LAUSR

Practical conceptual and technical innovations within ‘‘Enhancing Masculine Feature after massive weight loss’’ are the source of the article’s popularity. This four-year follow-up updates those innovations, along with refinements. The sheer magnitude of the skin deformity after massive weight loss demands a comprehensive approach far beyond isolated procedures for correction of gynecomastia, and skin laxity of the abdomen, flanks, buttocks, thighs, and arms. An organized plan including all those areas, as well as the boundaries between them, is necessary to obtain optimal results in as few stages as possible. In essence, a comprehensive approach first applied to craniofacial surgery is essential to body contouring surgery. For example, correction of the breast needs to include upper body lift often with the use of otherwise discarded nearby flaps, along with considerations of the long-term impact of circumferential lower body lift surgery. As most patients presenting for total body lift surgery are women, the aesthetic issues related to men do not receive adequate attention. Furthermore, operations that work very well for women, such as a buried de-epithelialized inferior skin flap, should not be advocated for men for the correction of gynecomastia. These buried flaps leave inappropriate bulk between the nipple-areolar complex and inframammary fold (IMF). Furthermore, the anterior chest adherences should relate to the lateral and inferior borders of the pectoralis muscle and not to the breast. As such, the IMF should be obliterated, and not accentuated as occurs with a low transverse excision that leaves a scar along the IMF. Through ultrasound-assisted liposuction across the fold, followed by superior traction on the lower chest skin, IMF obliteration is achieved. Extending the upper body lift transversely across the back, except for the most extreme cases, can be avoided with a lateral torsoplasty, which, because it dips inferior, is called a J torsoplasty. The J torsoplasty is an extension of the boomerang pattern excision of gynecomastia. Except for the most severely ptotic cases, both the gynecomastia and excess lateral bulk can be removed through these opposing oblique excisions encircling the nipple-areolar complex. These oblique excisions remove both transverse and vertical laxity, leaving a tight torso with the nippleareolar complex in the proper position. Traversing across the superior curve of the NAC visually breaks up the long meandering scar across the chest, making it less conspicuous. Care is taken not to extend the excision across the anterior midline and to avoid parasternal scar hypertrophy. Despite the mechanical advantages of the Boomerang pattern with the J Torsoplasty, chest scars beyond the NAC perimeter are undesirable. Until recently, moderate skin laxity with breast ptosis in the massive weight loss patient requires excision. Skin tightening through bipolar radiofrequency and improvements in fat grafting are gamechangers. With the reintroduction of BodyTite (InMode, Yackom, Israel) to our practice in 2017, mild and moderate cases of gynecomastia were managed. There are some with impressive results and others not satisfied even after three effective attempts to shrink their breasts. They have been pleased with smaller skin resection. When BodyTite & Dennis J. Hurwitz [email protected]