Hi, good evening, everybody. My name is Gregory Greco. I am the past president of the American Society of Plastic Surgeons, and I'm going to be moderating tonight's webinar series on male chest contouring, the Superman chest, and we're also going to be talking about gynecomastia. So welcome. Thank you for joining us this evening. Just an FYI, this will also be recorded, so everybody has the opportunity to go back and see the recordings again. So once again, we're excited to present another series of this global leadership webinars. So tonight, the format's going to be, we're going to have two presenters, Dr. Hassam Tasim Saleem and Dr. Luis Gonzalez Fernandez. They're going to be given approximately 20 to 22 minutes to present their information, and then you have several ways to ask questions either at the end, or we can also submit through the presentation using the Q and A feature at the bottom of your screen. So you'll see that at the bottom. So if there are a lot of questions, we're just going to kind of sort through and try to get through them. But many of you have emails that you received, and we'll also have something that you can send emails to the presenters if there's specific questions that we don't get through. So unfortunately, we usually have, we generate a lot of great questions and have a great post kind of debrief session after this. So you'll have the opportunity hopefully to have them, everything answered by the moderators. This will be recorded and posted to ASPS EdNet. So you have the opportunity to go and watch this as an ASPS member or international member. So once again, thank you for joining us. And I'm just going to present our first speaker tonight, Dr. Hassam Tahseen Salim. And Dr. Hassam Tahseen is a consultant of plastic surgery and aesthetic medicine. He's a graduate from Cairo University of Medicine and a faculty member and professor of plastic surgery in Cairo University. Dr. Tahseen is also one of the pioneers in plastic surgery in Egypt and the Middle East and has performed thousands of successful cases, always brought up to date through machinery and techniques from all over the world in plastic surgery in both Egypt and the Middle East. Dr. Tahseen is also a consultant of plastic surgery and aesthetic medicine as a graduate from Cairo University of Medicine and a faculty member and professor of plastic surgery in Cairo University. He's also one of the pioneers. He's a member of the International Society of Aesthetic Plastic Surgery and also a member of ASPS and a member of the Egyptian Society of Plastic Surgeons. He's also, I'm sorry, is an international lecturer and instructor at Total Definer Academy and a lecturer in many regional and international conferences. His main interest is high definition body contouring, liposuction, body lift surgery, abdominoplasty, and maloplastic surgery, as well as gynecomastia and total body sculpting with back rafting. So that is Dr. Tahseen's very impressive bio. We welcome him tonight. Before we get started, I do want to just introduce you to the next slide. And Maddie, if you don't mind just going to the next slide. Do we have the next slide? Ah, there we go. So just go to our international meeting, which will be happening, their global leadership meeting, which is going to be happening in Buenos Aires, Argentina. I believe it's the last slide in this slide deck. We were going to be in April 3rd. There we go. So the Global Plastic Surgery Congress, it is an open invitation to all of you. We have great educational content. We hope you can join us without taking up any more time. Please see the ASPS website for more details, but I just wanted to give everybody the opportunity to know about this great content, which is going to be happening in 2025. So with no further ado, welcome Dr. Tahseen Salim. Thank you for presenting tonight. Thank you, Gregory. Thank you very much for having me. Thank you very much. I will present today my work, actually our work in the post-massive in main chest contouring, especially in large cases and big cases with high BMI and in post-massive with those patients. The high definition body contouring, as we all know, is a modern artistic body contouring procedure created by Alfredo Hoyos and includes liposuction that may be combined with other excisional surgical procedures using the high end technologies to delineate the underlying anatomy or changing and improving this anatomy and usually tackling the whole body at once in order to achieve harmony. This is Alfredo Hoyos when he described the high definition liposuction procedures and since then whole new approach and concepts were defined for liposuction since then. This is such of the results we have when we do the high definition body contouring concepts in order to shape up the whole body at once, shaping the chest and the abdomen, the arms and the back and everything at once in order to achieve harmony. Another case, we are always trying to achieve natural harmonious results when working with this technique with the whole body at the same time. And as we can see this patient who is post-op and he's maintaining the results and he's motivated to maintain his post-op results by using these techniques. These are the kind of bodies we are meeting in the Middle East. Usually they have genetic fat distribution problem as we can see in the male patients lower there. We can see this gynecoid female features, gynecoid features in male bodies with wide hips, big buttock, a lot of fat and skin at the lower abdomen and the love handles and varying