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2 Anatomy oftheSubcutaneous Layers intheHuman Body
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Fig. 2.7 Schemas showing a comparison between the layers of the abdominal panniculus of a thin
person and another with localized adiposity. (a) A thin person presents a compact fascia supercialis separating the areolar layer and lamellar one; (b) on a person with localized adiposity presents
a thick fascia supercialis due to localized adiposity which divides into several layers
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lamellar layer is thick, the panniculus rmly adheres to the muscular level underneath, which can also be observed through the Illouz’s “pinch test” (Illouz 1983a)
(Fig. 2.3). However, in regions with a thin lamellar layer, the panniculus easily
slides over the abdominal musculature (Fig.2.7). On the other hand, the lateral
regions on the right and the left (Fig.2.5) do not present signicant anatomical
variations; rather, the areolar and lamellar layers show regular thickness, even in fat
people. Once again, the fascia supercialis shows rm structures separating both
layers. It shows several layers that make a network with vessels passing between
them (Figs.2.4, 2.7, and 2.8). And it is very rare in some people with localized adiposity (Avelar 1986a, 1987, 1989).
When liposuction is correctly performed, the areolar layer maintains the same
thickness because the operation must be performed on the lamellar layer. The nal
result for patients is a lamellar layer devoid of adipose tissue. The cicatricial tissue
is developed in the lamellar layer, making a very hard brotic tissue. The behavior
of the subcutaneous tissue is shown by the thick layer of cicatricial tissue (Fig.2.2c).
Also, the perforating vessels are not damaged by the cannula during liposuction
(Figs.2.4 and 2.9). The areolar layer must be totally preserved. If it is damaged it
may develop similar brotic tissue after liposuction resulting some ungraceful irregularities below the skin producing waves on the surface of the skin covering.
Such brotic tissue makes a strong and thick layer, which makes a secondary
liposuction on the same region difcult and dangerous to perform. It is possible to
do but should be done carefully because the hard thickness of the cicatricial tissue
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CV
Fig. 2.8 Diagrams showing a comparison of the vascularization of the abdominal panniculus
between a thin person and another with localized adiposity. (a) A thin person presents a compact
fascia supercialis separating the areolar layer and lamellar one; (b) on a person with localized
adiposity presents a thick fascia supercialis due to localized adiposity which divides into several
layers: P perforator vessels coming from muscle; CV communicating vessels which work similar
to a “peripheric heart” to supply smooth vascularization to areolar and subdermal layers as well as
to dermis as well
does not allow the cannula to cross through it (Fig.2.2c) and because the second
stage may damage the areolar layer, producing irregularities on the skin surface.
Therefore, liposuction should be performed on the deep layer (lamellar), maintaining the regular and harmonious thickness of the areolar layer and thus preserving the perforator vessels (Figs.2.9, 2.10, and 2.11). The nal result shows the relief
of the abdominal musculature through the cutaneous panniculus, which indicates a
natural and elegant body contouring.
Besides anatomic knowledge, knowing the difference between fat tissues is crucial to performing liposuction, even when some kind of injection is carried out
inside each layer. Because of the sophisticated vascularization of the panniculus,
insulin injection with short, thin needles as a treatment for diabetes must be performed inside the areolar layer; otherwise, the constitution of the fat tissue may
absorb the medical product. Even when using very thin needle, if the injection is
performed inside the lamellar layer of any other region of the body with a minimal
areolar layer, the abortion of insulin is not absorbed. Such a phenomenon is due to
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Fig. 2.9 Surgical principles on anatomic structures of the abdominal panniculus. Photo (a) the
panniculus of a patient who underwent liposuction 6 months before to perform conventional
abdominoplasty showing preservation of the perforator vessels (P) indicated by forceps, fascia
supercialis (FS) between areolar layer (AL) and lamellar layer (LL), rectus abdominalis (RAM);
(b) scheme of the panniculus: fascia supercialis (FS) and the communicated vessels (CV) which
work similar to a “peripheric heart” creating an arch between the perforator vessels (P) from where
small vessels go perpendicularly through the areolar layer (AL) to vascularize the cutaneous and
subdermal layers. The lamellar layer (LL) is placed between the rectus abdominalis muscle (RAM)
and fascia supercialis (F) where is the correct level to perform liposuction technique
a b c
Fig. 2.10 Constitution of an anatomic unit of a neuro-vascular pedicle of a perforator vessel.
