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190
R. G. Rosique and M. J. F. Rosique
Fig. 12.2 Pre-op and 3years post-op of a 39-year-old female with BMI 23 kg/m2, who underwent
liposuction (4L lipoaspirate) and injection of 400cc of fat in each buttock. In this patient, the widest part of her hips was too high, so we sculpted her hips grafting 400cc each side to turn into a
hourglass gure with a rounder buttocks
landmarks. When the amount of fat required to achieve the desired outcomes is
greater than the amount of fat available on the back, we place the patient supine to
harvest some fat from the abdomen and the thighs.
12.2.4 Anesthetic Technique
We perform gluteal fat augmentation under epidural anesthesia due to its longer
postoperative analgesia and proven benecial effect in preventing thromboembolic
events [9]. When the procedure is associated with an abdominoplasty or breast surgery where more than one intraoperative change of position is necessary, we use
general anesthesia with an epidural block to avoid acute hypoxic cardiac arrest,
which may occur during decubitus changes with a spinal block [10].
12 Gluteal Fat Augmentation– Our Personal Approach
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Fig. 12.3 Pre-op and 1year post-op of a 32-year-old female with BMI 23.2 kg/m2, who underwent
liposuction (4.0L lipoaspirate) and injection of 480cc of fat in each buttock. To achieve an hourglass shape, we had to emphasize saddlebags and thigh roots area liposuction and, target the fat
graft to augment buttock’s upper part projection. Note that thigh’s liposuction didn’t turn the buttock ptotic since and anatomically independent areas, separated by the infragluteal crease
191
12.3 Intraoperative Period
12.3.1 Fat Harvesting
12.3.1.1 Inltration
Inltration is performed with the same cannulas used for liposuction with a solution
of normal saline and epinephrine at 1:500,000 according to the wet technique. We
avoid using local anesthetics in the solution as there have been reports of decreased
adipocyte viability [11, 12] and since the patient already has a neural block, local
anesthetics are not necessary.
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R. G. Rosique and M. J. F. Rosique
12.3.1.2 Donor Sites
We minimize the ports of entry for the cannulas as much as possible. In the back, we
use one port in the center of the bra line and one at the apex of the intergluteal cleft.
The fat is harvested from the whole back in a fan-shape fashion, crisscrossing the
liposuction trajectory from the upper and lower cannula ports.
We prefer liposuctioning the deep fatty layer and leaving the most supercial
layer of fat intact to avoid supercial irregularities that are difcult to correct later.
We use one port in each infragluteal fold and aspirate fat from the saddlebags in
a deep plane, leaving an intact supercial layer of fat, in a continuous line starting
at the lateral aspect of the knees to avoid any contour irregularities. From these same
ports, the posterior inner thighs and the sub-gluteal fat is harvested as needed.
12.3.1.3 Equipment Used
An electrical vacuum-pump set at approximately −400mmHg is connected by a
exible silicone tube to a sterile glass canister covered with a rubber cap that will
store the lipoaspirate. A second exible silicone tube connects the canister to the
cannula. Cannulas of 4- and 5-mm diameter are used to harvest fat as some studies
have shown greater adipocyte viability when larger diameter cannulas are used [13,
14]. To avoid clots within the lumen of the cannula, we use blunt cannulas with
three holes.
12.3.1.4 Fat Processing
The lipoaspirate is decanted in a closed circuit. We open the canister only when
ready for fat grafting. At this point the supernatant fat is collected and injected.
12.3.1.5 Fat Injection
With the patient in prone and at position, fat is injected in the supercial fatty layer
in order to give contour and shape to the gluteal region, beginning laterally in multiple planes, delivering small amounts of fat at each pass of a single-hole, 3.5-mm
cannula attached to a Toomey tip 60cc syringe. After the most lateral part is lled,
we proceed medially. If there is hypoplasia at the medial buttock area, fat is injected
near the intergluteal cleft in a centrifugal mode, always in the subcutaneous plane
using the intergluteal incision site. Fat is then injected into the deep fatty layer
toward the lateral aspect of the gluteal muscles to increase projection, always keeping the cannula parallel to the sacral plane with a maximal angle of 30° to avoid
injecting inside the muscles. Approximately 20–30% of the fat is grafted in the deep
subcutaneous plane. Cannulas with an internal diameter of 3 mm are preferred
12 Gluteal Fat Augmentation– Our Personal Approach
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based on the classic theory of lipograft survival [15] or the more recent substitution
theory [16], which states that fat threads should be at most 1.5-mm radius to achieve
long-term retention rates. Toledo published his 30-year experience showing that
injecting 500 ccs of fat in each buttock is sufcient to achieve good results while
keeping the incidence of complications low [17]. We also avoid injecting more than
500 ccs of fat in each buttock. If the patient needs or desires more volume, a second
procedure can be done [18].
