The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

This 36-year-old man had grade IIB gynecomastia. UAL and SAL procedures re-
moved 725 cc from his left side and 700 cc from his right side. He is seen 8 months
postoperatively with good symmetry and skin retraction.
2670
Part XI  Breast Surgery

2671
Chapter 74  Treatment of Gynecomastia
This 38-year-old man presented with grade III gynecomastia. He is shown 7 months
postoperatively after removal of 650 cc from the right side and 600 cc from the left.

This 18-year-old was diagnosed with grade IV gynecomastia; he subsequently un-
derwent evacuation of 750 cc on the right side and 700 cc on the left side. Although
there is some persistent ptosis postoperatively, he shows marked improvement for
this more severe form of the disease.
Concluding Thoughts
The treatment of gynecomastia continues to be challenging because of the dense na-
ture of the breast tissue as well as the skin redundancy that is often present. We have
no doubt that some of the nonsurgical devices under investigation will be included in
treatment algorithms of the future.
2672
Part XI  Breast Surgery

Clinical Caveats
 Gynecomastia that is present clinically for more than 12 months does not typi-
cally resolve completely.
 The goal of treatment is restoration of a normal male breast contour, not elimi-
nation of all breast tissue.
 Excision alone should be avoided as the primary treatment for gynecomastia.
 The lateral inframammary fold incision is optimal to concentrate UAL/SAL or
PAL/SAL passes in the dense subareolar region.
 Liposuction should be performed cautiously in the adherent zone.
 UAL and PAL are effective for all grades of gynecomastia; SAL is primarily effec-
tive for grades IA and IIA.
2673
Chapter 74  Treatment of Gynecomastia
Annotated Bibliography
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ment. Plast Reconstr Surg 79:740-750, 1987.
The author presents the following treatment recommendations for gynecomastia: if the
gynecomastia is entirely due to fat, suction lipectomy alone is sufficient treatment. How-
ever, because suction will not remove breast parenchyma, patients whose gynecomas-
tia is caused by parenchymal hypertrophy also require local excision of the parenchyma.
Skin excision is rarely, if ever, necessary.
Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-Assisted Liposuction. St Louis: Quality Med-
ical Publishing, 1998.
A comprehensive work on the clinical applications of UAL and SAL.
Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defin-
ing the role of ultrasound-assisted liposuction. Plast Reconstr Surg 111:909-923, 2003.
This article proposes a new system of classification and graduated treatment for gy-
necomastia based on glandular versus fibrous hypertrophy and degree of breast ptosis
(skin excess). The authors have found UAL to be effective in treating most grades of gy-
necomastia. Excisional techniques are reserved for severe gynecomastia with significant
skin excess after attempted UAL.

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Artz S, Lehman JA. Surgical correction of massive gynecomastia. Arch Surg 113:199-201,
1978.
Balch CR. A transaxillary incision for gynecomastia. Plast Reconstr Surg 61:13-16, 1978.
Bannayan GA, Hajdu SI. Gynecomastia: Clinicopathologic study of 351 cases. Am J Clin
Pathol 57:431-437, 1972.
Barsky AJ, Kahn S, Simon BE. Principles and Practice of Plastic Surgery, 2nd ed. New York:
McGraw-Hill, 1964.
Beck W, Stubbe P. Endocrinological studies of the hypothalamo-pituitary gonadal axis dur-
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Beckenstein MS, Windle BH, Stroup RT. Anatomical parameters for nipple position and are-
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Botta SA. Alternatives for the surgical correction of severe gynecomastia. Aesthetic Plast Surg
22:65-70, 1998.
Bowers SP, Pearlman NW, McIntyre RC Jr, et al. Cost-effective management of gynecomas-
tia. Am J Surg 176:638-641, 1998.
Carlson HE. Current concepts: gynecomastia. N Engl J Med 303:795-799, 1980.
Chiu DT, Siegel HW. The pinwheel technique: an adjunct to the periareolar approach in gy-
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Cohen IK, Pozez AL, McKeown JE. Gynecomastia. In Courtiss EH, ed. Male Aesthetic Sur-
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Coleman WP III. Powered liposuction. Dermatol Surg 26:315, 2000.
Colombo-Benkmann M, Buse B, Stern J, et al. Indications for and results of surgical therapy
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Davidson BA. Concentric circle operation for massive gynecomastia to excise the redundant
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2674
Part XI  Breast Surgery

Foder PB, Vogt PA. Power-assisted lipoplasty (PAL): a clinical pilot study comparing PAL to
traditional lipoplasty (TL). Aesthetic Plast Surg 23:379, 1999.
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lipoplasty. Clin Plast Surg 26:283-288, 1999.
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Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg 124(1 Suppl):61e-
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Chapter 74  Treatment of Gynecomastia

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Part XI  Breast Surgery

BODY CONTOURING
PART XII

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Applied Anatomy
in Body Contouring

ANGELA S. LANDFAIR, J. PETER RUBIN
CHAPTER 75

A
pplied anatomy is the practical application of anatomic knowledge to diag-
nosis and treatment of a patient. Applied anatomy in body contouring demands
more than a passing familiarity with the underlying muscular, neurovascular, and
bony structures. During body-contouring surgery, substantial three-dimensional zones
of tissues may be simultaneously manipulated, transferred, and transformed. There-
fore intimate knowledge of the subcutaneous tissue structure and composition and
its relationship to the deeper tissues below is essential in optimizing surgical outcomes.
In this chapter we will review relevant universal anatomic principles that affect body
contouring, with an emphasis on the superficial fascial system (SFS), zones of ad-
herence, and the lymphatic system. Comprehension of these anatomic systems can
help surgeons refine their technique and ultimately improve outcomes. Our discus-
sion is not meant to describe operative techniques that are more extensively and ap-
propriately discussed elsewhere; we will focus on the application of broad anatomic
concepts for various surgical zones in body contouring.
Evolution of Technique
In the past four decades, the science of body contouring has reached new levels of so-
phistication and ingenuity. In the 1970s there were tremendous advances in suction-
assisted lipectomy, followed by innovations in tumescent, ultrasound-assisted, and
large-volume liposuction. The surgeon’s abdominoplasty repertoire has been aug-
mented by the mini-abdominoplasty, marriage abdominoplasty (combination of mini-
abdominoplasty and liposuction), limited dissection abdominoplasty, and lipoab-
dominoplasty, among others. Lockwood’s descriptions of the superficial fascial system
provided an anatomic basis for highly transformative excisional body-lifting proce-
dures. Circumferential body contouring began with belt lipectomy and now encom-
passes various excisional lifting procedures, including simultaneous circumferential
upper and lower body lifts.
The most recent advances in body contouring can be attributed to the increasing de-
mand for bariatric surgery. Massive-weight-loss patients have presented many new
challenges to plastic surgeons, introducing many unfamiliar contour deformities that
had been inadequately addressed by previously existing procedures.
Ever the innovators, plastic surgeons have devised new procedures to address the de-
formities associated with massive weight loss. As our surgical arsenal grows in breadth
and complexity, we can benefit by reevaluating the anatomic tenets that define the
limits of tissue dissection and resuspension.
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Part XII  Body Contouring

Superficial Fascial System
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Chapter 75  Applied Anatomy in Body Contouring
The superficial fascial system (SFS) is a vast connective tissue network extending
from the dermis to the muscular fascia. The SFS comprises vertically and horizon-
tally oriented fibers that interconnect to form a connective tissue scaffold. The ver-
tical SFS fibrils arise directly from the deep dermis and attach to one of three loca-
tions: another SFS fibril; a secondary SFS layer, such as Scarpa’s fascia; or directly
to the muscular fascia. The SFS provides structure and a strut for subcutaneous fat
and imparts additional biomechanical strength to surgical closures. Pathologically,
the SFS is responsible for dimpling and cellulite. Manipulation of SFS has been dis-
cussed as a critical step in both excisional and less-invasive body contouring.
Serratus anterior muscle
Pectoralis major muscle
Linea alba
Line of attachment of
external oblique muscle
to anterior sheath of
rectus abdominis muscle
External oblique muscle

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Part XII  Body Contouring
Suprascarpal fat
and SFS layer
Dermis
Epidermis
Histologically, the collagen and elastin content of the SFS is indistinct from that of the
deep dermis. In the deep reticular dermis, the collagen and elastin fibers that are
mostly horizontal in mid-dermis begin to orient themselves obliquely at angles that
are more perpendicular to the epidermis. At the dermis-SFS junction, there are con-
nective tissue fibers that emerge in a nearly vertical direction. The vertical SFS fi-
brils transmit interconnecting, more horizontal fibers to adjacent fibrils.
The SFS has a secondary component: the thin, gossamer sheets that emerge from the
fibrils to encase the fat globules interspersed among the scaffold. These fine connec-
tive tissue sheets suspend the adipose tissue in their three-dimensional position.
The collagen and elastin makeup of the SFS fibrils indicates that the SFS shares vis-
coelastic properties similar to those of the dermis, including creep (lengthening of
tissue under tension) and stress relaxation (decreased inherent tissue tension when
pulled bidirectionally over time). In biomechanical testing of subcutaneous tissues,
the SFS layer demonstrates viscoelastic properties independent of those of the der-
mis. When repaired along with dermis, the SFS confers supplementary initial tensile
strength to wound repair.
In our animal study, suture approximation in the SFS layer, in addition to the der-
mis, significantly increased the initial biomechanical strength of the surgical repair
and probably had a role in increasing permanent wound strength. Anchoring the SFS
to deep fascia during closure has also been credited with decreased migration and
widening of surgical scars.

