The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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81 Management of Breast Asymmetry
Glyn Jones
Abstract
This chapter identifies the causes of breast asymmetry, from
congenital through to required conditions of both the female and
male breast. Each condition is addressed systematically, identi-
fying the problem, its correction, and the technical nuances
required to achieve success.
Keywords
asymmetry, congenital, tuberous breast, Poland’s syndrome,
gynecomastia, breast augmentation
81.1 Introduction
Breast asymmetry is a distressing condition that carries signifi-
cant implications for patients in terms of psychosexual impact as
well as functional difficulties experienced on a daily basis with
the fit of clothing. The causes are either developmental or iatro-
genic. Correction involves surgical intervention and may require
a staged approach in more complex deformities.
81.2 Indications and
Contraindications
In order to understand the indications for corrective surgery in
breast asymmetry, one has to appreciate the plethora of causes
of asymmetry in both the female and male breast.
81.2.1 Causes of Breast Asymmetry
Developmental Causes
• Developmental hypoplastic breasts
• Tuberous, constricted breast deformity
• Poland’s syndrome
• Gynecomastia
Iatrogenic Causes
• Asymmetric breast reduction
• Incorrect implant positioning during augmentation
mammoplasty
• Consequences of capsular contracture
• Effects of breast reconstruction
• Effects of radiation after breast conservation
The preceding lists provide a working classification of breast
asymmetry. All the categories constitute potential reasons to
operate for asymmetry. However, contraindications to surgery are
relative and include the following:
• Body dysmorphic disorder
• Severe psychiatric illness
• Poor general health (breast procedures are elective and can be
delayed)
• Active smoking
• Metastatic disease
81.3 Pertinent Anatomy
The anatomy of the breast has already been covered, but a few
points bear reiteration. Correction of breast asymmetry centers
around re-creation of symmetric lower poles and good upper-
pole fullness and symmetry. Mallucci established the normal
upper pole/lower pole breast profile ratio as 45:55. If the
footprint of the breast base is abnormal, the aesthetic outcome
will be unsatisfactory. An abnormally placed inframammary
crease must be corrected in order to achieve symmetry. The
tight inframammary fold associated with a constricted or
tubular breast is tightly contracted. Correction involves release
of the fibrous developmental band using radial scoring along
the crease. This must be done up to the dermis in order to be
completely effective, allowing expansion of the lower pole of the
overlying breast tissue. Care should be taken to note and mark
the correct natural crease position. The uppermost extent of the
gland should be marked and deficiencies should be corrected,
with either implants, flaps, or fat injection. These two sets of
maneuvers will go a long way toward correcting the appearance
of the asymmetric breast. In addition, the contour of the underly-
ing chest wall and sternal contour should be noted as conditions
such as Poland’s syndrome or pectus excavatum can lead to the
requirement for larger than expected implant volumes in order
to correct hypomastia. The level and degree of development
of the nipple–areola complex are also essential to creating a
symmetric final result. Even if the underlying breast mound has
been perfectly matched, an asymmetric nipple level will mar the
esthetic outcome dramatically.
81.4 Preoperative Assessment
Patients should be evaluated after a careful developmental
history is taken, with specific reference to age of menarche
and telarche. Patients should be asked about upper extremity
development and function. During the examination it is helpful
to attempt to form an impression of the patient’s psychological
maturity, particularly in the case of younger women and teen-
agers. Parental and peer pressure should be evaluated. Clinical
examination involves an assessment of breast, chest wall, and
upper extremity development to exclude congenital problems,
such as Poland’s syndrome. The level of the inframammary

81 Management of Breast Asymmetry
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creases and their degree of tightness should be assessed care-
fully. Nipple size, level, and degree of development are evaluated.
Measurements include nipple-to-notch and inframammary fold-
to-nipple distances as well as pinch thickness tests to evaluate
the thickness of available breast tissue in all quadrants of the
breasts. Pectoralis major muscle bulk, thickness, and function
are also worth assessing. The presence of pectus excavatum or
carinatum can impact the nature and success of a reconstructive
attempt. Autologous fat donor sites on the abdomen and hips
should be assessed.
81.5 Management of
Developmental Breast
Asymmetries
81.5.1 Preoperative Planning and
2SerDWiYe 7eFKniTue
Many women develop minor breast asymmetry during oth-
erwise normal pubertal breast growth. It is not uncommon to
see a young adult woman with one nipple slightly higher than
the other or the lower pole of one breast slightly lower than
the opposite side. These minor discrepancies are insignificant
to most patients, and correction would require the addition of
breast scarring that is rarely justified given the subtlety of the
deformity. In other patients, however, the discrepancy in breast
volume may approach one or even two bra cup sizes. These
deformities are embarrassing for the patient and can lead to
psychosexual problems in adult life as well as during puberty,
when insensitive comments from peers during gym and sporting
activities can lead to social withdrawal. While catch-up growth
may occur in early to mid-teen years, it is rare, in my experience,
to see a severely lagging hypoplastic breast achieve acceptable
symmetry in late teens to early adulthood. It is my preference to
defer surgical intervention until after age 18, but occasionally a
severe deformity will mandate earlier surgery.
Asymmetric Hypoplasia
Developmental hypoplasia may range from mild to severe and
can be unilateral or bilateral. In one sense, a bilateral deformity
can be easier to correct, as it allows the surgeon the luxury of
operating on both breasts to achieve a symmetric outcome,
particularly when implants are being used.
Unilateral Hypomastia with a
Normal Contralateral Breast
This situation involves augmentation of the hypoplastic breast to
achieve volume symmetry. If ptosis is an additional component,
mastopexy augmentation is indicated. Hypoplastic breasts often
have an element of lower-pole constriction, which if not cor-
rected will lead to a double-bubble deformity developing post-
operatively. Every effort should be made to recognize and correct
this problem at the initial operative procedure. Correction can
be challenging and involves serial radial scoring along the tight
inframammary crease to allow it to expand laterally over the
implant curvature. These scoring incisions are passed through
the fat up to the dermis, taking care not to burn the dermis
with cautery. Cuts should be placed every centimeter along the
old inframammary crease until the deformity is eliminated.
The downside of performing these radial incisions is that they
increase the likelihood of implant palpability in the lower pole.
Inflatable, disposable implant sizers are extremely useful in
assessing final implant volumes on these patients. I usually use a
round implant for these patients. An inframammary approach to
the subpectoral plane is acceptable if no mastopexy is planned. If
a mastopexy is required, it is often relatively minor in extent, and
a periareolar approach can provide access for both the augmen-
tation and the required periareolar mastopexy scar. If there is
any element of tuberous deformity with herniation of the breast
into the areola, this approach provides the optimal exposure for
correction. Assessment of patient symmetry in the erect position
on the operating table is mandatory prior to skin closure.
Tuberous Breast Deformity
These patients often have a bilateral problem in that one or both
breasts are relatively constricted, with one side being larger and
more ptotic than the other. Breast crease levels may be asym-
metric, with a very short inframammary fold-to-nipple distance
present on the most hypoplastic side. The inframammary crease
may be very tight and well defined, with clearly visible banding
along the fold. Nipple areolar diameters are often dilated, and the
breast may exhibit a tendency to herniate into the areola, further
worsening the appearance of deformity. If the larger breast falls
within an acceptable size range for the patient, a mastopexy
alone may be required on this side. If, however, the larger side
is also relatively small, it is preferable to perform a mastopexy
augmentation on both sides with a larger implant inserted on
the more severely hypoplastic side. A periareolar mastopexy is
usually sufficient on the smaller side, whereas a vertical mas-
topexy augmentation may be mandated on the larger side to help
correct some of the glandular ptosis, which accompanies the
lower-pole development on this side. The larger lower pole can
be either imbricated or resected to allow for a more symmetric
correction compared with the smaller side and its deficient lower
pole fill. It is essential to radially score the tight inframammary
creases in order to achieve an adequate release of the breast
tissue and skin over the implants. This maneuver avoids the
troublesome and unsightly double-bubble deformity. As with all
mastopexy-augmentation procedures, it is essential to perform
the augmentation first before committing to any skin excision.
Failure to follow this simple dictum may result in excessive skin
resection creating a tight closure with risk of wound dehiscence
or necrosis. I make the initial incision in the lower periareolar
quadrant, at the juncture of the areolar–cutaneous junction.
Once the implant is in place, tailor-tacking the skin gives a good
impression of how much of the areola skin disc may be safely
resected as a periareolar mastopexy. Any vertical resection can
be assessed in the same way on the larger, more ptotic side if
necessary. In terms of implant positioning, it has always been
my preference to use the dual-plane subpectoral approach in
primary cases. This allows for a very safe manipulation of the
overlying breast tissue during mastopexy without concern for
nipple and skin viability. The tighter the inframammary crease

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and breast herniation, the more extensive the dual-plane dissec-
tion should be. A severe deformity will require a dual-plane type
III, whereas a minor correction may only require a dual-plane
type I correction (Fig. 81.1).
Poland’s Syndrome
Poland’s syndrome is a developmental abnormality involving the
breast, the nipple, and the entire upper extremity and shoulder
girdle. Typical patients have varying degrees of hypomastia and
abnormal nipple–areola complex development coupled with
absence of the sternal head of the pectoralis major. It may be
accompanied by varying degrees of shoulder muscle hypoplasia
as well as synbrachydactyly of the ipsilateral hand. All muscles
of the upper extremity are potentially at risk, including the del-
toid and, less commonly, the latissimus dorsi. The presence and
function of the latissimus dorsi should always be tested because
it can be used to reconstruct the ipsilateral anterior axillary fold
and the loss of pectoral muscle bulk. Fat injection has recently
been offered as an alternative to muscle transposition in less
severe cases.
Surgery for Poland’s syndrome involves the attainment of
three major aesthetic goals: creation of a breast mound, re-cre-
ation of the anterior axillary fold, and restoration of the missing
infraclavicular fill afforded by the absent sternal head of the
pectoralis major. Breast augmentation coupled with either latis-
simus flap transposition or fat grafting can achieve these goals.
If the skin envelope is extremely tight, it can be preexpanded
with an integrated valve tissue expander followed by subsequent
expander-implant exchange and latissimus transposition if
indicated. If athelia exists, nipple reconstruction is also necessary.
If the nipple is severely hypoplastic and located too high on the
chest wall, it may be preferable to resect the nipple and perform a
complete nipple reconstruction de novo. If the nipple is correctly
placed but merely smaller than normal, soft tissue augmentation
with a roll of acellular dermal matrix can be placed to increase
projection. Tattooing, if performed skillfully, can improve the
diameter of the areola. If correction is performed in the early
to mid-teens, the patient and family should be warned that the
breast implant will have to be exchanged for a larger one when
the patient reaches maturity in order to match the normally
developing contralateral breast. Patients should also be warned
that a ptotic but otherwise normal contralateral breast may
require a mastopexy at some point in the future in order to
achieve symmetry. When dealing with Poland’s syndrome, the
reconstructive surgeon should recall that the chest wall itself may
be less developed and have an unnaturally steep lateral curvature,
which may make the attainment of symmetry even more difficult
than it might otherwise be. An implant may tend to slide laterally
off the chest wall in such patients and cause the appearance of
less anterior projection from the device than would normally have
been achieved. In addition, the sloping chest wall may require a
much larger implant volume to be used in order to compensate for
loss of lateral fill provided by a normal chest wall contour.
Some authors have advocated the use of de-epithelialized free
flaps such as the superficial inferior epigastric artery (SIEA) or
parascapular flaps as an alternative to latissimus transposition in
an effort to spare as much upper extremity function as possible.
In recent years, autologous fat injection has become a mainstay
in the management of this condition as techniques to maintain
graft integrity have improved. The versatility of fat graft placement
allows for more precision in correcting the various deformities
associated with this condition while preserving muscle function
and preventing scarring at remote sites.
Gynecomastia
Gynecomastia involves abnormal enlargement of one or both
breasts in men. It has two peaks of incidence, the first in puberty
and the second in late middle age as male hormone balance
changes. Most pubertal cases are idiopathic, but endocrine and
chromosomal abnormalities should be identified when present.
Obesity is an increasingly common cause of large breast devel-
opment in men. Young men developing symmetric, increasing
breast enlargement after puberty in the absence of obesity
should be questioned about marijuana use, which can stimulate
breast growth quite strongly. In older age the use of medications
such as spironolactone should also be investigated. Most older
Fig. 81.1 (a,b) This 36-year-old woman developed severe breast
asymmetry in her teens. She had a constricted hypoplastic right
breast and a ptotic, almost tubular left breast. She requested breast
augmentation. An asymmetric breast augmentation with overlying
mastopexy was performed. A 325-mL implant was placed on the right
side with a periareolar mastopexy, while a 250-mL implant was placed
on the left side with a vertical mastopexy. The patient was delighted
with the early postoperative outcome.

81 Management of Breast Asymmetry
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men developing gynecomastia do so as a result of changing
hormone status with age, but breast cancer should be excluded,
particularly in unilateral cases in the elderly.
Management of gynecomastia in obese patients should focus
on weight loss before resorting to surgery. If medications such
as spironolactone are the likely cause, these should be stopped
and alternative medications may be tried. Once conservative
measures have been exhausted, surgery becomes the only option.
Many insurance companies do not cover these procedures,
because they are regarded as cosmetic in nature. Surgery usually
involves a two-pronged approach incorporating both liposuction
and surgical resection. Liposuction is used to contour the chest
wall fat peripheral to the enlarged gland, whereas resection of the
hypertrophied gland while leaving a small subareolar breast bud
improves the central contour.
Ultrasound–assisted liposuction has been touted as a successful
means of removing both fat and glandular tissue, but I have not
found it particularly helpful in dealing with the dense, fibrotic
subareolar breast disc. I use power-assisted liposuction for the
fatty component and then resect the excess glandular tissue.
Resection is performed through an infra-areolar incision. When
dissecting beneath the areola, great care should be taken to leave
enough subareola breast tissue in place to prevent the unsightly
hollowing that can occur when too much tissue is taken beneath
the nipple. This problem creates an extremely unattractive,
excavated appearance to the nipple, which is very difficult to
correct, as the nipple adheres to the underlying pectoralis muscle
and animates with arm motion. I leave a subareolar disc of breast
tissue and then bisect the deep gland down to the pectoralis major
fascia. Each half of the deeper gland can be resected in turn, which
provides easier access than is feasible when performing a mono-
bloc excision. Drains should always be inserted together with a
circumferential pressure garment in an effort to prevent seroma
formation. Ultrasonic liposuction seems to be associated with a
higher incidence of seroma than that seen with power-assisted
or conventional liposuction. Any resected tissue should always be
evaluated histologically to exclude malignancy.
81.5.2 Iatrogenic Causes of
Breast Asymmetry
Asymmetric Breast Reduction
The achievement of symmetry during breast reduction is a
mandatory goal of the operation. Under- or overresection on
one side can produce asymmetry requiring subsequent revision.
The patient’s symmetry should always be checked in the erect
position on the operating table prior to dressing application to
avoid this complication. Asymmetry caused by a focal problem,
such as inadequate resection of the inferomedial or inferolateral
quadrants of the breast, can be addressed with minor excisions
of both skin and breast tissue under local anesthesia. Localized
liposuction can also be used to address these issues provided the
breast is not very glandular. More gross asymmetries require a
redo reduction. Revisionary breast reduction can be a harrowing
experience when performed by another surgeon, who may not
have access to the original records and an understanding of the
pedicle technique used. Generally speaking, if the patient has
a Wise pattern scar performed more than 10 to 15 years previ-
ously, it is likely that an inferior pedicled technique was used.
Rarely, a superomedial technique may have been used. Vertical
scar techniques are usually associated with superior or supero-
medial pedicles, unless a short-scar periareolar inferior pedicle
reduction (SPAIR) technique was used. It is wise to leave as
much bulk around the pedicle as possible when performing redo
reductions, and patients should be carefully counseled about the
dangers of nipple loss and fat necrosis. Suctioning of the periph-
ery of the breast is usually safe in revisionary reduction, and skin
laxity resulting from suction should be tightened by excision as
needed. Stretched nipple areolar diameters can be reduced, but
this should only be done at the end of the procedure, because
tension on the periareolar skin inset is often tighter than antic-
ipated in redo procedures. In thin-skinned patients, a Gortex
periareolar purse-string suture as described by Hammond is
very useful in limiting skin stretch postoperatively.
Asymmetry Induced during Augmentation
Implant insertion for breast augmentation can be associated
with asymmetry. Usually this is either a failure to recognize and
correct a preexisting asymmetry or it occurs due to asymmetric
implant placement and overdissection of an implant pocket on
one side.
Preexisting asymmetry requires the use of a larger implant on
the smaller side and a smaller device on the larger side. This may be
more easily achieved with saline implants, which allow for minor
intraoperative adjustments to achieve as near perfect a result
as possible. However, asymmetry may also arise when implants
are placed in overdissected pockets, most commonly superior or
inferolateral overdissection. Excessive upward dissection toward
the clavicle causes abnormal fullness in the infraclavicular area,
creating a top-heavy appearance to the breast. This is a particular
risk of closed transaxillary augmentation, in which inadequate
release of the lower-pole attachments of the pectoralis major
can displace the implant superiorly. The use of the endoscopic
approach has alleviated this tendency considerably. Correction
can be performed with an endoscopic transaxillary release of
the lower pole, allowing the implant to settle in a more inferior
position (Fig. 81.2).
Overdissection of the inferior and medial aspects of the pocket
may create a double-bubble deformity, especially if a subpec-
toral approach without dual-plane release has been performed.
Correction requires either a subfascial conversion or more exten-
sive dual-plane 2 to 3 release depending on the severity of the
deformity (Fig. 81.3).
Overdissection of the inferolateral pocket allows the implant to
bulge into the axilla, but more important, it creates an unattractive
double-bubble appearance, as the implant bulges beyond the lat-
eral breast crease. Correction is extremely difficult, as the breast
skin needs to be tacked down to the serratus fascia or muscle,
all the while facing the outward force of a large implant being
squeezed laterally by an active pectoralis major muscle. Fixation
sutures of a nonabsorbable material such as 2–0 or 0 Mersilene
or Ethibond can be useful, but the tendency to tear through, with
failure of the repair, is high. The use of a Strattice porcine acellular
dermal inlay (Allergan) anchored to the serratus muscle deeply
and to the breast tissue and skin more superficially has met with

