2. Melvin A.Shiffman Alberto Di Giuseppe (Eds.) Body Contouring
Art,Science,and Clinical Practice
3. ISBN: 978-3-642-02638-6 e-ISBN: 978-3-642-02639-3 DOI:
10.1007/978-3-642-02639-3 Springer Heidelberg Dordrecht London New
York Library of Congress Control Number: 2009942715 Springer-Verlag
Berlin Heidelberg 2010 This work is subject to copyright. All
rights are reserved, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting,
reuse of illustrations, recitation, broadcasting, reproduction on
microfi lm or in any other way, and storage in data banks.
Duplication of this publication or parts thereof is permitted only
under the provisions of the German Copyright Law of September 9,
1965, in its current version, and permission for use must always be
obtained from Springer. Violations are liable to prosecution under
the German Copyright Law. The use of general descriptive names,
registered names, trademarks, etc. in this publication does not
imply, even in the absence of a specifi c statement, that such
names are exempt from the relevant protective laws and regulations
and therefore free for general use. Product liability: The
publishers cannot guarantee the accuracy of any information about
dosage and appli- cation contained in this book. In every
individual case the user must check such information by consulting
the relevant literature. Cover design: eStudio Calamar,
Figueres/Berlin Printed on acid-free paper Springer
Science+Business Media (www.springer.com) Melvin A. Shiffman, MD,
JD 17501 Chatham Drive Tustin, CA 92780-2302 USA
[email protected] Alberto Di Giuseppe, MD Department of
Plastic and Reconstructive Surgery, School of Medicine University
of Ancona 1, Pizza Cappelli 60121 Ancona Italy
[email protected]
4. v Dedication This book is dedicated to the women of my life,
to my mother, Sara, who died at the age of 82 in December 2008, who
was the dearest angel of my young age and to my wife, Isabella,
married for 20 years, who was my unique love and who has been
patient and helpful in sustaining all my work and dedication. I
wish the new genera- tion of nephews, Diana, Federico, and Saverio,
to continue our work following the same principles that have
imprinted our lives. Special thanks to my dearest friend, Melvin, a
man of special talent and humanity, sensible, and creative, who has
made the greatest effort to realize this book. Dr. Alberto Di
Giuseppe
5. vii Foreword As plastic surgeons, we seek to combine art and
science to improve the results we see in clinical practice. Through
our artistic sensibilities, we try to understand and obtain
aesthetic results. Scientific analysis provides the data to predict
which approaches will be successful and safe. Both art and science
connote a high level of skill or mastery. At the present time, our
literature is replete with descriptions of specific proce- dures
for body contouring. However, there remains a need for a definitive
reference describing the basic principles to address the complete
scope of body contouring including the postbariatric patient and
their plastic surgery deformities. Dr. Shiffman and Dr. Di Giuseppe
saw this need and sought to address the needs of plastic surgeons
faced with the complexities of body contouring surgery. This is a
comprehensive text aimed at providing multiple perspectives. The
numerous sections, which include adi- posity and lipolysis, the
breast, abdomen, chest, and buttocks, the extremities, and
liposuction, offer various approaches from the foremost authors.
Indeed it is with a tremendous amount of skill and mastery that Dr.
Shiffman and Dr. Di Giuseppe have successfully edited and collated
the numerous contributions to this work. In addition, they have
authored individually or, in collaboration, over a dozen of the 87
total chapters. Their combined work as editors and authors are evi-
dent throughout their text. The final result is a comprehensive
contribution that will benefit all plastic surgeons seeking to
improve their approach to body contouring. Division of Plastic
Surgery Jorge I. de la Torre The University of Alabama at
Birmingham Birmingham, USA
6. ix Preface Contouring of the body includes shaping of the
neck, torso, breasts, hip, abdomen, and extremities. The types of
procedures performed to shape the body involve surgi- cal
excisions, liposuction, implantation, injection of fillers, and in
rare instances other modalities. Since the advent of bariatric
surgery with extreme weight loss and sag- ging of tissues, body
contouring has become more extensive and consequently with more
possible complications. Clothes have been used to accentuate the
body contour in certain areas and mini- mize in other areas.
However, clothes that expose more of the body contour will
accentuate the bodys defects. Therefore, patients are requesting
improvement in the shape of their bodies in order to accommodate
the clothes that are fashionable. There are limits as to what
surgery will accomplish but certainly the procedures that are
available can improve the shape but rarely can make it perfect.
Patients should be made to understand the limits of the procedures,
the limits of correction that can be obtained, and the possibility
of complications that may permanently mar the patients appearance.
The cosmetic surgery patient usually expects perfection without
compli- cations even when the possible risks and complications are
thoroughly discussed. These are elective procedures on patients who
are usually in good health although this is not necessarily true
for the post bariatric surgery patient. Obesity increases the risks
of surgery and the patient who is overweight should be specifically
informed of this problem. This book is an attempt to bring to the
student and practicing plastic and cosmetic surgeon, or any
specialty where body contouring may be performed, the types of pro-
cedures available, the techniques of performing these procedures,
and their possible risks and complications. Special attention is
paid to the procedures and problems of the post bariatric patient
since this is a separate specialty of body contouring. Many
international specialists have been selected to contribute to this
book in order to expand the knowledge of those performing body
contouring surgery. Knowledge is international and should not be
restricted to local or national ideas only. The reader will be
introduced to old and new techniques and variations in tech- niques
in order to better understand what is available to the aesthetic
surgeon. Students and experienced surgeons of body contouring
surgery will greatly benefit by the extensive information available
that is not otherwise to be found in one book but mainly in a
variety of papers in the medical literature. Tustin, California,
USA Melvin A. Shiffman Ancona, Italy Alberto Di Giuseppe
7. xi Contents Part IAnatomy, Classification of Adiposities,
Body Contouring, Injection Lipolysis 1 Mammary Anatomy . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 3 Michael R. Davis 2 Gluteal Contouring Surgery: Aesthetics and
Anatomy. . . . . . . . . . . . . 9 Robert F. Centeno 3 Anatomy and
Topography of the Anterior Abdominal Wall . . . . . . . . . 27
Michael R. Davis and Matthew R. Talarczyk 4 History of
Classifications of Adiposity Excess . . . . . . . . . . . . . . . .
. . . . . 33 Melvin A. Shiffman 5 Body Contour: A 50 Year
Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39 Ivo Pitanguy and Henrique N. Radwanski 6 Injection Lipolysis for
Body Contouring. . . . . . . . . . . . . . . . . . . . . . . . . 59
Diane Duncan Part II Breast 7 History of Breast Augmentation . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Melvin
A. Shiffman 8 Inframammary Approach to Subglandular Breast
Augmentation . . . . 77 Anthony Erian and Amal Dass 9
Hydrodissection Axillary Approach Breast Augmentation . . . . . . .
. . . . 87 Sid J. Mirrafati and Melvin A. Shiffman 10 Complications
of Breast Augmentation. . . . . . . . . . . . . . . . . . . . . . .
. . . 93 Anthony Erian and Melvin A. Shiffman 11Regnault B
Mastopexy: A Versatile Approach to Breast Lifting and Reduction. .
. . . . . . . . . . . . . . . . . . . . . 119 Howard A. Tobin
8. xii Contents 12 Mastopexy/Reduction and Augmentation Without
Vertical Scar. . . . . 125 Sid J. Mirrafati 13Breast Reduction and
Mastopexy with Vaser in Male Breast Hypertrophy . . . . . . . . . .
. . . . . . . . . . . . . . . . 131 Alberto Di Giuseppe
14Gynecomastia Repair Using Power-Assisted Superficial Liposuction
and Endoscopic Assisted Pull-Through Excision . . . . . . . . 139
Yitzchak Ramon and Yehuda Ullmann 15 Mastopexy Complications. . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
145 Melvin A. Shiffman 16 History of Breast Reduction . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Melvin A. Shiffman 17 Strombeck Breast Reduction Technique . . . .
. . . . . . . . . . . . . . . . . . . . . . 155 Pierre F. Fournier
18 Inverted Keel Resection Breast Reduction . . . . . . . . . . . .
. . . . . . . . . . . . 169 Ivo Pitanguy and Henrique N. Radwanski
19 Vaser-Assisted Breast Reduction . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 179 Alberto Di Giuseppe 20
Complications of Breast Reduction . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 197 Melvin A. Shiffman Part III Abdomen,
Chest, Buttocks 21 History of Abdominoplasty . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 207 Giovanni Di
Benedetto and William Forlini 22 Abdominoplasty Principles. . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Melvin A. Shiffman 23 Liposculpture of the Abdomen in an
Office-Based Practice . . . . . . . . . . 219 Peter M. Prendergast
24Anchor-Line Abdominoplasty: A Comprehensive Approach to Abdominal
Wall Reconstruction and Body Contouring . . . . . . . . . . . 239
Paolo Persichetti, Pierfranco Simone, Annalisa Cogliandro, and
Nicol Scuderi 25 Circular Lipectomy with Lateral ThighButtock Lift.
. . . . . . . . . . . . . 249 Hctor J. Morales Gracia 26 Prevention
and Management of Abdominoplasty Complications . . . . . 267 Melvin
A. Shiffman
9. Contents xiii 27Mastopexy with Extended Chest Wall-Based
Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 277 Luiz Haroldo Pereira and
Aris Sterodimas Part IV Extremities 28 Brachioplasty: How to Choose
the Correct Procedure . . . . . . . . . . . . . . 287 A. Chasby
Sacks 29 Brachioplasty: A Body-Contouring Challenge. . . . . . . .
. . . . . . . . . . . . 293 James G. Hoehn, Sumeet N. Makhijani,
and Jerome D. Chao 30 Fish-Incision Brachioplasty . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 307 Rajiv Y.
Chandawarkar 31Brachioplasty Technique with Molds Combined to Vaser
Assisted Lipomyosculpture . . . . . . . . . . . . . . . . . . . .
313 Ewaldo Bolivar de Souza Pinto and Pablo S. Frizzera Delboni 32
Limited Incision Medial Brachioplasty . . . . . . . . . . . . . . .
