Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
.pdf
SUPERFICIAL ADIPOSE LAYER
2 Surgical Anatomy oftheBody inRelation toLipocontouring
https://t.me/medicina_free
Fig. 2.6 Different layers of
the abdominal adipose tissue
as a cut section
17
DERMIS
MEMBRANOUS LAYER
DEEP ADIPOSE TISSUE
• Its borders are ill dened both caudally and cranially, as it
appears continuous inferiorly over the inguinal ligament
into the thigh and cranially into the thorax as similar
tissue.
• The SAT has high structural stability and elastic properties.
• Supercial adipose tissue (SAT) when removed exposes a
membranous-looking brous layer, which is well organized macroscopically (Fig.2.5a).
• On dissection it is found as a continuous plane from the
thorax to the inguinal ligament.
• It is not uniform in thickness and appears as a well-dened
white layer in the lower abdomen that thickens toward the
inguinal ligament, where multilayered structure of collagen bundles layered in various angles is visible.
• Medially this membrane fuses with the linea alba, cranially continues into the thorax, and caudally continues into
the inguinal ligament and the osseous prominence of the
iliac crest (Fig.2.5b).
2.2.3.2 Deep Adipose Tissue (DAT):
Sub- Scarpa’s Fat
• This is a more diffuse fat layer with smaller and atter fat
lobes that are ill dened with less consistent and obliquely
oriented brous septa.
• The thickness of this layer of tissue is different in different areas.
• At the points of xation of the membranous layer such as
the inguinal ligament, bony prominences, and linea alba,
DAT becomes thinner and tends to progressively reduce
its fat component, while the network of collagen bers
(retinacula cutis profunda) becomes stronger and more
tightly packed, connecting the deep aspect of the membranous layer to the deep fascia.
• There is great difference in the DAT among various individuals in terms of strength and thickness of the retinacula cutis as well as its fat contents.
• Obliquely placed septa with good strength and elastic
properties allow the subcutaneous tissue to slide over the
deep fascia (Fig.2.6).
• The DAT compartment is clearly dened along the lines
of adherence identied for the membranous layer; as a
result the deep adipose compartment of the abdomen
appears to be isolated from that of the thighs.
• The deep fascia of the abdomen envelopes the abdominal
muscles and is present deeper to the DAT.
2.2.3.3 Anatomical Importance [2]
1. The movements transmitted to the skin by the deeper
muscular contractions are absorbed and dampened by
the sliding system formed by the membranous layer
(also called Scarpa’s fascia), the DAT, and the SAT.To
prevent a bad scar adhesion between muscle and skin
causing the transmission of these movements, it is
imperative that these layers should be repaired in different layers.
2. The membranous layer provides a tissue plane for aps in
reconstructive surgery, that is, adipocutaneous propeller
aps can be raised just supercial to the DAT, or can be
used as isolated ML–DAT aps.
3. The anatomical difference between SAT and DAT should
be kept in mind when undertaking liposuction in the
abdomen. Large cannulas should be used deeper so as to
aspirate fat from the DAT layer while the thin cannula
should be used for SAT.Using large cannulas in the SAT
layer will cause scaring and unevenness of the skin
surface.
18
1. Lateral Gluteal
Depression
2. Gluteal Crease
Tract
https://t.me/medicina_free
M. Thomas and J. D’silva
4. The “contraction” in the skin after liposuction especially
after ultrasound-assisted liposuction is due to the contraction of the membranous layer that is rich in elastic bers.
5. Although the membranous layer appears to undergo a
duplication in thickness with obesity, the fat layers, both,
quadruplicate, and the thickness and the density of the
retinacula is reduced as the size of the fat lobes increases
that leads to altered mechanical and anatomical
relations.
According to Frank [3], aggressive liposuction of the
supercial fatty layer, especially too close to the dermis. Can
cause injury to the subdermal vascular plexus causing loss of
vascularity of the subdermal fatty layer and thus causing
necrosis of the overlying skin [4]. This happens because the
arterial arcade traverses supercial to the Scarpa’s fascia,
within the SAT, which can be damaged during supercial
liposuction.
• Liposuction of the deep fatty layer, deep to Scarpa’s fas-
cia, can cause injury to the perforators connecting the
named arteries to the supra-Scarpa arterial network since
these run in the DAT.However, because of the great col-
lateral supply, any vascular injury of the perforators is
usually very well tolerated [5].