In limited areas of the body, the SFS has a distinct, substantial horizontal layer that
is suspended between the dermis and the muscular fascia below. This layer is called
Scarpa’s fascia in the trunk and Colles’ fascia in the perineum. These defined con-
nective tissue scaffolds most likely provide the majority of the tensile strength of the
SFS layer when incorporated in body contouring. In other areas such as the lower
legs, the SFS consists of layers of vertical fibrils and connecting horizontal fibers that
do not coalesce into a substantial intervening horizontal structure.
Sex differences in SFS have yet to be satisfactorily elucidated. In general, however,
the vertical components of the SFS are oriented more perpendicularly in women and
more obliquely, or in a crisscross pattern, in men. As previously mentioned, the SFS
scaffold consists of predominantly vertical/vertical-oblique fibers, with horizontal
connecting fibers. It has been observed that in women with cellulite, there is a paucity
of the horizontal fibers compared with women without cellulite, and that women
without cellulite have SFS anatomy more similar to that of men.
The appearance of dimpling after overaggressive liposuction is probably caused by
hollowed-out SFS pulling on the dermis. The appearance worsens with movement:
the unidirectional pull of the SFS fibers emphasizes the dimples. The sex differences
have not been investigated in morbidly obese or postbariatric patients. A reasonable
assumption is that the overall effacement of SFS fibers and decreased elastin content
seen with massive weight loss is likely to have a greater impact on SFS architecture
than the sex of the patient does.
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Chapter 75  Applied Anatomy in Body Contouring
Suprascarpal fat
and SFS layer
Dermis
Epidermis
Scarpa’s fascia
Subscarpal
SFS layer
Fascia over muscle
Dense (hip)
Loose (pannus)

SFS is a dynamic viscoelastic structure that relaxes with age and weight gain. Stretch-
ing of these organized SFS fibrils is probably partially responsible for pathologic dim-
pling of the skin (cellulite) and for horizontal descent of tissues above more densely
adherent areas, as seen in ptosis of the mons pubis. The impressive skin and soft tis-
sue rolls often seen in massive-weight-loss patients arise from stretching and relax-
ation of skin and SFS, with deflation of the adipose tissue from weight loss. In areas
of excess adiposity, SFS stretches from the burden of the intervening adipose tissue,
and it is often difficult to distinguish distinct SFS fibers in areas of excess adiposity.
In massive-weight-loss patients, the SFS fibers have been stretched to conform to a
much larger tissue burden and often appear effaced in areas of greatest adipose loss.
To equate body contouring with construction, the superficial fascial system is the
scaffold. The SFS exists in every area of body contouring, and a successful outcome
depends in large part on SFS reshaping and resuspension. Even when effaced by obe-
sity and subsequent massive weight loss, the SFS remains an important layer in re-
structuring subcutaneous fat and minimizing scar and tissue migration.
Zones of Adherence
The topographic anatomy of the body is determined by the relationship of the SFS
to the dermis above and the muscular fascia below. An area in which the SFS is specif-
ically adherent and thickened creates a linear crease in the skin and a valley in the
immediately surrounding soft tissue. These zones of adherence divide the adjacent
subcutaneous tissue on either side into surgical compartments.
The zones of adherence have been emphasized in the past because they were con-
sidered zones to be avoided during suction lipectomy. Avoiding suctioning across
these zones would result in conservation of subcutaneous connections between the
skin and muscle fascia, thus preventing the overlying skin from vertical descent.
However, the classic zones of adherence are often not zones of avoidance in the massive-
weight-loss population. In excisional lifting procedures, tissues within the zones of
adherence may be excessive and should undergo direct resection. In the most severe
massive-weight-loss deformities, the inferior tissue flaps may need to be draped over
and superior to the existing zone of adherence and anchored at a more superior lo-
cation. The new site to which the tissues are anchored may act as a de novo zone of
adherence.
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Part XII  Body Contouring

2685
Chapter 75  Applied Anatomy in Body Contouring
The zones of adherence do not occur equally between the sexes. The hip zone of ad-
herence is demonstrated most convincingly at the level of the iliac crest in men, but
several centimeters below the iliac crest in women. Adiposity below this zone of ad-
herence in women accentuates the so-called saddlebag deformity, a finding largely
absent even in obese men.
In massive-weight-loss patients, the combination of excess skin and attenuated SFS
fibers creates large hanging areas that can originate and/or terminate at the various
zones of adherence. An example of this is a moderate-sized pannus protruding and
then descending over a known zone of adherence in the suprapubic zone, with the
inferior margin of the pannus coalescing and attaching to the same zone of adher-
ence. In female massive-weight-loss patients, significant deflation and ptosis of the
breast occurs, with the majority of the ptotic tissue descending and hanging below the
inframammary fold, which is an important zone of adherence. This phenomenon is
seen in men as well, although to a lesser degree.
Zone of
adherence
in male
Inframammary fold
Umbilicus
Zone of adherence
(variable)
Zone of adherence
Zone of adherence
Zone of
adherence

Pathologic zones of adherence are often observed in massive-weight-loss patients.
For instance, the lateral chest roll that is often seen as a continuation of the breast
suggests that the fascial coalescence that defines the inframammary fold continues
laterally, causing overhang of lateral chest wall tissue in continuity with the breast
tissue. The pathologic inframammary fold continuation into the lateral chest wall is
likely present to some degree in all patients; however, this attachment is probably
clinically insignificant in the nonobese and never-obese population, who do not have
a significant quantity of lateral chest wall tissue excess.
Although the hips have been the most closely investigated area, zones of adherence are
present throughout the body and are encountered during any body-contouring pro-
cedure. Inframammary folds and infragluteal folds are easily recognizable zones of
adherence. The release of the crescent-shaped lower abdominal zone of adherence is
of utmost importance during contouring of the abdomen and mons pubis.
2686
Part XII  Body Contouring
Based on photographic evidence of massive-weight-loss patients, it appears that the
human body has numerous, although perhaps less well circumscribed, zones of ad-
herence that anchor the skin and subcutaneous tissue at various locations. These
zones become more obvious in a morbidly obese or massive-weight-loss patient.
These midabdominal, midflank, and midback zones of adherence are clinically sig-
nificant in massive-weight-loss patients, because these pathologic zones of adher-
ence need to be incorporated into excisional lifting procedures to create a smooth
contour where there are folds and indentations.

Lymphatic System
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Chapter 75  Applied Anatomy in Body Contouring
Often considered the third circulation, the lymphatic system exists in parallel to the
venous circulatory system. Lymphatic capillaries arise from the deep dermis and
along muscle fascia, coalesce to form larger lymphatic vessels, and travel unidirec-
tionally through a valvular system toward nodal basins (arrows) and lymphatic ducts.
The lymphatic ducts drain the lymph fluid into the central circulatory system by en-
try into the venous circulation. Venous capillaries reabsorb approximately 90% of
interstitial fluid, while the remaining 10% is transported by lymphatic channels.

The lymphatic system can be loosely divided in two configurations: the epifascial,
superficial system that collects lymph from skin and subcutaneous tissues, and a deep
system that collects from all subfascial structures. The superficial lymphatic system
is a factor during body contouring at all tissue levels. The initial lymphatic capillar-
ies are found in the dermal papillae, which form a superficial subdermal plexus of
lymphatic sinuses. Histologically, these lymphatic capillaries are composed of en-
dothelium on a discontinuous basement membrane without tight junctions. These
initial lymphatic vessels coalesce into superficial precollectors in the dermis, which
then coalesce into lymphatic ducts. Lymphatic ducts are differentiated from other
lymphatic vessels by the presence of smooth muscle in the walls. Lymph flow and
lymphatic contractility in the ducts increase in response to tissue edema, exercise,
mechanical stimulation, and temperature changes.
The surgeon must recognize the anatomic relationship between lymphatic vessels
and their surrounding structures to prevent lymphatic injury during surgical inter-
vention, which could lead to lymphedema. Specific areas should be carefully dis-
sected, particularly regions near major lymphatic ducts and/or nodes that are re-
gional basins of lymph transport. The lymphatic system exists in parallel to the venous
circulatory system, and injury to a major vein often coincides with injury to regional
lymphatic ducts. Some degree of lymphedema is common and expected after body-
contouring surgery, but prolonged or permanent lymphedema is an unfortunate out-
come that is at least somewhat preventable.
Lymphedema is a progressive pathologic accumulation of protein-rich fluid in the
interstitial fluid, leading to inflammation that causes adipose tissue hypertrophy and
fibrosis. When protein in the interstitium increases tissue colloid osmotic pressure,
additional fluid is driven into the interstitium. When lymphedema occurs in a limb,
it can impair the functional capacity of that limb. Plastic surgeons commonly en-
counter secondary lymphedema from excision of lymph nodes, such as in breast can-
cer patients who have undergone axillary dissection. More often, lymphedema is en-
countered in body-contouring patients as a sequela of lymphatic transport after
massive tissue excision.
2688
Part XII  Body Contouring
Dermis
Lymphatic ducts
Suprascarpal fat
and SFS layer
Scarpa’s fascia
Subscarpal fat
and SFS layer
Loose areolar tissue

