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2 Anatomy oftheSubcutaneous Layers intheHuman Body
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c
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Fig. 2.18 Diagram and photo of the localized adiposities on lower extremity. (a) Scheme showing
internal surface of the thigh. The upper and lower third present thick lamellar layer as is demonstrated in sections A and C, since section B shows the middle third which presents insignicant
thickness of lamellar layer; (b) photo of a female patient presenting localized adiposities indicated
by white lines on upper and lower third of internal thigh
perform this procedure on the medial third of the internal thigh in absence of the
accumulation of adipose tissue, because in this scenario, the lamellar layer is
very thin.
Legs
The legs are the segments of the lower extremities that normally do not present
localized adiposity in that the areolar and lamellar layers are normally quite thin
(Fig.2.19a). Consequently, it is quite unusual to perform liposuction on these segments. The anatomy presents fascia supercialis with a rich network of arterial,
venous, and lymphatic vascularization (Fig.2.19b, c).
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J. M. Avelar
a b
c
Fig. 2.19 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
Upper Extremities
Arms
The posterior surface of the upper arm is the only one that is a candidate for liposuction because it contains a thick lamellar layer. Testut’s book (1982) divides the arm
into anterior and posterior sections. After performing anatomical dissections, I suggested dividing it into four surfaces—anterior, external, internal, and posterior
(Fig.2.20a)—because each one has specic anatomical characteristics in its panniculus. The posterior surface of the arm should be considered because it may contain thick lamellar and areolar layers in patients with localized adiposities
(Fig.2.20b, c). So far, both layers are quite thin in people without localized adiposi-
ties. Nevertheless, patients with such abnormalities may present enough accumulation of fat for liposuction, even for a resection of the panniculus, especially after
severe weight loss.
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Fig. 2.20 Anatomical study showing the constitution and variation of thickness of the panniculus
in the four surfaces of the arm. (a) Scheme shows the situation on the four surfaces: (1) anterior,
(2) external and four internal present thin thickness of lamellar layer with very thin fascia supercialis, (3) the posterior surface present very thick thickness of the lamellar where usually may
present accumulation of fat; photos (b, c) of a fresh cadaver showing cutaneous incision on the
posterior surface (3) of the arm where one can see the panniculus with accumulated fat on lamellar
layer. It is marked with black ink on the skin (V, X, and Z) three levels of circumferences of the
arm as references study. It demonstrates that usually the posterior surface of the arm is the most
common surface to present a localized adiposity
Discussion
According to the anatomic dissections that I performed on cadavers, the subcutaneous
tissue in patients with localized adiposity clearly varies depending on the region
(Figs.2.5, 2.6, and 2.13). The lamellar layer increases in thickness thanks to the accumulated adipose tissue. The areolar layer does not change in thickness as much as the
lamellar one does (Figs.2.2, 2.7, and 2.8). With Illouz’s “pinch test” (Illouz 1983a, b,
c, 1986), the thickness of the panniculus and that of a thick lamellar layer can be esti-
mated (Fig.2.3). When the panniculus slides over the aponeurotic layer, there are no
localized adiposities and the perforator vessels are very thin. When this layer is thick,
the panniculus does not slide, because of the numerous perforating vessels (Fig.2.8).
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Fig. 2.21 Cover of our
book (LIPOSUCTION)
published in São Paulo
(Brazil) with didactic
information about the
position of surgeon’s left
hand with the cannula
between his ngers without
damaging the areolar layer
J. M. Avelar
Classic anatomy does not describe in detail the subcutaneous tissue over the entire
human body. Because the canula of liposuction technique works on subcutaneous tissue,
as soon as I started to perform the new method in 1983, I felt it necessity to study such
compartments in human body. Thus, I performed a considerable number of anatomic
dissections and liposuctions on cadavers to study the thickness and distribution of the
adipose tissue in every region while performing the new technique (Figs.2.1, 2.2, 2.3,
and 2.11). The tissue’s characteristics vary widely from one region to another. Even each
region may vary from person to person, depending on the degree of nutrition.
After I performed this anatomical research, I was able to gain specic knowledge
on supercial body contouring, which gave me enough information to create the
cover of our book, published in association with Prof. Illouz in 1986 (Liposuction,
edited by Avelar and Illouz) (Fig.2.21). On the cover, my left hand is holding the
abdominal panniculus with a cannula between my ngers to demonstrate the level
that the main surgical instrument should be at during a liposuction procedure.
In my previous publications (Avelar 1986a, 1987, 1989), I reached some conclu-
sions, which I repeat here:
1. The areolar layer is more resistant, and it is responsible for the terminal vascu-
larization of the skin (Fig.2.4a).
2. Daily injections of insulin must be carried out in the areolar layer because fat
cells are round, large, and full of fatty liquid inside and because it is well vascularized (Figs.2.3b and 2.11).