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better success. I prefer porcine to human acellular dermal matrix
(ADM) in these cases, as the porcine dermis stretches less than
human tissue. Another approach is the advancement of an inferior
skin flap, which can be tacked to the serratus muscle deeply; the
overlying lateral breast crease skin is then sutured to the advanced
skin, much as with the Ryan approach used in breast recon-
struction. The attachment of skin to skin provides a more stable
support mechanism than sutures between tenuous breast fat and
serratus muscle. Avoidance is definitely preferable to subsequent
attempts at repair (Fig. 81.4).
Overdissection of the medial breast pocket creates the poten-
tial for symmastia, an extremely unattractive deformity that is
very difficult to correct. Acellular dermal matrices have found
an immensely useful role in this area as they provide a strong,
suturable material, which, once incorporated and vascularized,
can provide a firm barrier to subsequent implant migration medi-
ally. The procedure is combined with a suture plication capsulor-
rhaphy reinforced with the Strattice or AlloDerm ADM (LifeCell).
AVymmeWry DV D &RnVeTuenFe
of Capsular Contracture
Capsular contracture is the single most common complication of
breast augmentation. As the condition deteriorates, contraction
causes increasing deformation of the augmented breast. Grade III
and IV contracture may pull the implant into an abnormal posi-
tion, displacing it in almost any direction as well as causing the
shape of the implant to change from a teardrop to a more glob-
ular form on the chest wall. The net result of these compressive
forces is breast asymmetry that deteriorates over time. Surgical
intervention is the only means of correcting the deformity.
Closed capsulotomy is no longer performed and has given way
to open procedures. Capsulotomy with implant exchange, or better
still total capsulectomy with implant exchange, has become the
mainstay of treatment. Once an established capsule has created
deformity, capsulotomy will tend to be associated with a higher
recurrence than capsulectomy. Capsulectomy provides the surgeon
with an opportunity to allow a fresh implant to generate a new
capsule around the device as well as adjusting the pocket position
and size as required to achieve a more aesthetic result. If needed,
ADMs such as AlloDerm can be incorporated into the procedure,
as it is becoming apparent that this material may be involved in
limiting the formation of a purely fibrous capsule within the area in
which it is placed. The high elastin content of human dermis in this
biologic mesh is possibly partially responsible for the elastic nature
of the capsule. In addition the cellular inflammatory response that
is seen in the usual fibrous capsules forming around breast implants
is virtually absent in the AlloDerm–implant interface, which likely
explains its probable role in reducing capsular contracture. This
unique ADM–implant interface has not been shown in other human
ADM interfaces, hence my preference for this particular material.
In addition, if a patient has had a gel-filled implant associated
with severe capsular contracture, it can be exchanged for a saline-
filled device in an attempt to minimize recurrence. The addition of
a textured surface may also help mitigate the capsular response,
albeit at the expense of potentially increased palpability and
wrinkling of the implant beneath the skin.
Adherence to strict biofilm reduction techniques is mandatory
in all forms of implant surgery, including 50% Betadine wash,
glove change, and the use of funnels for implant insertion.
Fat injection is also showing promise as a means of softening
the periprosthetic capsule, although data are still limited.
Fig. 81.2 (a,b) This young woman underwent transaxillary endoscopic breast augmentation with saline-filled implants. She was referred to me for
correction, complaining of excessively high-riding implants. Clinically her implants had been placed too high, with at least 60% of the implant volume
lying above the equator of the breast. Through the original transaxillary incision, an inferior capsulotomy was performed, allowing the devices to be
placed into a more natural position. She is shown early postoperatively with a more acceptable aesthetic appearance of her breasts.

81 Management of Breast Asymmetry
1279
Fig. 81.3 (a–c) Preoperative and (d–f) 2 months postoperative images of a patient who presented with asymmetry and recurrent ptosis after a
mastopexy-augmentation performed 5 years previously. Her right nipple was significantly lower than the left, and the right implant was higher than
the left. A right open capsulotomy was performed to lower the implant on the right. An asymmetric mastopexy was performed, raising the right
nipple more than the left to achieve symmetry.

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XI Breast Surgery
Fig. 81.4 (a–c) Preoperative and (d–f) postoperative images. This 34-year-old woman with hypomastia and ptosis had a subpectoral breast augmen-
tation with saline-filled implants. The patient was concerned that her breasts were not large enough, and she had a clear double-bubble deformity
on the left side. This was worsened by pectoral muscle action. The patient was advised to have an implant exchange to a larger size with subglandular
conversion. The problem was corrected completely with this approach, and the patient is shown postoperatively with a symmetrical result.

81 Management of Breast Asymmetry
1281
81.6 (̵eFWV RI %reDVW
Reconstruction
Breast reconstruction, particularly when performed unilater-
ally, may result in considerable asymmetry, particularly when
implant reconstruction is performed. It is not within the scope
of this chapter to cover all of the options available to achieve
symmetry in breast reconstruction. Bilateral implant-based
reconstructions tend to achieve a higher degree of symmetry
due to the fact that both breasts are shaped by an identical
implant, often with the assistance of ADMs placed at the time
of the initial mastectomy and implant insertion. Unilateral
implant reconstructions, however, often require adjustment of
the opposite breast in the form of a mastopexy augmentation or
reduction depending on the size and shape of the breast prior to
mastectomy (Fig. 81.5).
In addition, fat injection has proved to be a powerful tool
in helping shape the upper pole of the reconstruction where
implants often fail to achieve adequate volume fill. Autologous
reconstructions have the potential for achieving greater symme-
try without having to adjust the contralateral breast by virtue of
the availability of large quantities of skin and fat for shaping the
reconstruction.
81.7 (̵eFWV RI 5DdiDWiRn DIWer
Breast Conservation
Radiation is a powerfully negative force influencing breast shape
after reconstruction of breast conservation therapy (BCT). BCT
has clearly been shown to be associated with deteriorating
breast aesthetics over time, with larger breast volumes being
associated with the most serious retraction, fibrosis, and fat
necrosis when compared with smaller breasts. In addition, the
deformity caused by the lumpectomy itself can also deteriorate
with the addition of radiation therapy. In an effort to ameliorate
these consequences, oncoplastic reduction plays an increasingly
important role in treating patients undergoing BCT. Once the
deformity is established, however, complex reshaping of the
radiated breast is the only means available to correct the asym-
metry. The correction of BCT-induced breast deformity after
radiation has been delivered involves the movement of breast
flaps damaged by ionizing radiation. This results in compromised
blood flow to the tissues, as well as decreased tissue compliance
secondary to radiation-induced fibrosis and edema.
Radiated flaps do not move as well or as far as their nonradiated
counterparts, and seroma formation and infection rates are all
increased in radiated beds. If edema is still resolving after radi-
ation, I prefer to wait a further 3 to 6 months at least for edema
reduction to occur with massage and compression therapy.
Referral to a lymphedema specialist can often expedite this pro-
cess. Softer flaps are more pliable and move more easily than do
stiff, edematous tissues (Fig. 81.6).
Extreme caution should be exercised when dealing with such
patients, and undermining of radiated skin should be kept to a
minimum. Skin necrosis is much more common after radiation
therapy due to the reduction in cutaneous blood flow that accom-
panies the treatment. It is preferable to lift and/or reduce the con-
tralateral breast to match the smaller radiated side and keep tissue
redistribution on the radiated side to a minimum. In severely
asymmetric and radiation-damaged breasts, it may be necessary
Fig. 81.5 (a,b) This elderly woman underwent right mastectomy for breast cancer 10 years earlier, with immediate expander-implant reconstruction.
She developed capsular contracture around the high-riding implant with severe acquired breast asymmetry. She was then diagnosed with a new left
breast cancer requiring mastectomy. Treatment involved immediate implant insertion with AlloDerm coverage of the lower pole. On the right side,
an open inferior capsulotomy with capsulorrhaphy to the upper pole of the implant pocket was performed. This allowed for inferior placement of the
implant into a more anatomical position. Shape and symmetry were vastly improved; the patient declined nipple reconstruction.

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to perform a completion mastectomy with immediate autologous
reconstruction rather than attempt to reshape compromised,
poor-quality local tissue. This may achieve a volume and shape
match similar to the normal contralateral side. Alternatively, a
contralateral balancing procedure may be necessary to match the
reconstructed breast as a secondary procedure.
81.8 Postoperative Care
The postoperative management of these patients varies enor-
mously depending upon the nature of the deformity and the
procedure required for correction. It is beyond the scope of
this chapter to highlight all these procedures in detail, and the
reader is referred to the appropriate operative descriptions
in accompanying chapters for this discussion. Suffice it to say
that postoperative management involves the careful support of
implants in their correctly placed location and may require the
use of external taping or brassieres to assist with this process.
Careful preoperative counseling and preparation for possible
revisions should have been clearly explained to the patient to
avoid postoperative disappointment, particularly with sever
congenital deformities or radiation-induced asymmetry, both of
which can be particularly challenging to correct.
81.9 Problems and Complications
Breast asymmetry surgery generates the same spectrum of
risks and complications as the component operations used
to correct the deformities. The congenital anomalies, such
as constricted, tubular breasts, run the increased risk of
double-bubble deformity if the original crease is not fully
expanded and obliterated to make way for a new one. The posi-
tion of the new crease must be placed accurately to match the
contralateral normal position. Similarly, overdissection of the
new crease position results in an extremely unattractive bulge
of the implant beyond the desired breast crease level, and the
deformity is extremely difficult to correct. A capsulorrhaphy is
necessary between the breast capsule and the correct position
on the chest wall, but the tissues are thin and hold sutures
poorly, easily tearing through when a large implant exerts
pressure against the repair. The use of a piece of ADM such
as AlloDerm or Strattice is helpful in providing a more robust
material to anchor such a repair.
Revisionary surgery for breast asymmetry requires operating
in a previously scarred bed. The use of breast pedicles in such
situations or raising scarred or radiated skin flaps may result in
skin and fat necrosis or nipple loss. Every effort should be made
to maintain blood flow to tissues by ensuring thick, broad-based
pedicles and thicker flaps than might otherwise be used.
81.10 Outcomes
Breast asymmetry surgery is often difficult and may require
revisions. Given the wide range of deformities and the spectrum
of procedures required to correct them, it is almost impossible
to provide outcomes data for this subset of clinical conditions.
81.11 Concluding Thoughts
Breast asymmetry is a distressing physical entity with potentially
profound psychological impact. The treatment of established
deformity requires the use of a broad range of procedures and
techniques aimed at restoring a close facsimile of the normal
breast from a less than ideal foundation. Achieving good results
in these patients taxes the ability and skills of even the best
surgeons and should not be embarked upon lightly.
Fig. 81.6 (a,b) This 60-year-old woman presented 6 years after a right lumpectomy and radiation therapy for breast cancer. She had developed
severe breast asymmetry and requested improvement without resorting to extensive flap procedures. The right breast was stiff and fibrotic, with
lower-pole edema. Treatment involved a left vertical breast reduction coupled with a very conservative periareolar mastopexy to elevate the right
nipple into a more acceptable position without extensive undermining. Although symmetry is not perfect, she was very happy with the outcome
achieved through a conservative outpatient procedure with minimal risk to the radiated side.

81 Management of Breast Asymmetry
1283
Clinical Caveats
• Create symmetry of the mound and nipple position.
• Eradicate abnormally placed breast creases and re-create
them at a natural level.
• Perform radial scoring perpendicular to the crease to elimi-
nate a tight crease.
• Raise broad-based pedicles in revisionary surgery.
• Reduce a herniated areola by performing a periareolar
mastopexy.
Suggested Reading
[1] Caouette-Laberge L, Borsuk D. Congenital anomalies of the breast. Semin Plast
Surg 2013;27(1):36–41
[2] Coban YK, Sasmaz S, Celik M. Augmentation mammaplasty for mammari-
al hypotrophy and ptosis in a patient with ichthyosis. Aesthetic Plast Surg
2003;27(4):293–295
[3] Chaput B, Taizou M, Grolleau JL, Moreno B, Garrido I, Chavoin JP. Custom-made
silicone implants for pectus excavatum correction: the end of remodeling tho-
racic surgery? (Reply to Herlin et al.). Plast Reconstr Surg 2017;139(1):323e–324e
[4] DeLuca-Pytell DM, Piazza RC, Holding JC, Snyder N, Hunsicker LM, Phillips LG.
The incidence of tuberous breast deformity in asymmetric and symmetric
mammaplasty patients. Plast Reconstr Surg 2005;116(7):1894–1899, discussion
1900–1901
[5] Dreifuss SE, Macisaac ZM, Grunwaldt LJ. Bilateral congenital amazia: a case
report and systematic review of the literature. J Plast Reconstr Aesthet Surg
2014;67(1):27–33
[6] Fallon SC, Hatef DA, McKnight AJ, Izaddoost SA, Brandt ML. Congenital syn-
mastia with concurrent fibroadenomas in a pediatric patient. J Pediatr Surg
2013;48(1):255–257
[7] Flugstad NA, Pozner JN, Baxter RA, et al. Does implant insertion with a
funnel decrease capsular contracture? A preliminary report. Aesthet Surg J
2016;36(5):550–556
[8] Galdino GM, Nahabedian M, Chiaramonte M, Geng JZ, Klatsky S, Manson P.
Clinical applications of three-dimensional photography in breast surgery. Plast
Reconstr Surg 2002;110(1):58–70
[9] Glicksman CA, Ferenz SE. The etiologies of chest wall and breast asymmetry and
improvement in breast augmentation. Clin Plast Surg 2015;42(4):519–530
[10] Illouz YG, Sterodimas A. Autologous fat transplantation to the breast: a personal
technique with 25 years of experience. Aesthetic Plast Surg 2009;33(5):706–715
[11] Innocenti A, Innocenti M. Retro-areola distally based flap in the management of
the full expression of tuberous breast: a simple strategy to resolve a weak point
of the deformity. Aesthetic Plast Surg 2015;39(5):700–705
[12] Khouri RK, Khouri RK Jr, Rigotti G, et al. Aesthetic applications of Brava-assisted
megavolume fat grafting to the breasts: a 9-year, 476-patient, multicenter expe-
rience. Plast Reconstr Surg 2014;133(4):796–807, discussion 808–809
[13] .olker AR, Collins MS. Tuberous breast deformity: classification and treatment
strategy for improving consistency in aesthetic correction. Plast Reconstr Surg
2015;135(1):73–86
[14] Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg
2011;127(4):91e–102e
[15] 1ovakoviþ M, Lukac M, .ozarski -, et al. Principles of surgical treatment of
congenital, developmental and acquired female breast asymmetries. Vojnosanit
Pregl 2010;67(4):313–320
[16] Nuzzi LC, Cerrato FE, Webb ML, et al. Psychological impact of breast asym-
metry on adolescents: a prospective cohort study. Plast Reconstr Surg
2014;134(6):1116–1123
[17] Papadimitriou A, Karapanou O, Papadopoulou A, Nicolaidou P, Fretzayas A. Con-
genital bilateral amazia associated with bilateral choanal atresia. Am J Med Genet
A 2009;149A(7):1529–1531
[18] Rapuzzi G, Torre M, Romanini MV, et al. The Nuss procedure after breast
augmentation for female pectus excavatum. Aesthetic Plast Surg 2010;34(3):397–
400
[19] van Aalst JA, Phillips JD, Sadove AM. Pediatric chest wall and breast deformities.
Plast Reconstr Surg 2009; 124(1, Suppl):38e–49e

