By: George Bitar M.D.
Board Certified Plastic Surgeon
Aesthetic procedures for men are on the rise. Here are some of the more common ones
It is no secret that the popularity of aesthetic surgery for men is on the rise. American society tends to accept women having plastic surgery more than men, but that view is changing.1 Procedures for men increased nearly 20-fold from 1992 to 2004.2 Men's reasons for having aesthetic surgery are as varied as women's: improving self-esteem, becoming more attractive to the opposite sex, looking less "tired," or sometimes— quite plainly—jealousy of a partner who has had successful plastic surgery.
The advent of lasers, injectables, and less-invasive procedures in the 1990s has given men the green light to have aesthetic enhancement without having to explain those facelift scars in front of their ears. Another type of male plastic surgery that is becoming very popular is aesthetic surgery after massive weight loss, typically from a gastric bypass procedure
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Four of the procedures most frequently sought by men are explored here.
Unfortunately, there are few perfect noses in this world, and most could use improvement. Since the heyday of the Greeks, many criteria have been proposed to guide us toward the ideal dimensions of the aesthetically pleasing nose, given that it is the centerpiece of the face. As our society becomes more ethnically diverse, so do the noses that facial plastic surgeons have to address.
A man may seek a rhinoplasty for a variety of reasons. Sometimes the reason is self-consciousness about his nose and the belief that it makes him less attractive. Other times it is nominally for functional reasons—for example, difficulty breathing due to a deviated septum—"and maybe a little touch-up of the tip while I'm under anesthesia." Occasionally, there is the narcissistic male actor who receives a perfect rhinoplasty but is still unhappy because his career did not improve after that costly operation.
Rhinoplasty (Figure 1) done for the right reasons, on a normal patient who is realistic about his reasons and expectations, will yield tremendous satisfaction. This is one operation for which the margin for error is narrow. Therefore, I spend more time in consultation with rhinoplasty patients than most others, showing before-and-after photos, drawing a diagram of what the patient wants me to accomplish, and giving him names of previous rhinoplasty patients to discuss experiences gained and lessons learned.
Techniques to address noses are probably as diverse as their shapes. I first ask the patient what bothers him about his nose, dividing it into top, middle, and lower thirds. I try to get as much information as possible about the specific nose he would ideally like to have. I then discuss each aspect of a rhinoplasty in a systematic fashion, starting with the dorsum, then the tip, the nostrils, the columella, the bony pyramid, and the septum.
I also advise him as to whether an open or closed approach would be preferable, as well as to whether he would need an implant. If it is a secondary rhinoplasty, the patient needs to be advised that the level of difficulty is higher and that the results may be less predictable.
In the operating room (OR), the patient is initially anesthetized. If an open rhinoplasty is to be performed, a columellar incision is made. The skin is elevated from the dorsum to the extent needed. Initially, the dorsal hump is addressed by rasping the bone and excising the cartilage.
Next, the septum is addressed if necessary by performing a septoplasty. Then, the lower lateral cartilages are reshaped to improve the appearance of the tip, followed by turbinectomies if necessary. At this point, the columellar incision is closed. In the next step, Weir excisions are made to decrease the size of the nostrils. Finally, bilateral osteotomies may be performed if warranted.
Aftercare for a rhinoplasty patient is very important. Following up on the preoperative goals is essential for long-term satisfaction.
The Giampapa suture-suspension neck lift was designed for men who did not want the anterior auricular incision of a facelift, but were unhappy with their neck laxity. This technique was described at length in the August and September 2005 issues of Plastic Surgery Products, from the subtle nuances of evaluating the patient to the follow-up exam.
Men who want a more youthful neck find this alternative to a full facelift very appealing, because it gives significant facial rejuvenation with less downtime and fewer hidden scars without the stigma of a full facelift. In the preoperative evaluation, the main issue is whether the patient is an appropriate candidate—medically and psychologically—for neck-rejuvenation surgery.
Should the patient receive a neck lift versus neck liposuction or a full facelift? Furthermore, does he need a chin augmentation with the neck lift to give him a more prominent jawline? The submandibular glands need to be evaluated to determine whether they should be corrected at the same time. Otherwise, they will become more prominent after neck laxity is corrected.