. . . . . . . . . . . . 321 Andrew P. Trussler and Rod J. Rohrich
33 Augmentation Brachioplasty with Cohesive Silicone Gel Implants .
. . . 327 Gal Moreira Dini and Lydia Massako Ferreria 34 Long-Term
Outcomes and Complications After Brachioplasty . . . . . . . 331
James Knoetgen III 35 Lymphoscintigraphy: Evaluation of the
Lymphatic System . . . . . . . . . . 337 Cristina Hachul Moreno,
Aline Rodrigues Bragatto,Amrico Helene, Carlos Alberto Malheiros,
and Henrique Jorge Guedes Neto 36Medial Thigh Lift and Declive:
Inner Thigh Lift Without Using Colles Fascia . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 347 Daniele Spirito
37Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and
Augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . .
355 Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino 38A
Novel Treatment Option for Thigh Lymphoceles Complicating Medial
Thigh Lifting Procedures. . . . . . . . . . . . . . . . . . . 365
Wayne K. Stadelmann 39 Fat Augmentation of Buttocks and Legs . . .
. . . . . . . . . . . . . . . . . . . . . . . 373 Lina Valero de
Pedroza 40 Lower Leg Augmentation with Combined Calf-Tibial Implant
. . . . . . . 381 Afshin Farzadmehr and Robert A. Gutstein
10. xiv Contents Part V Liposuction 41Ultrasound-Assisted
Lipoplasty: Basic Physics, Tissue Interactions, and Related
Results/Complications. . . . . . . . . . . . 389 William W. Cimino
42 History of Ultrasound-Assisted Lipoplasty. . . . . . . . . . . .
. . . . . . . . . . . 399 William W. Cimino 43Face and Neck
Remodelling with Ultrasound-Assisted Lipoplasty (Vaser) . . . . . .
. . . . . . . . . . . . . . . . 405 Alberto Di Giuseppe 44 High
Definition Liposculpting . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 419 Alfredo Hoyos 45 Vaser-Assisted
Liposculpture for Body Contouring . . . . . . . . . . . . . . . .
425 Alberto Di Giuseppe 46Circumferential Para-Axillary Superficial
Tumescent (CAST) Liposuction for Upper Arm Contouring. . . . . . .
. . . . . . . . . . . 459 Andrew T. Lyos 47 Body Contouring with
Focused Ultrasound . . . . . . . . . . . . . . . . . . . . . . .
473 Javier Moreno-Moraga and Josefina Royo de la Torre 48 Focus
Ultrasound on Limited Lipodystrophies . . . . . . . . . . . . . . .
. . . . . 485 Michele Cataldo, Luca Grassetti, and David E. Talevi
49Aesthetic Body Contouring of the Posterior Trunk and Buttocks
Using Third Generation Pulsed Solid Probe Internal
Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 493 Onelio Garcia Jr. 50 Treatment
Options in Benign Symmetric Lipomatosis . . . . . . . . . . . . . .
505 Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso
51 Liposuction for Madelungs Neck . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 513 Robert Yoho 52Body Contouring of
the Thigh: The Third Dimension by Leonardo Da Vinci . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 517 Alberto Di
Giuseppe 53Liposuction of the Calves and Ankles Associated with
Calf Implant . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 539 Adrien E. Aiache 54Management
of HIV-Associated Lipodystrophy: Medical and Surgical Options for
Lipoatrophy and Lipohypertrophy . . . . . . . . . . . . . . . 545
C. Scott Hultman and Anne Keen
11. Contents xv 55 Prevention and Treatment of Liposuction
Complications . . . . . . . . . . . 553 Melvin A. Shiffman
56Comparison of Blood Loss in Suction-Assisted Lipoplasty and
Third-Generation Ultrasound-Assisted Lipoplasty . . . . . . . . . .
. . . 565 Onelio Garcia Part VI Fat Transfer 57 Fat Transfer
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 577 Melvin A. Shiffman 58Enhancing Muscle
Appearance with Extensive Liposuction and Fat Transfer. . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 587 Alfredo
Hoyos 59 Remodelling Breast and Torso with Liposuction and Fat
Grafts . . . . . . 595 Alfredo Hoyos and David Broadway 60 Buttock
Remodeling with Fat Transfer. . . . . . . . . . . . . . . . . . . .
. . . . . . 599 William L. Murillo 61 Complications of Fat Transfer
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
617 Hassan Abbas Khawaja, Melvin A. Shiffman, Enrique
Hernandez-Perez,JosEnriqueHernndez-Prez, and Mauricio
Hernandez-Perez Part VII Body Contouring After Severe Weight Loss
62 History of Bariatric Surgery . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 629 Melvin A. Shiffman
63Psychosocial Aspects of Body Contouring Surgery After Bariatric
Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 633 Troy W. Ertelt, Joanna M. Marino,
and James E. Mitchell 64 Psychosocial Issues in Body Contouring . .
. . . . . . . . . . . . . . . . . . . . . . . . 641 David B. Sarwer
65 Nutrition Issues After Bariatric Surgery for Weight Loss . . . .
. . . . . . . 651 George John Bitar and Sally Myers 66The Bodys
Aesthetic Units for Body Contouring Surgery in Massive Weight Loss
Patients . . . . . . . . . . . . . . . . . . . . . . . . . 661
Hctor J. Morales Gracia and Alberto Javier Coutt Mayora
67Classification of Contour Deformities After Massive Weight Loss:
Clinical Applications of the Pittsburgh Rating Scale . . . . . . .
. . . . . . . . 675 Angela S. Landfair, Dennis J. Hurwitz, Madelyn
H. Fernstrom, Raymond Jean, and J. Peter Rubin
12. xvi Contents 68 Facial Contouring in the Postbariatric
Surgery Patient . . . . . . . . . . . . . 687 Anthony P. Sclafani
and Vikas Mehta 69 Total Body Lift After Massive Weight Loss . . .
. . . . . . . . . . . . . . . . . . . . 695 Nestor Veitia and
Dennis J. Hurwitz 70Transaxillary Breast Augmentation/Wise-Pattern
Mastopexy in the Massive Weight Loss Patient . . . . . . . . . . .
. . . . . . . . . 709 George John Bitar 71Mastopexy with Extended
Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 719 Ruth Maria Graf,
Daniele Pace, and Alexandre Mansur 72Medial Thigh Lift Free Flap
for Breast Augmentation After Bariatric Surgery . . . . . . . . . .
. . . . . . . . . . . . . . . . . 725 Thomas Schoeller and Georg M.
Huemer 73Rotation-Advancement Superomedial Pedicle Mastopexy
Following Massive Weight Loss . . . . . . . . . . . . . . . . . . .
. . . . 735 Albert Losken 74 Flank Reshaping . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
743 Keith Robertson and Bilal Gondal 75Perforator Sparing
Abdominoplasty: Indications and Operative Technique . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 757 Ulrich M. Rieger and
Martin Haug 76Abdominal Lipectomy and Mesh Repair of Midline
Periumbilical Hernia After Bariatric Surgery Sparing the Umbilicus
. . . . . . . . . . . . . 763 Antonio Iannelli 77Combined
Abdominoplasty and Medial Vertical Thigh Reduction Following Severe
Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . 769
Mohammed G. Ellabban and Nicholas B. Hart 78Complications in
Abdominoplasty Patients After Bariatric Surgery. . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775 Mikko
Larsen and Peter W. Plaisier 79Quality of Life After Abdominoplasty
Following Bariatric Surgery . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 783 Wilson Cintra, Miguel Luiz
Antonio Modolin, Joel Faintuch, Rolf Gemperli, and Marcus Castro
Ferreira 80Algorithm for Surgical Plane in Brachioplasty After
Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 789 Claudio Cannistra
14. xix Contributors Francisco J. Agullo, MD Mayo Clinic,
Division of Plastic Surgery, 200 First Street SW, Rochester, MN
55905, USA and Department of Surgery, Texas Tech University Health
Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
[email protected] Adrien E. Aiache, MD 9884
Little Santa Monica Blvd, Beverly Hills, CA 90212, USA
[email protected] George J. Bitar, MD Bitar Cosmetic Surgery
Institute, 8650 Sudley Road 203, Manassas, VA 20110, USA
[email protected] Aline Rodrigues Bragatto, Jr, MD Rua
Vergueiro, 1353 cj 407, Paraiso CEP 04101-000, So Paulo, Brazil
[email protected] David Broadway, MD 9777 S Yosemite
Street, Suite 200, Lone Tree, CO 80124, USA [email protected]
Claudio Cannistr, MD Department of Surgery, Plastic Surgery Unit,
Bichat C. B. University Hospital, 71 rue de Rome, 75008 Paris,
France [email protected] or [email protected] Michele
Cataldo, MD via Turati 4, 20060 Trezzano Rosa, Milano, Italy
[email protected] or [email protected]
Robert F. Centeno, MD P.O. Box 24330, Christian Sted, VI 008240330,
USA [email protected] Rajiv Y. Chandawarkar, MD
Department of Surgery, Division of Plastic Surgery, University of
Connecticut, School of Medicine, Farmington, CT 06030, USA
[email protected]
15. xx Contributors Jerome D. Chao, MD Division of Plastic
Surgery , Albany Medical College, 25 Hackett Blvd, MC133, Albany,
NY 12208, USA [email protected] William W. Cimino, PhD Sound
Surgical Technologies, 1300 Plaza Court North, Suite 103,
Lafayette, CO 80026, USA and 578 W. Sagebrush Ct., Louisville, CO
80027, USA [email protected] or [email protected]
Wilson Cintra, JR, MD Plastic Surgery Service, Hospital das
Clnicas, Av. San Gabriel, 201 conj. 704/5, So Paulo, SP 01435001,
Brazil [email protected] Annalisa Cogliandro, MD Division of
Plastic and Reconstructive Surgery, Campus Bio-Medico University,
Via Fontanellato, 49, 00142 Rome, Italy [email protected]
Alberto Javier Coutt Mayora, MD Belisario Domnguez No. 2501,
Colonia Obispado, Monterrey, Nuevo Len C.P 64060, Mxico
[email protected] Amal Dass, MD Advanced AestheticsSurgery, 1,
Grange Rd, Orchard Bldg, #06-06 Singapore 239693
[email protected] Michael R. Davis, MD Division of Plastic
Surgery, University of Alabama, Birmingham School of Medicine, 510
20th Street South, 1164 Faculty Office Tower, Birmingham, AL
35294-3411, USA [email protected] Jorge I. De La Torre, MD Division
of Plastic Surgery, The University of Alabama at Birmingham, 510
20th Street South, 1164 South Faculty Office Tower, Birmingham, AL
35294-3411, USA [email protected] Josefina Royo de la Torre, MD
Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid,
Spain [email protected] Pablo Silva Frizzera Delboni, MD Plastic
Surgery Department, Santa Cecilia University UNISANTA, So Paulo,
Brazil [email protected] or [email protected] Lina
Valero de Pedrosa, MD Carrera 16 No 82-95-Cons: 301, Bogota, DC,
Colombia [email protected] Ewaldo Bolivar de Souza Pinto, MD,
PhD Plastic Surgery Department, Santa Cecilia University UNISANTA,
Alameda Santos, 455 cj. 306, So Paulo, Brazil
[email protected] or dePedrosa [email protected]
Giovanni Di Benedetto, MD, PhD Marche Polytechnic University
Medical School, Via Tronto, 20, Ancona, Italy
[email protected]
16. Contributors xxi Alberto Di Giuseppe, MD Department of
Plastic and Reconstructive Surgery, School of Medicine, University
of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy
[email protected] Gal Moreira Dini, MD Department of
Plastic Surgery, Universidade Federale de So Paulo, Escola Paulista
de Medicina, R. Vicencia faria Versage 400 ap. 113-14, Sorocaba Sao
Paulo 18031-080, Brazil [email protected] Diane Duncan, MD FACS,
1701 East Prospect Road, Fort Collins, CO 80525, USA
[email protected] Mohammed G. Ellabban, MD Plastic and
Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green
Lane North, Fulwood, Preston PR2 9HT, UK
[email protected] Anthony Erian, MD Division of Plastic
Surgery, Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK
[email protected] Troy W. Ertelt, MD Department of
Psychology, University of North Dakota, Grand Forks, and
Neuropsychiatric Research Institute, 120, 8th Street South, Fargo,
ND 58102, USA [email protected] Joel Faintuch, MD Plastic
Surgery Service, Hospital das Clnicas, So Paulo, SP, Brazil and
Division of Nutrology Residence Program, Plastic Surgery Service,
Hospital das Clnicas, So Paulo, SP, Brazil [email protected]
Afshin Farzadmehr, MD Plastic Surgery Center of Beverly Hills, 1125
South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA
[email protected] or [email protected] Madelyn H.