2.2.4 Zones ofAdherence
The zones of adherence (Fig.2.7) are caused by presence of
dense brous tissue that attaches skin to the deep fascia and
provides the shape as well as support and suspension to the
soft tissue in the area.
• The supercial fascial system in these areas is adherent in a
very dense manner to the underlying deep muscular fascia.
• Because of this dense adherence, there tends to be a thin
layer deep fat that is covered by the supercial fascial
system.
• The shape and the natural curve of the body is dened and
maintained by these zones of adherence.
• Liposuction if done aggressively in these areas of adherence does have a high risk of causing irregularities.
There are a total of ve zones of adherence throughout the
trunk and lower extremity:
• The lateral gluteal depression
• Gluteal crease
• Distal posterior thigh
• Mid-medial thigh
• Inferolateral iliotibial tract
Fig. 2.7 The red areas are
the zones of adherence caused
by presence of dense brous
tissue that attaches skin to the
deep fascia and provides the
shape as well as support and
suspension to the soft tissue
in the area [6]
3. Distal Posterior Thigh
4. Mid Medial Thigh
5. Inferolateral Iliotibial
2 Surgical Anatomy oftheBody inRelation toLipocontouring
https://t.me/medicina_free
19
2.2.5 Vascularity andNerve Supply
oftheSubcutaneous Tissue
2.2.5.1 Blood Supply andLymphatics
• Superior epigastric artery, which is the branch of the
internal mammary artery, and inferior epigastric artery,
which is a branch of the femoral artery, supply the anterior aspect of the abdomen in the vertical direction. The
lateral aspect of the abdomen is supplied by the segmental
arteries arising from the intercostal and lumbar arteries,
horizontally (Fig.2.8).
• These vessels anastomose with each other as well as trib-
utaries of the muscular branches.
• These supercial abdominal vessels are situated super-
cial to the fascia Scarpa but found deep to the Camper’s
fascia.
• This layer marks an important anatomical landmark for
surgery so as to avoid any damage to the vessels and lymphatics running through this layer.
Fig. 2.8 Vascularity and
nerve supply of the anterior
abdominal wall
2.2.5.2 Nerves
• The iliohypogastric, ilioinguinal, and the lower anterior
intercostal nerves are the primary motor and sensory supply of the anterior and lateral abdominal wall.
• The skin over the epigastric and supra-umbilical regions
has a sensory innervation from the seventh, eighth, and
ninth intercostal nerves. It also provides motor supply to
the supra-umbilical part of the rectus abdominis muscle.
The sensory supply of the skin at the level of the umbilicus comes from the tenth intercostal nerve, which also
provides motor innervation that extends inferiorly to the
level of the anterior superior iliac spine. The 11th and
12th intercostal nerves supply the skin from below the
umbilicus to the level of the inguinal ligament and the
groin.
• All of these nerves have to pass through Camper’s fascia
in order to innervate the skin.
• Liposuction causes edema of the skin causing stretching of
the nerve endings in the fascial layers of the skin causing a
numbing feeling due to the disturbances in sensation.
superior epigastric artery
iliohypogastric nerve
ilioinguinal nerve
xiphoid process
T9
T10
T11
T12
L1
T8
T7
lateral margin of
rectus sheath
intercostal arteries
lumbar arteries
deep circumflex iliac artery
position of deep inguinal ring
inferior epigastric artery
20
Subcutaneous tissue
subdermal plexus
https://t.me/medicina_free
M. Thomas and J. D’silva
2.2.5.3 Lymphatic Drainage
The lymphatic vessels of the anterior abdominal wall lie both
supercial and deep to the deep fascia.
2.2.6 Applied Anatomy
1. The blood supply to the abdominal wall was previously
described in a regional manner by Huger, consisting of
three anatomically distinct zones [7] (Fig.2.9). Zone I is
the area supplied by the superior epigastric vessels and
the deep inferior epigastric vessels situated in the upper
and central midline area of the abdominal wall (in
between the two linea semilunaris). Zone II consists of
the whole infraumbilical area extending up to the anterior superior iliac spine laterally and the inguinal ligament inferiorly and supplied by the supercial inferior
epigastric and supercial external pudendal arteries,
which are the branches of the femoral artery and supply
the supercial fascia and skin, while the deep inferior
epigastric arteries (DIEAs) and deep circumex iliac
arteries supply the musculature of this lower area. Zone
III is the area lateral to the linea semilunaris and is supplied by the lumbar and intercostal arteries arising from
the aortic trunk. These arcades supply the lateral part of
the abdominal wall and eventually they anastomose
with the midline vascular structures. Incisions for
abdominoplasty with limits of undermining of the
abdominal pannus are based on this vascular supply.