Before he enters the OR, the patient is marked for a suture-suspension neck lift with fibrin sealant. In the OR, after the patient is anesthetized, the neck is infiltrated with tumescent fluid, then liposuctioned if warranted. Afterward, the excess skin is excised from the postauricular area in an elliptical fashion.
A subcutaneous tunnel is created to the midline. Next, a curvilinear submental incision is made, and the subplatysmal fat is excised under direct vision. The platysmal bands are then sutured at the midline.
A Giampapa suture suspension is then performed with sutures interlocking at the midline at the level of the hyoid bone and anchored at the bilateral postauricular sulci. This creates a well-defined neck contour. Finally, fibrin sealant is sprayed under the neck's cutaneous flaps, and the incisions are closed.
Male patients tend to bleed more due to the rich blood supply in the neck, so it is imperative to have excellent hemostasis as well as good blood-pressure control postoperatively. Men must be counseled not to shave their necks for 2 weeks after surgery to avoid injuring the numbed neck flaps. The patient returns to work much sooner than with a facelift, and patient tends to get rid of the beard that was hiding the weak chin, "turkey gobble," or both after a neck lift (Figure 2, page 22).
One of the less-invasive procedures that gives men great satisfaction—but must be executed with extreme precision—is blepharoplasty.6 Men seek upper blepharoplasties because they are frequently told that they look tired when they are not. It is incumbent upon the surgeon to discuss other facial procedures that can be done simultaneously with a blepharoplasty—or instead of it—when a patient presents.
For example, if a 70-year-old man comes in because he is not happy with the bags under his eyes, it behooves the plastic surgeon to also discuss upper-eyelid lifts, because the upper and lower eyelids usually age similarly. Thus, both upper and lower blepharoplasties must be discussed.
Because men in general do not apply makeup around their eyes as women do, they do not have to deal with redundant upper-eyelid skin daily. Therefore, their awareness of the problem does not surface until the upper eyelids are in a more advanced stage of laxity—when they are in their 50s and 60s—as opposed to women, who tend to notice this when they are younger.
Techniques for upper-eyelid blepharoplasty vary. In the traditional technique, the excess skin of the upper eyelid is excised after the patient is preoperatively marked in the supine position. Removing additional lateral skin will decrease the chances of lateral hooding in the future. A strip of orbicularis oris is excised to decrease the chance of a prominent, "bunched-up"-looking supratarsal fold.
Next, the medial and middle fat pads are identified and resected. Care is taken not to be too aggressive, to avoid leaving the patient with a hollow look. If the lower eyelids are to be done simultaneously, the upper incision is left open to be used for a lateral canthopexy or canthoplasty if needed. If the upper eyelid is being done independently, it is then closed with a running suture.
Most men who seek lower-eyelid lifts complain about the bags under their eyes, so care must be taken to give them realistic expectations. Sometimes, patients complain about the lower eyelid, but what really bothers them are the festoons, which are a more difficult problem to address. Therefore, it must be clearly explained to the patient preoperatively what a lower blepharoplasty will accomplish.
The lower eyelid is very delicate, and complications can result that are difficult to correct if the lift procedure is not done properly the first time. Several questions must be addressed with the patient when planning a lower-eyelid lift:
I discuss all of the pertinent options with the patient, and try to be conservative, especially when it comes to the lower eyelids. If there is excess fat only, as in a younger man, a transconjunctival approach is reasonable. If the skin is lax, a subcilliary approach should be considered. When there is excess bulging fat, the surgeon must decide whether to resect the fat or combine it with the malar fat pad.
Releasing the arcus marginalis and suturing the SOOF to the malar fat pad require a longer healing time than for a traditional conservative SOOF resection. A lateral canthopexy in someone with lower-eyelid laxity decreases the chances of an ectropion, and does not add much time or morbidity to the procedure.
Male patients tend to be quite satisfied after having a blepharoplasty, whether performed alone or in combination with other facial procedures. Frequently, a blepharoplasty is all it takes to make a man feel rejuvenated and more energized—a truly amazing outcome (Figure 3). In addition, a patient with significant lateral hooding benefits from the improvement of his peripheral vision.
"Six-Pack" Abdominal Liposuction
Ever since liposuction was introduced to the United States from Europe in the early 1980s, it has been very popular. Men seek liposuction for the same reasons as women: to get rid of those extra pounds of fat that they cannot lose at the gym, or because they are "too busy" to exercise. In general, men who seek liposuction are health-conscious, eat a proper diet, and exercise, but they cannot seem to get rid of the extra unwanted fat.