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12.4 Postoperative Period
We routinely administer an intravenous dose of a rst-generation cephalosporin at
anesthetic induction and prescribe the same orally for 7days in the postoperative
period. Analgesics and multivitamins are also prescribed.
Following the deep venous thrombosis (DVT) risk factor assessment [19], we
administer a standard dose of low molecular weight heparin subcutaneously daily
for 7days after the procedure [20]. Patients also remain with intermittent pneumatic
compressive devices for 12h [21]. They are encouraged to ambulate as soon as possible and drink lots of liquids during the rst week.
12.4.1 Garments, Compression Socks, Massage
Compression socks and garments are used immediately post-op and continued for
1month and 2months, respectively. The garments compress the liposuctioned areas
but also stabilize the grafted areas. There is evidence that pressures as high as 6atm.
does not affect adipocytes viability [22]. Also, the garment promotes a graft stabilization effect.
Massages over the grafted areas are avoided during the rst 6weeks because it
can vigorously rupture the grafts’ ongoing vascular reconnection process. Massages
over liposuctioned areas are allowed and patients often feel much comfort.
12.4.2 Recommendations andRestrictions
Starting in the recovery room, patients rest over their buttocks. Pereira and
Radwanski [23] showed in 1996 that, clinically, anterior body procedures can be
associated while letting the patient lie over their buttocks without jeopardizing the
grafted areas. Most of our buttock augmentations are performed concomitantly with
abdominoplasty and breast surgery, and we observed that the supine position does
not jeopardize the nal outcomes of the procedure [24].
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R. G. Rosique and M. J. F. Rosique
12.5 Complications
Our patients had a mean age of 34years, a mean BMI of 24 kg/m2, and the mean
volume of fat injected per buttock was 490cc. Minor complications included seroma
in the sacral region and major complications included two cases of DVT conrmed
by CT angiogram (symptoms in the cases of DVT appeared at 7 and 9days postoperative), and occasional symptomatic hypovolemia requiring prolonged intravenous
hydration. We had one case of infection in the patient who we injected the highest
volume of fat (800cc on each side) treated with intravenous antibiotic and healed
well with no aesthetic sequelae. There were no death cases [25].
12.6 Discussion
By maintaining an average of almost 500cc of fat grafted in each buttock allowed
us to achieve patient’s satisfaction [24] while avoiding major complications and
buttocks ptosis complaints in long-term patients.
Except for the case where we injected over our usual volume range, we have
never had fat necrosis, formation of oil cysts, infection, which would be expected
according other casuistics [26].
By explaining preoperatively to the patient that a waist-to-hip ratio of 0.7 and the
hourglass shape are classic beauty standards, the expectations are aligned and the
concepts that curve and proportion are more important for female beauty than buttocks volume itself.
Since the unquestionable link made by Cardenas etal. between intramuscular fat
graft and mortality due to fat embolism, we changed our technique in order to use
only the subcutaneous plane for fat graft. But, by the aesthetic point of view, the fat
grafted and maintained invivo within gluteal muscles mass (as shown by several
published radiologic studies) allowed the effect of a more athletic buttock due to a
muscle hypertrophy simulation if compared with the use of only the subcutaneous
plane adopted for safety reason nowadays.
12.7 Conclusion
Gluteal augmentation with fat graft will continue to grow as long we can deliver
great results with maximal safety and trust from our patients.
Surgical interventions lead to permanent anatomic alterations that may be very
difcult to reverse, if not impossible. Therefore, we plastic surgeons have the
responsibility of ltering patients’ requests within the limits of common sense and
stable aesthetic standards, foreseeing the long-term results of our interventions.
12 Gluteal Fat Augmentation– Our Personal Approach
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195
Buttock fat graft is a procedure that is being made for more than 30years with
extensive accumulated experience. The best for our patients is that we humbly learn
from previous surgeons, keep investigating ways for improving the technique, and
recognize the need to work as a group for the advancement of plastic surgery.
References
1. ASPS.National Plastic Surgery Statistics. 2016. https://www.plasticsurgery.org/documents/
News/Statistics/2016/2016- plastic- surgery- statistics- report.pdf. Accessed 13 Sept 2017.
2. ASAPS.Cosmetic Surgery National Data Bank Statistics. 2016. https://www.surgery.org/sites/
default/les/ASAPS- Stats2016.pdf. Accessed 13 Sept 2017.
3. Singh D.Universal allure of the hourglass gure: an evolutionary theory of female physical
attractiveness. Clin Plast Surg. 2006;33(3):359–70.