Fernstrom, PhD 3811 OHara Street, Suite 1617, Pittsburgh, PA 15213,
USA [email protected] Marcus Castro Ferreira, MD Plastic Surgery
Service, Hospital das Clnicas, So Paulo, SP, Brazil
[email protected] Lydia Massako Ferreria, MD, PhD Department of
Plastic Surgery, Universidade Federale de So Paulo, Escola Paulista
de Medicina, So Paulo, Brazil [email protected] William
Forlini, MD, PhD Marche Polytechnic University Medical School, Via
Tronto, 20, Ancona, Italy [email protected]
17. xxii Contributors Pierre F. Fournier, MD 55 Boulevard de
Strasbourg, 75 010 Paris, France [email protected]
Onelio Garcia, Jr. MD Division of Plastic Surgery, University of
Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami,
FL 33146, USA [email protected] Daron Geldwert, MD Hurwitz Center
for Plastic Surgery, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA
15213, USA [email protected] Rolf Gemperli, MD Plastic Surgery
Service, Hospital das Clnicas, Rua Pedrosa Alvarenga, 120, So
Paulo, SP 04531-004, Brazil [email protected] Bilal Gondal, MB
BCh, BAO Dubl, BSc, BA King Fahd Uni of Petroleum and Minerals,
KFUPM, PO Box 372, Dhahran 31261, Saudi Arabia [email protected]
Ruth Maria Graf, MD, PhD Division of Plastic and Reconstructive
Surgery, Department of Hospital de Clnicas, Federal University of
Paran (UFPR), Curitiba-PR, Brazil [email protected] or
[email protected] Luca Grassetti, MD Department of Plastic and
Reconstructive Surgery, Marche Polytechnic University Medical
School, Ancona, Italy [email protected] Robert A.
Gutstein, MD Plastic Surgery Center of Beverly Hills, 1125 South
Beverly Drive, Suite 600, Los Angeles, CA 90035, USA Nicholas B.
Hart, MD, FRCS Plastic Surgery Unit, Castle Hill Hospital,
Cottingham Hull, East Yorkshire, HU16 5JQ, UK [email protected]
Martin Haug, MD Department of Plastic and Reconstructive Surgery,
Basel University Hospital, Spitalstrasse 21, 4056 Basel,
Switzerland Amrico Helene, Jr. MD Av Itacira, 577 Planalto
Paulista, CEP 04064-000, Sao Paulo, Brazil [email protected]
Charles K. Herman, MD Department of Plastic Surgery, Albert
Einstein College of Medicine, New York, NY, USA and Plastic and
Reconstructive Surgery, Pocono Health Systems, 100 Plaza Court,
East Stroudsburg, PA 18301, USA [email protected] Enrique
Hernandez-Perez, MD 7801 NW 37th St., Club VIP, Suite 369, Miami,
FL 33166-6503, USA [email protected]
18. Contributors xxiii Jos Enrique Hernndez-Prez, MD Center for
Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel
Local 3-1, Col. Escaln, San Salvador, CP 01-177
[email protected] Mauricio Hernandez-Perez, MD Center for
Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel
Local 3-1, Col. Escaln, San Salvador, CP 01-177
[email protected] James G. Hoehn, MD Division of Plastic
Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY
12208, USA [email protected] Alfredo Hoyos, MD Evolution Medical
Center, Calle 119, 11D-30 (nueva), Bogota, Colombia
[email protected] Georg M. Huemer, MD General Hospital Linz,
Krankenhausstrasse 9, 4021 Linz, Austria [email protected] C.
Scott Hultman, MD, MBA Division of Plastic and Reconstructive
Surgery, University of North Carolina, Suite 7040, Burnett-Womack
Building, CB 7195, Chapel Hill, NC 27599-7195, USA
[email protected] Dennis J. Hurwitz, MD Department of Plastic
Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA,
USA and Department of Surgery, New York-Presbyterian Hospital, 3109
Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA
[email protected] Antonio Iannelli, MD Chirurgie
Digestive et Centre de Transplantation Hpatique, Hpital LArchet 2,
University of Nice Sophia Antipolis, 151 Route Saint Antoine de
Ginestire, BP 3079, Nice, Cedex 3, France
[email protected] Raymond Jean, MD Department of Plastic
Surgery, Loma Linda University, 11175 Campus Street, Suite 21126,
Loma Linda, CA 92354, USA [email protected] Anne Keen, RN Division of
Plastic and Reconstructive Surgery, University of North Carolina,
Suite 7040, Burnett-Womack Building, CB#7195, Chapel Hill, NC
27599-7195, USA [email protected] Hassan Abbas Khawaja, MD
Cosmetic Surgery and Skin Center, 53 A, Block B II, Gulberg III,
Lahore, 54660, Pakistan [email protected] or
[email protected] James Knoetgen III, MD Private Practice,
20296, Bakersfield, CA 93390-0296, USA [email protected]
19. xxiv Contributors Angela S. Landfair, MD, MPH Division of
Plastic Surgery, University of Pittsburgh, 3553 Terrace Street,
Suite 6B, Pittsburgh, PA 15213, USA [email protected] Mikko Larsen, MD
Department of Plastic and Reconstructive Surgery, Free University
Medical Center, Amsterdam, The Netherlands; Department of General
Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands and
Van der Helmstraat 341, 3067HH Rotterdam, The Netherlands
[email protected] Albert Losken, MD Division of Plastic
Surgery, Emory University School of Medicine, 550 Peachtree Street,
Suite 84300, Atlanta, GA 30308, USA
[email protected] or [email protected] Andrew T.
Lyos, MD Division of Plastic Surgery, Bobby R. Alford Department of
Otorhinolaryngology and Communicative Sciences, Baylor College of
Medicine, Houston, TX, USA [email protected] Sumeet N. Makhijani, MD
Division of Plastic Surgery, Albany Medical College, 25 Hackett
Blvd, MC133, Albany, NY 12208, USA [email protected] Carlos Alberto
Malheiros, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, So
Paulo, Brazil [email protected] Alexandre Mansur, MD Rua
Alberto Foloni, 575 ap 23A, Centro Cvico Curitiba, Paran, CEP
80540-000, Sao Paulo, Brazil [email protected] Joanna M. Marino,
MD Department of Psychology, University of North Dakota, Grand
Forks, Neuropsychiatric Research Institute, 120 8th Street South,
Fargo, ND 58102, USA [email protected] David W. Mathes, MD
Department of Surgery, Division of Plastic Surgery, University of
Washington, School of Medicine, 98195, Seattle, WA, USA
[email protected] Vikas Mehta, MD The NY Eye and Ear
Infirmary, 310 East 14th Street, New York, NY 10003, USA
[email protected] Franco Carlo Migliori, MD Plastic Surgery Unit, San
Martino University Hospital, Largo Rosanna Benzi, 10, Monoblocco 8A
Piano Levante, Genoa 16132, Italy
[email protected]
20. Contributors xxv Sid J. Mirrafati, MD 3140 Redhill Avenue,
Costa Mesa, CA 92626, USA [email protected] James E.
Mitchell, MD Department of Clinical Neuroscience, University of
North Dakota School of Medicine and Health Sciences,
Neuropsychiatric Research Institute, 120 South 8th Street, Fargo,
ND, USA [email protected] Miguel Luiz Antonio Modolin, MD
Plastic Surgery Service, Hospital das Clnicas, So Paulo, SP
01486-000, Brazil [email protected] Hctor J. Morales Gracia,
MD Belisario Domnguez 2501, Colonia Obispado, Monterrey, Nuevo Len,
CP 64060, Mxico [email protected] Cristina Hachul Moreno,
MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, So Paulo,
Brazil [email protected] Javier Moreno-Moraga, MD Instituto
Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain
[email protected] William L. Murillo, MD Division of Plastic and
Reconstructive Surgery, Louisiana State University Medical Center,
1542 Tulane Avenue, New Orleans, LA 70112, USA and Division of
Plastic and Reconstructive Surgery, Universidad del Valle, Cali,
Colombia [email protected] Sally Myers, RD Bitar Cosmetic
Surgery Institute, Northern Virginia, 8501 Arlington Blvd. Suite
500, Fairfax, VA 22031, USA [email protected] Henrique Jorge Guedes
Neto, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, So
Paulo, SP, Brazil [email protected] Daniele Pace, MD, MSc
Rua Solimes, 1175, Mercs Curitiba, Paran, CEP 80810-070, Brazil
[email protected] Humberto Palladino, MD Department of
Surgery, Texas Tech University Health Sciences Center, 4800 Alberta
Avenue, El Paso, TX 79905, USA [email protected] Luiz
Haroldo Pereira, MD Luiz Haroldo Clinic, 45/206 Rua Xavier da
Silveira, Rio de Janeiro, 22061-010, Brazil [email protected]
Paolo Persichetti, MD, PhD Division of Plastic Surgery, University
Campus Bio-Medico of Rome, Via Bertoloni 19, 00197 Rome, Italy
[email protected]
21. xxvi Contributors Ivo Pitanguy, MD Ivo Pitanguy Clinic, Rua
Dona Mariana, 65, Rio de Janeiro, 22280-020, Brazil
[email protected] Peter W. Plaisier, MD Department of
General Surgery, Albert Schweitzer Hospital, PO Box 444, 3300 AK,
Dordrecht, The Netherlands [email protected] Peter M.
