Men have just as many concerns about their waistline and abdominal shape as women. But the anatomic basis for the male abdominal problem is usually different. Exclusive of the morbidly obese or the extreme weight loss patient, men have different skin, fat and muscle compositions of their abdominal shape. Men do not get pregnant so the amount of stretched and/or stretchy skin is less. Fat distribution in men has a more significant intraperitoneal component and usually less between the skin and the underlying muscle. Lastly, men rarely have significant muscle laxity or midline separation.
For these reasons, tummy tuck surgery is performed less on men than women because the excess skin and loose muscle issues are less. For every male that undergoes some form of an excisional abdominoplasty, ten women probably do. This is different in the extreme weight loss patient where the ratios are much more comparable.
Much abdominal reshaping in men can be done with liposuction. Aggressive liposuction of the entire abdomen extending into the flanks is necessary before any consideration of skin excision can be done. For most men with any amount of abdominal protuberance, it is not possible to get a near flat abdomen with liposuction alone. There is too much intraperitoneal fat for that to occur except in the already relatively fit male.
Most of the time whether simultaneous skin resection should be done with liposuction can be determined before surgery but not always. Some men are understandably reluctant to acquire a low horizontal scar which is relatively unnatural in a male. Women accept these scars much better as they have a long history of c-section and tummy tuck scars. When in doubt, it is most logical to use the ‘wait and see’ approach for the amount of skin retraction. But, psychologically, most men are not as tolerant of multiple procedures and are impatient to get to the final result.
Tummy tucks in men are usually more limited in scope of skin resection and length of the horizontal scar. In addition, muscle plication is rarely necessary or that beneficial unless there is an associated umbilical hernia. Infraumbilical skin and fat resections are all that is needed in most cases and the lateral resection should go as far as needed to work out any pleats or dog ears.
In removing the lower abdominal skin and fat, I avoid exposing the abdominal wall fascia and leave a layer of tissue just below Scarpa’s fascia. The upper abdominal skin is then advanced over top. By so doing, this reduces the amount of time a drain will be needed and decreases the risk of seroma later after the drain is removed. Men are not particularly tolerant of tubes exiting their body.
The concept of lipoabdominoplasty in men leans heavily toward the liposuction component in the non-bariatric or large weight loss patients. The tuck and tightening of lower abdominal skin is often quite helpful from a contouring standpoint and probably should be considered in more older male patients who seek a better waistline. In my Indianapolis plastic surgery practice, I find an increasing number of men who benefit by some version of a lower skin resection and do not have objection to the final scar that results.
Barry L. Eppley, M.D., D.M.D.
Indianapolis, Indiana