degrees of gynecomastia. And recently with the introduction of the GLP-1 and the post-bariatric patients, we are facing a lot of patients with post-massive weight loss problems that came to us and they needed to have a correction of their deformities in the high definition technique. Those kind of patients that we shown in the past slides, they look to our pages and the Instagram and they want to be like this. They don't understand the extent and difficulty of their deformities, but we have to be up to their expectations in order to try to help them to correct their deformities. Such patients with high BMI, with high depth liposuction, contouring of the chest and abdomen, arms and back and legs and buttocks and everything should be corrected at the same time in order to reach this harmonious results. And another patient with good skin quality, just by liposuction, we can achieve some reasonable results. With the introduction of the excisional surgery that we are going to show in these presentations, we still can achieve this shape and contour of the main chest and abdomen all together with this high definition concept. Another patient, which we will show later on, this already operated for correction of his gynecomastia and loose skin and we reached this problem and we corrected this problem with that we are going to show later on this L-shaped excision and neck graft with definition and augmentation of the pec major muscle with fat grafting and definition and augmentation of the rectus abdominis and the excision of the excess skin. Another patient we will show later on how we can correct these deformities in the upcoming, with the coming few slides and another very difficult case, we still can with the techniques that we are going to show later on, how we can convert this body into this body by again managing gynecomastia, excising the skin, neck graft, augmenting the muscle with fat, with definition of the abdomen and back and chest at the same time, giving this harmonious shape and results. But when we face patients with a post-massive weight loss patients, we always ask our question, what is the difference? What is the problem that needs to be corrected? Inspired by the Greeks and Egyptian statues, we all know that the male chest is prominent chest, prominent with well delineated bulky muscle, midline cleavage, lateral hollowness, defined lower chest crease and the inferior lateral placed adequate sized nipple areola complex. Understanding the deformity of the male chest will help us to correct this deformity. We all know that the body has facial attachment located at the midline anteriorly and posteriorly, preventing the descent of the tissues at the midline after weight loss, but still the lateral dropping of tissues laterally, which will give this the inverted V deformity, the lateral chest crease that may extend to the upper back with varying degrees of gynecomastia and tautic nipple areola complex with loss of the proper pattern size and shape and position of the neck. And usually those patients due to the catabolic state in occurring in the most post-massive weight loss patients, this will lead to weakening flatness and atrophy of the muscle bulk of the chest that need to be corrected by fat transfer and augmentation. Also this worth noting that there is no inframammary fold entity in male patients. If the fold is there, then there is a deformity. It should be named as lower chest crease, not an inframammary fold. And this lower chest crease anatomically is at the fourth or fifth intercostal space. And it is a connection between the skin and the fascia covering the pec major muscle. This is the anatomically connected to the pec major muscle. So it is lower chest crease and it is not an inframammary fold anymore. In my opinion, I will describe that later on. The male areola shape usually is an oval oblique elongated direction and perpendicular to the pectoralis major muscle fibers. There are many classifications tried to solve the problem of the post-massive weight loss patients. But as we all see here, that it all depends on the IMF. And I told you earlier, I described that the IMF is a pathological thing. It is not an anatomical thing. In my opinion, there shouldn't an IMF, there is no inframammary fold in male populations. It is the inferior chest crease. As we can see here, we cannot depend on the inframammary fold at all because usually, as we can see here in this patient, the inframammary fold is already redundant and it travels downward with the laxity of the adherence at the inframammary crease or the inferior chest crease. So by this presentation, by classification by Gosnoff and another classification by Zegler, they all depend on the IMF as an anatomical entity. And I don't think that it is the right way to manage the male chest and the high-definition era where we should consider the lower border of the pec major muscle here, not the inframammary fold, the lower border of the pec major muscle where the inferior chest crease is anatomically located. By this classification, I proposed this new classification for the male chest. This classification depends on three variants, which is the position of the neck from the pec major muscle, the quality of the skin of the lateral chest, the quality of the skin at the back. If the neck, if the nipple areola complex is at the lower border at its normal anatomical position, which is at the lower border or one or two centimeters above the lower border of the pec major muscle, in this case, we will do and for sure the lateral skin chest is of