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Fig. 18.1 Drawings of the ideal proportions of the
human body
A. Di Giuseppe and F. Giovagnoli
Fig. 18.2 Man abdominal and thorax muscle
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Fig. 18.3 Dorsal and back muscles
Fig. 18.4 Male and female abdominal muscles
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18.2 Technologies
The technologies I did use for sculpturing men and female
body are:
– Vaser™ ultrasound-assisted lipoplasty
– PowerX, Power-assisted lipoplasty
– Revolve™ cannister for fat harvesting
New technologies have entered the market in the last
decade, as power-assisted technology, ultrasound technology, and laser technology, in order to facilitate fat removal,
reduce trauma, and improve skin retraction. I have personally been one of the pioneers of ultrasound-assisted liposuction since they appeared in the early 2000s and contributed to
the realization of the new vaser device, more advanced and
safer than previous ultrasound-assisted devices in commerce
until 20years ago. Vaser™ is an acronym of vibration amplication sound at resonance and is a third generation of
ultrasound- assisted liposuction that uses ultrasound energy
to melt fat tissue (Fig.18.5).
Ultrasound technology emulsies the fat for removal in
such a delicate way that preserves as much of the tissue of
the matrix as possible while emulsifying the desired amount
of fatty tissue. Special titanium probes deliver the ultrasound
energy to fat tissue, after proper inltration with tumescent
solution, allowing the selective destruction of only the fat
tissue through three mechanisms: (1) cavitation, (2) mechanical, and (3) thermal (Fig.18.6).
In cavitation effect, the Vaser™ probes vibrate at ultrasonic frequencies creating compressive and rarefactive forces
around the grooved tip; cavitation microbubbles expand and
then implode, releasing energy that disrupts the adipocyte
architecture until an emulsion of fat and uid is formed.
Mechanical disruption of fat occurs at the tip of the probe,
where the vibrating metal surface comes in contact with the
adipocytes. Cavitation and mechanical disruption of adipose
tissue occur due to relative fragility of this tissue compared
to other tissues such as vessels, muscle, and nerves. This is
why this process is safe and effective, spears the connective
and vascular network of the skin and subcutaneous tissue,
allows a safe subcutaneous supercial undermining of the
skin, and is thus a major skin retraction of tissue. The thinnest is the dermal tissue, the highest is the skin retraction,
and liposuction is the term to dene vaser smoothening of
the fat. Careful emulsication, not an aggressive fat removal,
is selective where needed in two different layers: subcutaneous for supercial denition and deep dermal for volume
removal [3].
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A. Di Giuseppe and F. Giovagnoli
Minding the advantages of this technology, the plastic
surgeon must be able to achieve superior results in terms of
denition and shaping.
With supercial fattening and careful undermining, he
can achieve a thin layer of skin ap, ideal for superior skin
retraction.
Deeper fat removal can be done in a less traumatic mode,
leaving less scar tissue, with less chances of seroma formation and induration and asymmetry.
Fat removal can be accomplished with fat preservation,
harvesting, and preparation for further implant. Fat emulsied still contains the same amount of viable adipocytes as in
standard liposuction, with same stem-derived cells that are
vital to enhance fat survival rate when transferred to target
areas (breast, thighs, buttocks, face, etc.).
All those potential weapons must be utilized by the surgeon to better dene the body shape and achieve better
contouring.
PowerX is a power-assisted device, which utilizes
3–4mm Mercedes cannula with a range of rotation from
90 to 360°. The speed of suction can be set and controlled
by the surgeon as well. In my experience, I set the rotation to 180°, thus maximizing the aspiration at the edges
of the muscle where I wanted to create depression
(Fig.18.7).
Fig. 18.5 Vaser system (Photo taken from VASER Solta Medical
User’s Guide [2]. Courtesy of Bausch, ©2022 Bausch Health Companies
Inc., All Rights Reserved)
abc
Fig. 18.6 Fragmentation (a), cavitation (b), acoustic streaming (c) (Photo taken from VASER Solta Medical User’s Guide [2]. Courtesy of
Bausch, ©2022 Bausch Health Companies Inc., All Rights Reserved)
Fig. 18.7 PowerX system (Photo taken from VASER Solta Medical
User’s Guide [2]. Courtesy of Bausch, ©2022 Bausch Health Companies
Inc., All Rights Reserved)
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18.3 Fat Transfer Technology
In the last 4 years, I used the REVOLVE™ system by
LifeCell.
