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H. Durán
Images 15.1–15.2 Case Lipocontour HD
15 The Lipocontour Technique
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15.2.3 Fat Inltration intheButtock
Once fat is obtained, it is collected in closed canisters where it is decanted: if the calculated volume for inltration is less than 500cc per buttock and hip, then, we generally
use 60-mL Toomey syringes in a single-ported Tulip® cannula. However, if the calculated volume is greater than 500cc per buttock, then we use the Del Vecchio EVL technique [7]. With Lipocontour, gluteal inltration is performed subcutaneously and never
in the muscle [8]. We start the fat inltration in the deep subcutaneous space (between
fascia supercialis and the major gluteus muscle) from the center of the projection to the
periphery. Once it is full, we direct the inltration to the supercial subcutaneous space
(between the skin and the fascia supercialis) in only a small amount in the center to
generate projection. But be aware: if the amount of fat is higher than indicated it will be
lled in such a way that it forms a hardened plate that is not very malleable and will
detract the roundness of the gluteal contour, being counterproductive for aesthetics. To
improve it, one can use the Microaire with a basket cannula, to equalize and distribute
this fat, but this increases the risk of a blowout lesion (Images 15.3 and 15.4).
Images 15.3–15.4 Case Lipocontour HD
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H. Durán
Images 15.3–15.4 (continued)
We must consider that the buttock has the shape of a “p” or a “q” more than an
“o” due to insertion into the iliotibial tract of the gluteus maximus (Fig. 15.2).
Therefore, if there’s a lack of volume in the inferolateral area of the buttock, to
achieve more anatomical inltration and provide more support, we place the fat as
inltration pillars, which also yields a better relationship between the buttock and
the thigh [9]. The hip is inltrated in the lateral position to identify the effect generated by the fat in the contour and to provide the greatest expansion at the transverse
line extending from trochanter to trochanter. The buttock can be inltrated through
the superior gluteal mid-incision, although inltration can also be performed
through the infragluteal fold. An angulated cannula can be used to easily enter the
supercial space. Once the fat has inltrated, any PAL device can be used to equalize (distribute) the inltrated fat (Images 15.5 and 15.6).
At the end of the procedure, we insert closed drains to monitor bleeding. We
cover the patient with forced-air blankets and only applied cotton bandages. In the
immediate postoperative period, we administer analgesics such as parecoxib or
15 The Lipocontour Technique
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Fig. 15.2 The gluteus
maximus shape is a p (left
buttock) or a q (right
buttock) because a
extension reaching for the
iliotibial tract and
trochanter
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Images 15.5–15.6 Case Lipocontour SD
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H. Durán
Images 15.5–15.6 (continued)
tramadol. Sometimes tranexamic acid [10] is prescribed orally for 3days if heavy
bleeding occurs during the rst 8h. Most patients can leave the hospital 4–6h after
the procedure with oral analgesics and antibiotics. In the rst week, we never use
pressure garments (only cotton bandages) because they can exert pressure and cause
fat necrosis, and placing a compressive girdle is uncomfortable and painful in the
rst days after surgery.
15.3 Results
From 2014 to 2019, we completed a total of 210 liposuction procedures in women.
All patients underwent Lipocontour marking preoperatively and were surgically
treated by the author. The marking protocol has changed according to the learning
15 The Lipocontour Technique
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227
curve and successful or unsuccessful experiences, but since 2018, the marking protocol has been minimally modied. The average age of the patients was 33.9years,
the average weight was 63.77 kilos, the average height was 1.58 m, and the average
body mass index was 25.3kg/m2. A total of 71 patients received regional anesthesia,
and 139 patients received general anesthesia. The average operative time when
Lipocontour did not require additional procedures was 2h and 11min. The average
volume of fat extracted with liposuction was 3L and 113mL.The average volume
of inltrated fat was 590cc per side for a total of 1180mL of fat inltrated in the
buttock and the hip of each patient. A total of 138 (66%) smooth-denition
Lipocontour surgeries and 72 (34%) high-denition Lipocontour surgeries were
performed. No patient was lost to follow-up, and the maximum follow-up was
6years.
These were the complications of the procedure: three patients (1.6%) required
readmission due to bleeding; one patient did not receive a blood transfusion while
two patients required blood transfusions from a single globular bundle (Clavien
Dindo Grade II) [11]. Five seromas (2.6%) (Clavien Dido GI) were managed conservatively and did not require drainage, and no fat necrosis, infection, MIFE/
MAFE [11] or a single death was recorded. Overall, 97% of the patients were managed as outpatients. Only ve patients were hospitalized, including one patient who
was hospitalized for pain management, two patients who were hospitalized for
bleeding monitoring, and two patients who were hospitalized at their request for
more comfort (Images 15.7 and 15.8).
