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3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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63
1. For the reconstruction of the auricle, signicant technical improvements have
been published by outstanding authors such as Gillies (1937), Converse (1958a,
b, 1963), Tanzer (1959), Psillakis et al. (1990), Tanzer (1978) and Pitanguy
(1967), Pitanguy et al. (1972), with good aesthetic results. Nevertheless, each
reconstruction was a challenge because it requires performing several surgical
stages to achieve the nal result and because it comes with a very high incidence
of complications.
Therefore, at that time, I dedicated much time to studying the anatomy of a
normal auricle and its neighboring areas. In addition to reading textbooks, I
improved my knowledge by performing anatomic dissections on cadavers, and I
found out important information on the neighboring regions of the auricle, especially those concerning arterial and venous vascularization (Figs.3.3 and 3.15).
In the beginning, I identied that the temporal supercial artery and the posterior
auricular artery could be transferred to the ear in order to improve blood supply,
by providing better vascularization to the reconstructed organ. During my anatomical dissections, I concluded that I could perform such a vascular transposition
without causing any local damage because those vessels were between the fascia
supercialis.
Thanks to such anatomical information, I designed two aps: one supplied by
the temporal supercial artery and the other supplied by the posterior auricular
artery (Avelar 1977a, b). Each contained a very small vascular pedicle and the
wide surface of the fascia supercialis with a rich vascular network between the
connective layers. Because of the wide surface of the anatomical structure, I
named this ap the “racquet-shaped ap” (Figs. 3.3 and 3.15). It was such a
crucial anatomical nding to my research that it became possible to perform ear
reconstruction in one surgical stage (Avelar 1977a, b). Therefore, at the beginning of my career, I demonstrated that it was possible to reduce ear reconstruction surgery from six or eight surgical stages to one surgical stage (Fig.3.3). In
addition to reducing it to one surgical stage, this technique minimizes complications and improves aesthetic renements to the reconstructed auricles (Avelar
1978, 1979, 1986a, b). Since those publications, I have performed ear recon-
struction following the same surgical principles, with necessary variations
according to each deformity (congenital or acquired).
2. Abdominoplasty is an aesthetic surgery of the abdominal wall. There were several problems that required new ideas and new concepts to add to the basic techniques to minimize the high incidence of complications during and after
operations. At the beginning of my practice, those problems motivated me to
establish the Brazilian Symposium of Abdominoplasty in 1982 with the participation of all outstanding Brazilian plastic surgeons and some renowned specialists from other countries. Besides the event, we also published the annals of the
event, with participation from all the attending surgeons and featuring their
updated knowledge on the subject (Avelar and Padovez 1982). In the scientic
program concerning the techniques for abdominoplasty, the speakers presented
a high level of information. However, many questions regarding complications
during and after operation did not convince given that many problems remained
after all the discussions (Guerrerosantos 1982; Mélega 1982; D’Assumpção 1982).
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J. M. Avelar
At that moment, once again, I was sure that abdominoplasty presented
multiple challenges to plastic surgeons all over of the world. In my reections
and brainstorming, I identied three main problems with the operation: (1)
the creation of a new umbilical region; (2) complications during and after the
operation; and (3) remaining adiposities after surgery. First, I had already
presented a new method that makes triangular incisions around it to avoid
leaving a circular scar after surgery and thus resulting in smooth surgical
results (Avelar 1976a, b, 1978, 1979, 1983). Second, complications during
and after abdominoplasty were even more difcult to solve. I concluded that
abdominoplasty was a eld that still required technical improvements to minimize complications. Third, the remaining adiposities after abdominoplasty
were reduced thanks to development of liposuction by Illouz (1980, 1983a, b,
1984, 1986).
In 1983, I went to Paris to learn the liposuction technique by observing
Illouz’s performing his technique. When I performed my operations, the cannulas worked inside an unknown anatomical compartment of the human body. At
that time, I decided to study the anatomy of the subcutaneous layers in order to
gain more-precise anatomical knowledge. I performed anatomic research on
cadavers to nd new information, when possible, so that I could identify the
lamellar layer, which was close to the muscles, and the areolar layer, which was
supercially separated by the fascia supercialis.