1284
XI Breast Surgery
82 Treatment of Gynecomastia
Alfredo Hoyos and David E. Guarin
Abstract
The abnormal growth of male breast tissue is a common condition
that most of the time does not require of any treatment. Those cases
that fail to regress may need surgical management. Surgical plan-
ning for these patients requires adequate diagnosis and staging.
An individual analysis of the skin, fat, and glandular tissue
guides the procedure. Knowledge of the ideal anatomy of the male
chest contour is key. The procedure removes the excessive fat and
glandular tissue and re-creates the pectoral contour, including the
convexities and concavities, by selective removal and grafting.
The postsurgical care is as important as the procedure to ensure
adequate healing and the desired outcome.
Keywords
gynecomastia, chest liposuction, chest definition
82.1 Introduction
The abnormal growth of breast tissue in males is most commonly
a benign condition in which glandular and fat tissue is misplaced.
It can also be a result of endogenous or exogenous hormonal
imbalance resulting from organ injury and, most commonly,
from medications, such as antibiotics and cardiovascular, antitu-
moral, and psychoactive drugs.
This condition can be physically and psychologically uncom-
fortable, negatively impacting the self-confidence and the body
image. This can affect one or both sides, especially at the extremes
of life. It can appear in youngsters at an incidence as high as 60%
of the population, but most of the time it is a temporal condition.
82.2 Indications and
Contraindications
Most gynecomastia cases are self-limited and do not require
any treatment. The idiopathic pubertal condition can be physi-
cally and psychologically uncomfortable, impacting the child’s
self-confidence and body image. Explaining the natural course of
the condition can be effective for reducing parents’ and patients’
anxiety and can provide the time needed for spontaneous regres-
sion to occur. If an underlying cause is corrected, the condition
stops progression or even reverts. When the condition persists
for more than a year, medical treatment has limited benefit as
the sole therapy, and surgical correction may be required.
82.3 Pertinent Anatomy
The male upper torso is defined by the underlying contour of
the surface anatomy, reflecting the disposition and development
of the pectoralis muscle as the main component of this zone.
The pectoralis major is the alpha muscle of the pectoral zone
and is responsible for most of the bulk creating a convex form,
especially when the muscle is well developed. However, for the
pectorals to play the main role, it is important to consider the
surrounding areas to achieve optimal definition.
The pectoralis has multiple medial origins, from caudal to cephalic:
the superior external oblique aponeurosis, the costal cartilages of the
first six to seven ribs, the anterior surface of the sternum, and the
medial half of the clavicle. Laterally it inserts into the lateral intertu-
bercular groove on the anterior surface of the humerus.
The muscle can be divided into three parts: clavicular, sterno-
costal, and abdominal. The clavicular part arises from the clavicle,
travels inferolaterally until it is adjacent and parallel with fibers
of the deltoid, and passes over the other portions of the pectoralis
major. The sternocostal part travels below the clavicular part in a
horizontal manner. The abdominal portion has a deep cephalolat-
eral direction. The different directions of the fibers allow for the
adduction, anterior rotation, flexion, and extension of the humerus.
The superior fibers tend to lay flat against the rib cage, while the
inferior part has a bulkier mass and provides the smooth convexity.
The inferior pectoralis margin is straight and close to horizontal.
Laterally, as the muscle passes upward toward the axilla, there is a
rounded sweeping that can be interrupted by a separate curvature
formed by the abdominal portion when it passes toward and then
beneath the sternocostal portion of the pectoralis.
A fat pad near the nipple contributes to the anterior volume and
chest convexity. The lateral portion of the muscle creates the anterior
wall of the axillar fossa. The clavicular portion and deltoid define
the deltopectoral fossa. In the groove between the two muscles, the
deltopectoral groove, lies the cephalic vein. In the midline, there is a
medial depression or groove over the sternum between the insertions
of both pectoralis major muscles. This space between the pectoralis
muscles forms a triangular depression above the xiphoid process.
For purposes of definition the anatomy of the pectoral is divided
into zones (Fig. 82.1). First, it is divided into a superior and an
inferior pole. The upper pole must have a greater volume than the
inferior pole due to the greater muscle mass.
The peripectoral area has five ´negative spacesµ that are concave
to enhance the convexity of the pectoralis and the surrounding
muscles (Fig. 82.2). First, a rhomboid space lies between the infe-
rior borders of the pectoralis muscle, the xiphoid process, and the
origin of the rectus abdominis muscle at the midline. Second, a
triangle is defined by the pectoral line and the lateral border of the
rectus abdominis muscle (subpectoral triangle). The third is a tri-
angular area between the lateral border of the pectoralis and the
lateral border of the latissimus dorsi muscle (pectoral-latissimus
triangle). The fourth area is defined between the subclavicular line
with the deltoid muscle and the upper border of the pectoralis
muscle (subclavicular triangle). The fifth area contains a dynamic
transition zone and is a horizontal line along the inferior border
of the pectoralis muscle, usually 1 cm below the nipple level that
tilts upward when the muscle is in contraction, creating a zone
that follows the muscular movement.

82 Treatment of Gynecomastia
1285
The last zone is a triangular area defined by the inferolateral
border of the pectoralis muscle and an upper border of a line con-
necting the point of the internal border in the pectoralis line with
the lateral insertion of the pectoralis muscle. In the gynecomastic
patient this zone requires close attention and deep liposuction
must be done, sometimes extending to the limits of the fatty area
beyond the pectoralis muscle.
82.4 Preoperative Assessment
The gynecomastia assessment usually requires only a clinical
examination. The condition is characterized by the presence of a
soft, disc-shaped enlargement of hard tissue beneath the nipple,
with a diameter greater than 2 to 4 cm. The condition must be
differentiated from pseudogynecomastia, which is only fat and is
associated with obesity.
Some cases require additional laboratory work, such as
biochemical studies, ultrasound, and mammography. Invasive
histopathology methods may be necessary for confirmation. The
patient can develop an associated anxiety disorder, with low
self-esteem, embarrassment, functional problems, psychosocial
discomfort, and fear of malignancy.
The individual characteristics of the gynecomastic chest must
be carefully identified to understand the specific deformity of the
chest components and choose the most accurate technique and to
predict how much of the skin is going to retract with the approach.
Of the available classification scales available in the literature,
the ones proposed by Rohrich in 2003 and by Cordova and
Moschella in 2008 are both simple and easy to use. From the
patient assessment, the amounts of glandular, fat, and skin tissue
are used to classify the type and severity of the condition and also
as a guide for choosing the ideal method of treatment. The fat can
be extracted by means of liposuction, the gland may require an
open resection, and the third component, the skin, can be man-
aged by means of resection and/or skin-tightening techniques.
Based on these classifications we use the following guide to
choose the most accurate surgical option:
Grade 1: Liposuction alone
Grade 2: Liposuction and glandular excision using an
omega pattern
Grade 3: Liposuction and glandular excision using an
omega pattern: skin tightening technology such as
radiofrequency or RF plasma
Grade 4: Liposuction and glandular excision using a peri-
areolar incision for reduction
Grade 5: Liposuction and glandular excision, pectoral tuck
using axillary incision, with or without areolar mobilization
Fig. 82.1 Pectoral zones. This area is divided into a superior (green)
and an inferior (blue) pole. The upper pole has most of the pectoral
volume due to the greater muscle mass.
Fig. 82.2 Negative spaces (yellow). These areas of concavities or
negative spaces accentuate the pectoralis muscle convexity and the
relationship with surrounding structures. 1, Interpectoral rhomboid; 2,
subpectoral triangle; 3, pectoral–latissimus triangle; 4, subclavicular
triangle; 5, pectoralis line; 6, inferior pectoral zone.

1286
XI Breast Surgery
The patient is also required to have a laboratory evaluation of
the hemoglobin, hematocrit, white blood cell count, creatinine,
urea, and coagulation timing; an anesthesiologist consultation
and assessment for the use of antibiotic prophylaxis according to
the specific guidelines of each center; and the Caprini risk assess-
ment for thromboprophylaxis.
82.5 Markings
The marking should be done with the patient standing. Mark the
gland bud for selective extraction by the pull-through technique.
It usually extends beyond the pectoralis muscle limits.
Begin marking the deep fat deposits, which are commonly
placed on a triangular area between the lateral border of the
pectoralis and a line between the inner border of the muscle and
the lateral insertion of the muscle. Then mark the areas that need
more projection in the pectoralis, especially the upper pole, for
treatment with fat grafting (Fig. 82.3).
Mark the surface anatomy of the pectoral with the patient in a
resting and contraction position to demarcate the dynamic transi-
tion zone. It is important to induce contraction with the arms down
for accuracy. Mark the negative spaces, including the pectoral-
latissimus triangle, the inferior pectoral triangle, the pectoral line,
the interpectoral rhomboid, and the subclavicular triangle.
82.6 2SerDWiYe 7eFKniTue
82.6.1 ,nÀOWrDWiRn
General anesthesia is preferred. Infiltrate the pectoral area with
a solution consisting of 1,000 mL of Ringer’s lactate and 1:100,000
epinephrine and 20 mL lidocaine of 1% solution following a 2:1
ratio. Infiltrate half of the volume in the superficial layer and half
in the deep layer.
Begin the infiltration in the deep layer to ensure that there is
wetting solution in the superficial layer during ultrasound deliv-
ery. If the superficial layer is infiltrated first, migration into deeper
layers as time elapses may leave the skin unprotected from the
ultrasound probe energy.
82.6.2 (muOViÀFDWiRn
Begin the emulsification using the ultrasound (VASER, Solta
Medical) at 80% pulsed mode with a 2.9-mm probe in the super-
ficial layer. It is important to wait at least 12 minutes for the
epinephrine to produce vasoconstriction. The probe movement
must be smooth, and the ultrasound (VASER) should be tuned to
the pulsed mode to prevent excessive heat generation. Additional
time may be applied to the framing areas, and the marked areas
of negative spaces.
Last, do the deep layer emulsification using VASER in 80 con-
tinuous mode for deep fat fragmentation with a 2.9- or 3.7-mm
two-ring probe by rubbing the probe against the muscular layer
to ensure that all of the fat in this layer is covered. The end point is
the loss of resistance in the deeper layers.
82.6.3 Extraction
SuSerÀFiDO
The aspiration of the superficial layer defines the horizontal line
inferior to the pectoralis muscle. To accurately define this zone,
the arms must be adducted in contact with the body to avoid
the angulation and the sad pectorals deformity. The subdermal
liposuction has to be done in negative-space areas: the triangle
lateral to the pectoralis and the inferior squared area in the junc-
tion of the inferior pectoralis and the lateral rectus abdominis
muscle.
Intermediate
In the area of confluence between the superficial and the
deep zones a blended must be created to produce a defined
border of the pectoralis muscle (lateral and inferior). Also, the
subclavicular triangle is treated. An extensive removal of the
remaining breast tissue is performed doing liposuction with a
Baker cannula (basket). If after the procedure there is remnant
breast tissue that is resilient to liposuction, we change to an
open approach.
3uOO-7KrRugK 7eFKniTue
An omega-shaped incision is made around the nipple following
a semicircle in the lower border of the nipple and two branches
in a horizontal manner until meeting the areolar border giving
an exposure 3 to 4 cm wide, enough to perform any glandular
resection through an open access. The glandular breast disc is cut
into quadrants to facilitate the dissection and the resection of the
glandular tissue. The superficial bud is then removed completely.
Additional superficial liposuction can be performed to gain skin
retraction (Fig. 82.4).
82.6.4 Fat Grafting
Harvest the fat tissue from other areas of the body using a
3-mm blunt cannula to an empty, sterile bottle. The fat tissue is
separated from the fluid components by means of decantation.
Through the anterior axillary fold incision, the pectoralis major
is located and pinched for insertion of a 3-mm blunt 30° curved
Fig. 82.3 Surface anatomy marking.

82 Treatment of Gynecomastia
1287
cannula to follow the muscle shape into the intramuscular layer
and avoid the risk of thoracic penetration. Most of the volume
fat is grafted into the superior pole to enhance the muscular
appearance, avoiding the inferior pole (Fig. 82.5).
82.7 Postoperative Care
The postoperative care guidelines are created to achieve six goals:
(1) control and reduce the postsurgical bruising and edema; (2)
monitor and facilitate the healing process; (3) prevent and treat
fibrosis, adhesions, and other types of undesired scarring; (4)
improve visible, hypertrophic scars and keloids; (5) provide
continuous care advice to the patient to create confidence; and
(6) promptly identify complications.
82.7.1 Drainage
Swelling, bruising, and pain are the most common undesired
events in the postoperative period. These conditions appear due
to the accumulation of excessive fluid and blood in the extracellu-
lar space created during the mechanical disruption of capillaries
and lymphatics. Such procedures increase hydrostatic pressure
and thus extravasation of blood, water, and large molecular
weight substances into the interstitium. To aid and control this
condition the excessive fluid must be controlled by careful fluid
Fig. 82.4 (a–d) Glandular resection by pull-through with forceps in an omega incision.
Fig. 82.5 Pectoral fat grafting.

1288
XI Breast Surgery
administration and active drainage of the accumulated fluids. It
is important to keep a permeable port to guide the fluids out.
This can be made by using a closed silicone drain system or open
drains aided with manual drainage.
82.7.2 Compression
A compression garment must be applied at the end of the pro-
cedure in order to reduce the edema, aid the hemostasis, close
potential dead spaces, provide comfort, and facilitate the skin
redraping and retraction.
A foam dressing under the compression garment helps to
distribute the compressive force of the garment, improving the
skin stabilization and perfusion. This foam dressing is applied in
the form of a vest to compress the torso circumferentially. It is
placed either directly on the skin or over absorbent pads. Variable
compression can be achieved using Velcro straps.
A compressive garment is placed over the foam vest. It should
be worn for at least 2 weeks, followed by the garment alone for an
additional 2 to 4 weeks.
The garments must be removed after 24 hours to change the
dressings, check the condition of the skin, and gently massage
trapped subcutaneous fluid toward the drains or open incisions.
82.8 Outcomes
By using this approach, most gynecomastic patients have effec-
tive removal of the abnormal glandular tissue and also achieve an
optimal pectoral contour. An understanding of the ideal anatomy
is the key point to achieve reproducible and satisfactory results.
Although uncommon, the most expected complication is the
hematoma that is usually reported when an open excision is per-
formed. Careful hemostasis during the procedure, the early use
of compression garments, and the drainage systems effectively
prevent this type of complication (Fig. 82.6, Fig. 82.7).
82.9 Concluding Thoughts
A careful patient examination and diagnosis is the starting point
for ruling out associated conditions, identifying those cases that
will resolve without surgery, and beginning the planning process
by revealing the amount of fat, gland, and skin that needs to be
treated.
The traditional approaches to treat gynecomastia are focused
mainly in the removal of abnormal the fat and glandular tissue;
however, the shape and contour of the pectoral zone are far more
complex than the absence of the abnormal tissue. The only option
for achieving a fully shaped male chest has been pectoral implants.
The use of implants had its own morbidity and led to complica-
tions, patient dissatisfaction because of chronic pain, discomfort
in exercise, visible scars, deformities, and prosthesis migration.
This approach resolves both issues with fewer complications and
a faster recovery.
Careful planning is important to guide glandular resection, fat
extraction, and grafting and to guarantee the patient’s satisfaction.
Fig. 82.6 (a,b) A 25-year-old thin man with gynecomastia. High-definition liposuction, glandular resection, and 200 mL of fat grafting were done.

82 Treatment of Gynecomastia
1289
Clinical Caveats
• Gynecomastia is a very common condition that most of the
time does not require any treatment besides explanation of
the natural course.
• The male chest anatomy must be understood from an artistic
point of view, including the muscular position, insertions, and
actions; the fat disposition; and the ideal proportions of the
muscular volume, adhesion zones, and fat.
• Combined fat grafting and extraction is an effective, inexpen-
sive, and time-efficient alternative to implants or liposuction
alone for the male chest. It is a safe procedure with highly
defined, reproducible results. It is best performed in tandem
with dynamic-definition lipoplasty, a liposculpture that can
reproduce the anatomical landmarks of an athletic body.
Suggested Reading
[1] Anjanappa HT, Arjun A. Gynecomastia—diagnosis & management: a study of 25
cases. Sch J App Med Sci 2014;2(6D):3137–3139
[2] Barros AC, Sampaio M de CM. Gynecomastia: physiopathology, evaluation and
treatment. Sao Paulo Med J 2012;130(3):187–197
[3] Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it.
Cleve Clin J Med 2004;71(6):511–517
[4] Cordova A, Moschella F. Algorithm for clinical evaluation and surgical treatment
of gynaecomastia. J Plast Reconstr Aesthet Surg 2008;61(1):41–49
[5] Lapid O, Jolink F. Surgical management of gynecomastia: 20 years’ experience.
Scand J Surg 2014;103(1):41–45
[6] Hoyos AE, Prendergast PM. +LJK 'HfiQLWLRQ %RG\ 6FXOSWLQJ $UW DQG $GYDQFHG
Lipoplasty Techniques. Berlin, Germany: Springer; 2014
Fig. 82.7 (a,b) A 25-year-old man with gynecomastia. High-definition liposuction, glandular resection, and 240 mL of fat grafting were done.