Prendergast, MD Venus Medical Beauty, Heritage House, Dundrum
Office Park, Dundrum, Dublin 14, Ireland [email protected]
Henrique N. Radwanski, MD Ivo Pitanguy Clinic, Rua Dona Mariana,
65, Rio de Janeiro, 22280-020 Brazil [email protected]
Yitzchak Ramon, MD Elisha and Rambam Medical Centers, Haifa, Israel
[email protected] Maura Reinblatt, MD Department of Plastic
Surgery, Johns Hopkins School of Medicine, Johns Hopkins Bayview
Medical Center, 4940 Eastern Avenue, Suite A-513, Baltimore, MD
21224, USA [email protected] Ulrich M. Rieger, MD Department of
Plastic Reconstructive Surgery, Medical University Innsbruck,
Anichstrasse 35, 6020 Innsbruck, Austria [email protected] or
[email protected] Keith M. Robertson, MD Whitfield Clinic,
Waterford, Ireland [email protected] Rod J. Rohrich, MD
1801 Inwood Road, WA4.238, Dallas, TX 75390, USA
[email protected] Kenneth Rosenstein, MD Department of
Otolaryngology, Division of Facial Plastic Surgery, The New York
Eye and Ear Infirmary, 310 East 14th Street, North Building, New
York, NY 10003, USA [email protected] Joseph J. Rousso, MD
Department of Otolaryngology, Division of Facial Plastic Surgery,
The New York Eye and Ear Infirmary, 310 East 14th Street, North
Building, New York, NY 10003, USA [email protected] J. Peter Rubin,
MD Division of Plastic and Reconstructive Surgery, 3380 Blvd of the
Allies, Suite 180, Pittsburgh, PA 15238, USA [email protected] or
[email protected] A. Chasby Sacks, MD Arizona Cosmetic Surgery, 4202
North 32nd Street, Suite F, Phoenix, AZ 85018, USA
[email protected]
22. Contributors xxvii David B. Sarwer, PhD University of
Pennsylvania School of Medicine, Penn Behavioral Health, 3535
Market Street, Philadelphia, PA 19104, USA
[email protected] Thomas Schoeller, MD, MSc Department for
Handsurgery, Microsurgery, and Reconstructive Breast Surgery,
Marienhospital Stuttgart, Bheimstrae 37, 70199 Stuttgart, Germany
[email protected] Anthony P. Sclafani, MD Department of
Otolaryngology, Division of Facial Plastic Surgery, The New York
Eye and Ear Infirmary, 310 East 14th Street, North Building, New
York, NY 10003, USA [email protected] Nicol Scuderi, MD Department
of Plastic and Reconstructive Surgery, La Sapienza University,
Rome, Italy [email protected] Michele A. Shermak, MD Johns
Hopkins University School of Medicine, Division of Plastic Surgery,
Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Suite
A-518, Baltimore, MD 21224, USA [email protected] Melvin A.
Shiffman, MD, JD 17501 Chatham Drive, Tustin, CA 92780-2302, USA
[email protected] Pierfranco Simone, MD Division of Plastic
and Reconstructive Surgery, Campus Bio-Medico University, Rome,
Italy [email protected] Sadri Ozan Sozer, MD El Paso
Plastic Surgery, 1600 Medical Center Drive, Suite 400, El Paso, TX
79902, USA Department of Surgery, Texas Tech University Health
Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
[email protected] or
[email protected] Daniele Spirito, MD Via delle
Baleniere 107/b, 00121, Rome-Ostia, Italy
[email protected] Wayne K. Stadelmann, MD Pillsbury
Medical Office Building, 48 Pleasant Street, Suite 201, Concord, NH
03301, USA [email protected] Aris Sterodimas, MD, MSc Department of
Plastic Surgery, Ivo Pitanguy Institute, Pontifical Catholic
University of Rio de Janeiro, Rua Dona Mariana 65, Rio de Janeiro
22280-020, Brazil [email protected] Berish Strauch, MD Department
of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY
10467, USA [email protected] or
[email protected]
23. xxviii Contributors Matthew R. Talarczyk, MD Plastic and
Reconstructive Surgery, Wright-Patterson Medical Center, 88
SGOS/SGCQP, 2881 Sugar Maple, Wright-Patterson AFB, OH, USA
[email protected] David E. Talevi, MD Department of
Plastic and Reconstructive Surgery, Marche Polytechnic University
Medical School, Ancona, Italy [email protected] Howard A. Tobin, MD
Facial Plastic and Cosmetic Surgery Center, 6300 Regional Plaza,
Suite 475, Abilene, TX 79606, USA [email protected] Andrew P.
Trussler, MD Department of Plastic Surgery, University of Texas
Southwestern, 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA
[email protected] Yehuda Ullmann, MD Department of
Plastic and Reconstructive Surgery, Rambam Medical Center, 8
HaAliya Street, Haifa 31096, Israel [email protected]
Nestor Veitia, MD 3109 Forbes Avenue, Suite 500, Pittsburgh, PA
15213, USA [email protected] Robert Yoho, MD 797 South Arroyo
Parkway, Pasadena, CA 91105, USA [email protected]
24. Part Anatomy, Classification of Adiposities, Body
Contouring, Injection Lipolysis I
25. 33M. A. Shiffman and A. Di Giuseppe (eds.), Body
Contouring, DOI: 10.1007/978-3-642-02639-3_1, Springer-Verlag
Berlin Heidelberg 2010 1.1Introduction A thorough understanding of
breast development and anatomy is a requirement for modern plastic
surgeons. Advanced techniques of reduction mammaplasty, mas-
topexy, augmentation, and reconstruction demand a comprehensive
knowledge of the current detailed descriptions of breast
architecture. As a complicated physiologic and aesthetic structure,
the form and func- tion of the breast weighs heavily on a womans
psyche. Significant improvements or complications can impact
greatlyontheselfimageforbetterorworse.Optimizing results and
avoidance of complications takes root in the knowledge of breast
anatomy. Only then can a plastic surgeon engage his full creativity
in sculpting the breast form. 1.2Development (Fig.1.1) As a
cutaneous appendage, the breast takes its origin
fromtheectoderm.Thebreastbudbeginsdifferentiation during weeks 810
along the milk ridge. The normal human breast develops over the
fourth intercostal space of the anterolateral chest wall.
Supernumerary nipples and breasts can occur anywhere along the milk
ridge from the axilla to the groin. Statistically, they are most
common near the left inframmary crease. Following a brief period of
activity shortly after birth in response to maternal hormones,
breast devel- opment becomes dormant until the onset of puberty.
Pubertal onset is becoming ever earlier in modern soci- ety but
currently occurs at approximately 9 years of age. Typically, by the
age of 14, parenchymal growth has extended to its mature borders.
These include the sternum medially, the anterior border of the
latissimus dorsi laterally, the clavicle superiorly, and the infra-
mammary crease inferiorly. These represent approxi- mate anatomic
landmarks and are not rigidly defined borders. Breast tissue can
extend across the midline and beyond the inframammary crease. An
extension of the breast tissue normally penetrates the axillary
fascia into the axillary fat pad and is termed the Tail of Spence.
Mature breast morphology projects off the chest wall in a conical
fashion with its apex deep to the nippleareola complex. Development
of overall breast shape is multifacto- rial. Breast form is
dependent on fat content and loca- tion, muscular and skeletal
chest wall contour, and skin quality. These structures display
complex attach- ments and interactions to result in the final form.
Breast shape and size is unique to each individual and is
determined largely by heredity. 1.3Parenchyma (Fig.1.2) Embedded
within the fibrofatty stroma lays the glan- dular portion of the
breast. Glandular structure consists Mammary Anatomy Michael R.
Davis M. R. Davis Division of Plastic Surgery, University of
Alabama, Birmingham School of Medicine, 510 20th Street South, 1164
Faculty Office Tower, Birmingham, AL 35294-3411, USA e-mail:
[email protected] 1
26. 44 M. R. Davis of millions of lobules clustered to comprise
approxi- mately 2025 lobes. Interlobular ducts come together to
form approximately 20 main lactiferous ducts. Lactiferous sinuses
collect milk, and specialized ducts
withinthenippletransmitmilktothesurface.Glandular size remains
relatively constant from individual to individual. The bulk of the
breast consists of fat. Subcutaneous as well as interlobular fat
content deter- mine the texture, contour, and density. The breast
parenchyma is encompassed and supported by an intricate fascial
system. The superficial fascial sys- tem is variable and sometimes
indistinct from the overly- ing dermis anteriorly. Fat content of
the subcutaneous tissue between the dermis and superficial fascia
deter- mines the clarity of these structures. Continuous with the
superficial fascia is a deep component that separates the
parenchyma from the pectoral fascia as well as the fascia overlying
the adjacent muscles. Interposed between the superficial and deep
components of the superficial fascial system are fascial extensions
termed Coopers ligaments. Anchored to the muscular fascia, these
ligaments act to suspend the parenchyma. Attenuation of these
tissues is largely responsible for ptosis. Fig. 1.1 The breast
overlies the anterolateral chest wall containing primarily
glandular tissue and fibrofatty stroma Fig. 1.2 Glandular breast
tissue is lobular in structure with 2025 lobes each drained by a
lactiferous duct. Milk then enters the collecting ducts followed by
lactiferous sinuses prior to exit- ing the nipple
27. 51 Mammary Anatomy 1.4Musculature At its foundation, the
breast sits on a prominent mus- culature that also impacts form and
physiology. The five primary muscle groups that lie deep into the
breast are pectoralis major and minor, serratus anterior, upper
external oblique, and upper rectus abdominis. Perfo rating these
structures are the breasts primary arterial, venous, nerves, and
lymphatic supply. 1.5Skeletal Support Breast symmetry and form is
also dependent on nor- mal skeletal support. The breast overlies
the antero lateral thorax principally over ribs 26. Conditions
which manifest chest wall abnormalities such as pec- tus excavatum
and carinatum, Marfans syndrome, and Polands syndrome can present a
challenge in optimizing breast aesthetics. It is also important to
take note of the changes in the chest wall contour induced by
plastic surgical intervention such as breast augmentation.
