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1 The Art andScience ofBody Sculpting: Sculptor’s Perspective
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7
sense the weight, strength, lassitude, strain, tension, or
relaxation of muscles engaged. This positioning allows the
viewer to experience the multisensory integration and
energy of the pose of the model from the inside and the outside [4, 29]. Health, tness, attractiveness, energy, masculinity, femininity, and emotion can be perceived from the
model in his or her pose. The outward shape of the gure
should serve as the focal point, provide linear clues to the
subtleties of shape and form, then communicate a specic
body type to the model be that triangular, rectangular, diamond-shaped, hourglass, or rounded.
1.5 Principal Masses
Sculpting the human gure requires both deconstructive
and reconstructive processes. Initially, the body is examined by imaginative visual dissection contemplating the
underlying layers contributing to the surface shape and
form, followed by physical reconstruction of the model in
clay. The additive reconstructive approach to learning
human anatomy is an invaluable three-dimensional proprio-spatial learning experience [30, 31].
To appropriately analyze the model, varied lighting by
intensity, angulation, and distance from the body will bring
out different accentuations and values of form. These basic
principles of light dene how the eye perceives form, distinguishing peaks and the valleys and the values of light through
highlights and shadows of surface anatomy. The retina perceives images in two dimensions, while reconstructing the
human body requires three-dimensional perspective.
The bony infrastructure of the body consists of three principal masses: the oval (head), egg (thorax), and the trapezoid
(pelvis) (Fig.1.5). These large forms represent the rudimentary shapes of core skeletal form, connected vertically by the
spine varying in length by curvatures and angulations. Using
the head height as the standard unit for measurement, the
principal body masses are sculpted, and the extremities of
the armature are covered sparingly to represent the bony
limbs. Primary masses create the infrastructure for many
bony landmarks serving as measurements, orientation, and
visual clues to the overlying soft tissues.
Fig. 1.5 Armature and clay building of masses: oval (head), egg (thorax), and trapezoid (pelvis). (© 2021 Peter M.Schmid)
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1.6 Sculpting Anatomical Shape
andForm
Representational sculpting proceeds by the additive process
from which slips of clay are applied piece by piece, strand by
strand to the armature building the human body. Sculpting
anatomical detail demands mental constructs of origins and
insertions of muscles and muscle and tendon shapes, consistently using the model as a reference point. The method of
applying clay is directional, laying out muscle groups linearly transitioning between plane and three-dimensional
convexities while building the infrastructure volume. The
clay becomes systematically layered in “reverse dissection.”
As the myofascial layers of the body are placed, structural
anatomy is built, along with positive convex volumes of prole lines, transition zones, denition, and shadows by negative volume, all construction in exacting measures. Muscles
and their attachments inherently display individual squareness, collective sinuous patterns, S-shaped curves, and planes
throughout the body (Fig. 1.6). The body naturally
demonstrates contour offsets, and rhythmic ow patterns as
muscles join primary masses and course down the extremities. The artist’s eye is continuously tested for anatomical
accuracy, symmetry, proportions, and deciencies.
The surface convexities of the various areas of the body
reveal unique inections, degrees, apogees, and transition
points that reect the cumulative shape of all underlying
anatomy from bone to skin. As the plastic expression unfolds,
certain aesthetics are deliberately enhanced and visually
expressed. A fourth dimension unfolds through muscle
accentuation and gestural expression. Understanding structural–shape associations relays important visual clues in live
patients, as over time the eye recognizes surface form as
related to specic underlying anatomy.
Fig. 1.6 Additive sculpting of thorax chest, and breast from skeleton to surface and breast form. (© 2021 Peter M.Schmid)
1 The Art andScience ofBody Sculpting: Sculptor’s Perspective
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1.7 Application ofArt totheScience
ofFacial andBody Contouring
Transitioning from studio to surgical suite with newly established ideas and perspectives, the cosmetic surgeon can now
approach aesthetic challenges with deliberate aesthetic plans
from conceptualization to management, be that prejuvenation, renement, enhancement, rejuvenation, or reconstruction of human form. Artistically tailored techniques preserve
patient-specic cosmetic needs sensitive to age, ethnicity,
femininity, masculinity, self-expression, and expectations.