Chronic lymphedema of the lower extremity is a common clinical entity that plagues
even a svelte individual but can be especially pronounced in a morbidly obese per-
son. Improvement in the appearance of lymphedema when treated with mechanical
squeezing of the lower extremities suggests that lymphedema indicates a functional
deficit of lymphatic transport rather than an absence of or a decrease in the number
of lymphatic vessels. It is probably akin to venous stasis in that the conduits are pres-
ent, but the valves are not propelling its contents forward.
There are lymphatic channels in the dermis and subdermal plexus and along muscle
fascia. Interruption of lymphatic vessels is often cited as a worrisome complication of
suction lipectomy, but clinical experience indicates otherwise. Lower extremity suc-
tion lipectomy without excisional surgery (with a 3-month follow-up) was not shown
to cause a significant change on lymphoscintigraphic examination. Liposuction with-
out excision probably does not permanently damage the lymphatic system, and tem-
porary reduction in lymphatic drainage could be explained by postoperative edema
that compresses the lymphatic vessels. In contrast, a study by Moreno and colleagues
of patients after medial thighplasty showed that at the 6-month postoperative visit,
30% of patients exhibited abnormal findings on lymphoscintigraphy compared with
their preoperative scan. This study demonstrated that excisional surgery, in contrast
to suction lipectomy, can cause enduring anatomic and functional changes to the
lymphatic system.
The nodal system is a pit stop for lymphatic fluid before it joins the venous circula-
tory system: the node basins allow passage of lymph fluid while trapping foreign par-
ticles. Chronic lymphedema of the upper extremity after axillary nodal dissection is
caused by an absence of basins for lymph fluid from the affected extremity. The lym-
phatic vessels are present and probably still functional, but an absence of nodal basins
causes a backflow of lymphatic fluid. However, clinically significant lymphedema oc-
curs in a minority of axillary dissection patients, suggesting that even in the absence
of nodal basins, lymphatic channels have direct connections to the ducts that drain
into the venous circulation. Prolonged edema of the arm is reported rarely with bra-
chioplasty, suggesting that disruption of lymphatic channels through excision of the
posteromedial arm is rarely destructive enough to cause chronic lymphedema.
The superficial lymphatic system is a unidirectional network of lymphatic vessels
and nodes that transport excess interstitial fluid into the circulatory system. Although
it is a valved system, lymph vessels are vulnerable to temporary changes in local phys-
iology created by local inflammation and postsurgical edema as well as chronic
changes, such as the tissue burden of morbid obesity or massive weight loss. During
excisional surgery, it is crucial to avoid the large lymphatic structures that often run
alongside veins as well as efferent and afferent lymphatic vessels adjacent to nodal
basins. Chronic lymphedema can be an unfortunate complication of excisional lift
body-contouring surgery, and patients should be educated about the potential for
this complication.
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Chapter 75  Applied Anatomy in Body Contouring

2690
Part XII  Body Contouring
Arms
Guerrerosantos’ classification divides the upper arm into four surfaces: anterior, me-
dial, lateral, and posterior. These surfaces are defined with the arms hanging loosely
at the sides, with the medial surface defined as the surface resting against the tho-
rax. A common error in planning can make a scar too posterior, rendering it visible
with the arms at rest. With aging or weight fluctuations, the laxity of the skin and
soft tissues in the posterior proximal arm results in unsightly tissue redundancy. In
patients of all weights, subcutaneous fat is most abundant in the posterior aspect of
the proximal arm. After massive weight loss, excess skin and often excess adiposity
persist.
Medial
Lateral
Posterior
Anterior
Medial
Lateral
Incorrect placement of scar

During brachioplasty, the structures most at risk for damage are the intercosto-
brachial, medial brachial cutaneous, and medial antebrachial cutaneous sensory
nerves. The medial antebrachial cutaneous nerve penetrates the deep fascia of the
forearm at an average of 14 cm proximal to the medial epicondyle, becoming a su-
perficial structure. The anatomic study by Knoetgen and Moran showed that the
range for this distance was 8 to 21 cm and that the nerve did not run consistently
with the basilic vein. The course of this nerve is variable, but it does reliably run in
close proximity to the intermuscular septum. Careful dissection around this area can
drastically reduce the likelihood of injury to this sensory nerve as well as to the basilic
vein. The medial brachial cutaneous nerve runs posterior to the basilic vein and is
at risk for injury if posteriorly placed incisions are used. The cephalic vein, which is
superficial to the deep fascia throughout the arm, is generally safe from injury, as are
superior lateral brachial cutaneous nerves, inferior lateral brachial cutaneous nerves,
posterior brachial cutaneous nerves, and posterior antebrachial cutaneous nerves.
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Chapter 75  Applied Anatomy in Body Contouring
Inferior
lateral brachial
cutaneous nerve
Cephalic vein
Medial antebrachial
cutaneous nerves
Medial brachial
cutaneous nerves
Intercostobrachial nerves
Superior lateral brachial
cutaneous nerves
Basilic
vein
Lateral
antebrachial
cutaneous nerve
Posterior
antebrachial
cutaneous nerve
Posterior brachial
cutaneous nerves

The preferred placement of incisions varies among practitioners; some surgeons fa-
vor a medial incision in the bicipital groove, whereas others choose posterior place-
ment. Current designs in brachioplasty remove an ellipse of skin and soft tissue from
the posterior arm as well as skin and soft tissue from the axilla. The dissection is su-
perficial in the axilla and is unlikely to be in proximity to any vital structures.
According to Lockwood, the SFS of the arm has two distinct layers. First is the in-
herent SFS present throughout the rest of the body that encases and supports adi-
pose tissue, undergoing stretching and relaxation with weight fluctuation and age.
The second component is a longitudinal fascial system, or suspensory ligament, that
extends from the inherent SFS to insert into the clavicopectoral and axillary fascia.
Loss of tension in this suspensory portion of the SFS is most responsible for the pto-
sis of the posteromedial arm that is frequently seen in massive-weight-loss patients.
Fascial anchoring of the suspensory ligament into the axillary and clavicopectoral
fascia during brachioplasty to recreate this sling is crucial to performing a recon-
touring and rejuvenating procedure rather than a simply reductive procedure.
The suspensory ligament attachment to the axilla defines an important zone of ad-
herence of the SFS to the underlying muscular fascia. Re-creating this zone of ad-
herence produces a youthful axillary contour. After resuspension of the SFS in the ax-
illa, the resulting zone of adherence should be concave compared with the posterior
arm, with a sharp near–right angle when the arms are held in 90-degree abduction.
Small lymphatic vessels of the arm are distributed evenly and circumferentially
throughout the arm. Anatomic studies have shown that large groups of superficial
lymphatics are concentrated along the course of the basilic vein. A fair amount of skin
and soft tissue reduction is performed in close proximity to the basilic vein during
standard brachioplasties. Despite this, postoperative chronic lymphedema of the arm
is rare in these patients, suggesting that the high concentration of lymphatic vessels
in the rest of the arm can compensate for the vessels transected during brachioplasty.
Chest
Breast tissue is often severely affected by massive weight loss from relaxation of con-
nective tissue layers, involution of breast parenchyma, and resulting skin excess. Lock-
wood described an anterior SFS layer of the breast as an indistinct connective tissue
layer that lies between the dermis and the breast parenchyma, and the posterior SFS
as the connective tissue fibers that travel through the breast parenchyma to attach to
the pectoralis fascia. SFS fibers of the breast are not easily identified intraoperatively,
2692
Part XII  Body Contouring