On a scale of patient satisfaction, (result on a questionnaire 3months after surgery) 85.6% of patients mentioned being satised or completely satised with the
result, and 5.7% reported dissatisfaction with no answer in 8.5%. Two of these
Image 15.7 Lipocontour
front
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Image 15.8 Lipocontour
back
H. Durán
patients required repeat treatment after 6 months due to dissatisfaction with the
result, which was mainly related to bulging remnants in the hypogastric area (this
was in the rst 50 cases), indicating to be more aggressive in this area and remove
the largest volume at this site. After this change, none of the patient experimented
insatisfaction. Among these patients, none required reoperation. The maximum
follow-up of the patients was 6years, and the minimum follow-up was 6months.
15.4 Discussion
This is a marking technique for liposuction and safe buttock inltration called
Lipocontour, to guide the surgery. This technique involves standardized marking,
which guides the surgeon, achieving satisfactory results in 85.6% of patients. Its
needs a short learning curve, but it can be easily adopted.
The main advantage of Lipocontour is that the markings serve as a guide for the
surgeon to perform the procedure and maintain the planned objectives during surgery. We believe that this option is necessary because no standardized marking protocol has been established for liposuction. The only publication on marking found
in the literature is a 2002 article by Chang [12] that describes grid marking. However,
we did not nd any other article referring to standardization of body marking as a
guide for liposuction. We have generally observed that most surgeons mark the
midline where an excessive fat volume is typically observed using concentric circles
for identication. However, this strategy is disadvantageous because it is based
more on excess fat volume rather than on the areas that should not be treated and
does not consider the underlying anatomical structures.
The Lipocontour technique was developed based on anatomical landmarks corresponding to the surface anatomy to produce a common marking map of contours
and appropriate silhouettes. The markings mainly indicate to the surgeon where fat
aspiration or inltration should be performed in relation to the underlying anatomy
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to achieve a more natural result with satisfactory body ratios. Moreover, the technique provides the surgeon with the freedom to adjust the dimensions of his patient
according to expectations.
The lines marked on the anterior abdomen correspond to the midline, the linea
alba, and the ratio between the abdomen and the upper (rib cage) and lower (inguinal region) limits, which are framed by the lateral oblique muscles. In the lateral
region [13], the markings facilitate continuity between anterior and posterior liposuction, emphasizing the region at the 12th rib where an adherence zone is located,
which is where the main reduction of the entire torso is performed. The markings
also identify the trochanters or the Cuenca-Guerra point [14], which denote where
the widest area should be to maintain a 0.6–0.7 waist–hip ratio [3], providing visual
feedback at all times. The technique strategically locates the incision sites to control
the dimensions of the body, identies the framework according to the types described
by Mendieta [15], and provides a simpler view by delineating the areas to be treated
while also identifying the quadrants and areas that should be expanded the most in
the anteroposterior plane in the buttock and laterally. On the back, the midline is
traced to identify asymmetries from side to side. The division of the buttock into
two vertical quadrants establishes an anatomical limit of the infragluteal fold. If the
fold extends beyond this line laterally, then the fold is not considered aesthetic and
should be improved. The best technique for such improvement usually involves fat
inltration vertically or in pillars. This inltration method achieves three effects: (1)
shortening of the infragluteal fold, (2) buttock support, and (3) volume addition to
the thigh to minimize any disparity in the ratio [9].
The next challenges related to this technique are teaching it to other surgeons,
detailing the technical differences between the smooth-denition and high- denition
methods.
15.5 Conclusions
This preliminary report shows that Lipocontour, a liposculpture technique involving
a standardized marking protocol, is perfectly adapted to the aesthetic standards previously established in other references, although the technique is not intended to
replace any former techniques. Thus, surgeons who wish to use Lipocontour can
easily adapt to it because the technique is based on anatomical landmarks related to
the surface anatomy, which also provides exibility by ensuring that the technique
can be used in any patient regardless of their features. The markings cover the entire
trunk and buttock on the front, back, and sides of the body. In buttock, Lipocontour
helps the surgeon to perform gluteal inltration in an organized and consistent manner. The main advantage of Lipocontour is the markings indicate the areas with
excess fat volumes and fat-decient areas in a simple manner to guide plastic surgeons to a straightforward intraoperative decision-making.
