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techniques for abdominoplasty. Therefore, after a long period of research, I concluded that the abdominal panniculus may be undermined as long as the perforator
vessels are preserved; these vessels work as multiple pedicles to the remaining panniculus, providing adequate blood supply (Avelar 1999a, b, c, 2000a, b) (Figs.1.4,
1.5, 1.6, 1.8, 1.9, and 1.13).
My anatomical studies gave me adequate support to perform combined procedures (liposuction with panniculus resection) with minimal complications. Similar
procedures may be employed for remodeling other regions, such as anks, torsos,
medial thighs, arms, and axilla (Figs.1.5, 1.6, 1.8, 1.9, 1.10, 1.11, 1.16, 1.17, and
1.18) (Avelar 1999a, b, c)
At the beginning of my career, I employed mammary silastic implants for the
reconstruction of severe acquired deformities on the buttocks from complex infections caused by injections into the gluteal regions (Fig.1.2) (Avelar 1974a, b, 1977)
Although these prostheses were not made specically for gluteal regions, they still
improved body contouring. Later, a new prosthesis was developed specically to
improve the aesthetics of gluteal implants.
J. M. Avelar
Conclusions
Body-contouring surgeries have undergone an evolution over the past few decades.
Direct approaches to removing localized adiposities on the lateral and inner side of
the thighs (Farina etal. 1960) have been replaced by horizontal and anatomic incisions on the gluteal sulcus (Pitanguy 1964, 1977) to remodel the trochanteric
regions. A few years later, Illouz (1980, 1983a, b, 1984, 1986a, b) introduced the
revolutionary method of liposuction, yielding outstanding surgical results with minimal complications (Figs.1.3, 1.12, 1.15, 1.17, 1.18, and 1.21). Nevertheless, liposuction leaves redundant skin that requires treatment, which opened up another
modality for body contouring and introduced new techniques for abdominoplasty
(Avelar 1985a, b, 1986). So far, the very high rates of seroma formation and other
sorts of complications after combined procedures of liposuction with the resection
of the excess cutaneous covering motivated me to research new approaches (Avelar
1999a, b, c, 2000a, b) (Figs.1.4, 1.5, 1.6, 1.8, and 1.9).
After a long period of research and anatomical study, I found the key to avoiding
those frequent complications during and after operations, where the abdominal panniculus is undermined but the perforator vessels are preserved during surgery, providing normal vascularization to the remnant panniculus and thus avoiding seroma
formation and other sorts of complications. The new techniques originated as
lipoabdominoplasty (Figs.1.4, 1.5, 1.6, 1.8, and 1.9), and the same surgical principles may be employed for remodeling other regions, such as thighs and buttocks
(Figs.1.10, 1.11, 1.13, and 1.18), arms, axilla, and torsos, achieving smooth shapes
and thus improving body contouring.
1 Surgical Principles forBody-Contouring Approaches
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23
a
b
c
Fig. 1.21 Isolated liposuction of the anks, supra iliac, trochanteric, and gluteal regions leaving
inconspícuos scars, without skin resection in a 22-year-old patient presented accumulation of fat
with unaesthetic appearance. Photos (a, c) before operation; (b, d) after liposuction on the buttocks, supra iliac, anks, and trochanteric regions
References
Avelar JM (1974a) Reparation of Buttocks deformities using mammary prosthesis. (Reparação
de deformidades de nádega com emprego de próteses mamárias). Presented at Brazilian
Congress of Plastic Surgery (BSPC) (as thesis to be full member of the BSPC), Belo Horizonte
(Brazil), May
Avelar JM (1974b) Reparation of severe Buttocks deformity employing mammary prosthesis.
(Reparación de severa deformidad de náldegas con emplego de próteses mamárias). Presented
at V Congress of the Mexican Association of Plastic Surgery (Associación Mexicana de Cirugia
Plástica. Acapulco (México), October.
Avelar JM (1977) Buttocks reconstruction. (Reconstrução de nádega) Braz. Journ of Medicine
(Jornal Bras. de Medicina). Fevereiro, 43–55
Avelar JM (1985a) Combined liposuction with traditional surgery in abdomen Lipodystrophy.
XXIV Instructional Course of Aesth Plast Surg of ISAPS, Madrid.
Avelar JM (1985b) Fat-suction versus abdominoplasty. Aesthetic Plast Surg 9:265–276
Avelar JM (1985c) Fat-Suction of the Submental and Submandibular Regions. Aesth Plast Surg
9:257–263
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Avelar JM (1986) Liposuction of Abdominal Wall (Lipoaspiração da Parede Abdominal). In
Liposuction (Lipoaspiração). Ed. by Avelar JM. & Illouz YG. Sao Paulo (Brasil). Editora
Hipócrates 27:158–176.