Liposuction can be performed in many ways. Most surgeons would agree that the current standard of care is to initially inject tumescent fluid that includes saline, epinephrine, and lidocaine. The actual method of liposuction varies, depending on the surgeon, from the standard suction-assisted lipectomy, to power-assisted lipoplasty, to ultrasonic liposuction.
In low-volume liposuction (less than 2 liters), the various techniques do not offer significant differences, but in high-volume liposuction, they can. Most surgeons have their own preferred technique because liposuction is such a common procedure.
Most men—and women, for that matter—who work out and take care of their bodies find the abdominals one of the most difficult areas to "tame." "Muscle men," with defined biceps and thigh muscles but bulging abdomens, can be found in any gym. Even if the abdomen has well-defined muscles, they can be covered with fat. The solution is a specialized form of liposuction: "six-pack" abdominal liposuction, or abdominal etching.
Abdominal etching can be performed separately or in conjunction with a traditional abdominal liposuction. If a man is muscular with good definition of the rectus abdominus musculature, but has some overlying fat, abdominal etching is all he needs. It is a 1-hour procedure that may be done under general anesthesia or heavy sedation. First, the abdomen is marked with three vertical lines delineating the linea alba and the lateral borders of the rectus abdominus muscles. Next, two to four lines are drawn horizontally, delineating the rectus abdominus muscle inscriptions and forming a tic-tac-toe-like grid.
In the OR, tumescent solution is injected along the drawn lines, and liposuction is performed along the lines as well, with a few hidden incisions, to create a sculpted-looking six-pack abdomen. Some people believe that prostheses or implants are placed to create those bulges, but that is not true.
If the patient has more fat to be liposuctioned from his abdomen, a traditional abdominal liposuction is performed, followed by a six-pack etching. This patient must be warned beforehand that his results are not going to be as good as someone with less fat and more defined muscles.
After the procedure, 1¼2 x 7-inch strips of cotton are laid down on the abdominal skin and taped over the drawn lines to compress the skin to the fascia in the liposuctioned areas, thus accentuating the six-pack abdomen appearance. The taped cotton dressing is changed in 1 week and kept for another week, after which the patient can gradually resume activity.
A six-pack abdominal liposuction is the "push" that most men want to improve their abdominal appearance (Figure 4). It also serves as a springboard to working out the abdominal muscles more, improving the diet, and receiving positive feedback, especially when they get compliments at the gym!
Aesthetic surgery in general is on the rise, and the male segment of the population is requesting more and more procedures. The procedures discussed here are some of the more common ones, but this was by no means a comprehensive discussion. Ultimately, aesthetic surgery is about making our patients happy. Careful listening, good planning, and constant technique improvements go a long way toward accomplishing this goal.
George John Bitar, MD, is a board-certified plastic surgeon in private practice in northern Virginia. He is on staff at INOVA Fairfax Hospital in Falls Church, Va, and Prince William Hospital in Manassas, Va. He can be reached at (703) 206-0506 or via his Web site, www.drbitar.com.
1. American Society for Aesthetic Plastic Surgery. 10 Cosmetic Plastic Surgery Predictions for 2006. Available at: http://www.surgery.org/.... Accessed January 20, 2006.
2. American Association of Plastic Surgeons. 2004 Gender Quick Facts. Available at: http://www.plasticsurgery.org. Accessed January 20, 2006.
3. Giampapa VC, Bitar GJ. Use of fibrin sealant in neck contouring. Aesthetic Surg J. 2002;2:59–525.
4. Bitar GJ. Liposuction or lift? An algorithm for neck rejuvenation. Plastic Surgery Products. 2005;15(9):24–28.
5. Bitar GJ and Giampapa VC. The suture-suspension neck lift. Plastic Surgery Products. 2005;15(10):31–34.
6. Guyuron B. Blepharoplasty and ancillary procedures. In: Achauer BM, Eriksson E, Guyuron B, Coleman JJ III, Russell RC, Vander Kolk C, eds. Plastic Surgery Indications, Operations, and Outcomes. Philadelphia, Pa:Mosby; 2000:2527–2547.
7. Mentz HA, et al. Abdominal etching: Differential liposuction to detail abdominal musculature. Aesthetic Plast Surg. 1993;17:287–290.
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