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Part XII
Body Contouring
XII

(Trang không có chữ)

83 Applied Anatomy in Body Contouring
1293
83 Applied Anatomy in Body Contouring
Alfredo Hoyos and Mauricio Perez
Abstract
Body contouring techniques require precise location and com-
prehension of underlying anatomy in order to achieve optimal
results. Basic concepts about origin and insertions, muscle
dynamics, and adipose tissue accumulation are key points
that help us understand why and how Dynamic and 4D Hi-Def
Liposculpture (Millard Plastic Surgery) is performed.
This chapter presents new concepts regarding zones for
specific liposculpture procedures to enhance the muscular and
athletic, and also the slight and natural, appearance of each
patient’s gender and phenotype. Most men opt for an enhanced
muscle-mass appearance, whereas women prefer a slim figure
but with more pronounced curves, but both are agreed that an
athletic look should be more than fictitious. On this foundation
the chapter discusses special considerations required during 4D
Hi-Def Liposculpture.
Moreover, the chapter considers lipoinjection and liposhifting
as required therapies for volume boosting, always in pursuit
of minimum reabsorption rates as well as zero relative risk for
complications.
Finally, the chapter highlights surgical cautions (SCs) that will
be critical to understand in order to avoid the most frequent
pitfalls during body sculpting.
Keywords
liposculpture, dynamic anatomy, lights, shades, lipoinjection,
liposhifting, high definition, dynamic definition
83.1 Introduction
As human beings we are always pursuing different features and
physiognomies that should help us feel better and fulfill our
comfort. Although cosmetic procedures have a very low odds
ratio for complications, it remains a very important concern for
most patients around the world, because body contour proce-
dures meet the criteria for major surgery.
Up-to-date body liposculpture techniques have become chal-
lenging for new plastic surgeons, requiring a profound awareness
not just of muscles and tendons but also of anatomical bound-
aries, connective tissue, and fat placement. This straightforward
comprehension will help you sculpt the underlying anatomy
rather than build shapes and stereotypes over the patient’s body.
Body shape has been the foremost muse for artists around the
world. History has witnessed the rise of outstanding sculptors
who made their masterpieces by studying human body anatomy
in detail. Back to the fifth century BC, classical Greek sculptors,
such as Polykleitos and Phidias, created the most important
sculptures before the Common Era, Doryphoros and Diadumenos
(Pentelic and Roman marble; Polykleitos) and the gold statue
of Zeus at Olympia and the wounded Amazon (Phidias). Both
sculptors emphasized the main muscular and athletic appearance
of the male figure, but Phidias also portrayed the curvaceous and
voluptuous facets of the female figure.
The functional human body is purely characterized by concav-
ities, convexities, lights, and shadows that instantly reveal the
bone structure, the muscle shapes, its change in motion, and most
of all, the skin and subcutaneous fat blueprint. Galen of Pergamon
(Greek, AD 129–201) also performed a meticulous description of
the primate anatomy over his thousands of dissections performed
during his life. These texts were the basis for the also eminent
De Humani Corporis Fabrica (On the Fabric of the Human Body),
published by the Flemish Anatomist Andreas Vesalius. The first
two volumes of this six-book set depict the main features of
bones, cartilages, muscles, and tendons and their correlation
with movement, force vectors, and dynamics in human natural
movement and in the standing and resting positions.
After detailing the initial features of human anatomy, many art-
ists, anatomists, and scientists around the world have broadened
our knowledge. As doctors, we have referred to many of these
books of artistic drawings and cadaveric dissections, although
some other artistic sources may not be recognized during medical
school and residency programs. The sections that follow describe
some important key points regarding artistic human anatomy and
the concept of beauty.
83.2 Art and Anatomy
Although several ancient Greek and Middle East philosophers
and scientists tried to explain beauty, it wasn’t until Aristotle’s
time that the term became important for human activities and
art. In fact, the term was defined according to its relation to
poetry and rhetoric; thus it was related to the state, the Roman
Catholic or Orthodox Church, powerful ecclesiastical individuals,
and wealthy secular patrons. Moreover, mathematics and other
sciences were strongly linked to beauty and art, as some relations
and proportions were described in an effort to predict its value.
For example, Polykleitos wrote his book, Canon, a text based on
the proportion of 1:¥2, wherein he establishes this proportion as
ideal for a male aesthetic figure. The renowned golden ratio was
the subject of thousands of writings, papers, and descriptions
in geometry, pentagrams, and architecture by ancient Greek
mathematicians (Phidias, Plato, Euclid, Pythagoras, etc.). An
object, plane, or figure was in the golden ratio if its proportion
was the same as the proportion of the sum of the larger of the
two quantities. Many authors defined an object as ´perfectµ
based on calculations and analysis, including the golden ratio.
Moreover, Leonardo Da Vinci illustrated De Divina Proportione, a
book written by Luca Pacioli about mathematical proportions and
their applications to geometry, visual art through perspective,
and architecture, printed in 1509. The “great mean” described by
Pacioli gave the artists and architects of the era a new paradigm
to improve their masterpieces, although some other scholars

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were not in agreement. Diverse structures around the world
were built under this premise, such as the cathedrals of Chartres
(12th century), Notre-Dame of Laon (1157–1205), and Notre Dame
de Paris (1160), as the historian of architecture Frederik Macody
Lund argued in 1919. Likewise, the Pentagram and Human Body
was drawn by Heinrich Cornelius Agrippa, in which a relationship
between the human body and the golden ratio was implied.
Many artists between the 13th and 18th centuries encouraged
another point of view through paintings and mathematics.
Countless creations based on human behavior became the sub-
ject of multiple analyses and publications, such as the Fibonacci
sequence (Leonardo of Pisa), the Vitruvian Man (Leonardo da
Vinci), the Kepler Triangle (Johannes Kepler), and thousands of
others that extend beyond the scope of this chapter.
One of the most important thinkers during the medieval
period, Thomas Aquinas, identified the three main characteristics
of beauty in Aquinas’s philosophy of aesthetics: integritas sive
perfectio (integrity), consonantia sive debita proportion (objective
proportion), and claritas sive splendor formae (magnificent forms).
While Aristotle likewise took advantage of perfection and propor-
tions, St. Thomas conceived forms and shapes as glorious from
principles developed by Neoplatonic and Augustinian thinkers.
This new Thomist philosophy or recognition of how to conceive
human aesthetics changed the way that many artists and even
populations understood beauty, even though there was a shift
from the Middle Ages to the Renaissance, in which art changed its
focus, as much in its content as in its mode of expression.
Art apogee was reached during the Renaissance, in which art-
ists expressed their own talents through many anatomic models
with different styles. Certainly Leonardo da Vinci should be con-
sidered the most influential artist of all time in art relating to the
human anatomy. As alluded to earlier, the meaning of symmetry
and proportions in the dynamic motion of the human body could
be appreciated in minute detail over the topographic anatomy
described in his outstanding drawings and paintings. Influenced
by Andrea del Verrocchio, Leonardo da Vinci performed multiple
corpse dissections that outlined the principles of biomechanics
but also a vast majority of the internal organs in the human body.
Correspondingly, Michelangelo also sculpted one of the best
chefs-d’oeuvre of all time: David. Michelangelo’s famous marble
sculptures are characterized by their natural and almost vivid
representations of human muscles, skin appearance, landmarks,
and expressions. The sculptures’ facial expression and physical
distribution on the space almost transmit unique human feelings
to the observer.
The Oxford English Dictionary (OED, ) defines
art as “the expression or application of human creative skill
and imagination, typically in a visual form such as painting or
sculpture, producing works to be appreciated primarily for their
beauty or emotional power,” which cannot be more easily and
purely outlined, for our purposes, regarding the anatomy of the
human body.
Standards for beauty, more for females than for males, have
changed throughout history; in fact, they were drastically differ-
ent in recent decades from those in the past. More emphatically,
two opposing images of female beauty were depicted in America’s
19th century: one a slight and frail “steel engraving lady” and
the other a plump and curvaceous “voluptuous woman.” These
contrasting images of feminine beauty continued into the early
20th century; the 1920s saw a trend toward a slender figure, as
the body seemed to lose its curves and the focus was on the legs
and face. In the 1930s, the Esquire magazine illustrator George
Petty provided a new aesthetic ideal: a toned, athletic, yet cur-
vaceous woman with long, muscular legs. Later in the 1940s and
1950s, Alberto Vargas (Petty’s successor at Esquire) preserved the
muscular athletic look but added large breasts. The trend toward
larger breasts as an aesthetic ideal continued and probably still
exists today to some extent, given the rising number of breast
augmentations performed annually.
Men, on the other hand, have been a relatively minor subject in
discussions of beauty standards. A woman’s brain is considered to
be less focused on appearance than on many other preferences and
individual considerations when she is seeking a mate. Some of the
features that women claim to seek in their male mates include an
athletic appearance and a tall stature. Characteristics of the face
and legs can also be important. Most men and women today are
looking for an athletic appearance, with a preference for natural
and lean bodies, where the anatomy and underlying musculature
are the preferred features. Because art may be considered the way
to express desires and benchmarks for perfection, one should
consider body sculpting art as the best way to portray a perfect
human form. As mentioned earlier, premises for this purpose
include symmetry, proportions, curves, ratios, and indices.
By today’s concepts of a beautiful body, we should consider the
one that attracts our attention and elicits a positive emotional
response. Youth, health, attractiveness, and function are so inti-
mately related but variable for human procreative purposes that
different balances between these qualities make the ´perfect mateµ
different for each individual. Humans have evolved and changed so
much throughout history that we cannot “make” the perfect male
or the “perfect” female for everyone; rather, we strive to follow
some standards that include attractiveness, health, and of course
functionality in order to sculpt a natural body through surgery.
Based on our previous premises and purposes, we now focus
our attention on our patients’ diverse body shapes and fat deposits
in order to understand and design an optimum procedure. Around
1940, the American psychologist William Sheldon proposed
a classification of body types that is still widely used today. He
described three main body types based on his observations: ecto-
morph, mesomorph, and endomorph (Fig. 83.1). The ectomorphic
body is typically tall and thin, with a low fat content, narrow
shoulders, and high metabolism. These individuals find it difficult
to gain weight. The mesomorphic body is muscular and lean, with
medium bones and a solid torso. These individuals may gain some
fat if caloric intake is too high or exercise is deficient. The endo-
morphic body has big bones, a wide waist, and a tendency to have
midbody fat deposits. Endomorphs gain weight easily and require
high-intensity exercise and a strict diet to become lean. On a
regular daily basis, exercise and a healthy diet must be carried out
in all body types in order to avoid other systemic complications of
actual human behavior and manners.
Depending on each body type (endomorph, ectomorph, meso-
morph), some considerations have to be settled on in the preoper-
ative evaluation in terms of the nature and type of procedure that
the patient needs. This will contribute to a natural and optimal
outcome. Dynamic and high-definition liposculpture procedures
are not the same for everyone, since each patient is different, and
there are various complaints and desires.

83 Applied Anatomy in Body Contouring
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83.3 Human Form
Genetics and environmental features determine the adult human
body for both males and females. Genes will define our skeletal
framework, muscle mass and tone, fat distribution, and metabolic
behavior. Environment causes some of these features to increase
and decrease, whereas it can alter the normal course of others
and may dramatically change what we were supposed to be (e.g.
neoplasia, surgery, trauma, heat, cold). One of the most important
anatomical landmarks to remember in high-definition liposculp-
ture is the underlying muscle anatomy, which is referred to often
throughout this and subsequent chapters. Various anatomical fea-
tures are named after the geometric form they resemble, including
the deltoid, rhomboideus, trapezius, and scalenius muscles. This is
also true for some bones: trapezoid, hamate, pisiform, incus, and
stapes. Poor posture, related to infirmity or a lack of exercise, also
affects the shape of the body. Correct understanding of human
aesthetics requires an appreciation of various shapes and lines
that delineate the human body in resting and active states. The
adequate harmony and continuity of these shapes and lines are
essential to understanding the human reproductive situation,
endocrine status, longevity, athleticism, and strength.
In men, well-developed and lean muscle mass produces curves
and concavities, although the form tends to be more angular
than curvaceous (Fig. 83.2). Shapes are variable and sometimes
bigger or differently arranged due to genetics, trauma, and
other variables (malformations, surgery, diet, etc.). These are the
main issues regarding male shape, but the female issues are a
little more elaborate. Natural physical curves in women usually
produce attraction. These include lumbar lordosis, convexities of
the chest and buttocks, and muscular definition in the calves (Fig.
83.3). Undesirable curves appear when there are muscle atrophy,
obesity, advanced age, posture deterioration, and hormonal
changes, among others. Since lipoplasty affects only subcutane-
ous abdominal fat, it is not a surgery for abdominal protrusion
secondary to muscle wall weakness or excess intra-abdominal
fat deposits. Muscle weakness and herniation do need specific
surgical procedures, sometimes with mesh repair, and are clearly
beyond the aims of this chapter. Additionally, intra-abdominal fat
deposits need a specific diet and workout to become smaller.
Fig. 83.1 William Sheldon’s body types: mesomorph, endomorph, ectomorph.

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Those undesirable changes in body shape are the major com-
plaints when patients appear at our office asking us to restore and
improve them. However, standards of beauty and attractiveness,
as described earlier, cannot be sorted out in an objective way.
Female beauty has been the subject of extensive research over a
number of decades by experts in the fields of biology, psychology,
philosophy, and anthropology. Unsurprisingly, what determines
physical attractiveness is still subjectively determined. In other
words, beauty is still somewhat in the eye of the beholder, and
its meaning changes temporally and geographically. Taking into
account what we have already mentioned, we have proposed
aesthetic ideals based on ranges and constants described by some
measurements, such as body mass index, waist/hip ratio, and
curvaceousness. Despite the fact that some evidence supports
asymmetry, we believe that symmetry is something to keep in
mind during any aesthetic procedure so as to ensure valuable
outcomes, as asymmetry could turn toward the haphazard.
83.4 Symmetry and Proportions
Like students at art and design schools, anatomy and aesthetic
surgery students will be captivated by the unique arrangement
and design of the human body. Atoms and electrons are perfectly
arranged into cells, each cell type is grouped in functional units
to form specific organs and several other tissues, organs and tis-
sues are synchronously working in systems, and different body
systems complement each other to function within the body.
Proportions are crucial for art and sculpture. Leonardo da Vinci’s
On the Proportions and on the Movements of the Human Figure
and Albrecht Dürer’s Four Books on Human Proportions detail
human proportions and highlight the importance of harmony
and proportions in aesthetics and in art.
Following what we described earlier, the golden ratio
(Ǩ a 1.61) is measurable throughout nature, explains dynamic
symmetry in human proportions, and is essential for symmetry.
Mathematically, this dynamic uniformity is expressed in the
Fibonacci sequence: a series of numbers where any number in
the series is the sum of the previous two numbers: 0; 1 + 1 = 2;
1 + 2 = 3; 2 + 3 = 5; 3 + 5 = 8. Each number within a sum divided
by the previous number approximates 1.62 (Ǩ). :hen there is
dynamic symmetry, numerous human proportions and aesthet-
ically pleasing ratios approximate Ǩ (Fig. 83.4). Furthermore,
proportions of the vertical body height are fairly consistent. The
body length from the suprasternal notch to the sole of the feet can
be divided into thirds. One third forms the torso from the sternal
notch to the symphysis pubis, another third is the thigh length
from the anterior superior iliac spine to the patella, and the lower
leg length from the patella to the sole is also a third of body height.
The head height is one-eighth of the total height, and the neck is
half of the head height. As a matter of fact, George Hebert did a
wonderful explanation of these proportions in his book Muscle et
Beauté Plastique Féminine (1919).
Three proposed and well-researched determinants of female
beauty are (1) waist-to-hip ratio (WHR), (2) body mass index
(BMI), and (3) curvaceousness. Most studies agreed that the most
attractive WHR, measured by dividing the circumference of the
waist by that of the hips, is 0.7. Since estrogen has the effect of
Fig. 83.2 Men’s angular shape. Note the muscular and prominent
square-shaped chest appearance.
Fig. 83.3 Women’s curvaceous shape. Note the multiple concavities
and convexities that make the female body slender and rounder.

