形体雕塑手术的美学单元与黏附区：躯干及四肢切口规划的系统分类与六原则

Abstract 原文摘要

Background:Aesthetic units (AUs) and zones of adherence (ZAs) have been previously noted in the face and torso. A systematic classification of common AUs and ZAs has not been previously described for the torso and extremities. Contour and scars are equally important in obtaining the best result. Therefore, the six principles to consider in body contouring surgery (BCS) are that the resulting scar be anchored at a zone of adhesion; at the interface of AUs; concealed within flexion or extension skin creases, or placed according to conventional usage and experience; positioned on the medial aspect of a limb; hidden when nude, topless, or in a variety of clothing such as one-piece and two-piece swimsuits, crop tops, short sleeves, etc; and positioned to avoid a contracture across a flexion joint crease or a dehiscence across the extension aspect of a joint.

Methods:Images of male and female massive weight loss (MWL) patients with a history of MWL were reviewed and analyzed.

Results:AUs and Zas are described and codified. An algorithm is provided to aid in planning incisions for BCS.

Conclusion:With the increase in BCS after MWL, a classification of AUs and ZAs is considered useful in planning surgery and optimizing the aesthetic result.

Takeaways

Question: The key problem is optimizing scar locations and preserving aesthetic units when performing body contouring surgery in patients after massive weight loss.

Findings: Aesthetic units, zones of adherence, and the medial aspect of the thigh or arm are used to guide incisions for body contouring surgery and provide patients with the optimal result.

Meaning: Planning body contouring surgery based on aesthetic units and zones of adhesion is a practical approach to optimize results.

INTRODUCTION

In a letter to Robert Hooke in 1675, Isaac Newton made his most famous statement: “If I have seen further, it is by standing on the shoulders of Giants.” This statement is now often used to symbolize scientific progress and to give credit to those who have laid the foundations of our cognitive and practical skills. I would like to acknowledge the immeasurable knowledge and good sense that was handed down to me by Frederick McCoy, my program director and mentor at the University of Missouri Kansas City, without whom this article would probably not have seen the light of day.

Excluding fetal surgery, 1 a surgical incision results in a scar. The ideal scar is an invisible one. For a plastic surgeon, the choice of incision from the very first cut (direction and location) is not only the first step on a journey but akin to firing a cannonball. Once the ordinance leaves the barrel, trajectory and destination are, for all practical purposes, irrevocable and unchangeable. Similarly, a “good incision” often predicts a successful outcome, and a bad one, the opposite. Frederick McCoy would say, “if you aim for less than perfection you will hit it every time.” 2 This article is an attempt to provide a trajectory for that aim, in creating an atlas of aesthetic surgery for the human body.

Burget and Menick 3 previously described aesthetic subunits of the nose. It is interesting that the alar sill, while not noted as such, is also a zone of adherence (ZA). Figure 4, Chapter 1 4 shows the consequences of “patching holes,” and the result of ignoring aesthetic units (AUs). Gonzalez-Ulloa et al 5 and Millard 6 have also discussed the head and neck in terms of AUs. The body may also be divided into AUs 7 – 14 and ZAs 15 (Tables 1 – 4 ). It is important to note that even in cases of massive obesity, the skin does not simply hang like a “onesie” garment (Fig. 1 ) but is tethered by these ZAs. 15

Fig. 1. A 56-year-old woman after 200-pound weight loss, oblique view.Choosing the ideal incision, particularly in body contouring surgery (BCS) and indeed, for all aesthetic and reconstructive procedures, is a choice between the good, the bad, and the ugly. This article is limited to below the clavicle and also excludes hands and feet. This does not imply that these anatomical regions are irrelevant, but for the purpose of this article that focuses on BCS, these anatomical parts are omitted.