2 Anatomy oftheSubcutaneous Layers intheHuman Body
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3. The lamellar layer contains a large number of connective tissue layers that form
“bridges” through which larger vessels pass, giving softness to the tissues
(Figs.2.4a, 2.8, and 2.10).
4. The regular thickness of the areolar layer must be preserved (Figs.2.1, 2.2, and
2.3) because traumatism during the liposuction of the local tissue causes cutane-
ous depressions.
5. The lamellar layer is the region that can be aspirated. The larger vessels do not
suffer the local effects caused by the traumatism of the cannula (Figs. 2.4a
and 2.9a).
6. In the regions featuring thin skin, the cannula can be used supercially if regu-
larity is maintained (Fig.2.13).
In the regions featuring thick and rm skin, liposuction has to go deeper, leaving
more thickness in the dermal-fat ap (Fig.2.18).
Conclusions
The distribution and characteristics of fat tissue in the subcutaneous layer have been
described after intensive research via dissection and liposuction on cadavers. Each
region of the surface of human body has a specic anatomic composition that is
vital in body-contouring surgery (Figs.2.5, 2.6, and 2.13). There are differences
between the areolar and lamellar layers, and each layer has specic anatomic characteristics (Figs.2.7 and 2.8). The areolar one is formed by large, round, and turgid
cells that are piled together where small vessels pass to irrigate the subdermal layer
and the deep aspect of the skin (Figs.2.4a, 2.8, and 2.9a). To identify localized adiposities, careful examinations, careful patient selections, and region-specic evaluations for treatment options are recommended before surgery. The behavior of the
subcutaneous tissue after surgery shows that it develops a thick and hard brosis,
indicating that liposuction should be performed on the lamellar layer when the
accumulation of adipose tissue occurs (Fig.2.2). This sort of brotic tissue on the
areolar layer will cause irregularities and unsightly waves on the skin’s surface.
References
Avelar JM (1983) Submentonean and Submandibular Adiposity – Liposuction X Lipectomy
(Adiposidade Submentoniana e Submandibular– Lipoaspiração X Lipectomia). In: Annals of
the Brazilian Symposium on Facial Contouring, organized by Dr. Juarez Avelar, Sponsored by
Brazilian Society of Plastic Surgery (Section of São Paulo), September pag. 69–72
Avelar JM (1985a)- Fat-suction versus abdominoplasty. Aesth Plast Surg 9:265–276, 1985.
Avelar JM (1985b) - Combined liposuction with traditional surgery in abdomen lipodystrophy.
XXIV Instructional Course of Aesthetic Plastic Surgery of the ISAPS.Madrid, September 19.
Avelar JM (1986a) - Surgical Anatomy and Distribution of Adipose Tissue on Human Body
(Anatomia cirúrgica e distribuição do tecido celular no organismo humano). In: Liposuction
(Lipoaspiração), ed. by Avelar and Illouz, Ed. Hipócrates, São Paulo (Brazil) 9:45–57.
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Avelar JM (1986b) Liposuction of Abdominal Wall (Lipoaspiração da Parede Abdominal). In
Liposuction (Lipoaspiração). Ed. by Avelar JM. & Illouz YG. Sao Paulo (Brasil). Editora
Hipócrates 27:158–176.
Avelar JM (1986c) Liposuction of the Submental and Submandibular Regions (Lipoaspiração
das Regiões Submentoniana e Submandibular). In Liposuction (Lipoaspiração). Ed. by
AvelarJM. & Illouz YG.Sao Paulo (Brasil). Editora Hipócrates 24:139–147.
Avelar JM (1987)- Study of the anatomy of the subcutaneous adipose tissue applied for fat-suction
technique. In: Maneksha RJ (ed): Trans IX Int Congr Plast Reconstr Surg. New Delhi, India,
March 1–6, pp377–379.
Avelar JM (1989) Regional distribution and behavior of the subcutaneous tissue concerning selec-
tion and indication for liposuction. Aesth Plast Surg 13:155–165.
Avelar JM (1996) Creation of a Natural and Denitive Inguino-Crural Crease During Lifting of the
Upper Medial Thigh (Criação de Natural e Denitivo Sulco Inguino-Crural no Lifting da Face
interna da Coxa). Rev Bras Cirug 86(5):213–228
Avelar JM (1999a) A new technique for abdominoplasty– closed vascular system of subdermal
ap folded over itself combined to Liposuction. (Uma nova técnica de abdominoplastia–
sistema vascular fechado de retalho subdérmico dobrado sobre si mesmo combinado com
lipoaspiração). Rev Bras Cir 88/89(1/6):3–20.
