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27 Thighplasty
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27.8 Pearls
1. Assess skin laxity in all directions and in all regions of
the thigh so as to create a comprehensive treatment plan.
2. If extensive liposuction of the thigh is required, then defer
the thigh lift to a later date.
3. Where possible the distal thigh ap should be suspended
to anatomically rm structures such as periosteum or fascia using permanent sutures.
4. There should be no drag on the proximal skin ap which
will cause widening of the scars as well as a deformity of
the introitus.
5. The chances of breakdown of the incision are maximum
at the T junction due to tension on the suture line during
walking and using the pot. May need further dressings
and at times secondary suturing.
References
1. Lewis JR.Correction of ptosis of the thighs: the thigh lift. Plast
Reconstr Surg. 1966;37(6):494–8.
2. Pitanguy I.Surgical reduction of the abdomen, thigh, and buttocks.
Surg Clin North Am. 1971;51(2):479–89.
3. Lockwood T. Fascial anchoring technique in medial thigh lifts.
Plast Reconstr Surg. 1988;82:299–304.
4. Xie S, Small K, Stark R, Constantine R, Farkas J, Kenkel J.Personal
evolution in Thighplasty techniques for patients following massive
weight loss. Aesthetic Surg J. 2017;37(10):1124–35.
5. https://www.plasticsurgery.org/documents/News/Statistics/2019/
plastic- surgery- statistics- full- report- 2019.pdf.
6. DiPietro V, Gianfranco M, Cervelli B, Gentile P.Medial thigh contouring in massive weight loss: a liposuction-assisted medial thigh
lift. World J Plast Surg. 2019;8(2):171–80.
7. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA,
Rubin JP. A classication of contour deformities after bariatric weight loss: the Pittsburgh rating scale. Plast Reconstr Surg.
2005;116(5):1535–46.
8. Bertheuil N, Carloni R, De Runz A, Herlin C, Girard P, Watier E,
Chaput B.Medial thighplasty: current concepts and practices. Ann
Chir Plast Esthet. 2016;61(1):e1–7.
9. https://www.lipedema.org/treating-
Upper Body Lifts
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JoachimFinckenstein
28
28.1 Introduction
When male patients with gynecomastia due to constitution,
age, drugs, or weight loss undergo a “classic” mammaplasty,
the chest wall is scarred when seen in the frontal view. The
fact remains that the skin tightness over the breast in a male
can only be achieved by skin resection, which cannot be performed adequately through periareolar approaches.
In reduction mammaplasty for women, scars are limited
to the aesthetic units of the breast and are hidden in the
shadow of the organ.
In men, the shape of the chest is not three dimensional, so
there is no shadow, in which the scars can be hidden.
The mostly commonly treated region of skin redundancy
especially after weight loss beside the lower abdomen is the
breast. The satisfying results after abdominoplasty and lower
body lifts are due to scars being limited in the aesthetic units
as well as removing the loose skin.
As the only aesthetic limit in male breasts where the scars
can be hidden is the areola, scar positioning is very limited
and remains a problem if more skin resection is needed.
The presently written treatment modality achieves skin
tightness in the frontal thoracic area while avoiding noticeable scars at the same time; redundant skin excision is hidden
in the axilla and wound closure is placed in the middle axillary line by means of a so-called “Chest lifting” procedure
which is part of the upper body lift. Male patients are by far
more concerned about prominent scars than a female since
they usually go bare chested.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_28].
J. Finckenstein (*)
Starnberg, Germany
e-mail: dr.med@nckenstein.de
28.2 Materials andMethods
Patients mostly concerned are male patients with disharmony in the shape of the breast and the thoracic wall, and
usually fall in the Grade III and IV classication of Simon
and Mc Kinney: [1]
Cases of gynecomastia that fall in Grade III and IV.
Cases of pseudo-gynecomastia (specially in elder men).
Cases of massive weight loss in men having large
gynecomastia.
Female patients with indication for chest lifting are:
Cases of skin redundancy in the area of the axilla and lat-
eral thoracic wall.
Although we also had 16 female patients in our series,
men are by far more affected than women; in women the
problem of chest disharmony can mostly be solved by mammaplasty, where scars can easily be hidden in the shadow of
the organ than in male breasts.