good quality, in this case and back skin is of good quality, we will use the liposuction-assisted, the ultrasound-assisted liposuction with pec augmentation with fat grafting and maybe one of the new RF technologies in order to tighten the skin of the chest like Renovion or BodyTight or whatever else. If the neck is within two to three centimeters from the lower border of the pec major muscle, the lateral chest of good quality, the back is of good quality, then here we are going to do the axillary lift. We are going to show the axillary lift later on in our presentation, how you draw it and how you do it. But if you have, if there is hanging poor skin of the lateral chest, although the neck is two to three centimeters from the lower border of the pec major muscle, so we can go to L or Z lift. The latest stage when the neck is more than three centimeters below the pec major muscle, below the lower border of the pec major muscle, our new anatomical guideline. In this case, with hanging lateral, usually with hanging lateral chest roll, we will do the L lift. If there is poor quality of the hanging fat roll at the back, then we will do the Z lift. I will describe later what is L lift, L-shaped scar and Z-shaped scar and how we can do it. And I consider stage four as all the redo cases or revision cases. They are considered as stage four. And in this case, you can manage to do the different strategies in order to correct the problem, as we already noticed in the previous patients with redo cases. We will show you here, if the patient is just stage one, what we do is after tumescence anesthesia and infiltration, we will use the ultrasound assisted liposuction in order to remove all the fat around the muscle from the midline, below the lower border of the pec major and from the lateral chest, excisioning all the fat around the muscle and augmenting the muscle itself will give the shape and contour we are looking for, which is this prominent shape of the muscle and the shape of the pec major, shaping up the shape of the pec major muscle, as we can see here, and then excising all the fat from below the lower border of the pec major muscle, from the lateral border of the pec major muscle and the interpectoral sulcus and augmenting the fat at the, augmenting the pec major with fat transfer. And for sure, if there is agonicomastia, that should be removed completely. And then at the end, at the, at the stage, we augment the pec major muscle with fat transfer. And if needed some tightening skin procedure as the lateral chest and the chest proper by different RF technology that we have right now. And we can see here the shape post-operatively after shaping the, shaping of the, of the chest wall. Another patient we saw earlier, this is by the same technique, we can reshape the chest and giving this muscular strong interpectoral sulcus, hollowness at the lower, removing all the fat at the, below the lower, the lower border of the pec major, lateral hollowness, augmenting the muscle and putting the neck at its proper position at the lower border of the pec major muscle, which is usually by removing the fat and just shaping the muscle, as we can see here. What is the axillary lift? The axillary lift here, we are going to move up the nipple areola complex, which usually at two centimeters below the pec major muscle into its new position by this technique. This is how we draw it. We define the lower border of the pec major muscle and the lateral border of the pec major muscle. We can see here, it is just two centimeters below the lower border of the pec major muscle, and we will do this axillary lift. We excise the skin from the axilla and we will show later how, how also we should fix the nipple areola complex to the pectoral fascia in order to allow this normal movement of the nipple areola complex with contraction of the pec major muscle. That's why it should be connected to the fascia of the pec major muscle. This is how we do it, by excision, excising this ellipse and then going down to the lateral border of the pec major muscle. We show the flap and the pec major muscle. Then by fixing sutures, we fix the pec major, we fix the neck, either from the upper border of the neck, sometimes from the lower border of the neck, we fix it to the fascia and doing series of sutures to decrease the tension on the scar, decrease the tension of the scar at the axilla, and then augment the muscle with fat and doing some definition in order to achieve these results. This is how we can do it. This is stage two. How you do the L scar lift? Again, when the nipple areola complex is more than three centimeters below the lower border of the pec major muscle, we will do this excision and neck grafts. This excision neck graft will help us, as we can see here, pulling the skin forward will tighten the lateral chest and will tighten the upper back at the same time, and pulling the skin upward here will tighten the upper abdominal skin, as we can see here. By excising all the skin, usually we draw the nipple areola complex intraoperatively, but it is just 11 to 13 centimeters. This is just for demonstration, 11 to 13 centimeters from the midline and two centimeters above the lower border of the pec major muscle. This is the normal position of the nipple areola complex. It should be inferiorly laterally placed in order to be in its normal anatomical position. This is how we do the surgery. Again, we do this L-shaped excision followed by the tailor tucking and putting, as we can see here, 11 to 13 centimeters from the midline and maybe using