Avelar JM (1999b) Aesthetic plastic in the inner side of the thigh – new concepts and tech-
nique without cutaneous or subcutaneous undermining. (Cirurgia Plástica de Face Interna de
Coxas – novos conceitos e tecnica sem descolamento cutâneo e subcutâneo). Rev Bras Cir
88/89(1/6):57–67.
Farina R., Baroudi R., Coleman B., & Castro O. (1960) Riding trousersilke type of pelvicrual
lipodistrophy (trochanteric lipomatosis). Brit. J.Plast. Surg. XIII(2): July.
Gray H (1974)- Anatomy, descriptive and surgical. Philadelphia: Running Press.
Illouz YG (1980) Une nouvelle technique pour les lipodystrophies localisées. Rev Cir Esth
Franc 6(9)
Illouz YG (1983a) Liposuction - My technique and applications. First Course of Liposuction.
Organized by Dr. Juarez M.Avelar, heled at São Paulo Hospital, Service of Prof. Andrews at
Escola Paulista de Medicina. Sponsored By Brazilian Society of Plastic Surgery (São Paulo
Section) October São Paulo (Brazil).
Illouz YG (1983b) - My technique of suction lipectomy. Meeting of the American Society of
Aesthetic and Plastic Surgeons and Instructional Course, April
Illouz YG (1983c) Body contouring by lipolysis: 5 years’ experience with over 3,000 cases. Plast
Reconstr Surg 72(5):591–597
Illouz YG (1984) – My technique of Liposuction – 4 Years Evolution. Second Course of
Liposuction. Heled at 9 de Julho Hospital. Organized by Juarez M. Avelar, Sponsored By
Brazilian Society of Plastic Surgery. September, São Paulo (Brazil).
Illouz YG (1986) - Basic principles of liposuction technique (Princípios básicos da técnica de
lipoaspiração). In Lipoaspiração (Liposuction), ed. by Avelar and Illouz, Ed. Hipócrates, São
Paulo (Brazil) 3:13–18
Lockwood T (1995) High lateral-tension abdominoplasty with super cial fascial system suspen-
sion. Plast Reconstr Surg 96:603–615.
Pitanguy I (1964)- Trochanteric lipodystrophy. Plast Re-const Surg 34:280, 1964
Pitanguy I (1977) – Dermolipectomy of the Abdominal Wall, Thighs, Buttocks, and Upper
Extremity. In Plastic and Reconstructive Surgery, Ed. by Converse JM, Ed. W. B.Saunders
Company– Philadelphia and London, 92:3800-3823.
Sobotta, Figge (1977)- Atlas of human anatomy. Baltimore: Urban & Schwarzenber.
Spalteholz W (1970)- Atlas de anatomia humana, (Atlas of Human Anatomy) 5th ed. Espanha:
Editora Labor.
Testut L, Jacob O (1975)- Tratado de Anatomia Topográca. (Compedia of Topograc Anatomy)
Barcelona,– Madrid, Bogota, Buenos Airees, Rio de Janeiro.: Salvat Editores, 1975
Testut L, Jacob O (1984)- Tratado de Anatomia Topográca. Salvat Editores. Barcelona, Madrid,
Bogota, Buenos Airees, Rio de Janeiro. 1984.
J. M. Avelar
Chapter 3
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Importance andBehavior ofFascia
Supercialis forBody-Couturing Surgery
JuarezMoraesAvelar
Abstracts The human body contains the fascia supercialis, which is between the
skin and muscular or bony level in almost all the body’s regions, with peculiar characteristics in each one. The anatomy and behavior of the fascia supercialis are so
important that it may be considered as a “second skin” because it is present in
mostly regions, providing adequate vascularization to the dermis and to the subdermal layer. Anatomically, the fascia supercialis is a very thin structure containing
connective tissue in several layers, with vessels between them. This anatomical
structure is between the skin and the muscular plane at one of two levels: (1) In
some regions, it 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 panniculus struc-
tures. The main anatomical characteristic is that it may present localized adiposities only in some regions: the abdominal walls, the upper and lower third of the
medial thigh, the posterior side of the arms, the gluteal regions, the suprailiac
regions, and all regions of the posterior aspects of the torso. When the panniculus is incised during an operation, in those regions, it is necessary to suture the
fascia supercialis to reinstate the subcutaneous layers. If it is not correctly
sutured, the anatomical structure will be damaged, which may develop unaesthetic surgical scarring with retraction and contraction.
2. The fascia supercialis close to the muscle or bone level. It may occur in most of
the regions of the upper and lower extremities and underneath the scalp. The
fascia supercialis on the scalp has a peculiar anatomical composition in that the
vessels (arteries, veins, and lymphatics) connect a wide network similar to those
between the areolar and lamellar layers on the abdominal wall. In cranial regions,
the fascia supercialis is an important anatomical structure that I created tempo-
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_3
49© The Author(s), under exclusive license to Springer Nature
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roparietal fascial aps for, to improve ear reconstruction they are excellent and
useful surgical resource options for craniofacial surgery.