83 Applied Anatomy in Body Contouring
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depositing fat in the hip area and preventing deposition in the
abdomen, it follows that premenopausal women with normal
estrogen levels will have a lower WHR than women who have
reached menopause. Liposculpture removes fat from the waist and
transfers it to the hips in order to decrease the WHR and improve
attractiveness (Fig. 83.5). BMI, calculated by dividing the body
weight (kilograms) by 2 times the height (square meters), can be
considered to be an index of overall fat percentage. Although a BMI
in females of 20 to 25 kg/m2 is normal, some studies reveal that a
BMI of 20 is considered optimally attractive; however, we need to
factor in some other considerations once a procedure is planned
for a specific patient. Curvaceousness is described as a woman’s
shape compared to an hourglass, such that the breasts and hips
are relatively large and the waist relatively slender. Liposculpture,
breast augmentation, and fat grafting to buttocks improve curva-
ceousness by increasing these indices. Nevertheless, the relative
importance of WHR and BMI as models of physical attractiveness
is debated, since there is a positive correlation between the two:
if BMI increases, so does WHR. In cross-cultural studies, BMI was
found to account for over 75% of the variance in attractiveness
ratings, whereas WHR failed to emerge as a strong predictor. This
could be explained because of the way fat deposits are distributed
during weight gain, depending on each body type and race. Still,
there is a role for WHR in attractiveness judgments, and some
evidence states that an improved WHR activates some regions of
the brain associated with neural reward mechanisms, such as the
anterior cingulate cortex and nucleus accumbens.
In a similar manner, attractiveness ratings for men suggest that
a low waist to chest ratio is desirable. This V-shaped body results
from increased muscular mass in the chest and upper back, com-
bined with minimal fat and good muscular tone in the abdominal
wall. The tendinous intersections of the rectus abdominis can be
seen and appreciated in individuals with minimal fat overlying
the anterior abdominal wall, so as the muscular genetics of bigger
latissimus dorsi, deltoid, and trapezoid muscles make the torso
attractive and protective for female mates. Body image plays an
important role in the psyche of both sexes, though males are more
prone to admire about female shape than women do about male
shape. A slim but curvaceous, delicate, and toned appearance in
women indirectly resembles vitality and reproductive health
just as the muscular, athletic, protective, and bigger appearance
in men does, making them an ideal couple for evolutionary and
reproductive purposes. Body sculpting procedures should improve
and restore these natural and evolutionary aspects through spe-
cific hallmarks that we describe in the following paragraphs. In the
Fig. 83.4 Phi (Φ) proportions in human form (dynamics).

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next section we detail the most relevant muscles and anatomical
landmarks for high-definition liposculpture.
83.5 Anatomical Milestones
High-definition liposculpture is planned at the patient’s first
physical exam. After the locations of fat deposits are identified,
in the immediate preoperative stage we mark some specific
references and zones where muscles and bony prominences are
located in resting and active postures. This enables us to esti-
mate the postoperative result. The muscular and bony anatomy
needs to be perfectly understood so that the trained eye can look
beyond the superficial appearance and perceive the hidden, deep
anatomy. In most individuals with a normal BMI, an athletic and
toned appearance can be created through high-definition body
sculpting by removing fat and highlighting major muscle groups.
However, in the obese patient, a long learning curve is needed
to support a safe and high-quality procedure. The following
paragraphs are strictly focused on anatomical features relevant
to liposculpture. We provide a brief description of muscle out-
lines, origins, insertions, orientation, form, and relationships to
adjacent muscle groups.
83.5.1 Trunk Muscles
The trunk muscles consist of large and small groups of muscles
arranged anteriorly and posteriorly over the abdomen and back,
respectively. They form the muscular body wall, where they
connect the rib cage to the bony pelvis. The trunk muscles have
various actions on the torso, including flexion, extension, lateral
bending, and rotation. Chest wall muscles are also included.
Fig. 83.5 Waist to hip ratio (WHR). A 26-year-old female patient who underwent high-definition body sculpting surgery. (a) Notice the preoperative
picture where the ratio is high due to the amount of fat pads over the “love handles,” (b) compared with the 4-month postoperative picture where
the ratio is decreased due to a new slim waist and a better-contoured hip.
a
b

83 Applied Anatomy in Body Contouring
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Definition of the trunk muscles provides an appearance of ath-
leticism, strength, and health. In men, the posterior trunk mus-
cles create a V-shaped form, or a triangular wedge: the broad
latissimus dorsi tapers inferiorly to a narrow waist. Anteriorly,
the fleshy bellies of the rectus abdominis bulge between tendi-
nous intersections, along with the pectoralis major, provide a
convex muscular mass over the chest (Fig. 83.6). In women, the
anterior and posterior trunk muscles between the rib cage and
pelvis narrow the waist. Posteriorly, the broad V shape is roughly
missed, but the smaller erector spinae provide an attractive defi-
nition on either side of the midline. Anteriorly, a subtle shadow
over the linea alba and at the lateral borders of the rectus abdom-
inis create beautiful definition of the female abdomen (Fig. 83.7).
Rectus Abdominis
The rectus abdominis arises from the symphysis, crest, and pecten
of the pubis and runs upward to insert into the xiphoid process
and costal cartilages of the fifth to seventh ribs. Its main action is
to flex the trunk. The inferior part of the rectus abdominis is cov-
ered only on its anterior surface by the rectus sheath, and above
the costal margin the muscle lies directly on the costal cartilages.
The paired rectus abdominis is separated in the midline by the
linea alba and by three horizontal tendinous intersections. These
fibrous bands are usually located at the level of the xiphoid process,
at or just above the umbilicus, and halfway between these two. A
fourth tendinous intersection may be visible below the umbilicus
and marks the location of the arcuate line. The tendinous inter-
sections on one side may be in line with the contralateral side or
may be at different levels, giving an asymmetrical appearance to
the anterior abdominal musculature. The intersections closest to
the umbilicus tend to run horizontally, whereas the uppermost
tendinous intersections often run more diagonally. The orienta-
tion of tendinous intersections is highly variable, and all may be
horizontal (Fig. 83.8, Fig. 83.9, Fig. 83.10).
Careful palpation of the anterior abdominal wall in slim indi-
viduals confirms the surface anatomy. The intersections divide
the muscle into segments of fleshy protruding bellies that create
the quintessential muscular male abdomen commonly referred to
as the six-pack. The superior borders of the upper segments usu-
ally coincide with the inferior margin of the pectoralis major, but
variations exist. The muscle may continue superiorly under the
pectoralis major, or it may end lower down, exposing the costal
cartilages and creating a depression between the lower border of
the pectoralis major and the superior border of the rectus abdom-
inis. The borders of the segments created by the intersections are
rounded. The lateral border of the rectus abdominis is often visible
as a vertical groove in the anterior abdominal wall between the
ninth costal cartilage and the pubic tubercle. This semilunar line
typically runs along a line drawn from the midpoint of the clavicle
to the middle of the thigh. It starts superiorly as a depression just
below and medial to the nipple in men, runs inferiorly between the
Fig. 83.6. Male torso. (a) Anterior abdominal bellies and pectoral shape and (b) posterior V-shape delineated by the muscular landmarks.
a
b

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XII Body Contouring
Fig. 83.7 Female torso. (a) Anterior slim abdomen and breast shape and (b) posterior waist curves delineated by the muscular landmarks.
Fig. 83.8 Rectus abdominis (1) and external oblique (2) anatomical muscle disposition. Also notice the indentations of the serratus anterior muscle (3).
a
b

83 Applied Anatomy in Body Contouring
1301
Fig. 83.9 Rectus abdominis bellies and oblique surface anatomy in (a) the male and (b) the female.
Fig. 83.10 Serratus anterior muscle digitations in (a) the male and (b) the female.

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anterior limits of the muscular part of external oblique and lateral
border of the rectus abdominis, and expands into a triangular area
over the aponeurosis of the external oblique above the inguinal
ligament. In the midline, diastasis or separation of the rectus mus-
cles with widening of the linea alba occurs following pregnancy or
as a congenital deformity and may result in an abnormally convex
abdominal contour. When the body is hyperextended, stretching
the skin and muscle over the rib cage, a thoracic arch is easily seen
where the costal cartilages meet the sternum in the midline. Even
at rest, this may be seen in females and in thin individuals.
The umbilicus lies within a defect in the linea alba, at the
level of the fourth lumbar vertebra, and about midway or in the
junction of the first and second thirds over the midline, between
the xiphoid process and symphysis pubis. Nonetheless, a lower
location can be seen in multiparous women or obese patients. In
athletic males, a sharp rim is usually present at the upper border
of the umbilicus, whereas the lower border is less well defined.
([WernDO 2EOiTue
This muscle limits the lateral abdominal wall as its fibers pass infe-
riorly and inferomedially superficial to the other flat muscles (Fig.
83.8, Fig. 83.9). It originates from the external and inferior surfaces
of the lower seven or eight ribs. This muscle has two parts, an upper
thoracic portion and a lower flank portion. The thoracic portion
consists of separate elongated bundles of muscle that run parallel to
one another and in a straight line from the external surfaces of the
ribs to their aponeurosis at the semilunar line. The lower fibers of
the thoracic portion form a transitional zone above the flank portion
that coincides with the waist. The anterior irregular edge of the tho-
racic portion of the external oblique inserts into its own aponeurosis
as separate bundles. The flank portion of the muscle runs from the
external surfaces of the inferior ribs to the anterior half of the lip of
the iliac crest posteriorly, and the external oblique aponeurosis and
linea alba anteriorly. The flank pad represents a chubby trapezoid
between the ribs and pelvis that wraps around the waist. This
comprises the flank portion of the external oblique anteriorly and
a flank fat pad posteriorly. Even with good muscular development,
external oblique muscle fibers are not visible in the smooth, convex
flank pad. The inferior margin of the flank pad is the iliac line.
Since the muscle fibers of the external oblique insert into the
iliac crest, an iliac line lower than this is created by ptotic fat, and
not muscle. The most posterior fibers of the flank portion of the
external oblique pass vertically from the lower two ribs to insert
into the iliac crest, creating a posterior free border. These fibers do
not insert into the thoracolumbar fascia and constitute the ante-
rior border of the inferior lumbar triangle of Petit, the posterior
and inferior borders of which are formed by the latissimus dorsi
and iliac crest, respectively. This triangle is usually covered with
the fat pad, but some hernias have been described.
The external oblique becomes aponeurotic medially at the
midclavicular line and inferiorly at the spinoumbilical line
(between the anterior superior iliac spine and the umbilicus). The
aponeurosis passes anterior to the rectus abdominis as part of the
rectus sheath and decussates with the aponeurotic fibers of the
contralateral external oblique, internal oblique, and transversus
abdominis at the midline. The external oblique aponeurosis
passes the midline to be continuous with the aponeurosis of the
contralateral internal oblique.
Functionally, the external oblique and the contralateral internal
oblique can be considered a digastric muscle, since their simulta-
neous action flexes and rotates the abdomen, as occurs when the
shoulder is turned toward the contralateral hip. The inferolateral
fibers of the external oblique turn backward and upward between
the anterior superior iliac spine and the pubic tubercle to form the
inguinal ligament. A triangular tendinous expansion occurs just
below the spinoumbilical line and lateral to the rectus abdominis.
There may be a slight groove above and parallel to the inguinal
ligament in this area created by the internal oblique muscle lying
beneath. The tip of the 10th rib marks the base of the rib cage and
the superior limit of the abdominal portion of the external oblique.
A small triangular depression along the semilunar line occurs here
in athletic people. Also, a prominent rib angle can be appreciated
at the level of the midclavicular line in some individuals.
Serratus Anterior
This quadrilateral muscle originates anteriorly as fingerlike bun-
dles from the external surfaces of the upper eight or nine ribs and
wraps around the rib cage to insert into the vertical, medial edge of
the scapula. Contraction of its fibers causes shifting of the scapula
laterally and around the rib cage (as seen in punching). The inferior
part of the muscle rotates the tip of the scapula laterally, raising the
arm. In muscular individuals, the anterior parts of the lowest third
to fourth digitations of the serratus anterior can be seen on the
lateral chest wall as they mingle with fibers of the external oblique
(Fig. 83.8, Fig. 83.10). The superior bundle is usually seen immedi-
ately below or at the inferior margin of the pectoralis major.
The digitations of the serratus anterior are easily distinguished
from the external oblique as thicker, more pronounced bundles
of muscle that are oriented more horizontally relative to fibers of
the external oblique. The remaining serratus anterior is hidden
from view by the pectoralis major superiorly and the latissimus
dorsi posteriorly or is present between the two, where it forms
the medial wall of the axilla. Posteriorly, the mass of the serratus
anterior can be appreciated where it bulges underneath the flat
latissimus dorsi muscle that covers it. Frequently the posterior
limit extends more medial to the scapula, where its fibers insert
into part of the rhomboid major. The anterior serratus muscles are
usually covered by fat deposits, which cover its indentations over
the external oblique muscles. Improving its definition guarantees
a clearly muscular and youth appearance in the male patient.
Pectoralis Major
This is the greatest muscle of the chest. It gives the chest an
exceptional, convex form, particularly when the muscle is well
developed. It emerges from the medial half of the clavicle, the
anterior surface of the sternum, and the costal cartilages of the
first six to seven ribs, as well as inferiorly from the superior part
of the external oblique aponeurosis of the abdomen. Due to its
origin, this muscle can be divided into clavicular, sternocostal,
and abdominal portions. All portions of the pectoralis major
insert into the lateral lip of the intertubercular groove on the
anterior surface of the humerus. The clavicular portion arises
from the clavicle, and its fibers pass laterally and downward until
they are adjacent to and parallel with fibers of the deltoid, where
the muscle bundle of the clavicular portion passes over other

83 Applied Anatomy in Body Contouring
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portions of the pectoralis major. The sternocostal portion passes
almost horizontally and the abdominal portion upward and
laterally, deep to the other portions. Depending on the position
of the arm, the pectoralis major adducts, rotates forward, flexes,
and extends the humerus. The upper muscle tends to be flatter
against the rib cage, whereas the inferior part has more mass and
provides a smooth convexity, which ends in a slight downward
curve over the horizontal limit from medial to lateral (Fig. 83.11).
There is a lateral, rounded, sweeping form as the muscle passes
upward, defining the anterior wall of the axilla. This may be inter-
rupted by a separate curvature created by the abdominal portion of
the muscle as it arises from the abdominal aponeurosis and passes
toward and then beneath the sternocostal portion of the pectoralis
major. A pectoral fat pad near the nipple contributes to the volume
and anterior convexity of the chest. The deltopectoral fossa (trian-
gular) is formed between the clavicular portion of the muscle and
the deltoid. Then the deltopectoral groove extends inferolaterally
between the two muscles, in which lies the cephalic vein. In the
midline, there is a medial depression or groove over the sternum
between the insertions of both pectoralis major muscles; depend-
ing on the development of the muscle mass it could be deep or
shallow. As the origin of the muscle moves away from the midline
inferiorly, the space between the left and right pectoralis muscles
forms a triangular depression above the xiphoid process. One of
the foremost aspects of the muscular appearance of the male torso
is the pectoral projection and sharpness; this must be achieved
through high-definition liposculpture and possibly fat grafting.
Latissimus Dorsi
The latissimus dorsi is a triangular, sheetlike muscle that passes
from the midline to the arm, covering the deeper muscles of the
mid and lower back. Its origin rises from the spinous processes of
the seventh to twelfth thoracic vertebrae, those of all lumbar and
sacral vertebrae, the posterior third of the iliac crest, and the external
surfaces of the lower three ribs. The muscle bundles converge toward
the axilla and insert via a tough, square tendon into the proximal
humerus proximal to the insertion of the pectoralis major. As they
converge, they wrap around the teres major muscle, creating a sling
that forms the posterior wall of the axilla. The V shape of the male
posterior torso is created by both latissimus dorsi muscles and forms
the lateral border of the back and the waist (Fig. 83.12, Fig. 83.13). Its
upper fibers run horizontally from the midline and form the superior
free edge of the muscle as they pass laterally at about the same level
as the inferior margin of the pectoralis major anteriorly. They cover
the tip of the scapula, teres major, and serratus anterior muscles. The
latissimus dorsi medial tendon creates a groove from in the midline
over the thoracic vertebrae to the crest of the ilium. They are draped
over the deeper muscles, including the erector spinae, teres major, and
serratus anterior. Contraction of all these muscles, or the stretching of
the latissimus dorsi over them, frames bulges and shadows beneath.
Although the form of the muscle is normally evident in its middle and
superior portion, inferiorly, the dorsal fat pad obscures both it and the
inferior flank portion of the external oblique (Fig. 83.13).
Erector Spinae
The erector spinae comprises a group of muscles. There is a
common tendon in its sacral origin, then it becomes thick and
fleshy in the lower back, and then it tapers to form several thin
slips of muscle before they end at their insertion points along
the ribs and vertebrae. From lateral to medial, the erector spinae
muscles are the iliocostalis, longissimus, and spinalis.
The iliocostalis forms a lateral mass in the lower back. It originates
from the posterior third of the iliac crest, the lateral and medial crests
of the sacrum, and the spinous processes of the lumbar vertebrae
(through the erector spinae aponeurosis). The iliocostalis has three
portions, according to the insertions: the iliocostalis lumborum
Fig. 83.11 Pectoral zone. The pectoralis major muscle forms most of the quadrilateral shape of the male chest. (a) Compare the anatomical land-
marks with (b) the surface structure.

