We are very proud to announce that Dr. Mordcai Blau will be speaking at the 50th Anniversary Aesthetic Meeting for the American Society for Aesthetic Plastic Surgery (ASAPS) in San Diego on May 1st at the San Diego Convention Center. Dr. Blau will be featured on a panel entitled “Male Body Countouring: Men are from Venus; Women are from Mars,” at 8:15 am on May 1st alongside esteemed colleagues Douglas Steinbrech, MD; W. Grant Stevens, MD; and Simeon Wall, Jr., MD.
For more information or to register for the Aesthetic Meeting, please visit their website at: http://www.surgery.org/
Dr. Blau will be speaking on Male Body Contouring at the San Diego Convention Center at 8:15 am on May 1st.
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.
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