Avelar JM (1988) Abdominoplasty – Reections and Bio-psychological Perspectives
(Abdominoplastia – reexões e perspectivas biopsicológicas). Rev Soc Bras Cir Plast
3(2):152–154.
Avelar JM (1999a) New concepts for abdominoplasty. (Novos conceitos para abdominoplastia).
Paper presented at the 36th congress of the Brazilian Society of Plastic Surgery, Rio de Janeiro,
November.
Avelar JM (1999b) A new technique for abdominoplasty– closed vascular system of subdermal
ap folded over itself combined to liposuction (Uma nova técnica para Abdominoplastia –
Sistema vascular fechado de retalho subdérmico dobrado sobre si mesmo combinado com
lipoaspiração). Rev Bras Cir 88/89(1/6):3–20.
Avelar JM (1999c) Abdominoplastia: nuevos conceptos para una nueva técnica (Abdominoplasty:
new concepts for a new technique). XXVI Annual international symposium of aesthetic plastic
surgery, Chairman: Prof. Jose Guerrerosantos, Puerto Vallarta, pp10–13.
Avelar JM (1999d) Aesthetic Plastic in the Inner Side of the Thigh– New Concepts and Technique
without Cutaneous or Subcutaneous Undermining. (Cirurgia Plástica de Face Interna de
Coxas– novos conceitos e técnica7 minutos sem descolamento cutâneo e subcutâneo). Rev
Bras Cir 88/89(1/6):57–67.
Avelar JM (1999e) Aesthetic plastic in the inner side of the thigh – new concepts and tech-
nique without cutaneous or subcutaneous undermining. (Cirurgia Plástica de Face Interna de
Coxas – novos conceitos e tecnica sem descolamento cutâneo e subcutâneo). Rev Bras Cir
88/89(1/6):57–67.
Avelar JM (1999f) Flankplasty and torsoplasty – a new surgical approach. (Flancoplastia e
Torsoplastia- Nova Abordagem Cirúrgica). Rev Bras Cir 88/89(1/6):21–35.
Avelar JM (2000a) Abdominoplasty: a new technique without panniculus undermining and with-
out panniculus resection. 57th Instructional Course of ISAPS, Chairman: Lloyd Carlsen, in
Montreal, Canada.
Avelar JM (2000b) Abdominoplasty: a new technique without undermining and fat layer removal
(Abdominoplastia: uma nova técnica sem descolamento e remoção da camada de gordura). Arq
Catarinense de Med 29:147–149
Callia WEP (1965) Contribuição ao estudo de correção cirúrgica do abdomen pêndulo e globus
(contribution to the study of surgical correction of the pendulum abdomen and globus). original
art. Doctoral Thesis Fac Med USP, São Paulo.
Farina R, Baroudi R, Coleman B. & Castro O (1960) Riding trousersilke type of pelvicrual lipo-
distrophy (trochanteric lipomatosis). Brit. J.Plast. Surg. XIII(2): July.
Illouz Y (1980) Une nouvelle technique pour les lipodystrophies localisées. Rev Chir Esthet 4:19.
Illouz YG (1983a) Instructional Course on Liposuction Technique First Course of Liposuction.
Organized by Dr. Juarez M.Avelar, Sponsored by Brazilian Society of Plastic Surgery (São
Paulo Section) Heled at São Paulo Hospital, Service of Prof. Andrews at Escola Paulista de
Medicina. October São Paulo (Brazil).
Illouz YG (1983b) Body contouring by lipolysis: 5 years experience with over 3,000 cases. Plast
Reconstr Surg 72(5):591–597.
Illouz YG (1984) My technique of Liposuction– 4 years evolution. Second Course of Liposuction.
(Minha Técnica de Lipoaspiração– 4 Anos de Evolução. 2° Curso de Lipoaspiração)- Heled
at “9 de Julho Hospital”. Organized by Juarez M.Avelar, Sponsored By Brazilian Society of
Plastic Surgery. September, São Paulo (Brazil).
Illouz YG (1986a) Basic Principles of liposuction technique (Princípios básicos da técnica de
lipoaspiração). Liposuction (Lipoaspiração). Ed. by AvelarJM. & Illouz YG. Sao Paulo
(Brasil). Editora Hipócrates 3:22–225.
J. M. Avelar
1 Surgical Principles forBody-Contouring Approaches
https://t.me/medicina_free
Illouz YG (1986b). Study of the Adipocite in Lipodistrophy (Estudo do Adipócito nas
Lipodistrogias). In Liposuction (Lipoaspiração). Ed. by AvelarJM. & Illouz YG.Sao Paulo
(Brasil). Editora Hipócrates 4:19–23.