the base of a syringe of 20 cc syringe we can put the site of the nipple areola complex where we remove the skin and put back the neck as a graft in its position and we may then fill the peak major muscle with grafted with fat in order to augment grafting the muscle with fat not only giving the bulk of the muscle this is very important but it also creates the inferior chest crease that we need to hide our transverse scar this is very important to notice this is the patient secondary post-op and the last thing is the z lift or what i name it the zoro lift in this case as we can see here which is the nipple areola complex is more than three centimeters below the lower border of the peak major muscle there's the lateral chest wall which is lateral chest roll which is extending backward to the upper back in this case we need to do z-shaped incision so we are going to add as we are going to see here we are going to add to to our incision to our l-shaped incision we are going to add this z we see this is just an l till now pull the skin forward in order to tighten the lateral chest wall and the upper back the skin at the upper back and then because of this this discrepancy between this limb and this limb of the this ellipse we needed to add this transverse limb this transverse limb will help to redistribute the skin to the axilla and this way avoiding any crumpling of the skin or irregularities at the transverse core which is the very the very visible in in in this case so by adding this transverse limb giving this z shape one two three z-shaped incision of of of the skin will help you to achieve the the results as we can see this is the excision excisional pattern of of this part and as we can see here this these are the vectors we are using when you do this technique you will do you will have three vectors upward upward forwards and upwards forwards and this transverse vector this help to tighten the skin of the lateral chest tighten the skin of the back and tighten the skin of the upper abdomen all by the same by only one incision and this is the at the end of the excision that's why I name it the Zorro because it looks like the mask of Zorro and here is what we do there is the excision the z-shaped z-shaped excision and then we do the tailor tucking and we can see by this tailor tucking we redistribute the skin laterally in order to have proper alignment of the skin of the transverse core and then we augment with fat transfer and putting the nipple airlock complex in place again at the end of surgery and this is some results showing that this is stage one this is we already showed this patient again stage one and this patient is again stage one c you will always return to my classification in order to just put it in in in front of you in order to know what to do and how to manage this case nipple aerial complex in this in the lower border of the peak muscle normal skin quality of the lateral chest and lower then it is stage one c then what to do lipo ultrasonic lipo and rf in order to tighten the skin this one c this is 2a which is where the nipple area complex is within two centimeters below the peak major muscle and there is a little bit of lateral skin roll and here what we do is to do auxiliary lift as you can see here this is auxiliary lift tightening the skin to the axilla and another patient with auxiliary lift tightening the skin by pushing the skin up into the axilla with the with definition of the abdominal wall augmenting the chest and you can see very good quality of the scar another patient with the can be corrected such case because the nipple aerial complex is just in one to two centimeters below can be corrected by axilla lift but in this case i prefer to do the l lift because of the excess redundancy of the skin at below the nipple complex and i'm showing here these patients to show you how we when you augment the muscle you create the inferior chest sulcus creating the inferior chest sulcus will give you the proper positioning of your scar which will improve a lot with time another trick here in this patient is that we pull the skin of the upper flap and fix it into the cartilage of the chest wall this way will make will will will fix the scar in its position and will heal properly and will lead to fantastic results and shape of the transverse scar we can see here this is the stage two again 2a and correcting the scar and putting creating this inferior chest sulcus is very important and we can see the scar already healed very nicely due to fixing the scar at the cartilage and creating this inferior chest sulcus as we can see here in those several patients another patient stage 2b and we can see this patient's redo case to the it should be put as stage 4 actually but just giving the idea of the l-shaped scar how it looks again the l-shaped scar and this is z-shaped scar due to redundancy more than three centimeters below the peak measure redundant skin at the lateral chest that may extend to the up the uh the back as we can see here uh as we can see here it it is the back roll it's extending the skin redundancy extending here to the back so the z-shaped scar will help you to achieve fantastic results with this with these patients another patient 3a with the z-shaped scar and this patient with oh sorry another patient with this difficult results we can achieve nice results with this patient this is on table results by the z-shaped scar tightening the skin of the of the chest and tightening of the skin of the abdomen and we have this just one week one week post-op as you can see