28.3 Clinical Examination
Skin, fat, or breast gland excess in the upper torso of male
patients leads to a feminine appearance of the breast. A
mammary crease develops in women (Fig.28.1a) specially
when the hand is kept by the side of the body. The position of
the nipple areola complex (mamilla areola complex) is
assessed as if the mammilla areola complex (MAC) is positioned too medially; the indication for Chest Lifting is perfect. The reason being since the excess tissue is excised
laterally, this operation leads to a lateralization of the
MAC.The aim of this surgery is to restore the breast shape
and centralize the MAC preventing noticeable frontal scars
in the chest wall by placing the wound in the shadow of the
upper arm in the middle axillary line.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_28
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abc
Fig. 28.1 (a–c) The inframammary fold disappears the moment the arms are lifted or when the frontal skin of the chest wall is tightened in the
axilla
28.3.1 Procedure
Skin redundancy of the chest wall leads to an unesthetic
breast appearance in male patients (Fig.28.1a–c). The anterior and mid axillary line is rst marked vertically in such a
way that it falls in the shadow of the arm when placed by the
side of the body.
Lifting up the arms, the skin is held at the anterior axillary
line and is pulled upwards toward the mid axillary line till
the excess skin fold at the inframammary crease disappears;
at the same time the nipples are lifted up in a more natural
lateral part of the chest wall (Fig.28.1b), so that the breast
shape becomes more harmonious.
Pulling the skin upwards in the axilla direction with a 80°
vector (Fig.28.1c), the same effect is achieved. Pulling of
skin means stretching and stretching—in surgicalterms—
means tightening in terms of cutting this excess tissue away.
28.3.2 Markings
The marking of the skin to be removed corresponds to an
elliptic resection whose cranial part ends in the crease of the
axilla and whose distal part ends at the area between the seventh and tenth rib in the middle line of the axilla.
A vector of approximatively 80° must be marked in the
standing position to dene the line for tissue transposition
(Fig.28.2a–c), The resulting scar will correspond to the middle axillary line.
It is impossible to define the markings as the patient is
laying on the operation table. Even the control of aesthetic success in tissue transposition is nearly impossible
during the operation; that is why it is indispensable to
perform a meticulous marking preoperatively in a standing position
28.3.3 Operation Procedure
1. After conventional inltration of solution of Klein, lipo-
suction is done as a rst step to separate the tissue from
the fat, to reduce skin tension, and to perform a preundermining of the area to be treated. It is important to
include the pectoral area for liposuction so that the tissue
can be further tightened (Fig.28.3a, b).
2. The marked skin is removed with its fat attachments.
Wide undermining of the frontal thoracic wall is performed, up to the dorsal part of the gland. If needed parts
of the gland or fat can be removed without torsion of the
frontal nipple appearance leaving glandular tissue behind
the mammilla (Fig.28.3c).
3. Movement of the skin ap is undertaken in the 80°
upwards direction by using tension reducing sutures
between the detached subdermal attachments of the
supercial fascia system (SFS) and the pectoralis muscle
fascia. This is performed to prevent seromas in the pectoral area specially after such an extensive undermining and
tissue excision (Fig.28.3d).
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ab c
427
Fig. 28.2 (a) Showing the excess skin when the arm is placed by the
body (b) Elliptical Skin to be excised has been marked superiorly
ending in axilla and inferiorly between 7th to the 10th rib. The ante-
ba
ed
rior margin is along the anterior axillary fold. (c) A vector marking
the direction of tissue pull is marked as an arrow in the standing
position
c
Fig. 28.3 (a, b) Tumescent uid being inltrated in the pectoral area.
(c) excision of the marked skin with undermining of the chest ap to
excise the glandular component under vision (d) The rst suture to be
placed is at the marked axis so as to lift the chest tissues (e) shows the
completed closure
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J. Finckenstein
4. The wound closure is performed by suturing the supercial fascial system to avoid skin tension and nally by an
intradermal suturing (Fig.28.3e).
Drainage and compression bandage are needed in the
postoperative period for a couple of days (Fig.28.3a–e).
In selected cases, women may benet with the chest
lifting treatment specially when there is excess skin and
fat in the area of the anterior axillary crease which is
prominently visible as a fold and causes a disharmonious
shape of the axillary fold.
28.4 Results
We performed chest lifting in 123 cases since 2003:
• 107 male patients:
– 45 patients with isolated gynecomastia or pseudogyne-
comastia and
ab
– 62 patients after massive weight loss and a disharmo-
nious breast shape.
In 48 of these cases, abdominoplasty was performed
at the same time or as a prior procedure (Figs.28.4 and
28.5 show pre- and post-procedure photographs).
• 16 female patients:
– 11 patients with a shape disharmony in the transition
of the upper breast to axillary crease (Fig.28.6).
– 5 patients with an additional breast hypertrophy.
