Body Contouring

Melvin A. ShiffmanAlberto Di Giuseppe (Eds.)

Body Contouring

Art, Science, and Clinical Practice

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.

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Melvin A. Shiffman, MD, JD17501 Chatham DriveTustin, CA 92780-2302USAshiffmanmdjd@yahoo.com

Alberto Di Giuseppe, MDDepartment of Plastic and ReconstructiveSurgery, School of Medicine University of Ancona1, Pizza Cappelli60121 AnconaItalyadgplasticsurg@atlavia.it

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

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 TorreThe University of Alabama at BirminghamBirmingham, USA

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 body’s 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 patient’s 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. ShiffmanAncona, Italy Alberto Di Giuseppe

xi

Contents

Part I Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis

1 Mammary Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Michael R. Davis

2 Gluteal Contouring Surgery: Aesthetics and Anatomy . . . . . . . . . . . . . 9Robert F. Centeno

3 Anatomy and Topography of the Anterior Abdominal Wall . . . . . . . . . 27Michael R. Davis and Matthew R. Talarczyk

4 History of Classifications of Adiposity Excess. . . . . . . . . . . . . . . . . . . . . 33Melvin A. Shiffman

5 Body Contour: A 50 Year Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Ivo Pitanguy and Henrique N. Radwanski

6 Injection Lipolysis for Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . 59Diane Duncan

Part II Breast

7 History of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Melvin A. Shiffman

8 Inframammary Approach to Subglandular Breast Augmentation . . . . 77Anthony Erian and Amal Dass

9 Hydrodissection Axillary Approach Breast Augmentation . . . . . . . . . . 87Sid J. Mirrafati and Melvin A. Shiffman

10 Complications of Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . 93Anthony Erian and Melvin A. Shiffman

11 Regnault B Mastopexy: A Versatile Approach to Breast Lifting and Reduction . . . . . . . . . . . . . . . . . . . . . . . 119Howard A. Tobin

xii Contents

12 Mastopexy/Reduction and Augmentation Without Vertical Scar . . . . . 125Sid J. Mirrafati

13 Breast Reduction and Mastopexy with Vaser in Male Breast Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . 131Alberto Di Giuseppe

14 Gynecomastia Repair Using Power-Assisted Superficial Liposuction and Endoscopic Assisted Pull-Through Excision. . . . . . . . 139Yitzchak Ramon and Yehuda Ullmann

15 Mastopexy Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Melvin A. Shiffman

16 History of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Melvin A. Shiffman

17 Strombeck Breast Reduction Technique . . . . . . . . . . . . . . . . . . . . . . . . . 155Pierre F. Fournier

18 Inverted Keel Resection Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . 169Ivo Pitanguy and Henrique N. Radwanski

19 Vaser-Assisted Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179Alberto Di Giuseppe

20 Complications of Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Melvin A. Shiffman

Part III Abdomen, Chest, Buttocks

21 History of Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Giovanni Di Benedetto and William Forlini

22 Abdominoplasty Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Melvin A. Shiffman

23 Liposculpture of the Abdomen in an Office-Based Practice . . . . . . . . . 219Peter M. Prendergast

24 “Anchor-Line” Abdominoplasty: A Comprehensive Approach to Abdominal Wall Reconstruction and Body Contouring . . . . . . . . . . 239Paolo Persichetti, Pierfranco Simone, Annalisa Cogliandro, and Nicolò Scuderi

25 Circular Lipectomy with Lateral Thigh–Buttock Lift . . . . . . . . . . . . . . 249Héctor J. Morales Gracia

26 Prevention and Management of Abdominoplasty Complications . . . . . 267Melvin A. Shiffman

Contents xiii

27 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Luiz Haroldo Pereira and Aris Sterodimas

Part IV Extremities

28 Brachioplasty: How to Choose the Correct Procedure . . . . . . . . . . . . . 287A. Chasby Sacks

29 Brachioplasty: A Body-Contouring Challenge . . . . . . . . . . . . . . . . . . . . 293James G. Hoehn, Sumeet N. Makhijani, and Jerome D. Chao

30 “Fish-Incision” Brachioplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307Rajiv Y. Chandawarkar

31 Brachioplasty Technique with Molds Combined to Vaser Assisted Lipomyosculpture . . . . . . . . . . . . . . . . . . . 313Ewaldo Bolivar de Souza Pinto and Pablo S. Frizzera Delboni