but should theoretically be a strength layer that encases the breast par enchyma. The
suspensory ligaments of the breasts are called Cooper’s ligaments; it appears that
Cooper’s ligaments are synonymous with Lockwood’s SFS of the breast. The de-
scription differs in that Lockwood characterizes the anterior SFS layer as being some-
what separate from the posterior SFS throughout the parenchyma.
In massive-weight-loss patients the SFS is effaced, and the suspensory qualities of
the SFS fibers are lost. Parenchymal reshaping techniques that rely on anchoring large
areas of deepithelialized tissue to the periosteum of the rib or pectoral fascia are of-
ten more successful in massive-weight-loss patients with severe breast deformities.
These techniques correct the vertical descent of the breast tissue and restore volume
by resuspending, rather than excising, the descended breast tissue. There is often a
large roll of soft tissue excess in the lateral chest wall in continuity with the breast.
These soft tissue rolls can be deepithelialized and rotated medially on a random-
pattern blood supply to augment the breast tissue.
Even in massive-weight-loss patients with the most severe deformities, the infra-
mammary fold is usually intact. In most body-contouring surgeries, it is crucial to
preserve the inframammary fold as the single most important zone of adherence in
the upper trunk. Boutros et al performed a study to elucidate the anatomy of the in-
framammary fold. Through histologic evaluation, it was determined that the dermis
of the inframammary fold houses regular arrays of horizontally oriented collage fi -
brils. The arrangement is consistent through all layers of the dermis and is especially
prominent in the papillary dermis. On gross examination, the SFS at the inframam-
mary fold is condensed and thick, directly connecting the dermis to the pectoralis
fascia below. The authors concluded that the inframammary fold is an intrinsic der-
mal structure consisting of regular horizontal arrays of collagen held in place by a
zone of adherence formed by the SFS.
The symmetry of the inframammary fold is important in male body contouring as
well, particularly because the inframammary fold is always visible in the normal
male chest. In male chest contouring, the location of the horizontal scar for excision
can lie at the inframammary fold. A well-placed horizontal scar can create the illusion
of an inframammary fold, even without actual fascial attachments. The male infra-
mammary fold should be located 4 to 5 cm inferior to the edge of the areola.
Lymphatic drainage of the chest wall is seldom problematic because of the proxim-
ity of tissues to the axillary nodes and the major lymphatic ducts, including the tho-
racic duct. Although some lymphatic flow through the nipple-areola complex is dis-
rupted during breast-contouring procedures, the preservation of a dermal pedicle
appears to provide adequate efferent lymphatics.
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Chapter 75  Applied Anatomy in Body Contouring

Trunk and Mons
The anterior trunk aesthetic unit comprises the abdomen, flank, and the mons. The
abdominal wall is bound superiorly by the costal margin and inferiorly by the pelvic
girdle. The umbilicus lies at the junction of the midline and the horizontal line drawn
at the upper margins of the iliac crests. The natural waist is defined by a multilayer
muscular suppression, which is approximately 1 inch above the umbilicus.
Sex differences in regional adiposity of the abdomen are well established. In general,
women have a more protuberant anterior abdomen, and the adiposity is more pro-
nounced in the inferior umbilical region. In men, the anterior abdomen is flatter and
has a less pronounced flare at the iliac crest. With obesity, men tend to deposit more
fat within the muscular envelope and in the flanks region compared with women.
With massive weight loss, the sex differences are somewhat blunted, hidden beneath
large areas of excess tissue. Ideally, body contouring should make the sex difference
more pronounced, restoring masculinity and femininity to the patient’s contours.
Both superficial and deep systems contribute to the blood supply of the anterior ab-
dominal wall. Recent CT angiography and venography studies have revealed that
perfusion of the soft tissue of the abdominal wall occurs through the subdermal and
suprafascial plexus. The blood supply of the abdomen has been elucidated in multi-
ple anatomic studies. The deep vascular supply to the abdominal wall comes from
the following:
 The deep inferior epigastric artery and deep superior epigastric artery, which
is an extension of the internal mammary artery. The vessels anastomose on the
deep surface of the rectus abdominis muscle between the umbilicus and the
xyphoid.
 The deep intercostal arteries T6-12, which travel in the plane between the
transversus abdominis and internal oblique muscles, then join the central vas-
culature of the deep epigastric vessels at the semilunar line.
 The inferomedial to superolateral axis includes the deep circumflex iliac ar-
tery, which anastomoses with the lower intercostal and lumbar arteries.
The superficial blood supply consists of a network of connections between the inher-
ent superficial vessels and the musculocutaneous perforators from the deep system:
 The superficial circumflex iliac artery, which supplies the inferolateral ab-
dominal skin and anastomoses with superficial branches from the intercostal
vessels and perforators from the deep circumflex iliac system. This is divided
during an abdominoplasty or other truncal excision procedures.
 The superficial inferior epigastric artery, which supplies the inferomedial ab-
dominal wall and always runs superficial to Scarpa’s fascia. This vessel is pres-
ent in 80% of patients. The vessel forms an anastomotic network with the su-
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Part XII  Body Contouring

Lateral
perforators
from
intercostal
arteries
Superior
superficial
epigastric
artery
Superficial
external
pudendal
artery
Superficial
circumflex
iliac artery
Superficial
inferior
epigastric
artery
Perforators
from deep
epigastric
artery
perficial circumflex iliac artery, perforators from the deep inferior epigastric
artery, the lateral thoracic artery, and superficial branches of the intercostal
arteries.
 Intercostal musculocutaneous perforators at the level of origin of the external
oblique muscle.
 Musculocutaneous perforators from the superior and inferior deep epigastric
arteries, the deep circumflex iliac artery, including the superficial superior epi-
gastric artery, which enters the superomedial abdominal wall through the up-
per rectus abdominis muscle. The lateral branch of the superficial superior epi-
gastric artery runs along the eighth costal cartilage and anastomoses with the
eighth intercostal artery.
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Chapter 75  Applied Anatomy in Body Contouring
Intercostal
arteries
Perforating
branches
from deep
superior
epigastric
artery
Semilunar
line
Deep
inferior
epigastric
artery
Deep
circumflex
iliac artery
Iliac artery
Deep
superior
epigastric
artery

After abdominoplasty and other excisional truncal contouring surgeries, the super-
ficial inferior epigastric perforators from the deep inferior epigastric artery and the
superficial circumflex iliac arteries are divided. Flap survival depends on the super-
ficial perforators of the intercostal musculocutaneous perforators and the superficial
branches of the superior epigastric artery. The anastomoses between the deep cir-
cumflex iliac artery and the lower superficial intercostal vessels augment the flap sup-
ply; however, these anastomoses are divided during circumferential body contour-
ing. Dye studies have revealed that the blood supply of the inferiormost portions of
the abdominal flap is random, and any tension in the midline inferior margin can
lead to skin and soft tissue necrosis.
The intercostal perforators and the subdermal and suprafascial plexus must be pro-
tected to ensure the viability of the abdominal flap after excisional contouring. With
preservation of the superficial blood supply, abdominoplasty with deep plane resec-
tion of subscarpal fat can be safely performed in most patients. Lipoabdomino-
plasty—an abdominoplasty with selective undermining with liposuction of abdom-
inal wall and flanks—has a low incidence of ischemic complications as a result of
superior preservation of the blood supply.
Manipulation of the SFS is particularly significant in truncal contouring. Scarpa’s
fascia is the primary strength-retaining portion of the SFS network. Scarpa’s fascia is
congruent with Colles’ fascia in the perineum. The deep fascia (innominate fascia,
fascia of Gallaudet) that is adherent to the musculoaponeurosis is continuous with the
fascia lata of the thigh. After excisional body contouring, the SFS must be resus-
pended to maintain the new contour. Frequently this means deep suspensory sutures
tacking the SFS to the deep fascia in the desired location, creating a new zone of ad-
herence with suture anchors.
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Part XII  Body Contouring

Sheath
of rectus
abdominis
muscle
rolled back
Rectus
abdominis muscle
Internal
oblique muscle
Semilunar line
Aponeurosis
of transversus
abdominis muscle
Transversus
abdominis muscle
External
oblique muscle
Transversalis fascia
Arcuate line
The musculoaponeurosis of the abdomen, consisting of the external oblique, internal
oblique, and transversus abdominis muscles, which envelope the anterolateral wall
of the abdomen, and the aponeuroses of these muscles make up the anterior and
posterior leaves of the rectus sheath. Relaxation of these aponeurotic connections
within the rectus sheath creates the various diastases seen in the abdomen, especially
in multiparous women. The aponeurotic layers coalesce at the midline, creating the
linea alba. Frequently in multiparous women, there is significant relaxation of the
midline aponeurosis, containing a rectus diastasis. During truncal-contouring pro-
cedures, various maneuvers may be performed to address relaxations in the aponeu-
rotic layer. Vertical supraumbilical and infraumbilical figure-of-eight sutures are
placed to close areas of diastasis. Horizontal or oblique imbricating sutures can nar-
row areas of true diastasis or aponeurotic excess.
Superficial lymphatic vessels of the abdominal wall drain into two systems. The lower-
half lymphatics coalesce into trunks that drain into the superficial lymph nodes of
the groin, whereas the upper abdomen vessels drain, along with the chest wall, into
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Chapter 75  Applied Anatomy in Body Contouring
Aponeurosis
of external
oblique muscle
Line of
attachment
of external oblique
aponeurosis
to anterior
sheath of rectus
abdominis muscle
Internal oblique
muscle
Cut edge
of external
oblique
aponeurosis

