Beauty is associated with proportions. A body part that is disproportionate to the rest of the body can impair appearance. An example would be women with arms that are large when compared to the torso. It is a common aesthetic concern in plastic surgery practice.
Arms are tubular structures. They consist of soft tissues around a bone. The soft tissues are made up of structures like fat, muscles, and vessels. It is surrounded by skin. Large arms usually involve a relative excess of fat and skin. The fat occupies the layer deeper to the skin. As the volume of fat increases, the overlying skin stretches to adjust to the increased volume. Hence, a reduction in the size of the arms involves a reduction in the size of the fat and skin excess. We can achieve this through surgical, and non-surgical techniques.
Why do some individuals get big arms?
The increase in the size of the arms is associated with excess weight. This excess fat gets deposited in various areas of the body. Some of us tend to deposit this fat more in our arms. This intrinsic tendency varies from one individual to another.
Other conditions can be associated with an increased size of the arms, lymphedema, soft tissue swellings, etc. But they are relatively less common causes of big arms. This article deals with the management of the arms as a result of excess fatty tissue.
What can be done to improve the appearance?
A reduction in the size of arms has to address the two types of tissues involved, namely fatty tissue and skin.
First, the fat. Fat occupies the area between the muscles and skin. The amount of fatty tissue correlates with the amount that can be rolled between two fingers. Fat is amenable to dietary modifications. A reduction in body weight usually leads to a reduction in the amount of fatty tissue and a resulting in a decrease in the size of arms.
Liposuction is a surgical technique to remove the fatty tissue with the help of small tubes (cannula). It is useful for individuals with fatty tissue that is resistant to dietary modifications. A good candidate for liposuction is someone with close to ideal body weight. Liposuction does not directly address the excess skin.
Next, the skin. The skin stretches to accommodate the excess fatty tissue. Once there is a reduction in the fatty tissue with diet or liposuction, there is a recoil of this skin. Recoil is the shrinking of the skin to a smaller area. However, this recoil of the skin takes time. It can take as much as a year for the skin to maximally recoil. In cases of massive weight loss, the recoil can be incomplete. This is seen as a persistent loose fold(s) of the skin. It is usually seen on the undersurface of the arms. Skin recoil is also reduced with advancing age and in smoking. Brachioplasty is a surgical procedure to remove excess skin. During brachioplasty, skin is removed as an ellipse from the medial surface (inside) of the arm. This is the part of the skin that abuts the torso. The decision to undertake a brachioplasty is taken after waiting for the skin to maximally recoil. Hence, it is usually not carried out during liposuction. The extent of skin removal is customized depending upon the extent of skin excess. Brachioplasty helps in improving the contour by removing the loose skin folds.
What are the advantages of the management of this condition?
It helps in improving the appearance of the arms in individuals with disproportionately large arms. The role of diet and exercise play a very important role in the appearance of the arms. Liposuction and brachioplasty are two surgical procedures that help to further optimize the appearance of arms.
Gynecomastia is an enlargement of the male breast. It is a common condition. Surgical correction of gynecomastia achieves a reduction in the excess breast tissue. A reduction in the breast tissue helps improve the aesthetics of the male chest. In most cases, surgery involves liposuction and gland excision. Liposuction addresses fat, and direct removal addresses the gland. These two steps are usually adequate for most individuals with gynecomastia. However, this may be insufficient to restore the aesthetics in those with excess skin. They may require additional treatments.
The stretched-out skin usually recoils adequately after reduction in most of the individual. The problem relating to excess skin is observed commonly in two subsets of patients. They are,
How do we manage excess skin while treating gynecomastia?
The treatment approach depends on the presentation. We tend to follow a conservative wait and watch in younger individuals, and those with a less severe presentation. This is because of better skin recoil in younger individuals. Also, the removal of the gland will reduce the effect of the weight on the skin. This helps the skin to recoil better. It is common practice to wait for more than ten months to assess the full extent of skin recoil. Any secondary corrections are done after this period.
The conservative approach may not help in older individuals and those with severe forms of excess. In such cases, we may opt to add a skin removal procedure during the management of gynecomastia. Good candidates for primary correction of the skin would include nonsmokers. They must have a stable weight. Skin removal procedures in those with unstable weight may result in suboptimal outcomes.
