Plastic and Cosmetic Surgery of the Male Breast

By Alessandro Innocenti

The thorax has a fundamental role in the aesthetic of the male body: congenital or acquired alterations are experienced as extremely frustrating clinical situations. Most breast surgery texts briefly mention  gynecomastia, but no text comprehensively addresses the male breast and thorax, including reconstructive and cosmetic surgery and surgery in transgender patients. This gap is now thoroughly filled by Plastic and Cosmetic Surgery of the Male Breast: after introducing principles of anatomy and aesthetics for the male thorax, the first part focusses on the main congenital malformations and their treatment; the main benign acquired pathologies and their treatment (including an ample section dedicated to gynecomastia), the carcinoma of the male breast, with reference to familiar forms; the treatment of carcinoma and reconstruction of the thorax. The book closes with a chapter dedicated to breast surgery in transgender patients. While female breast surgery is increasinglypracticed in specific Breast Units and highly specialized centers, male breast issues are treated in general and plastic surgeries units. This handy volume is a sound reference for the most complex clinical cases, and the latest reconstruction treatments for the male thorax and will be useful for general and thoracic surgeons, plastic surgeons and senologists.

• Language: English
• Publisher: Springer
• Release date: Jan 31, 2020
• ISBN: 9783030255022

Book preview

Part IAesthetic Aspects of the Male Chest

© Springer Nature Switzerland AG 2020

A. Cordova et al. (eds.)Plastic and Cosmetic Surgery of the Male Breasthttps://doi.org/10.1007/978-3-030-25502-2_1

1. Arts and Aesthetics of Male Chest

Massimiliano Tripoli¹   and Adriana Cordova¹  

(1)

Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy

Massimiliano Tripoli (Corresponding author)

Adriana Cordova

1.1 Aesthetic Aspects of the Male Chest

In the 2006 World Cup final, Italy were losing against France 1-0. In a moment of agitation, Zinedine Zidane, hero of the French national team, reacted to a verbal provocation from the Italian defender Materazzi by giving him a headbutt right in the chest. A furious gesture, the violation of the inviolable. The chest of man. The chest of the sportsman, the warrior, the hero; the chest of God. The point that symbolizes strength and protects the heart. Strength, beauty, and prowess have been concentrated at this point ever since ancient times.

Since he acquired the upright position, man has exhibited the chest, protection of the heart and symbolically the seat of courage and virtue. The chest boldly offers itself to the enemies, the chest defends dear life, and is the prevailing element for the harmony of the whole figure. In this chapter, we want to deepen the evolution of the ideal of beauty of the male chest through the plastic representation of the chest in sculptural art and through the evolution of taste and fashion [1].

What makes a male chest beautiful? Which parameters, measurements, and characteristics must a masculine torso have to be considered ideal? The golden rectangle, the expression of universal harmony, is found exactly in the male chest and has inspired classical sculptural art. Already in 700 BC the monumental statuary called Dedalica celebrated the beauty of the male chest with monumental statues of young men (the kouroi) in which the trunk appears compact and square, brought to life by slight incised relief anatomical notations.

In these statues, the nipples and the inframammary fold are alluded to, the salience of the pectoral muscles is visible but not marked, the sternum neither protrudes nor is depressed, and the chest line follows the synchondrosis of the last 5 or 6 ribs and the ensiform apophysis of the sternum to outline the lower edge of the chest. In the oldest statues and bas-reliefs, the chest line has a triangular shape. When it passes to the athletic ideal of the Dedalic style, it becomes almost horizontal with a small median triangular area, closer to anatomy as we see it today.

In the sumptuous statues of the fifth century BC, the torso and arms are muscular but slender; no muscular hypertrophy or fat deposits are observed, except for slight typical male adiposity above the iliac crest. The abdomen becomes more and more structured, excluding any kind of fat indulgence.

The fifth century BC is the age of Phidias and Policleto, with the latter developing and codifying a rational study of the naked male body; the Doriforo (Fig. 1.1) of Policleto has been identified since antiquity as the canon being used as a reference for measurements and lines of the perfect human figure: Fecit et quem canona artifices vocant, he also made that statue the artists call canon, wrote Pliny the Elder.

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Fig. 1.1

Doryphoros, Roman copy from original statue executed in bronze by Polykleitos, 440 BC, Museo Archeologico Nazionale di Napoli, Napoli, Italia (https://​www.​museoarcheologic​onapoli.​it/​en/​room-and-sections-of-the-exhibition/​sculptures-of-roman-campania/​). Reproduced with kind permission by Museo Archeologico Nazionale di Napoli

The work of Policleto, unfortunately, has been entirely lost. We know it only through Roman copies and descriptions by ancient critics. The only sentence attributable with certainty to Policleto is:

τὸ εὖ παρὰ μικρὸν διὰ πολλῶν ἀριθμῶν γίνεται.

