Aesth. Plast. Surg. 17:179-181, 1993

Aesthetic Plasuc Surgery © 1993 Springer-Verlag New York Inc.

Editorial: From the Panniculus Carnosus (PC) to the Superficial Fascia System (SFS) Peter Bela Fodor, M.D., F.A.C.S. New York, New York, USA

Abstract. There is a renewed interest in the anatomy of

the subcutaneous fat. These studies have been stimulated by the recent clinical popularity of liposuction. Attention has been drawn to the superficial fascia system and to its role in wound healing and in skin contraction. What is the origin of this SFS? This article proposes that the panniculus carnosum (except for the platysma) did not disappear in man. Instead, it is present throughout the body as the superficial fascia system. Therefore, the superficial fascia system is nothing else but the evolutionary form of the panniculus carnosum. Key words: Panniculus carnosum -- Anatomy -- Evolutionary development

It is often stated that the platysma is the only anatomic structure that persisted in humans as an evolutionary remnant fi'om the panniculus carnosus, which is widely present in primates. It may not be surprising for the platysma to remain since in the Chacma baboon [23], Papio Ursinus, the platysma is "the largest of the facial muscles, longer, wider, thicker and heavier than any of the others." For that matter, it is larger than the buccinator which itself is overdeveloped as a function of the buccinator pouch. In addition to its role in mastication, a distended pouch visible from several yards may possibly serve as a signal to other animals that food is available. Research in primates on integument blood supply, resistance to bacterial invasion, tissue expansion,

Correspondence to Peter Bela Fodor, M.D., 200 East End Avenue, New York, NY 10128, USA

and wound contraction resulted in much information regarding the response of the panniculus carnosus to surgical manipulations [1-3, 5, 7-10, 16, 20-22, 24, 26]. However, as often mentioned, caution should be exercised in directly translating any result of animal research to human skin. Upon close scrutiny, it appears that the issue is further muddied by the fact that in some of these animal studies, when flaps were being elevated, the dissection was kept superficial to the panniculus carnosus while in others it was deep into it. In the course of evolution, except for the platysma, has the panniculus carnosus disappeared or has it become modified into a number of different anatomic structures of varying functional significance? Could it be that the palmar, plantar, Scarpa's, Camper's, Dartos' fasciae, and the entire superficial fascia system for that matter (fasciae superficialis), with its retinaculae cuti and their condensations into what Illouz [14, 15] termed as "fixed points," is what has become of the panniculus carnosus? Could not these be condensations of the panniculus carnosus and superficial fascia system that define the inframammary, axillary, gluteal, nasolabial, and other, if not all, of the skin folds? These same folds have been known to stubbornly resist plastic surgical manipulations. In the course of combined procedures, such as suction with facelifts, thigh plasties, and abdominoplasties, this network of fibrous attachments is nicely demonstrated every time when skin flaps are elevated in areas where suction was performed just prior to flap elevation. A plethora of recently published papers [4, 14, 15, 19, 25], studies mostly stimulated by the increasing popularity of lipolasty, indirectly shed new light on the functional role of the panniculus carnosus and superficial fascia system. Similarly, a number of sur-

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gical implications can be drawn. To start with, the advantage of blunt-tipped cannulae in performing liposuction was established. In contrast to curettes, these spare the fibrous attachments. The network of contracting fibers that remain play an important role in the postoperative skin retraction process. In addition, the blood vessels, nerves, and lymphatics coursing along with these fibers are similarly saved. It has generally been maintained that adipoaspiration should be limited only to the deep compartment of the subcutaneous fat; a concept recently reemphasized by Illouz [14, 15]. However, in contrast to this, others [6, 11-13, 27] advocate suction in the superficial layer also, and I believe rightfully so. They claim that by using this technique, the additional benefit of better skin retraction will result and, therefore, the procedure can be offered to patients who, in the past, were not considered candidates. Also, in an attempt to treat cellulite, suction of the superficial fat compartment in combination with reinjection of some fat, has been advocated. Longterm results are anxiously awaited since the ultimate fate of autologous fat transfer to date is not very promising. A well-defined panniculus carnosus and superficial fascia system that partitions the subcutaneous fat into a superficial and deep compartment is clearly present in some body areas, such as in the hypogastric region (Scarpa's fascia), in the trochanteric region, or the neck (platysma). In contrast, it is less clearly defined in other areas such as the epigastric region, hip rolls, and the lower extremity distal to the knee joint. The body regions with a well-defined panniculus carnosus can be suctioned with more ease, and the procedures are followed by a shorter postoperative edema phase. Just compare the epigastrium to the hypogastric region. Furthermore, in body regions with a poorly defined, honeycomb-like panniculus carnosus and superficial fascia system, pretunnelling is essential in order to establish an even superficial layer of fat that is to be preserved, otherwise postoperative irregularities can readily occur. It appears that depending on its function, the form in which the panniculus carnosus and superficial fascia system is present differs in different anatomic areas. For example, in the palms and soles, for obvious reasons, it is very dense and is connected to the palmaris and plantaris longus muscles, respectively, with their "dispensable" tendons. It also has denser attachments elsewhere such as, for example, in the center of the back in a vertical plane or at the horizontal attachments that form the folds of fat in the back of overweight individuals. This has recently been studied by Lockwood [17, 18]. Therefore, it makes sense that closing incisions for body sculpting procedures in anatomic regions where the panniculus carnosus and superficial fascia system is well defined, attention should be paid to reapproximating

From PC to SFS

the PC/SFS as a separate layer. In this way, tension is distributed away from the skin and a better scar results. Continued investigation of the anatomy and function of the panniculus carnosus and superficial fascia system will lead to further improvements in body sculpting surgery.

References

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