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8 Deaths Caused by Gluteal Lipoinjection: What Have We Learned from Microscopic…
125
nearby the exact mechanism of passage of fat from the subgluteal space through the
blood circulation will be described. We will also see new strategies and techniques
of subcutaneous fat inltration to obtain excellent aesthetic results; for example,
when penetrating the fascia of the gluteus maximus muscle it hurts, even though the
subcutaneous space is inltrated with local anesthesia, maybe this can help to
develop a gluteus inltration technique with an excellent safety prole [33] inlocal
anesthesia procedures. It will be also necessary to retrain surgeons to learn the safe
technique of subcutaneous fat inltration, because although it is simple, certain
skills are required to be able to perform surgery with the cannula at the subcutaneous level at all times. However, we expect subcutaneous fat transfer to remain at the
head for a foreseeable time among the options currently available for gluteoplasty.
In fact, buttock fat inltration is still considered the best option in relation to the
complications of the other options [34].
Apart from the MIFE and MAFE, the procedure is not free of unusual complications [35], however, in general we believe it should be reconsidered as a safe procedure, with a low rate of complications (once all surgeons understand why it should
not be inltrated at a muscular level) and it can be performed with a good degree of
safety and excellent aesthetic results. The concept is, only inltrate the fat subcutaneously and do not allow intramuscular inltration. If this very simple concept is
taught and followed by all plastic surgeons, the procedure will continue to be safe
and mortality will decrease until it disappears.
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4. Bayter-Marin JE, Cárdenas-Camarena L, Aguirre-Serrano H, Durán H, Ramos-Gallardo G,
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Glob Open. 2018;6:83–4.
12. Ramos-Gallardo G, Medina-Zamora P, Cardenas-Camarena L, Orozco-Rentería D, DuranVega H, Mota-Fonseca E. Where does the transplanted fat is located in the gluteal region?
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13. Del Vecchio DA, Villanueva NL, Mohan R, etal. Clinical implications of gluteal fat graft
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2019;143(5):1343–51. https://doi.org/10.1097/PRS.0000000000005521.
15. Cárdenas-Camarena L, Gerardo LPA, Durán H, Bayter-Marin JE.Strategies for reducing fatal
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org/10.1097/GOX.0000000000001539.
16. Villanueva NL, Del Vecchio DA, Afrooz PN, Carboy JA, Rohrich RJ. Staying safe during
gluteal fat transplantation. Plast Reconstr Surg. 2018;141(1):79–86. https://doi.org/10.1097/
PRS.0000000000003934.
17. Kalaaji A, Dreyer S, Vadseth L, Maric I, Jönsson V, Haukebøe TH. Gluteal augmentation
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18. Cárdenas-Camarena L, Durán H.Improvement of the gluteal contour: modern concepts with
systematized lipoinjection. Clin Plast Surg. 2018;45(2):237–47. https://doi.org/10.1016/j.
cps.2017.12.005.
19. Del Vecchio D, Wall S. Expansion vibration lipolling: a new technique in large-volume
fat transplantation. Plast Reconstr Surg. 2018;141(5):639e–49e. https://doi.org/10.1097/
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20. Pane TA.Experience with high-volume buttock fat transfer: a report of 137 cases. Aesthet Surg
J. 2019;39(5):526–32. https://doi.org/10.1093/asj/sjy191.
21. Ghavami A, Villanueva NL, Amirlak B.Gluteal ligamentous anatomy and its implication in
safe buttock augmentation. Plast Reconstr Surg. 2018;142(2):363–71. https://doi.org/10.1097/
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22. Frank K, Casabona G, Gotkin RH, etal. Inuence of age, gender and body mass index on the
thickness of the gluteal subcutaneous fat—implications for safe buttock augmentation procedures. Plast Reconstr Surg. 2019;144:83–92. https://doi.org/10.1097/prs.0000000000005707.
23. Cansancao AL, Condé-Green A, Vidigal RA, Rodriguez RL, D’Amico RA. Real-time
ultrasound- assisted gluteal fat grafting. Plast Reconstr Surg. 2018;142(2):372–6. https://doi.
org/10.1097/PRS.0000000000004602.
24. Condé-Green A, Kotamarti V, Nini KT, et al. Fat grafting for gluteal augmentation. Plast
Reconstr Surg. 2016;138(3):437e–46e. https://doi.org/10.1097/prs.0000000000002435.