Photos (a) internal perioperative view from the abdominal panniculus after liposuction procedure
performed on lamellar layer showing the preserved perforator vessels coming from rectus abdominalis bilaterally; (b) photo in close up that one can see the perforator vessels; (c) schema showing
the neuro-vascular structures of the pedicle formed by: A artery, V vein, N nerves, L lymphatics
the type of adipose tissue in the areolar layer, which has round and turgid fat cells,
as described previously (Avelar 1986a, b, c, 1989) (Figs.2.2b, 2.3b, and 2.4a). Such
an observation is crucial because the areolar layer of the abdominal wall is the preferable region for injecting insulin, and it must be carried out inside this layer
(Figs.2.4a, 2.6b, and 2.12).
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S
AL
A
LL
I
FS
AL
LL
P
FS
Fig. 2.11 Anatomical study in cadavers to show relationship of the subcutaneous panniculus layers in the abdominal wall. Photo (a) the whole panniculus was sectioned where one can see all
layers and internal viscera in the abdominal cavity of a cadaver without localized adiposity: skin
(S), areolar layer (AL), fascia supercialis (FS), lamellar layer (LL) muscular-aponeurosis of the
abdomen (A), internal viscera (I); (b) photo of a fresh cadaver after liposuction performed on left
side of the abdomen and the whole thickness of the panniculus on right side without liposuction.
On left side of the abdomen the perforator vessels (P) and areolar layer were preserved. On right
side one can see the areolar layer (AL), fascia supercialis (FS) as well as the lamellar layer (LL)
with perforator vessels included. The panniculus of both side is pulled by two hooks
a b
Fig. 2.12 Diagram demonstrating the correct injection of insulin in areolar layer (between skin
and fascia supercialis)
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Because I am diabetic, two unusual situations have happened to me from the
injection of insulin. Once, I rapidly developed severe hypoglycemia symptoms
immediately after I injected insulin into the subcutaneous level of my abdomen. I
concluded that the tip of the needle damaged some small vessels during injection
and that the insulin was absorbed in an erratic way. Because I was at home, I ingested
several units of sugar to treat the symptoms. My physician agreed with me about the
possibility of accidental damage to the vessels, but such an abnormal occurrence is
extremely rare. Another complex situation happened despite three regular daily
injections of insulin: my glycemia level progressively became too elevated. Although
I injected higher and higher doses of insulin, the level of glycemia was out of control. I concluded that the injections were inserted into a lamellar layer, where small
vessels are in a lower proportion of adipose tissue, so the insulin was not regularly
absorbed. Afterward, I was assured that the injections were inserted into my abdominal panniculus, inside the areolar layer, and after four days, the glycemia level
normalized. Therefore, the anatomy of the panniculus is also important because
such injections must be carried out within the areolar layer in order for the absorption to occur normally.
Posterior Regions oftheTrunk
The posterior regions of the torso are as follows: three odd, namely interscapular
(IS), vertebral (V), and sacral (SC), and three even, namely scapular (S), lumbar (L),
and suprailiac (SI) (Fig.2.13a). Also, the regions that most frequently present localized adiposities can be identied to prove that adiposity occurs inside the fascia
supercialis (Fig.2.13b).
Fig. 2.13 Regions of the
torso. Diagram (a) one can
see the three odd regions:
interscapular (IS), vertebral
(V), and sacral (SC) and
three even regions:
scapular (S), lumbar (L)
and suprailiac regions (SI);
(b) shows the most
frequent regions presenting
localized adiposities, inside
the fascia supercialis
FS
AL
M
M
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All the regions of the posterior aspect of the trunk feature the ideal anatomical
constitution to perform liposuction on localized adiposities. Usually, the areolar
layer is very thick and the fascia supercialis is quite close to the muscular aponeurotic level, but not in those regions with localized adiposities in the lamellar layer,
whose distribution is quite similar to that in abdominal walls (Figs. 2.4a, 2.6b,
and 2.13b).
