There is a rise in male patients seeking out more sculpted bodies
The combination of social medial obsession, online dating and lockdown has led to a rise in certain trends. One is the desire for more male patients to have more sculpted bodies. Lockdown has led to the so-called ‘Zoom boom’, where many people spend hours on Zoom calls and looking at their own faces. Being a live call, there is no airbrushing or photograph filtering option, so the ‘real’ us is seen on the screen. The same applies to online dating, which, during lockdown, had to stop, and most people on the dating scene relied on photographs alone to choose a potential partner. Men are less likely to airbrush and filter their photographs compared to women, and, therefore, there is a pressure to have to look good in photographs. Since the start of the pandemic, many people began to work from home, making this an ideal time for them to consider aesthetic treatments and surgery, as it was easier for them to recover from a treatment.
Male vanity is not a myth
According to the media, male vanity is no myth (Bhatia, 2019). Men take as much care about their looks as women do. Over the past few years, there have been articles published about the rise in male vanity, and even coining the term ‘manity’. The skincare industry now caters a lot more for men compared to recent years. Many men now know to use a face moisturiser and sun cream, and male grooming is a lot more acceptable and accessible now, with many barber shops offering not just a haircut, but also a beard trim and a wet shave.
Although 20 years ago, when the author started their cosmetic private practice, mostly women were treated, with approximately 5% of the patient population being male, now men form approximately 40% of patients, and the numbers are rising. It is now common to see a female patient bringing along her male partner for a cosmetic procedure like botulinum toxin or dermal filler treatment. More couples come through the doors too for ‘his and hers’ treatments. Sometimes, the male partner will just observe his female partner having a treatment and then proceed to book himself in.
» Distinguishing between visceral and subcutaneous fat is very easy. Visceral fat makes the abdomen bulge, while subcutaneous fat can be pinched on the outside of the abdomen «
Tycoons and transformations
When Jeff Bezos, the Amazon tycoon, showed off his new muscular body at the Sun Valley Conference in 2017, he almost went viral. He turned from an unnoticeable balding man into a masculine specimen deemed worthy of his own empire. There are many other examples of male grooming in the celebrity world, among them, Russell Brand and Prince Charles (GQ. com, 2010).
The vanity paradox
Throughout history, art has depicted the ‘perfect’ male body (Kunitz, 2017). From Greek statues of warrior-athletes to Michelangelo's David, they have all established a standard of male beauty that abides today in Western societies: the muscular and athletic male body. This physique was considered unattainable until very recently. Presently, we see many more examples of the perfect male body, whether this is in the gym or on the beach. This is partly due to better nutrition, better exercise facilities and knowledge from men who are concerned about their looks on how to achieve this.
However, there is a male vanity paradox (The Fertility Hub, 2019), which is important in explaining why the surgical choice of treatment can sometimes can make more sense for the patient. This paradox comes from the fact that some men may want to look good to attract a partner, and, by doing that, pass their genes onto the next generation. However, to achieve a ‘perfect’ body, many men opt for some extra help with anabolic steroids, which, in turn, suppresses testosterone production by a negative feedback mechanism and prevents men from exactly achieving that (low testosterone means low sperm production). Therefore, many men are now turning to an alternative option: both non-surgical and surgical aesthetic treatments. However, some patients may feel that their ideal result cannot be achieved without surgery, and may need assistance from surgical and non-surgical practitioners alike in recommending treatment.
Liposculpture
One treatment in particular is vibration amplification of sound energy at resonance (VASER) liposculpture. Although this is a form of liposuction, it is a totally different concept to liposuction as many may know it. The first big difference is that the patients treated are not overweight, they are generally fit and have a well-developed muscle mass under a layer of fat. This is very different from the standard (debulking) type VASER or classic liposuction, where the aim is to just remove fat. With VASER liposculpture, the aim is to reveal the muscle contour and show it in the best way possible. To achieve this, a layer of fat that is overlaying the muscles is removed. In the author's experience, it is most help to say to patients who enquire about the procedure that if they do not have the muscles, this procedure cannot show them. The first requirement is to have reasonably well-developed muscles, and the practitioner's job is to show them to the world.