Artistry avoids the Einstellung effect, the untailored cookie
cutter, or antiquated philosophies of treatment. Sculptural
awareness contemplates heightened preconceptions of
beauty and the strategic surgical goals needed to achieve aesthetic aims and endpoints. Thus, outcomes remain true to the
preservation of natural beauty.
Patient examination requires multi-perspective lighting
and with specic anatomical markings (anatomical, sculptural, aesthetic specic) outlining geometrics, proportions,
details, depletions, or deciencies. With attention to detail,
appraisals assess skeletal and/or cartilaginous structural
landmarks, muscle anatomy, fat tissue compartment dispositions, tendinous ligamentous or bro-septal network integrity, and the status of the skin of the body equally by touch
and visual inspection.
Surgical objectives are accomplished through skillful
application of additive, reductive, or synergistic sculpting
materials and techniques to augment, reduce, reshape, contour, lift, or dene human form (Fig.1.7). Working from a
palate of options, treatments entail safe and selective application of llers, neuromodulators, skin resurfacing, autologous fat transfer, implants, tissue/fascial release and lifting,
tightening, excisional surgery, or combinations thereof.
Whether volume enhancement is in the face, breast, buttock,
or body, treatment must address the multi-perspective prole
lines, and complement and conform into the natural anatomical curves and surface to optimize visual enhancement,
ratios, form, and balance. As artistic surgeons we must ethically guide the patient toward volumetric shape and curvatures that complement the patient’s frame and physique now
and as the body ages.
Facial augmentation is accountable to structural bony
facial platforms, the overlying soft tissue layers including
the fat compartments, and the concertina effect of aging and
the skin [32]. Aesthetic treatment must complement
anthropometrics, the malar platform, and the inuence of the
forehead and jawline. Treatments should always avoid curve
distortion, over-enhancement, disgurement, or deformity.
Restoration should balance ogee curves, volumes, and bony
contour and angulations respective to age and individual
masculine or feminine secondary characteristics.
Rhinoplasty remains a sophisticated sculptural procedure
that addresses the most visible central feature on the human
face. From computer imaging and conception to surgical
alteration, rhinoplasty demands nesse in planning and execution as the surgeon renes, reduces, and alters the disposition of the nasal framework and overlying soft tissues. Tip
shape and projection serves as the crucial dening point
from which adjacent visual alterations are based. The artistic
directive becomes the expression of the attitude of the nasal
dorsum to the tip, all in relationship to the facial prole plateaus and feature by degrees and millimeters.
Breast and buttock augmentation requires artistic planning with visual insight and sensitivity to size, shape, volume, orientation, projection, asymmetries, attitude, and the
anticipation of the natural aging process. Breast and buttock
augmentation requires a keen sense of gurative scale, symmetry, and proportion to complement the existing body curvatures and dimensions during performance of reductive,
augmentation, or fat transfer techniques. Aesthetic impact is
as much about proportion as it is about size. The breast and
buttock should sync with the body contour, blend naturally,
and reect cultural values avoiding articial or unnatural and
inorganic “stuck on” shapes in appearance.
Body contouring by cannula, energy, and tissue transfer
simulates sculpting in clay by knife and wire loop. The aesthetic sculptural intent is to control surface form and light
values by altering subcutaneous convexities, concavities, and
transition zones. Contemporary artistic techniques of body
sculpting lie far from the days of generalized liposuction,
merely aspirating and reducing tissues by “non-thinking”
technique or hands. What artistic training now brings to the
table is an inspired artistic mindset by which the surgeon
skillfully operates with “sculpting hands” and by visuotactile sense. Subcutaneous selective sculpting reduces,
modies, preserves, or feathers adipose disposition incrementally while accentuating or softening of myofascial
shape translates to improved surface form. Creating either
high- or low-denition torsos and extremities requires both
an aesthetic plan and technical precision. The aesthetic
details lie in the surgeons’ adept execution, as undertreatment conceals form and overtreatment skeletonizes, or can
destroy, natural form. As discovered through clay sculpting,
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Fig. 1.7 From visual conception and planning in the atelier to the operating room (OR): applying art to science. (© 2021 Peter M.Schmid)
1 The Art andScience ofBody Sculpting: Sculptor’s Perspective
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one should avoid destroying form by excessive attening of
three-dimensional volumes, or creating unnatural severely
etched or sharp linear forms, grid-like patterns, or horizontal
lines. Vertical lines create the illusion of length and ow to
the gure. Sculpted human form should have pleasing balances of negative and positive spaces and volumes, hierarchical light reexes, and feathered peripheral zones avoiding
abrupt step-offs end zones. Liposculpting the human gure
in-the-round and by subtle blending into adjacent anatomical
zones maintains a visual ow to the body. Fat is the surgeon’s
advocate and serves as an aesthetic dener, and by degree of
fullness reects youth, beauty, and health.
