1. 1. Body Contouring
2. 2. Melvin A.Shiffman Alberto Di Giuseppe (Eds.) Body Contouring Art,Science,and Clinical Practice
3. 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 shiffmanmdjd@yahoo.com Alberto Di Giuseppe, MD Department of Plastic and Reconstructive Surgery, School of Medicine University of Ancona 1, Pizza Cappelli 60121 Ancona Italy adgplasticsurg@atlavia.it
4. 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. 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. 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. 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. 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. 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. 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. 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. 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
13. 13. Contents xvii 81 L Brachioplasty Following Massive Weight Loss . . . . . . . . . . . . . . . . . . . 795 Daron Geldwert and Dennis J. Hurwitz 82 Brachioplasty After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 803 Franco Migliori 83Brachioplasty and Axillary Restoration with Treatment Algorithm for Brachioplasty . . . . . . . . . . . . . . . . . . . . . . 809 Charles K. Herman and Berish Strauch 84 Current Techniques in Medial Thighplasty . . . . . . . . . . . . . . . . . . . . . . . 815 David W. Mathes 85 Thighplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827 Cristina Hachul Moreno, Aline Rodrigues Bragatto, Amrico Helene Jr, Carlos Alberto Malheiros, and Henrique Jorge Guedes Neto 86 Combined Thigh and Buttock Lift After Massive Weight Loss . . . . . . . 837 Claudio Cannistr 87Venous Thromboembolism in Bariatric Body Contouring Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847 Maura Reinblatt and Michele A. Shermak Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
14. 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 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, So Paulo, Brazil alinerbragatto@ajato.com.br David Broadway, MD 9777 S Yosemite Street, Suite 200, Lone Tree, CO 80124, USA davidb@bodevolve.com Claudio Cannistr, 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 008240330, 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
15. 15. 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 Clnicas, Av. San Gabriel, 201 conj. 704/5, So 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 Coutt Mayora, MD Belisario Domnguez No. 2501, Colonia Obispado, Monterrey, Nuevo Len C.P 64060, Mxico ajcouttem@msn.com Amal Dass, MD Advanced AestheticsSurgery, 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, So 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, So 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
16. 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 adgplasticsurg@atlavia.it 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 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 Clnicas, So Paulo, SP, Brazil and Division of Nutrology Residence Program, Plastic Surgery Service, Hospital das Clnicas, So 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 OHara Street, Suite 1617, Pittsburgh, PA 15213, USA fernstrommh@upmc.edu Marcus Castro Ferreira, MD Plastic Surgery Service, Hospital das Clnicas, So Paulo, SP, Brazil mferrei@uol.com.br Lydia Massako Ferreria, MD, PhD Department of Plastic Surgery, Universidade Federale de So Paulo, Escola Paulista de Medicina, So Paulo, Brazil lydiaferreira@uol.com.br William Forlini, MD, PhD Marche Polytechnic University Medical School, Via Tronto, 20, Ancona, Italy williamforlini@msn.com
17. 17. 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 Clnicas, Rua Pedrosa Alvarenga, 120, So 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 Clnicas, Federal University of Paran (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 Amrico 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
18. 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 enrimar@vip.telesal.net Mauricio Hernandez-Perez, MD Center for Dermatology and Cosmetic Surgery, Plaza Villavicencio 3er Nivel Local 3-1, Col. Escaln, 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 and Department 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 Hpatique, Hpital LArchet 2, University of Nice Sophia Antipolis, 151 Route Saint Antoine de Ginestire, 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
19. 19. 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, So Paulo, Brazil camalheiros@terra.com.br Alexandre Mansur, MD Rua Alberto Foloni, 575 ap 23A, Centro Cvico Curitiba, Paran, 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
20. 20. 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 Clnicas, So Paulo, SP 01486-000, Brazil miguelmodolin@uol.com.br Hctor J. Morales Gracia, MD Belisario Domnguez 2501, Colonia Obispado, Monterrey, Nuevo Len, CP 64060, Mxico drhectormorales@hotmail.com Cristina Hachul Moreno, MD Rua Vergueiro,1353 cj 407, Paraiso CEP 04101-000, So 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, So Paulo, SP, Brazil drguedes@drguedes.med.br Daniele Pace, MD, MSc Rua Solimes, 1175, Mercs Curitiba, Paran, 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
21. 21. 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
22. 22. 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, Bheimstrae 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 Nicol 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
23. 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 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 HaAliya 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
24. 24. Part Anatomy, Classification of Adiposities, Body Contouring, Injection Lipolysis I
25. 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: drcutmd@aol.com 1
26. 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. 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. 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. 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. 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: drcenteno@stcroixplasticsurgery.com 2
31. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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