**1. Introduction**

#### **1.1 Overview**

Humankind has observed and drawn, sculpted media and their own physique since earliest recorded history. Pictograms of fertility and barren, conquerors and down-trodden, leaders and protectors, deities and devils, and young and old, are some of our earliest shared memories. Whether thin or thick, young, or old, athletic, or sedentary, fertile, or fragile, we carry with us preconceived visions of what each of these descriptors means to us. We critically evaluate each human we encounter against these standards which predate spoken word and have been genetically embedded in every member of the *Homo Sapiens* family. In fact, we often respond and are responded to initially based solely on our physicality. Since appearance is often evaluated before function or cognition, it is of great importance, often playing a pivotal role in our life opportunities, paths, health, and happiness.

#### **1.2 Patient assessment**

Each cosmetic patient who shares their time, goals, and dreams with us is concerned about the appearance they present to their family, spouse, peers, and the world in general. Often, there is adipose between the skin and the muscles that we may be able to sculpt and reveal by selective reduction, addition, tightening of the

enveloping cutaneous shell and beyond what has been genetically predetermined. Diet, supplements, exercise, lifestyle, and genes amalgam to create the ultimate exterior expression possible to achieve, short of surgically implanted prosthetic contours.

Our task is to sieve through the unrealistic options and present the possible. Balance risk with reward, outcome with economy and counsel our patients appropriately and patiently, perform our tasks skillfully, and rejoice in our patient's success.

After a thorough discussion of the patient's medical history, physical exam and desires we must counsel them on the possible avenues of intervention. Liposculpting, fat shifting and grafting, and tissue tightening are the major tools of rejuvenating the appearance of the dorsal aspects of a human to help them appear more youthful, healthy and powerful.

#### **1.3 Pertinent anatomy**

Specifically, we evaluate the looseness and elasticity of the skin, the contour and definition of the deltoids, trapezius, latissimus dorsi, rhomboids, gluteal muscles, shoulder blades, posterior rib cage, spine, and hip bones as well as the curves, symmetry, and proportions that we aspire to emulate in athletic, vigorous, hormonally optimized men and women considering age and ethnic heritage.

## **2. Technique**

#### **2.1 Markings**

Once standardized digital pictures are obtained (standing, 6 views with arms out to sides or relaxed behind and additional flexing and extending views if the procedure will be "Hi Def") the skin is cleaned (Hypochlorous Acid works well) and dried. Surgical markers, or "Sharpie Permanent markers" can be used to outline the effects of gravity on the standing form. A topography map is developed that shows elevations, depressions, adhesions, dimples, cellulite, transition areas and extent of tumescent anesthesia to be instilled. In my office we often use Green Sharpie for elevations and extent of tumescence, cross-hatched areas for divots and cellulite that may be addressed, blue for areas to have fat shifting or fill. Red means be careful or needs more attention/precision) for insertion sites and areas to maximally thinned for desired definition or energy application or both.

In general, we seek to emphasize sinuous muscle and bone contours, debulk horizontal planes to supply "snatched" female waists and celebrate the transitions between the horizontal dimensions of the posterior rib cage framed by the shoulders, traps, lats and rhomboids; waist including the obliques and expansion of the hips and buttocks, where the ideal female waist may be significantly smaller than its borders. Male measurement comparisons may be less dramatic but endeavor to show off muscle contour, sometimes to the extreme in HiDef cases.

Phi (the "Golden Ratio of measure) can be loosely applied to the torse in that the maximal chest and buttocks circumference is roughly 1.618 times the desired waist measurement. The vertical fold of the buttocks is roughly 1.618 as high as the desired horizontal intragluteal fold (tethering of tissue to the ischial tuberosity) under each cheek and the height of the buttocks, measured from the infra-gluteal fold is 1.618 as high as the desired perpendicular projection of the buttocks (depending on ethnic background and the current esthetic swings of

#### *Posterior Torso and Buttocks Contour Enhancement DOI: http://dx.doi.org/10.5772/intechopen.100529*

the pendulum). The low back and lateral waist generally have a gentle rather than abrupt transition into the hip and buttocks projection.

Buttocks projection, starting somewhat below the height of the superior iliac spine, may be maximized based on desired ethnic appearance: Patients of Latin heritage sometimes want a lower point of maximal projection with blending into the lateral hip, a Caucasian "bubble butt" has maximal projection about mid buttocks height, around the level of the greater trochanter and patients of African American heritage may desire their maximal buttocks projection at the level of the upper pole and prefer somewhat more global volume.

The lateral hip depression, sometimes referred to as "Hip Dip" is formed from a condensation of the gluteus medius and maximus, vastus lateralis, quadratus femorus and greater trochanter. It is more apparent in thinner, athletic, and older/ deflated patients and may be accentuated or filled as desired, consistent with the overall esthetic goal.

There is a "V" shaped contour arising from the superior pole of the vertical gluteal crease that outlines the superior-medial aspect of the upper buttocks adjacent to the sacrum which can be emphasized or not, again depending upon esthetic goals. Similarly, the posterior dimples (of "Venus") presented by where the spine amalgams with the bones of the pelvis, align with the vectors of the posterior superior iliac spines, help outline the superior medial buttocks should probably be left intact [1].
