Introduction

Although the ideal of female beauty has varied throughout history, the key principles of the desirable male physique have not significantly changed. Ancient Greek urns depicted the same chiseled midsections and well-defined musculature that Michelangelo’s David exhibits to crowds of Florentine tourists. Male protagonists in TV and cinema have become more muscular, and advances in diet and training have allowed physique athletes to achieve ever lowest levels of body fat and higher definition. The “six-pack” or “washboard” abs have remained throughout as the benchmark of male physical fitness and athletic appearance.

Many male patients present seeking improved definition and shape of their midsection with minimally invasive methods, such as liposuction. They tend to be younger and in good health, and have dedicated a considerable effort to achieving their goals through diet and exercise. No studies exist regarding the body fat percentage levels that allow for clear definition of the rectus abdominis. Anecdotal sources point to the answer being somewhere around 8% to 15% body fat, with appropriate muscle bulk. ¹ This should be framed in the setting of CDC data showing mean body fat percentage in the U.S. population ranging from 22.9% in men aged 16 to 19 to 30.9% in men over 60.2

Liposuction of the male abdomen can be a challenging endeavor, as conservative treatment will leave the patient unsatisfied, but aggressive liposuction can result in contour irregularities, poor skin draping, or damage to the skin with overuse of laseror ultrasound-assisted devices in the superficial layer. Liposuction in the superficial layer is the most likely to provide the dramatic improvement in definition, but also has a steeper learning curve. ^{3 , 4} With these caveats, liposuction has shown itself to be a markedly effective tool to produce the desired contour improvements in men who have not been able to achieve them with diet and exercise. ^{1 , 5 , 6} Addition of fat grafting has allowed the surgeon to provide even more dramatic improvements, by enhancing projection of the “six-pack” in patients lacking significant muscular development of the rectus abdominis.

Physical Evaluation

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  Examine the abdominal wall for any scars, incisions, and hernias.

  
  
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  Assess the protrusion of the abdominal wall (i.e., the contribution of visceral adiposity compared to the subcutaneous adipose tissue). The patient must be counseled that no amount of liposuction will address a protuberant belly, and etching a defined six-pack will appear unnatural.

  
  
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  Ask the patient to flex the rectus muscles to mark the linea alba and linea semilunaris bilaterally. If there is insufficient muscle bulk to palpate the borders of the rectus, symmetric approximations of the ideal placement of these lines must be used.

  
  
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  Assess the position of the inscriptions in the rectus abdominis when the abs are flexed, and mark them appropriately. The inscriptions are commonly asymmetrical and marking them according the patient’s own anatomy will produce a more natural and aesthetically appealing result than attempting to achieve some idealized geometric pattern, ^{1 , 7} but this must be explicitly explained to the patient and discussed preoperatively. All markings must be done with the patient standing.

  
  
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  Examine the fat pad thickness of the chest, back, arms, and thighs to understand the patient’s body fat distribution and the limits of what can be accomplished to avoid unnatural-appearing results. The contouring performed in the abdomen and flanks must work in concert with the rest of the patient’s physique. Patients with excess skin or soft-tissue laxity, especially in the lower abdomen, are at a higher risk for poor skin redraping and should be counseled that an excisional procedure such as abdominoplasty may be needed to provide the best result.

  
  
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  Perform the pinch test to assess subcutaneous fat layer thickness; this may determine whether the patient will need both contouring and generalized liposuction in the deep fat layers, as opposed to just the contouring maneuvers.

  
  
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  Perform a complete history and physical. Patients presenting for this procedure, unlike those presenting for excisional contouring after massive weight loss, tend to be in overall good health. Preoperative laboratory tests in this population have shown to have little benefit and are not routinely indicated without any specific concerns raised in the patient’s history. ⁸

  
  
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  Explain the overall plan for the procedure to the patient during the preoperative visit. Show before and after photographs, highlighting less or more aggressive contouring outcomes to better assess the amount of change the patient desires. Showing photographs of possible complications, such as asymmetry, contour deformity, or poor skin redraping will better inform the patient regarding the risks.