Beauty is achieved gradually through many numbers.

Everything is arranged according to numbers and mathematical forms, as Pythagoras wrote, and as the Greeks had guessed, the rules are always the same.

The principle that The beauty of the body comes from symmetry and—above all—from the proportions of its parts is stated within this sentence.

By symmetry, we mean the absence of imbalances and differences between the right and left sides of the body; by proportion, we mean the relationship between the parts of the body itself, which, although variously interpreted, has not changed over the centuries.

The real innovation enshrined in the canon is the principle of proportions between the parts of the body; the absolute numerical element already present in Egyptian figurative culture, which emphasizes symmetry—six boxes for the knee, eleven for the pelvis etc.—is exceeded by the relationship between the measurements of the different parts.

When people talk about how bodies are portrayed in the media, they usually refer to women. But men have to deal with body image issues as well. In fact, the perfect male body has changed drastically over time, even more so than that of women.

From around 12,000 BC to 8000 BC, humans were beginning to switch from a hunter/gatherer society to a life based around agriculture. Growing food right where men lived, instead of stalking a buffalo all day, certainly made life a little easier [2].

Different studies have stated that the ideal man at the time was heavy. Agriculture allowed those with power over the land to have huge feasts and thereby gain weight. So, a heavier man was seen to be more appealing than his skinny counterparts.

Like women, men also had to deal with body ideals throughout history. In fact, there was more pressure on them than women. The ultimate proof of this is art like paintings and sculptures from ancient Greece or the Roman Empire, which often depicted men as having tall, lean, muscular bodies.

During times when the gym or weight training did not exist, this means that the man would have had to be very active and be able to undertake challenging labor just to look like that ideal.

During the Middle Ages, the concept of beauty and harmony as a ratio of proportions was still maintained but was stylized and simplified. In the Renaissance, an aesthetic elaboration re-emerged that saw the symmetry and principle of proportions and the relationships between the parts of the body as the foundation and presupposition of ideal beauty. As human thought acquired familiarity with the possibility of abstracting proportions, rather than measuring them, these were compared according to different systems; for example, they are likened to musical fractions (Note 1).

Note 1

(De Armonia Mundi totius 1525 Francesco Giorgi: ratio between the head and the height corresponds to 1/8 or a musical tone, the relationship between the torso and the legs is ¾ or a diatessaron, the relationship between pelvis-navel distance—buttock and thorax—jugular distance—navel—is ½ like the diapason.)

In the mythical drawing of Leonardo’s Vitruvian man (Fig. 1.2), in a long self-written caption, he lists the proportions of the human figure through which the entire order of the universe can be recognized (Note 2).

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Fig. 1.2

An example of a slim male chest, typical of the 1950s Hollywood actors

Note 2

Vetruvio architetto mette nella sua opera d’architettura che lle misure dell’homo sono della natura disstribuite in quessto modo. Cioè, che 4 diti fa un palmo e 4 palmi fa un piè; 6 palmi fa un cubito, 4 cubiti fa un homo, e 4 cubiti fa un passo, e 24 palmi fa un homo; e cqueste misura son ne’ sua edifizi. Se ttu apri tanto le gambe che ttu chali da chapo 1/14 di tua alteza, e apri e alza tanto li bracci che colli lunghi diti tu tochi la linia della sommità del chapo, sappi che ’l cientro delle stremita delle aperte membra fia il bellicho. E llo spatio che ssi truova infra lle gambe fia triangolo equilatero. These are the words with which Leonardo da Vinci (Vinci, 1452–Amboise, 1519) opens the description of the famous Vitruvian Man, in the five lines that are found at the top of the sheet preserved in the Galleries of the Academy of Venice.

Although common in art, from Michelangelo’s David to Arno Breker’s fascist sculptures, the physique depicted was considered unattainable until very recently.

The notion of muscularity was reintroduced to the world in the mid-sixteenth century, with the discovery of the Farnese Hercules, a Roman copy of an ancient Greek sculpture. But, it had an extremely limited influence until the current era. Only after the myths surrounding muscle—that it contributed to heart disease, made one slow and inflexible, and was not something produced through training but was instead a God-given marker of a low caste—were debunked did it become a marker of health and prosperity.

In the early nineteenth century, in Europe, the ideal male beauty had no muscles because it was associated with physical work; the ideal man had to be almost completely pale, because he had not toiled in the sun, and he had to be tall because he was well nourished. This masculine type held sway until very recently.

