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3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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a
e
b cd
fg
hij
Fig. 3.3 Drawings on transverse sections showing a comparison of the subcutaneous panniculus
of a thin person (above) and a person with localized adiposity (below). The fascia supercialis and
lamellar layer in person with localized adiposity increases the thickness much more than the areolar layer. The perforator vessels coming from rectus abdominalis muscle crossing perpendicularly
the lamellar layer reaching fascia supercialis where create the communicating vessels (CV)
which provide smooth vascularization to subdermal layer and dermis as well. Due to my anatomical research in cadaver I created two fascial aps for ear reconstruction which became possible to
perform in one single stage: one supplied by temporal supercial artery and other one by posterior
auricular artery. Sequential photos and illustrations during surgery: (a) patient with microtia on left
side; (b–d) diagrams showing rotation of the two fascial aps covering the new cartilagem auricular framework; (e) perioperative photo shows the fascial ap already rotated covering the new
auricular framework; (f) nal surgical reconstruction of the ear with skin graft on posterior side.
Sequential photos of dissection on cadaver to demonstrate creation of the temporal fascia ap on
left side to be used on ear reconstruction and cranio-facial surgeries as well. Photo (g) incision on
scalp was done followed by cutaneous undermining just below the hair follicles without any damage to them. The scalp ap is raised from its place in order to create the temporal fascial ap supplied by temporal supercial artery; (h) the temporal fascia ap is demarcated with blue ink; (i) the
fascia supercialis ap is already raised; (j) the temporal fascia ap having temporal supercial
artery in its pedicle is already rotated and covering the left auricle demonstrating its use during ear
reconstruction
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J. M. Avelar
Surgical Anatomy andDistribution ofFascia Supercialis
The fascia supercialis is an anatomical structure formed through connective tissue
layers, one on top of another, with vessels between them. The arteries come from
underneath the muscular plane in those regions and may have localized adiposities
in specic regions.
Anatomically, the fascia supercialis is a very thin connective tissue structure
formed of several layers with vessels between them. Its sophisticated distribution is
a peculiar and important anatomical structure that appears between the skin and the
muscular or bone planes at one of two levels: (1) In some regions, the fascia supercialis is in the middle of the subcutaneous structures, and (2) in other regions, it is
near the muscle or bone level.
1. The fascia supercialis is in the middle of the subcutaneous structures. All the
regions of the anterior aspect of the abdominal wall (Fig.3.4a) feature a peculiar
distribution in several layers, where fat cells increase the thickness because of
the accumulation of fat inside them, as I have demonstrated in my anatomical
research with perforator vessels on the projection of the rectus abdominalis
(Figs.3.1, 3.2, and 3.5) (Avelar 1986a, b, 1987, 1989a). On the posterior aspect
of the torso (Fig.3.4b), among the 11 regions are eight that may present with
localized adiposities: two odd, namely interscapular and sacral, and three even,
namely scapular, suprailiac, and gluteal (Fig.3.4c).
During an operation, when the skin and subcutaneous panniculus are incised
and the fascia supercialis has not been correctly sutured, it may develop scar
ab c
Fig. 3.4 Diagram (a) showing the supercial aspect of the abdomen with its nine anatomical
areas. They are three odds: epigastric, umbilical, and hypogastric; three even: hypochondriac, lumbar and inguinal. Diagram (b) the supercial aspect of the torso with its 11 regions: three odds:
interscapular, vertebral and sacral; four even: scapular, lumbar, suprailiac and gluteal. On (c) the
interscapular, scapular and suprailiac may present localized adiposities
cd
3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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ab
RAM
Fig. 3.5 Drawing and anatomical study in fresh cadaver to show relationship of the layers of the
subcutaneous panniculus in the abdominal wall. (a) Scheme of the panniculus: skin (S), Areolar
Layer (AL), Fascia Supercialis (FS) Communicated Vessels (CV), Perforator Vessels (P) crossing
perpendicularly Lamellar Layer (LL). The communicated vessels (CV) create an arch between the
perforator vessels (P) from where small vessels go perpendicularly through the areolar layer (AL)
to vascularize the areolar 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; (b) photo of the cadaver’s panniculus after liposuction performed on left
side of the abdomen—CV, FS, AL, P and LL.The right side of the abdomen was incised but liposuction was not performed, where one can see the full-thickness of the panniculus with all anatomic elements
CV
FS
P
AL
LL
ab
Fig. 3.6 A 59-year-old patient with unaesthetic surgical scars on abdomen caused by previous
operations when fascia supercialis was not properly sutured and the areolar layer lost the anatomical structure causing depression, retraction and contraction scars. Photos (a, c) one can see
unaesthetic scars on abdominal wall with deep and retracted surgical scars; (b, d) after surgery
performed with adequate reparation of the fascia supercialis
retraction and contraction with inelegant results (Figs.3.6, 3.7, 3.8, and 3.9). In
such circumstances, the areolar layer loses the important anatomic support naturally provided by the fascia supercialis, causing a deep collapse, an unaesthetic
surgical scar with irregularities, depression, retraction, and even contraction. If
the fascia supercialis has not been properly sutured, the nal scar may present
inelegant irregularities caused by the absence of its reparation, which is itself
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J. M. Avelar
ab
Fig. 3.7 A 46-year-old patient with ungraceful and deep surgical scars on abdomen caused by
previous operations. It is evident that the fascia supercialis was not properly sutured during original surgery. Photos (a, c) the scars are so deep, retracted and unaesthetic on abdominal wall; (b, d)
after lower lipoabdominoplasty performed with adequate reparation of the fascia supercialis
ab c
d
Fig. 3.8 A 41-year-old patient presenting deep and unaesthetic surgical scars on supra pubic
region due to previous abdominoplasty performed elsewhere and the fascia supercialis was not
sutured correctly during operation. Even the umbilical region was too wide and ungraceful. Photos
(a, c) unaesthetic scars secondary to previous abdominoplasty performed in other service presenting deep scar and ungraceful umbilicus; (b, d) after correction of the scars with adequate suture of
the fascia supercialis and reparation of the umbilical scar following my technique
due to a disturbance in the vascularization of the areolar layer and the subdermal
layer (Fig.3.10e–g).