1.6Arterial Supply (Fig.1.3) Breast tissue possesses a rich blood
supply from mul- tiple arterial sources. These sources
collateralize within the breast to make a redundant system with
significant clinical implications. Division of parenchyma is safe
provided one of the several primary axes is preserved. Entering the
superomedial portion of the breast over intercostal spaces 26 are
perforators from the internal mammary artery. These vessels supply
the medial pec- toralis muscle prior to entering the breast tissue
and overlying skin. The dominant perforators emanate from the
second and third intercostal spaces. These should be spared during
reduction mammoplasty uti- lizing the superomedial pedicle. Of
note, they are occasionally of adequate caliber for use as
recipient vessels for free flap breast reconstruction. Supplying
the breast superolaterally is the lateral thoracic artery, also
termed the external mammary artery. This vessel originates from the
axillary artery and enters the breast from the inferior axilla. It
distrib- utes its main branches in the upper outer quadrant of the
breast. Intercostal vessels represent an additional important blood
supply to the breast. The lateral breast receives anterior
intercostal arteries from the third through sixth interspaces.
These perforate the serratus anterior just lateral tothe
pectoralborder. Lateral intercostal vessels enter the breast at the
anterior margin of the latissimus dorsi to supply the lateral
breast and overlying skin. Medial intercostal perforators are
responsible for directly supplying the inferomedial and central
paren- chyma inferior to the nipple. These perforators course
upward through the breast tissue to supply the gland and are one
source for nippleareola complex perfusion. 1.7Venous Drainage Two
systems of veins drain the breast. The subdermal venous plexus
above the superficial fascia is quite vari- able and represents the
superficial system. These veins arise from the periareolar venous
plexus. Within the parenchyma, the superficial system anastomoses
with the deep system. Deep venous drainage of the breast
corresponds with the arterial supply. Venous perfora- tors
following internal mammary perforators drain via Fig. 1.3 Blood
supply: The arterial supply to the breast is pre- dominantly by
perforators from the internal mammary artery followed by the
lateral thoracic and anterolateral intercostals arteries
28. 66 M. R. Davis the internal mammary vein to the innominate
vein. Lateral thoracic veins or external mammary veins drain into
the axillary vein. Intercostal veins drain via the azygos vein into
the superior vena cava. 1.8Innervation (Fig.1.4) Mammary
innervation is dense and has considerable redundancy. In addition
to the abundant general cuta- neous sensitivity, the central
portion of the breast including the nippleareola complex serves as
an erog- enous zone and therefore is supplied by fibers contrib-
uting to a sensual character. Just as with the perfusion of the
breast, innervation of the skin comes from all directions.
Superiorly the cervical plexus contributes fibers that course
beneath the platysma to innervate the upper portion of the breast.
These fibers course in the subcu- taneous tissue and can be
elevated and preserved with skin flaps of proper thickness.
Intercostal segmental nerves contribute the remain- der of breast
sensation and should be viewed as the primary sensory nerves.
Through the interdigitations of the serratus anterior emanate the
third through sixth anterolateral intercostal nerves. They enter
the lateral breast at the lateral pectoral margin. Entering the
medial breast along with the internal mammary perfo- rators are
contributions from the second through sixth anteromedial
intercostal nerves. As with the anterolat- eral intercostal nerves,
they contribute sensation to the nippleareola complex.
1.9Lymphatics (Fig.1.5) Lymphatic drainage of the breast has been
extensively studied for its oncologic implications. Breast surgeons
of all disciplines should have an intimate knowledge of the
lymphatic anatomy within the breast. The predominance of lymph from
the mammary gland passes along the interlobular lymphatic vessels
to the subareolar plexus. Lymph is then directed pri- marily toward
the axillary lymph nodes (75%) cours- ing along the venous
drainage. Lateral lymphatics course around the edge of the
pectoralis major to enter Fig. 1.4 Innervation: Branches of the
cervical plexus supply the superior breast. The anteromedial and
anterolateral intercostal nerves supply the mass of the breast
inferiorly from their respec- tive directions Fig. 1.5 Lymphatic
drainage: Lymphatic flow from the paren- chyma coalesces first in
the subareolar plexus and is then directed predominantly to the
axilla. Medial lymphatics are directed to the internal mammary
nodes or to the contralateral breast. Inferior lymphatics may enter
the subperitoneal plexus
29. 71 Mammary Anatomy the pectoral nodal group. Additional
lymphatics route through the pectoral muscles leading to the apical
nodal group. From the axilla, the lymph drains into the subclavian
and supraclavicular nodes. The medial portion of the breast
contributes lymphatic vessels which drain via the parasternal or
internal mammary nodes. They follow internal mam- mary perforators.
There are occasional lymphatic con-
tributionstothecontralateralbreast.Inferiorlymphatics may enter the
rectus sheath and drain into subperito- neal plexus.
1.10NippleAreola Complex As mentioned previously, the nippleareola
complex deserves special attention for its unique aesthetic, sen-
sual, and lactational function. It is an area of dense per- fusion
and innervation. Every attempt should be made to preserve these
meaningful functions. Secondary to its physiologic redundancy, the
nippleareola complex can be reliably preserved with attention to
anatomic principles. Importantly, the blood supply to the
nippleareola complex is both parenchymal and subdermal. The var-
ied dermoglandular pedicles used in reduction mam- maplasty and
mastopexy thus preserve potential lactation and perpetuate
redundant perfusion. The sub- dermal plexus encompassing the
nippleareola com- plex serves to directly perfuse the skin of the
nipple and areola. The nipple itself represents the apex of the
mam- mary gland. Specialized contractile lactiferous ducts within
the nipple facilitate lactation. Montgomerys glands, which reside
in the areola, lubricate the nip- pleareola complex functioning
primarily during lac- tation. Clinically, they appear as small
nodules distributed throughout the areola and should be preserved.
The nipple serves as a port of entry for bacteria into the mammary
gland. Bacteria can be cultured from throughout the glandular
portion of the breast. Thus, the division of the gland as in most
breast surgery can elaborate bacteria (typically Staphylococcus
epider- midis). Bacterial prophylaxis should be strongly con-
sidered in any breast surgery, but especially with implant
placement.
30. 9M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring,
DOI: 10.1007/978-3-642-02639-3_2, Springer-Verlag Berlin Heidelberg
2010 2.1Introduction Most plastic surgeons are probably more
familiar with the anatomy of the face, abdomen, or breasts than
with the anatomy of the gluteal region. Because only a small
percentage of plastic surgery procedures involve the buttocks,
retaining knowledge of its clinical anatomy is not a high priority
for most surgeons. This picture, however, is changing as increasing
number of patients request body contouring and are increasingly
aware of the numerous techniques now available for enhancing the
gluteal region. These include the use of implants, autologous fat
transfer, autologous gluteal augmenta- tion with tissue flaps,
excisional procedures (lifts), and liposuction. Combinations of
more than one of these techniques often produce superior aesthetic
results. Unfortunately, these procedures can produce glu- teal
deformities as well as serious complications if the anatomical
structures of the buttocks are not well understood. Obviously, the
buttocks are subjected to a great amount of pressure, especially
when sitting or bending. Any wound complication that develops will
require a prolonged healing time and keep patients from resuming
their daily activities. Even more serious is a surgery that
interferes with gluteal muscle function or alters nerve activity in
the legs. A well-developed and aesthetically-pleasing gluteal
region is a trait unique to primates, which was likely an
evolutionary adaptation to erect posture and bipedal locomotion.
Buttock projection is largely formed by the gluteus maximus muscle
and fat deposits in the superficial fascia. In addition, our erect
posture con- tributed to the lumbosacral curve, which is also
unique to primates. Evolutionary biology suggests that an hourglass
figure, with a small waist and full buttocks, has historically been
associated with female reproduc- tive potential and physical health
across cultures, gen- erations, and ethnicities [1]. A waist-to-hip
ratio of 0.7 in women remains the ideal of beauty even as different
ethnic groups prefer different gluteal shapes and cur- vatures. As
women age and fertility declines, skin lax- ity increases and the
shape of the gluteal region usually changes as the content and
distribution of fat and mus- cle change [2, 3]. The hourglass shape
fades and the waist-to-hip ratio approaches 1.0, similar to men. An
aesthetic outcome of gluteal contouring relies on the knowledge of
clinical anatomy, both superficial and deep, in and around this
region. Such knowledge also reduces the incidence of complications
and improves patient satisfaction. Anatomical knowledge is
essential for procedures that augment, reduce, or recontour the
buttocks in this still evolving area of plastic surgery.
2.2Codifying the Gluteal Aesthetic To determine the appropriate
surgical plan for a patient inquiring about gluteal enhancement or
body contour- ing surgery, the characteristics of ideal gluteal
aesthet- icsmustbecarefullyconsidered.In2004,Cuenca-Guerra and
colleagues first reported their analysis of more than 2,400 images
of the gluteal area taken from various media sources [4, 5]. This
study helped to codify four Gluteal Contouring Surgery: Aesthetics
and Anatomy Robert F. Centeno R. F. Centeno P.O. Box 24330,
Christian Sted, VI 00824-0330, USA e-mail:
[email protected] 2
31. 10 R. F. Centeno of the most recognizable characteristics
of an aestheti- cally-pleasing gluteal region (Fig. 2.1). The
following landmarks are discussed in detail later in this chapter.
1. Two well-defined dimples on each side of the medial sacral crest
that correspond to the posterior-superior iliac spines (PSIS). 2. A
V-shaped crease (or sacral triangle) that arises from the proximal
end of the gluteal crease with each line of the V extending toward
the sacral dimples. 3. Short infragluteal folds that do not extend
beyond the medial two-thirds of the posterior thigh. 4. Two mild
lateral depressions that correspond to the greater trochanter of
the femur. Most of these characteristics are universally accepted
byavarietyofcultures.However,Robertshasdescribed specific
variations in aesthetic ideals between ethnic groups in the U.S.