There are some relationships between the anterior regions of the abdominal wall
and some between the posterior ones (Avelar 1989). Therefore, plastic surgeons
must examine the torso every time a patient complains about any problem in the
abdominal wall. The abdomen must be also evaluated when the problem is in the
torso (Figs.2.5, 2.6, and 2.13).
All the regions of the posterior aspect of the trunk present a similar constitution
in both cutaneous and subcutaneous tissue. Thin people show a thick and rm areolar layer, and the lamellar layer is also thin. Patients presenting localized adiposity
show a noticeable growth in the lamellar layer, which is responsible for the alterations in unaesthetic shapes requiring liposuction for their remodeling (Figs.2.6b
and 2.13b).
In all regions of the torso, the panniculus is very thick, but it is not uniform,
because each one presents peculiarities on which liposuction can be performed.
The nal results may present outstanding surgical contouring, providing a smooth
appearance when the selection of patients and adequate indications are performed
preoperatively. Some regions present external alterations—for example, the
lamellar layer has shown increased thickness in cases of localized adiposity
(Fig.2.13b).
On one hand, some areas of the torso, such as the lumbar region, seldom show
the accumulation of adiposity because the lamellar layer does not present anatomical characteristics for those abnormalities. On the other, the suprailiac regions may
present the accumulation of localized adiposities, which are good indications for
requiring remodeling via liposuction (Fig.2.13b). The scapular regions of the torso
may present accumulations of adipose tissues in the lamellar layer, which may help
reshape the body’s contouring (Fig.2.13a, b). The areolar layer shows peculiar reg-
ularity without any alterations in thickness.
The interscapular region is another area that may present localized adiposities on
lamellar layer which may achieve smooth surgical result ever since deep liposuction
is performed (Fig.2.13a, b). The regions on the anterior aspect of the chest present
panniculus constitutions similar to those of the posterior ones: The lamellar layer is
very thin, and the fascia supercialis is quite close to the muscular level, presenting
the thick areolar layer (Fig.2.14).
During examination, the surgeon should identify that when the lamellar layer
shows localized adiposity, the subcutaneous panniculus does not slide over the muscular plane.
a
bc
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d
Fig. 2.14 Photo during surgery showing the subcutaneous panniculus of the chest wall. Areolar
layer (AL) is the full thickness of the panniculus, since the lamellar layer (LL) is very thin associated with fascia supercialis (FS) which slides easily on the muscles (M) underneath. One can see
the fascia supercialis (F) is held with a forceps
The Trochanteric andGluteal Regions
Trochanteric lipodystrophy and gluteal lipodystrophy used to be treated through
panniculus resection via the vertical approach (Farina etal. 1960). Later, Pitanguy
introduced new techniques via incisions after remodeling the gluteal sulcus in both
the trochanteric region and the gluteal region (Pitanguy 1964, 1977). By using this
technique, the gluteal and trochanteric regions can be reshaped, but the nal result
leaves a long scar on the subgluteal fold and the inguinal sulcus (Fig.2.15). Later, a
new era of liposuction was introduced by Illouz (1980, 1983a, b, 1984), leaving
only inconspicuous scars while improving body contouring (Fig.2.16).
