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Chapter 11
Preferred Surgical Techniques inFat
Transplantation totheGluteal Region:
Antigravitational Liposculpture
AlejandroNajarMendez
11.1 Najar Marking Description
Najar marking consists of 11 drawn lines based on the anatomy of the surface of the
trunk, hips, gluteal muscles, and proximal third of the thighs. The lines are divided
and subdivided into segments within the ve following aesthetic units: Unit A (lumbosacral area), Unit B (trunk; high back, middle back, and ank (the abdominal
zone is not included), Unit C (hip), Unit D (gluteal support, proximal third of the
thigh). and Unit E (glutei). A detailed description of Najar marking is provided in
Table 11.1, Video of Najar marking (Video 11.1) and Fig.11.1, Fig. 11.2, and
Fig.11.3.
Characteristics of the antigravitational liposculpture technique:
1. A single surgeon
2. A systematic technique
3. Selective liposuction
4. Selective fat grafting
5. Support treatment
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 13802- 7_11.
A. N. Mendez (*)
Dr Najar Center, Culiacan, Sinaloa, 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_11
169
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Table 11.1 A guide for Najar marking
Line
Layout
order
number and
color Anatomy of the surface reference
1 10a (green) The anterior hip surface from the anterior axillary line
through the anterosuperior iliac spine until the caudal
limit of the proximal third of the thigh
2 1 (aqua) A sagittal line from the intergluteal fold through the level
of the twelfth rib over the vertebral bodies
Drawing the gluteal circumference
3 8 (red) A transverse line at the level of the infragluteal fold that
goes from the inner thigh to the interior lateral border of
the hip
4 5 (light
orange)
A transverse line at the superior limit of the buttocks that
goes from LINE 1 to the lateral superior border of the hip;
it meets/coincides with the anterosuperior iliac spine
5 2b (green) A line lateral and parallel to LINE 1, located at the
maximum gluteal projection point, which extends
cephalically toward the twelfth rib and caudally to the
infragluteal fold
6 11 (blue) A transverse line located at the natural fold close to the
cephalic end, known at fascial tissue xed points or back
rolls
7 11 (blue) The second transverse line of the fascial tissue xed
points parallel to LINE 11
8 7c (navy) A transverse line located at the level of the trochanter (x)
that goes from the intergluteal fold until the lateral border
of the hip
9 9 (yellow) Transverse line located under the infragluteal fold at its
inferior limit that goes from the inner thigh to the lateral
border of the thigh
10 6 (red) An oblique line that goes from the cephalic border of
LINE 2 through the trochanteric prominence of the hip to
the caudal limit of the proximal third of the thigh
11 3 (dark
orange)
A transverse line that goes from LINE 2 at its cephalic
limit to the border of the lateral ank
12 4 (green) A transverse line at the level of the superior border of the
iliac crest that goes from LINE 2 to LINE 10
a
Over this line, all transverse lines coalesce
b
Reference points to mark lines 3, 4, 6, and 11
c
Once LINE 2 crosses, gluteal quadrants are obtained
A. N. Mendez
Line
direction
Sagittal
Sagittal
Transversal
Transversal
Lateral
Transversal
Transversal
Transversal
Transversal
Oblique
Transversal
Transversal
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
171
Fig. 11.1 Najar marking: 3-D marking for posterior body enhancement contour (front) 1
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A. N. Mendez
Fig. 11.2 Najar marking: 3-D marking for posterior body enhancement contour (oblique) 2
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
173
Fig. 11.3 Najar marking: 3-D marking for posterior body enhancement contour (back) 3
11.2 Single Surgeon
The technique can be performed by a single surgeon or a team. The attending plastic
surgeon must make a diagnostic plan and a treatment plan, following the procedures
of the technique based on Najar marking, independently or in the presence of
another plastic surgeon or a surgical team.
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A. N. Mendez
11.3 Systematic Technique
Antigravitational liposculpture is a systematic technique since it comprises steps
and schematic processes including Najar marking, selective liposuction, and selective fat grafting, which are described later.
11.4 Selective Liposuction
Selective liposuction consists of guided liposuction following a previously established surgical plan and is based on the following guidelines:
1. Initiate suction from the deep to intermediate plane (perform supercially when
abdominal etching is requested).
2. Perform symmetric and comparable suctioning in the cephalic-caudal direction.
3. Record the injection and suction amounts per subunit.
4. Once subunit suctioning is performed and the desired thickness of the subcutaneous fat is veried, suctioning must not be performed again during the procedure (Pinch test, Fig.11.4).
I recommend symmetric suctioning, starting with subunits B7, B6, B5 on the
right side and continuing to the opposite subunits, leaving the cephalic cellular subcutaneous tissue thickness thinner than the caudal thickness, with a ratio 1:1.5. With
this thickness difference, the caudal thickness helps maintain the cephalic thickness,
obtaining an antigravitational effect in the standing position. The effect is reinforced
with the use of laser technology or any other preferable energy technology by the
surgeon.
Fig. 11.4 The pinch test 4
Cephalic
thickness
thickness
Caudal
Before After
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
175
Selective liposuction consists of subcutaneous fat in the subunits A–D through
deep plane to intermediate suctioning with the patient in different positions (supine,
prone, lateral decubitus, right and left) [1]. It is considered supercial when it
requires high denition [2] and a cephalic-caudal direction.