2. Majority of the supercial vessels are present supercial
to the Scarpa’s fascia and they anastomose at the subdermal plexus, as seen in Fig. 2.10. Once the perforators
from the deeper vessels are transected, the vascularity of
the abdominal ap is based on the subdermal plexus
being supplied by the supercial vessels.
Fig. 2.9 Delineated Huger’s zone on the anterior abdominal wall
Fig. 2.10 The abdominal
skin being supplied by
perforators as well as the
subdermal plexus
Epidermis
Dermis
Fascia
Muscle
Perforatory
blood vessels to
e
2 Surgical Anatomy oftheBody inRelation toLipocontouring
https://t.me/medicina_free
2.3 Anatomy oftheBack
• The anatomy of back is unique; the dermis is very thick
and the subcutaneous layer has a dense brotic fat.
• The subcutaneous layer of the back is composed of
brotic and compact supercial and intermediate layers
and the underlying areolar layer is loose.
• These anatomical implications make liposuction with traditional suction assisted liposuction (SAL) difcult in the
back region. Technologies such as ultrasound assisted liposuction/power assisted liposuction (UAL/PAL) due to their
tissue-penetrating capability tend to work well in the tough
brous tissue of the back.
• Liposuction causes only a moderate amount of fat removal
but signicantly improved shape is visible due to release
of the tissue folds from their deeper attachments that
cause back rolls.
• Care should be taken while performing liposuction of the
back, because of its brous nature. The muscles of the
back are at fan shaped and cover important structures
such as the lungs and the renal triangle (Fig.2.11).
• Liposuction cannula should not be redirected forcibly as
the brous attachments may redirect the cannula tip into
the unsafe zone such as the intercostal space.
21
Fig. 2.11 Muscles of the back
Trapezius
Latissimus dorsi
External Oblique
Posterior border
Petit’s lumbar triangl
Gluteus maximus
Fig. 2.12 The torso being divided into nine regions for ease of description with regard to the area of liposuction
• Suctioning from areas away from the thoracic cage such
as going from the hip region to the posterior back should
be avoided, as the possibility of intrathoracic penetration
exists and because of the dense skin and the brous nature
of the tissue, results are less than ideal.
• The classic anatomy described by Sobotta [8] and
Spalteholz [9] classied the back and the torso based on
the underlying muscles.
• Surgically speaking, they suggested dividing the torso
into nine regions (Fig.2.12): three paired on either side of
the midline (scapular, lumbar, and supra-iliac) and three
single (sacral, vertebral, and interscapular areas) in the
central area.
22
https://t.me/medicina_free
M. Thomas and J. D’silva
2.3.1 Supra-Iliac Area
• The supra-iliac region is the rst region of the torso and is
the most common site of adipose tissue accumulation in
both men and women but very prominent in men.
• The prominent bulge in this area is caused by the signicant growth of the lamellar layer of fat in this region
(Fig.2.13).
• The increased fat deposit in this layer gives the typical
apple shape to the midriff. This causes loss of narrowing
at the waistline especially in females having polycystic
ovary disease.
2.3.2 Lumbar Area
• The lumbar area is considered the second area of the torso
and is situated just above the rst one.
• Rarely does it show signicant fat collection enough to be
treated by liposuction alone.
• Often problems on the supra-iliac region appear because
of the lumbar region.
• Anatomically, this area has a very thin lamellar layer of
fat that does not increase prominently in spite of signicant fat deposits (Fig.2.13).
Applied Anatomy of Lumbar Area Liposuction should be
performed vertically or perpendicularly to the fat roll axis so
that tunneling happens below the skin, and muscle adhesions
and new collagen thus formed will have a vertical framework, and when it heals it will support the back skin against
gravity. The gravitational force is thus distributed in the vertical direction as if it were a sheer curtain panel heading in a
standard way, as shown in Fig.2.14a. If the direction of liposuction is transverse, the scar will form in the same direction
as the fat roll axis and the tissue will remain unsupported
giving the effect very similar to that of a sheer curtain
Austrian festoon panel [10] (Fig.2.14b).