Disclosure/Conict of Interest Statement The author has no conict of interest or disclosures.
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H. Durán
References
1. Castro CC, Cupello AMB.Liposuction—personal approach around 120 cases. Plast Reconstr
Surg. 1990;85(2):325.
2. Mendieta CG.Classication system for gluteal evaluation. Clin Plast Surg. 2006;33(3):333–46.
3. Singh D.Adaptive signicance of female physical attractiveness: role of waist-to-hip ratio. J
Pers Soc Psychol. 1993;65(2):293–307. https://doi.org/10.1037/0022- 3514.65.2.293.
4. Dixit VV, Wagh MS.Unfavourable outcomes of liposuction and their management. Indian J
Plast Surg. 2013;46(2):377–92. https://doi.org/10.4103/0970- 0358.118617.
5. https://www.equator- network.org/reporting- guidelines/preferred- reporting- of- case- series- in-
surgery- the- process- guidelines/. Accessed 20 Aug 2019.
6. Wall SHJ, Lee MR.Separation, aspiration, and fat equalization: SAFE liposuction concepts for
comprehensive body contouring. Plast Reconstr Surg. 2016;138(6):1192–201.
7. Del Vecchio D, Wall S.Expansion vibration lipolling: a new technique in large-volume fat
transplantation. Plast Reconstr Surg. 2018;141(5):639e–49e.
8. Del Vecchio DA, Villanueva NL, Mohan R, Johnson B, Wan D, Venkataram A, Rohrich
RJ. Clinical implications of gluteal fat graft migration: a dynamic anatomical study. Plast
Reconstr Surg. 2018;142(5):1180–92.
9. Vartanian E, Gould DJ, Hammoudeh ZS, Azadgoli B, Stevens WG, Macias LH.The ideal
thigh: a crowdsourcing-based assessment of ideal thigh aesthetic and implications for gluteal
fat grafting. Aesthet Surg J. 2018;38(8):861–9.
10. Cansancao AL, Condé-Green A, David JA, Cansancao B, Vidigal RA.Use of tranexamic acid
to reduce blood loss in liposuction. Plast Reconstr Surg. 2018;141(5):1132–5.
11. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classication of surgical
complications: 5-year experience. Ann Surg. 2009;250(2):187–96.
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2004;114(5):1292–7. https://doi.org/10.1097/01.PRS.0000135908.46918.36.
13. Hoyos AE, Perez ME, Castillo L. Dynamic denition mini-lipoabdominoplasty combining multilayer liposculpture, fat grafting, and muscular plication. Aesthet Surg
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14. Cuenca-Guerra R, Quezada J.What makes buttocks beautiful? A review and classication of
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15. Mendieta CG.The art of gluteal sculpting. St Louis: Quality Medical Publisher; 2011.
Chapter 16
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Buttocks Dynamic Denition (HD2)
Liposuction: for Adipose Harvesting
and Grafting
AlfredoHoyos andMauricioPerez
16.1 Background
The gluteal region has been historically associated with healthiness and couple mating while considered one of the most appealing features of the human body for both
men and women.
Its shape and best projection can be perceived in the standing position and during
bipedal locomotion. The glutes are dynamic and change their shape depending on
age, gender, weight, and lifestyle. They are not only responsible for the leg movement, but also play an important erotic issue as a secondary sexual erogenous area,
the concept of its ideal contour changes among different ethnicities and time.
As new lipoplasty techniques evolved in body contouring surgery, the gluteal
region was rapidly included, and fat modeling enhanced its overall shape. However,
the lack of projection was a concern that only got overpassed with the introduction
of implants and/or fat grafting. Since then, multiple approaches for female buttock
contour enhancement were described, though the male gluteal aesthetics were left
somehow behind. In fact, the male patient was subject to liposculpture procedures
based on female premises, which in turn derived in suboptimal results. So recently,
we reported our experience on the male aesthetics for the gluteal region, by describing some different anatomic perspectives: the contour is squared rather than round;
fat deposits are not predominant; and the musculature projects two different bulges
that in the antero-posterior view results in a buttery shape (Fig.16.1).
Current gluteal contouring treatments include the use of implants, autologous fat
transfer, excisional procedures, autologous gluteal augmentation with tissue aps
and liposuction. Implants have a considerable higher rate of complications
A. Hoyos (*)
Bogotá, Colombia
M. Perez
Rochester, MN, USA
© 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_16
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