25. Muresan C, Davis JM, Hiller AR, etal. The safe gluteoplasty: anatomic landmarks to predict
the superior and inferior gluteal veins. Eplasty. 2019;19(2017):63–70.
26. Alvarez-Alvarez FA, González-Gutiérrez HO, Ploneda-Valencia CF. Safe gluteal fat
graft avoiding a vascular or nervous injury: an anatomical study in cadavers. Aesthet Surg
J. 2019;39(2):174–84. https://doi.org/10.1093/asj/sjy237.
8 Deaths Caused by Gluteal Lipoinjection: What Have We Learned from Microscopic…
27. Cansancao AL, Condé-Green A, David JA, Vidigal RA.Subcutaneous-only gluteal fat grafting: a prospective study of the long-term results with ultrasound analysis. Plast Reconstr Surg.
2019;143(2):447–51. https://doi.org/10.1097/PRS.0000000000005203.
28. Whiteld RM, Rios LM, DiBernardo BE.Making fat transfer to buttocks safer. Aesthet Surg
J. 2017;37(10):1199–200. https://doi.org/10.1093/asj/sjx185.
29. Teitelbaum SQ. Discussion: late seromas after breast implants: theory and practice. Plast
Reconstr Surg. 2012;130(2):439–40. https://doi.org/10.1097/prs.0b013e31825c71a2.
30. Everett M, Morales R, Newall G, etal. Safest practices for autologous buttock augmentation
with fat grafting using a roller pump injection technique. Aesthet Surg J. 2018;38(7):751–62.
https://doi.org/10.1093/asj/sjx113.
31. Ramos-Gallardo G, Orozco-Rentería D, Medina-Zamora P, Mota-Fonseca E, GarcíaBenavides L, Cuenca-Pardo J, Curiel-Beltran JA.Prevention of fat embolism in fat injection
for gluteal augmentation, anatomic study in fresh cadavers. J Invest Surg. 2018;31(4):292–7.
32. Sinno S, Chang JB, Brownstone ND, Saadeh PB, Wall S.Determining the safety and efcacy
of gluteal augmentation: a systematic review of outcomes and complications. Plast Reconstr
Surg. 2016;137(4):1151–6. https://doi.org/10.1097/PRS.0000000000002005.
33. Chia CT, Neinstein RM, Theodorou SJ.Evidence-based medicine: liposuction. Plast Reconstr
Surg. 2017;139(1):267e–74e. https://doi.org/10.1097/PRS.0000000000002859.
34. Asserson DB, Kulinich AG, Orbay H, Sahar DE.Differences in complication rates of gluteoplasty procedures that utilize autologous fat grafting, implants, or local aps. Ann Plast Surg.
2019;82(5S Suppl 4):S342–4. https://doi.org/10.1097/SAP.0000000000001765.
35. Grome LJ, Bartlett E, Izaddoost S.Liposuction fat emboli resulting in myocardial infarction: a case report and review of the literature. Eur J Plast Surg. 2019;42:509–12. https://doi.
org/10.1007/s00238- 019- 01514- 035.
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Chapter 9
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Avoiding Complications inButtock
Surgery
DavidOrozco-Rentería, GuillermoRamos-Gallardo, JesúsCuenca-Pardo,
andLázaroCárdenas-Camarena
Buttock surgery is a surgical procedure that has gained acceptance and popularity in
the social eld due to beauty standards promoted in mass media or social media.
This has caused each year to increase the number of surgeries reported in the practice of plastic surgery. After analyzing the data of the American Society of Plastic
Surgery, a total of 24,000 gluteal augmentation surgeries with autologous fat were
documented in 2018, which compared to the 2017 data corresponds to a 19%
increase in the number of this type procedures [1].
There are several factors that have promoted the increase in gluteal surgeries,
which include changes in the behavior of physical activity and cult of the body, the
popularization of the “thong style” of women’s underwear and swimsuits [2], as
well as the increase in bariatric surgeries. However, so far there is no ideal as for the
aesthetics of the buttocks since this is dependent on cultural and ethnic factors [3].
Although the beauty of the gluteal region is determined by cultural and ethnic
factors, great efforts have been made to standardize the proportions closest to perfection. Such proportions are currently considered ideal if there is a 1.4 times greater
proportion of the gluteal region with respect to the waist or in a post-anterior relationship a waist to hip ratio (WHR) of 0.65 and in a lateral WHR ratio of 0.7 with a
50:50 vertical proportion [4, 5].