[2]. Of the four landmarks just described, numbers 1 through 3 are
generally constant features of attractive buttocks regardless of
ethnicity. Number 4 (mild lateral depressions) is not preferred by
Hispanic-Americans or African-Americans. Other aesthetic
differences among ethnic groups have also been identified by
Roberts. A short buttock with a high point of maximum projection is
popular among Asian- Americans because this shape creates the
illusion of longer legs and a balanced proportion between the torso
and extremities. In Roberts analysis, Hispanic- Americans and
African-Americans seem to prefer more projection than either Asians
or Caucasians, with a higher point of maximum projection and more
severe lumbosacral depression. Caucasians in the U.S. trend toward
a more athletic ideal with greater definition of the muscular and
bony anatomy or a rounded appear- ance, with either shape having
less anterior-posterior projection. Another way of evaluating the
buttocks to help plan body contouring procedures and then assess
their out- comes is to view the gluteal region as having eight aes-
thetic units (Fig. 2.2) [6]. From the posterior-anterior view, the
gluteal region consists of two symmetrical flank units, a sacral
triangle unit, two symmetrical gluteal units, two symmetrical thigh
units, and one infragluteal diamond unit. All eight gluteal
aesthetic units play a role in improving the aesthetic outcome of
body contouring in the gluteal region, and all should be considered
during the surgical planning process. Particular units may benefit
from being augmented, reduced, preserved, or better defined. To
enhance over- all gluteal appearance, the junctions between these
aesthetic units should guide incision placement during excisional
procedures. Procedures performed on the torso, gluteal region, and
lower extremities may have an important impact on the aesthetic
perception of the buttocks. As an example, patients who have
significant intraabdominal fat may have a widened, squared
appearance if only abdominoplasty is performed. The same procedure
in a patient without significant intraabdominal fat can better
define the waist and improve gluteal aesthetics. Gluteal aesthetics
can be greatly enhanced by judi- cious liposuction of the abdomen,
anterior thigh, medial thigh, lateral thigh, flanks, and
lumbosacral region. However, overly aggressive liposuction of the
buttock, infragluteal fold, or hips often produces sub- optimal
aesthetic results. Poorly placed incisions also detract from the
gluteal aesthetic. For example, a cir- cumferential body lift (CBL)
incision that runs straight across the back will make the buttock
appear too long and rectangular or too square, depending on whether
the incision is too high or too low, respectively. An incision that
curves into a V shape along the lateral and inferior borders of the
sacral triangle can greatly help define this aesthetic unit (Fig.
2.3). This inverted dart incision has been previously described
[68]. Fig. 2.1 Well-defined sacral dimples and sacral triangle,
lateral depressions, and a short infragluteal crease are important
aes- thetic characteristics of the gluteal region
32. 112 Gluteal Contouring Surgery: Aesthetics and Anatomy Fig.
2.2 The eight gluteal aesthetic units are: 2 symmetrical flank
units (1 and 2); 1 sacral triangle unit (3); 2 symmetrical buttock
units (4 and 5); 1 infragluteal diamond unit (6); and 2 symmetrical
thigh units (7 and 8) Fig. 2.3 Preoperative markings and
postoperative position of the inverted dart modification to the
posterior circumferential body lift incision
33. 12 R. F. Centeno A patients existing anatomy plays an
important role in Mendietas gluteal evaluation system, which is
helpful for determining the best way to augment or recontour the
buttocks [9, 10]. Because of space limi- tations, only portions of
his system can be mentioned here, but it involves analysis of the
underlying bony framework of the buttocks, the skin, and the
subcuta- neous fat distribution, in addition to the musculature
that overlies the bony frame. Mendieta suggests that surgeons begin
by evaluating the frame, including the height of the pelvis, and
the shape of the frame (round, square, A- or V-shaped). The gluteus
maximus muscle should be evaluated to determine whether the muscle
is tall, intermediate, or short compared with its width. This
information can guide the surgeon in selecting the most appropriate
procedure for a patient. Also, they should determine where volume
is needed by analyz- ing whether volume should be added or removed
from the upper inner, lower inner, upper outer, and lower outer
quadrants of the gluteus maximus. Useful infor- mation for
determining the procedure that would pro- duce a superior aesthetic
result additionally requires an evaluation of the four points at
which the gluteal maxi- mus muscle and frame join: the upper inner
gluteal/ sacral junction, the intergluteal crease/leg junction, the
lower lateral gluteal/leg junction, and the lateral midg-
luteal/hip junction. Finally, from the lateral view, they should
determine the degree of ptosis, which is assessed much like breast
ptosis, but identifies the degree to which skin droops over the
infragluteal fold [9, 11]. Improvement of severe (grade III) ptosis
usually requires an excisional procedure such as a buttock lift,
and Gonzalez has recently described several tech- niques: an upper
buttocks lift, a lower DTA (dermo- tuberal anchorage) lift, a
lateral buttocks lift, and a medial buttocks lift [12]. Some of
these lifts may be incorporated with gluteal implant or autologous
tissue augmentation. Patients who have lost a massive amount of
weight typically have an excess of lax skin through- out the
gluteal region in addition to buttocks ptosis. They may be best
served with a CBL and autologous
tissueaugmentationforadditionalvolume[8].Although some massive
weight loss patients may not need addi- tional volume, they may
benefit from moving the vol- ume to another part of the buttocks to
produce better gluteal projection at the level of the mons pubis.
In these cases, fat transfer provides a good option. Gluteal
implants are not a good choice for MWL patients because the poor
quality of their subcutaneous tissue and skin may increase the risk
of complications. 2.3Topical Anatomical Landmarks The superficial
features shown in Fig. 2.1 are clinically relevant to gluteal
augmentation with Alloplastic implants or autologous tissue, either
a flap or trans- ferred fat [2, 1320]. The definition of these
features also can be greatly improved with liposuction and
transferred fat [2, 21]. As mentioned earlier, the sacral dimples,
sacral triangle, lateral depressions, and infra- gluteal folds that
are well defined and proportioned are judged to be appealing across
many cultures [2, 4, 7]. Several bony landmarks important to
gluteal proce- dures are easy to identify in most patients. The
palpable and often visible iliac crest forms the superior border of
the buttocks and is important for guiding incision placement in a
buttock lift or CBL with or without augmentation. The incision can
be placed more superi- orly or inferiorly with respect to the iliac
crest depend- ing on the postoperative result desired.
Unfortunately, the incision location requires a trade-off between
waist definition and buttock elongation. A higher incision can
better maintain a pleasing waist-to-hip ratio, but it violates the
sacral triangle aesthetic unit, elongates the buttocks, and limits
autologous flap placement so that maximum projection is higher than
ideal. A lower inci- sion diminishes waist definition, but
preserves the sacral triangle aesthetic unit, shortens the
buttocks, and permits the point of maximum projection at the level
of the mons pubis. Good waist definition is nearly impossible to
achieve in MWL patients with a long history of obesity no matter
where the incision is placed because many years of an expanded rib
cage have left them with a barrel chest deformity that can- not be
corrected. The PSIS, which are typically easy to palpate, form two
distinct depressions called the sacral dimples pro- duced by the
confluence of the PSIS, the multifidus muscles, the lumbosacral
aponeurosis, and the inser- tion of the gluteus maximus. Because
the sacral dim- ples are characteristic of attractive buttocks,
attempts should be made to create, enhance, or unmask this ana-
tomical feature [6]. The sacral dimples are also good reference
points for aesthetic analysis of the buttocks.
34. 132 Gluteal Contouring Surgery: Aesthetics and Anatomy
Another reason for the sacral dimples being important is that they
serve as the superior corners of the sacral tri- angle, which is
defined by the two PSIS with the coccyx as the inferior border of
the triangle. Liposuction and/or the inverted dart modification of
the posterior CBL incision mentioned earlier are useful for
enhancing the sacral triangle during body contouring procedures
[6]. In all gluteal contouring procedures the location of the
sacral triangle feature should be respected and marked prior to
surgery. If implants are to be used for augmenta- tion, regardless
of their position, the sacral triangle serves as the medial borders
of the dissection (Fig. 2.4). Another important topical landmark is
the lateral trochanteric depression formed by the greater
trochanter and insertions of thigh and buttocks muscles, including
the gluteus medius, vastus lateralis, quadratus femoris, and
gluteus maximus. This depression is important in the aesthetics of
an athletically-toned buttock preferred by many Caucasians, but
some ethnic groups such as African-Americans and U.S. Hispanics
request that the trochanteric depressions not be emphasized or even
filled in if they are prominent [2]. The infragluteal fold is a
fixed and well-defined structure that serves as the inferior border
of the but- tock proper and is formed by subcutaneous fat and thick
fascial insertions from the femur and pelvis through the
intermuscular fascia to the skin [22]. The length and definition of
the infragluteal fold play important roles in
aesthetically-pleasing buttocks. In his study of ideal buttock
aesthetics, Cuenca-Guerra determined that an infragluteal fold that
does not extend beyond the medial two-thirds of the posterior thigh
contributes to a full, taught, and youthful-looking buttock. A
longer infragluteal fold typically suggests an aged, ptotic, and
deflated-looking buttock with skin and fascial excess [4, 23].
Although not a part of the buttock proper, the ischial tuberosities
are the bony prominences upon which people sit. a b c Fig. 2.4
Implant augmenta- tion locations for (a) submuscular, (b) intra-
muscular, and (c) subfascial procedures. IC iliac crest; PSIS
posterior-superior iliac spine; GT greater trochanter; IGF
infragluteal fold
35. 14 R. F. Centeno 2.4Gluteal Aesthetics and Subcutaneous Fat
Distribution The amount and distribution of subcutaneous fat con-
tent accounts for the round shape and projection of the buttocks.
Subcutaneous fat content in the gluteal region is usually greater
in women vs. men, infants vs. adults, and in some ethnic groups.
Some evolutionary biolo- gists believe that subcutaneous gluteal
fat is important for padding the buttock region when sleeping in
the supine position and evolved as an adaptive mechanism for heat
dissipation while maintaining sufficient adi- pose stores critical
to normal physiology [24]. The distribution of gluteal fat, as well
as its volume, also plays an important role in gluteal aesthetics.