“The superficial fascial system (SFS) produces many of the topographical landmarks of body-surface anatomy. The creases, plateaus, valleys, and bulges of our bodies are explained by the anatomy of the SFS and its relationships to skin, fat, and the musculoskeletal system. Understanding the anatomy and age-related pathologic changes of the SFS of the trunk and extremities may help explain body contour deformities and provide the [aesthetic] basis for surgical correction.”15

An AU may be determined in shape by an underlying muscle or group of muscles, such as the pectoralis major, rectus abdominis, or anterior leg compartment muscles, or may simply be the anterior or posterior anatomical aspect, such as the anterior and posterior thigh. AUs are bordered by other AUs. ZAs occur at the boundary of an AU but the converse does not apply. AUs are aesthetic building blocks and are applicable to all patients, nonobese, obese, and massive weight loss (MWL) patients alike (Tables 1 – 3 ). In this article, there is no attempt to subdivide AUs as proposed in liposculpture. 16 – 20 Breast subunits have also been previously described and are not further discussed. 7 – 12

Five terms discussed in this article are defined as follows:

• A.Aesthetic unit, (AU) (Tables 1 – 3 ): marked as solid blocks of color (Figs. 2 – 10 ). A specific AU of the body is characterized by one of the following:An underlying muscle or group of muscles such as the external oblique (EO), pectoralis major, deltoid, and/or the muscle group of the anterior compartment of the leg.An AU such as the breast, mons pubis, or ankleA specific anatomical aspect such as anterior or posterior, for example, anterior thigh (AT) and posterior thigh (PT) and anterolateral (ALA) and posterolateral arm (PLA).
• B. Zone of adherence (ZA) (Table 4 ): marked as solid black lines (Figs. 2 – 10 ). The attachment of the SFS to the deep fascia or periosteum. 15 A ZA occurs at the boundary or interface of an AU (AUI) such as the junction of the hypogastrium and the inguinal ligament (the exception being the medial thigh ZA that occurs at the medial interface of the AT and PT AUs) but the opposite does not apply, in that an AUI is not always associated with a ZA (Figs. 5 – 9 ). 15
• C. AU interface (AUI): the abutment of one or more AUs. This may coincide with a ZA (solid black line) or may be a “soft” interface (dotted black line) with no ZA, such as the lateral AUI between ALA and PLA (Figs. 4 , 8 ), lateral AUI between MFA and LFA, medial and lateral AUIs between the AT and PT, and the AUI between the rhomboid (RH) and paraspinal (PS) AUs (not illustrated in Figs. 5 and 6 .) (Tables 1 , 3 ).
• D. Extension crease (EC): It is a crease caused by muscle movement or skin redundancy in proximity to a ZA, but not by a ZA specifically, for example, the curvilinear flank line between the scapula (SC), RH, PS and EO AUs (Figs. 5 , 6 ).
• E. Flexion crease (FC): It is a crease caused by muscle movement, or skin redundancy in proximity to a ZA, but not by a ZA specifically. Examples are the horizontal folds in the neck, anterior abdominal wall, and the oblique lines of the lateral inferior boundary of the décolletage where the medial superior breast abuts the sternal ZA (Table 2 ). FCs have been previously described. 21 – 26

Depending on the procedure performed, the principles for optimal planning of a scar for BCS are that the incision satisfies one or more of the following six criteria, which may apply with different emphases (Table 5 ); ( See Video [online] , which displays the body contouring AUs and zones.)

Ideal scars should, therefore, be:

• Anchored at a ZA.
• At an AUI, but not transgressing an AUI.
• Concealed within an FC or EC.
• Positioned on the medial aspect of a limb.
• Hidden when nude, topless, or in a variety of clothing such as one-piece or two-piece swimsuit, crop top, short-sleeved and sleeveless tops, Yoga pants, etc.
• Positioned so as to avoid a contracture across a joint concavity or FC or a dehiscence across the extensor aspect of a joint. Examples of the former are incisions, which extend along the medial aspect of the knee and elbow when extending a vertical thigh lift and brachioplasty, respectively, and zig-zag incisions at the apex of the axilla with a brachioplasty extending onto the lateral chest. Examples of the latter are curvilinear incisions in the EC between the SC,RH,PS and EO AUs.

Fig. 2. AU distribution. Female, anterior torso and arm after LBL, brachioplasty, and mastopexy with curvilinear lateral chest extension. ACZA indicates antecubital FC ZA; BR, breast AU; DELT, deltoid muscle AU; DZA, deltoid insertion ZA; ICZA, iliac crest ZA; ILZA, iliac crest ZA; IMZA, inframammary fold ZA; LRZA, lateral rectus ZA; MFA, medial (ventral) forearm AU; MONS, mons pubis AU; PSYMZA, pubic symphysis ZA; ST, sternum AU.

Fig. 3. AU distribution. Male, upper anterior torso after MWL. IPZA indicates caudal edge of PMM ZA; LRZA, lateral rectus ZA; STZA, sternum ZA.