2.3.3 Scapular area
• The third area of the torso to present accumulation of fat
is the scapular region.
• The lamellar layer of fat greatly increases in thickness as
compared to other areas and sometimes asymmetry of the
fat bulges can also be observed.
• There are some fat deposited in the areolar layer but never
to the extent as seen in the lamellar layer.
• When the lamellar layer shows localized adiposity, the
subcutaneous panniculus is rm and does not slide easily
over the muscular plane.
• The best test to assess the overall thickness of the subcutaneous layer is the Illouz pinch test. It shows an increase
in the overall thickness of the panniculus.
• Surgical Anatomy Deep and aggressive liposuction in
this area can damage the cutaneous branches arising from
the muscles causing a bloody liposuction return. Use of
Fig. 2.13 Typical fat
deposits in the supra-iliac and
the lumbar area
2 Surgical Anatomy oftheBody inRelation toLipocontouring
https://t.me/medicina_free
23
Fig. 2.14 (a) Outcome of
vertical liposuction of the
back rolls. (b) The effect after
a horizontal liposuction
a
b
vibration amplication of sound energy at resonance
(VASERR) technology is safer due to the density of the
subcutaneous tissue.
2.3.4 Interscapular area
• The interscapular region is even rmer, more resistant,
and more adherent than the previously discussed areas.
• This is one region where there is increase in the fat deposits in both the lamellar and areolar layers to about the
same level.
• Surgical procedures when performed should always be in
the deeper plane so as to preserve the supercial areolar
layers and the cutaneous surface from unevenness.
• Interscapular region showed hard, regular, immovable,
and difcult bi-digital pinching fatty tissue and local rm
skin with easy retraction, which could be noted immediately after the surgical procedure (Fig.2.15).
Surgical Anatomy Fat gets deposited in the lower cervical
and upper thoracic vertebra segments in the interscapular
region called the “buffalo hump.” It was among the rst recognized manifestations of lipodystrophy (body fat changes)
reported after the use of protease inhibitors in human immunodeciency virus (HIV) treatment came into widespread
use in the late 1990s. However, buffalo hump has been
noticed even in untreated HIV-infected patients with the
hump caused by lipodystrophy in the subcutaneous plane
and in normal people due to posture causing abnormal curvature of the cervical spine and poor muscle tone [11].
2.3.5 Sacral Region
• The fth area to have localized fat deposits on the torso is
the sacral region. It is anatomically located on the sacral
bone anked by the supra-iliac regions on either side.
24
https://t.me/medicina_free
Fig. 2.15 Lipodystrophy of the interscapular region in an HIV positive
patient
M. Thomas and J. D’silva
2.3.6 Gluteal Region
In 2006, Cuenca-Guerra and Quezada [12] published four
main criteria for gluteal aesthetics:
• Lateral depression: This is present on the lateral aspect of
each buttock and its oor is formed by the greater trochanter. This is a zone of adherence and there is no muscle overlying this anatomical area.
• Infragluteal fold: It is a horizontal crease that arises from
the median intergluteal cleft and runs laterally below the
ischial tuberosity with a slight upward convexity.
• Supra-gluteal fossettes: Two hollows located on either side
of the medial sacral crest. These hollows are anked by the
sacro-iliac joints and the posterior superior iliac spine laterally and by the erector spinae muscle medially.
• V-shaped crease: Two lines that arise in the upper portion
of the intergluteal cleft and extend toward the supragluteal fossettes.
2.3.6.1 Waist-to-Hip Ratio (WHR)
The waist-to-hip ratio is a crucial measurement that is used
in calculating the ideal aesthetics of the buttock, regardless
of ethnicity (Fig.2.17). It is the ratio taken between circumference taken at the most narrow part of the waist and the
hip circumference taken at the level of maximum prominence of the buttocks [13]. The ratio is measured in posterior view and in lateral view (Fig. 2.17) with the most
pleasing ratio being 0.65 and 0.7, respectively, in the posterior and lateral views.
Waist-to-hip ratio is almost constant for all ethnic gluteal
types; however, there is variation with regard to buttock
size, lateral buttock fullness, and lateral thigh fullness that
may be different among various ethnic types. In fact, Singh
Fig. 2.16 Landmarks identifying the sacral region
• Skin is deeply adherent to the brous tissue overlying
the spinous processes and posterior iliac spine forming
a midline groove and dimples. “Sacral pad” is a pad of
fat deposit inferiorly that obliterates the curve
posteriorly.
