Ideas and Innovations Boomerang Pattern Correction of Gynecomastia Dennis J. Hurwitz, M.D. Pittsburgh, Pa.

Background: After excess skin and fat are removed, a body-lift suture advances skin and suspends ptotic breasts, the mons pubis, and buttocks. For women, the lift includes sculpturing adiposity. While some excess fat may need removal, muscular men should receive a deliberate effort to achieve generalized tight skin closure to reveal superficial muscular bulk. For skin to be tightly bound to muscle, the excess needs to be removed both horizontally and vertically. To aesthetically accomplish that goal, a series of oblique elliptical excisions have been designed. Methods: Twenty-four consecutive patients received boomerang pattern correction of gynecomastia. In the last 12 patients, a J torsoplasty extension replaced the transverse upper body lift. Indirect undermining and the opposing force of a simultaneous abdominoplasty obliterate the inframammary fold. To complete effacement of the entire torso in 11 patients, an abdominoplasty was extended by oblique excisions over bulging flanks. Results: Satisfactory improvement was observed in all 24 boomerang cases. A disgruntled patient was displeased with distorted nipples after revision surgery. Scar maturation in the chest is lengthy, with scars taking years to flatten and fade. Complications were limited and no major revisions were needed. Conclusions: In selected patients, comprehensive body contouring surgery consists of a boomerang correction of gynecomastia. J torsoplasty with an abdominoplasty and oblique excisions of the flanks has proven to be a practical means to achieve aesthetic goals. Gender-specific body lift surgery that goes far beyond the treatment of gynecomastia best serves the muscular male patient after massive weight loss.  (Plast. Reconstr. Surg. 135: 433, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A

unique excision pattern was published in 2004 for the correction of gynecomastia, obliteration of the inframammary fold, and removal of upper torso skin excess.1 Asymmetrical draping of elliptical skin excisions across each nipple-areola complex resembled an Australian boomerang. Along with a posterior upper body lift extension, the boomerang pattern has been successfully applied to 24 consecutive patients.

For optimal contours and scar aesthetics, a series of complementary crisscrossing oblique excisions of the upper and lower body are designed. Although the lower and upper body operations may be performed separately, they are best planned together,

PATIENTS AND METHODS

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).

Following body contouring surgery, visible muscular definition requires developed muscles covered by tightly wrapped skin with thin subcutaneous layer. Generalized excess fat is eliminated through preoperative weight loss. Localized adipose deposits are either excised or suctioned. Loose skin is removed in both horizontal and vertical planes. From the Hurwitz Center for Plastic Surgery, University of Pittsburgh Medical Center. Received for publication July 7, 2014; accepted August 13, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000933

Disclosure: The author has no financial interest to declare in relation to the content of this article.

A "Hot Topic Video" by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on "Plastic Surgery Hot Topics" in the "Videos" tab to watch.

www.PRSJournal.com

433

Plastic and Reconstructive Surgery • February 2015

Fig. 1. Frontal and right anterior oblique views of a total body lift, including boomerang pattern correction of gynecomastia with a J torsoplasty. (Left) The preoperative condition with surgical markings on a 26-year-old graduate student. He is 6 feet tall, and weighs 210 pounds (body mass index of 29) after losing 200 pounds through diet and exercise. He has an androgynous appearance with loose skin and no muscular or intermuscular definition. There is moderate-size ptotic gynecomastia with a well-defined inframammary fold, descending medial (seventh rib) to lateral (eighth rib). Abdominal skin and mons pubis are sagging. The flanks are bulging. For the boomerang pattern, the superior two-thirds of the nipple-areola complexes (1) were marked first. Then, the receiving mosque-like dome (2) approximately 3  cm superior to the inferolateral pectoralis muscle was marked. The medial oblique excision ellipse (3) was drawn descending to approximately the seventh costochondral junction. Next, the lateral ellipse excision (4) was drawn descending toward the ninth rib at the anterior axillary line. Finally, the reverse-J midlateral excision (5), based on the lateral chest and back laxity, was drawn from there to the axilla. The markings for his abdominoplasty with oblique extensions over his bulging flanks are also completed. (Right) Four-month postoperative frontal and right oblique views after uncomplicated healing from his total body lift. Not only has loose skin been removed but his masculinity is