During surgery, each anatomical structure must be sutured with the same one
on the other border of the wound, particularly for the abdominal wall and all the
regions of the anterior aspects of the chest to reinstate all layers of the panniculus. When the anatomical architecture of the panniculus has been correctly
sutured, it avoids an unaesthetic depression or retractile scars because the fascia
supercialis is the basis of the areolar layer, which prevents abnormalities from
forming after healing has completed (Fig.3.11a–c, e–g).
During a medial tight lift procedure, the fascia supercialis is an important
structure and must be sutured to achieve the adequate suspension of the
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Fig. 3.9 A 36-year-old patient with deep surgical scar on supra pubic region caused by previous
intra cavity operation performed by gynecologist. The fascia supercialis was not properly sutured
during surgery. Photos (a, c) the scar is deep with retraction and ungraceful appearance; (b, d) after
lower lipoabdominoplasty performed with adequate suture of the fascia supercialis
panniculus (Figs.3.12 and 3.13). Such a suture works as a strong suspension to
maintain the panniculus in the proper position, as I previous described (Avelar
1997, 1999a, b). Regarding medial thigh suspension, a similar report was pub-
lished by other authors (Lockwood 1995).
2. The fascia supercialis is close to the muscle or bone level. It may appear in
most regions of the upper and lower extremities (Fig.3.14) and underneath the
scalp (Fig.3.3). In those regions, during surgery, it is also necessary to suture the
fascia supercialis. In the temporoparietal region, the presence of the fascia
supercialis is an important anatomical structure for which I created useful temporoparietal aps to improve ear reconstruction (Figs. 3.3 and 3.15) (Avelar
1977a, b, 1978). Also, the temporoparietal fascia aps are excellent surgical
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ef g
J. M. Avelar
d
Fig. 3.10 A 49-year-old male patient with unaesthetic surgical scars on abdomen caused by previous operations performed elsewhere when the fascia supercialis was not properly sutured. Photos
(a, c) one can see deep and unaesthetic scars on abdominal wall presenting deep and retracted
surgical scars; (b, d) after surgery performed with adequate reparation of the fascia supercialis.
(e) Scheme showing incision of the panniculus with inadequate suture of the subcutaneous layers;
(f) as far as only skin was sutured, both sides of the fascia supercialis are not correctly repaired
indicate by arrow; (g) nal aspect of the wrong suture of the wound, since fascia supercialis was
not sutured it does not reinstate the normal anatomy of the panniculus and areolar layer collapsed
downwards causing brosis, local depression with retraction and contraction of the scar, because
options for craniofacial surgery (Avelar 1992; Avelar and Padovez 1982; Avelar
and Psillakis 1981). Each ap contains a single pedicle supplied by the temporosupercial artery, and the other one contains the posterior auricular artery. In my
rst publications, because of vital vascularization, performing reconstruction on
the auricle in only one stage became possible (Figs.3.3 and 3.15) (Avelar 1977a,
b, 1978).