Fig. 4. AU distribution. Female, lateral torso and arm, after MWL, preoperative. ABD indicates rectus abdominus muscle AU; BR, breast AU; DELT , deltoid muscle AU; DZA, deltoid insertion/lateral arm ZA; ICZA, lateral chest AU; ILZA, inguinal ligament ZA; IMZA, inframammary fold ZA; LBZA, lateral breast ZA; LC, lateral chest AU; LHCOLZA, lateral humeral condyle to olecranon ZA; LRZA, lateral rectus ZA.

Fig. 5. AU distribution. Female, posterior torso, preoperative. DELT indicates deltoid muscle AU; DZA, deltoid insertion ZA; ICZA, iliac crest ZA; LHC, lateral humeral condyle; MHC, medial humeral condyle; MLZA, midline torso spinous processes ZA; OL, olecranon; PLA, posterior lateral arm; PS, paraspinal muscles AU; SC, scapula AU; SCZA, scapula ZA.

Fig. 6. AU distribution. Male, posterior torso, preoperative. BUTT indicates buttock AU; EO, external oblique muscle AU; GCZA, gluteal crease ZA; ICZA, iliac crest ZA; MLT ZA, midline torso ZA; PS, paraspinal muscles AU; RH, rhomboid muscles AU; SC, scapula AU; SCZA, scapula ZA.

Fig. 7. AU distribution. Female left upper extremity anterior, preoperative. ALA indicates anterior lateral arm; AZA, axillary ZA; BGZA, bicipital groove ZA; DELT , deltoid muscle AU; DZA, deltoid insertion ZA; MFA, medial (ventral) forearm AU; MHC-OLZA, medial humeral condyle-olecranon ZA P;LA, posterior lateral arm; RH, rhomboid AU.

Fig. 8. AU distribution. Female left upper extremity posterior, preoperative. ALA indicates anterior lateral arm AU; DELT, deltoid muscle AU; DZA, deltoid insertion ZA; LFA, lateral forearm AU; LHC, lateral humeral condyle; OLZA, olecranon ZA; PLA, posterior lateral arm.

Fig. 9. AU distribution. Female lower extremity anterior, preoperative. AT indicates anterior thigh AU; ILZA, inguinal ligament ZA; LL, lateral leg AU;ML, midline anterior leg AU; MLZA, midline anterior leg ZA; PAT , patellar AU; SPZA, suprapatellar ZA.

Fig. 10. AU distribution. Female, lower extremity posterior, preoperative. AK indicates ankle AU; CF, calf AU; GAZA, gastrocnemius ZA; GCZA, gluteal crease ZA; MTZA, medial thigh ZA; PFZA, popliteal fossa ZA; PT, posterior thigh AU.

METHODS

This study is based on multiple patients in the United States and the United Kingdom who have presented for BCS during the author’s 35 years in practice. This article draws on the application of solid plastic surgery principles during this time. As Frederick McCoy would have said, many of the observations are “measured scientifically by eye.” Methods and results are limited by an analysis of three patients (two females and one male). There will obviously be variations between patients in the same way that there are anatomical variations of internal anatomy. Nonetheless, there is overall consistency, as evidenced by Lockwood’s study of 12 fresh cadaver segments and 20 body-contour patients. 15

Preoperative and postoperative male and female, anterior, posterior, and lateral views of the torso and upper and lower extremities were studied after MWL. AUs were identified that demarcated specific parts of the torso and extremities. AUs were defined as above. ZAs always demarcated boundaries of AUs but not vice versa (see above). No attempt was made to subdivide AUs further, as this was not felt to be relevant to planning BCS (Figs. 2 – 10 ). In the figures presented, AUs are filled with single blocks of color, and ZAs are identified as solid black lines. “Soft” AUIs without a ZA are identified as dotted black lines. AUs are labeled by their abbreviations, without any additional suffix, whereas ZAs are labeled with their abbreviations plus the additional ZA suffix, to avoid confusion with AUs. AUIs are not labeled. AUs (Tables 1 – 3 ) and ZAs (Table 4 ) are tabulated and illustrated (Figs. 2 – 10 ).