The aim of chest lifting is to tighten, to atten, and /or to
harmonize the surface over the frontal thoracic wall without
leaving any noticeable scars in the frontal view but hiding
these in the shadow of the arm. In all cases performed, we
achieved these aims. The results were aesthetically pleasing
and easily reproducible (Fig.28.6).
Pre-OP
Fig. 28.4 (a–d) A 28years old patient after weight loss of 30kg (a). Result of chest lifting (and abdominoplasty) 6days (b), 6weeks (c) and
6months (d)) postoperatively
6 days 6 weeks 6 months post-OP
28 Upper Body Lifts
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Fig. 28.5 A 52years old
patient with gynecomastia.
After chest lifting, no visible
scars are left on the frontal
view of the chest wall 5days
postoperatively; glandular
tissue is excised from an
axillary approach
abc
429
Fig. 28.6 (a–c) A 48years old woman after mammoplasty performed 5years ago (a). She disliked the lateral tissue surplus especially visible
when wearing a bra (b). Result after chest lifting 3months postoperatively (c)
Acute revision surgery was necessary in only three cases,
due to hematomas in two cases, and to infection with abscess
in 1 case.
Later scar revision was done in two cases due to dog ears
in one case and scar hypertrophy in another case. All secondary interventions occurred in male patients.
28.5 Discussion
Gynecomastia treatment through the axillary approach is not
new [2]. The new idea in this presentation is an additional
tightening of the chest wall area, by removing excess skin
and hiding the scar in the middle axillary line.
430
ab
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J. Finckenstein
From the plastic surgical view, gynecomastias and
pseudo-gynecomastia’s are treated with two aims: the resection of excess tissue and a minimum of visible scaring.
In cases of simple fat excess liposuction is sufcient, as
adequate skin retraction will occur after liposuction-based
tissue removal (Simon and Mc Kinney Grade I and II) [1];
glandular surplus without soft skin redundancy may need
periareolar approach to directly remove glandular tissue [3].
As gynecomastias are often combinations of fat and gland
excess, both treatments—liposuction and gland removal
from periareolar approach [4]—are usually performed simultaneously (Simon and Mc Kinney Grade II and III). Some
authors suggest a two-stage procedure [5–9]. However, the
periareolar scar might warp the mammilla, when gland tissue
underneath the mammilla is not wide enough, or when tension is too strong [4, 10, 11]. These techniques have been
discussed in another chapter of this book which is dedicated
to gynecomastia surgery.
In cases of skin redundancy (Simon III), a “classic” mammaplasty is required to achieve skin tightness beside gland
excision. One of the many published techniques (inverted T,
vertical or horizontal skin resection) when undertaken causes
scarring in the frontal chest wall (Fig.28.7) [12–19].
“Chest Lifting” technique avoids noticeable scarring on
the frontal chest wall. This treatment is undertaken in patients
with gynecomastia Simon Grade III and IV, where a periareolar approach would not lead to a satisfying result,
because wider skin resection is required. In the chest lifting
approach, the resected skin is undertaken through an incision
in the axilla which leaves the undesired scars hidden in the
middle axillary line under the shadow of the arm. These
patients are mainly male patients with fat, glandular, and/or
skin surplus over the pectoral thoracic wall due to constitution or after weight loss (Fig.28.8).
Since the redundant skin is excised and suture line hidden
aside in the axilla in the middle axillary line by means of a
so-called chest lifting, it adds to the condence of male
patients, who are by far more concerned than females.
In some selected cases, this method may help in female
patients too, when the transition of the lateral breast shape to
the axilla is disharmonious and needs a more feminine chest
and anterior axillary fold contouring.
As the movement and resection of the excess tissue is
settled, the question to be answered in future is, whether this
treatment can be achieved by endoscopic procedures. In
Simon Grade I to III endoscopic tissue removal might
become a common procedure in combination with liposuction; this would mean a minimal invasive procedure of gynecomastia treatment.
In cases of Simon Grade III and IV, the limits of endoscopy will be exceeded, and skin resection will be needed in
the way described above.
The low complication rate reconrms that this operation
is a safe way to treat the chest shape in men having excess
chest skin with or without breast tissue.
Fig. 28.7 A 23years old
man after weight loss of 25kg
(a) A periareolar approach
would not resolve the problem
of skin redundancy, so that a
mammoplasty is needed (b)
leaving visible and
unaesthetic scars on the
frontal chest wall
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431
abc
Fig. 28.8 (a–c) A 36years old man after weight loss of 46kg (a). 3months after chest lifting and body lift (b). Scar result following the middle
axillar line (c)
28.6 Pearls
1. Always mark the excess skin in the standing position.
2. The extent of excision should be marked only after pinching and bringing together the excess skin with the hand
raised.