The gluteal region is not only an area that highlights body beauty, but it is also of
great importance given the amount of muscles, vascular, and nervous structures
D. Orozco-Rentería · J. Cuenca-Pardo · L. Cárdenas-Camarena
Comite de Seguridad, Asociacion Mexicana de Cirugía Plastica, Estética y Reconstructiva,
Mexico City, Mexico
G. Ramos-Gallardo (*)
Comite de Seguridad, Asociacion Mexicana de Cirugía Plastica, Estética y Reconstructiva,
Mexico City, Mexico
Centro Universitario de la Costa, Universidad de Guadalajara,
Puerto Vallarta, Jalisco, Mexico
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_9
129
130
D. Orozco-Rentería et al.
necessary for ambulation, sitting, and other essential activities for humans. What is
essential is to know their anatomical relationship, as well as take the appropriate
safety measures during the surgical act to avoid the maximum presentation of complications that due to their type could cause temporary or permanent disability and
in the most serious scenario the death of the patient.
Although the physical activity, especially the gym activity that involves the use
of weight, can inuence the increase in the volume of the muscles of the gluteal
region, a rigorous training will be required to achieve an increase in the volume that
in many cases It will not be signicant for the wishes of the patients and who will
resort to a procedure that will allow them to remodel, lift, or increase their buttocks
to obtain greater volume, rmness, roundness, and denition. As the gluteal region
is not only an area that highlights body beauty, but also of great importance because
of the amount of muscles, vascular, and nervous structures necessary for ambulation, sitting, and other essential activities for the human being, it is an obligation to
be intimately familiar with the anatomy to signicantly reduce the chances of injury
during a surgical procedure [6].
We have two surgical techniques to perform buttock augmentation surgery: (1)
gluteal augmentation with implants and (2) gluteal augmentation with autologous
fat or BBL (Brazilian butt lift), which will have a different range in terms of presenting complications for which the necessary measures must be taken to avoid them as
much as possible.
9.1 Gluteal Augmentation withImplants
It is currently a technique that is not used as much as autologous fat is because of
the limited capacity of the muscles and the gluteal region framework for the placement of large volume implants.
In those cases in which the use of impatient buttocks is decided, we will have the
following options to use depending on the need of the patients and their anatomic
characteristics: round or oval base implants. The material is cohesive silicone,
which differs from that used in breast implants in its rmness that makes them more
resistant to the compression forces of the buttocks [7].
The rst report of the use of a prosthesis for the improvement of the gluteal contour was in 1969 [8] and as anecdotal data given that there was no implant designed
specically for the gluteal region at that time, breast implants were used [9].
As the use of implants for the gluteal region became popular, new surgical techniques were also developed, whose main purpose was to improve cosmetics, to have
better implant coverage and primarily to reduce complications related to the use of
these prostheses. The techniques used are based on the pocket execution plane for
implant placement, which are: submuscular plane [10], subfascial plane [11], and
intramuscular plane [12, 13]. Although the subcutaneous plane for implant placement was initially described, over the years it fell into disuse due to the unsatisfactory cosmetic result related to the implant and its relationship with the tissues [9].
9 Avoiding Complications inButtock Surgery
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131
9.2 Gluteal Augmentation withImplants
inSubmuscular Space
This technique has the disadvantage of offering a greater projection in the upper
area and lack of volume in the lower area making this last area look empty, so they
are not an adequate alternative when it comes to the correction of buttocks ptosis. It
is important when dissecting the submuscular space to take into account the points
between the middle third of a line that runs from the posterosuperior iliac spine
toward the ischial tuberosity and from this to the greater trochanter as it is the site
where the sciatic nerve emerges [14].
Although this technique is still used, its main indication is for patients with good
development of the buttocks in its lower portion but with lack of volume in the
upper portion. Unfortunately, over time they tend to produce a double bubble effect
when soft tissue products of the age develop.
9.3 Gluteal Augmentation withImplants inSubfascial Space
The fascia of the gluteus maximus muscle is very strong from its origins and to its
insertions, covers the entire extension of the muscle, and is able to hold the gluteal
implants in position due to their strength at the insertion sites and in turn has a soft
area in the middle that provides a very aesthetic appearance. It was popularized by
De la Peña [11] as it offers the main advantage of adequate dissection without the
danger of injuring the sciatic nerve. It is an ideal technique for young and thin
patients with mild ptosis, overweight, or moderately obese patients.