Anatomy

The anatomy of the abdominal wall will be familiar to most surgeons from their experience with lipoabdominoplasty and detailed descriptions are available. ⁹ Briefly, the abdominal wall is composed of paired sets of muscles: the pair of strap-like rectus abdominis in the midline are flanked by the three-layered muscular construct comprised of the external oblique, internal oblique, and transversus abdominis muscles, from superficial to deep. The surface topography of a muscular and well-defined abdominal wall is made up of a consistent series of relative depressions over the areas of muscle insertions into condensations of fascia. These include the vertical linea alba between the paired rectus muscles, the slightly curved linea semilunaris at the lateral edge of the rectus muscles where the obliques insert into the rectus sheath, and the horizontal inscriptions in the rectus muscles, which act to improve their mechanical advantage and are the reason for the “six-pack.” The inferolateral edge of the oblique muscles rolling over to the inguinal ligament produces a V-shaped taper running from the iliac crest to the pubis, known as the iliac furrow, Apollo’s or Adonis’s belt. The serratus muscles over the inferior rib cage can produce a very muscular and athletic appearance if visible but are often lacking in bulk.

Subcutaneous fat over the abdominal wall that obscures these muscles is divided into deep and superficial layers relative to Scarpa’s fascia—the supra-Scarpa’s fat is denser and more vascular relative to the sub-Scarpa’s fat, which is relevant when choosing the plane for liposuction. Removing the deep (sub-Scarpa’s) fat has less risk of contour deformities, but will also yield less definition, as the dense subcutaneous fat will obscure the fine muscle contours. Original descriptions of sculpting techniques for the male abdomen make a point to distinguish the need for deep liposuction for overall fat bulk reduction, followed by selective liposuction of the superficial layer to produce the desired definition. ^{1 , 5}

Segmental Innervation to the abdominal wall and overlying soft tissues is segmental from branches of the T7 to T12 intercostal nerves. The vascular supply is rich and originates from a number of thoracic and pelvic vessels. The superior epigastric and musculophrenic arteries mirror the inferior epigastric and circumflex iliac systems. Laterally, the terminal branches of the intercostal, subcostal, and lumbar arteries run between the internal obliques and transversus abdominis. All of these systems give perforators to the skin and fat, with a rich network of anastomoses such that in the absence of a large incision or wide undermining, as would be done in an abdominoplasty, a robust blood supply is ensured ( Fig. 37.1 ).

Patient Selection

The patient population most-suited-for this technique are men with mild to moderate excess adipose tissue around the trunk who do not have pronounced muscular development of the abdominal wall musculature. Patients should not have so much adipose tissue that excessive liposuction would be needed to define the muscular contours—this is meant to be a contouring, not a body size reduction procedure. The fat-grafting component of the technique is meant to create the appearance of the six-pack “mounds,” so the ideal patient is one who is lacking projection of the rectus muscle bellies.

Steps for Creating Six-Pack Abdominals with Liposuction and the BodyBanking Principles

Incision

Incision sites are marked and infiltrated with 2% lidocaine and epinephrine. Three stab incisions are placed in the suprapubic area at the underwear line—one centrally for access to the linea alba and two laterally for access to define the linea semilunaris and the V-taper over the inguinal ligaments in the lower abdominal area. Four incisions are made inside the umbilicus for access to the linea alba and the transverse inscription. Incisions are made under the nipples bilaterally to access the upper rectus/costal margin insertion and the most superior inscription. For access to the second and third inscriptions, a single incision is placed lateral to the rectus muscle at the level of each inscription. Finally, one incision is made at the top of the gluteal cleft to access the lower back and posterior flank on either side ( Fig. 37.2 ).

Related posts:

Part III Body Surgery Part III Body Surgery CHAPTER 33 Triceps Augmentation with Silicone Implant CHAPTER 34 Forearm Implant CHAPTER 36 Silicone Six-Pack: Abdominal Enhancement with Subfascial Anatomical Implants CHAPTER 35 Calf Augmentation

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