Keywords Fascia · Fascia supercialis · Antomical structure
J. M. Avelar
Introduction
In almost all regions of the human body, there is a fascia supercialis, and each one
exhibits a peculiar distribution. The fascia supercialis is formed through connective tissue in multiple layers through which run the arterial, venous, and lymphatic
vessels. Owing to its constant presence, it may be considered as a second skin
because it is present in almost all regions, providing adequate vascularization to the
dermis and the subdermal layer. In the traditional textbooks on anatomy, such as
those by Testut and Jacob (1975, 1984), Gray (1974), Spalteholz (1970), and Sobotta
(1977), there is little information on the subcutaneous panniculus and few words
concerning the fascia supercialis. Anatomically, the fascia supercialis is a very
thin connective tissue structure in several layers with vessels between them. This
anatomical structure is 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. There are some regions where the fascia supercialis is situated between the
areolar and lamellar layers, which are in the middle of the subcutaneous panniculus structures. Its main anatomical characteristic is that it may be inlocalized adiposities in regions of the abdominal wall, the upper and lower third of the
medial thigh, the posterior side of the arms, the gluteal regions, the suprailiac
regions, and some regions of the posterior aspects of the torso. My anatomic
research (Avelar 1986a, b, 1987, 1989a, b, 1996, 2000) features a comparison
between the panniculus of a person without localized adiposities and that of
other person presenting with localized adiposities (Fig. 3.1). In fact, in those
regions, the fascia supercialis is located between the areolar and lamellar layers, where it may be present with localized adiposities. Fat cells in the lamellar
layer are elongated when there is no fat inside. However, when there are localized adiposities, those fat cells (inside of lamellar layer) become rounded, presenting considerable increase to the thickness of the panniculus, dividing the
fascia supercialis into several layers of connective tissue (Fig.3.2). Liposuction
may be performed only in those areas presenting with localized adiposities
between layers of the fascia supercialis.
2. The fascia supercialis is close to the muscle or bone level. It may appear in
most regions of the upper and lower extremities and underneath the scalp
(Fig.3.3b–g). In those regions, during surgery, it is necessary to suture the fascia
supercialis to avoid bleeding afterward—even when a fascial ap is raised to
cover another anatomical segment, as happens during ear reconstruction. The
vessels inside the fascia supercialis create a wide network between the tempo-
3 Importance andBehavior ofFascia Supercialis forBody-Couturing Surgery
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a
b
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c
Fig. 3.1 Diagrams: (a, c) research in cadaver: (b, d) this is a comparison between THIN person
(without localized adiposities) (a, b) and FAT person (with localized adiposities) (c, d)
d
ral supercial artery and the posterior auricular artery, which work like communicating vessels (CVs), similar to a “peripheric heart” that provides the
well-balanced blood pressure of terminal vascularization to the subdermal layer
and to the cutaneous covering of the scalp (Fig.3.3g–j).
Because of the localization of the vessels, dissecting the cutaneous covering
of the scalp to create fascial aps on the temporoparietal regions is quite difcult. Just below the subdermal level and above the fascia supercialis are very
small vessels coming from the communicating vessels inside the fascia. It is
advisable to not carry out local inltration, because doing so may damage the
vascular network. I recommend performing a careful dissection with a knife to
preserve the vascular network inside the fascia supercialis. Do not use an electric cauterization, because it will damage the communicating vessels underneath,
causing bleeding after the operation. The dissection must be carried out precisely between the fascia supercialis and the subdermal layer to preserve the
full thickness of the cutaneous covering (Fig.3.3e, g).
Hair follicles are essential anatomical references because they cannot be
damaged during undermining, as one can observe on scalp aps. In the
temporoparietal region, the presence of the fascia supercialis is an important
anatomical detail for which I created useful temporoparietal aps to improve ear
reconstruction (Fig.3.3) (Avelar 1977a, b, 1978). Also, the temporoparietal fascia aps are excellent surgical options for craniofacial surgery, as described in
my publications (Avelar 1983, 1992; Avelar and Psillakis 1981).
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J. M. Avelar
a
3
b
1
9
$
/
/
3
CV
c
$
Fig. 3.2 Diagram (a) demonstrates a comparison of the subcutaneous panniculus between a thin
person (above) and a person with localized adiposity (below). The fascia supercialis and lamellar
layer in person with localized adiposity (below) increases the thickness much more than the areolar
layer. Perforator vessels (P) coming from the muscle cross the lamellar layer until to reach fascia
supercialis creating communicator vessels (CV) which work as a “periferic heart” to provide
smooth vascularization to subdermis layer and dermis as well; diagram (b) anatomic unit of a
perforator vessel, presenting: V vein, A artery, L lymphatic, N nerve
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