• Supra-gluteal fossettes one on either side over the sacroiliac joint (marked with a blue outline in Fig.2.16), created by the erector spinae muscle, the lumbosacral
aponeurosis, and the insertion of the gluteus maximus
muscle, and a V-shaped crease, arising in the proximal
portion of the gluteal crease (marked by a red ellipse in
Fig.2.16), mark the borders of the sacral region. This is
also referred to as “triangle of Venus.”
Applied Anatomy The sacro-iliac joints, the posterior iliac
spine, as well as the coccyx are important landmarks for any
gluteal cosmetic surgery.
a
a
b
b
Waist-to-Hip Ratio = a/b
Fig. 2.17 The waist-to-hip ratio in posterior and lateral views [14].
(Adapted from: Abulezz T (2019) A Review of Recent Advances in
Aesthetic Gluteoplasty and Buttock Contouring. Plast Surg Mod Tech
6: 147)
Gluteus medius m.
Gluteus maximus m.
(cut)
Inferior gluteal a.
2 Surgical Anatomy oftheBody inRelation toLipocontouring
https://t.me/medicina_free
Fig. 2.18 Different muscles,
vessels, and nerves of the
gluteal region
25
(cut)
Inferior gluteal n.
Gluteus minimus m.
Superior gluteal
a. and v.
Superior gluteal n.
Insertion of gluteus
medius m.
Obturator internus m.
Medial circumflex
femoral a.
Pudental n.
Quadratus femoris m.
Posterior femoral
cutaneous n.
[13] proposed that a particular type of female body that men
universally nd most attractive is the one that has full buttocks and narrow waist, and he theorized and gave extensive
evidence to support the concept that a waist-to-hip ratio
(WHR) of 0.7 was the universal ideal female shape.
2.3.6.2 Muscles oftheGluteal Region (Fig.2.18)
Supercial Layer ofMuscles
• Gluteus maximus: It forms the major bulk of the buttocks
and is 6–7cm thick at its origin and hence an intramuscular implant can be easily placed in the intramuscular
pocket.
• Gluteus medius.
• Gluteus minimus.
Deep Layer ofGluteal Muscles
• Pyramidalis muscle: It is the reference for the location of
important vessels and nerves deriving from the pelvis. It
covers the ischial foramen dividing it into superior and
inferior parts. The superior gluteal artery and vein along
with superior gluteal nerve pass from the superior gluteal
foramen while the sciatic nerve, inferior gluteal vessels
along with inferior gluteal nerve, pudendal nerve, and
posterior cutaneous nerve of thigh pass from the inferior
foramen.
• Gemellus superior and inferior.
• Obturator externus and internus.
The gluteus maximus is the only gluteal muscle that is not
inserted into the trochanter of the femur.
2.3.6.3 Cutaneous Adhesions asExtensions
oftheLigaments intheButtocks
The interlacing ligaments from the spinous process of the
sacrum, coccyx, lumbar spine, ischium, and also from the
opposite side form dense connective tissue expansions along
with the bers of the gluteal fascia that inserts into the der-
26
https://t.me/medicina_free
Fig. 2.19 Various cutaneous
adhesions of the buttocks that
maintain the buttock shape
M. Thomas and J. D’silva
mis. These preserve the intergluteal crease as well as form
the inferior gluteal crease (Fig.2.19).
• Buttock has the thickest areolar layer as compared to any
other region in the human body.
• Even normal people without increase inlocalized fat have
a thick lamellar layer; hence liposuction undertaken in
exactly this layer gives very good results.
• Localized adiposity should be differentiated from hypertrophy of the gluteal muscles. This can be done by asking
the patient to contract the gluteal muscle by squeezing the
buttocks. Fat will slide over the contracted muscle.
2.3.7 Applied Anatomy: Danger Zone
oftheButtock
• “Bermuda triangle” was a term coined by Illouz and
emphasized by Fournier, which is the medial segment of
each buttock having the maximum vascularity to be
respected during fat suction. The superior vertex of the
triangle is the sacral region and the base of the triangle is
formed by the sulcus of buttocks (Fig.2.20).
• This area has the largest caliber vessels, and fat grafting
during brazilian butt lift (BBL) should be undertaken
absolutely subcutaneously in this area.
Соседние файлы в папке Библиотека им академика М.И. Перельмана