434

Volume 135, Number 2 • Boomerang Correction of Gynecomastia as each excision interrelates to achieve an overall tight skin envelope throughout the torso (Fig. 1). For this complex pattern to be applied, the plastic surgeon designs the excisions by pushing and grasping the tissues. (See Video, Supplemental Digital Content 1, which demonstrates the markings for the boomerang pattern excision of gynecomastia combined with the J torsoplasty, followed by the critical moments of the operation in a 24-year-old massive weight loss patient who had a prior abdominoplasty with oblique excision extension over his flanks, http://links.lww.com/PRS/ B197.) The superior chest anchor line is stable. The residual skin should tightly cover the torso. Both the ptotic gynecomastia and the loose mid-torso skin are corrected with obliteration of the inframammary fold. An appropriately sized nipple-areola complex is vascularized by an inferiorly based fullthickness skin pedicle for superior translocation. The nipple-areola complex is relocated into a receiving dome that lies approximately 3 cm superior to the inferolateral margin of the pectoralis major muscle. A subtle contour depression, corresponding to the lateroinferior pectoralis muscular edge, rises from medial to lateral. This muscular adherence is roughly one interspace superior to the gynecomastia-related inframammary fold. The boomerang excision patterns consists of a symmetrical pair of two asymmetrical elliptical excisions that drape at right angles over superiorly repositioned nipple-areola complexes (Fig. 1, left). They are created large enough to correct both the gynecomastia and treat mid-torso skin laxity. For the first 12 of the 24 patients, the upper body lift proceeded to the inferior border of the scapula. Since then, visible scar was reduced by turning the upper body lift extension superior along the mid-lateral chest to end near the axilla (Fig. 1, below, left). With a short sweeping extension toward the flanks, the excision resembles a J.2 This vertical midlateral chest excision also tightens the skin covering over the chest. The bulk



Fig. 1. (Continued) revealed. His gynecomastia has been corrected with symmetrical positioning of his nipple-areola complexes. The larger left nipple-areola complex has remained larger. The pectoralis muscle fullness and intermuscular definition is apparent. Tight skin and defined lateral borders of the pectoralis and latissimus dorsi muscles replace the amorphous lateral chest. The descending inframammary fold was replaced one interspace superior with the natural upward inferolateral pectoral adherence. Bending forward reveals no sagging skin throughout the torso. The fine-line scars are fading and not visible over the superior nipple-areola complex and along the lateral chest with the arms at rest.

Video. Supplemental Digital Content 1 demonstrates the markings for the boomerang pattern excision of gynecomastia combined with the J torsoplasty, followed by the critical moments of the operation in a 24-year-old massive weight loss patient who had a prior abdominoplasty with oblique excision extension over his flanks, http://links.lww.com/PRS/B197.

reduction between pectoralis and latissimus dorsi muscles defines their lateral borders. In the usual case, total body lift surgery is planned as in Figure 1. Before the upper body contouring surgery, an abdominoplasty with the oblique extensions over the flanks is performed. The operation starts with the patient in the prone position with direct excision of the flank excess skin and bulging tissue. Each wound is closed with no. 2 polydioxanone Quill and 2-0 Monoderm (Surgical Specialties Corp., Reading, Pa.).3 A lipoabdominoplasty follows. As the abdominoplasty is being completed, a second surgeon incises the inferior line of the combined boomerang pattern and J torsoplasty. (See Video, Supplemental Digital Content 1, http://links.lww.com/PRS/B197.) The gynecomastia is excised. The inferior pedicle and inframammary fold are thinned and indirectly undermined through ultrasonic-assisted lipoplasty and beyond the costal margin. The inframammary fold is further released by means of LaRoux dissectors and coincidental abdominoplasty. The drawn superior incision line of the excision is adjusted to achieve appropriate tension after chest long closure.

RESULTS An office chart review retrieved 58 patients who had undergone excision of gynecomastia and ultrasonic-assisted lipoplasty since 2001. Of this group, 24 patients underwent boomerang excision pattern correction of gynecomastia with lower torso excision surgery. Twenty-two cases were performed in a single stage.