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XII Body Contouring
inserts into the posterior aspects of the inferior six ribs. The iliocos-
talis thoracis contains muscle slips that run from the inferior six ribs
to the first six ribs, and the iliocostalis cervicis runs from the first six
ribs to the transverse processes of C6–C4. The form of the iliocostalis
lumborum can often be appreciated through the thin anterior layer
of the thoracolumbar fascia that covers it (Fig. 83.12, Fig. 83.13).
The longissimus lies medial to the iliocostalis and also contains
three portions: thoracis, cervicis, and capitis. The longissimus
thoracis runs from the medial part of the posterior iliac crest and
from the spinous processes of L3 to the sacrum, then inserts into
the base of the L1 to L5 transverse processes and to the tips of
the T1 to T12 transverse processes, as well as to the adjacent ribs.
Fibers from the longissimus cervicis and longissimus capitis pass
to the cervical processes and mastoid process, respectively.
0uOWiÀduV
This muscle stabilizes the vertebral column and assists in exten-
sion, lateral flexion, and rotation of the back. Its strands cover
the space on either side of the midline between the spinous and
transverse processes. The multifidus contributes to the elongated
mass in the lower back on either side of the midline, where it lies
deep to the longissimus and spinalis.
83.5.2 Shoulder and Arm
The main prominence of the shoulder is attributed to the muscular
mass of the deltoid that cups the shoulder joint. Because the cla-
vicular portion of the pectoralis major lies alongside and almost
blends with the anterior portion of the deltoid, a “seamless”
progression from the definition of the chest to the shoulder is cre-
ated. In turn, the middle portion of the deltoid points downward
to the upper arm muscles that lie on either side of its insertion.
The major muscles of the shoulder and arm should not be ignored
when sculpting the chest and torso. Moreover, the surgeon cannot
give a huge projection to the chest without giving a proportional
one to the shoulder, or the “Ken” appearance will be undesirable.
Deltoid
This potent triangular muscle has three segments: anterior, middle,
and posterior. The anterior segment originates from the lateral
third of the clavicle, the middle section of the acromion, and the
posterior segment from the inferior surface of the spine of the scap-
ula. All portions insert into the deltoid tuberosity on the midportion
of the humerus. The deltoid raises the arm anteriorly, laterally,
and posteriorly. The anterior portion is usually well defined as a
distinct teardrop-shaped muscle, separated from the pectoralis
major by the deltopectoral triangle and groove (Fig. 83.13, Fig.
83.14., Fig. 83.15). The middle portion gives the shoulder a rounded
appearance on a frontal view and inserts lower than the anterior
and posterior parts. A less-defined groove splits the anterior and
middle portions of the deltoid. The posterior portion is visible as a
mass that separates the deltoid from the long and lateral heads of
the triceps. The tendon of the clavicular portion of the pectoralis
major passes under the tendon of the anterior portion of the deltoid.
The latter inserts into the deltoid tubercle on the anterior surface of
the humerus, while the other two parts insert into the lateral aspect
of the humerus. Because the active movement of muscles modifies
their shape and position in anatomical associations, once the arm
is rotated medially or laterally, the shape and form of the deltoid
changes slightly as the insertion points twist and the muscle moves
Fig. 83.12 Back muscles: trapezius (1), infraspinatus (2), teres minor
(3), teres major (4), and latissimus dorsi (5). Note the relation in the
lower back with the gluteus and the deltoid in the upper limb.
Fig. 83.13 Surface anatomy of the back and upper limb (posterior
view). Notice the wedge-shaped triangle of the male back, and the
lumbar mass from the erector spinae and latissimus dorsi muscles.
Focus on the natural landmarks of the muscles in the arms and shoul-
ders. The lateral and long heads of the triceps muscle are noted, as well
as the posterior and medial portions of the deltoid muscle.

83 Applied Anatomy in Body Contouring
1305
accordingly. Because the medial portion is multipennate, tendon
branches within the muscle and muscle fascicles attach obliquely
to the tendons. In slim, muscular individuals, the muscle bundles
can be seen to interdigitate diagonally, producing a segmented
appearance over the lateral aspect of the shoulder.
Triceps
The triceps muscle has three heads: long, lateral, and medial. The
long and lateral fascicles provide most of the surface form of the
posterior upper arm and form a prominent bulge just distal to the
rounded contour of the deltoid (Fig. 83.13, Fig. 83.14, Fig. 83.15).
The medial head lies deeply and contributes to the volume and
thickness of the arm. The long head of the triceps arises from its
tendon between the teres major and teres minor, below the glenoid
fossa of the scapula. It crosses the shoulder joint and forms the
main mass of the posterior upper arm. Proximally, tendinous fibers
from the scapula compress the long head when it is contracted,
visibly dividing the belly of the muscle into anterior and posterior
parts on the inner surface of the arm. The long head inserts into
the upper medial edge of the large, flattened tendon of insertion of
the triceps. The lateral head originates from the proximal posterior
surface of the humerus and is easily visible as a mass on the lateral
aspect of the arm near the deltoid. It inserts high up into the flat,
rectangular triceps tendon. A thin part continues to run down
along and adjacent to the lateral part of the triceps tendon, creating
a tail-like form when the arm is tensed. The three-head triceps
muscle inserts via its individual tendons on the posterior aspect of
the proximal olecranon. A cylindrical form that comprises part of
the medial head of triceps can be appreciated on the inner surface
of the arm where it emerges from between the biceps brachii and
the long head of the triceps about halfway down the arm.
Biceps
This is the most important muscle that men seek to improve
in the gym, as the prominent convexity that covers the anterior
aspect of the upper arm is provided mostly by the mass of the
biceps brachii. Its development exemplifies strength, athleticism,
and aesthetically ideal upper arm contour. The long head of the
biceps originates from the supraglenoid tubercle of the scapula.
The short head originates from the coracoid process of the scapula.
The biceps brachii emerges from beneath the pectoralis major and
creates a groove between the two muscles, particularly when the
arm is abducted and externally rotated (Fig. 83.14, Fig. 83.15). The
long and short heads of the muscle travel over the humerus but do
not attach to it. Instead, they insert into the tuberosity of the radius
via the biceps tendon deep between the flexors and extensors of
the forearm. The two heads of the biceps brachii usually appear as
one bulging form over the upper arm, although sometimes the sep-
aration between the two heads can be seen running longitudinally
over the muscle just medial to the cephalic vein. In the inner part
of the arm, the belly of the short head of the biceps creates a convex
prominence that is directed toward the axilla. As it emerges from
underneath the pectoralis major, it is joined by the coracobrachialis
on its medial side. The coracobrachialis is a cylindrical muscle that
runs from the coracoid process to the medial aspect of the mid-
portion of the humerus. In the middle third of the arm, the biceps
is separated by a groove from the long head of the triceps and the
medial head of the triceps more distally. The neurovascular bundle
lies within the brachial fascia deep to the groove. Flexing to 90°
and supinating the arm cause the rounded inferior margin on the
biceps brachii to become prominent. Testing this muscle against
resistance reveals the bicipital aponeurosis, a prominent and thin,
sharp, tendinous sheet that crosses from the biceps brachii over the
Fig. 83.14 Surface anatomy. Lateral view of the triceps and biceps
muscles. Note the bulky appearance of the posterior arm due to the
lateral head of the triceps and the anterior round contour due to the
convexity caused by the biceps muscle. Also note the three portions of
the deltoid muscle.
Fig. 83.15 Upper limb anatomy. Triceps lateral (1) and long (2) heads.
The medial head runs medially. Biceps (3) and brachialis (4) muscles
build the anterior bulk in the arm. Deltoid posterior (5) and medial
(6) portions. Fibers of the infraspinatus (7), teres minor (8), and teres
major (9) muscles are also noted partially. The muscles of the forearm
are also noted but are not described in this chapter.

1306
XII Body Contouring
medial aspect of the elbow. This aponeurosis passes medially and
wraps around the forearm flexors.
Brachialis
The brachialis provides width to the flexor half of the upper arm.
It is a broad, flat muscle that lies on the humerus behind the
biceps brachii. The brachialis originates from the anterior lower
part of the humerus and crosses the elbow joint to insert into the
coronoid process of the ulna. On the anterior view, the brachialis
is seen to protrude laterally from behind the biceps brachii. An
indentation at the superolateral origin of the brachialis on the
humerus marks its junction with the deltoid. Closer to the elbow,
its medial fibers form the floor of a concave space (where brachial
vessels travel), bordered anteriorly by the bicipital aponeurosis
and posteriorly by the medial head of the triceps (Fig. 83.15).
83.5.3 Thighs and Hips
Although, even more important for women, it is essential to
enhance and sharpen the male and female thighs and hips
to obtain a remarkable high-definition liposculpture result.
Autologous fat grafting, liposhifting, and specific liposculpture
in the hip muscles play an important role in gluteal sculpting
and in improving the silhouette and waist to hip ratio in
female patients. The major muscles that should be considered
in contouring and sculpting the hip region and lower limb are
described in this section.
Gluteus Maximus
Most of the convexity in the posterior buttocks and their volume
in slim individuals are due to the gluteus maximus size and
shape. Its origin rises from the posterior gluteal line of the inner
upper ilium (from the iliac crest), the posterior lateral surface
of the sacrum, the coccyx, and the sacrotuberous and sacroiliac
ligaments. Most of the muscle fibers run inferolaterally, curving
around the hip to insert into the iliotibial tract (Fig. 83.16). Deep
fibers from the lower portion of the muscle insert into the gluteal
tuberosity on the posterior proximal surface of the femur shaft.
The muscle bulk creates a convex form posteriorly that contrib-
utes to the desirable S curve formed by the gluteus maximus and
the lumbar lordotic curve superiorly (Fig. 83.17).
A depression is formed over the posterior superior iliac spine
since the medial fibers of the gluteus maximus originate from but
do not cover it. Between those depressions the base of a triangle
is formed at either side of the midline with the vertex on the
gluteal cleft. These depressions have to be cautiously marked
by lipoplasty as by resembling the triangle helps to improve the
future youthful and round shape of the buttocks. The popliteal
region and the posterior thigh need to be carefully recognized for
high-definition body sculpting because they are prohibited zones
except in some specific circumstances (Fig. 83.19, Fig. 83.20). The
gluteal fat pad covers the inferior medial border of the gluteus
maximus and forms the medial part of the infragluteal fold.
Laterally, the gluteus maximus tapers between the long head of
the biceps femoris and the vastus lateralis. The inferiorly pointing
form of the muscle may be visible in male patients, but in females
Fig. 83.16 Gluteus maximus (1) and gluteus medius (2) anatomical
landmarks. Remember the triangle over the upper border of the
superior iliac spine (see description in the text).
Fig. 83.17 Gluteal area. Curvaceous S shape in the lateral projection.
Note the continuity of the gluteal mass convexity with the lumbar
concavity.

83 Applied Anatomy in Body Contouring
1307
the overlying gluteal fat usually obscures its form. Moreover,
when extending the hip, a band of fascia across the inferior part
of the gluteus maximus creates a deep infragluteal crease. This
crease extends from the gluteal cleft in the midline for a variable
distance laterally, depending on the volume of the buttock and the
tone of the skin. Gluteal augmentation using autologous fat can be
performed from an incision over the infragluteal crease with the
patient in the prone position. The iliotibial tract covers the vastus
lateralis and runs inferiorly to insert into the lateral condyle of
the tibia. The muscle bulk of the gluteus maximus posteriorly and
the gluteus medius superiorly creates a C-shaped form, with the
greater trochanter lying centrally (Fig. 83.18).
Gluteus Medius
Anterior to the gluteus maximus lies the gluteus medius, a
strong, fan-shaped muscle that runs from the anterior part of the
lateral aspect of the ilium to the lateral surface of the greater
trochanter. The posterior part of the gluteus medius is hidden
deep to the anterior fibers of the gluteus maximus. Anteriorly,
the gluteus medius is bounded by the thin, teardrop-shaped
tensor fascia lata that passes from the iliac crest just posterior to
the anterior superior iliac spine and inserts on the iliotibial tract
just above the level of the infragluteal fold.
Iliopsoas
The iliopsoas cannot usually be appreciated on the surface; it
forms the floor of a triangular space bounded superiorly by the
inguinal ligament and laterally by the sartorius. It also comprises
two muscles, the iliacus and the psoas major. The iliacus fibers
originate from the iliac fossa and the sacrum and insert into the
shaft of the femur just below the lesser trochanter. The psoas
major rises from the transverse processes and the bodies of the
lumbar vertebrae and inserts into the lesser trochanter of the
femur. Lipoplasty over the iliopsoas just inferior to the inguinal
ligament makes the ligament appear more prominent and
defines the inferior extent of the abdomen.
Quadriceps
This large muscle group forms a large bulky mass over the anterior
thigh. The quadriceps femoris consists of four muscles: vastus
lateralis, vastus intermedius, vastus medialis, and rectus femoris.
The form of the muscles, except the vastus intermedius, can be
appreciated on the surface, particularly when the knee is forcefully
extended (Fig. 83.19). The muscle bellies taper inferiorly toward
their strong quadriceps tendon. The vastus lateralis originates
from the anterior surface of the greater trochanter and along the
Fig. 83.18 (a) The gluteal profile on the male muscular buttocks, compared with (b) the slim and round shape of the female. Look at the concavity
between the greater trochanter and muscle fibers of the gluteus maximus (where the muscle inserts into the iliotibial tract). It must be carefully
treated on gluteal shaping.

1308
XII Body Contouring
linea aspera on the posterior surface of the femur shaft. The muscle
sweeps over the anterolateral aspect of the thigh, creating a convex
form. The more bulky inferior portion ends abruptly at the quad-
riceps tendon below the insertion of the adjacent rectus femoris
insertion into the tendon. Laterally, the iliotibial tract passes from
the greater trochanter, along the lateral thigh over the vastus
lateralis, and inserts into the lateral condyle of the tibia. A concave
space is formed above the knee, laterally, that is bordered by the
iliotibial tract posteriorly, the distal limit of the vastus lateralis belly
superiorly, and the patella anteriorly. An obvious groove is usually
present along the lateral thigh that separates the quadriceps ante-
riorly from the hamstrings posteriorly (Fig. 83.20). This extends
from the gluteus maximus to the posterior aspect of the iliotibial
tract, before the latter inserts into the tibia, and represents an area
of focused sculpting to enhance the definition of the thigh muscles.
Unlike the vastus, the rectus femoris crosses both the hip joint and
the knee joint. It acts to flex the hip and extend the knee. The rectus
femoris arises from the anteroinferior iliac spine and inserts into
the patella first and then into the tibial tuberosity via the patellar
tendon. Near its origin superiorly, the form of the muscle belly is not
easily appreciated, because it is hidden between the tensor fascia
lata laterally and the sartorius medially. The fusiform muscle belly
occupies the upper two-thirds of the anterior thigh and attenuates
inferiorly before joining its tendon between the muscle bellies of
the vastus lateralis and the vastus medialis. The latter gives rise to
the medial teardrop-shaped form on the lower medial thigh and
originates from the linea aspera and medial supracondylar line of
the femur and inserts into the quadriceps tendon and upper lateral
part of the patella. The convexity of the vastus medialis is lower
than that of the rectus femoris and the vastus lateralis, extending
down medially to the level of the patella or below this level. The fat
below the inferior margin of the vastus medialis can be removed to
define the knee and improve the tapered appearance of the thigh.
Hamstrings
This muscle group forms the posterior thigh compartment and
comprises the long and short heads of the biceps femoris laterally
Fig. 83.19 (a) Lower limb, anterior view. Compare the anatomical relationships of the quadriceps muscle—vastus lateralis (1), vastus medialis (2), and
rectus femoris (3) heads—with the surface structure over the other leg. Also, the sartorius (4), adductor longus (5), and gracilis (6) muscles are noted.
(b) Posterior view. Hamstrings: biceps femoris (1), semitendinous (2), and semimembranous (3) muscles are illustrated. Note also the popliteal region
(*), a zone that should be avoided for deep liposculpture.