Nevertheless, I later found an anatomical opportunity to perform primary ear
reconstruction without employing the temporoparietal fascial aps. My preference since that time is to preserve the temporoparietal region and all the structures inside the fascia supercialis for other situations, such as the treatment of
eventual complications that may occur after the rst or second stage of ear
reconstruction (Avelar 1979; Avelar and Psillakis 1980) So far, it has been very
ef
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3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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c
B
A
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Fig. 3.11 A surgical scar on chest wall of a male patient 5years after removal of rib cartilage on
right side in which the fascia supercialis and all layers of panniculus were properly sutured during
surgery. Photo (a) the arrow indicates the nal scar; (b) perioperative photo shows incision on the
panniculus of the chest with arrow indicates the fascia supercialis held by two forceps; (c) after
correct suture of the fascia supercialis (indicates by arrow) providing important anatomical support for areolar layer; (d) photo in close up of the same patient showing on photo (a) the scar with
excellant healing due to adequate suture of the fascia supercialis providing normal anatomical
structure of the panniculus. (e) Scheme demonstrating the correct sutures of the panniculus on
regions presenting fascia supercialis between thick areolar and lamellar layers.One can see the
suture A is done repairing the fascia supercialis, and the suture B is done repairing the dermis; (f)
demonstrates that the fascia supercialis is well repaired creating an adequate support for areolar
layer, since the nal scar on the skin is smooth without retraction or contraction to the cutaneous surface
useful for secondary ear reconstruction and complex deformities caused by the
traumatic amputation of the auricle, for which the temporoparietal aps may be
primarily employed during rst stage of reconstruction (Avelar 1997).
In some regions, the fascia supercialis is quite close to the cutaneous covering, with very few layers, and its behavior here is similar to that in other regions.
An excellent example is in the mastoid region: Here, the fascia supercialis is
just above the periosteum and is quite close to the skin. Such knowledge is
important when ear reconstruction (on congenital or traumatic amputations) is
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Fig. 3.12 Diagram and photo of the thigh. (a) Internal surface of the thigh. The upper and lower
third present thick lamellar layer as is shown in sections A and C.Section B shows the middle third
which does not have a lamellar; (b) photo of a female patient presenting localized adiposity on
upper third of internal thigh
J. M. Avelar
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Fig. 3.13 Comparison between location of the fascia supercialis in panniculus of chest, anterior
side of the thigh and scalp. Photo (a) transoperatory of the right side of the chest for removal of
cartilage. One can see: areolar layer (AL), fascia supercialis (FS) is marked with blue ink, muscle
(M) underneath; (b) photo of the anterior side of the thigh showing the fascia supercialis (FS) is
held by a forceps, the areolar layer (AL) is very thin and attached to the dermis, muscle (M) on
depth; (c) incision on scalp showing the fascia supercialis (FS) and areolar layer (AL) are very
close to each other and just above the bone (B) of the cranium
performed because it is necessary to undermine the skin in order to create a subcutaneous tunnel to embed the new auricular framework in (Avelar 1979; Avelar
and Psillakis 1980, 1981). Such a detachment must be carried out just underneath the subdermal layer and above the fascia supercialis, and surgeons must
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Fig. 3.14 Diagram and anatomic dissections on cadaver’s photos of the right leg. In the diagram
(a) shows the cutaneous and subcutaneous layers in three levels: upper, medial and lower; (b) the
skin of the leg was incised and undermined just above the fascia supercialis which lies on the
muscles; (c) the fascia supercialis is rotated laterally to show the muscles underneath
avoid damaging the vessels inside so that enough blood supply is provided to the
cutaneous covering (Fig.3.3e, g). When such a procedure is carried out on the
correct level, there is no bleeding during or after the operation. For this reason,
it is not necessary to use any kind of postoperative drainage after ear
reconstruction. To nd an adequate level, inject saline solution with a thin needle
just underneath the skin in a parallel position. Cutaneous incision and undermining must both be performed while the surface of the skin shows elevation from
the injection of the saline solution.
In all regions of the face, the fascia supercialis is also quite close to the skin.
When cutaneous undermining is performed during a face lift, select the level that
is just below the fascia supercialis to preserve adequate vascularization to the
subdermal layer and to the skin. This structure is above the supercial musculoaponeurotic system (SMAS), according to Mitz and Perronie (1976).
Usually, in the upper and lower extremities, the fascia supercialis is quite
close to the muscular level, except on the posterior surface of the arm and on the
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Fig. 3.15 Creation of the fascial aps on temporal and parietal regions during anatomical dissections on fresh cadaver. Photo (a) the ap is marked with ink, having its pedicle supplied by temporal supercial artery; (b) the long ap is raised from scalp showing its pedicle
J. M. Avelar
upper and lower thirds of the internal surface of the thigh (Fig.3.12). Once
again, in these areas, the fascia supercialis is divided into several layers thanks
to the presence of localized adiposities.
In all the regions of the lower and upper extremities, the fascia supercialis
features a peculiar distribution that is very close to the musculoaponeurotic level,
where arterial and venous vascularization is present (Fig.3.13).
Discussion
Ever since I started my professional activities in 1973, I’ve noticed that several
elds in plastic surgery still require further technical development to achieve better
aesthetic results and to reduce the incidence of complications. Among those elds
were two that came with challenges requiring new techniques to incorporate updated
technical knowledge:
1. Ear reconstruction
2. Abdominoplasty
In both elds, I concluded that such technical development requires gaining
more anatomic information to achieve scientic progress.
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