4. Wong WW, Motakef S, Lin Y, Gupta SC.Redening the ideal buttocks: a population analysis.
Plast Reconstr Surg. 2016;137(6):1739–47.
5. Gonzalez R, Spina L.Grafting of fat obtained by liposuction: technique and instruments. Rev
Bras Cir. 1986;76(4):243–50.
6. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast
Reconstr Surg. 1983;72(5):591–7.
7. Rosique RG, Rosique MJF. Reply: the difference between trends and standards on gluteal aesthetics: the impact of social media on beauty preferences. Plast Reconstr Surg.
2019;144(4):712e–3e.
8. Rosique RG, Rosique MJF.Augmentation gluteoplasty: a Brazilian perspective. Plast Reconstr
Surg. 2018;142(4):910–9.
9. Hafezi F, Naghibzadeh B, Nouhi AH, Salimi A, Naghibzadeh G, Mousavi SJ. Epidural
anesthesia as a thromboembolic prophylaxis modality in plastic surgery. Aesthet Surg
J. 2011;31(7):821–4.
10. Pollard JB.Common mechanisms and strategies for prevention and treatment of cardiac arrest
during epidural anesthesia. J Clin Anesth. 14(1):52–6.
11. Moore JH Jr, Kolaczynski JW, Morales LM, etal. Viability of fat obtained by syringe suction
lipectomy: effects of local anesthesia with lidocaine. Aesthet Plast Surg. 1995;19(4):335–9.
12. Keck M, Zeyda M, Gollinger K, etal. Local anesthetics have a major impact on viability of preadipocytes and their differentiation into adipocytes. Plast Reconstr Surg. 2010;126(5):1500–5.
13. Ozsoy Z, Kul Z, Bilir A.The role of cannula diameter in improved adipocyte viability: a quantitative analysis. Aesthet Surg J. 2006;26(3):287–9.
14. Erdim M, Tezel E, Numanoglu A, Sav A.The effects of the size of liposuction cannula on
adipocyte survival and the optimum temperature for fat graft storage: an experimental study. J
Plast Reconstr Aesthet Surg JPRAS. 2009;62(9):1210–4.
15. Carpaneda CA, Ribeiro MT. Study of the histologic alterations and viability of the adipose
graft in humans. Aesthet Plast Surg. 1993;17(1):43–7.
16. Khouri RK Jr, Khouri RE, Lujan-Hernandez JR, Khouri KR, Lancerotto L, Orgill DP.Diffusion
and perfusion: the keys to fat grafting. Plast Reconstr Surg Glob Open. 2014;2(9):e220.
17. Toledo LS.Gluteal augmentation with fat grafting: the Brazilian buttock technique: 30 years’
experience. Clin Plast Surg. 2015;42(2):253–61.
18. Rosique RG. Gluteal contouring—global perspectives: South America. ISAPS Newslett.
2017;11(1):27–8. https://www.isaps.org/wp- content/uploads/2017/10/ISAPS- News- 11.1.pdf
19. Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med.
2010;16(5):448–52.
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20. Iorio ML, Venturi ML, Davison SP.Practical guidelines for venous thromboembolism chemoprophylaxis in elective plastic surgery. Plast Reconstr Surg. 2015;135(2):413–23.
21. Hartman JT, Pugh JL, Smith RD, Robertson WW Jr, Yost RP, Janssen HF.Cyclic sequential
compression of the lower limb in prevention of deep venous thrombosis. J Bone Jt Surg Am.
1982;64(7):1059–62.
22. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph MA, Austen WG Jr. The effect
of pressure and shear on autologous fat grafting. Plast Reconstr Surg. 2013;131(5):1125–36.
23. Pereira LH, Radwanski HN.Fat grafting of the buttocks and lower limbs. Aesthet Plast Surg.
1996;20(5):409–16.
24. Rosique RG, Rosique MJ, De Moraes CG.Gluteoplasty with autologous fat tissue: experience
with 106 consecutive cases. Plast Reconstr Surg. 2015;135(5):1381–9.
25. Rosique RG, Rosique MJ.Deaths caused by gluteal lipoinjection: what are we doing wrong?
Plast Reconstr Surg. 2016;137(3):641e–2e.
26. Shah B.Complications in gluteal augmentation. Clin Plast Surg. 2018;45(2):179–86.
R. G. Rosique and M. J. F. Rosique
Chapter 13
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Preferred Surgical Techniques inFat
Transplant totheGluteal Region
AlexanderAslani andMiguelG.Bravo
Gluteal fat augmentation has attracted a considerable demand in the past several
years. Fat grafting is a predictable and practical approach to modify the gluteal area.
Nevertheless, this procedure has many potential risks. It is imperative to avoid gluteal vessel damage, which can lead to fat embolism and other severe complications.
