Case 5.1 is a 44-year-old frustrated male recreational body builder. He distains his gynecomastia, submental fullness, and generalized lack of muscular show. He has no loose skin. He was marked blue on his neck and torso for liposuction, black for etching depths, and green for lipoaugmentation (Fig. 5.2). Red marks indicate no treatment. The operation was started prone. After infusion of 4,200 cc of saline with xylocaine and epinephrine, 3-ring VASER probe was applied at 80 % VASER mode for 44 min to the back and flanks through stab incisions in the lower lumber midline, posterior Iliac crests, upper back, and arm back junction. The midline of the back was deeply etched. The liposuction through 3 and 3.7 mm diameter VenTx low-pressure cannulas delivered into the Harvester jar 900 cc of emulsion from the flanks and lower back, 600 cc from upper back and 175 cc from each arm. Excess fluid was decanted. The remaining emulsion was strained through a colander. 100 cc of particulate fat was injected within the green zone of each buttock. After he was turned supine, the process was repeated. 1,400 cc saline was injected into the anterior torso, and then after VASER application for 30 min, 1,400 cc of emulsion was extracted. As marked in black, the rectus abdominis inscriptions, the lateral and inferior pectoralis muscle adherences, and the costal groove were accentuated by deliberate oversuctioning beveled depressions with high-vacuum 3 mm cannula. His gynecomastia was completely aspirated, obviating the need for a pull-through resection of gland. 175 cc of aspirated and filtered fat is injected into each pectoralis major muscle and 40 cc into each deltoid muscle. One year later, his gynecomastia has been corrected with no nipple or glandular ptosis (Fig. 5.3). Excess fat has been removed from his neck and throughout his torso. All his torso superficial muscles are better defined along with highlighted skin adherences. His fat-grafted central buttocks and pectoralis and deltoid muscles are esthetically fuller. The abdominal and back midlines are deeply defined. The upper body is dominant.

In addition to adipose, the remaining men in Chapter 5 have both horizontal and vertical skin excess, which requires excisional procedures to reveal underlying muscles.

In Case 5.2, complimentary obliquely oriented ellipses draping over the nipples were drawn to capture both horizontal and vertical excess skin (Fig. 5.4). The 90° orientation of the ellipses capped by a dome that bridges the current to new location of the superior rim of the NAC effectively removes excess anterior chest skin in both the vertical and transverse axes. The long scar is broken up by the NAC and usually fades over time (Fig. 5.5). The skin redundancy caused by extensive torso ultrasound-assisted lipoplasty (UAL) was absorbed by the boomerang/transverse upper body lift excision. As seen in the preoperative markings and the yellow overlay in Fig. 5.4, the smaller ellipse starts roughly at the lowest costochondral sternal junction and rises to across the planned raised NAC cutout. The larger second elliptical excision rises from about the 7th rib at the anterior axillary line to meet the smaller ellipse at roughly right angles at the new NAC. In these initial cases, the lateral ellipse is extended transversely across the back for the upper body lift. This unique asymmetrical excision, which encircles 60 % of the NAC, is called a boomerang pattern because of its likeness to the Australian weapon. The remaining surgical markings in Case 5.1 consists of pluses within large circles indicative of quantity of planned ultrasound-assisted lipoplasty (UAL) of the entire trunk in this 240 lb, 6′ male. This gynecomastia correction is associated with 4,000 cc UAL of the trunk, which would have left loose skin if not for the wide skin resections. The result 2 years later in this relatively simple case shows satisfactory correction of the gynecomastia and no loose skin of the trunk (Fig. 5.5).

The boomerang pattern correction is usually combined with a J-torsoplasty. Case 5.3 demonstrates through photographs and Videos 5.1, 5.2 the current management of multiple upper torso rolls and gynecomastia after MWL. He is a 6′ 6,″ 210 lb 24-year-old male requesting total body contouring (Fig. 5.6). Obese in childhood, he lost 175 lb in college. He has a distinct set of back rolls at the lateral breasts, around the mid torso and the flanks. In the first stage, an abdominoplasty with oblique extensions over the flanks removed lower torso excess. The result of stage-one lower body surgery is seen 2 years later when he is marked for his upper body surgery (Fig. 5.7, left). The lower abdominal and flank excess and bulge have been corrected. The scar is symmetrical, flat, and mildly hyperpigmented. There is mild adipose-glandular fullness under his ptotic lower pole and NACs. As a muscular male, he desires correction of his gynecomastia and skin tight covering over his pectoralis muscles. He wants no epigastric, mid-back, and lateral breast rolls. He accepts a long zigzag scar pattern of an upper body lift but prefers no additional back scars.

The companion video shows the marking and surgery for a boomerang correction with a J-torsoplasty. The early result shows excellent healing, chest contour, and NAC position (Fig. 5.7, right

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