Much was discussed about the strength of the muscular fascia and its tensile
strength that some considered insufcient for the placement of a prosthesis and that
despite the existence of a soft area located in the middle zone there are at least 14
tension points in the fascia that show a breaking force of at least 20N [15].
9.4 Gluteal Augmentation withImplants
inIntramuscular Space
This technique described by Vergara and Marcos [12] is the one with the greatest
worldwide acceptance for gluteal implant placement. It offers as an advantage over
the submuscular technique the minimization of the sciatic nerve lesion during dissection and in turn being able to perform more broadly in a caudal direction, which
translates into a more natural position of the implant. However, it is technically
more challenging than the rest because a cover of at least 2cm thick of the muscle
bers is required for adequate implant coverage and that not having anatomical
reference sites could cause irregularities in the contour of the pocket or a deepening
dissection with potential risk of nerve injury.
132
In spite of the certain security that it offers in the preservation or injury of the
sciatic nerve, the presence of the lower gluteal nerve, which runs 70% below the
total thickness of the muscle must be taken into consideration when dissecting to
avoid injury [16].
Among the main complications of implants in these anatomical spaces are:
dehiscence, seroma, infection, loss of the implant due to exposure, asymmetry,
implant migration or malposition, implant rupture, capsular contracture, sciatic paraesthesia, and muscular atrophy.
D. Orozco-Rentería et al.
9.5 Dehiscence Lesion
This is the most common complication in these procedures and occurs in approximately 30% of cases when the intramuscular plane is used and between 15 and 30%
in the subfascial plane [11, 17]. It typically appears to be healthy skin; however in
the deep layers, it is possible to show nonviable subcutaneous tissue, usually with
negative cultures. It is presumed that because of the wet and poor irrigation of the
area, coupled with the trauma of pocket dissection, this area is prone to develop
ischemia. It usually heals with debridement and healing, closing by second intention in an approximate time of 2–3months.
To reduce the presentation of this complication it is necessary during the dissection to cause the least trauma and preserve the greatest amount of viable tissue,
perform a hermetic closure by layers to decrease the possibility of presenting this
complication up to 5% [17].
9.6 Seroma
The formation of seroma around the implants usually occurs between 2 and 4% in
both placement planes [11, 18]. There is an association between the use of textured
implants with a higher prevalence of seroma, so it has been decided to change to
smooth implants in order to improve this problem [12]. The placement of a closed
drain to prevent the accumulation of liquid and wait for its withdrawal until the
expense is less than 25cc for 24h is the main recommendation.
If the drainage expense persists high without decreasing, it is recommended to
perform a new surgical intervention to mark the capsule, make the implant extraction, take a sample for culture and placement of a closed drain due to the important
association of mycobacterial infection in the presence of chronic seromas and therefore wait to have negative cultures for implant repositioning [19, 20].
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133
9.7 Infection
The incidence of infections is 2–3% when the intramuscular plane is used and 7%
in the subfascial plane [11, 12]. In the presence of erythema, pain, and redness of the
area it is convenient to perform a culture and start empirical antimicrobial therapy
until the nal culture is achieved. Once the diagnosis is conrmed, the recommended treatment involves the removal of the implant, irrigation and cleaning of the
pocket with placement of closed drains [21]. The use of a plastic sleeve to introduce
implants decreases colonization at the time of placement.
Although the implant can rarely be rescued, the infection causes its loss. It is not
recommended to change the dissection plane in order to reposition the implants, but
a time between 6 and 12months after explantation should be expected to reposition
the implants [22].
9.8 Migration or Malposition oftheImplant
It is a complication that occurs less frequently since the intramuscular space is used
for implant placement. When it occurs it is due to supercial dissection that communicates the subfascial or subcutaneous plane; this leads to an increase in pressure
in the area that is within the muscular plane with the consequent sliding of the
implant.
Within the technical aspects, a thickness of 2cm is required inside the muscle to
ensure proper implant placement without this phenomenon happening. It occurs in
about 2% of cases and the correct behavior consists of assessing the muscular thickness of the pocket through a tomographic study and if it is less than 2cm proceed to
reposition the implant in a new pocket, but if this comes to occur in a pocket with a
thickness greater than 2cm, the ideal is to remove the implant, allow the tissues to
heal, and reposition the implants between 3 and 6months later [20].