Revealing, not removal
Some people may wonder how fit individuals who exercise regularly have any fat. The answer is that, unless you are down to 7–10% of body fat, there will still be a layer of fat over the muscles. This layer varies depending on diet and lifestyle. Even bodybuilders have this extra layer, but they go on a strict diet just before a competition, which allows them to lose body fat so that they can go down to sometimes as low as 7% body fat. This gives the audience the best view of their muscles. The author often gives the analogy that the muscles are there, but there is a duvet on top of them. This procedure will replace the duvet with a thin sheet, which will allow people to see the muscles underneath. In their book, this is what Alfredo Hoyos and Peter Prendergast call ‘removal versus revealing’: ‘Traditional liposuction in overweight patients focuses on removal, whereas high-definition lipoplasty in patients of normal weight focuses on revealing. In essence, the advanced lipoplasty surgeon is a sculptor revealing the elegant underlying muscular and bony anatomy’ (Hoyos and Prendergast, 2014). Many male patients have a reasonably good diet, a healthy lifestyle and exercise regularly, but they are struggling to lose weight from certain areas of their body, which could be the flanks, abdomen or chest. Therefore, the most frequently asked areas for body contouring are the abdomen, chest (including gynaecomastia) and arms.
Chest and abdomen high definition treament (courtesy of Dr Alex Chambers): before and after
An old-fashioned way of looking at liposuction is fat being removed from a certain area—perhaps just the abdomen or flanks.
Patients still often request to have liposuction carried out on on just the abdomen. The fact of the matter is that the body is a 3D structure. Therefore, it is very rare that liposuction of the abdomen in isolation works well, usually it is performed in a 360° manner to instead carry out liposuction of the abdomen, flanks and the sides of the body. This not only ensures that there is a good reduction of volume all the way around the trunk, but also helps with the skin contraction post-operatively, which is much better after 360° liposuction. This 360° liposuction can be one of three types: debulking, mid- or high-definition. In high-definition body sculpting, sometimes fat is not only removed, but also has to be added to bulk up the muscles that the practitioner wants to define. This is known as 4D high-definition body sculpting. Therefore, high-definition VASER body sculpting can usually be divided into 3D and 4D procedures. Needless to say, these are much more demanding procedures in terms of skill and anatomy knowledge of the operator compared to a standard or debulking-type liposuction.
Gynaecomastia/chest contouring: before and after treatment
The three stages of VASER body sculpting
The procedure consists of three main stages, which are detailed below.
Infiltration
The first stage is the infiltration. This is the process of applying a wetting solution, which has three main purposes. Firstly, it numbs the area, so, if the patient is awake, they will not feel any pain during the following stages. The second aim of the wetting solution is to create a bloodless field by including adrenaline in the solution, which creates vasoconstriction and reduces the bleeding during surgery. As a result, yellow-coloured fat comes out in the tubing instead of bloodstained fat. The third purpose is to facilitate removing the fat. Think of rinsing dishes: it would be hard to clean them without water, which helps to rinse them. Similarly, the wetting solution makes the fat easier to remove.
The VASER stage
The second part of the procedure is the VASER stage. In essence, ultrasound waves are used to break up and liquify the fat cells. Specially designed VASER probes are used to breakdown the fat and turn it into liquid. Usually, this is visible as a yellow/pink-coloured liquid that flows from the operating site(s).
The liposuction stage
The third stage of the procedure is the liposuction stage. This involves using different types of liposuction probes, which vary in shape and size (length and diameter). Depending on what results they want to achieve, each probe is specially chosen by the surgeon. The fat is aspirated with the help of a powerful pump and passed from the cannula through some tubing into container bags with graduation to calculate the amount removed.