here augmenting the muscle creating a new inferior chest crease hiding the scar of the inferior chest crease putting the nipple areola complex in its position this is very important 11 to 13 centimeters from the midline at the infralateral border of the peak measure muscle this is very important in order to achieve this shape and avoid this medialization of the nipple areola uh of the nipple areola complex and another patient showing this z-shaped scar with very nice uh uh technique and this is how also we shape his back some cases we're gonna have you wrap up please just for the sake of timing for the uh of our other speaker oh we just finished such cases such very difficult cases we might need to do transverse excision not l-shaped excision but i believe that z is is incision now is very helpful to correct all kind of chest back and upper back deformities this is the secondary cases we can do in stage four some cases with socialization of the neck with excess skin of the lateral chest and this stuff and this is just corrected with liposuction and release of the neck and augmentation of the of the big major muscle and here we go a very uh natural results another patient corrected with only liposuction and redistribution of the fat and peak major augmentation and redo case we showed earlier excision of the scar neck graft definition of the muscle peak augmentation properly placing the scar at the lower border the peak major muscle and fixing it to the chest wall will lead to very nice healed scar and another case patients showing the same results so in conclusion our uh this new classification of the chest and back lift in post-massive weight loss patients will provide guideline for management of chest problem in my in my opinion the circum area chest reduction in male patients didn't show any advantage and led to many chest deformities if we are going to excise a lot of skin this will lead to widening of the scar it should be part of total body work to achieve harmony and symmetry and the vertical the vertical scar in male patients i believe is is is to be avoided and this new technique and the results will improve and looking for more natural results for the next few years thank you very much thank you very much for that just terrific lecture um that just seemed that was really wonderful um i would like to now introduce dr luis alberto gonzalez fernandez uh dr luis alberto gonzalez fernandez is a board certified general surgeon certification was completed during the years of 1996 and 1999 he became a board certified plastic and reconstructive surgeon during the he became a board certified plastic and reconstructive surgery during the years 2000 2003 and then spent two years participating in a fellowship in aesthetic surgery in the united states from 2004 to 2005 he spent 21 years in aesthetic private practice and he's current medical he is the current medical director at plastic surgery mias hospital in antigua xilapa honduras thank you dr fernandez thank you ray ory um i want to talk about the surgical treatment for gynecomastia grade three in the silent justification everybody knows what gynecomastia is so i'm going to go through that and every also everybody knows about what created it most of the time i related to obesity and also related to genetic factors so i'm going to focus on grade three silent justification and uh something very important is to know the breast blood supply so we can design the uh the flap that we're going to have for each case we can use painful flaps according to every anatomy of each patient in his preference most of these patients with gynecomastia grade three have a bmi greater than 30 so i come up with basically three examples 180 year old and 38 year old and 68 year old patient in most of them my lateral pedicle flap is a superior medial uh pedicle flap because it's dermal but it doesn't mean that you cannot do an inferior pedicle so i decided to show you an inferior pinball rather rather than a superior medical or if the patient have a established metabolic syndrome i will advise you to go for a free nipple graft so in this case um this is a patient with bmi 30 32 and these are my initial mark i mark the nipple areal complex i mark the midline the inferior mammary fold in the axillary uh anterior line uh surgical treatment for gynecomastia grade three according to psycho-classification this can be defined well i already spoke about this i'm gonna go through it and we're gonna talk about grade three in the classification this is what i talk about slide in the blood supply and uh what i said most of these patients have a bmi greater than 30 and i have three um example of patient one is 80 year old the other one is 30 and the other one is 68 my preference is the superior medical people flat but in my technique i show you i'm going to show you the inferior pedicle flap when they have a established metabolic syndrome a free nipple graft will be advised in my case can you see it now hello yes yes everything's fine thank you so uh okay i have this is my markings i have the midline the inferior mammary fold i have the nuclear complex and the anterior axillary midline what i do is that i talk with each patient and i'm i explain a little bit about where do the superior border or the nipple are all complex will be according to their preference and this this is my patient i'm asked them and all they want they have a they want a flat chest not too fancy but they want a flat chest and get rid of the dynacomastia stigma and so um what you're seeing right now i know you're