1.8 Conclusion
The Art of the Aesthetic Surgeon guided by artistic “visual
enlightenment” can be founded in the Surgical Sculptural
Arts. Aesthetic didactics establishes a unique paradigm shift
from archaic philosophy and practices toward a surgical
intelligentsia. Artist–technology associations working within
collective mind inspire ideas and creativity, inuencing innovative thought and aesthetic judgment. Driven by the passion
for beauty of the human form, sculptural arts enable one to
discover new levels of consciousness, and bridge unparalleled gaps and sensitivities to conceiving and treating the
human body. Training in aesthetics ultimately disciplines the
hand, mind, and eye, as the human body may now be
addressed as art form. Aesthetic anatomy, intimately learned
through sculptural study of the live model, the cadaver, and
life, not only cultivates a deeper understanding of human
beauty, but also provides perspective and aesthetic direction
to deliberate modication of the human body upholding
visual harmony and balance. These newly founded sensitivities advance cosmetic surgery to a whole new level of expertise, a value to novice or accomplished surgeon alike. Artistic
temperament drives one to critically appraise one’s work and
seek personal improvement by focused “perfect practice,”
satisfying the desire to strive for perfection in the ideal.
Beauty now lies in the mind and hands of the cosmetic
surgeon.
Sculpting for Surgeons™ is an original artistic platform
by which the cosmetic surgeon can advance aesthetic skills
and intellect to form sense and three-dimensional anatomy
of the human body under a professional instructor [33]. As
altering the appearance alters the patient’s self-perception
and esteem, it is the impetus of the aesthetic surgeon to do all
in his or her power to expand upon knowledge, understanding, planning, and technique to provide optimal results.
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Contemplation. (© 2021 Peter M.Schmid)
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9. Vasari G, Bondanella JC, Bondanella P.The lives of the artists. The
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15. Root-Bernstein RS, Root-Bernstein MI.Sparks of genius: the thirteen thinking tools of the world’s most creative people. Boston:
Houghton Mifin Co.; 1999. p. viii, 401 p.
16. Kruk KA, etal. Comparison of brain activity during drawing and clay
sculpting: a preliminary qEEG study. Art Ther. 2014;31(2):52–60.
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18. Brown S, et al. Naturalizing aesthetics: brain areas for aesthetic appraisal across sensory modalities. NeuroImage.
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19. Merzenich MM, Nahum M, Van Vleet TM.Changing brains: applying brain plasticity to advance and recover human ability, Progress
in brain research. 1st ed. Amsterdam: Elsevier; 2013. p. xxvi, 466
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mind: essays in honor of Roger W.Sperry. Cambridge: Cambridge
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21. McKim RH.Thinking visually: a strategy manual for problem solving. Belmont: Lifetime Learning Publications; 1980. p. x, 210 p.
22. Colvin G. Talent is overrated: what really separates world-class
performers from everybody else. London: Nicholas Brealey; 2008.
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Surgical Anatomy oftheBody
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inRelation toLipocontouring
MohanThomas andJamesD’silva
Body contouring using liposuction requires a fundamental
understanding of subcutaneous fat and its anatomical relation to the underlying fascia in order to provide optimal
results. Subcutaneous fat is variable in density, thickness,
and adherence throughout the body. Illouz in the 1980s was
the rst to introduce Modern Liposuction and his presented
technique has undergone many transformations to get to its
present state due to the medical technological advances and
use of newer drugs and physiological understanding in recent
times. Better understanding of the biochemical and physiologic properties of the process of liposuction has improved
the safety features in liposuction primarily by reducing blood
loss. Body contouring by liposuction requires a complete
knowledge of the anatomy of the area and understanding of
the physiological basis of liposuction.