Cuenca-Guerra and Lugo-Beltran have analyzed glu- teal aesthetics
from the lateral view that incorporates the buttock, surrounding
torso, and lower extremities. Ideally, the ratio of the
anterior-superior iliac spine (ASIS) to the greater trochanter and
the greater tro- chanter to the lateral point of maximum projection
of the buttock should not exceed 1:2 [5]. The author has found this
analytical system based on the lateral view to be very useful and
clinically relevant in determining which surgical procedure(s)
should best achieve desired results. In addition to attaining the
ratio of 1:2 when viewed from the side, attractive buttocks have
other characteristics that relate to the distribution of
subcutaneous fat. A visible lumbosacral depression should help to
distinguish the back from the buttocks. There should be no excess
fat either in the lum- bosacral area or in subgluteal region.
Excess fat in areas commonly referred to as the love handles,
saddle-bags, and banana roll also detract from gluteal aesthetics.
The point of maximum projection of the buttocks should correspond
to the level of the mons pubis. Attaining these characteristics may
require the use of combined procedures. Impressive recontouring can
be achieved with liposuction alone, especially to better define the
lumbosacral depression, the sacral triangle, and the subgluteal
area. However, liposuction must not be too aggressive in the area
of the banana roll, just inferior to the infragluteal fold. Too
much liposuction in the most superior portion of the posterior
thigh can exacerbate buttock ptosis and cause deformities in the
infragluteal fold, a structure that is very difficult to replicate
surgically [22]. A good understanding of glu- teal anatomy reduces
the risk of these outcomes. Anthropometric and radiological studies
have deter- mined that both aging and weight gain cause the distri-
butionoffatinthebuttockstochange.Oneinvestigation of 115 randomly
selected women ranging in age from 17 to 48 found statistically
significant changes in sev- eral measurement parameters [23].
Weight gain pro- duces an overall increase in buttock height and
width, lengthens the intergluteal crease, and shortens the
infragluteal fold. Aging, independent of weight gain, also
increases buttock height and lengthens the inter- gluteal crease,
but makes the infragluteal fold longer. Both aging and weight gain
are associated with droop- ing of the infragluteal fold. Although
weight gain alone increases buttock width, this measurement
decreases with age regardless of weight. Changes in subcutane- ous
fat content and distribution, in addition to skin and fascial
laxity, are believed to explain these findings. Fat distribution
has been studied in both men and women, and generalized body types
have been described. These include the android, gynoid, and
intermediate body types. An individuals body type may change
according to weight loss, aging, or gender. For example, as women
age and reach menopause, they tend to develop a more centralized
fat distribution (both intraabdominal and subcutaneous fat), and
the gynoid body type of youth develops more android
characteristics. The most visible differences in the dis- tribution
of subcutaneous fat when comparing young and older women occur at
the waist and mid-trochanter level. In addition, obesity increases
the android ten- dency or centralized fat distribution of both
sexes. This helps explain why body type and overall fat distribu-
tion patterns are relatively consistent among people with rapid and
significant weight loss [24]. Massive weight loss patients are
greatly affected by platypygia, partly because weight loss, whether
through diet or surgery, often occurs in an uneven manner. Studies
have suggested that adipose tissues in certain body regions are
more resistant to weight loss than oth- ers [25]. The genetic
programming of the resistant adi- pocytes seems to differ from
adipocytes in areas that are more responsive to weight loss, which
may mean that genetics influence different somatotypes. Within the
android, gynoid, and intermediate body types are sub- groups of
somatotypes. Following weight loss, the Apple somatotype seems to
have less adipose tissue in the gluteal region than the Pear.
Regardless of somato- type, however, many MWL patients tend to lose
gluteal
36. 152 Gluteal Contouring Surgery: Aesthetics and Anatomy
volume and projection and want to have this deformity specifically
addressed along with the skin laxity. Skeletal changes in massive
weight loss patients: In addition to redistribution of subcutaneous
fat follow- ing massive weight loss, anatomical changes in several
areas of the skeleton are common, especially in patients who were
morbidly obese before losing weight. Many of these changes relate
to posture and permanently affect the morphology of the skeleton,
which may limit the effectiveness of gluteal contouring efforts.
Spinal column lordosis, vertebral compression, and pelvic rotation
all negatively affect gluteal projection [26]. In obese
individuals, restrictive pulmonary dis- ease is often associated
with a postural obstructive component that produces pulmonary
hyperinflation [27], which often leads to permanent expansion of
the thoracic cage. This barrel-chested appearance can- not be
corrected and has a deleterious impact on glu- teal aesthetics.
Massive weight loss does not improve these skeletal abnormalities,
which may be magnified or even worsened as the body mass index is
lowered. A worsening of skeletal changes after surgical weight loss
procedures may relate to poorly managed chronic hypocalcemia,
vitamin D deficiency, and serum telo- peptides that lead to
osteopenia [28]. Although they cannot be corrected, some of the
problematic skeletal changes can be disguised, at least partially,
with gluteal procedures, especially autolo- gous gluteal
augmentation with a tissue flap or fat transfer. Knowledge of the
anatomical abnormalities common in MWL patients can help surgeons
under- stand why the buttocks appear flattened after the poste-
rior portion of a CBL or buttock lift. In many patients, a CBL
magnifies preexisting gluteal hypoplasia. Understanding where and
why more volume is needed to recreate gluteal projection comes from
familiarity with the anatomy of the gluteal and hip region. 2.5The
Importance of Fascial Anatomy The aesthetics of the aging buttocks
are greatly affected by the fascial anatomy of the gluteal region.
In addi- tion to volume loss and skin laxity, which also affect MWL
patients, relaxation of the fascial apron con- tributes to gluteal
ptosis. This superficial fascial apron and the deep gluteal fascia
fuse, become tightly adher- ent, and form the infragluteal fold,
which is an impor- tant feature of aesthetically-pleasing buttocks
[22, 29, 30]. The fascial apron (Fig. 2.5) is analogous to the
superficialfascialsystem(SFS)describedbyLockwood [31]. Liposuction
in the infragluteal fold area (for cor- rection of a banana roll)
must be done carefully and a b Fig. 2.5 Gluteal and SFS fascial
anatomy. (a) The structure of the SFS fascial apron. (b) The
lumbosacral and gluteal fascia
37. 16 R. F. Centeno prudently because this feature is
extremely difficult to surgically recreate. Resection and
tightening of the skin and this superficial fascial apron are major
com- ponents of the CBL procedure or buttock lift with or without
autologous gluteal augmentation and play an important role in
improving gluteal ptosis. The deep gluteal fascia, or investing
fascia of the gluteus maximus muscles, is critically important as a
fixation point in many types of gluteal procedures (e.g.,
autologous augmentation and/or lifts). It also serves as a strong
retaining fascia in the subfascial approach to augmentation with
implants. 2.6Superficial Neurovascular Anatomy Perfusion to
musculocutaneous structures in the gluteal region is supplied by
perforating branches of the supe- rior and inferior gluteal
arteries, both of which are ter- minal branches of the internal
iliac artery and ultimately pass through the greater sciatic
foramen into the thigh (Fig. 2.6). As described by Ahmadzadeh and
colleagues, the superior gluteal artery can usually be found by
envi- sioning a line between the posterior-superior iliac spine and
the greater trochanter [32]. Several perforators from this artery
should lie 510 cm adjacent to the medial two-thirds of this line.
Before it enters the gluteus maxi- mus muscle to supply perforators
to the superior portion of this muscle and overlying skin, the
superior gluteal artery passes superior to the piriformis muscle
[32, 33]. The inferior gluteal artery passes inferior to the piri-
formis muscle and supplies the lower half of the gluteus maximus
muscle and overlying structures. All perfora- tors from the
inferior gluteal artery pass through the gluteus maximus, as do
half the perforators from the superior gluteal artery; the other
half pass through the gluteus medius muscle. The superior gluteal
artery typi- cally has 5 2 cutaneous perforators, with the inferior
gluteal artery typically having 8 4 [32]. Some of these perforating
vessels must be sacri- ficed during the posterior portion of a CBL,
an autolo- gous gluteal augmentation, or a buttock lift. Even with
this loss, however, the rich and reliable vascular supply in the
gluteal region provides robust perfusion [3235]. Many other
arteries also supply the region, including the deep circumflex
iliac, lumbar, lateral sacral, obtu- rator, and internal pudendal
arteries. Sensation to the gluteal region and lateral trunk comes
from several sources: the dorsal rami of sacral nerve roots 3 and
4, the cutaneous branches of the iliohypogas- tric nerve arising
from the L1 root (Fig. 2.7), and the superior cluneal nerves that
originate from the L1, L2, and L3 roots and then pass over the
iliac crest (Fig. 2.8). A lower body or buttock lift with or
without autoaug- mentation temporarily disrupts protective
cutaneous sensation transmitted by these nerves. Consequently,
patients should be counseled about the need for frequent positional
changes and avoidance of heating pads and blankets to prevent
pressure necrosis or burns. As branches of the L1 nerve root, the
iliohypogastic and ilioinguinal nerves originate in the sacral
plexus (Fig. 2.7). They then travel inferiomedially between the
transversus abdominis and internal oblique muscles. The
iliohypogastric nerve divides into lateral and ante- rior cutaneous
branches to supply skin overlying the lateral gluteal region and
the area above the pubis on the anterior surface. These nerves are
put at risk when a CBL incision is made at or below the inguinal
crease. The lateral cutaneous branch of the iliohypogastic and the
intercostal nerves also can be entrapped laterally during surgery.