Since many people are increasingly choosing to undertake fat grafting procedures,
more plastic surgeons are attracted to this eld, improving the surgical techniques
to achieve better outcomes. The greater amount of surgeons embarking on this,
however, will also increase the risk of poor technique and fatal outcomes.
If the surgeon uses the right technique and the patient complies with perioperative protocols, gluteal fat augmentation can be safe, effective, and consistent in the
outcome. This chapter aims to explore the different techniques used in fat transplant
to the gluteal region.
No liposuction technique is perfect and universally superior to all others.
We favor a variation of power-assisted liposuction, namely, the SAFE-technique
(fat Separation, fat Aspiration and Fat Equalization) approach used as described by
Wall Jr and Lee [1]. To our opinion, it offers the best risk-benet ratio, and importantly it achieves a signicant amount of fat separation without the use of any
energy-based device, which is a notorious source of problems. SAFE liposuction is
also highly compatible with EVL (expansion vibration lipolling) as described by
Del Vecchio. A closed suction/inltration system saves valuable surgery time. We
prefer to abstain from any extensive manipulation of the harvested fat apart from
decantation.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 13802- 7_13.
A. Aslani (*) · M. G. Bravo
Cirumed Clinic Marbella, Marbella, Spain
e-mail: aaslani@cirumed.es
© 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_13
197
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A. Aslani and M. G. Bravo
The next step involves transferring the fat to the gluteal area with concurrent
power-aided tunnelization and vibration and continuous owstream fat-inltration
at 200–300mL/min. Learning curve and key to success here is to nd the perfect
balance between tissue separation and inltration. Excessive separation can lead to
fat blow-out or fat cysts and too little fails to sufciently separate the recipient bed
(Fig.13.1).
Power-assisted gluteal augmentation best suits patients with at buttocks and
moderate or mild excess fat. This method improves tissue competency for transferring large volumes of fat reducing the duration of the surgery and therefore increasing patient safety.
Gluteal augmentation entails a synergistic approach that enables the removal of
excess fat from regions around the buttocks and transplanting the same to regions
with insufcient fat. The resulting buttocks’ frame depends on the sculpting of the
lateral anks, the abdomen and upper back in order to achieve a narrow waistline.
Even when some of the fat injected into the gluteal area is reabsorbed after some
time, sculpting of the areas surrounding the buttocks provides attractive gluteal
appearance in the long term [2].
Expansion vibration lipolling is our preferred surgical technique to transfer the
fat to the gluteal region. Del Vecchio and Wall described in [3] how expansion
vibration lipolling prepares the recipient site by separating the tissue creating
space for the grafts. It combines rapid oscillations at 500/min angled cannulas, fast
ow rates, and bigger diameters, which result in more thorough and extensive distribution of the fat in the recipient area. The use of an exploding-tip cannula (4mm)
allows transfer of fat into the expanded area concurrently while expanding the subcutaneous tissue. Unlike in classic syringe-lipolling where the fat might be excessive in some areas creating bumps or skin blow-outs [4, 5] oscillations allow the
surgeon to distribute fat lobules homogeneously. The main overall advantage is control. The tip of a syringe is prone to bending, even without Luer-Lock connection,
and bending means loss of palpatory control (Fig.13.2).
Fig. 13.1 Preinltration
ultrasound mapping to
determine thickness of
subcutaneous buttock
tissues measuring different
tissue thickness
13 Preferred Surgical Techniques inFat Transplant totheGluteal Region
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Fig. 13.2 Hip expansion
fatgrafting to lateral
trochanteric
depression area
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13.1 Operative Technique
We typically start a body feminization procedure with 360° liposuction in a supine
position. Incisions are typically placed in the “bikini line” and the umbilicus. This
is followed by liposuction in the lateral decubitus, and nally in the prone position.
Whether we use four different positions or just prone/supine is case-dependent, the
main parameter for our decision making is the pelvic bone. If the patient has a high
and square pelvic bone shape, the lateral decubitus may be useful to avoid skeletonizing the iliac crest (Fig.13.3).
For tumescent inltration and separation we use 4 or 5mm exploding tip cannulas at 5000 oscillations/min. We use full aspiration pressure of approximately
450mmHg for fat harvest and have not found this to be in any way detrimental to
fat graft survival. The fat graft is prepared employing decantation in a 3000 or
5000cc canister. Importantly, the canister is connected with a rigid tube to a vibrating handpiece armed with a 4mm slim cage basket cannula. For inltration, we
bring the patient’s hips into approximately 30° of exion. We favour fat inltration
from three key incisions per side: (1) from the center point of the infragluteal fold,
(2) from the apex of the gluteal cleft, and (3) from slightly below the level of the
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