3. This marking of excision should be reconrmed on the
table after liposuction and excision of the breast tissue.
4. The angle of lift should be 80° to achieve adequate movement of the breast tissue upwards.
5. Closure should be in layers with adequate hemostasis.
References
1. Simon BE, Kahn S.Classication and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51:48–52.
2. Balch CR.A transaxillary incision for gynecomastia. Plast Reconstr
Surg. 61(1):13–6.
3. Gasperoni C, Salgarello M, Gasperoni P. Technical renements in the surgical treatment of gynecomastia. Ann Plast Surg.
44(4):455–8.
4. Voigt M, Walgenbach KJ, Andree C, Bannasch H, Looden Z, Stark
GB.Minimally invasive surgical therapy of gynecomastia: liposuction and exeresis technique. Chirurg. 72(10):1190–5.
5. Pascal JF, Le Louarn C.Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223–30.
6. Lockwood T. Body contouring of the trunk/thigh aesthetic unit.
Plast Surg Nurs. 23(3):110–3; quiz 114/2003 Fall/
7. Fruhstorfer BH, Malata CM.A systematic approach to the surgical
treatment of gynaecomastia. Br J Plast Surg. 56(3):237–46.
8. Hurwitz DJ.Single-staged total body lift after massive weight loss.
Ann Plast Surg. 52(5):435–41.
9. Sagrillo D, Kunz S.Addressing skin redundancy after major weight
loss. Plast Surg Nurs. 24(3):130–3.
10. Smoot EC 3rd. Eccentric skin resection and purse- string closure
for skin reduction with mastectomy for gynecomastia. Ann Plast
Surg. 41(4):378–83.
11. Persichetti P, Berloco M, Casadei RM, Marangi GF, Di Lella
F, Nobili AM. Gynecomastia and the complete circumareolar
approach in the surgical management of skin redundancy. Plast
Reconstr Surg. 107(4):948–54.
12. Tashkandi M, Al-Qattan MM, Hassanain JM, Hawary MB, Sultan
M. The surgical management of high-grade gynecomastia. Ann
Plast Surg. 53(1):17–20; discussion 21
13. Hurwitz DJ, Golla D.Breast reshaping after massive weight loss.
Semin Plast Surg. 18(3):179–87.
14. Wiesman IM, Lehman JA Jr, Parker MG, Tantri MD, Wagner DS,
Pedersen JC.Gynecomastia: an outcome analysis. Ann Plast Surg.
53(2):97–101.
15. Hurwitz DJ, Rubin JP, Risin M, Sajjadian A, Sereika S.Correcting
the saddlebag deformity in the massive weight loss patient. Plast
Reconstr Surg. 114(5):1313–25.
16. Aslan G, Tuncali D, Terzioglu A, Bingul F.Periareolar-transareolarperithelial incision for the surgical treatment of gynecomastia. Ann
Plast Surg. 54(2):130–4.
17. Prado AC, Castillo PF.Minimal surgical access to treat gynecomastia with the use of a power- assisted arthroscopic-endoscopic
cartilage shaver. Plast Reconstr Surg. 115(3):939–42.
18. Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg.
29(5):423–9; discussion 430
19. Ramon Y, Fodor L, Peled IJ, Eldor L, Egozi D, Ullmann
Y. Multimodality gynecomastia repair by cross-chest powerassisted supercial liposuction combined with endoscopic- assisted
pull-through excision. Ann Plast Surg. 2005;55(6):591–4.
Brachioplasty (Arm Reduction)
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JereyA.Swetnam
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29.1 Why Arm Reduction?
With the progress made in the performance of bariatric surgery, and constantly improving medical weight loss, body
contouring procedures have also ourished. This progress
has had major inuence from advancement in technology
for laparoscopic techniques and prominence of laparoscopic training. With this, the safety prole of bariatric procedures has dramatically changed for the better, making
surgical weight loss common. With weight loss of any kind,
and specically the loss of large volumes of weight associated with bariatric surgery, cosmetic problems associated
with excess skin become visible, create issues with selfesteem, cause chronic rashes, create difculty nding
attire, and issues limiting normal activities due to skin laxity and excess. For the purpose of this chapter, massive
weight loss is dened as the loss of one hundred pounds or
more after bariatric surgery. The areas of most concern are
common across the weight loss spectrum and are listed in
Table29.1 [1].