32 Limited Incision Medial Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . 321Andrew P. Trussler and Rod J. Rohrich

33 Augmentation Brachioplasty with Cohesive Silicone Gel Implants . . . 327Gal Moreira Dini and Lydia Massako Ferreria

34 Long-Term Outcomes and Complications After Brachioplasty . . . . . . 331James Knoetgen III

35 Lymphoscintigraphy: Evaluation of the Lymphatic System . . . . . . . . . 337Cristina Hachul Moreno, Aline Rodrigues Bragatto,Américo Helene, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto

36 Medial Thigh Lift and Declive: Inner Thigh Lift Without Using Colle’s Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347Daniele Spirito

37 Spiral Lift: Medial and Lateral Thigh Lift with Buttock Lift and Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355Sadri O. Sozer, Francisco J. Agullo, and Humberto Palladino

38 A Novel Treatment Option for Thigh Lymphoceles Complicating Medial Thigh Lifting Procedures . . . . . . . . . . . . . . . . . . . 365Wayne K. Stadelmann

39 Fat Augmentation of Buttocks and Legs . . . . . . . . . . . . . . . . . . . . . . . . . 373Lina Valero de Pedroza

40 Lower Leg Augmentation with Combined Calf-Tibial Implant . . . . . . 381Afshin Farzadmehr and Robert A. Gutstein

xiv Contents

Part V Liposuction

41 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications . . . . . . . . . . . . 389William W. Cimino

42 History of Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . 399William W. Cimino

43 Face and Neck Remodelling with Ultrasound-Assisted Lipoplasty (Vaser) . . . . . . . . . . . . . . . . . . . . . 405Alberto Di Giuseppe

44 High Definition Liposculpting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419Alfredo Hoyos

45 Vaser-Assisted Liposculpture for Body Contouring . . . . . . . . . . . . . . . . 425Alberto Di Giuseppe

46 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring . . . . . . . . . . . . . . . . . . 459Andrew T. Lyos

47 Body Contouring with Focused Ultrasound . . . . . . . . . . . . . . . . . . . . . . 473Javier Moreno-Moraga and Josefina Royo de la Torre

48 Focus Ultrasound on Limited Lipodystrophies. . . . . . . . . . . . . . . . . . . . 485Michele Cataldo, Luca Grassetti, and David E. Talevi

49 Aesthetic Body Contouring of the Posterior Trunk and Buttocks Using Third Generation Pulsed Solid Probe Internal Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493Onelio Garcia Jr.

50 Treatment Options in Benign Symmetric Lipomatosis . . . . . . . . . . . . . 505Anthony P. Sclafani, Kenneth Rosenstein, and Joseph J. Rousso

51 Liposuction for Madelung’s Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Robert Yoho

52 Body Contouring of the Thigh: The Third Dimension by Leonardo Da Vinci. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517Alberto Di Giuseppe

53 Liposuction of the Calves and Ankles Associated with Calf Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539Adrien E. Aiache

54 Management of HIV-Associated Lipodystrophy: Medical and Surgical Options for Lipoatrophy and Lipohypertrophy . . . . . . . . . . . . . . 545C. Scott Hultman and Anne Keen

Contents xv

55 Prevention and Treatment of Liposuction Complications . . . . . . . . . . . 553Melvin A. Shiffman

56 Comparison of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Ultrasound-Assisted Lipoplasty. . . . . . . . . . . . . 565Onelio Garcia

Part VI Fat Transfer

57 Fat Transfer Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577Melvin A. Shiffman

58 Enhancing Muscle Appearance with Extensive Liposuction and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587Alfredo Hoyos

59 Remodelling Breast and Torso with Liposuction and Fat Grafts . . . . . 595Alfredo Hoyos and David Broadway

60 Buttock Remodeling with Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . 599William L. Murillo

61 Complications of Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617Hassan Abbas Khawaja, Melvin A. Shiffman, Enrique Hernandez-Perez, José Enrique Hernández-Pérez, and Mauricio Hernandez-Perez

Part VII Body Contouring After Severe Weight Loss

62 History of Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629Melvin A. Shiffman

63 Psychosocial Aspects of Body Contouring Surgery After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633Troy W. Ertelt, Joanna M. Marino, and James E. Mitchell