2
Apical fat layer
Mantle fat layer
Deep fat layer
2.1 Gross Anatomy
Deposition of fat cells in the body is usually in the form of
three layers as seen in Fig.2.1: the apical fat layer, the mantle fat layer, and the deep fat layer.
1. Apical Layer of Fat: This layer is the most supercial of
all fat layers and is continuous with the deepest aspect of
the reticular dermis. These extend upward into the deep
dermis in the form of peri-adnexal fat surrounding the
sweat glands and hair follicles and also along the vascular
arcade. This is usually visible as yellow dots on the
undersurface of the thick split-thickness skin graft.
Liposuction of this layer of fat is not possible without
injury to the dermal vascular plexus. The understanding
that supercial liposuction undertaken in this layer will
cause skin shrinkage is faulty; rather, it may cause partialof full- thickness skin loss.
M. Thomas (*) ∙ J. D’silva
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
Fig. 2.1 The distribution of adipocyte layers as seen from the
dermis to the muscular fascia. The apical and mantle layers should
not be treated denoting “no man’s zone” of liposuction [1].
(Adapted from: Kaminski M.V. (2010) The Adipocyte Anatomy,
Physiology, and Metabolism/Nutrition. In: Shiffman M. (eds)
Autologous Fat Transfer. Springer, Berlin, Heidelberg. https://
doi.org/10.1007/978- 3- 642- 00473- 5_4)
2. Mantle Layer: This has columnar fat cells that are verti-
cally oriented and are present at the interface of the dermis and the discrete sheet of facial brous tissue, as seen
in Fig.2.1. This layer is present in all body parts except in
areas such as the eyelids, nasal bridge, and penis to name
a few. In specic body parts such as the legs, this segment
accounts for all the subcutaneous fat in the area. Its function is to protect, insulate, and cushion the area.
3. Deep compartment layer: This is the layer where fat
deposition happens due to increasing weight. The size
and shape of these fat deposits depend on the sex of the
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_2
13
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External Oblique
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M. Thomas and J. D’silva
individual, their genetic predisposition, and the degree
of obesity. The function of this layer is to store the
excessive energy consumed by the person. This is the
layer that needs maximum fat removal during
lipocontouring.
2.2 Anatomy oftheAbdomen
The most common area being liposuctioned is the abdomen
as it usually is the primary area of concern for both men and
women. It is also a very challenging area due to its anatomy,
very obvious results, comfort of the patient, and the unevenness arising due to weight gain.
Abdominal fat is either located in the subcutaneous plane
(outside the muscle) or viscera (part of omentum and
between loops of intestine). Grossly, the division of abdomen can be done into an upper abdomen and a lower abdomen. In thin people, the skin is uniform to pinch and
showcases the shape of the underlying muscle. Fat may
deposit predominantly in the upper or lower abdomen in
females or may be uniform such as in a male. In obese
females there might be a distinct demarcation at or just
above the umbilicus between the upper and lower abdomen
called the waistline sulcus, which has an underlying diffuse
brosis that corresponds with the superior extent of the
Scarpa’s fascia. This is adherent supercially to skin and
deeply to the abdominal muscle sheath requiring an extra
effort to traverse during liposuction.
2.2.1 Skin
• The skin over the anterior abdomen is thin.
• Thick hair is often present in the lower midline of the
male and pubic area in a female.
• The inguinal ligament demarcates the abdomen from the
thighs, and the skin in the area is very thin and forms the
groin fold. Similar shallow groove is present below the
iliac crest.
• Striæ gravidarum or striæ albicantes are vertical white
lines formed due to sudden abdominal distension second-
ary to pregnancy or obesity.
• A brown pigmented streak visible often during pregnancy
between the umbilicus and the pubic symphysis is called
the linea nigra of pregnancy. Linea alba is a shallow fur-
row extending from the xiphoid process in the midline to
below the umbilicus.
• The position of the umbilicus is the middle line. Its posi-
tion with respect to its height may vary; in an adult it is
situated above the line dividing the middle of the body,
and more specically is situated 2–2.5cm superior to the
line joining the tubercles of the iliac crests.
2.2.2 Muscles
Muscles of the abdomen (Fig.2.2)
• External oblique and the rectus abdominis are the only
muscles that have an inuence on form and shape of the
abdomen.
• The external oblique muscle originates as digitations that
intersperse with those of serratus anterior and well marked
in a muscular subject.