An integrated, high-volume fat processing system
designed by adipose transplantation pioneers and founders
of the International Federation for Adipose Therapeutics and
Science.
It is an autologous fat tissue [AFT] collection device and
tissue delivery system. It collects autologous adipose tissue
and rapidly washes and delivers the tissue for body
contouring.
REVOLVE™ System is a sterile single-use disposable
tissue canister used for harvesting, ltering, separating, concentrating, and transferring autologous tissue components
for reintroduction to the same patient during a single surgical
procedure for repair, reconstruction, or replacement of integumentary or musculoskeletal tissues.
For additional volume of tissue, canister may be lled and
emptied a second time during the same surgery on the same
patient.
It is an all-in-one closed system, for harvest, lter, active
wash, and remove strands.
Mesh lter designed to lter and strain lipoaspirate during
the harvesting phase and active mechanical washing process.
It rapidly removes tumescent, reduces cell debris, eliminates free oil, and nally concentrates adipose tissue
(Fig.18.8).
The system contains a prepeller for active washing, it
does enhances washing process for high-quality fat and
removes collagen strands to minimize injection syringe
clogging.
Fat is extracted by syringes. It is possible to direct load
syringes for injection from canister to minimize steps.
Extraction with catheter tip or luer lock syringe is performed (Fig.18.9).
The system is a high-volume fat processing system: it
processes up to 700mL of lipoaspirate in less than 10min. It
is easier to use, requiring fewer steps to process large quantities of adipose tissue.
It can control critical fat grafting variables and is sterile,
single-patient, disposable device.
It is a closed system that minimizes tissue handling and
exposure to outside air. It can control critical fat grafting
variables and is sterile, single-patient, disposable device.
Clinical result shows that REVOLVE™ system processed a higher percentage of adipose tissue compared
with the two other methods: decantation and centrifugation. It yielded signicantly less blood cell debris and a
lower percentage of free oil. It has signicantly higher fat
graft retention (73.2%) than decantation (37.5%) and similar to centrifugation (67.7%) and maintained fat in physiological conditions (pH and osmolality) (Figs.18.10 and
18.11).
Fig. 18.8 REVOLVETM system (Photo taken from VASER Solta
Medical User’s Guide [2]. Courtesy of Lifecell Inc.© 2022, All Rights
Reserved)
Fig. 18.9 REVOLVETM system syringes for extracting fat (Photo
taken from VASER Solta Medical User’s Guide [2]. Courtesy of
Lifecell Inc.© 2022, All Rights Reserved)
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Fig. 18.10 REVOLVE System minimized potential inammatory
response for transplanted tissue by signicantly removing red blood
cells, fatty acids and debris (Photo taken from VASER Solta Medical
User’s Guide [2]. Courtesy of Lifecell Inc.© 2022, All Rights Reserved)
A. Di Giuseppe and F. Giovagnoli
18.4 Fat Anatomy
The subcutaneous tissue is divided into three layers: a supercial adipose tissue layer, an intermediate membranous
layer, and a deep adipose tissue.
The thickness and proportion of those layers vary throughout the body depending on the anatomic region: the abdominal has a prominent fascial plane, making it easier to
distinguish between the two fatty layers.
In the leg, there is an attenuated brous membrane that
separates from the muscle fascia. In the trunk, the adipose
tissue is similar, as in gross appearance and density and
structure (Fig.18.12).
Fig. 18.11 Higher fat graft retention than decantation and similar to
centrifugation (Photo taken from VASER Solta Medical User’s Guide
[2]. Courtesy of Lifecell Inc.© 2022, All Rights Reserved)
Fig. 18.12 Fat anatomy [4]
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18.5 Surgeon Ability inShaping
withShadow andDepression Lines
The introduction of vaser allows efcient and safe emulsication of fat in supercial and deep layers while preserving
vascular and neural structures.
This is a new chisel in surgeon hands to sculpture the
body as a work of the artist, working in all subcutaneous
planes, by adding and subtracting fat with delicate instruments and rened techniques. The subdermal plane is no longer a taboo area; controlled deformities are desirable; and
muscular denition is attainable through lipoplasty by
revealing the underlying anatomy.
The full understanding of muscle anatomy is essential to
try to recreate a muscle-shaped body and enhance denition
and contouring [5, 6] (Fig.18.13).