64 Psychosocial Issues in Body Contouring . . . . . . . . . . . . . . . . . . . . . . . . . 641David B. Sarwer

65 Nutrition Issues After Bariatric Surgery for Weight Loss . . . . . . . . . . . 651George John Bitar and Sally Myers

66 The Body’s Aesthetic Units for Body Contouring Surgery in Massive Weight Loss Patients . . . . . . . . . . . . . . . . . . . . . . . . 661Héctor J. Morales Gracia and Alberto Javier Coutté Mayora

67 Classification of Contour Deformities After Massive Weight Loss: Clinical Applications of the Pittsburgh Rating Scale . . . . . . . . . . . . . . . 675Angela S. Landfair, Dennis J. Hurwitz, Madelyn H. Fernstrom, Raymond Jean, and J. Peter Rubin

xvi Contents

68 Facial Contouring in the Postbariatric Surgery Patient . . . . . . . . . . . . 687Anthony P. Sclafani and Vikas Mehta

69 Total Body Lift After Massive Weight Loss. . . . . . . . . . . . . . . . . . . . . . . 695Nestor Veitia and Dennis J. Hurwitz

70 Transaxillary Breast Augmentation/Wise-Pattern Mastopexy in the Massive Weight Loss Patient . . . . . . . . . . . . . . . . . . . 709George John Bitar

71 Mastopexy with Extended Chest Wall-Based Flap After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719Ruth Maria Graf, Daniele Pace, and Alexandre Mansur

72 Medial Thigh Lift Free Flap for Breast Augmentation After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 725Thomas Schoeller and Georg M. Huemer

73 Rotation-Advancement Superomedial Pedicle Mastopexy Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . 735Albert Losken

74 Flank Reshaping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743Keith Robertson and Bilal Gondal

75 Perforator Sparing Abdominoplasty: Indications and Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 757Ulrich M. Rieger and Martin Haug

76 Abdominal Lipectomy and Mesh Repair of Midline Periumbilical Hernia After Bariatric Surgery Sparing the Umbilicus . . . . . . . . . . . . . 763Antonio Iannelli

77 Combined Abdominoplasty and Medial Vertical Thigh Reduction Following Severe Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . 769Mohammed G. Ellabban and Nicholas B. Hart

78 Complications in Abdominoplasty Patients After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775Mikko Larsen and Peter W. Plaisier

79 Quality of Life After Abdominoplasty Following Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783Wilson Cintra, Miguel Luiz Antonio Modolin, Joel Faintuch, Rolf Gemperli, and Marcus Castro Ferreira

80 Algorithm for Surgical Plane in Brachioplasty After Massive Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789Claudio Cannistra

Contents xvii

81 L Brachioplasty Following Massive Weight Loss . . . . . . . . . . . . . . . . . . 795Daron Geldwert and Dennis J. Hurwitz

82 Brachioplasty After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 803Franco Migliori

83 Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty . . . . . . . . . . . . . . . . . . . . . 809Charles K. Herman and Berish Strauch

84 Current Techniques in Medial Thighplasty. . . . . . . . . . . . . . . . . . . . . . . 815David W. Mathes

85 Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827Cristina Hachul Moreno, Aline Rodrigues Bragatto, Américo Helene Jr, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto

86 Combined Thigh and Buttock Lift After Massive Weight Loss . . . . . . 837Claudio Cannistrà

87 Venous Thromboembolism in Bariatric Body Contouring Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847Maura Reinblatt and Michele A. Shermak

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865

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 frankagullo@elpasoplasticsurgery.com

Adrien E. Aiache, MD 9884 Little Santa Monica Blvd, Beverly Hills, CA 90212, USA aaiachemd@sbcglobal.net

George J. Bitar, MD Bitar Cosmetic Surgery Institute, 8650 Sudley Road 203, Manassas, VA 20110, USA georgebitar@drbitar.com

Aline Rodrigues Bragatto, Jr, MD Rua Vergueiro, 1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil alinerbragatto@ajato.com.br

David Broadway, MD 9777 S Yosemite Street, Suite 200, Lone Tree, CO 80124, USA davidb@bodevolve.com

Claudio Cannistrà, MD Department of Surgery, Plastic Surgery Unit, Bichat C. B. University Hospital, 71 rue de Rome, 75008 Paris, France c.cannistra@aliceadsl.fr or cla.cannistra@gmail.com

Michele Cataldo, MD via Turati 4, 20060 Trezzano Rosa, Milano, Italy michele.cataldo@termeditrescore.it or plastic@aesthetic-rejuven.com