CASE EXAMPLES

Patient 1

Our patient is a 56-year-old White woman with the height of 5’ 3” and maximum weight of 154 kg. Her current weight is 73 kg and body mass index is 28 kg/m 2 with history of self-induced weight loss of 81 kg over a period of 24 months and stable weight for 6 months. The patient lost a further 15 kg after consultation and before initial surgery. The patient was self-referred. She has no significant medical history. She is a nonsmoker and social drinker. In-patient surgery was performed at Greenwich Hospital, Greenwich, Connecticut. Preoperative view and postoperative views are shown 4.5 months after lower body lift (LBL) and 1 month after an extended brachioplasty contiguous with a mastopexy-breast autoaugmentation 27 – 29 (Figs. 11 , 12 ).

Fig. 11. A 56-year-old woman after self-induced MWL, preoperative front view.

Fig. 12. A 56-year-old woman after self-induced MWL, 4.5 months after LBL, and 1 month after extended brachioplasty and mastopexy, postoperative front view.

Patient 2

Our patient is a 34-year-old White woman with the height of 5’ 6” and weight of 58 kg. Her body mass index is 20.7 kg/m 2 with a history of self-induced weight loss of 77 kg and stable weight for an undetermined period. Patient was self-referred. She has no significant medical or surgical history. She is a nonsmoker and nondrinker. In-patient surgery was performed at the Princess Grace Hospital in London, United Kingdom. Preoperative view and postoperative views are shown 3 months after extended abdominoplasty and 1 month after breast lift and breast autoaugmentation 27 – 29 with an upper body lift (UBL) (Figs. 13 , 14 ).

Fig. 13. A 34-year-old woman, after self-induced MWL, preoperative right-side view.

Fig. 14. A 34-year-old woman, 3 months after extended abdominoplasty and 1 month after breast lift and breast autoaugmentation, postoperative right-side view.Table 1. AUs of the Upper Extremity

Table 2. AUs of the Anterior, Lateral, and Posterior Torso

Table 3. AUs of the Lower Extremity

Table 4. ZAs

Table 5. Body Contouring Procedures: Choice of Scar Incisions, Based on Procedure and Clothing Considerations

RESULTS

AUs, ZAs, AUIs, ECs, and FCs are identical between men and women, except for the anterior chest wall, as reflected by the female curvilinear inframammary fold ZA, infra-pectoral ZA with the most caudal point at the breast meridian versus the male IPZA, which has an oblique medial-inferior to latero-superior direction.

DISCUSSION

With increasing demand for BCS after MWL, both contour and resulting scars must be considered in obtaining the optimum result. The six principles in optimal planning of an incision for BCS have been stated above. Each of these principles has varying degrees of importance, depending on the procedure (Table 5 ).

AUs have been described from the cartographic viewpoint. 13 Others have discussed AUs as they pertain to liposuction. 16 – 20 Gusenoff et al 14 stressed the importance of AUs in the treatment of pseudogynecomastia. With regard to incisions, Courtiss et al 21 commented that “certainly a prime method by which a patient judges the competence of his surgeon is by the appearance of the resultant scar.” Webster 22 suggested that wrinkle lines should be followed when making skin incisions. “The simplest rule for making incisions in the most favorable direction is to follow the natural wrinkle lines. These are usually recognizable on the face, the neck, the wrist, the axilla, the groin, or the back of the knee.” 22 Kraissl 23 further reviewed wrinkle lines with respect to the face and body, explaining differences in the scapular region between his lines and those of Langer. 24 – 26 Wilhelmi et al 30 stated that Kraissl lines rather than Langer lines (LLs) may be the best guides for elective incisions of the body. However, excluding joints, in the lower extremities, LLs reconcile with modern surgical approaches (Fig. 21 from Kraissl article). 23 Kraissl incisions for the abdomen and back reconcile with current body contouring incisions and are similar to LL except in the midline of the back where Kraissl lines are vertical as compared with the horizontal lines of Langer (Figs. 17, 18 from Kraissl article). 23 Relaxed skin tension lines of the face have been described by Borges and Alexander. 31 Incision lines have been further analyzed by Paul. 32