The design of the skin excess is variable. This is based on the extent of skin excess and patient preferences. A circumareolar (around the areola) approach is preferred in milder cases. In individuals with severe excess, we prefer extensile (long) incisions with the grafting of the nipple and areola. Needless to say, individuals with longer incisions have longer scars.
What is the advantage of staging a skin removal procedure?
In other words, why wait between a gynecomastia correction and a skin excisional procedure.
Skin can recoil significantly with time. It may not be able to predict the full extent. Adequately recoiled skin results in acceptable aesthetics. The full extent of skin recoil after gynecomastia correction takes time. Avoiding a skin removal procedure means lesser scars. However, this approach may not be suitable in those with severe forms of skin excess.
Are there any approaches to prevent this issue with excess skin?
They would include the following.
Avoiding excess body weight. The excess skin problem is not common in individuals with normal or ideal body weight.
Early treatment of gynecomastia. The ability of the skin to recoil reduces with age.
Smoking is bad for skin recoil. Nonsmokers tend to have better outcomes when compared to smokers.
What is the advantage of managing the excess skin in individuals with gynecomastia?
It leads to better aesthetic outcomes.
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Should one lose excess weight before a body contouring surgery? Or should it be postponed to sometime after the surgery? Many of the patients I come across seem to have this dilemma. It is common for individuals to delay losing any excess weight until after the surgery.
Does it make any difference if the excess weight is reduced before or after liposuction? It does make a difference. It is better to lose excess weight before rather than after the surgery. This is best achieved with a healthy lifestyle. Both exercise and adequate diet play an important role.
What are the reasons? A few of them would be as follows,
Hence, it is better to bring the bodyweight close to ideal before undergoing a fat reduction procedure. Liposuction or lipoplasty can then help target resistant fat.
To summarise, should one lose excess weight before a body contouring procedure? Yes. It has its benefits. Ideally, weight loss is attained using sustainable lifestyle modifications. It is associated with better outcomes and lesser complications. They continue to reap the benefits of the procedure long after the surgery.
Liposuction is among the more popular procedures done by a plastic surgeon. Liposuction is carried out as a single procedure or in combination with other surgical procedures. Some individuals refer to it as the 'keyhole' surgery for gynecomastia.
Liposuction has certain advantages over open or conventional surgery. These include small incisions, faster recovery, and less postoperative discomfort. Liposuction can be carried out both under general or local anesthesia. Doing liposuction under local anesthesia has certain benefits.
So, what are these benefits?
The important ones include,
Are there any differences in technique with liposuction under local anesthesia?
There are a few differences.
Firstly, the patient is awake, and the monitoring of the patient is simple. When done in an awake patient, it takes longer to complete the procedure. There are a few reasons for this. The initial infiltration of the anesthetic solution in the treatment areas is done in multiple steps and takes longer to complete. Also, we prefer the use of smaller cannulas for infiltration and fat aspiration (suction). We usually use cannulas of sizes 3 mm or below in an awake individual. Due to the smaller cannulas, the aspiration of fat takes more time to complete. Liposuction in the awake individual is more gentle.
Who is the right candidate for liposuction under local anesthesia?
Almost all candidates for the procedure under general anesthesia are also good candidates for the procedure to be carried out under local anesthesia. However, if the patient is very anxious or has a fear of needles they may not be a good candidate for local anesthesia alone. Such individuals would be better suited for general anesthesia.
To summarize liposuction, in awake patients has a better safety profile. It has the added benefits of a faster recovery, and this also makes it suitable as an outpatient procedure.
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Pressure sores tend to occur in bedridden individuals. It is more common among the elderly, though persons of any age can get affected. Pressure sores could be as a result of spinal injury or any prolonged debilitating illness. It is a cause of increased stress in the affected individual and caregivers. It results in increased medical expenses.
Proper care can help us reduce the incidence (prevent) and achieve early healing of pressure sores. The following three aspects form an important part of care among individuals at risk of developing a pressure sore:
The onset of a skin breakdown must be viewed seriously. It may not be possible to eliminate all of the risk factors that can lead to a pressure sore. However, with adequate care, it is possible to prevent this condition.