2698
Part XII  Body Contouring
the axillary nodes. Long-standing edema in the abdominal wall after an abdomino-
plasty or other excisional trunk procedure of the abdomen could be caused at least
in part by the lack of lymphatic channels that drain the inferiormost part of the ab-
dominoplasty flap. Residual postoperative edema in the tissues likely compresses ex-
isting lymphatic capillaries, preventing transport of interstitial fluid. Lipoabdom -
inoplasty, which minimizes direct excision of soft tissue and instead uses suction-
assisted lipectomy to debulk the abdominal wall, probably preserves a greater number
of lymphatic vessels initially, resulting in improved contour and a decreased incidence
of seromas.
Anatomic studies have delineated the presence of superficial lymphatic vessels at the
fascial layer, but the nature of the connection of these two systems in the subcuta-
neous fat remains somewhat obscure. In general, it is likely that the initial swelling
seen after any excisional body-contouring procedure is caused by the disconnection
of lymphatic channels and lymphatic-venous anastomoses in the area of excision and
dissection. The eventual improvement in edema suggests that there is some degree of
lymphangiogenesis. Intervening infection or fat necrosis can cause scarring in the
subcutaneous tissue, making it difficult for new channels to develop. Compression
garments activate lymphatic ducts and temporarily improve their efficiency. One can
extrapolate that panniculitis in the dependent abdominal tissue after massive weight
loss may be not cellulitis but lymphangitis: inflammation of poorly mobilizing or
stationary lymphatic fluid.
In the lower abdomen, leaving Scarpa’s and subscarpal tissue intact above the mons
to a height of approximately 3 fingerbreadths below the umbilicus will leave most
of the lymphatics directly above the mons intact, allowing better control of postop-
erative lymphedema. Scarpa’s fascia from below is then affixed to superficial rectus
fascia at approximately the height of the umbilicus to create a lifting effect for the
mons pubis and upper medial thighs.
No changes in sexual sensation will occur if mons fat is removed superior to the pu-
bic symphysis and if labia majora fat is excised lateral to the pubic symphysis and
clitoral hood. Anchoring the excised superior edge of pubic skin succeeds in creat-
ing a de novo zone of adherence and preventing further mons ptosis.
The pathophysiology of abdominal excess encompasses skin excess, striae/rash,
thinned dermis, and attenuated SFS fibers, including Scarpa’s layer. In massive-weight-
loss patients, the excess abdominal tissue can be compromised by chronic lymph -
edema, rash, and panniculitis. In contouring the trunk, several anatomic principles
must be adhered to:
 The umbilicus should be anchored to the proper position and the inferior ab-
dominal wall anchored to create a new zone of adherence.
 The SFS fibers should be encompassed in lifting maneuvers to create a new
contour.

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Chapter 75  Applied Anatomy in Body Contouring
 Initial deterrence in lymphatic outflow should be expected to some degree, and
postoperative compression can increase interstitial pressure, preventing lym-
phatic fluid from becoming static in the subcutaneous tissues.
 The vascular supply to the newly contoured abdomen comes from the supero -
lateral abdomen through the intercostal perforators; the midline inferiormost
tissue is random in blood supply.
 The lateral cutaneous branches of the iliohypogastric and intercostal nerves
are at risk for entrapment, particularly during a circumferential body lift. Ag-
gressive lateral plication of the external oblique muscle for waist definition can
increase the risk for nerve entrapment.
Hips
Patients frequently express concern about their hips and flanks, although hips are
more likely to have excess adiposity in women, whereas the flanks are more frequently
a problem area in men. The hips and flanks have a continuation of the SFS, with su-
perficial fat above Scarpa’s layer encased in more closely related vertical SFS fibers,
while fat below Scarpa’s has fewer fascial fibers and the fat appears more mobile. The
boundaries of the deep fat compartments are defined by zones of adherence.
The zone of adherence, as described by Lockwood and further defined by Rohrich
et al, describes sex-specific areas of fascial attachments where the superficial, more
dense SFS fibers send direct attachments to the muscle fascia below, creating a bound-
ary between two fat compartments and creating an area of defined contour. In men’s
hips, the zone of adherence is along the iliac crest, whereas in women, the zone of
Zones of
adherence

2700
Part XII  Body Contouring
adherence of the hip is below the iliac crest. The fat compartments create a slight
bulge both superior and inferior to this zone of adherence, even in normal-weight
women. In overweight and even in many normal-weight women, excess fat deposited
laterally below this zone of adherence imparts an unsightly saddlebag deformity. In
men, the lateral deposits of fat are more frequently found above the zone of adher-
ence, creating flank adiposity referred to as “love handles” or a “spare tire.” Con-
touring in this area frequently involves selective liposuction above and below the
zone of adherence, since interruption of the zone of adherence will not correct a con-
tour deformity caused by excess adiposity.
In massive-weight-loss patients the skin excess is often circumferential, and patients
of both sexes will have contour deformities both above and below the hip zone of
adherence. A lower body lift and other associated excisional lifting procedures actu-
ally remove the fascial attachments that previously defined a zone of adherence.
A zone of adherence is, to begin with, less well defined and lax in this population.
By lifting and reanchoring soft tissue above a prior zone of adherence, a de novo ar-
tificial zone of adherence is fashioned.
Buttocks
Senescent changes and changes from massive weight loss have very similar effects on
buttock contours, including a loss of adipose volume, ptosis of soft tissue and skin,
increased hip width, and lengthening and flattening of the gluteal fold. Central adi-
posity in the lower back increases with age and blunts the trunk-gluteal angle, further
contributing to loss of projection. All these changes combine to create a buttock that
appears flat, square, and in women, less feminine.
The buttocks in a massive-weight-loss patient appear hypoplastic. The deformities
include loss of gluteal projection; effacement of the lower back/gluteal sulcus; loose,
misshapen buttock skin; lateralization and inferior displacement of the remaining
soft tissue; and a lax gluteal fold. In addition, the central crease and inferior gluteal
crease droop. Midline skin and soft tissue should be excised as part of the lower body
lift to recreate a more pleasing gluteal cleft without surrounding excess tissue.
Centeno and Young defined the eight gluteal aesthetic units: two flank units, the
sacral triangle, two buttock units, the infragluteal diamond, and two symmetrical
thigh units. Buttock reshaping is best achieved by enhancement of the buttock units
in conjunction with reshaping and reduction of the other aesthetic units.

Anatomic landmarks in aesthetic surgery of the buttocks have been well summa-
rized; these are the sacral triangle, sacral dimples, trochanteric depressions, poste-
rior iliac crest, coccyx, and gluteal folds. The sacral dimples are created by the con-
fluence of the posterior superior iliac spines, lumbosacral aponeurosis, and the
insertion of the gluteus maximus and define the superior medial border of the but-
tock. The sacral triangle is defined by the bilateral sacral dimples and the coccyx,
and liposuction of the triangle can further augment the protuberance of the buttock
cheeks.
Traditional excisional lower body lifts significantly improved buttock contours but
failed to correct the loss of gluteal projection, which often imparted an unfeminine,
flattened buttock. Recently, gluteal contouring has focused on raising large deepithe-
lialized flaps based on the superior gluteal artery perforator, anchoring the tissue be-
neath the superior and interior flaps of a lower body lift. This retains volume in com-
bination with skin excision to create a tighter, more protuberant buttock. Various
designs and techniques have been described, including island, mustache, and rota-
tional flaps. In each case, the goal is to add projection and volume to the buttocks
while diminishing the adjacent gluteal aesthetic areas. One cannot overemphasize
the importance of not interrupting the natural infragluteal fold, which will shorten
in appearance with excision and lifting of superior redundant tissue.
The deepithelialized gluteal flap is isolated on two major perforators from the supe-
rior gluteal artery and rotated in a superomedial direction to augment gluteal pro-
jection. To identify the superior gluteal artery perforators, a line is drawn from the
posterior iliac spine to the greater trochanter, and the two major perforators are iden-
tified 6 to 9 cm from the midline along this line. These vessels send forth large mus-
culocutaneous perforators that can be easily identified during suprafascial dissection.
Anchoring of the SFS of the inferior flap in a lower body lift to the muscular fascia
plays a significant role in achieving the initial contour. The gluteal fold is a natural
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Chapter 75  Applied Anatomy in Body Contouring
Sacral triangle
Posterior iliac crest
Coccyx
Posterior superior
iliac spine
Lumbosacral
aponeurosis
Insertion of
gluteus maximus
Sacral dimple
Gluteal fold
Trochanteric
depression