seeing a inferior border double line and i did this on purpose because sometimes when i'm doing the tater tracking i'm missing some skin and i put some and the incision is not going to be it's not going to be very good so uh i got the patient all the incision i ordered the linings that i do i bring the patient in standing up position so i put him in inside here and this is what i do i change it so you so you can see most of the time i use a uh medium superior medial um flat but in this case i choose this one i choose a inferior one so i can show you the way i've done it so this is my daily session so that will be my um piece of skin and fat and all the remaining um gland and you can see how thin is because all my blood supply would be in the inferior pitiful and this is what i do have all the time i'm trying to do and to put it in an atomical position right there where you're seeing in this picture so this is what i do i pretty much exhibit the whole pectoral muscle and at that level i'm going to put my nipple area complex exactly where i want it and i do three um stitches one superiorly and the other one the other two are medially and the other one is lateral so in this way i will be able able to um to set the position of my nipple areola complex whatever i wanted i'm taking all the time i put him in a in a drain and uh this is my right side doing and this is all my marking 17 8 centimeter from the midline and sometimes two or four centimeters from the hole as you can see there's no uh way that i have to extend my incision exactly in this case sometimes i have to be i have to go a little bit um laterally to kind of get the extra skin and the extra fat sometimes i perform a liposuction but again like i said they did at least my patient they want to get rid of that stigmata they don't want any bump they want a flat chest i already said that okay and the left side i do exactly the same thing see how thin can i get my pedicle very thin because i know my blood supply either in this case which is an inferior pedicle flap but again like i said most of the time i use the superior medial flap and again i am here uh with this t-shirt or jupiter the medial and the lateral sorry about the music and again once the breast the skin and the fat tissue is removed patient is set in a sitting position at the surgical table in other words it's not in zero degrees it's in 90 degrees so i can have all my incision whatever i wanted i don't cross the midline so you can see i respect that and uh i agree with him that it's going to be eight centimeters from the midline for for the inferior manifold and 17 the height from the superior uh border so i pretty much do the circle and i know that my nipple areola complex is going to be right there and according to what they want i go and i do a little reduction in the nipple areola complex and sometimes a little bit i let them more than four centimeters this is like about 3.2 centimeters each so once i achieve this result i can put the patient back on in a zero grade position i like i said here patient is kept in a sitting position at the surgical table until all the incisions are closed and of course the specimen is going to go through pathology and i'm going to show you why the reason of this and i of course separated the right from the left one okay so this is the results the pre-op and the post-op this is another patient this is the 18 one year old and in this case i did a superior medial flap different from the other one that i did an imperial flap but i wanted you to take a look close of the um the reliability of the nipple areola complex uh blood supply this is right there that's about just two centimeters the specimen and there he is like six months after the surgery He kept his weight and, well, these two patients are being very happy. Some of them are not, but this is just, remember, the plastic surgery is the part of the medicine that you have so many ways to solve one problem. And this is a 68-year-old patient who all he wanted is to get rid of that stigma of the gynecomastia. In his case, I performed a superior medial flap, and I did all the things you already know about my technique. I don't cross the midline, tried not to, I don't think it was necessary in this case. And I extended, in this case, I extended my incision laterally so I can get the extra skin and the extra fat as well. About four centimeters from the inframammary fold. And one thing I forgot to mention, I think you saw the way that I left, when I exhaled the pectoralis muscle, I was also creating some holes, you know, and those holes were filled with the extra fat that I left in the superior border from my incision. I don't know if that makes any sense, but I can explain that to you. So it will be definitely a flat chest. Of course, I've been having complications like any other gynecomastia surgery, seromas, scarring, unsatisfactory results, fat necrosis, nipolar aureolar epidermolysis, nipolar aureolar pericardial necrosis, and this was because most of these patients had metabolic syndrome established, and chest deformity, wound dehiscence, and infection in one of the regions. But from all those 900 cases that I've done throughout all my career, including when I was working in a public hospital, I found four, for this, I mean, it's not very usual, but I found four carcinomas, you know, and unfortunately, they had it, they had their treatment, and one of the good news was because with this technique, all of them were with capsula, so it didn't go any other way. So it was two in sudo, ductal carcinoma, one