Robert F. Centeno, MD P.O. Box 24330, Christian Sted, VI 00824–0330, USA lisa@stcroixplasticsurgery.com

Rajiv Y. Chandawarkar, MD Department of Surgery, Division of Plastic Surgery, University of Connecticut, School of Medicine, Farmington, CT 06030, USA chandawarkar@uchc.edu

xx Contributors

Jerome D. Chao, MD Division of Plastic Surgery , Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA chaojd@mail.amc.edu

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 cimino@soundsurgical.com or williamcimino@comcast.net

Wilson Cintra, JR, MD Plastic Surgery Service, Hospital das Clínicas, Av. San Gabriel, 201 conj. 704/5, São Paulo, SP 01435001, Brazil wcintra@terra.com.br

Annalisa Cogliandro, MD Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Via Fontanellato, 49, 00142 Rome, Italy a.cogliandro@unicampus.it

Alberto Javier Coutté Mayora, MD Belisario Domínguez No. 2501, Colonia Obispado, Monterrey, Nuevo León C.P 64060, México ajcouttem@msn.com

Amal Dass, MD Advanced Aesthetics & Surgery, 1, Grange Rd, Orchard Bldg, #06-06 Singapore 239693 amaldass_2000@yahoo.com

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 drcutmd@aol.com

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 jdlt@uab.edu

Josefina Royo de la Torre, MD Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain consulta@iml.es

Pablo Silva Frizzera Delboni, MD Plastic Surgery Department, Santa Cecilia University – UNISANTA, São Paulo, Brazil pablo_delboni@hotmail.com or pablodelboni@terra.com.br

Lina Valero de Pedrosa, MD Carrera 16 No 82-95-Cons: 301, Bogota, DC, Colombia lvalero@lafont.com.co

Ewaldo Bolivar de Souza Pinto, MD, PhD Plastic Surgery Department, Santa Cecilia University – UNISANTA, Alameda Santos, 455 – cj. 306, São Paulo, Brazil ewaldobolivar@uol.com.br or dePedrosa ewaldo@desouzapinto.com.br

Giovanni Di Benedetto, MD, PhD Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy dibenplast@hotmail.com

Contributors xxi

Alberto Di Giuseppe, MD Department of Plastic and Reconstructive Surgery, School of Medicine, University of Ancona, 1, Piazza Cappelli, 60121 Ancona, Italy adgplasticsurg@atlavia.it

Gal Moreira Dini, MD Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, R. Vicencia faria Versage 400 ap. 113-14, Sorocaba Sao Paulo 18031-080, Brazil dr.gal@uol.com.br

Diane Duncan, MD FACS, 1701 East Prospect Road, Fort Collins, CO 80525, USA dduncanmd@aol.com

Mohammed G. Ellabban, MD Plastic and Reconstructive Surgery Unit, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK mohammedellabban@hotmail.com

Anthony Erian, MD Division of Plastic Surgery, Orwell Grange, 43 Cambridge Road, Wimpole, Cambridge, UK erian@erian.demon.co.uk

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 tertelt@nrifargo.com

Joel Faintuch, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil and Division of Nutrology Residence Program, Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil blfaintuch@hotmail.com

Afshin Farzadmehr, MD Plastic Surgery Center of Beverly Hills, 1125 South Beverly Drive, Suite 600, Los Angeles, CA 90035, USA dr90210@sbcglobal.net or dermasurgeon@hotmail.com

Madelyn H. Fernstrom, PhD 3811 O’Hara Street, Suite 1617, Pittsburgh, PA 15213, USA fernstrommh@upmc.edu

Marcus Castro Ferreira, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP, Brazil mferrei@uol.com.br

Lydia Massako Ferreria, MD, PhD Department of Plastic Surgery, Universidade Federale de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil lydiaferreira@uol.com.br

William Forlini, MD, PhD Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy williamforlini@msn.com

xxii Contributors

Pierre F. Fournier, MD 55 Boulevard de Strasbourg, 75 010 Paris, France pierre.fournier27@wanadoo.fr

Onelio Garcia, Jr. MD Division of Plastic Surgery, University of Miami, Miller School of Medicine, 3850 Bird Road, Suite 102, Miami, FL 33146, USA ogarciamd@aol.com

Daron Geldwert, MD Hurwitz Center for Plastic Surgery, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA dgeldwert@aol.com