9.9 Exposure andLoss oftheImplant
Its incidence is 2–5%, but it can be higher and reach up to 30% in overweight
patients or those in whom implants of >350cc or >3.5cm of projection are placed.
It is suggested to use sizers prior to the placement of the denitive implant, as
well as to make a pocket of adequate size to be able to make a closure with little
tension [19, 23].
134
D. Orozco-Rentería et al.
9.10 Capsular Contracture andRupture oftheImplant
These entities are uncommon in gluteal augmentation with alloplastic material.
Capsular contracture occurs in a maximum range of 2%, while implant rupture
occurs in less than 1% [24].
9.11 Muscular Atrophy
The placement of gluteal implants causes muscular atrophy; however this does not
entail any clinical or physical limitation [25]. The variation in force is not primarily
attributed to the surgical procedure or to the implants; psychological and multifactorial variations should be considered as well. The buttock augmentation with implants
is therefore effective in improving the waist–hip index and changing the anthropometric pattern from android to gynecoid [26].
It is necessary to emphasize that for many patients with low fat tissue this type of
procedure is the only possible option to correct the lack of volume of the gluteal
region. Although complication rates are low for this procedure, modications in the
technique are still required to reduce the complications presented [27].
9.12 Gluteal Augmentation withAutologus Fat Graft
In these times, autologous fat grafting has become the most common technique for
treating contour irregularities in cosmetic and reconstructive surgery, being used by
80% of plastic surgeons [28].
Autologous fat grafts have a large number of benecial characteristics: easy
access, simple surgical procedure, low cost, and zero immunogenicity, in addition
to being composed of a fraction of vascular stroma that has a large number of stem
cells derived from adipocytes and pre-adipocytes [29].
Autologous fat grafting is performed through the incisions planned for liposuction, the most commonly used in the intergluteal fold or those located in the subgluteal groove. The amount of grafted fat will depend on the needs of each patient and
the protocols of each surgeon; however the most important factor to consider is the
survival and integration of the fat which are dependent on the patient’s own factors
and the Injection technique.
Despite being a procedure that has been performed more and more frequently for
20years, there is still no evidence of a standardization of the procedure, so there is
no universal protocol that guarantees safety and reduces the complications that may
occur when performing the graft [30, 31].
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9.13 Complications
9.13.1 Fat Necrosis
Fat grafting requires an adequate blood supply for its integration and survival in the
recipient site, so that if lacking or being diminished, necrosis of the affected area or
areas will occur. The organism has a problem absorbing areas formed by oily droplets resulting from the destruction of fat and that will be inltrated by macrophages
that attempt to phagocyte them slowly [32] and which, failing to do so, will cause a
permanent inammatory state with calcication.
Of the processes used for the preparation of the fat prior to the transfer, centrifugation produces greater damage to the membranes of the adipocytes with consequent necrosis if compared with decantation [33]. Other factors to consider are the
lumen of the cannula with which the fat is obtained and the volume of fat that will
be transferred to the area since if the receiving site lacks adequate compliance to
receive the fat, an increase in interstitial pressure will occur in tissues with the consequent decrease in tissue O2 concentration [34].
9.13.2 Fat Embolism
Despite having a low incidence, macroscopic fat embolism syndrome (MAFE)
associated with liposuction is a life-threatening entity. The microscopic fat embolism (MIFE) is relatively rare in nontraumatic pathologies, but when it occurs during or after a liposuction is serious as well [35].
Minor complications due to liposuction occur in approximately 5–10% of cases,
but when MAFE or MIFE occurs, it has higher mortality [36].
During liposuction and fat grafting, ruptures of small-sized blood vessels and
adipocyte damage are caused, this causes microlipid fragments that reach the venous
circulation and consequently lung damage. In studies on animal models, circulating
fat microparticles and lung lipid deposits have been located in all the animals studied [37].
In the presences of MIFE this syndrome consists of two phases that are not mutually exclusive, but explain the presentation times of the signs and symptoms.
The biochemical phase explains how micelles that reach the pulmonary capillaries are hydrolyzed by pneumocytes; this produces free fatty acids that are toxic to
endothelial and alveolar cells. This local lesion causes the release of vasoactive
amines and prostaglandins. In addition, there is recruitment of neutrophils that lead
to hemorrhage, interstitial, and alveolar edema. While in the mechanical phase a
fatty embolus enters the bloodstream reaching the pulmonary capillaries causing
mechanical obstruction and possible migration to the nervous system [36, 38, 39].
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