435

Plastic and Reconstructive Surgery • February 2015 There were three complications requiring reoperation. Two patients had hematomas drained in the operating room. One patient complained of slightly superior placement of nipple-areola complexes. Surgical lowering caused vertical elongation and a disgruntled patient. A fourth patient developed early hypertrophic medial chest scars that matured to flat but widened scars. Scar revision is anticipated. One patient noted slight infraareolar skin laxity that had not yet been corrected 2 years later. The surgeon and all patients agreed that upper torso and gynecomastia results were very good to excellent (Table 1).

DISCUSSION A precisely planned series of upper body oblique excisions corrects moderately severe gynecomastia and leaves tight skin covering to reveal muscularity in the male patient. At extreme deformity, this mid-torso operation may fail because the skin is too loose to remove all the gynecomastia and chest excess while transposing the nipple-areola complex a relatively short distance. The boomerang pattern removes both horizontal and vertical skin excess to leave long obliquely oriented closures over the chest. The undulating scar appears interrupted as it encircles the superior nipple-areola complex. The continuation through a lateral torsoplasty hides that portion of the body lift scar under the resting arm. Others have also suggested that oblique excisions are the most aesthetic for correction of gynecomastia.5 Nevertheless, the oblique scar between the nipple-areola complex and sternum can exhibit prolonged hypertrophy. Midchest transverse excisions4 mostly remove vertical excess. The long transverse excision and scar positioned along the prior inframammary fold appears to simulate a new inframammary fold. The residual redundancy of skin disappointedly hangs when the patient leans over. An Table 1.  Gynecomastia Questionnaire Statement

Score (1–4)*

I am pleased with the overall result. I am comfortable shirtless in public. The gynecomastia is corrected. The chest scars are acceptable. The surgery improved the visibility of your upper body muscles. I need minor revision chest surgery. I need major revision chest surgery. Lower abdominal skin excess is corrected. The abdominoplasty scar is acceptable. Love handles are corrected. *1 = disagree, 2 = slightly disagree, 3 = agree, and 4 = totally agree.

436

inferior buried pedicle flap to nourish the nippleareola complex3 leaves too much inferior fullness. When the pectoralis muscle contracts, the inferior pole should be empty, but that cannot occur when there is an inferior buried pedicle. The presence of two hematomas in 24 of our operations is consistent with the reported higher incidence of hematoma and seroma in men having body contouring surgery after massive weight loss.6 The indication for the boomerang pattern and J torsoplasty is moderate to severe gynecomastia with skin laxity of the torso. Mild deformity can be treated with less scarring. Severe mid-torso skin excess is better treated with transverse excision and nipple skin grafting. The patient must accept long undulating chest scars. The ideal patient is a muscular young male patient with considerable loose upper torso skin and sagging gynecomastia. Also suitable are less sinewy men who desire no residual excess skin. In either case, they must accept lengthy operations throughout their torso.

CONCLUSIONS Boomerang excision pattern correction of gynecomastia can be safely combined with a J torsoplasty and lower body contouring, yielding excellent aesthetics, with a high rate of patient and surgeon satisfaction. Further clinical study should reveal the reliability of this approach. Dennis J. Hurwitz, M.D. Hurwitz Center for Plastic Surgery University of Pittsburgh Medical Center 3109 Forbes Avenue Pittsburgh, Pa. 15213 [email protected]

REFERENCES 1. Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg. 2004;52:435–441. 2. Clavijo-Alvarez JA, Hurwitz DJ. J torsoplasty: A novel approach to avoid circumferential scars of the upper body lift. Plast Reconstr Surg. 2012;130:382e–383e. 3. Hurwitz DJ, Reuben B. Quill barbed suture in body contouring surgery: A six year comparison study with running absorbable braided sutures. Aesthet Surg J. 2013;33:44S–56S. 4. Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight loss: Detectability of technique, patient satisfaction, and classification. Plast Reconstr Surg. 2008;122:1301–1311. 5. Letterman G, Schurter M. Surgical correction of massive gynecomastia. Plast Reconstr Surg. 1972;49:259–262. 6. Chong T, Coon D, Toy J, Purnell C, Michaels J, Rubin JP. Body contouring in the male weight loss population: Assessing gender as a factor in outcomes. Plast Reconstr Surg.2012;130:325e–330e.

Boomerang pattern correction of gynecomastia.

After excess skin and fat are removed, a body-lift suture advances skin and suspends ptotic breasts, the mons pubis, and buttocks. For women, the lift...
504KB Sizes 0 Downloads 14 Views