This is most likely when aggressive lat- eral plication of the
external oblique muscle is per- formed to enhance waist definition
or if 3-point or quilting sutures are used laterally to close dead
space. Fig. 2.6 Superior and inferior gluteal arteries and
lumbo-sacral perforator arteries
38. 172 Gluteal Contouring Surgery: Aesthetics and Anatomy
While contouring the lateral and anterior trunk and thighs during
body contouring procedures, surgeons must be aware of clinically
significant anatomic variations of the ilioinguinal, iliohypogas-
tric, and lateral femoral cutaneous nerves. In a fresh cadaveric
study, Whiteside and colleagues deter- mined that, on average, the
ilioinguinal nerve enters the abdominal wall 3.1 cm medial and 3.7
cm inferior to the ASIS and terminates 2.7 cm lateral to the mid-
line and 1.7 cm above the pubic symphysis [36]. The iliohypogastric
nerve enters the abdominal wall mus- culature 2.1 cm medial and 0.9
cm below the ASIS and ends 3.7 cm lateral to the linea alba and 5.2
cm above the pubic tubercle. Fig. 2.7 The ilioinguinal and
iliohypogastric nerves, the latter of which extends around the body
to supply the lateral and anterior aspects Fig. 2.8 Posterior
cutaneous nerves: (a) Dorsal rami of S3 and S4. (b) The superior
cluneal nerves
39. 18 R. F. Centeno However, another study of human cadavers
found that the position of the iliohypogastric nerve in relation to
the ASIS can vary by as much as 1.58 cm on the right side and
2.33.6 cm on the left side. The ilioin- guinal nerve and its
relation to the ASIS vary by as much as 36.4 cm on the right and 25
cm on the left [37]. A study of 110 patients undergoing hernia
repair determined that the course of both nerves was consis- tent
with descriptions in anatomy texts in 41.8% of cases, but varied
significantly in 58.2% of patients [38]. Most variations were
related to take-off angles, bifurcations, aberrant origins, or
accessory branches occurring at deeper layers of the abdominal
wall. However, in 18 of 64 cases, the ilioinguinal nerve was
superficial to the external oblique aponeurosis and the superficial
inguinal ring. Injury to the lateral femoral cutaneous nerve (LFCN)
was described as early as 1885. Meralgia parasthetica is the
clinical syndrome caused by LFCN compression or injury and is
characterized by anes- thesia, causalgia, and hypesthesias in its
dermatomal distribution. Typically, the nerve is described as
coursing anterior to the ASIS and inferior to the ingui- nal
ligament. Aszmann et al. showed that in 4% of cadavers dissected,
the nerve exited posterior to the ASIS and across the iliac crest
[39]. In another cadav- eric study, Grothaus and colleagues
demonstrated that the LFCN is susceptible to injury as far as 7.3
cm medial to the ASIS and 11.3 cm below the ASIS on the Sartorius
muscle [40]. 2.7Deep Neuromuscular Anatomy The expansive gluteus
maximus muscle (Fig. 2.9) originates in the fascia of the gluteus
medius, the exter- nal ilium, the fascia of the erector spinae, the
dorsum of the lower sacrum, the lateral coccyx, and the sacro-
tuberous ligament. It inserts on the iliotibial tract and proximal
femur. Innervation of the gluteus maximus comes from the inferior
gluteal nerve. This muscle is a powerful extensor of the flexed
femur and provides lat- eral stabilization of the hip. Correct
positioning of sub- muscular, intramuscular, and subfascial
implants in relation to fascial structures and the gluteal maximus
muscle are shown in Fig. 2.10. Originating on the external ilium
and inserting on the lateral greater trochanters, the gluteus
medius abducts the hip and thigh and helps stabilize the pelvis
during standing and walking (Fig. 2.11). Nearby, the gluteus
minimus muscle originates on the external surface of the ilium and
inserts on the anterior-lateral greater tro- chanter (Fig. 2.12).
This muscle abducts the femur at the hip joint and also serves as a
pelvic stabilizer. Both the gluteus medius and gluteus minimus are
innervated by Fig. 2.9 Gluteus maximus muscle and relationships to
nearby neurovascular structures
40. 192 Gluteal Contouring Surgery: Aesthetics and Anatomy Fig.
2.10 Implant position in relation to gluteal anatomy: (a)
submuscular, (b) intramuscular, and (c) subfascial augmentation a b
c Fig. 2.11 Gluteus medius muscle and relationships to nearby
neurovascular structures
41. 20 R. F. Centeno the superior gluteal nerve. The superior
gluteal artery and nerve, which supply both muscles, exit the
sciatic foramen above the piriformis muscle and travel through the
plane between the gluteus medius and minimus. A lateral rotator and
abductor of the femur, the piri- formis muscle is innervated by
branches of L5, S1, and S2. The small, triangular-shaped
piriformis, which is obliquely oriented, originates at the anterior
sacrum and inserts on the superior medial border of the greater
trochanters. The piriformis muscle divides the greater sciatic
foramen into inferior and superior portions. The piriformis
overlies the sciatic nerve and plays an important role as a
landmark for the gluteal neurovas- cular structures, as well as the
sciatic nerve (Fig. 2.13). For example, the piriformis marks the
most inferior extent of an implant pocket for augmentation in the
submuscular plane. Many other muscles are lateral rotators and
abduc- tors of the femur, including the superior gemellus, infe-
rior gemellus, and obturator internus muscles, which all lie caudal
to the piriformis. The most anterior of the gluteal muscles is the
tensor fascia lata (Fig. 2.14). It Fig. 2.12 Gluteus minimus muscle
and relationships to nearby neurovascular structures Fig. 2.13 The
location of the sciatic nerve in relation to the piriformis
muscle
42. 212 Gluteal Contouring Surgery: Aesthetics and Anatomy
originates on the lateral iliac crest and ASIS, passes superficial
to the gluteus medius and minimus, and inserts on the iliotibial
tract. It helps with flexion, abduction, and rotation of the thigh,
and stabilizes the knee during extension. The terminal branch of
the lat- eral femoral circumflex artery provides perfusion, with
innervation supplied by the superior gluteal nerve. The sciatic
nerve is the largest nerve of the body and originates in the sacral
plexus at the nerve roots of L4 through S3. Its only gluteal branch
provides innervation to the hip joint. The sciatic nerve exits the
gluteal region through the greater sciatic foramen below the
piriformis muscle and above the superior gemellus muscle to enter
the posterior compartment of the thigh (Fig. 2.15). Above the
popliteal space, the sciatic nerve splits into the common peroneal
nerve and the tibial nerve. Compression or injury of the sci- atic
nerve may cause loss of function of the posterior thigh compartment
muscles, all muscles of the leg and foot, and loss of sensation in
the lateral leg and foot, as well as the sole and dorsum of the
foot [41]. Anatomical studies indicate that the sciatic nerve and
its main branches the tibial and common per- oneal nerves are
subject to variability in relation to the piriformis muscle. The
sciatic nerve leaves the pel- vis through the infrapyriform foramen
in 96% of cases. However, in 2.5% of cases, the common peroneal
nerve may branch away from the sciatic nerve early and exit through
the piriformis muscle while the tibial nerve exits below the
piriformis. In another 1.5% of cases, the common peroneal nerve
divides from the tibial nerve and exits the pelvis above the
piriformis Fig. 2.14 Tensor fascia lata with gluteal-lumbosacral
fascia removed Fig. 2.15 The sciatic nerve in relation to the
superior and infe- rior gluteal arteries and veins
43. 22 R. F. Centeno muscle, while the tibial nerve exits below
the muscle [42,43]. Although uncommon, these anatomic varia- tions
must be looked for during gluteal procedures because injury to
these nerves could lead to clinical complications during
submuscular and intramuscular implant augmentation. Although rare,
gluteal compartment syndrome has been reported in the literature.
Possible causes include trauma, alcoholism, drug-induced coma,
Ehlers- Danlos syndrome, sickle cell disease, gluteal artery
aneurysm rupture, abdominal aortic aneurysm repair, orthopedic
surgery, bone marrow biopsy, intramuscu- lar injections,
rhabdomyolysis, extreme physical over- exertion, and prolonged
surgical positioning in the lateral decubitus or lithotomy
positions. Even though gluteal surgery rarely causes gluteal
compartment syndrome, surgeons need a thorough knowledge of the
gluteal compartments and the poten- tial impact different aesthetic
procedures may have. A low index of suspicion and early
intervention will reduce any permanent negative sequelae of this
poten- tially devastating clinical problem. Three gluteal
compartments have relatively inelastic boundaries: the gluteus
maximus compartment, the glu- teus medius-minimus compartment, and
the tensor fas- cialatacompartment.Thegluteusmaximuscompartment
consists of the muscle plus its superficial and deep fibrous
fascia, which is contiguous with the fascia lata of the thigh. This
compartment attaches superiorly to
theiliaccrestandlaterallytotheiliotibialtract.Medially, the
superficial and deep gluteal fascia join the sacral, coccygeal, and
sacrotuberous ligaments. The gluteus medius-minimus compartment is
defined superiorly by the deep gluteal fascia, the tensor
compartment, and the iliotibial tract laterally. The ilium
comprises the deep surface. The tensor fascia lata compartment is
formed by the tensor fascia lata and the iliotibial tract. The
gluteus medius-minimus compartment con- tains most of the critical
neurovascular structures. Precise knowledge of their locations will
help prevent operative injury and improve understanding of this
rare compartment syndrome. The superior gluteal artery, vein, and
nerve exit superior to the piriformis muscle. The inferior gluteal
artery, vein, and nerve exit beneath the inferior edge of the
piriformis and above the superior gemellus muscle to penetrate the
gluteus maximus muscle. In addition, the sciatic nerve, poste- rior
femoral cutaneous nerve, pudendal nerve, and nerves to the
obturator internus and superior gemellus muscles exit in the same
compartment, beneath the inferior border of the piriformis muscle.
Increased compartment pressures with diminished perfusion to the
gluteal muscles and tensor fascia lata can be caused by mass effect
within these compart- ments. Damage to the vessels with bleeding
and hema- toma formation, or mass effect from a large implant, can
theoretically increase compartment pressures beyond a safe limit.
While still disputed in the litera- ture, a compartment pressure
higher than 30 mmHg may cause necrosis of muscle in as little as 46
h and Wallerian nerve degeneration in 8 h [4446]. 2.8Surgical
Injuries Many inadvertent opportunities for injuring patients are
possible during gluteal procedures as the common prone and lateral
decubitus positions carry risks, such as development of pressure
sores, corneal abrasions, peripheral nerve compression, and
traction injuries. Although the entire operative team is
responsible for being vigilant and preventing these types of
injuries, the surgeon possesses the most specialized knowledge of
the impact that improper intraoperative positioning can have on a
patient. Major peripheral nerve structures are especially at risk
in the lateral decubitus position commonly used for a CBL or
contouring liposuction of the flanks, back, and lateral thighs. An
axillary roll can protect the brachial plexus from compression
against the clavicle while in this position. The common peroneal
nerve can be protected by using a gel mattress on the operative bed
and avoiding compression against hard surfaces. Perioperatively, a
gel mattress, Roho, or egg-crate, will provide extra padding to
prevent ne