The lines of body are described as natural curves that
are dened by muscle, bone frame, and fat deposit. Posture
is another component to assess the natural body appearance, and man and woman are different of course.
Lipoplasty can address only subcutaneous tissue and is not
a solution for abdominal protrusion secondary to muscle
weakness or intraabdominal fat. This will require muscle
exercise and diet to compensate. The achievement of symmetry and proportion is the goal of any body contouring
procedure. The man of Vitruvio, designed by Leonardo da
Vinci, remains the golden reference of human proportions.
In the recent age, new trends in fashion have dened new
more athletic gure, more toned, even in woman, answering to the so popular attended gym all over the world.
The surgeon view and sense of artistry are essential in
planning a good shaped body. He must create in his mind a
tridimensional view of the new body to shape: ideally must
thin the subcutaneous tissues as much as to display and
reveal the supercial musculature, removing fat and highlighting major muscle groups. The salient features of the
muscular anatomy relevant to body contouring are outlined
such as origin, insertion, orientation, form created, and relationship to adjacent muscle groups.
Main muscles involved are the rectus muscles, the oblique
muscle, the pectoralis in the front appearance, the latissimus
dorsi, the lumbaris, and the gluteus in the back.
ba
Fig. 18.13 Muscle anatomy. (a) Anterior and posterior male body muscles (Copyright ©2023 Region Skånes medicinhistoriska samling,
Anatomisk plansch;”Anatomiska väggtavlor över människokroppen utarbetade av Gustaf Wennman under överinseende av professorn vid
Karolinska Institutet Erik Mülle. II. Muskler” MS13640) (b) Rectus abdomini muscles with interdigitations dening the six
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A. Di Giuseppe and F. Giovagnoli
The muscle edges and the intermuscular digitations must
be outlined to better dene an athletic abdomen, together
with the linea alba and linea semilunaris recreation.
Lines of transition between muscles must be obtained with
more suction in a supercial manner. The main concept is
removing and revealing what is underneath in normalweighted patients, while traditional liposuction focuses in
removing fat in overweight patients. The sculpturing surgeon
tries to reveal the underlying musculature and body anatomy;
shaping is a combination of removal to reveal what is underneath and adding in areas of deciency to give more
curvature.
It is a mixture of light and shadow and depression and
concavities to give the impression of a more dened and
toned body [7–11].
18.6 Fat Grafting inBody Shaping
Indications for fat transfer in men body shaping are:
1. enhancing buttock frame and increasing volume and
roundness
2. enhancing muscle volume where lacking (pectoralis, rec-
tus abdomini, biceps, and triceps muscles)
18.6.1 Enhancing Buttock Frame
andIncreasing Volume andRoundness
In man, fullness is desirable in the upper pectoral region, the
deltoid, and the biceps, and even in the medium gluteus muscle: fat is grafted to enhance the volume, giving an image of
a more sculptured and dened muscle region.
An example of this high-denition surgery in man is
given [12, 13].
Case 1
This 32-year-old athletic body was looking for enhancment
of shaping, denition and more bulky, six pacs, and abdominal muscle shape.
A mix of fat graft and extra anatomical resection, followed by multilayer fat grafting, and the creation of negative
spaces (shadows) is the key for obtaining an attractive shaped
athletic body frame (Fig.18.14).
In Fig.18.14a, the pre op appearance of this 32-year-old
man is shown; patient was looking for more athletic denition all over his upper trunck, removal of his mild gynecomastia, denetly enhancing volume of his pectoralis and
rectus abdominis muscles.
Expecially he wanted his six pacs really evident as well as
the inguinal ligament and the oblique muscles.
In Fig.18.14b, planning of a high-denition surgery from
the frontal view is shown. The areas of biceps muscle are
marked, the area of male gland reduction is circled, the area
of supercial and deep fat transfer for pectoralis is marked:
the area of fat transfer is dened in red, minding that mostly
the upper portion fat is added in the supercial layer, while
in the lower portion fat is placed intramuscularly.
The linea alba is marked in the central abdomen; the outer
margin of the rectus muscle and the interdigitations of the
muscle area are marked as well dening the semimembranous line.
