Abdominal and Pectoral Etching

Chest Liposuction, Pectoral Etching and Abdominal Etching Submitted for publication in Plastic Surgery Products Under New Plastic Surgery Techniques

Henry A. Mentz, MD, FACS, FICS

The Aesthetic Center for Plastic Surgery, Houston, Texas

Gynecomastia is a condition in which excessive male breast development is found. The literature reports an incidence of 32-65% occurrence in the male population. The classification of overdevelopment has actually been broadened in the last 30 years and now includes patients with very modest “excess,” in addition to the generally perceived condition of a feminized chest. The procedures for treating this area have advanced through the years and the patients who are seeking surgical solutions are different. In my practice, I have found that there are many athletic men who are seeking optimization of their physiques. They are very fit and would like to appear more athletic. They are seeking operations like abdominal etching, which was introduced in 1992 by our group, to enhance and unveil their already developed abdominal muscles. In this operation the abdominal fat pad is sculpted to augment the fullness of the underlying muscles and to sculpt the muscular inscriptions and linea alba. This procedure has allowed us to turn a softer appearing abdomen into a more athletic “six pack.” It is a popular approach to male contouring because the puncture incision scars are generally undetectable and the results reveal a result previously unachievable with workouts. Most men seeking improvement in their abdomen and love handles are also candidates for chest improvement. The male chest can be treated with the same philosophy, but with an additional hitch. The chest can be suctioned with the traditional method of liposuction, and when indicated, the muscular appearance may be maximized by more aggressive suctioning or etching along the inferior and lateral edges of the pectoralis muscle and axilla. This details and enhances the outline of the pectoralis major creating a more athletic and masculine appearing chest. The gland presents somewhat of a problem since it is fibrous and does not suction well. This is the reason that gland removal requires open excision. Traditional surgically incisions have left a semicircular periareolar scar that is not always “beach friendly.”

A new approach utilizing a single puncture incision and “piece meal” removal of the gland helps to reduce the scar. The Procedure On the morning of surgery, markings are made with the patient standing. Trunk and pectoral flexion may be necessary to outline landmarks. The chest and abdominal landmarks and the liposuction access sites are accurately marked. The fullness and perimeter of the gland is assessed and marked. The incisions that are useful are just under the anterior axillary fold, at the lower edge of the areola and sometimes when cross tunneling is necessary, at the lateral end of the inframammary fold. A #15 blade is used to make 3 mm punctures. A pump with a 2 mm infusion cannula is used to instill the tumescent fluid which consists of one liter normal saline, one cc of 1:1000 epinephrine, 50 cc of 1% lidocaine, and sometimes one cc of 10 mg/cc triamcinolone. Triamcinolone is used for its purported speedier resolution of postoperative edema and diminution of reduce postoperative bruising. One to two liters of solution are typically needed for delivery into the chest and axillary subcutaneous tissue. A 3, 4 and 5mm cannula can be used for liposuction. "Cross-tunneling" is done in all areas. I prefer the three hole basket cannula for the chest suctioning. The chest is suctioned to an appropriate thinness, then more complete and aggressive suctioning is performed in the axilla and areas to be etched. The fat overlying the pectoral muscle may be two to three times thicker than the axilla and etched perimeter. At intervals, the pad thickness should be checked for symmetry and smoothness. The intraoperative results closely correlate with the final results. Superficial erythema, especially in the "etched" areas, is often seen intraoperatively. The incisions are left open. Then the glandular portion must be reassessed. Occasionally, the liposuction can be adequate treatment and no further gland removal is necessary. However, often there is persistent glandular tissue that is resistant to suction removal. Through the periareolar puncture incision a thin blunt tipped scissors is used to perform subareolar dissection, cutting the gland ducts connecting the nipple to the gland. Then use the scissor to dissect around the back of the glandular tissue to leave the resistant fibrous tissue nearly free floating. Then strips of glandular tissue are cut and removed in a “piece meal” fashion for complete removal. The contour here should be only slightly overcorrected. One 4-0 catgut suture is placed to close the dermis. Dressings consist of ABD's or 4x4's, adhesive foam (RestonTM) cut into linear strips are used with caution at the lateral and inferior edge of the pectoral muscle, and an elastic vest with sleeves. A sleeved vest provides better axillary compression than the alternative. The foam remains in place for one week; patients shower with it in place and dry it with a towel or blow-dryer before returning to the vest. The binder is worn for at least one week then garments are usually changed to a tight elastic tee shirt. The foam gradually loosens and falls off. Exercise is allowed five days after surgery.

DISCUSSION:

Generally, a smooth, even fatty layer is most important in liposuction. Contour irregularities of the chest are easily created and remain readily visible. Problems with skin excess and wrinkling make heavy breasts a difficult area for aggressive liposuction. Many surgeons leave a centimeter of fat under the skin and generally leave the original contours. This technique does not always accomplish the goals of many young, athletic patients. Furthermore, generalized liposuction can leave the chest too flat and with no appealing architecture. This sculpting liposuction outlined above is another approach to chest contouring. Leaving a thicker fat pad over the muscle bulk with etching at the edges can create a more athletic appearance and enhance the muscular appearance. Removing the glandular portion through a puncture incision can be more satisfying for the patient because of a more inconspicuous scar. CONCLUSION: Puncture removal and pectoral etching was designed specifically to enhance the natural musculature for athletic men. Pectoral etching utilizes liposuction to create an athletic chest in weekend athletes. Puncture removal allows men to undergo breast gland removal with a “beach friendly scar.” The procedure has minimal risks and is easily performed. The surgeon selectively reduces chest fat, and removes excess glandular tissue based upon the patient's anatomy. The patient's athletic appearance is enhanced by refining the chest muscle bulk to approach the chiseled, linear anatomy seen in classic anatomical drawings of the chest. Photo No 1. “Piece meal” glandular tissue removed through a small puncture incision Photo No. 2. Before and after pectoral and abdominal etching Photo No. 3. Before and after puncture removal of gynecomastia Photo No 4.- Before and after 6 months of chest, flank & abdominal liposuction Photo No. 5- Before and after pectoral and abdominal Etching.