zone of adherence but can appear effaced or discontinuous after massive weight loss.
The zone of adherence must not be disrupted to avoid creating a new deformity.
During circumferential body lifts, the cutaneous branches of the iliohypogastric nerve,
the superior cluneal nerves L1-3, and the dorsal rami of sacral nerve roots 3 and 4
are at risk. Permanent changes to protective sensations may occur, and this poten-
tial morbidity should be discussed with the patient preoperatively.
Thighs
Relaxation of the SFS fibers in a negative vector combined with excess adiposity can
lead to a ptotic appearance of the medial thigh as an individual ages or undergoes
massive weight loss. In postbariatric patients, a tremendous amount of excess skin
and subcutaneous tissue can lead to an extra soft tissue roll in the medial thigh. Re-
cent articles have noted that much of the excess in the medial thigh after massive
weight loss is vertical rather than horizontal. Because of this, the great majority of
thighplasties in the postbariatric population require a vertical scar.
In medial thighplasty, the lifted portion of the medial thigh tissue must be anchored
to the Colles’ fascia of the perineum to prevent scar migration and early recurrence of
ptosis. The anchoring sutures should also create a well-defined perineal-thigh crease.
This is another way linear and sequential anchoring of the SFS can create new, well-
defined topographic marks with little or no excess tissues blurring the anatomy. Colles’
fascia attaches to the ischiopubic rami of the bony pelvis; anteriorly it is continuous
with Scarpa’s fascia; and posteriorly it fuses with the urogenital diaphragm. At the
junction of the perineum and the medial thigh, this layer is clearly identifiable by
dissecting to the origin of the adductor muscle on the ischiopubic ramus and re-
tracting the skin and subcutaneous tissues of the vulva medially.
Anatomic studies reveal that 80% of lymph vessels run into the inner surface of the
thigh, 20% on the lateral surface. Because of the risk of significant chronic edema
after a medial thighplasty, some authors advocate leaving a layer of subcutaneous
tissue along the muscle fascia of the area of resection, not completely resecting the
lymphatic vessels in the area. Significant incisions and tissue excisions are also made
away from veins, which are the natural accompanying structures of the lymphatic
vessels. Anatomic studies show that around the thigh and groin area, the lymphatic
ducts are concentrated around the greater saphenous vein, while in the lower leg the
lymphatic ducts are more evenly distributed circumferentially around the leg. This
suggests that interruption of tissues around the greater saphenous vein should be
minimized to decrease the potential for trauma to the lymphatic ducts of the thigh
and groin. The area anterior to the greater saphenous vein is particularly suscepti-
ble, with an afferent “bottleneck” visualized in anatomic studies.
2702
Part XII  Body Contouring

In summary, the medial thigh is an unforgiving area for the plastic surgeon because
of poor tissue quality, a high concentration of lymphatic vessels, the risk for scar mi-
gration and vulvar deformation with soft tissue anchoring, and the pain associated
with anchoring sutures in the perineum. Although associated with discomfort and
sometimes deformation of the vulva, a medial thighplasty is unlikely to be success-
ful without strategic anchoring of thigh tissues to Colles’ fascia. Careful preserva-
tion of the lymphatic vessels can help to reduce postoperative edema.
Knees and Legs
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Chapter 75  Applied Anatomy in Body Contouring
A natural zone of adherence occurs along the area at which the quadriceps muscle’s
aponeuroses coalesce along the upper edge of the patella. Fullness at the knee is of-
ten from the bulk of the quadriceps femoris as well as the medial muscle group con-
taining the gracilis, sartorius, semitendinosus, and semimembranosus muscles. Com-
monly there is a localized pocket of adiposity overlying the medial muscle group.
Excess fat around the knee is considered a particularly displeasing problem for
women for which there is no good solution. In massive-weight-loss patients, a pan-
nuslike envelope of skin and soft tissue can drape over the superior knee zone of
Quadriceps
femoris muscle
Gracilis muscle
Greater
saphenous
vein
Peroneus
longus muscle
Tibialis
anterior
muscle
Soleus muscle
Sartorius muscle
Extensor hallucis
longus tendon
Peroneus
brevis muscle
Saphenous
nerve
Extensor digitorum
longus muscle
Semi-
tendinosus
muscle
Gracilis
muscle
Semi-
membranosus
muscle
Medial head of
gastrocnemius
muscle
Flexor digitorum
longus muscle
Achilles tendon
Tibialis
posterior
muscle
Iliotibial tract
Biceps femoris
muscle
Lesser
saphenous vein
Soleus muscle
Sural nerve
Lateral head of
gastrocnemius
muscle

2704
Part XII  Body Contouring
adherence. Although direct excision leaves an unsightly scar, the procedure has been
performed. Often medial thighplasties incorporate a vertical scar that extends to the
knee, creating some lifting and thinning in the medial aspect of the knee.
The anatomic basis for an undesirable silhouette is often muscular, making it more
difficult to treat with traditional methods of liposuction and excisional lifting pro-
cedures. A bulky calf is often caused by a large gastrocnemius muscle proximally and
the soleus muscles, particularly in the distal two thirds of the leg. The desired slender
leg silhouette from calf to ankle is often obliterated by a wide, thick distal soleus, or a
natural fullness of the lateral compartment muscles, particularly the peroneus brevis
anterolaterally, and the flexor digitorum longus muscles posteromedially. A combi-
nation of undesirable muscle bulk and excessive length, along with excess tissue from
massive weight loss, can cause an unattractive leg shape.
Fat distribution over the lower leg, except for a lack of fat over the anterior tibia,
shows a pattern that is diffuse and circumferential. For these anatomic reasons, lower
extremity contouring remains one of the greatest areas of challenge.
Ankles and the lower extremities are the anatomic areas most susceptible to lymph -
edema. Lower extremity lymph vessels eventually coalesce and merge into the su-
perficial groin lymph nodes, making them the longest traveling lymphatic system in
the body. With age and obesity, chronic lymphedema from an inactive or underac-
tive lymphatic system is already likely to be present at baseline, and no doubt con-
tributes to some degree to effacing the contours. Suction lipectomy must be used with
utmost caution in the ankle and lower extremity, and with the expectation that long-
term use of compressive garments will be essential to decrease lymphedema.
Recent cadaveric studies suggest that injection of tumescent fluid and longitudinal
rather than transverse movement with the suction cannula decrease damage to lym-
phatic vessels. This is especially crucial in lower extremities with preexisting lymph -
edema and in zones of high concentration of lymphatic vessels within a narrow zone,
such as the medial knee.
Concluding Thoughts
In the past, much of the discussion in applied anatomy of body contouring concerned
neurovascular structures, musculoaponeuroses, and regions of adiposity. Although
knowledge of blood supply and adjacent nerve structures is crucial, we think that
understanding the roles of SFS, zones of adherence, and lymphatic drainage in the
superficial subcutaneous tissue can help to elucidate problem areas in body con-
touring and aid in the innovation of new therapies.

Clinical Caveats
 The SFS is a subdermal soft tissue scaffold that exists throughout the body; it en-
compasses adipose tissue and imparts biomechanical strength to surgical repairs.
 Pathologic conditions of the SFS are partially responsible for cellulite, ptosis, and
the large overhanging soft tissue rolls seen in massive-weight-loss patients.
 Incorporation of the SFS in surgical repair is particularly important in parenchy-
mal reshaping and excisional lifting techniques of body contouring.
 The zones of adherence are pathologic and sometimes displaced in postbariatric
patients.
 Zones of adherence are often interrupted during excisional body contouring, and
anchoring and suspension of tissues are important to prevent tissue descent.
 Violation of certain zones of adherence (inframammary fold, gluteal fold) can lead
to secondary deformities that are challenging to correct.
 Lymphatic vessels are found in the deep dermis, subdermal plexus, and along
muscle fascia.
 Interruption of lymphatic channels through excision can cause chronic edema in
surgical zones, particularly if a nodal basin is interrupted.
 Liposuction causes temporary slowing of lymphatic drainage but does not cause
permanent damage to lymphatic vessels.
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Chapter 75  Applied Anatomy in Body Contouring
Annotated Bibliography
Warren AG, Bronson H, Borud LJ, et al. Lymphedema: a comprehensive review. Ann Plast
Surg 59:464-472, 2007.
The authors review the diagnostic and treatment modalities for lymphedema. The util-
ity of various imaging modalities is discussed. Initial treatment with decongestive lym-
phatic therapy can provide significant improvement in patient symptoms and volume
reduction of edematous extremities. Surgical treatment with circumferential liposuction
is explored.
Lockwood TE. Superficial fascial system of the trunk and extremities: a new concept. Plast
Reconstr Surg 87:1009-1018, 1991.
This study first defined the superficial fascial system as being composed of all connec-
tive tissue between the dermis and muscle fascia. Understanding the structural anatomy
of the system allows us to understand the changes in body contour with age and adi-
posity. Fresh and cadaveric dissections were used to characterize SFS appearances across

