and of course most muscular. Competitors suffering from even a mild case of gynecomastia will be most vulnerable in posing the: quarter turn, side chest, and side tricep.
Most Vulnerable Poses
Quarter Turn
Side Chest
Side Tricep
Apex of Aesthetic Points
Contour
A surgery in which the primary intention is to remove mammillary glandular tissue will often result in failure. There are several features that demand more attention in catering a corrective surgical protocol to bodybuilders. Bodybuilders obtain an extremely low percent body fat for a duration of time. Percent body fat is inversely proportional to the aesthetic appearance of the gynecomastia present. This is another reason why correcting the condition is required. The musculature of the chest is a focal point in posing and more generally an accented feature on bodybuilders. Breast tissue proceeds to develop as follows: growth and division of ducts, formation of club-shaped terminal end buds, then forming alveolar buds, clusters of buds make up a lobule, lobules differentiate into ductules. This is significant because of the protrusion caused behind the nipple often made more pronounced by adipose tissue behind the gland. The amount of tissue removed will be unique to the severity of each bodybuilder’s condition and physique. Not removing enough tissue results in the failure to meet aesthetic requirements and enables the possibility of further breast development. Removing excess tissue may result in depressions that cannot be acceptably fixed. Achieving a natural contour is key to a successful surgery. Achieving a natural contour will require a plastic surgeon with specialized experience, perfected technique, and skill.
Scars
Scars are unwanted by a general patient and as such are absolutely unacceptable for bodybuilders. Avoiding scars requires delicate cosmetic surgical techniques. A periareolar incision does not rule out the possibility of scaring. A specialized surgeon with experience is key.
Example of Successful Surgical Treatment of Gynecomastia
Post-Operative Photos: 1 Year
Before photo: Bodybuilder with Bilateral symmetric gynecomastia. Post Op Photo: No scarring.
Before photo: 3/4 Turn showing protrusion feminizing chest. Post-Operative Photo: Tight, natural contour with no scarring or depressions.
The best outcome in most aesthetic procedures is achieved with a well informed patient. A complete and thorough understanding of Breast Augmentation is relevant and desired by most inquisitive patients. Your questions and concerns will be discussed during a comprehensive consultation, and you will be provided with reading material to help you fully understand this procedure.
The breast implants are saline filled with a silicone rubber shell and a valve for adding saline solution. The size is selected in proportion to your body frame and body shape. Dr. Blau’s prefers periareolar (under the of nipple) insertion of the implant. The length of the incision is kept to about one inch. Scars resulting from the periareolar entry are usually less noticeable than other entry points (circumareolar, axillary, IMC / IMF).
The implant can be placed in the subglandular (under the breast tissue, external to the pectoralis muscle), subpectoal (under the pectoralis muscle), or dual plane position (partially under the pectoralis muscle / partially external to the pectoralis muscle). Each position has unique characteristic more appropriate for certain patients with respect to physical activity, desired breast dynamics, and other factors. Dr. Blau’s location for the breast implant is most often, subpectoral, which placement offers benefits in better concealment of upper pole rippling (unnatural surface appearance sometimes present when moving), and markedly less ptosis (sagging – caused by gravities weakening the Cooper’s ligaments in the breast over time), than subglandular augmentation. The result in most patients, is a more natural look and feel. However, the location of the implant is ultimately determined by the needs of each individual patient.
Nipple and breast sensation is important to most women.A part of the determining factors of the site of entry, implant placement, and implant size is limiting loss of NAC (nipple-areola complex) sensation. Implant volume was found to be highly predictive of sensory outcomes, with an inverse relationship between implant size and the degree of sensitivity within the NAC.While hypoesthesia often occurs initially during recovery, it is frequently transient and normal nipple sensation can be attained during the final phase of healing.
Conclusion
Recovery time varies, despite this variance, many patients are able to return to work within a weeks time. It is very important to avoid strenuous activity like weight training, jogging, sexual intercourse, for a few weeks. The individualized instructions and information packet given to you may be used as a guide prior to and after the operation to maximize the positive outcome of the procedure. The staff and plastic surgeon, Dr. Blau, are accessible and supportive throughout the process.
You will be provided with personal reference numbers upon request. Many former breast implant patients are willing to answer your questions and address your concerns. Provided expectations are realistic, Breast Augmentation can not only enhance the way a person looks (aesthetic enhancement), but also the way she feels about herself (positive psychological and emotional experience).
Figure. Patient preoperative and postoperative photo (1-years time).Notes:Ptotic breast improvement, with markedly fuller upper pole thickness, enhance IMF, enhanced medial cleavage, minimal periareolar scarring, natural appearing breast, breasts dynamics appear realistic and natural (no rippling present), firm upon palpation, patient retains NAC sensitivity.
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