This liposuction technique avoids excess remaining fat, modifying the result of
the body contour. A at subcutaneous surface is obtained, avoiding contour-related
skin irregularities due to the antigravitational effect.
11.5 Selective Lipotransfer
Selective lipotransfer consists of treating the subunits on the side with the lowest
volume during evaluation once marking is performed and photographs are taken.
It is of great help to verify these ndings with 3D photographs (Fig.11.5) to
observe differences in the body contour in different positions. Additionally, the
patient can objectively see that body contour irregularities are the reason for unsatisfactory aesthetic appearance.
Fat grafting must be performed considering the following
1. Utilize only the subcutaneous plane
2. Work only in the direction from the deep plane to the supercial plane
3. Perform fat grafting in the caudal-cephalic direction
4. Initiate the procedure on the side with less volume
Fig. 11.5 3-D before and after the procedure 5
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A. N. Mendez
11.6 Subcutaneous Plane Exclusivity
Cutting-edge, evidence-based medicine must be considered by all plastic surgeons
in deciding which surgical technique to use in a procedure.
According to recent scientic reports, the safest zone for gluteal fat grafting is at
the level of the cellular subcutaneous tissue [3, 4]; therefore, that is the proposal of
this technique.
This application should be performed taking into account the angle of the cannula.
11.7 Fat Grafting fromtheDeep Plane
totheSupercial Plane
Due to the anatomical characteristics of each plane at the level of the cellular subcutaneous tissue [5], when fat is rst applied on the supercial plane of the cellular
subcutaneous tissue, tightening at that level occurs, which makes fat manipulation
difcult when applied in the deep plane. Initiation in the deep plane allows an
adequate distribution of fat. Moreover, if the cannula is vibrated with an infusion
pump- type EVL, as described by Del Vecchio and Wall [6], improved expansion of
each plane can be achieved with decreased risk since the inltration pressure is
reduced.
11.8 Fat Grafting intheCaudal-Cephalic Direction
(Antigravitational Fat Grafting)
The objective of fat grafting in the caudal-cephalic direction is to strengthen the
foundation (gluteal support), reduce gluteal ptosis, and improve the infragluteal fold
of the patient. This fat grafting sequence helps create convexity in the hip once unit
D has undergone fat grafting.
In this way, fat grafting boosts the turgidity of the cellular subcutaneous tissue
planes, creating a light tension that prompts tissues in a cephalic direction, reducing
its natural fall in the standing position, providing an antigravity effect.
11.9 Initiation ontheSide withtheLowest Volume
Body contour asymmetry is very frequent and is one of the greatest challenges when
performing liposculpture.
I recommend to start fat grafting on the side with the lowest volume since this
area will have less capacity than the side with greater volume. Until fat grafting is
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
Fig. 11.6 Measuring the symmetry projection 6
177
completed, it will be used as the visual reference point and reference for inltration
volume to inltrate the opposite side.
It is convenient to use a leveling device to verify the asymmetry in the projection
(Fig.11.6) and during fat grafting in the gluteal area (Unit E); it also serves as a
visual reference point to compare the distribution of the inltrated volume.
Symmetry is achieved according to the visual perspective of the surgeon, measured
according to the amount of fat that has been grafted in each buttock, and corroborated by photographs taken from above the patient (from a “birds-eye” view), as
recommended by Dr. Coleman [7].
Fat grafting should expand the volume to the permissible compliance of the soft
tissues without compromising the viability of the fat due to the overcorrection of
volume since this situation favors fat necrosis [8].
11.10 Support Treatment
The aesthetic nature and rmness of the buttocks are related to the rmness of its
foundations in the support system described by Morestein in 1984 [9].
The longitude of the infragluteal fold and the gluteal projection play a deterministic role in the aesthetic nature of the buttocks [10]. The longer the infragluteal fold
is, the less aesthetically pleasing the buttocks will be. I consider that the better the
turgidity of the gluteal support (D) is, the more aesthetically pleasing the buttocks
will be (Fig.11.7).
Recent studies note that in the lateral view, the ideal proportion between the
gluteal volume of the cephalic half and the caudal half is 1:1 [11].
Therefore, with the purpose of improving the gluteal projection and the infragluteal fold to enhance the appearance of the buttocks, treatment of the trochanteric
area, and in the infragluteal area (gluteal support) by fat grafting is essential and
requires exceptionally minimal liposuction.
Different authors have recommended applying fat in this area, suggesting that fat
grafting in this zone could cause a lifting or pushup effect [12]. Applying fat in the
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Fig. 11.7 See before and after photo and then tight focus 7
A. N. Mendez
inferior-lateral side of the hip and thigh (D3, D4, D5, and D6 and C2, C3) will
tighten the subcutaneous space and correct gluteal ptosis (when grades 1, 2, or 3 are
present), as ptosis can be decreased by 3–4 grades. This effect has been mentioned
by Dr. Rosique and is known by Drs. Del Vecchio and Rohrich [1].
11.11 Patient Selection andDiagnostic andTreatment Plans
Patient selection is rst performed by matching the patients’ surgical goals with
ours. We select patients according to the international recommended standard,
including healthy patients with a body mass index (BMI) less than 30, previous
medication suspension, as medication can affect the coagulation and wound healing
processes, and previous cessation of smoking and alcohol consumption.
Routine preoperative laboratory tests and a cardiological evaluation are required.
Diagnostic and treatment plans result from the unit and subunit evaluations once
marking is performed and photographs are taken. A surgical plan is established by
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