83 Applied Anatomy in Body Contouring
1309
and the semimembranosus and semitendinosus medially. The
individual muscle forms are not very pronounced on the surface,
except for the tendons that border the popliteal fossa when the
leg is flexed. Hip and knee flexion usually produces a groove or
ridge between the long and short heads of the biceps femoris and
the vastus lateralis. The popliteal region and the posterior thigh
need to be carefully addressed in high-definition body sculpting,
because they are prohibited zones except in some specific cir-
cumstances (Fig. 83.19, Fig. 83.20).
The short head of the biceps femoris rises from the linea aspera
of the femur, while the long head, semimembranosus, and semi-
tendinosus originate from the ischial tuberosity of the pelvis. Both
heads of the biceps femoris insert into the head of the fibula. The
semimembranosus inserts into the posterior part of the medial
condyle of the tibia, whereas the semitendinosus inserts lower
down on the medial aspect of the proximal shaft of the tibia. The
biceps femoris heads are best noticed by knee flexion; the short
one joins the common biceps tendon from the posterior, forming
a tough, flat sheetlike structure that becomes very prominent
with knee flexion, and becomes the lateral margin of the popliteal
fossa. A triangular fossa is also marked out between the biceps
tendon and the vastus lateralis while flexing the knee.
Sartorius
The sartorius is a long, thick, ropelike muscle that creates a cylin-
drical form on the anterior and inner thigh between the forms of
the rectus femoris and the adductor muscles. It emerges from a
point just below the tip of the anterior superior iliac spine, then
spirals down the inner thigh and around the vastus medialis to
cross the knee joint and insert into the upper medial shaft of the
tibia below the medial condyle. Smoothly removing fat over the
adductor compartment in the medial thigh can improve defini-
tion of the medial border of the sartorius. It forms a thick band in
the medial knee section that is sometimes obscured by overlying
fat pads (Fig. 83.19).
Adductor Group
The adductor longus, adductor magnus, and gracilis lie in the
upper inner thigh and contribute to the mass in this part of
the upper leg. The adductor magnus is the largest of the three
muscles and forms the mass of the medial part of the posterior
thigh, blending with the semimembranosus and semitendino-
sus, which lie laterally. The adductor longus has its origin just
below the pubic tubercle and expands into a flat belly toward the
femur. It inserts into the middle third of the posterior surface of
the femur and lies in front of the other adductors, but its form
is hardly visible on the surface. The gracilis originates from the
pubic arch, passes down along the inner thigh, and then has
its insertion into the superior medial aspect of the tibial shaft,
below the medial condyle. The gracilis tendon of origin may be
visible when the legs are abducted, but the muscle belly itself is
rarely seen as a distinct entity (Fig. 83.19).
Increased muscular definition of the thigh is achieved by accen-
tuating the groove between the vastus lateralis and the biceps
femoris. A shadow must be carefully but deeply defined in the
superficial layer by removing fat along the vertical ridge between
the extensor and flexor compartments. Muscle masses around the
knee are defined by removing the knee fat pads superiorly and
medially to define the vastus medialis and the vastus lateralis
above and the sartorius medially.
83.5.4 Lower Leg
Although controversial, lower leg lipoplasty is part of high-
definition body sculpting, because attractive curves of the
lower leg are attributable to the main muscles in the posterior
compartment of the leg: the lateral and medial heads of the
gastrocnemius and the soleus. These provide smooth, convex
prominences in the superior part of the lower leg that taper and
narrow inferiorly toward the ankle. They insert through the
Achilles tendon into the calcaneus. The delicacy of the ankle
relies on a prominent Achilles tendon with very little fat medial
and lateral to it.
Gastrocnemius
The medial and lateral heads of the gastrocnemius form the
main muscle bulk of the calf. The medial and lateral heads arise
from the medial and lateral condyles, respectively. The medial
head is larger and forms a convex bulge that is slightly lower
than the lateral head (Fig. 83.21). The medial portion occupies
Fig. 83.20 Lower limb, lateral view. Note the groove dividing the
quadriceps (anterior pack) and hamstrings (posterior pack) muscles.

1310
XII Body Contouring
the superior medial quadrant of the posterior aspect of the
lower leg and wraps around to cover part of the medial aspect
of the leg. The lateral portion wraps around to the lateral aspect
of the leg to a lesser degree. Both heads are teardrop-shaped
and end inferiorly where the muscle inserts into the broad, flat
gastrocnemius tendon. This tendon covers the posterior lower
aspect of the leg and fuses with the tendon of the soleus beneath
it to form the Achilles tendon. The key for successful contouring
of the leg is to reveal the convex forms of the gastrocnemius
and taper the leg inferiorly toward the sharply defined Achilles
tendon.
Soleus
The soleus has its origin in the posterior surface of the head and
superior shaft of the fibula and the soleus line on the posterior
surface of the tibia. The belly of the soleus lies deep to the heads
of the gastrocnemius and gives the calf thickness. Its lateral
and medial edges may be seen to bulge from beneath the gas-
trocnemius tendon when the foot is plantar-flexed. The soleus
inserts into the posterior surface of the calcaneus via the Achilles
tendon.
83.6 Fat Distribution
Subcutaneous fat is present in nearly every region of the body in
varying quantities. The fat lies predominantly in the superficial
fascia between the skin and muscles and is more plentiful on
the trunk than on the limbs. In general, females have a greater
percentage of body fat than males, particularly over the pelvic
region: the hips (iliac crest), gluteal muscles, and upper thigh.
Regional fat anatomy and volume play an important part in the
aesthetics of human form, particularly in females, where breast
fat and hip fat improve curvaceousness.
Although fat is present throughout the body, certain areas
have a propensity to accumulate relatively more fat in men and
women. In females, fat tends to accumulate around the hips and
buttocks. In men, the most prominent fad pads are usually in the
chest, abdomen, and flanks (Fig. 83.22). Lipoplasty performed
to improve muscular definition typically involves removing the
majority of the subcutaneous fat that obscures the appearance of
the muscular form beneath, leaving only a thin subdermal layer.
Augmentation of muscles can be achieved by autologous fat trans-
fer intramuscularly in a multilayer fashion with enriched fat stem
cells (e.g., in the pectoralis major, deltoid, or gluteus maximus).
83.7 Basis of Body Sculpting
Body sculpting has become the most frequent procedure for aes-
thetic plastic surgery worldwide because of multiple zones for
framing and multiple types of procedures that can be performed
to improve body shape. The latest statistical data published by
the International Society for Aesthetic Plastic Surgery show
that liposuction is one of the most frequent body sculpting pro-
cedures, but other procedures, such as buttock augmentation,
limb procedures, and abdominoplasty, are required to achieve
the desired outcomes. Keeping in mind our previous discussion
on art, the ´marbleµ should be our patient at the office, and the
follow-up model would be the muscles, tendons, and bony land-
marks that underlie the patient’s own anatomy. Consequently,
a deep knowledge of osteology and myology is necessary for
body sculpting. In point of fact, there are no flat surfaces in the
human body, nor is it completely convex or uniformly curved.
Subtle irregularities, contrasts, and angles contribute to physical
attractiveness; convex forms, elegantly linked through transi-
tion zones and spaces, with myriad planes, curves, and contrasts,
unite to create the whole.
Body sculpting is a form of free-standing sculpture or sculpture
´in the round.µ The figure must be viewed from a three-dimensional
perspective. The magnificence of the final work is manifested
through the interplay between lights and shadows, summits and
valleys, resting and movement. The body profiles that fall away
from the light source appear darker than those rising toward it. By
developing artistic skills in appreciating the interaction between
light and form, the surgeon can begin to define the anatomy and
the traits that represent cues for physical attractiveness.
83.8 7eFKniTueV in %Rdy SFuOSWing
At the present time, there are as many personal strategies as
techniques described for lipoplasty. Numerous improvements
Fig. 83.21 Gastrocnemius muscle. Lateral (1) and medial (2) heads.
Compare proportions and position related to the whole lower limb.

83 Applied Anatomy in Body Contouring
1311
and additions to the original technique have been reported
over the last century. In 1921, Dujarrier used a crude curetting
technique to remove fat from the lower limb of a ballerina, and it
resulted in gangrene and amputation. Lipexheresis was described
by the German surgeon Schrudde, using a special uterine curet
through small incisions. Multiple complications associated with
the procedure itself (e.g., visible scars, bleeding, infection, and
various grades of irregularities) hampered progression in this
area. The “curet approach” depicted by Kesselring and Meyer
was noted to be beneficial only for the greater trochanteric
regions. Furthermore, Goodstein and Hoȩin attempted to
use a cannula with a sharp trailing edge acting as a curet in the
subdermal tissues, but this gave rise to lymphorrhea and skin
necrosis in several cases. After that, Giorgio and Arpad Fischer
used a cannula with rotating blades, or planatomes, to suction
fatty deposits, with successful cases published in 1975. But it
was not until the formidable work of Ilouz and Fournier that
liposuction became popular and safe; they trained and assisted
physicians in learning the technique throughout the world.
After some success and reproducible techniques were reported,
the industry focused on refining and enhancing the materials
and equipment and facilitating surgeons in implementing the
procedure. Doctors, in turn, upgraded the original technique
with adaptations and by adding and testing some medications
and fluids to avoid or lessen complications (tumescent solution,
lidocaine, colloids, etc.). In the beginning it was not reasonable or
Fig. 83.22 Fat deposits distribution in (a) males and (b) females.

1312
XII Body Contouring
safe to remove large volumes of fat using blunt or sharp instru-
ments, because some drugs could lead to toxicity. However, in
1987, Dr. -effrey .lein developed a diluted local anesthetic and
epinephrine solution that allowed surgeons to harvest and
remove larger amounts of fat (the tumescent technique).
After this outstanding improvement to the original technique,
liposuction reached its apogee and, as stated earlier, remains one
of the most common surgical aesthetic procedures performed
around the world. That said, over recent years, the procedure has
changed drastically from one of basic, debulking, fat removal to a
form of artistic body sculpting. At this moment in time, liposuction
has become the art of body sculpting as surgeons have learned
to perceive figures, planes, and shapes in the three- dimensional,
dynamic contours of the body as a unit. Consequently, multiple
technologies and renovated instruments also needed to be
developed: a smaller, multiholed cannula replaced the larger
single-holed ones to provide smoother, more precise results and
decrease trauma and bleeding. As already mentioned, the medical
industry was also very interested in developing new technologies
to decrease the rate of complications. The advent of power-assisted
hardware for liposuction created another wave of new technolo-
gies to improve body sculpting. Today, there are diverse types of
gadgets with new systems and specifications that allow surgeons
to choose whichever best fits their own and their patients’ needs
for comfort during the procedure. In our personal experience,
third-generation, ultrasound-assisted lipoplasty technology and
instrumentation allow very gentle fat emulsification, even in
superficial subcutaneous planes. Although some kinds of defini-
tion may be possible with traditional suction-assisted methods,
high-definition body sculpting cannot be safely achieved without
the assistance of today’s more advanced technology.
83.9 Sculpt and Carve
Some time is required to train the surgeon’s eye to discern as
a sculptor rather than as a doctor. Although fat removal is part
of high-definition body sculpting, it is not the main feature.
Traditional liposuction in overweight patients focuses on fat
deposit removal, whereas high-definition liposculpture in
patients of normal weight focuses on revealing. Underlying
muscles, fascias, blood vessels, bony prominences, and natural
fat deposits are the sculptor’s end points for achieving natural
and genuine results. Sculptors start with a piece of matter and
add or remove “clay” to sculpt the human form; surgeons start
with a human form and modify it by removing excess, adding in
deficient areas, and creating controlled deformities that will help
them achieve the standard of beauty or the purposes they have
agreed to with their patient. The next paragraphs describe some
specific terms (chief lines, lights, shadows, positive and negative
spaces) that are crucial to understanding why and how the body
is turned into a new masterpiece rather than just a thinner one.
As a sculptor, the surgeon must consider the chief lines in the
form. Anteriorly this runs from the suprasternal notch, through
the midline of the sternum, along the depressed linea alba. In fact,
breast projection in females and upper pectoral fullness in males
dominate the chief line. The posterior chief line runs along the
midline of the back as a gully between the erector spinae group
or above the spinous process of the vertebrae. On profile, the
posterior chief line depends on posture, spinal anatomy, and glu-
teal soft tissue volume. The actual appearance of the chief lines,
lines of contrast, and surface definition are produced as a result of
the interaction of light and shadow.
The patterns of light reflection and absorption from surfaces
determine what we see. The changes in light and shadow let the
eye distinguish between deep and surface in a two- or three-
dimensional figure. As a matter of fact, the skin is semimatte, and
light reflects from skin in a uniform manner referred to as form-
light. Convexities are perceived as smooth, three- dimensional
structures because they display a spectrum of light and shadow.
The aspect of the form that directly faces the light source appears
lighter; the part that rolls away from the light appears darker
or shaded. From the lighter part of the form to the darker part,
there is a tonal progression. This artistic concept must never be
ignored; if it is, shadows with sharp borders may produce an
unnatural appearance (“Ken body”); for example, in abdominal
liposculpture this can lead to an undesirable woodlike aspect
(overmodeling—art). By allowing contours to project convexly we
are ensuring more light reflection and the smoother appearance
of the amendment. Depressions between or adjacent to convex
forms are created to hide these spaces from light so that they
bathe in shadow and appear darker. In addition, by removing
fat selectively in these spaces, the convexities appear relatively
augmented. Indeed, contouring over the chest wall around the
female breast enhances the perceived size of the breasts, making
them look bigger. Likewise, darker performed shadows around the
bellies of the rectus abdominis make the muscle segments appear
to project. Actually, smooth or subtle shadows play an important
role in the improvement of definition and the creation of a natural
appearance: the shadows over the posterior superior iliac spines
that form the sacral triangle (Fig. 83.23) intensify the roundness
of the gluteal area and resemble youth, the shadow below the tip
of the tenth rib enhances the athletic appearance, and the shadow
between the linea semilunaris and the inferior border of the
pectoralis major improves the projection of the chest (Fig. 83.24).
Along the same lines, it is important to consider an appropriate
plan to perform successful body sculpting. Individual surgeons can
approach this process in their own manner; we can all arrive at the
same point by different paths. Since the human figure’s attributes
are diverse, one should address them as complementary, with
the aim of avoiding asymmetries and stereotypes. These features
include volume, contrast, continuity, curvatures, and organi-
zation. The body consists of major and lesser forms, and each
should have the appropriate volume or fullness. In men, fullness
is desirable in the upper pectoral region, deltoids, and biceps, and
high-definition body sculpting takes advantage of autologous fat
grafting to augment the pectorals and deltoids. In contrast, female
buttocks and breasts frequently require augmentation to improve
fullness and curvaceousness. There are some other anatomical
zones (packed forms) that rest on major forms and contribute to
the appearance of athleticism; these include the convexities of the
rectus abdominis between the tendinous intersections and slips
of the serratus anterior, over the lateral aspect of the torso. These
forms must be carefully detailed by sculpting shadows around
them rather than by directly augmenting them with fat.
The major and lesser forms that make up the human body are
continuous with one another (like a wave), creating a type of
harmony and continuity. Even so, they do not blend so seamlessly

83 Applied Anatomy in Body Contouring
1313
Fig. 83.23 Female high- and dynamic-definition liposculpture. Note the negative spaces and transition zones. Plus, great attention must be paid to
gluteal reshaping (sacral triangle and superior iliac spine definition in gluteal lights and shadows).
Fig. 83.24 Male pectoral enhancing. Note that the linea semilunaris and the inferior border of the pectoralis muscle are defined by the subpectoral
triangle (2). Negative spaces, dynamic zones, and areas for fat grafting are also illustrated.

1314
XII Body Contouring
that there is uniform smoothness. Each discrete form is slightly
separated from surrounding ones by small transition zones where
smooth liposuction must be done; these little ramps will lead
from one form to the next. Small cannulas are used to shape these
transition zones, which usually receive less light than the forms
they define. The surgeon should carefully mark these zones in
the standing position at the immediate preoperative preparation,
because the posture on the surgery table could change the per-
spective and the impact of light over them.
In the same way, contrast is a notable feature in aesthetic sur-
gery, especially in body sculpting. The large form of the pectoralis
major contrasts with the serratus anterioinferiorly, the converging
muscle fibers of the pectoralis major and the deltoid contrast with
the vertically oriented fibers of the rectus abdominis, the volume
of the breasts contrasts with the slim abdominal muscles, as the
buttocks do with the erector muscles of the back. These opposed
muscles catch our eye and interrupt the homogeneity that might
otherwise relegate the human form to an uninteresting mass of
uniformity and sameness. The divergence between forms, shadows,
and spaces that constitute the human form are carefully arranged
in a fashion to guarantee functionality and long-lasting health.
Normal and functional structures need to be cautiously carved, as
we cannot overlap aesthetic over functionality, then always take
care of anatomical landmarks and underlying muscles to avoid
harmful complications or major asymmetries. Some artists actu-
ally think that attractiveness comes from irregularity, but always
in a harmonious fashion, so it is that most surface anatomical
features are regularly irregular. In particular, horizontal tendinous
intersections in the rectus abdominis occur in pairs, but left and
right pairs are not always at the same level (Fig. 83.25). In the same
way, other irregularities include tendon insertion morphology
and asymmetry within the umbilicus. In addition to irregularity,
preservation of three-dimensionality is important in the sculpting
process. The different planes of muscles, subcutaneous tissue, and
skin give us the chance to work in diverse amounts of deep and
superficial approaches; for example, between the upper rectus
abdominis, pectoralis major, and deltoid, the planes are created
or amplified during body sculpting by removing fat in the lower
planes and preserving or adding fat to the higher planes.
Finally, after planning how to portray light and shadow to create
forms and define features, now we perform it through the concept
of negative and positive spaces. The surgeon is able to add shadow
by removing more subcutaneous fat in a localized area, and add
light by creating a convexity (fat transfer). Positive spaces receive
more light, whereas negative spaces receive less and are there-
fore darker. A huge number of important positive and negative
spaces in men and women are the key to successfully achieving
high-definition body sculpting. For the male patient, these spaces
draw up the pectoralis major and the rectus abdominis anteriorly,
and define the lower back muscles posteriorly. On the other hand,
in women the negative spaces enhance the appearance of the
breasts and the rectus abdominis, but horizontal tendinous inter-
sections are not (or only slightly) defined to avoid masculinizing
the female abdomen (Fig. 83.23, Fig. 83.24). Techniques required
to create negative spaces are discussed elsewhere in this book,
as they are created to achieve shade, tonal progression, and the
superimpositions of planes that represent a significant departure
from traditional methods of liposuction.
83.10 Concluding Thoughts
:hile many books and clinical reports differ on the amount of
fat extraction and the kind of liposculpture technique recom-
mended, we do agree that relying on the learning curve, clinical
expertise, and the patient population that we look after day by
day are the most important determinants of the decision making
involved in body sculpting surgery.
Fig. 83.25 Rectus abdominis muscle. (a) Horizontal same-level and (b) different-level insertions.