Rolf Gemperli, MD Plastic Surgery Service, Hospital das Clínicas, Rua Pedrosa Alvarenga, 120, São Paulo, SP 04531-004, Brazil rgemperli@sti.com.br

Bilal Gondal, MB BCh, BAO Dubl, BSc, BA King Fahd Uni of Petroleum and Minerals, KFUPM, PO Box 372, Dhahran 31261, Saudi Arabia bilalgz@gmail.com

Ruth Maria Graf, MD, PhD Division of Plastic and Reconstructive Surgery, Department of Hospital de Clínicas, Federal University of Paraná (UFPR), Curitiba-PR, Brazil ruthgraf@bighost.com.br or ruthgraf@bsi.com.br

Luca Grassetti, MD Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy lucagrassetti2000@yahoo.it

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 nb.hart@hotmail.com

Martin Haug, MD Department of Plastic and Reconstructive Surgery, Basel University Hospital, Spitalstrasse 21, 4056 Basel, Switzerland

Américo Helene, Jr. MD Av Itacira, 577 Planalto Paulista, CEP 04064-000, Sao Paulo, Brazil latarika@hotmail.com.br

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 charleshermanmd@hotmail.com

Enrique Hernandez-Perez, MD 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA enrimar@vip.telesal.net

Contributors xxiii

José Enrique Hernández-Pérez, MD Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 enrimar@vip.telesal.net

Mauricio Hernandez-Perez, MD Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escalón, San Salvador, CP 01-177 enrimar@vip.telesal.net

James G. Hoehn, MD Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA jamesmd@hoehn.us

Alfredo Hoyos, MD Evolution Medical Center, Calle 119, 11D-30 (nueva), Bogota, Colombia alhoyos@gmail.com

Georg M. Huemer, MD General Hospital Linz, Krankenhausstrasse 9, 4021 Linz, Austria ghuemer@drhuemer.com

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 cshult@med.unc.edu

Dennis J. Hurwitz, MD Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA andDepartment of Surgery, New York-Presbyterian Hospital, 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA drhurwitz@hurwitzcenter.com

Antonio Iannelli, MD Chirurgie Digestive et Centre de Transplantation Hépatique, Hôpital L’Archet 2, University of Nice Sophia Antipolis, 151 Route Saint Antoine de Ginestière, BP 3079, Nice, Cedex 3, France antonio_iannelli@hotmail.com

Raymond Jean, MD Department of Plastic Surgery, Loma Linda University, 11175 Campus Street, Suite 21126, Loma Linda, CA 92354, USA rjean@llu.edu

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 anne_keen@med.unc.edu

Hassan Abbas Khawaja, MD Cosmetic Surgery and Skin Center, 53 A, Block B II, Gulberg III, Lahore, 54660, Pakistan drhassan@nexlinx.net.pk or drhassan7@hotmail.com

James Knoetgen III, MD Private Practice, 20296, Bakersfield, CA 93390-0296, USA jknoetgen@gmail.com

xxiv Contributors

Angela S. Landfair, MD, MPH Division of Plastic Surgery, University of Pittsburgh, 3553 Terrace Street, Suite 6B, Pittsburgh, PA 15213, USA songa@upmc.edu

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 mikkolarsen@hotmail.com

Albert Losken, MD Division of Plastic Surgery, Emory University School of Medicine, 550 Peachtree Street, Suite 84300, Atlanta, GA 30308, USA albert_losken@emoryhealthcare.org or alosken@emory.edu

Andrew T. Lyos, MD Division of Plastic Surgery, Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX, USA info@lyosmd.com

Sumeet N. Makhijani, MD Division of Plastic Surgery, Albany Medical College, 25 Hackett Blvd, MC133, Albany, NY 12208, USA makhijs@gmail.com

Carlos Alberto Malheiros, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil camalheiros@terra.com.br

Alexandre Mansur, MD Rua Alberto Foloni, 575 – ap 23A, Centro Cívico Curitiba, Paraná, CEP 80540-000, Sao Paulo, Brazil acmansur@uol.com.br

Joanna M. Marino, MD Department of Psychology, University of North Dakota, Grand Forks, Neuropsychiatric Research Institute, 120 8th Street South, Fargo, ND 58102, USA jmarino@nrifargo.com

David W. Mathes, MD Department of Surgery, Division of Plastic Surgery, University of Washington, School of Medicine, 98195, Seattle, WA, USA dwmathes@u.washington.edu

Vikas Mehta, MD The NY Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA vmehta@nyee.edu