This structure had rich vascularization coming from the perforator vessels,
which I call the communicating vessels (CVs), as a “peripheric heart”,” because
the blood pressure decreases to irrigate the areolar layer and the subdermal layer
(Figs.3.1a, c, 3.2, and 3.5). I performed dissections on several cadavers of various ages, sexes, levels of adipose tissue, heights, and ethnicities and used liposuction to look for new information and explore the behavior of the subcutaneous
compartment after liposuction (Avelar 1986a, b, 1987, 1989a, b).
The fascia supercialis is an anatomical structure between the areolar and
lamellar layers with peculiar characteristics in abdominal wall and with differences between each region and between thin people and people with localized
adiposities. A similar anatomy was found in upper and lower thirds of the medial
thighs (Fig.3.12) and in some regions of the torso. On the abdominal wall and in
the posterior regions of the torso, the fascia supercialis is well identied on
computerized tomography (CT) when the image is well analyzed on same level
while observing the bone structures as anatomic references (Fig.3.16).
The fascia supercialis must be well sutured during surgeries on the abdominal wall to repair the architecture of the panniculus (Fig.3.10e–g). If it is not
adequately sutured, the areolar layer will not reinstate the anatomical structure,
thus leaving behind unaesthetic and inelegant surgical scars (Figs.3.6, 3.7, 3.8,
3.9, and 3.10a, c).
The fascia supercialis in the scalp regions contains a rich vascular network
supplied mostly by the temporal supercial artery, the posterior auricular artery,
and the occipital artery. They run between the connective tissue layers of the
fascia supercialis, providing vascularization to the areolar and subdermal lay-
U2
3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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65
ab
Fig. 3.16 Computerized Tomography (CT) of a patient, before and one year after full lipoabdominoplasty combined with reinforcement of the abdominal muscular aponeurotic wall. One can see
that both images are on the same level as showing the references of the bone structures. The fascia
supercialis is well identied on supra iliac region. Photo (a) image of CT before operation showing diastasis of the muscles on umbilicus indicated by arrow (U1); (b) CT of the same patient
1year after full lipoabdominoplasty combined with reinforcement of the muscular wall repairing
umbilical region (U2), and thick layer of fascia supercialis (FS) which is placed between areolar
layer (AL) and lamellar layer (LL)
U1
FS
AL
LL
ers and the dermis, similar to how the CVs operate. The fascia supercialis in the
temporoparietal region (galea) is useful for ear reconstruction (Avelar 1977a, b,
1978) and the reparation of cranial defects (Avelar 1983). Those aps must be
designed with a knife without local inltration to avoid damaging the vascular
network.
The subdermal fat layer must remain attached to the dermis to preserve vascularization to scalp. I have had the opportunity to attend some patients presenting with defects on the cranium that the neurosurgeon intended to remove by
using cranial fascial (galea) as a graft to replace the defect. Members on a neurosurgeon’s staff accepted my surgical plan for repairing the cranial defect without performing a graft of the cranial fascial structure. Instead of following their
surgical plan, I suggested rotating the full thickness of the scalp with the cranial
fascia ap, where rotation is carried out from the back to the anterior in order to
cover the cranial defect (Fig.3.17). The full thickness of the scalp ap is supplied
with blood by the posterior auricular artery and the occipital artery, providing
adequate vascularization to the wide area of the scalp ap. If neurosurgeons had
resected the temporoparietal fascia and grafted on the cranial defect in order to
cover the brain tissue, the scalp ap could certainly not have been rotated. If the
temporoparietal fascia is removed from the scalp, it will damage the blood supply of the scalp and it will therefore no longer be available for use as a wide ap.
After all, the fascia supercialis on the cranium’s surface is in charge of the
vascularization of the scalp through a wide arterial and venous network of communicating vessels.