Pitanguy I (1964) Trochanteric lipodystrophy. Plast Reconstr Surg 34:280.
Pitanguy I (1977) Dermolipectomy of the abdominal wall, thighs, buttocks and upper extremity–
In: Reconstructive Plastic Surgery. Ed. By Converse JM. pg. 3.800-3.823– Ed. W.B.Saunders
Company (Philadelphia and London).
Pitanguy I (1982) Phylosophic and Psychological Perspectives of the Abdomen. (Perspectivas
Filosócas e Psicológicos do Abdomen). In Annals of Brazilian Symposio of Abdominoplasty
(Anais do Simpósio Brasileiro de Abdominoplastia), Ed. by Juarez M.Avelar, Sponsored by
Brazilian Society of Plastic Surgery-Regional São Paulo, (Patrocinado pela Sociedade Brasileira
de Cirurgia Plástica– Regional São Paulo). 1:15–24. Editora Cidade, Rio de Janeiro– Brazil.
Pitanguy I (1983) Philosophical and Psychological Aspects of the Facial Contouring Surgery
(Aspectos Filosócos e Psicológicos da Cirurgia do Contorno Facial). In Annals of the
Brazilian Symposium of Facial Contouring (Anais do Simpósio Brasileiro Do Contorno
Facial), Ed. By Juarez M.Avelar, Sponsored by Brazilian Society of Plastic Surgery-Regional
São Paulo (Patrocinado pela Sociedade Brasileira de Cirurgia Plástica- Regional São Paulo),
1:2–9. Editora Cidade, Rio de Janeiro Brasil.
Pitanguy I (1986) Philosophical and Psychosocials Perspectives of the Body Contouring.
(Perspectivas Filosócas e Psicossociais do Contorno Corporal). In Liposuction (Lipoaspiração),
Ed. By Avelar and Illouz,- 1:3–7- Editora Hipócrates- São Paulo (Brasil).
Pitanguy I (1967) Abdominal lipectomy: an approach to it through an analysis of 300 consecutive
cases. Plast Reconstr Surg 40(4):38
Sinder R (1975) Plastic Surgery of the abdomen - Técnica pessoal de abdominoplastia, com
prévio deslocamento de retalho supraumbilical (antes da resseccão infraumbilical) e uso de
retalho dermoadiposo,– VI International Congress of Plastic and Reconstructive Surgery, Paris
(France) August
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Chapter 2
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Anatomy oftheSubcutaneous Layers
intheHuman Body
JuarezMoraesAvelar
Abstract Ever since I learned the liposuction technique, the subcutaneous com-
partment of the human has obviously needed to be studied so that the new method
for reshaping the face and body can be performed. I dedicated much effort to studying it, performing anatomic dissections on cadavers and even performing liposuction on them to determine the subcutaneous layers. Created and popularized by
Illouz, liposuction remains one of the most recent, important methods introduced in
plastic surgery to improve body contouring. As soon as I learned such a revolutionary procedure directly from its creator in early 1982, two concerns immediately
came to my mind: (1) the unknown anatomy of the subcutaneous layer and (2) the
behavior of the tissue after the liposuction procedure. More specically, my concerns on the anatomical descriptions of the subcutaneous panniculus centered on a
lack of sufcient information in textbooks and other publications on the relevant
anatomy. I did not feel comfortable performing liposuction procedures without having sufcient knowledge about the anatomy underneath the cutaneous covering of
the abdomen wall and other regions concerning body contouring.
At that time, I found information on anatomical dissections performed on cadavers of various ages, sexes, levels of adipose tissue, heights, and ethnicities. I found
enough important anatomical information in publications to clarify the specic and
detailed ndings to plastic surgeons. The distribution of the adipose tissue in the
subcutaneous layer was described. After I started performing anatomic dissections
on cadavers that had undergone liposuction, I found peculiar characteristics in each
region of the human body; a careful evaluation of the adipose tissue revealed specic distributions, which were well described. I mentioned in my earlier publications that there are two layers: the areolar layer and the lamellar layer, which are
separated by fascia supercialis all over the subcutaneous panniculus. Later, another
author described fascia supercialis in thigh lifting. The behavior of the subcutane-
J. M. Avelar (*)
Brazilian Scientic Institute of Plastic and Reconstructive Surgery, São Paulo, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_2
27© The Author(s), under exclusive license to Springer Nature
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ous tissue after an operation frequently produces a thick and hard brosis, which
shows that liposuction should be performed on the lamellar layers. This type of
brotic tissue in the subcutaneous areola layer often brings about irregularities and
inelegant waves on the skin surface.