invasive ductal, and another one invasive ductal. That's what I have for you. Thank you. Hello? Thank you very much, appreciate your presentation, again, really, it's nice to see everybody's technique and how you treat this complicated problem. We're going to now open this up to the Q&A. I don't see any questions from anybody out there, however, you still have the opportunity, please, oh, okay, we're starting to get them in the chat, so instead of in the Q&A. So here is from Andreas Walter, and then, what are your concepts for the ideal placement of the nipple areolar complex, free or pedicle, pectoralis muscle edge? And there's a question mark, and that's in the chat. You can see the question as well. So we'll give you both the opportunity to answer that. Thank you very much for the question. As I mentioned during the presentation, we depend on the shape and the borders of the peak measure muscle, as you already mentioned in your question. But in measures, the nipple areolar complex usually is at 11 to 13 centimeters, this is my opinion, 11 to 13 centimeters for the midline, and the nipple areolar complex should be above maybe within one or two centimeters above the lower border of the peak measure muscle in order to achieve this in inferior lateral placement of the nipple areolar complex in relation to the peak measure muscle. This is if I answered your question. Thank you very much. Dr. Fernandez, anything to add when you're placing anything you consider, again, you know, so many different body habituses that you all seem to work on. So is there any latitude for your placement? Yes, definitely. Gregory, let me tell you something. In the three example, you could see that all the nipple areolar complex have completely different position. What I do is, even though I can be very happy with the result, what I wanted to be playing, I put the patient right into the mirror, and I advise them, this is what I would do, but where would you like to have it? So I kind of concerned with them, and then when we agree, folks, I will place whatever they want. Because I said, you don't want it too in the middle, you don't want it too lateral, you don't want it too inferior. What about this one? And so I put them participating because the result was going to be for them, not for me. So I just involved the patient with this issue, and then they all have been very, very satisfied. However, from those 900 that I have done so far, 11 were not satisfied at all with the result. Okay, great. Thank you for that. Dr. Tocin, I have a question about two things. For one, your fat grafting volumes that you're doing, because I like the idea that you're fat grafting. I think that this is very useful for contour. Anything in particular? I mean, there's so many ways to fat graft, and everybody does what they do. What are your average volumes that you're putting? You stated that you're using it on the inferior border. Just a follow-up question, overall, because again, there's some really complex stuff, and it's a massive weight loss. What would you say your overall revision rate is for these patients? Okay, regarding the pig augmentation, usually we concentrate on the upper part of the chest, which is this upper part of the chest that will be augmented, will give this fullness of the chest, and will create the inferior chest crease, or sulcus, as we mentioned before. The volume is within 150 cc to 150 cc. This is according to the shape and contour of the chest. The number of revision cases in this technique, maybe some scar revisions, nothing else. Some scar revisions, but we didn't notice any problem that need revision, because actually, this surgery is created for revision cases. Yes. No, I appreciate that. With your grafting, are you finding that your graft volumes, you're pretty happy, and are you placing where exactly? How much are you putting in the muscle, where exactly? It should be put in the muscle itself. Yes, it should be in the muscle itself. Usually we use ultrasound-guided, but with the experience, you don't need to do that, but usually it is in the pig measure itself. We graft the muscle itself. Dr. Chassin, in the Q&A, we have someone asking, you seem to be skin grafting your nipple-areola complexes. Please confirm whether that is true, and if so, do your patients regret losing sensation? This is a very important question. I don't think that patients, if patients during consultation, if they are, they needed to maintain their sensation, and they didn't notice that in male population at all, that they are looking for nipple sensation, but if happened to, then I will avoid this technique. Usually, yes, we do the neck graft. It is well-known technique, and we all do, and it gives very, very nice results. Great. Thank you. Let me just see, and let's see, there's another one in the chat. Let's see. What is the criteria to put the NAC at 18 centimeters in gynecomastia? You can see that in the chat box. Yes, I think I mentioned that, but again, we're not talking about a nipple-areola complex for women. We're talking about a man, so in men, we can definitely go higher or lower. I can see, Dr. Chassin, that we go very low, as he explained, and it looks great, but in my case, I don't know, my patients are different, but they wanted a flat chest, and this is not a rule. Like I said, 18 centimeters, that was specific for that case, and I said 17 and 4 for that case. For some others, I have done 19, 20 in front of the midline, 10 or 12. That definitely, you have to ... What I do is that I discuss it with my patient. I