66
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J. M. Avelar
a
d
e f
ghi
Fig. 3.17 Perioperative photos showing rotation of the temporal muscle ap for reparation of
10cm defect on temporal bone with exposition of brain. Photo (a) a defect missing 10cm diameter
on temporal bone with exposition of the brain indicated by arrow; (b, c) arrows indicate the rotation arch of the temporal muscle ap; (d) the ap is already sutured covering exposition of the
brain through bone defect. Members of neurosurgeon’s staff intended to remove the tempo-parietal
fascia for grafting to cover the cranium defect, but proposed to rotate a composite scalp ap to
repair the defect. Photo (e) the scalp is already raised with its pedicle supplied by posterior auricular artery (PAA) and occipital artery (AO) with arrow indicates the rotation arch; (f) a 3cm incision
is done to provide rotation of the ap; (g) the ap is rotated from back forward; (h) the scalp ap
is already sutured covering the bone defect; (i) the same patient one month after surgery
Conclusions
The fascia supercialis is a sophisticated anatomical structure that is present in
almost all the regions of the human body between the skin and the muscular or bone
levels (Figs.3.1, 3.2, and 3.3). Because of its importance and peculiar behavior after
surgery, it can be considered as second skin.” During operations on the abdominal
wall, the posterior aspect of the torso, and the posterior side of the arm—regions
where the fascia supercialis is between the areolar and lamellar layers—the fascia
supercialis should be sutured to reinstate the full thickness of the panniculus
(Fig.3.11). If it is not adequately sutured during surgery, it may leave unaesthetic
3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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67
and retractile scars because it could damage the areolar layer and even cause vascular alterations in the subdermal level (Figs.3.6, 3.7, 3.8, 3.9, and 3.10).
The fascia supercialis, which is just above the muscles and on bone structures,
also must be sutured from border to border to reinstate it, although the areolar and
lamellar layers are too thin (Figs.3.3, 3.14, and 3.15). These anatomical characteristics appear on the upper and lower extremities—except on the upper and lower
thirds of the media thigh (Fig.3.13) and except on the posterior side of the arm,
where the fascia supercialis is between thick layers of the areolar and lamellar layers, which is described in more detail in Chap. 2.
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Part II
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Abdominoplasty on Body Contouring
Chapter 4
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Sinder’s Technique: AUseful andSafe
Approach forAbdominoplasty
JuarezMoraesAvelar
Abstract The rst abdominoplasty was credited to Kelly when he performed a
panniculus resection of the lower segment of the abdominal wall. According to
Sinder, in 1890 Demars and Marx described a resection of skin and the subcutaneous abdominal wall. During the twentieth century, several authors developed substantial developments in different types of panniculus resections. A remarkable
operation was introduced by Vernon, who performed the reimplantation of the
umbilicus on the cutaneous abdominal wall. A memorable abdominoplasty was
described by Callia as a cutaneous incision on the suprapubic region followed by
panniculus undermining. Later, Pitanguy performed wider panniculus undermining
by using reinforcement from the musculoaponeurotic wall to reinstate the body
contouring.
Sinder introduced new concepts to abdominoplasty by bringing more security to
the operation, starting with the detachment of the abdominal panniculus through a
supraumbilical incision. Afterward, the cutaneous ap of the upper abdominal wall
is pulled downward so that an appropriate location for the skin incision in the suprapubic region can be determined. Therefore, the resection of the abdominal panniculus is carried out once the surgeon has properly evaluated its extension into the
infraumbilical area. The plication of the musculoaponeurotic wall is performed after
the abdominal panniculus undermining has been completed according to surgical
planning. Sinder’s method also to introduced a new, safe technique for
abdominoplasty.
Keywords Abdominoplasty · New technique · Upper undermining · Safe
approach · First superior incision
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_4
73© The Author(s), under exclusive license to Springer Nature
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J. M. Avelar
Introduction
For patients with cutaneous accidity, unaesthetic skin surgical scars, or a voluminous abdomen, the operation will leave a horizontal scar localized to the suprapubic
region (Pitanguy 1967). But when there is poor elasticity and less accidity in the
supraumbilical region, there may be some difculty in bringing the supraumbilical
ap to the suprapubic edge of the incision. If the suture is made under strong tension, it poses a risk of causing dehiscence in the central part of the wound and other
complications.
To avoid this risk, Sinder (1975a, b) introduced new concepts to abdominoplasty
through adequate surgical planning (Fig.4.1). He started his operation by rst performing the detachment of the supraumbilical area, creating a cutaneous ap
(Fig.4.2). Afterward, the upper abdominal ap is pulled on in a downward direction, and the surgeon may then properly evaluate the correct location for an incision
in the suprapubic region (Fig.4.3). Once the surgeon has completed their evaluation, the infraumbilical panniculus can then be correctly demarcated for a nal cutaneous incision in the suprapubic region (Fig.4.4a). The skin of the umbilicus is
isolated on all sides by making triangular incisions (Avelar 1976a, b, 1979, 1983,
Fig. 4.1 Surgical
demarcations before
operation of Sinder’s
technique. A triangular
area with base on the lower
line is drawn inside of the
area of skin resection to
provide adequate surgical
support to the
abdominal ap
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