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Patients with gynecomastia have increased gland in addition to the fat. Fat is found both within the glandular tissue and immediately underneath the skin. Fat in both these places contributes to the deformity. In an overweight individual, the proportion of fat is more than that of a person with ideal body weight. During the surgical correction, fat is removed with the help of liposuction. Small cannulas are introduced under the skin and fat is removed with the help of suction combined with repeated movements of the cannula. Removal of fat leads to an improvement in the contour.
Prolonged and severe gynecomastia is also associated with excess skin. In most individuals removal of the breast tissue leads to the recoil of the skin during the months following surgery. However, in certain individuals, this recoil may not be complete. We may have to perform additional skin excisional procedures to improve the contour in such cases.
Individuals with excess weight should try to reduce weight by non-surgical methods. This involves dietary and lifestyle modifications. There are many advantages to doing so. It leads to better postoperative outcomes with more pleasing results. This is in addition to the other health and psychological benefits. Operating in a near-ideal bodyweight individual also means a simpler and shorter surgery. There is a lesser chance of wound-related adverse events such as infection and prolonged healing. BMI or body mass index is commonly used to assess the weight in comparison to the height of the individual. We usually discourage operations on individuals with a BMI greater than 30.
Being overweight increases the deformity associated with gynecomastia. However, it is possible to give a good outcome with surgical correction in conjunction with the appropriate lifestyle and dietary changes.
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Gynecomastia is a commonly seen condition among young men. It presents as fullness near the nipples that give a feminine appearance to the male chest.
A very frequently mentioned symptom among such individuals is the appearance of the nipple and the surrounding pigmented skin (areola). Other than the fullness, the appearance seems to look worse when exposed to warmth and improves when exposed to cold or mechanical stimulation. A certain part of the consultation is usually devoted to an explanation of this phenomenon.
The pigmented skin surrounding the nipple has radially (like spokes of a wheel) oriented smooth muscles in the skin. Exposure to cold and mechanical stimulation leads to a contraction of these smooth muscles and a resulting contraction of the skin (areola). When the smooth muscles are relaxed the areola tends to look globular. The globular appearance of the areola is considered to be less aesthetic.
The presence of smooth muscles in the skin should not be confused with the skeletal muscles situated in a deeper plane. Similar smooth muscles are also found in the scrotum and react in a similar way to variations in temperature and mechanical stimulation. The presence of smooth muscles in the nipple-areola is normal. It is found in everyone.
In individuals with gynecomastia, the presence of glandular tissue makes the nipple-areola region more prominent. It also makes the above-mentioned changes in appearance due to the smooth muscle activity more prominent. But that does not mean that the variations as a result of the smooth muscle activity are abnormal.
Gynecomastia surgery is undertaken for improvement in the appearance of the male chest. With the removal of the excess breast tissue, the prominence of the nipple-areola is reduced. As the areola is no longer stretched out due to the glandular tissue, the changes of the overlying skin are also significantly reduced. As in other cosmetic surgical procedures, this can also lead to a better body image and more self-confidence.
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Gynecomastia is a relatively common condition that can affect men of all ages. It may result in significant mental distress in those affected by it. A frequently asked query is regarding the necessity to undergo surgical correction of gynecomastia. Usually, gynecomastia is a benign condition. As in most cosmetic surgical procedures, the desired outcome is an improvement in appearance and body image. Hence, gynecomastia surgery is most beneficial in those who are distressed by this condition.
In other words, the surgery may not be indicated in those who are not affected by the appearance.
Uncommonly gynecomastia can be a result of some other pathology. These can be ascertained by clinical examination and blood tests. In such situations, it may be necessary to ascertain the cause of gynecomastia. Because of this, we recommend the medical screening of gynecomastia. The treatment to undertake any cosmetic surgical correction is a personal one. It has to be arrived at after proper consideration of the possible outcomes, recovery, and complications.
A + B = C. So C - B = A. This may apply to simple arithmetic, but things get a bit complex when we are dealing with weight gain and weight loss.
We store our excess energy in the form of fat. Excess calories we may have acquired from our diet. This excess of fat gets stored in our body as fat deposits in different locations. Fat immediately under the skin can be pinched. This layer of fat is found between the skin and muscles. This is also the layer that can be removed with liposuction. Fat also gets stored deep inside our body, close to our internal organs. This is visceral fat. We can neither pinch this fat nor get it removed with plastic surgery.