• A small lumbar triangle is formed between the lateral
margin of the external oblique muscle and the edge of the
latissimus dorsi with its base formed by the iliac crest,
and its oor by the internal oblique muscle.
• Linea semilunaris is a curved line that is convex laterally
and extending from the tip of the cartilage of the ninth rib
superiorly to the public tubercle inferiorly, essentially
marking the lateral border of the rectus abdominis muscle. At the level of the umbilicus, it is about 7cm from the
middle line.
• Three transverse furrows are usually seen on the surface of
the rectus abdominis muscle, which are primarily the tendinous intersections: the upper two are well demarcated
and one is located at the tip of the xiphoid process and the
second, midway between this and the umbilicus while the
third, which is opposite the umbilicus, is not well dened.
• The anatomical location of the umbilicus is considered to
be the level of the brocartilage between the third and
fourth lumbar vertebrae.
• The rectus abdominis muscle takes the maximum brunt
during increase in intra-abdominal pressure due to pregnancy, ascites, or obesity. This causes weakness in the
linea alba. Once the intra-abdominal pressure is released,
the muscle may not go back to its original tone and there
may be separation of the two recti in the midline called
diastasis recti.
Rectus Abdomini
Tendinous
Intersections
Linea Alba
Linea Semilunaris
Umbilicus
Groin Fold
Fig. 2.2 Muscle orientation of the anks and the anterior abdominal
wall
navel
navel
navel
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Applied Anatomy The weakness of the abdominal muscles
in the midline due to separation of the two recti is called
diastasis recti. It can present as one of the four types as mentioned in Fig. 2.3 below. The treatment of this condition
involves plication and tightening of the rectus sheath thus
strengthening the abdominal wall. Sometimes a polypropylene mesh may be required as an extra support.
Diastasis
around
Fig. 2.3 Different types of diastases due to weakness of muscle wall
Diastasis
below
Diastasis
above
Open
diastasis
2.2.3 Subcutaneous Tissue
Fat distribution pattern is based on gender, age, and race of a
person. Typically, the female body has a gynoid pattern of fat
deposit with a curvilinear silhouette and increased tendency
to accumulate fat in the lower body such as the hips, upper
thighs, lower trunk, and buttocks. Males have an android pattern that has a linear shape with excess fat deposit occurring
uniformly on the trunk.
The waist-to-hip ratio (WHR) in a female is smaller
(0.87) as compared to that in males (1.0).
Racial differences in fat distribution are prominently vis-
ible in African-Americans who tend to accumulate more fat
in the buttocks and hips, which is also the case in some communities in Western India (Fig.2.4).
According to observations and cadaver dissections by
Lancerotto etal. in 2011 [2], three layers of fat are usually
identied under the dermis in the abdominal region: a
supercial adipose layer (SAT), a membranous layer
(ML), and a deep adipose layer (DAT), as shown in
Fig.2.5a–c.
Fig. 2.4 Different layers of the abdominal wall fat deposits with relation to the waistline brosis
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M. Thomas and J. D’silva
Fig. 2.5 (a) SAT (the
supercial adipose tissue) has
been dissected and reected
medially, while ML
(membranous layer) has been
isolated as a ap. (b) The
membranous layer (ML) has
been dissected and overturned
medially with a small area
dissected but left attached to
the inguinal ligament (blue).
(c) Deep adipose tissue (DAT)
raised as a ap. (Adapted
from: Lancerotto, L., Stecco,
C., Macchi, V., Porzionato,
A., Stecco, A., & De Caro, R.
(2011). Layers of the
abdominal wall: anatomical
investigation of subcutaneous
tissue and supercial fascia.
Surgical and Radiologic
Anatomy, 33(10), 835–842.
https://doi.org/10.1007/
s00276-010-0772-8)
a
b
c
2.2.3.1 Supercial Adipose Tissue (SAT)
Supercial adipose tissue is also called Camper’s fascia by
some authors.
• This is the rst layer of adipose tissue that is present just
below the dermis.
• This layer has prominent brous septa with a honeycomblike structure encasing large fat globules and has constant
characteristics throughout the layer.
• These well-dened septa (retinacula cutis supercialis) are
oriented perpendicular to the skin surface and are mechanically very strong, anchoring the dermis to deeper tissues.
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