Keywords Fat tissue · Distribution of adiposities · Subcutaneous layers · Areolar
layer · Lamellar layer · Fascia supercialis · Behavior of subcutaneous tissue
J. M. Avelar
Introduction
As soon as I learned the liposuction technique for face and body contouring, I gured out that the subcutaneous layer was an unknown compartment of the human
body (Avelar 1983, 1986c). Also, I noticed that there was cutaneous redundance
after liposuction on the abdomen. Those circumstances motivated me to dedicate
my time to researching the anatomy of the subcutaneous compartments all over the
human body (Avelar 1986a, 1987, 1989). The excess skin left after liposuction gave
me the inspiration to resect it, which opened up the new eld for abdominoplasty
(Avelar 1985a, b, 1986b).
The liposuction technique became popular among plastic surgeons all around the
world thanks to the intense efforts of Illouz’s publications, lectures, and surgical
demonstrations (Illouz 1980, 1983a, b, c, 1984). Ever since I started to perform the
liposuction technique, my curiosity has been directed toward learning about the
anatomy where the cannulas work underneath the skin in order to remove excess fat
tissue. Testut’s textbooks (Testut and Jacob 1975, 1984), Gray (1974), Spaltroltz
(1970), and Sobotta (1977) contained little information on the subcutaneous panniculus. Only two layers were mentioned: the areolar layer, which is more supercial and external and which is situated just below the skin, and the lamellar layer,
which is just beneath the areolar layer.
I immediately started to study the subcutaneous segment in order to obtain anatomic information that had not been well described at the time. I found a specic
distribution and peculiar characteristics in each particular region of the human body
that I studied, and I have described all of them (Avelar 1986a, 1987, 1989) (see
Fig.2.1).
My anatomical dissections and my liposuctions on the abdominal regions, torsos, and upper and lower extremities of several corpses aimed to learn more about
this eld so that I could better perform liposuction. In my rst publication on this
subject (Avelar 1986a), I described the measurements of the subcutaneous layers in
several regions of the human body associated with the liposuction technique. I compared fat people and thin people to determine the thickness of the subcutaneous
tissue (Avelar 1987). I found (Fig.2.2) wide variation in the thickness of the lamellar and areolar layers in all regions of the body concerning the thickness of the
subcutaneous adipose tissue (Fig.2.3). The thickness of the layers in children also
presents peculiar variations because the lamellar and areolar layers are not well
2 Anatomy oftheSubcutaneous Layers intheHuman Body
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29
abc
Fig. 2.1 Anatomical study on dissection on cadaver showing the perforator vessels preserved after
liposuction on abdominal wall. Photo (a) liposuction was done in lamellar layer (LL) on right side
showing remaining areolar layer (AL) and on left side of the cadaver fascia supercialis is marked
with black ink; (b) the remaining panniculus lies on muscles with demarcation of A, B, C for anatomical study; (c) the panniculus after liposuction is pulled upwards where one can see the preserved areolar layer (AL) and perforator vessels between rectus abdominalis muscle (RAM) and
fascia supercialis (FS)
ab c
Fig. 2.2 Comparison of the anatomical segments of the abdominal panniculus between a thin
cadáver, a thin patient, and a patient after liposuction showing relationship of its layers: S skin, AL
areolar layer, FS fascia supercialis, LL lamellar layer. Photo (a) a section of a thin cadaver showing very thin lamellar layer; (b) a section of a thin patient; (c) a section of fat patient after liposuction on lamellar layer. It is important to emphasize that lamellar layer is very thin one and fascia
supercialis in all abdominal panniculus is well identied
identied. For this reason, performing liposuction in infancy is not advisable
(Avelar 1986b).
Ever since I completed anatomic studies, I found that between those two adipose
layers is a connective structure with vessels, namely the fascia supercialis
(Fig.2.4). In fact, it separates the two adipose layers where arterial, venous, and
lymphatic vessels and the nerves are. According to the anatomic information I
found, the liposuction technique can be combined with panniculus undermining as
long as the perforator vessels do not incur damage (Avelar 1999a). Some years later,
another author described the fascia supercialis in thigh lifting (Lockwood 1995).