A proper diet can help us get back to our ideal body weight. In some situations, bariatric surgery achieves the same end. However, a prolonged period of increased fat has effects beyond the fatty tissue. It stretches out the overlying skin. Visceral fat also stretches out the fascial layer. This layer is closely associated with the abdominal muscle layer. When we lose fat, the size of the fatty layer reduces. This may be dramatic in cases of severe weight reduction as with weight loss (bariatric) surgery.
The stretched out skin and fascia may not get back to the dimensions before the weight gain. As a result, individuals end up with loose folds of skin. To improve this appearance, we have to surgically remove the excess folds of skin. These surgeries are together clubbed under body contouring procedures. We usually wait for a year or more for the weight to stabilize and allowing the skin to recoil by itself before attempting any skin correction. The same approach is used for different body parts, arms (brachioplasty), abdomen (abdominoplasty), thighs (thighplasty) and torso (body-lift).
The presence of stretched out skin and fascia is the reason why liposuction may not be the right procedure for abdominal fat. Liposuction can't do much to tackle the laxity of skin and underlying abdominal fascia. With liposuction alone, we may worsen the skin laxity of the abdomen resulting in an increase in loose folds of skin after the procedure. The same line of reasoning is applied to individuals who present for a reduction in the size of arms. We undertake it in two stages, with the first being deflation with diet or liposuction and a second stage with the removal of loose folds of skin.
To conclude, we have to tackle the laxity of skin and deeper fascia in cases of weight loss following periods of excess weight gain. These may have undergone irreversible changes. Treatment of such deformities often requires the management of tissues like skin and fascia with the help of body contouring procedures. Such an approach helps us to optimize aesthetic outcomes.
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In this age, it is almost essential to look lean and fit. Lean is associated with health and vitality. It is common knowledge that a large waistline is contributed by excess fat deposits. And because of this many individuals turn to plastic surgery for liposuction as a solution to this problem. However, all cases of the protuberant belly cannot be tackled by plastic surgery.
Excess deposits of fat can be found in many places within the abdomen. They are found in the layer between the skin and the muscles of the abdominal wall. This is the layer that can be pinched between the fingers as a roll. Fat is also deposited deep inside the muscle layer. This fat is referred to as visceral fat and is found in association with our gut and the area behind it.
Other than fat deposits, laxity of the abdominal wall can contribute to protuberance. Laxity of the abdomen can be seen as a result of changes due to aging and pregnancy. A separation of the abdominal muscles in the midline, known as divarication is often seen in such individuals. Some of the above-mentioned deformities can be tackled with the help of plastic surgery. The modalities used for correction include procedures such as liposuction and abdominoplasty.
Liposuction involves suction of fat with the help of small cannulas inserted through the skin. Fat is aspirated with the help of a vacuum producing device. Advantages of this procedure include the treatment of relatively large areas with the help of tiny incisions. Patients usually recover fast and are ambulant as soon as they are awake from the effects of anesthesia. It does not involve a prolonged stay in hospital. Liposuction targets only fat that is superficial to the abdominal muscles. We are not able to access the deep or visceral fat with liposuction. Another limitation of liposuction is that it does not address the laxity of the abdominal wall or skin.
Abdominoplasty translates into reshaping the abdomen. During an abdominoplasty, we tighten the layer of the muscles. This helps tackle the laxity of the muscle layer. Liposuction is often carried out as a part of abdominoplasty. Liposuction is used to reduce the fat deposits on the flanks and in the upper abdomen. This improves the appearance and increases the safety of the procedure by limiting the areas of surgical dissection. We also reduce the excess skin as an ellipse from the lower abdomen. The rest of the skin is draped to result in a tighter-looking abdomen. As with liposuction, abdominoplasty can't address the visceral fat.
A clinical examination helps reveal the cause of the deformity and arrive at a treatment plan. Ideal candidates for both the procedures include patients close to their ideal body weight. They should be non-smokers and have reasonable expectations about the procedure. It is also important to be aware of what can be achieved using plastic surgery. We can achieve a reduction in the fat deposits that are external to the muscles and obtain a tightening of the muscle-fascia layer and skin. Plastic surgery does not address the visceral fat. And because of this, patients need to adopt a dietary and exercise regimen to maintain appropriate levels of visceral fat.
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