Franco Carlo Migliori, MD Plastic Surgery Unit, “San Martino” University Hospital, Largo Rosanna Benzi, 10, Monoblocco 8A Piano Levante, Genoa 16132, Italy franco.migliori@fastwebnet.it

Contributors xxv

Sid J. Mirrafati, MD 3140 Redhill Avenue, Costa Mesa, CA 92626, USA drmirrafati@youngerlook.com

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 mitchell@medicine.nodak.edu

Miguel Luiz Antonio Modolin, MD Plastic Surgery Service, Hospital das Clínicas, São Paulo, SP 01486-000, Brazil miguelmodolin@uol.com.br

Héctor J. Morales Gracia, MD Belisario Domínguez 2501, Colonia Obispado, Monterrey, Nuevo León, CP 64060, México drhectormorales@hotmail.com

Cristina Hachul Moreno, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, Brazil hachulmoreno@terra.com.br

Javier Moreno-Moraga, MD Instituto Medico Laser, General Martinez-Campos 33, 28010 Madrid, Spain consulta@iml.es

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 williamurillo@hotmail.com

Sally Myers, RD Bitar Cosmetic Surgery Institute, Northern Virginia, 8501 Arlington Blvd. Suite 500, Fairfax, VA 22031, USA sallyCPT@aol.com

Henrique Jorge Guedes Neto, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, São Paulo, SP, Brazil drguedes@drguedes.med.br

Daniele Pace, MD, MSc Rua Solimões, 1175, Mercês Curitiba, Paraná, CEP 80810-070, Brazil danielepace@hotmail.com

Humberto Palladino, MD Department of Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA humbertopalladino@gmail.com

Luiz Haroldo Pereira, MD Luiz Haroldo Clinic, 45/206 Rua Xavier da Silveira, Rio de Janeiro, 22061-010, Brazil haroldo@unisys.com.br

Paolo Persichetti, MD, PhD Division of Plastic Surgery, University Campus Bio-Medico of Rome, Via Bertoloni 19, 00197 Rome, Italy p.persichetti@unicampus.it

xxvi Contributors

Ivo Pitanguy, MD Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020, Brazil pitanguy@pitanguy.com.br

Peter W. Plaisier, MD Department of General Surgery, Albert Schweitzer Hospital, PO Box 444, 3300 AK, Dordrecht, The Netherlands p.w.plaisier@asz.nl

Peter M. Prendergast, MD Venus Medical Beauty, Heritage House, Dundrum Office Park, Dundrum, Dublin 14, Ireland peter@venusmed.com

Henrique N. Radwanski, MD Ivo Pitanguy Clinic, Rua Dona Mariana, 65, Rio de Janeiro, 22280-020 Brazil dr.henrique@pilos.com.br

Yitzchak Ramon, MD Elisha and Rambam Medical Centers, Haifa, Israel ramon-y@inter.net.il

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 mreinbl1@jhmi.edu

Ulrich M. Rieger, MD Department of Plastic Reconstructive Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria ulrich.rieger@uki.at or ulrich.rieger@i-med.ac.at

Keith M. Robertson, MD Whitfield Clinic, Waterford, Ireland plasticsurgery68@yahoo.com

Rod J. Rohrich, MD 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA rod.rohrich@utsouthwestern.edu

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 krosenstein@nyee.edu

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 jrousso@nyee.edu

J. Peter Rubin, MD Division of Plastic and Reconstructive Surgery, 3380 Blvd of the Allies, Suite 180, Pittsburgh, PA 15238, USA chakurdabl@upmc.edu or rubinjp@upmc.edu

A. Chasby Sacks, MD Arizona Cosmetic Surgery, 4202 North 32nd Street, Suite F, Phoenix, AZ 85018, USA chasby@cox.net

Contributors xxvii

David B. Sarwer, PhD University of Pennsylvania School of Medicine, Penn Behavioral Health, 3535 Market Street, Philadelphia, PA 19104, USA dsarwer@mail.med.upenn.edu

Thomas Schoeller, MD, MSc Department for Handsurgery, Microsurgery, and Reconstructive Breast Surgery, Marienhospital Stuttgart, Böheimstraße 37, 70199 Stuttgart, Germany thomas.schoeller@aon.at

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 asclafani@nyee.edu

Nicolò Scuderi, MD Department of Plastic and Reconstructive Surgery, La Sapienza University, Rome, Italy nicolo.scuderi@uniroma1.it