Table 29.1 Weight loss spectrums as seen and treated in 2017 and
2018
Procedures after loss 2018 2017
Breast lift after MWL 15,360 14,811
Lower body lift after MWL 6463 6407
Thigh lift after MWL 4034 3864
Abdominoplasty after MWL 23,206 22,994
Arm lift after MWL 6955 7249
Totals 56,018 55,275
29.2 2018 Body Contouring After Massive
Weight Loss
The upper arm is an area of concern for many weight loss
patients. Statistically, arms are addressed third after the
abdomen and breast. Second only to the face, however, arms
are one of the areas of highest visibility affected by skin laxity and excess adiposity. In most cosmetic practices, addressing the arms is one of the top three desired areas when
correcting changes from weight loss or skin laxity with aging
and this fact is born out in the statistics. Arms are seldom
considered for third party payment which may contribute to
the lower numbers recorded. According to the ASPS, over
17,000 arms were treated in 2019 [1] by all methods. The
biggest concern for surgical brachioplasty is scarring. The
area is not only highly visible for loose skin and fat, but it is
also a difcult area to hide scarring as well.
For those patients with massive weight loss (Fig.29.1),
scarring is not generally as big a consideration due to such a
dramatic change achieved in arm contour that overshadows
the postoperative scar. Fortunately, in most cases, the scarring signicantly fades with time and can be revised in sections if needed.
Fig. 29.1 Arms after massive weight loss, “batwing deformity.” A
55-year-old female prior to weight loss surgery
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_29].
J. A. Swetnam (*)
General Cosmetic Surgery, Facial Cosmetic Surgery and General
Surgery, Fayetteville, AR, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_29
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29.3 Classication oftheUpper Quarter
Arms and the upper quarter can be classied in a number of
ways and can be included in a number of upper body classications. Patients who lose a small amount of weight and
maintain a lower BMI may have minimal residual adipose
tissue and only a small amount of skin laxity. Patients after
massive weight loss, however, may have large amounts of
excess skin along with signicant residual adipose tissue adding to bigger problems in the upper body (Table29.2). In one
group, treatment is fairly straight forward and uncomplicated;
in the second group, the treatment may be very complex.
29.3.1 Class 1: Upper Arms Only
When only the upper arm is involved. A subclassication
that is very simple can be used for the upper arms. There are
many published classication models that tend to be somewhat confusing. This classication is easy and covers all categories of upper arm pathology. Class 1 is limited to the
upper arm only and treatments range from non-invasive to
surgical excision to be discussed.
Subclass A: Mild and localized adipose tissue with good
skin elasticity and quality. Usually present in patients who
have lost and gained small amounts of weight and are
younger on the age spectrum or have genetic pre-disposition
(Fig.29.2).
Subclass B: Patients in this category are those who have
mild-to-moderate adiposity with some skin laxity and good
skin quality and elasticity (Fig.29.3).
Subclass C: Patients in this category are those who have
mild-to-moderate adiposity with signicant skin laxity and or
poor skin quality and elasticity (Figs.29.4, 29.5, and 29.6).
J. A. Swetnam
Fig. 29.2 Class 1 subclass A.A 35-year-old woman with mild, hereditary adipose tissue in upper arms
Fig. 29.3 Class 1 subclass B. A 34-year-old woman with moderate
adipose tissue and excellent skin quality
Table 29.2 Classication of skin laxity in the upper body
Classication of
upper quarter Description
Class 1—Upper
arm only
Class 2—Arm
and axillae.
Class 3—Arm,
axillae, breast
Class 4—
Axillae and
breast
A.Mild and localized adipose tissue with good
skin elasticity and quality
B.Mild-to-moderate adiposity with some skin
laxity and good skin quality and elasticity
C.Mild-to-moderate adiposity with signicant
skin laxity and, or poor skin quality and
elasticity
Batwing deformity where there is no clear
demarcation between the arm and axillae or
axillary rolls are present
Signicant breast and nipple ptosis with or
without macromastia and a desire for a lift or
reduction and axillae and arm are also involved
Breast and nipple ptosis, with or without
macromastia, and excess skin and adipose tissue
in the axillae
Fig. 29.4 Class 1 subclass C.A 44-year-old female with stable weight
after gastric bypass
29.3.2 Class 2: Arms andAxillae
The second classication involves addressing more than one
anatomic area when they are intimately associated. In class 2
patients (Figs.29.7, 29.8 and 29.9), the separation between
the upper arm and axillae is blurred and correcting the arm
only leaves excess tissue in the axillae that is unsightly and
difcult to deal with doing the brachioplasty alone. In massive weight loss patients, there may be multiple rolls of skin
and adipose tissue starting from the upper arm and traveling
through the axillae. These cases take creativity and exibility
because of differences in presentation from patient to patient
and from side to side in the same patient. The other issue to
entertain is the changes in plans that occur when combining
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