In later years, industries such as film, fashion, and music, or even business and politics often had different ideas of how a man should look. From the chubby members of exclusive clubs just for overweight men, to the lean, matinee idol types of old Hollywood, to the androgynous, lanky frames of the 1970s rock stars, to the bodybuilders of the 1980s and 1990s, men’s ideal body shapes have changed significantly (Figs. 1.3 and 1.4). Like women, men should embrace and work with what shape they are born with. The literature reports that the male chest evolved to house large lungs that can deliver more oxygen for running and chasing activities. Broad-chested men historically commanded greater respect and power.

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Fig. 1.3

In the 1980s and 1990s the ideal male chest is the body builder’s one, with large and squared pectoralis muscles

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Fig. 1.4

Today it is considered sexually attractive a man with V-shaped or inverted triangle torso

Today it is not clear whether muscles, and large, square pectoralis in particular, are an indication of health or narcissism, menace or manliness. The concept of athleticism developed very late in the last century although physiques showed in movies like Tarzan, or James Bond were very popular in the 1940s and 1950s. The fitness revolutionized the life style only in the early 1970s; the ideal male chest inspired the old Hollywood actors remained the same for twenty years.

Recently, according to studies on what the ideal male body should look like, The physique of a slim waist, broad shoulders, and muscular chest are often found to be attractive. Several research studies have shown that usually women, with heterosexual orientation, consider physically strong men attractive, while weaker or feminine male bodies are not considered sexually significant.

All men can be classified as a rectangle, an oval, a triangle, a rhomboid, or an inverted triangle. In the last two decades, a near-universal sexually attractive feature of a man is a V-shaped or inverted triangle torso: a relatively narrow waist offset with broad shoulders.

The anatomical features of the chest, now as in the past, are represented by shape, contour, chest line, position, and dimensions of the nipple areola [3]. These identify an individual as male or female, and even the smallest detail contributes to determining the appropriate appearance for each gender. The ideal chest is not flat. There is a defined contour and natural fold just below the chest where the abdomen begins. The chest fold is predominantly horizontal. On the ideal chest, the nipple must be prominent and small; it is typically 5–6 cm above the chest fold and faces forward. The areola is flush with the surrounding skin [4]. The chest must be defined, with low fat deposits, but to establish the perfect measurements is not possible because of the variability in height, weight, and shape of the body.

Reconstruction of the male chest and its gender-specific contour is often required by patients after massive weight loss, in high-grade gynecomastia, and in transsexual patients.

In patients who are in transition to a male identity (female-to-male), the most important and often the only step in sexual reassignment surgery is the creation of an aesthetically pleasing male chest. In these patients, the breast represents the stigma of feminine identity, and it is important to remove them, creating a male chest with an accurate repositioning of the NAC [5].

Men commonly expose chest and nipples during recreational and social activities, and patient satisfaction with the aesthetic appearance of the nipple and areola after gynecomastia procedures or female-to-male gender reassignment is significant.

In men the shape of the areola should be elliptical rather than circular, and there are no significant differences between a supine or standing position.

To analyze the anatomical characteristics of the male chest, different studies have been performed to verify the hypothesis of the relationship between the pectoralis major muscle and the NAC but regardless of exact values, patients and surgeons should always share the consensus about where the NAC should be placed before surgery is performed. In over a thousand years of reflection and representation of male beauty this chapter has summarized for us in the chest nothing and, at the same time, much has changed. We continue to desire a broad and compact chest with small nipples, equidistant from the midline and in harmony with the rest of the body.

There are today still several methods for the calculation of ideal proportions of the body; one of the most accredited is John McCallum’s formula, based on wrist girth:

1.

6.5 times your wrist gives chest girth.

2.

85% of the chest girth is equal to the hips.

3.

The waist is 70% of the chest girth.

4.

53% of the chest gives the thigh girth.

5.

The neck size is 37% of the chest.

6.

36% of chest gives the upper arm girth.

This formula is not correct for everybody because it suggests that the size of the wrist strongly depends on the size of other human bones.

If the measurements can change, depending on biological evolution or a representative need, the proportions are imposed by nature. Modifying them is a cultural prerogative.

It follows that nature establishes the canon. Culture, fashion, and the evolution of thought can work to counteract the natural canon, to break it, to adapt it, or to follow it.

In primitive societies, when it was necessary to procure food by hunting and by heavy labor in the fields, a robust and rather heavy human figure was desirable.

The Greek and Roman civilizations bring us back to figures of men, athletes and warriors, with a dry and vigorous physique without excess that is still the male aesthetic model in the Western world today.

Finally, if in our reconstructive procedures we give the right salience to the pectorals, positioning the NAC at the right distance from the jugular and the chest fold, equidistant from the mediosternal line, thereby obtaining the desired result, we will surely have chosen the same thicknesses and the same distances that Leonardo, Vitruvius, and Policleto would have chosen, respecting the mathematical proportions suggested by the canon of nature.