A demanding procedure
Body sculpting surgery is also physically demanding for the surgeon. Both hands are used, but in a different capacity. The right hand (if the surgeon is right-handed) usually holds the infiltration, VASER or the liposuction cannula. The left hand is placed in the skin, and called the ‘thinking hand’. This hand has an important role. Being a closed procedure (i.e. the surgeon cannot see how they are removing the fat, they can only feel it) means that the left hand (or the right hand in a left-handed surgeon) feels where the tip of the cannula is and it acts as their eyes and brain at the same time. This is the hand that senses if the cannula is near a danger zone, such as a vital organ, or at the right depth. If the cannula is too deep, it can enter the abdominal or chest cavity and damage the internal organs. If it is too superficial, it can cause irregularities, so it has to be at a precise level. There is a saying that, in liposuction, the cut on the skin is very small (2–4 mm), but the surgical wound is very big, as it is the whole area that has been treated. This applies even more so to high-definition VASER body sculpting (3D and 4D), as, from a patient's perspective, the recovery is longer and the aftercare more demanding. Many patients underestimate the recovery time, as they only see a very small surgical scar. However, the aftercare plays a big part in the success of body sculpting surgery. Personally, the author ensures that patients are committed to the follow-up visits, or they can choose to have their follow-up at a place near their home. Without this commitment, the surgery is not carried out.
The main aim of aftercare
In the first 2 weeks after the surgery, the main aim of aftercare is to get rid of any excess fluid. This is because the lymphatics have been damaged by the surgery and it takes time for them to recover. Therefore, initially, the body is not capable of getting rid of excess fluid, and this can accumulate and cause complications such as haematoma or seroma. Usually, manual lymphatic drainage is the treatment of choice for the first 2 weeks. Following this, a firmer massage, possibly combined with ultrasound, is used to treat any possible hard areas that may be developing as a result of the healing process.
Gynaecomastia/chest contouring: before and after treatment
Treating the abdomen
The abdomen area is the most popular treatment area of all. This is one of the most common requests from male patients. Most men can get reasonably good arm definition with weightlifting, and if they have no gynaecomastia, they can get good chest contours too. However, it is usually the abdomen that bothers them. With exercise alone, it is very hard to achieve a six-pack, as there are other factors that play a part, such as genes and dietary habits. For example, most men will drink occasionally. Usually, this will increase the fat layer around the abdomen and waist. However, there is an important distinction to be made here: the difference between visceral and subcutaneous fat. Subcutaneous fat can be treated with any form of liposuction or liposculpture. On the other hand, visceral fat is located around the internal organs, below the abdominal wall, and the only way to remove this fat is through diet and exercise that results in weight loss. Liposuction cannot help here at all.
Patient categories
Distinguishing between visceral and subcutaneous fat is very easy. Visceral fat makes the abdomen bulge, while subcutaneous fat can be pinched on the outside of the abdomen or other areas of the body, and can be measured with fat callipers. These days, there are scales on the market that can measure body fat percentage. Of course, it is also possible to quantify those measurements with the help of ultrasound scans. However, another important guide is the body mass index (BMI) of the patient. Ideally, patients with a BMI around 30 or higher would need to lose weight prior to any surgical procedure. Even if the patient has a good diet and exercises regularly, like in the case of some athletes, it can be hard to reveal a perfectly defined six-pack. This is because of genetic elements that make certain men store fat in areas that make muscle definition less visible. Patients can change their dietary habits and exercise regularly, but cannot do anything about genetic factors, which is where high-definition VASER can help remove that fat permanently.