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Part XII  Body Contouring
gender, region, and degree of adiposity. Manipulation of the SFS provides the anatomic
basis for surgical lifting techniques in body contouring.
Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower ex-
tremity. Plast Reconstr Surg 80:248-254, 1987.
The authors attempted to shed light on the anatomy of the subcutaneous tissue in the
trunk and lower extremity using fresh and embalmed cadaver dissections and CT scans.
Diagrammatic comparisons of the subcutaneous adipose tissue are presented, showing
differences in both adiposity and density of connective tissue fibers between regions.
The anatomic basis for deep plane liposuction is also discussed.
Song AY, Askari M, Azemi E, et al. Biomechanical properties of the superficial fascial sys-
tem. Aesthet Surg J 26:395-403, 2006.
Through a series of biomechanical tests of both human and porcine models the authors
demonstrated that the SFS is an connective tissue strength layer independent of the der-
mis. They also performed tissue dissections that characterized the dermis-SFS junctions
as a continuous collagen and elastin bridge. The porcine model suggested that perma-
nent sutures in the SFS layer may enhance the biomechanical strength of the repair.
Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The zones of adherence: role in mini-
mizing and preventing contour deformities in liposuction. Plast Reconstr Surg 107:1562-
1569, 2001.
The authors expanded on Lockwood’s observations of anatomic zones of adherence of
the SFS that divided the subcutaneous tissue into compartments. These zones bring the
subcutaneous fat into a shallower layer, making these areas more susceptible to dim-
pling and contour deformities during liposuction. The importance of avoiding these
zones is emphasized.
Suggested Readings
Superficial Fascial System
Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg 82:299-
304, 1988.
Lockwood TE. Lower body lift with the superficial fascial system suspension. Plast Recon-
str Surg 92:1112-1122, 1993.
Lymphatics
Felmerer G, Muehlberger T, von Rautenfeld B, et al. The lymphatic system of the deep infe-
rior epigastric perforator flap: an anatomical study. Br J Plast Surg 55:335-339, 2002.
Schacht V, Luedemann W, Abels C, et al. Anatomy of the subcutaneous lymph vascular net-
work of the human leg in relation to the great saphenous vein. Anat Rec 292:87-93,
2009.
Witte CL, Witte MH. Circulatory dynamics and pathophysiology of the lymphatic system.
Rutherford RB, ed. Vascular Surgery, 5th ed. Philadelphia: Elsevier/Saunders, 2000.

Arms
Baroudi R. Dermatolipectomy of the upper arm. Clin Plast Surg 2:485-494, 1975.
Guerrerosantos J. Brachioplasty. Aesthetic Plast Surg 3:1-14, 1979.
Knoetgen J III, Moran SL. Long-term outcomes and complications associated with bra-
chioplasty: a retrospective review and cadaveric study. Plast Reconstr Surg 117:2219-
2223, 2006.
Lockwood TE. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg
96:912-920, 1995.
Trunk
Alter GJ. Management of the mons pubis and labia majora in the massive-weight-loss pa-
tient. Aesthet Surg J 29:432-442, 2009.
Brink RR, Beck JB, Anderson CM, et al. Abdominoplasty with direct resection of deep fat.
Plast Reconstr Surg 123:1597-1603, 2009.
Gasperoni C, Salgarello M. Rationale of subdermal and superficial liposuction related to the
anatomy of subcutaneous fat and the superficial fascial system. Aesthetic Plastic Surg
19:13-20, 1995.
Knoetgen J, Moran S. Long-term outcomes and complications associated with brachioplasty:
a retrospective review and cadaveric study. Plast Reconstr Surg 117:2219-2223, 2006.
Lockwood TE. High lateral tension abdominoplasty with superficial fascial system suspension.
Plast Reconstr Surg 96:603-615, 1995.
Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg 124:934-
942, 2009.
Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective
and safe undermining. Aesthetic Plast Surg 27:322-327, 2003.
Saldanha OR, Federico R, Daher P, et al. Lipoabdominoplasty. Clin Plast Surg 35:95-104,
2008.
Schaverien M, Saint-Cyr M, Arbique G, et al. Arterial and venous anatomies of the deep in-
ferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Recon-
str Surg 121:1909-1919, 2008.
Breasts
Boutros S, Kattash M, Wienfeld A, et al. The intradermal anatomy of the inframammary
fold. Plast Reconstr Surg 102:1030-1033, 1998.
Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive weight loss: detectabil-
ity of technique, patient satisfaction, and classification. Plast Reconstr Surg 122:1301-
1311, 2008.
Lockwood TE. Reduction mammaplasty and mastopexy with superficial fascial system sus-
pension. Plast Reconstr Surg 103:1411-1420, 1999.
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Chapter 75  Applied Anatomy in Body Contouring

Thighs/Buttocks
Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery in the massive-weight-
loss patient. Clin Plast Surg 35:73-91, 2008.
Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body contouring surgery. Clin
Plast Surg 33:347-358, 2006.
Colwell AS, Borud LJ. Autologous gluteal augmentation after massive weight loss: aesthetic
analysis and role of the superior gluteal artery perforator flap. Plast Reconstr Surg
119:345-356, 2007.
Cram A, Aly A. Thigh reduction in the massive-weight-loss patient. Clin Plast Surg 35:165-
172, 2008.
Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg 35:151-163,
2008.
Moreno CH, Neto HJ, Junior AH, et al. Thighplasty after bariatric surgery: evaluation of
lymphatic drainage in lower extremities. Obes Surg 18:1160-1164, 2008.
Richter DF, Stoff A, Velasco-Laguardia FJ, et al. Circumferential lower truncal dermatolipec -
tomy. Clin Plast Surg 35:53-71, 2008.
Lower Legs
Frick A, Hoffmann JN, Baumeister RG, et al. Liposuction technique and lymphatic lesions
in lower legs: anatomic study to reduce risks. Plast Reconstr Surg 103:1868-1873; dis-
cussion 1874-1875, 1999.
Haddad Filho D, Kafejian-Haddad AP, Alonso N, et al. Lymphoscintigraphic appraisal of
the lower limbs after liposuction. Aesthet Surg J 29:396-399, 2009.
Hoffman JN, Fertmann JP, Baumeister RG, et al. Tumescent and dry liposuction of lower
extremities: differences in lymph vessel injury. Plast Reconstr Surg 113:718-724, 2004.
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Part XII  Body Contouring

CHAPTER 76
Clinical Decision-Making
in Body Contouring

FOAD NAHAI

It’s all about the skin.
It’s all about safety.
T
he advent and increasing popularity of liposuction over the past 30 years
not only revolutionized but also forever changed body contouring. Even today,
the tremendous impact of liposuction is influencing the further evolution of body-
contouring procedures. The incorporation of liposuction has not only made body
contouring safer, faster, and possible with minimal scarring, but also liposuction has
been the most common of all aesthetic surgical procedures for several years running,
according to the American Society for Aesthetic Plastic Surgery (ASAPS) statistics,
only to be displaced to number two by breast augmentation in recent years. Most
notable, however, is the fact that through liposuction, body contouring has become
an option to many who would not otherwise have considered it because of the oblig-
atory long scars.
Not all those who seek body contouring are candidates for liposuction as their ideal
procedure. It is very disappointing to have to explain to a patient why he or she is
not a candidate for liposuction. Although contraindications and relative contraindi-
cations to liposuction, such as morbid obesity, intercurrent cardiac disease, or en-
docrinologic disease apply to all forms of body contouring, in reality the major rea-
son that most patients are not “ideal” or the “best” candidates for liposuction relates
to the quality and quantity of their skin.
Whether we are discussing short-scar face lift, short-scar breast surgery, or body con-
touring through liposuction, the limiting factor is skin quality and skin quantity. In-
elastic, stretched, poor-quality skin will not redrape or contract and must be excised.
Evaluation of the skin is the key to decision-making in body contouring. Once the
surgeon has decided that skin quality or skin quantity is such that it will redrape, in
most patients and in most anatomic areas liposuction alone will be the procedure of
choice. If the surgeon decides to resect skin, the location and length of the incision
are determined. The decision as to the exact method of skin resection—a single-stage
versus a multistage procedure—must also be made at this time.
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Part XII  Body Contouring

Patient Evaluation and Counseling
When I greet a new patient who is interested in body contouring, one of the first
questions I ask is, “Would you like to look better in your clothes, or in and out of
your clothes?” Most younger women answer that they wish to look good in and out
of their clothes, especially in bikini bathing suits. Older women and most men reply
that they would like their bulges improved so that they appear more shapely and bet-
ter contoured in their clothes. The patients’ goals and expectations of the result are a
useful guide to me. I then examine them and make recommendations. We must bal-
ance the goals and their vision of the results against the realities of their tissues, es-
pecially their skin. I try to establish whether the patient is seeking reshaping or re-
shaping and skin tightening.
After I examine the patient, which includes evaluating the skin and fat, we discuss
the patient’s options. The options and decisions are straightforward in patients who
are ideal candidates for liposuction. Similarly, for those who obviously require skin
excision, the options and decisions are straightforward. However, for a group of pa-
tients between these two extremes, a complex discussion concerning skin excision
is entertained. The tradeoff is a longer scar with skin and soft tissue excision and a
better result, versus a minimal scar from liposuction, recontouring without skin im-
provement, or even a worsening of skin laxity and the appearance of skin folds. An-
other issue to consider is the risk-benefit ratio of the more complex procedures. For
some patients in this middle group, the risk of more extensive surgical procedures
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Chapter 76  Clinical Decision-Making in Body Contouring
Normal elasticity
Normal quality
Minimal or no excess
DECISION-MAKING IN BODY CONTOURING
SKIN
Length
Location
Single-stage
Multistage
Liposuction
Inelastic
Poor quality
Excess
Skin excision
Form