In my previous publications, I have described that the behavior of the subcutaneous
tissue after an operation develops a thick and hard brosis, which shows that liposuction should be performed on the lamellar layers. I also described that the areolar
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AL
Fig. 2.3 Anatomical study in cadaver to show by Illouz’s “pinch test” the modications of the
thickness of the panniculus in the abdominal wall after liposuction procedure. (a) Frontal view of
the abdomen after liposuction performed on left side of the cadaver. With my hands pinching the
panniculus one can see the difference of thickness with the right side without liposuction procedure. (b) In the same cadaver an incision was done on left side and another on right. On left side
the areolar layer (AL) is preserved, since liposuction was properly performed on lamellar layer.
The fascia supercialis (FS) with perforator vessels was preserved on the lamellar layer (LL) lie
smoothly on the muscular abdominal wall. On right side the areolar layer (AL), fascia supercialis
(FS), and lamellar layer (LL) are identied
J. M. Avelar
1
2
FS
3
Fig. 2.4 Drawings showing the anatomical structures of the abdominal panniculus and proper
level of liposuction. (a) Diagram of the panniculus from top to bottom: skin (S), areolar layer (AL),
fascia supercialis (FS) with communicating vessels (CV) which work as a “peripheric heart,”
lamellar layer (LL) with perforator vessels (P) that must be preserved during liposuction and rectus
abdominalis muscle (RAM); (b) the proper level to perform liposuction: (1) (on top) the cannula
is introduced through the skin incision with its tip in the lamellar layer (LL), below fascia supercialis, (2) the perforator vessels are preserved without fat in lamellar layer and in areolar (AL)
where skin resection is done, (3) on bottom the areolar layer is pulled downwards with inclination
of the perforator vessels which work as multiple pedicle to blood supply to remain panniculus
2 Anatomy oftheSubcutaneous Layers intheHuman Body
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layer is formed by large, round, and turgid cells that are piled together where small
vessels pass to irrigate the subdermal layer and the deep aspect of the skin (Fig.2.2).
On the opposite side, the lamellar layer contains much smaller, empty, and horizontally elongated fat cells (Avelar 1986a).
I described that the thick vessel coming from the aponeurosis and muscular plane
perpendicularly crosses the lamellar layer and perforates in the direction of the fascia supercialis. The connective tissue that forms the fascia supercialis behaves in
a distinct manner in each region of the human body (Fig.2.4).
Finally, I conrmed that the subcutaneous panniculus is formed by two specic
layers: the areolar layer and the lamellar layer, each of which has a different thickness depending on the region of the human body that it is in. Obviously, the tissue’s
behavior varies depending on the degree of nutrition and the excess of adiposity in
the organism. After studying the same region in fat people and thin people, I notice
a great difference that is relevant to liposuction (Fig.2.2).
Another important role of the subcutaneous cellular tissue is to protect the body’s
surface, creating a smooth contour. This structure has a peculiar behavior in different areas, where it can produce more protection in regions of attrition, such as in the
plantar, palmar, and digital areas.
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Anterior Abdominal Wall
Ever since my rst liposuction procedure, the abdominal wall has motivated me to
study the anatomy of the subcutaneous compartment. In fact, the anterior abdominal
panniculus shows immense variation in anatomic constitutions, which were
described for performing liposuction to remodel the body’s contours (Avelar 1986a,
1987, 1989). The abdominal panniculus contains a complex variety of anatomical
changes, which is crucial information to have before performing liposuction (Avelar
1986a, 1987, 1989).
The anterior abdominal wall can be divided into the following regions: three odd,
namely epigastric, umbilical, and hypogastric, and three even, namely hypochondriac, lumbar, and inguinal (Fig.2.5). The main anatomical structures include the
fascia supercialis and the perforator vessels. The odd regions present more alterations than the even ones do and even more so in fat people than in thin people
(Fig.2.6a, b).
The fascia supercialis in those regions contains several layers separated by
adipose tissue in patients with localized adiposity (Figs.2.7 and 2.8). The measurement of and the variation of thickness in the areolar and lamellar layers have
been described in different types of persons to determine indications for
liposuction.
The thicker zone of the abdomen corresponds to the projection of the rectus
abdominalis muscle, from which the large perforating vessels come and in which
they are situated (Figs.2.5 and 2.6). The thickness of the lamellar layer progressively decreases in the lateral regions of the abdomen (Figs.2.7 and 2.8). When the
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Fig. 2.5 The anterior
abdominal is divided into
nine regions: three odd
(epigastric, umbilical, and
hypogastric; six even:
hypochondriac, lumbar,
and inguinal)
J. M. Avelar
a b
Fig. 2.6 Location of the perforator vessels on abdominal wall coming from rectus abdominalis
muscle (RAM). (a) Diagram showing the perforator vessels coming from the rectus abdominalis;
(b) photo of a patient with projection of the perforator vessels where the areolar layer is thick
which is adequate to perform insulin injections using short needle
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