don't do anything that they don't allow me to do, so once they are ... As you can see, when I'm doing all the marking, I put it in a standard position right in front of the mirror, and when they accept it, then I go for it, and most of them, again, are happy, but again, in those 900 that I've done, more than 900, 18 were not satisfied at all. Thank you. I couldn't say. I think it's interesting that we certainly have been very more in tune to the cultural differences that we see throughout the world, whether it's we're seeing this with breast reconstruction for the female breast, and the cultural and just aesthetic with different countries as far as what the cultural norm is, because it seems like, Dr. Fernandez, you're not fat grafting your patients. You're saying that they prefer more flat chest. Do you think that is more cultural with you, or is that just your preferred technique to not graft at the time, or you don't feel it's necessary? Oh, no. I've done that. I just didn't present it, but again, in those 900 series, these are patients, most of them are for a public hospital, but in my practice, when they are not that BMI higher, they would definitely go with what Dr. Azeem said. So in those cases, I do, and I take some fat from here, and I combine sometimes with abdominoplasty or some other cases in my own patient, but that is dependent, again, from each patient to another. When the patient is more or slightly younger than those others, then I perform more surgeries on them. But again, I think my advice would be to be honest with your patient, and have them looking in the mirror, because they are going to have the surgery done, not me. So I might be, oh, I'm going to do this, I'm going to do that. But I have learned this from one patient who said, doctor, I came here for a flat chest. I don't want anything fancy. I just want to get rid of this stigmata that I've been having all my years. So it depends, depends upon each patient. That will be my answer, Gregory. Thank you. You've both given us a lot to think about, some great information. To close, could you each give us your one surgical pearl, whether it's the one thing that we all, if you look over your career, there was one thing that you used to swear was the best way to do something. And now we look at those results, and of course, we've changed our minds and our techniques. Is there one specific pearl that you can give to the audience tonight, for those who do male body contouring, and chest in particular, that you think is an imperative that everybody should think about prior to performing this procedure? I'll start with Dr. Khasim. Yes, in my opinion, that we should study the normal shape. This is how the muscular male chest looks like. So study it, try to draw it by your hands, try to sculpt it by whatever technique. You have to see, to feel, to know how the muscular male chest should look like. I don't depend on the patient preference. This is, we all know what is the male chest preference. So you should study the norm, a lot of norm, bring patients, bring normal patients, bring normal photos, look to statues, do whatever you want in order to copy this image in your head before going to your patient. The other pearl in surgery, which is the, if you are going to do this excision with the neck graft, so please consider tucking the skin of the upper flap into the cartilage. This way you will create, consider creating inferior chest sulcus, creating this sulcus and fixing the scar. In this position, the scar will heal nicely without just very fine scar and not be noticed by the patient later on. And the third pearl is you have to augment the muscle. Most of those patients, they are in catabolic state, they lost their muscles, the muscles is atrophied. And usually even if they eat and do the training and whatever they are going to do, they cannot have this fullness of the chest. So now we are augmenting everywhere, augmenting the deltoids, the biceps, the triceps, the traps, the longissimus, the lumbar muscles, the lats, the vastus lateralis, medialis, rectus femoris, we are augmenting everything, the chest and even the raft and the obliques. So we are augmenting everything with the help of the ultrasound. So use an ultrasound, look to the muscle and get used to using the ultrasound. And this way you have this confidence of doing the fact. Thank you. Those are, I think, great pearls. Do you have a final pearl to leave us with, Dr. Fernandez, before we wrap up? Absolutely. It's just something that I've learned, Gregory, all these years, is that I do what makes happy, the patient happy. I might be happy with the surgery, like it happened with my noses or facelifts. I say, oh, you did a great job. I love it. And then they go, hmm, it's good, but I'm not completely 100% happy with it. So the opinion with my patient is very important because, at the end, they are going to be the best referral patient from Denver. Well, thank you both for joining us tonight. Thank you for sharing your expertise with our audience. And as mentioned, those of you who may have joined us later, this is going to be a recorded webinar. You can go to ASPS.EdNet. These are all available to you to watch. I thank you all for joining us tonight. Once again, enjoy your evening, and we will hopefully have the next webinar in the next several weeks. Okay? Thank you, everybody. Thank you.

male chest contouring

gynecomastia

ultrasound-assisted liposuction

nipple-areolar complex

plastic surgery

body contouring

patient satisfaction

surgical techniques

aesthetic outcomes