When planning incisions for BCS, it is important to appreciate the topography of AUs, ZAs, FCs ECs, joints, and skin tension lines. 21 – 33 One feature may override or mitigate against another. For example, the posterior LBL incision in the male is often lower than the iliac crest ZA, to ensure concealability beneath a swimsuit or a pants waistband, whereas in women, the incision should follow the iliac crest ZA along the superior curvilinear border of the buttock AU, which is coincidentally in a desirable position for concealability beneath a thong-style bikini bottom. See the LBL posterior scar in a woman (Fig. 2 by Rohrich et al 34 ), which is not curvilinear and lies above the AUI, and the LBL posterior scar in a man, (Fig. 13 by Lockwood 35 ), which demonstrates a low horizontal scar. Parenthetically, many articles of clothing highlight AUs and ZAs such as the “thong-style” bikinis and work-out “muscle” T shirts. ( See figure, Supplemental Digital Content 1 , which displays “muscle” T-shirt outlining scapula AUs, http://links.lww.com/PRSGO/C624.). The ideal incision for gynecomastia excision after MWL, also described as pseudo-gynecomastia, 14 is at the AUI between the PMM, abdomen (ABD), and EO AUs (Table 2 ). For women, inframammary fold (IMF) incisions permit the wearing of a crop top. In the female breast, it is important to avoid the upper medial quadrant in terms of scar visibility and to use the IMF as one border of an AU reconstruction. 7 A lower abdominoplasty scar permits wearing of high- or low-waisted pants. In contrast, a “fleur-de-lis” vertical scar precludes wearing an outfit such as a crop top, which exposes the midriff. Gynecomastia excision with a free nipple graft and a transverse scar through the center of the breast 36 and the “boomerang” scar 37 technique transgress the integrity of the PMM AU. High posterior curvilinear incisions 38 in an LBL prevent concealment of the scar below the waistband of pants, swim shorts, or a bikini bottom. UBL incisions, which cross the midline of the back will prevent wearing a low-backed dress or one-piece swimsuit. 39

Results of reconstructive procedures are published in the contemporary plastic surgery literature, which ignore AUs and create a patchwork quilt-like appearance. 40 The concept of AUs, as described by Burget, Spear, and others, 3 – 15 is further elaborated in this article, in the context of torso and limb surgery (Tables 1 – 3 ). ZAs, previously described, 15 are cataloged and classified (Table 4 ). The concept of the interface between an AU and ZA (AUI) is defined. Clothing preferences are reviewed with respect to scar placement and AUs. This classification is intended to act as a basis for planning BCS and for measuring outcomes based on scar position and visibility. Finally, an algorithm is presented, which outlines the six primary decision points in planning incisions for different BCS procedures. The six decision points are represented as a horizontal row with columns of procedures below. A single procedure may occur in multiple columns since more than one decision point may affect the choice of incision (Fig. 15 ). ( See Video [online] , which displays the body contouring AUs and ZAs together with the principles of planning BCS.)

Fig. 15. Body contouring surgery. Decision points in planning incisions.补充视频 / 附件（原文未随文提供原图，可于出版方页面查看）gox-11-e5093-s001.mp4Video 1. This video shows the body contouring aesthetic units and zones.

CONCLUSIONS

This article describes a practical, comprehensive description of AUs and ZAs of the trunk and extremities. This is a metaphorical “quantum theory” for aesthetic and reconstructive surgery, combining multiple concepts and anatomical landmarks into one simple unifying theory that applies to all elements of the practice of plastic surgery of the torso and extremities. This “atlas of aesthetics” is for planning and execution of BCS and also for other aesthetic and reconstructive surgery of these body parts. AUs, ZAs, and AUIs are not limited to the torso and extremities, but also occur in the head, neck, hands, and feet, and a description of these may serve as subject matter for a publication by this or another author.

This article, with its presentation of AUs, ZAs, FCs, and ECs, and the accompanying figures may also serve as a useful addition to the curriculum for plastic surgeons in residency and fellowship training, as well as a guide for practicing plastic surgeons. At a minimum, it will stimulate a conversation and an exchange of ideas. Other authors may disagree or may choose to further improve on this analysis, as is the nature of scientific discourse. As plastic surgeons, we live and breathe the “aesthetic canons” of the human body, and it is inculcated into our training and practice that we be constantly mindful as to what will create a good, bad, or ugly result, with a view of avoiding, at all costs, the second and third options. Again, let us not forget the words of Dr. McCoy, past president of the ASPS (1976), “if you aim for less than perfection you will hit it every time.” Perfection must be our goal.

DISCLOSURES

The author has no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENTS

This paper would not be of its current high quality without the unpaid efforts and recommendations of the anonymous reviewers of PRS Global Open to whom I express my sincere gratitude. I am always wiser and better informed after reading their comments (positive and negative), and the final draft is literally more readable and substantial after taking their recommendations into consideration.

Ethical Compliance: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Supplementary Material