References

1.

Kunitz D. How art has depicted the ideal male body throughout history. Artsy ed; 2017.

2.

Rachel C, Boroughs M. The impact of western beauty ideals on the lives of women and men: a sociocultural perspective. In: Swami V, Furnham A, editors. Body beautiful: evolutionary and sociocultural perspectives. New York: Palgrave Macmillan; 2007. p. 259–8.

3.

Kasai S, Shimizu Y, Nagasao T, Ohnishi F, Minabe T, Momosawa A, Kishi K. An anatomic study of nipple position and areola size in Asian men. Aesthet Surg J. 2015;35(2):20–7.

4.

Yue D, Cooper LR, Kerstein L, Charman SC, Kang NV. Defining normal parameters for the male nipple-areola complex: a prospective observational study and recommendations for placement on the chest wall. Aesthet Surg J. 2018;38(7):742–8.

5.

Tanini S, Lo Russo G. Shape, position and dimension of the nipple areola complex in the ideal male chest: a quick and simple operating room technique. Aesthet Plast Surg. 2018;42(4):951–7.

Part IIAnatomy of the Male Chest

© Springer Nature Switzerland AG 2020

A. Cordova et al. (eds.)Plastic and Cosmetic Surgery of the Male Breasthttps://doi.org/10.1007/978-3-030-25502-2_2

2. Preoperative Considerations on the Thorax: Anatomy and Surgical Landmarks

Alessandro Innocenti¹  , Davide Pino², Fabio Buccheri³, Francesco Cappello³ and Lorenz Larcher²

(1)

Careggi University Hospital, Florence, Italy

(2)

Plastic, Aesthetic and Reconstructive Surgery Sanitaetsbetrieb South Tyrol (SABES), Bolzano, Italy

(3)

Department of Biomedicine, Neuroscience and Advanced Diagnostics, Institute of Human Anatomy and Histology, University of Palermo, Palermo, Italy

Alessandro Innocenti

Keywords

ThoraxChest wall anatomyMale chest wall anatomyMale mammary regionMale pectoral region

Key Points

Modern anatomical concepts of the male chest must include considerations on seven different subunit areas;

The most attractive standard of male chest must maximize the visibility of the muscular contour minimizing at the same time the amount of breast tissue;

Surgical landmarks must be taken into account during preoperative considerations;

The internal mammary artery and the anterior intercostal arteries represent the most important source of cutaneous perforators in the anterior part of the male chest.

The thorax is the part of the body between the neck and the abdomen. The thoracic wall comprises all the musculoskeletal structures that surround and limit the thoracic cavity including the vascular, nervous, and lymphatic components.

Its dimension is influenced by age, gender, and lifestyle, including physical fitness. It may change in shape and size depending on respiration: generally, males present an abdominal respiration pattern, while females usually display a thoracic respiration pattern.

The clavicle and jugular notch form the upper anterior edge of the thorax, while xiphoid process and the synchondroses from the seventh to the tenth rib form the lower one. The diaphragm, separating internally the thoracic cavity from the abdomen, is attached to the posterior surfaces of the xiphoid process and the lower six ribs and costal cartilages. The anterior chest wall is laterally delimited by the anterior axillary fold, which is formed by the lateral edge of the pectoralis major, where the tendon attaches to the lateral lip of the intertubercular sulcus of the humerus.

The anatomy of the chest differs between men and women, with further considerable variations between different ages and races. The skin is thicker in males than in females. In the male thorax, body hair is frequently present and the mammary glands are undeveloped. It must be noted that in this area, pathologic scar formation is relatively common.

We will now introduce some details of anatomical structures that are of interest for this book.

2.1 Nipple-Areola Complex

The nipple-areola complex (NAC) varies in size and it is located laterally, higher up in males than in females; generally, in the former, the NAC is located 4–5 cm above the chest fold and 1–2 cm above the pectoralis major border. The areola is well defined, including a small and poorly projected nipple. The areola can have either oval (91%) or round (7%) shape, and while it is not flat, it lies flush with the surrounding skin. The pigmentation can vary according to race and skin phototype. It may or may not have hair on its external perimeter. The nipple-areola complex contains many sensory nerve endings, smooth muscle, and a subareolar lymphatic plexus [1–7].

2.2 Breast

After birth, the male breast has a brief period of activity due to maternal prolactin production. During puberty, male breast tissue regresses due to testosterone activity and the lack of female hormones, usually remaining undeveloped throughout the life of the individual. Macroscopically, the gland can be described as a small gray disk within the superficial fascia system,