83 Applied Anatomy in Body Contouring
1315
Art anatomy may be defined as the optical manifestation of the
underlying muscles, bones, and milestones that will define our
strategy for sculpting a body. Although each patient has different
anatomical features, some common hallmarks will help us outline
and frame the body they want us to sculpt. These specific attri-
butes are critical to understand and must always be kept in mind
to achieve the results we are looking forward to. Summing up,
we can infer that three main steps are required in body sculpting
surgery: (1) marking of hallmarks; (2) liposculpture with lights
and shadows, negative spaces, smooth definition; and (3) fat
grafting. Every one of these steps has one specific purpose, as we
have described.
In this chapter we have reviewed and shared our clinical
knowledge of and surgical experience with high-definition
body-sculpting anatomy. Instead of aiming to standardize our
surgical technique, we have sought to advise you on some clinical
stratagems and landmarks on the surface anatomy that render
body sculpting an art rather than just a procedure.
Clinical Caveats
Art Anatomy
Remember the three main body types: ectomorph, meso-
morph, and endomorph. The ectomorphic body is typically
tall and thin with low fat content, narrow shoulders, and high
metabolism. The mesomorphic body is muscular and lean, with
medium bones and a solid torso. The endomorphic body has
big bones and a wide waist, with a tendency to have fat depos-
its in the middle body. A healthy diet and exercise are needed in
all three body types for long-lasting results and to decrease the
relative risks of most organic acquired diseases.
Human Form
Three proposed and well-researched determinants of female
beauty are (1) waist to hip ratio (WHR), (2) body mass index
(BMI), and (3) curvaceousness. The latter and WHR are the most
important determinants for women, while BMI and muscular
appearance are the most important ones for men. However,
some variations are accepted according to the patient’s expec-
tations and wishes.
Although many anatomical hallmarks are important,
some critical steps are sine qua non for high-definition
body sculpting: (1) mark the different zones and fat pads for
superficial and deep liposuction, (2) determine some specific
anatomical references to avoid overdefinition and asymme-
tries, (3) mark with a different color the positive and negative
spaces for liposuction, (4) use smooth liposuction to create
shadows, and (5) use fat grafting to enhance projection of
some areas.
Muscles such as the gluteus maximus, pectoralis major, del-
toid, rectus abdominis, serratus, and latissimus dorsi are critical
muscles to sculpt, because they are the predominant mass
at their anatomical zones, but they also need to be carefully
shaded and enhanced to achieve optimum results.
Body Sculpting
High-definition body sculpting surgery is the technique that
revolutionized today’s liposculpture due to its natural and
outstanding results. The secret “behind the walls” is none
rather than taking advantage of ultrasound technology to
perform a safety and precise liposuction over an anatomical
location that was forbidden before: the superficial layer. By
removing the superficial-layer fat pads, while preserving
perfusion and integrity, the skin is now able to adhere to the
underlying anatomy of the individual and define its own mus-
cular and bony anatomy. Moreover, ultrasound technologies
are optimizing their frequencies and probes to avoid even
more tissue damage, by vibrations specifically designed toward
adipose cells. By the same way, the body sculptor, in this case
the surgeon, is now able to modify the adipose tissue and give
the muscles a different look by depicting shadows and light and
also projection through fat grafting.
Always remember that symmetries and proportions must
be kept in mind according to each patient, as we must avoid
overdefinition or “Ken” appearance as well as different sizes of
paired muscles. Finally, fat grafting must be performed on a
regular basis to enhance muscle projection and mass. We prefer
multilayer intramuscular fat grafting, enriched with autologous
adipose stem cells, in order to increase the fat graft survival.
Suggested Reading
[1] Banner L. American Beauty. New York, NY: Knopf; 1983
[2] Buss DM. The Evolution of Desire. Strategies of Human Mating. New York, NY:
Basic Books; 2003:55–57
[3] Cimino WW. Ultrasound-assisted lipoplasty: basic physics, tissue interactions,
and related results/complications. In: Prendergast PM, Aesthetic Medicine: Art and
Techniques. Berlin/Heidelberg, Germany: Springer; 2011
[4] Cornelissen PL, Toveé MJ, Bateson M. Patterns of subcutaneous fat deposition and
the relationship between body mass index and waist-to-hip ratio: implications
for models of physical attractiveness. J Theor Biol 2009;256(3):343–350
[5] Fisher ML, Voracek M. The shape of beauty: determinants of female physical
attractiveness. J Cosmet Dermatol 2006;5(2):190–194
[6] Hoyos A, Prendergast PM. +LJK'HfiQLWLRQ %RG\ 6FXOSWLQJ Springer; 2014
[7] Hoyos AE, Millard -A. VASER-assisted high-definition liposculpture. Aesthet Surg J
2007;27(6):594–604
[8] International Society of Aesthetic Plastic Surgery (ISAPS) International
Survey 2018
[9] Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg
1987;4(4):236–237
[10] Mazur A. US trends in feminine beauty and overadaptation. J Sex Res
1986;22(3):281–303
[11] Platek SM, Singh D. Optimal waist-to-hip ratios in women activate neural reward
centers in men. PLoS One 2010;5(2):e9042
[12] Sheldon WH. The Varieties of Human Physique: An Introduction to Constitutional
Psychology. New York, NY: Harper; 1940
[13] Simblet S. Anatomy of art. In: Anatomy for the Artist. New York, NY: DK Publish-
ing; 2001
[14] Singh D, Young RK. Body weight, waist-to-hip ratio, breast, and hips: role in
judgements of female attractiveness and desirability for relationships. Ethol
Sociobiol 1995;16(6):483–507
[15] Singh D. Adaptive significance of female physical attractiveness: role of waist-to-
hip ratio. J Pers Soc Psychol 1993;65(2):293–307
[16] Singh D. Mating strategies of young women: role of physical attractiveness. J Sex
Res 2004;41(1):43–54
[17] Swami V, Tovée MJ. Female physical attractiveness in Britain and Malaysia: a
cross-cultural study. Body Image 2005;2(2):115–128
[18] Tovée MJ, Cornelissen PL. The mystery of female beauty. Nature
1999;399(6733):215–216
[19] Toveé MJ, Hancock PJB, Mahmoodi S, Singleton BRR, Cornelissen PL. Hu-
man female attractiveness: waveform analysis of body shape. Proc Biol Sci
2002;269(1506):2205–2213

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84 Clinical Decision Making in Body Contouring
Mikaela Kislevitz and Jeffrey M. Kenkel
Abstract
Body contouring procedures continue to be choices for aesthetic
plastic surgery patients. It is important to incorporate a thorough
stepwise evaluation of body contouring patients. This evaluation
should include an honest provider–patient discussion about real-
istic results, patient goals, and procedure risks.
Keywords
liposuction, abdominal contouring, fat, skin quality, abdomino-
plasty thigh lift
84.1 Introduction
Liposuction remains in the top two surgical procedures reported
to the American Society for Aesthetic Plastic Surgery. The
fundamental principles have changed little over the past three
decades. That being said, there have been some refinements
allowing it to maintain its importance in body contouring sur-
gery and to remain the gold standard for body contouring with
which all modalities are compared. It is often an integral part
of many excisional procedures. Liposuction is extremely efficient
at reliably removing fat. The resultant contour is dictated by the
redraping of the skin and the remaining fat. Inelastic, stretched,
poor-quality skin will not redrape or contract and requires exci-
sion to allow sufficient highlighting of the underlying contour.
As the body contouring patient is evaluated, the skin is the first
fork in the road. When skin resection is needed, the extent and
location of the proposed scar need to be determined and reviewed
with the patient.
84.2 Patient Evaluation and
Counseling
It is important to establish the patient’s goals when initially
meeting with potential body contouring patients. There are times
when one recognizes that the patient’s expectations are not
realistic early in the consultation. This is most commonly seen
with patients who are significantly overweight and are looking for
nonsurgical and surgical options to change that. Having an appre-
ciation of the importance of looking good without clothing on
identifies the patients who will mandate smooth skin as a critical
component of their procedure. If this is less important it may open
up other options for the patient to simply look better in clothing.
After a detailed history it is helpful to examine patients in front
of a mirror. This allows them to show the physician their areas of
concerns, and in the case of excisional surgery they can appreciate
the length and location of the incision and the impact on adjacent
areas. The extent and thickness of the fat is noted, as are the qual-
ity and distribution of the excess skin. In the abdomen the fascia
should be assessed for laxity and hernias.
Following the examination, a thorough discussion of both surgical
and nonsurgical (when appropriate) options is reviewed with the
patient, often in front of a mirror. Anticipated outcomes are discussed,
as are the risks and recovery. Patient safety, morbidity, and length of
recovery should all be taken into account in the decision-making
process. This includes risks for more serious complications, including
venous thromboembolism. The patient’s medications and general
health are again reviewed, and when appropriate the patient is
referred for preoperative assessment and evaluation. Photographs are
taken of the patient for preoperative considerations and planning. The
patient then sees the patient coordinator to discuss the surgical fees.
It is not uncommon to see any aesthetic patient back a
second time to discuss the recommendations made at the first
consultation. This is an excellent time to review the proposed
procedure and anticipated outcomes. Risks of the procedure are
also discussed. Imaging may be used in some patients to allow
them to objectively see what we feel may be realistic for them.
It is imperative that the patients understand that imaging is an
educational tool and by no means a guarantee of a result.
There are many factors that go into single staging versus multi-
stage procedures. Patient safety is of the utmost importance. How
this is integrated into one’s practice depends on many factors. A
thorough review of the pros and cons of each procedure should
be reviewed with the patient so that the best decision is made for
that individual. 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. While import-
ant, cost should not factor into a final decision about the procedure.
Patients should appreciate that a partnership is created when
a surgeon and patient embark on contouring procedures. Their
final result will be dependent on the procedure chosen and its
execution in addition to the patient embracing proper dietary,
exercise, and lifestyle changes.
84.3 Abdominal Contouring
Surgical abdominal-contouring procedures range from liposuc-
tion to circumferential liposuction combined with a body lift.
Causes of Abdomen Fullness
1.
Fat
2.
Skin excess
3.
Myofascial laxity
4.
Intra-abdominal fat
It is also important to consider the impact of the hips/flank region
when addressing the waist of a patient. Isolated anterior contour-
ing may leave the patient unhappy with a disparity between the
front and back of the trunk with an accentuation of the fullness of
the flank region. Isolated contouring may not significantly change

84 Clinical Decision Making in Body Contouring
1317
the waist of the patient. For this reason, it is important to review
this region as well as the impact of the breast and back and even
the thighs when evaluating a patient for abdominal contouring.
84.4 Abdominal Exam and
Assessment
We evaluate the patient in the upright position in front of a
mirror as well as supine. This allows for a thorough examination
and involves the patient in the process.
84.4.1 Skin Quality
We assess the quality and quantity of the abdominal skin. The
presence and extent of striae are determined. Skin quality and
elasticity are assessed through observation for stretch marks and
the pinch test, in which the skin is pinched and pulled away from
the underlying subcutaneous tissues. It is particularly useful to
note the degree of skin laxity and striae in the epigastrium, because
this area can be difficult to predictably contour when present.
During the pinch test, the degree of adiposity as well as skin elas-
ticity and recoil can be assessed, all playing a role in surgical planning
and managing expectations. A history of prior abdominal surgeries is
imperative to elicit. Abdominal scars can affect the sequencing of the
intraoperative procedures as well as anticipated outcomes. A com-
plete exam should evaluate the patient for both incisional hernias
and incidental hernias. Many women going through pregnancy can
develop incidental hernias, most commonly of the umbilicus. Their
presence and need for correction may impair the circulation and
change the operative plan (Fig. 84.1, Fig. 84.2, Fig. 84.3).
84.4.2 Fat
The amount of excess fat and its location are noted. The fat in the
epigastrium is a bit more fibrous and compact. Depth and extent
should be determined, particularly if a lipoabdominoplasty is
planned. It is important to note the degree of lipodystrophy over
the costal margin as well as the adjacent flanks.
84.4.3 Myofascial Laxity
The patient is examined while standing and recumbent. The mus-
cles and fascia above and below the umbilicus are evaluated. With
the patient standing, the silhouette of the abdomen is evaluated.
A “rounded” appearance may be seen with a prominent diastasis
and/or the presence of intra-abdominal fat. The pinch test can help
the physician distinguish between the two. 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, with forced expiration and
on straight-leg-raising, which contracts the abdominal muscles,
making weakness, diastasis, and any hernia much more obvious.
Diastasis and hernias will have to be repaired to achieve
flattening of the abdominal contour. :hen abdominal fullness
is due only to lipodystrophy, liposuction only may achieve the
goal of flattening the abdominal contour. Skin laxity, myofascial
laxity, and hernias would need to be additionally addressed when
present to achieve the optimal outcome (Fig. 84.4).
84.4.4 Intra-abdominal Fat
The presence of intra-abdominal fat or “visceral” fat may
adversely affect abdominal contour. This is often seen in higher
body mass index patients and in men. In the case of the former,
the patient should be counseled that weight loss will be necessary
to improve this and lead to a better contour. In men, it may limit
how much improvement can be seen, even with an abdomino-
plasty. As a general rule, myofascial plication does not adequately
correct the presence of intra-abdominal fat (Fig. 84.5).
Fig. 84.1 (a,c,e) Pre- and (b,d,f) 6 months post–lower body lift.

1318
XII Body Contouring
Fig. 84.2 (a,c,e,g) Pre- and (b,d,f,h) 4 months post–lower body lift and thighplasty.
Fig. 84.3 (a,c,e,g) Pre- and (b,d,f,h) 1 year postliposuction to abdomen, hips, and thighs.

84 Clinical Decision Making in Body Contouring
1319
Fig. 84.4 (a,c,e) Pre- and (b,d,f) 7 months post-aplasty.

1320
XII Body Contouring
Fig. 84.5 (a,b,d,e,g,h) Pre- and (c,f,i) 1 year postabdominoplasty.
a
d
g
c
f
i
b
e
h

84 Clinical Decision Making in Body Contouring
1321
Adjacent Areas
In most patients after an isolated abdominoplasty, the recon-
toured abdomen blends in well with the adjacent areas—the
upper thighs, hips, buttocks, flanks, and back³especially if the
abdominoplasty is combined with some liposuction of the flanks.
However, in an increasing number of patients seeking abdominal
recontouring, especially after massive weight loss, the abdomen
cannot and should not be dealt with in isolation. We therefore
have to evaluate the adjoining areas³the 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 abdominal operation. These will
range from belt lipectomy to abdominoplasty combined with a
body lift, simultaneously or in a staged fashion.
84.5 3DWienW 3rRÀOeV
84.5.1 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 contraction (Fig. 84.6).
84.5.2 Class 2
Class 2 patients have normal-quality skin with minimal to mod-
erate 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 abdominal wall plication to achieve maximum
contour improvement.
A miniabdominoplasty allows the lipodystrophy and fascia
to be addressed through a modest skin incision. Although some
skin excision is possible through the lower abdominal incision
with a miniabdominoplasty, 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
umbilical 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 miniabdominoplasty
approach, it is not easy in longer torsos (Fig. 84.7).
84.5.3 Class 3
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
Fig. 84.6 (a,c,e,g) Pre- and (b,d,f,h) 3 months postliposuction to the abdomen, hips, and thighs.

1322
XII Body Contouring
be muscular or fascial weakness. Liposuction or an endoscopic
or miniabdominoplasty approach is not appropriate for these
patients. They require a full abdominoplasty with resection of
the excess skin and fat, with umbilical 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 a position that will avoid any
unnatural elevation of the pubic hairline (Fig. 84.8).
84.5.4 Class 4
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 abdominoplasty is not an appropriate
procedure for class 4 patients; they are best treated through a combi-
nation of procedures that will include an abdominoplasty and a thigh
or body lift. Most patients in this category have undergone massive
Fig. 84.7 (a,c,e) Pre- and (b,d,f) 10 months postminiabdominoplasty.
Fig. 84.8 (a,c,e) Pre- and (b,d,f) 1 year postabdominoplasty.