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Part XII  Body Contouring
may not be justified by improved skin tightening. Patient safety, morbidity, and
length of recovery should all be taken into account in the decision-making process.
Obviously, the expense of the procedures is another issue that may be more im-
portant to some patients than to others. Clearly, liposuction is less time consuming
and less expensive than resectional body-contouring procedures.
These factors must be borne in mind and openly discussed with patients before em-
barking on expensive body-contouring procedures, especially in patients who have
experienced massive weight loss. These patients present a special challenge to the
aesthetic surgeon in that extensive skin resection and recontouring procedures may
be needed in all anatomic areas. The question of single-stage versus multistage pro-
cedures is an important consideration. Although a single-stage procedure obviously
will be less expensive and perhaps more appealing to more patients, this should be
balanced against the increased risk posed by prolonged surgical procedures in this
group of patients.
Decision-making in body contouring, especially for massive-weight-loss patients,
must take into account the balance between the quality of the results and safety
issues. Ultimately, cost should not factor into a final decision about the procedure.
Safety
Low morbidity
Simple procedure
Short scars
Lower cost
Increased risk
Higher morbidity
Complex procedure
Long scars
Greater cost
Balancing the quality of the result with safety, scars, and cost

Abdominal Contouring
Abdominal-contouring procedures range from liposuction to circumferential ab-
dominoplasty combined with a body lift.
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Chapter 76  Clinical Decision-Making in Body Contouring
The first patient (left) is a suitable candidate for liposuction; the second patient (cen-
ter) requires an abdominoplasty; and the third patient (right) is best suited to full-
body contouring, including a circumferential abdominoplasty and body lift.
Abdominal Contouring Evaluation Checklist
 Skin
 Fat
 Muscle and fascia
 Adjacent areas

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Part XII  Body Contouring
Evaluation and classification of abdominal changes precedes decision-making and
the selection of the appropriate operation. The skin, fat, and musculofascial contour
have traditionally been the three major components to be assessed; however, we do
not evaluate and treat the abdomen in isolation, especially in massive-weight-loss
patients. To these three major components we now add a fourth: assessment of the ad-
jacent areas, including the thighs, flanks, and back. These four primary components
of abdominal changes assist in classifying the severity of the problem and selection
of appropriate treatment. Most patients fall into one of the four categories.
Skin
We assess the quality and quantity of the abdominal skin. We assess the quality and
elasticity through observation for stretch marks and the pinch test, in which the skin
is pinched and pulled away from the underlying subcutaneous tissues; during the
pinch test, we look for elasticity and recoil as indicators of retraction and redraping
after surgical intervention. We also look for scars that may affect liposuction or be
improved through excision with open abdominoplasty procedures. We also look for
excess skin above and below the umbilicus, for umbilical hooding, which is an indi-
cation of periumbilical skin excess, and for loss of skin elasticity.
Classification of Abdominoplasty Candidates
Class 1
Class 2
Class 3
Class 4
Skin excess
None—minimal
None—minimal
Moderate-severe
Severe
Skin elasticity
Normal
Normal
Poor
Poor
Fat excess
Mild-moderate
Mild-moderate
Moderate-severe
Moderate-severe
Musculofascial
Normal
Abnormal
Normal or
Normal or
contour
abnormal
abnormal
Adjacent areas
Normal
Normal
Normal
Abnormal
Skin Evaluation Checklist
 Skin quality
 Skin excess
– Stretch marks
– Below umbilicus
– Pinch test
– Above umbilicus
– Scars
– Umbilical hooding

Fat
The amount of excess fat and its location are noted. In general, larger volumes of ex-
cess fat are usually seen with excessive amounts of poor-quality stretched skin and
striae requiring excision. Smaller and more moderate volumes of fat are amenable
to liposuction as long as the skin is suitable. The location of the fat above and be-
low the umbilicus and flanks is noted.
Musculofascial Contour
The patient is examined while standing and recumbent. The muscles and fascia above
and below the umbilicus are evaluated. With the patient standing, the general ap-
pearance and protuberance of the abdomen are noted. The patient is asked to relax
and to tighten the abdominal muscles so abdominal wall strength and integrity can
be evaluated. Any abdominal weakness, diastasis, or hernia is noted. Then, with the
patient lying down, the abdomen is again examined at rest and on straight-leg–
raising, which contracts the abdominal muscles, making weakness, diastasis, and
any hernia much more obvious. Extensive diastasis and hernias will have to be re-
paired to achieve flattening of the abdominal contour. If there is no abdominal pro-
tuberance, liposuction only may achieve the goal of flattening the abdominal con-
tour. On the other hand, any diastasis or umbilical or midline ventral hernia will
require open or endoscopic repair to effectively recontour the abdomen.
Adjacent Areas
In most patients after an isolated abdominoplasty, the recontoured abdomen blends
in well with the adjacent areas, the upper thighs, hips, buttocks, flanks, and back,
especially if the abdominoplasty is combined with some liposuction of the flanks.
However, in an increasing number of patients seeking abdominal recontouring, es-
pecially after massive weight loss, the abdomen cannot and should not be dealt with
in isolation. We therefore have to evaluate the adjoining areas—the thighs, flanks,
hips, and back. If any of these areas require recontouring to restore balance to the
patient’s trunk, a combination of other procedures must be included with the ab-
dominal operation. These will range from belt lipectomy to abdominoplasty com-
bined with a body lift.
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Chapter 76  Clinical Decision-Making in Body Contouring

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Part XII  Body Contouring
Patient Profiles
Class 1
Typically, class 1 patients have excess abdominal wall fat, often localized below the
umbilicus, with normal fascia without laxity, diastasis, or herniation. The skin is of
normal quality, with no excess. Ideally there should be no preexisting abdominal
scars. These patients will have a good result after liposuction. No fascial tightening is
needed, and any minimal skin excess will respond well to redistribution and con-
traction.
Class 2
Class 2 patients have normal-quality skin with minimal to moderate excess fat. They
do not require skin excision, and the excess fat is amenable to liposuction. However,
these patients have significant musculofascial laxity, which may include diastasis,
midline ventral hernia, or umbilical hernia. These patients must have anterior ab-
dominal wall plication to achieve maximum contour improvement.

I believe they are ideal candidates for endoscopic abdominoplasty as a first-choice
procedure. A mini-abdominoplasty would be an acceptable alternative. Although
some skin excision is possible through the lower abdominal excision with a mini-
abdominoplasty, the primary role of the incision is access to the abdominal wall for
repair. Through this incision, the infraumbilical abdominal wall is readily exposed
and the repair of the fascia from the umbilicus down is easily accomplished. The um-
bilical stalk can be divided (umbilical float) to allow access to the upper abdomen
for fascial repair above the umbilicus. Although this repair is possible through the
mini-abdominoplasty approach, it is not easy.
In these patients, the advantages of the endoscopic approach include a much shorter
scar, 4 to 5 cm in length, decreased postoperative pain and morbidity, and accurate
repair of the fascia from the xyphoid process down.
Class 3
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Chapter 76  Clinical Decision-Making in Body Contouring
Patients in class 3 have moderate to severe amounts of excess skin of poor elasticity
riddled with stretch marks; they also have moderate to severe amounts of excess fat.
There may or may not be muscular or fascial weakness. Liposuction or an endo-
scopic or mini-abdominoplasty approach is not appropriate for these patients. They
require a full abdominoplasty with resection of the excess skin and fat, with umbil-
ical transposition. Liposuction may assist lateral contouring. A variety of incisions
are available for the dermolipectomy in this group, and the final choice is a matter
of patient and surgeon preference. However, the scar should be placed low enough
and in such a position to avoid any unnatural elevation of the pubic hairline.

Class 4
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Part XII  Body Contouring
Typically, class 4 patients have all the features of class 3 patients and much more:
more skin and fat excess in the adjoining areas—the flanks, back, and thighs. Most
if not all massive-weight-loss patients are in this category. An isolated abdomino-
plasty is not an appropriate procedure for class 4 patients; they are best treated
through a combination of procedures that will include an abdominoplasty and thigh
or body lift. Most patients in this category have undergone massive weight loss. In
addition to routine preoperative tests, an assessment of nutritional status is essen-
tial in this group of patients.
Safety Issues
Abdominoplasty, in particular an abdominoplasty combined with a body lift, is one
of the highest risk procedures that aesthetic surgeons perform. Patient safety is of
paramount importance. The risks are minimized and patient safety is ensured through
appropriate patient selection, patient preparation, assessment of nutritional state,
and staging of the procedures, if necessary. Intraoperative precautions include deep
venous thrombosis prophylaxis, expert administration of anesthesia, and limiting
not only the length of the procedure but also the combination of procedures.
The risk of venous thromboembolism (VTE) is highest with abdominoplasty and in-
creases further when abdominoplasty is combined with other procedures. Chemo-
prophylaxis should be considered for such patients.