The ideal patient has just a little bit of excess fat that blurs the muscle borders
There are four categories of patients here:
- The overweight patient with considerable amount of visceral body fat, which has given him a bulging abdomen. He will need to lose weight prior to surgery to get a good surgical result
- The patient who does not have excess visceral fat, but has a good amount of subcutaneous fat. This patient will firstly need debulking VASER to remove the vast majority of the excess fat, followed by high-definition sculpting to reveal the underlying muscles
- The ideal patient: this patient has just a little bit of excess fat that blurs the muscle borders and gives him poor definition. This patient only needs removal of that fat by high-definition VASER sculpting and he will have his six-pack
- The very slim patient. This patient usually does not have a lot of body fat, but maybe just enough to blur the muscle borders. The problem with this patient is that he does not have very bulky muscles, because, genetically, he is very slim. This is where 4D VASER sculpting comes into play. By injecting fat into those muscles, they can be bulked up, and this creates a bigger muscle appearance to somebody who is naturally very slim.
Chest contouring
Chest contouring is another sought-after area by male patients. Many male patients, especially the ones with gynaecomastia, will treat their chest as a priority. Many will be embarrassed to go to the gym and may get into a vicious circle where they cannot exercise, so they gain more weight and their gynaecomastia gets worse. In most cases, gynaecomastia is a combination of gland overdevelopment and fat accumulation. Regardless of that, VASER or power-assisted liposuction is capable of removing both glands and fat at the same time. Most gynaecomastia patients can be treated just with VASER/liposuction. Those who have ptosis (Grades 3 and 4) may additionally need a skin tightening treatment (BodyTite or Renuvion) or a small skin excision to get rid of the excess skin.
Men who do not suffer with gynaecomastia may have the problem of underdeveloped pectoralis muscles. This is the muscle that defines the male chest. To define the male chest, one needs to create good volume of the pectoralis muscle, but also treat the neighbouring areas to make the muscle stand out more. In the past, and even now, some men have resorted to pectoral implants to achieve the bulk that they desire. However, implants can be more expensive, have more complications and can lead to poor aesthetic results (Hoyos and Prendergast, 2014). A well-executed high-definition 4D body sculpting of the chest can yield much superior results than implants. Unlike the natural female breast, the male chest has greater volume in the upper pole compared to the lower pole as a result of the bigger muscle bulk there. Therefore, most of the fat transfer should happen in that area if the patient does not have much muscle mass. There are areas around the pectoralis muscle that are a negative space, so they have to be completely devoid of fat to make the muscle stand out more. As a result, the patient will have a much more athletic appearance, and, often, chest contouring will be combined with other abdomen (six-pack) treatments for the best results.
Treating the arms
Male arms are subconsciously linked to the physical strength and power of the individual. In male patients, usually the arm and shoulder are seen as one unit. The main muscles there are the deltoid, biceps and triceps muscles. Those muscles create distinctive curves in the arm. Whenever addressing the arm with liposuction, there should always be a 360° design. This is because the arm is moving and rotating constantly, and it is easy to appreciate the 3D structure of it more than any other part of the body. It is important to reflect the movement of fat based on arm movements (Park, 2018). Contouring the male arm is a very intricate procedure, because fat and skin thickness vary depending on the different regions of the arm. For example, the posterior arm has thin skin and deep fat, therefore, it is prone to fat accumulation, which varies depending on the weight of the patient. This is what determines the so-called youth angle. In a young patient with normal body weight, the angle between the proximal posterior arm in a vertical line is acute. In overweight patients or older patients, the angle tends to be obtuse due to fat accumulation or excess laxity of the skin (Hoyos and Prendergast, 2014). High-definition liposuction can change those angles and reinstall the natural, more youthful curves of the arms, compared to conventional liposuction, which only gets rid of excess fat.
Conclusion
In summary, the author has seen that male body sculpting is on the rise. Most male patients who seek body sculpting are of a normal BMI and require mid- or high-definition body contouring to expose their muscles. This is a very skilled procedure that takes years of training. Therefore, it is important that patients go to properly trained surgeons who know how to deliver this procedure. The British Association of Body Sculpting (BABS) unites surgeons who specialise in body sculpting. They undergo rigorous assessments of their skills and constantly update their skills, knowledge and training. It urges the general public to do the research before they choose a surgeon for any cosmetics procedure that they might consider.