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 masherma@jhmi.edu

Melvin A. Shiffman, MD, JD 17501 Chatham Drive, Tustin, CA 92780-2302, USA shiffmanmdjd@yahoo.com

Pierfranco Simone, MD Division of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Rome, Italy pierfranco.simone@fastwebnet.it

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 ozansozer@elpasoplasticsurgery.com or griselda@elpasoplasticsurgery.com

Daniele Spirito, MD Via delle Baleniere 107/b, 00121, Rome-Ostia, Italy d.spirito@chirurgiaplastica.it

Wayne K. Stadelmann, MD Pillsbury Medical Office Building, 48 Pleasant Street, Suite 201, Concord, NH 03301, USA nitro3706@aol.com

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 aris@sterodimas.com

Berish Strauch, MD Department of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY 10467, USA bstrauch@montefiore.org or bstrauch.mmcp09.mmcd03@montefiore.org

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 matthew.talarczyk@wpafb.af.mil

David E. Talevi, MD Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, Ancona, Italy tlvdvd@yahoo.it

Howard A. Tobin, MD Facial Plastic and Cosmetic Surgery Center, 6300 Regional Plaza, Suite 475, Abilene, TX 79606, USA drtobin@newlook.com

Andrew P. Trussler, MD Department of Plastic Surgery, University of Texas Southwestern, 1801 Inwood Road, WA4.238, Dallas, TX 75390, USA andrew.trussler@utsouthwestern.edu

Yehuda Ullmann, MD Department of Plastic and Reconstructive Surgery, Rambam Medical Center, 8 Ha’Aliya Street, Haifa 31096, Israel y_ullmann@rambam.health.gov.il

Nestor Veitia, MD 3109 Forbes Avenue, Suite 500, Pittsburgh, PA 15213, USA nesveitia@yahoo.com

Robert Yoho, MD 797 South Arroyo Parkway, Pasadena, CA 91105, USA ryrobert2@spamarrest.com

Part

Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis

I

33M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_1 © Springer-Verlag Berlin Heidelberg 2010

1.1 Introduction

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 woman’s psyche. Significant improvements or complications can impact greatly on the self image for better or worse. 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.

1.2 Development (Fig. 1.1)

As a cutaneous appendage, the breast takes its origin from the ectoderm. The breast bud begins differentiation during weeks 8–10 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 nipple–areola 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.

1.3 Parenchyma (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: drcutmd@aol.com

1

44 M. R. Davis

of millions of lobules clustered to comprise approxi-mately 20–25 lobes. Interlobular ducts come together to form approximately 20 main lactiferous ducts. Lactiferous sinuses collect milk, and specialized ducts within the nipple transmit milk to the surface. 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 Cooper’s 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 20–25 lobes each drained by a lactiferous duct. Milk then enters the collecting ducts followed by lactiferous sinuses prior to exit-ing the nipple

51 Mammary Anatomy

1.4 Musculature

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 breast’s primary arterial, venous, nerves, and lymphatic supply.

1.5 Skeletal Support

Breast symmetry and form is also dependent on nor-mal skeletal support. The breast overlies the antero-lateral thorax principally over ribs 2–6. Conditions which manifest chest wall abnormalities such as pec-tus excavatum and carinatum, Marfan’s syndrome, and Poland’s 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.

1.6 Arterial 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 2–6 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 to the pectoral border. 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 nipple–areola complex perfusion.

1.7 Venous 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

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.

1.8 Innervation (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 nipple–areola 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 nipple–areola complex.

1.9 Lymphatics (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

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-tributions to the contralateral breast. Inferior lymphatics may enter the rectus sheath and drain into subperito-neal plexus.

1.10 Nipple–Areola Complex

As mentioned previously, the nipple–areola 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 nipple–areola complex can be reliably preserved with attention to anatomic principles.

Importantly, the blood supply to the nipple–areola 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 nipple–areola 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. Montgomery’s glands, which reside in the areola, lubricate the nip-ple–areola 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.

9M. A. Shiffman and A. Di Giuseppe (eds.), Body Contouring, DOI: 10.1007/978-3-642-02639-3_2, © Springer-Verlag Berlin Heidelberg 2010

2.1 Introduction

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.

2.2 Codifying 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-ics must be carefully considered. In 2004, 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: drcenteno@stcroixplasticsurgery.com

2