Deformities in the trochanteric and gluteal regions are usually localized to the
subcutaneous cellular compartment with inelegant shapes in the lower segment of
the body. Usually, people without localized adiposity show a good proportion and a
good relationship between the areolar and lamellar layers. So far, heavier patients
without localized adiposity in this region show a proportional augmentation in both
layers, keeping well-balanced shapes in the body contours. However, localized adiposity may be caused by the excessive augmentation of the lamellar layer, which
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Fig. 2.15 Diagrams showing trochanteric lipodystrophy combined with dysmorphy of the gluteal
regions remodelling by Pitanguy’s technique. (a) Posterior view with asymmetric deformities with
surgical demarcations of the technique; (b) oblique view showing the incision extending anteriorly; (c) demarcation goes to the upper internal thigh for correction of typical deformities; (d) after
suture on right side showing advancement of lower ap indicated by arrows
can be much thicker than that in people without localized adiposity, while the areolar layer presents few alterations in its thickness. Ever since the introduction of
liposuction, it has been performed in such a way as to achieve harmonious surgical
results (Fig.2.16). Nowadays, a combination of it with fat grafting is an excellent
approach to reshaping the trochanteric gluteal regions when carried out according to
specic deformities and with adequate surgical planning.
A clinical examination should be carefully carried out to evaluate each region
that shows an abnormal accumulation of adipose tissue. All the data from physical
examinations are useful for elaborating surgical planning before performing any
operations. Each surgeon must follow their own orientation to prepare their surgical
planning, which is essential before performing any operations.
a
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c
d
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Fig. 2.16 Unaesthetic deformities of the buttocks and trochanteric regions due to accumulation of
adiposities treated by liposuction procedure. Photos (a, c) preoperative showing ungraceful appearance due to extensive trochanteric lipodystrophy; (b, d) post-operative view after isolated liposuction remodelling gluteal trochanteric lipodystrophy
Lower Extremities
In Testut’s classic Treatise on Human Anatomy (1975, 1984), the thigh has been
divided into two surfaces: anterior and posterior. Now that I have performed anatomical research, I consider dividing it into four surfaces—namely anterior, posterior, external, and internal—more convenient because each of them presents peculiar
histological characteristics (Fig. 2.17a). The anterior surface of the thigh is an
extensive and regular region because the panniculus has a thick areolar layer and
thin lamellar one. The fascia supercialis is underneath the areolar layer and immediately above the aponeurosis. The panniculus slides over the muscular level because
the cutaneous and subcutaneous layers are regular and quite near the muscles.
Therefore, this region does not often undergo liposuction, because if the areolar
layer were damaged, it might develop severe irregularities on the cutaneous surface
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a b
Fig. 2.17 Anatomic constitution and variation of thickness of the panniculus in the three surfaces
of the thigh. (a) Scheme shows the situation on three surfaces: (1) anterior, (2) external, (3) posterior. (b–d) Photos show cutaneous incisions on the thigh where one can see the panniculus of a
cadaver with variation of the thickness on the anterior, external, and posterior surfaces. (b) The
forceps hold the fascia supercialis and one can see that the lamellar layer is very thin and close to
muscles underneath. (c) The external surface of the thigh where areolar layer, fascia supercialis,
and lamellar layer make a compact structure. (d) The posterior surface of the thigh where areolar
layer is quite thick, the fascia supercialis and lamellar layer make a compact structure
(Fig.2.17b). The external surface of the thigh has some similarity to the anterior
one, but the areolar layer is thinner and the lamellar layer does not exist or is too thin
to observe. The fascia supercialis is between the areolar and the aponeurosis. For
this reason, the panniculus slides on the muscular level (Fig.2.17c). Also, the posterior surface has the same anatomical and histological distribution as the anterior
surface (Fig.2.17d). Therefore, liposuction is not a good technique to be performed
on those regions.
On another hand, the internal surface of the thigh can be divided into three segments: superior, middle, and inferior. The upper third has very thin skin and a soft
and thin areolar layer. The lamellar layer is present even in thin patients. One can
estimate the lamellar layer because it contains adiposities (Fig.2.18). Therefore,
this region quite often undergoes liposuction. Also, excess skin from the upper
internal thigh is removed according to the technique proposed by Pitanguy (1964,
1977) (Fig.2.15a, c). Some years later, other procedures were described that confer
smooth contouring to internal thigh (Avelar 1996, 1999b).
When the lower third of the thigh presents localized adiposity, that is an adequate indication for liposuction (Fig. 2.18). So far, it has not been adequate to
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