The upper and medium rectus abdomini muscle interdigitations are marked in blue and green. Those two areas will be
lled with fat transfer to increase the volume and the
bulkyness of the muscle.
ab c
Fig. 18.14 (a) Pre op. (b) Planning; red zone pectoralis enhancement,
blue upper rectus abdomini muscle, green medium rectus abdomini
muscle. (c) Post op 6months. Pre op and post op oblique view. (f) Pre
op lateral view. (g) Marking of areas of fat removal and fat adding (in
red). (h) Post op appearance
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de
fgh
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Fig. 18.14 (continued)
The margin of the oblique muscles, the inguinal ligament
to create a marked depression, and the extra fat surrounding
the navel are circled, and nally, the lateral anks are lined
where fat needs to be removed.
“Planning” of lateral side: margin of the oblique muscle
outlined, edge of latissimus muscle, the inguinal ligament,
and in red the outer medium gluteus zone to be grafted with
fat to increase roundness.
Result of denition of an athletic young body is shown,
after linea alba and linea semilunaris deepening and oblique
muscle and inguinal ligament being enhanced.
Note the concavities and shadows created, give an image
of an athletic well-shaped body with enhanced muscle projection and denition (Fig.18.14).
The gluteal region is approached in a distinct way: lateral
anks are reduced in an aggressive way; the inguinal ligament is enhanced and glutes’ prominence reduced, while the
outer medium gluteus muscle is lled with fat in order to
improve the roundness of the area and compensate a muscle
deciency (Fig.18.14f–h).
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A. Di Giuseppe and F. Giovagnoli
18.6.2 Enhancing Muscle Volume Where
Lacking
Case 2
Other case of men body denition: 25-year-old man with a
standard body frame, mildly overweight. Was looking for a
modeling job and asked a really shaped athletic frame.
VaserTM and PowerX devices were used for achieving a
better dened contour. Fat was transferred to the pectoralis
area to enhance and better dene the contouring.
Post op 6months (Fig.18.15).
Fig. 18.15 Body high
denition surgery. (a, c) Pre
op appearance. (b, d) Post op
6months with fat transfer to
the pectoralis area
ab
Case 3
This 32-year-old patient was looking for a more athletic
body shape. High denition of abdomen, anks, and chest
was accomplished together with fat transfer to enhance the
upper chest volume and improve the shape.
Figure 18.16b shows the planning of the surgery.
Fig. 18.16c shows the early post-op appearance.
Figure 18.16d and e shows the immediate post-op result.
Figure 18.16f shows 6 months post-op appearance of the
new frame with enhanced abdomen and thorax.
1year post-op (Fig.18.16).
cd
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abc
de f
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Fig. 18.16 (a) Pre op. (b) Planning. (c) Pos op 1 year. (d, e) Immediate post op. (f) Six months post op
Case 4
This 42-year-old oriental patient was looking for an athletic
appearance. Unfortunately his abdominal muscles were not
the fat are indicated. Usually 2 or 3mm large cannula are
indicated for fat transfer to male trunk.
1-year post op (Fig.18.18).
particularly strong and he did not spend much time in gym
for tness.
So fat transfer was used to enhance the volume and the
bulky appearance of the rectus muscle.
1-year post op (Fig.18.17).
Case 5
A 28-year-old patient requiring pectoralis enhancement. A
total of 180 mL of fat were transferred to the chest area.
40mL on each side were placed on the deep muscle, which
does not allow more than this limit. The remaining 140mL
18.6.2.1 Pectoralis Enhancement
Pectoralis enhancement is a compelling technique in body
shaping. Chest shape sculpturing must follow the lines of the
of fat were diffused on the supercial layer. Pre- and post-op
results are presented in Fig.18.19.
Post op 6months (Fig.18.19).
pectoralis major muscle. A clear depression must be created
on the lateral chest, starting from the axilla, and projecting
down laterally to the nipple. Pectoralis muscle is a fanshaped large triangle muscle. It terminates at the level of the
nipple.
In order to achieve consistent nice results, the area must
be treated with fat transfer in both the supercial and the
deep layers. In Fig.18.18a, the area of fat transfer, supercial
Case 6
A 35-year-old patient, mildly overweighted, with loose skin
at chest and abdomen, and poor muscle shape and strength.
A program of tness muscle reinforcement was adviced,
complimentary after surgery. Chest wall and abdominal
muscle were further reintegrated with fat transfer as well to
improve the nal shape and outcoming.
and deep are drawn. In Fig.18.18b, incision lines for placing
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