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Chapter 18
Overcoming Fear inGluteal Surgery
PauloGodoy
18.1 Introduction
Fear is an organism’s response to a threatening situation.
This feeling is also linked to the anxiety generated by the mental anticipation of
the danger to be faced. Despite serving the survival of the species, excessive fear
paralyzes the person and prevents from evolving.
Fear is part of people’s life. Some people do not know how to face it, others learn
to live with it and see it not as a negative thing, but as a feeling of
self-preservation.
Fear is often caused by negative experiences or it is heightened by a lack of
knowledge on a particular subject.
In medicine, and, with special relevance, in esthetic plastic surgery, fear also
plays a benecial role, preventing adventurous surgeons and those who do not have
the necessary experience in a particular area of activity from causing iatrogenic
sequel, and harm to patients [1].
During the development of gluteal surgery, there were several reports of compli-
cations, which discouraged many surgeons from performing this procedure. Above
all, there is a greater fear when it comes to the management of silicone implants for
gluteus augmentation. For some reason, plastic surgeons who are starting to operate
gluteus with implants, tend to compare this procedure to breast augmentation.
Although the two procedures involve the use of silicone implants, the organs, tissue
dynamics, techniques, and the silicone implant itself are totally different.
This improper comparison leads many surgeons to underestimate the technical
difculty of gluteoplasty with implants. As a consequence, surgeons not used to
P. Godoy (*)
Private practice, São Paulo, Brazil
e-mail: paulo@paulogodoy.com.br
© 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_18
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P. Go doy
gluteal anatomy, and unfamiliar with techniques tend to generate complications.
Thus, discouragement and disinterest in performing this procedure increase.
Overcoming fear in gluteal surgery requires the acquisition of theoretical and
practical information in order to minimize complications and make the procedure safer.
The surgeon who is interested in expanding his knowledge in this particular eld
should return to cadaveric studies and look for some of the hands-on courses offered
around the world.
For many surgeons, the peculiar anatomy of the gluteal region is not a routine
eld of study.
In addition to the anatomical variations of the different types of pelvic girdle,
attention should be paid to muscle dynamics and the interactions between implants
and surrounding tissues.
The introduction of implants in the intramuscular plane of the gluteus maximus
requires knowledge of this unique anatomy [2].
At its origin in the sacrum and sacrum tuberal ligament, the gluteus maximus
muscle is thinner and tends to thicken as it progresses to its central region, becoming thinner again until its insertion into the gluteal tuberosity of the femur and condylum. Lateral of tibia.
During preoperative planning, it should be kept in mind that the implant needs to
be strategically placed in the thickest part of the muscle. However, as there is a
thickness variation along the muscle extension, an over-dissection of the pocket
plane can lead the implant to a lateral displacement and, consequently, a lateral
herniation [3].
In order to empower surgeons and encourage them to evolve in the eld of glu-
teal augmentation through a didactic sequence of events, we sought to enumerate
the main steps to minimize complications in gluteal surgeries and consequently
reduce any fears for performing this procedure.
18.2 Preoperative Marking
The entire preoperative marking is based on one reference point: the ischial tuberosity [4]. With the patient in the ventral decubitus position, the ischial tuberosity is
easily identied as a large protuberance posteriorly on the superior ramus of the
ischium. It is the most projected bone part that can be found during the palpation of
the gluteal region.
One medial line is drawn on the intergluteal cleft (line A). Next, two lines, one
from each side, are drawn parallel at a distance of 4cm to the medial line (lines B).
One horizontal line is drawn from one ischial tuberosity to the other, on the contralateral side (line C). The identication of the correct localization of the ischial tuberosity is primordial since it is going to be the inferior limit of the pocket plane
dissection. The superior and lateral limits of the pocket plane dissection are established by the imprinting of the implant on the gluteal skin: an anatomic implant is
18 Overcoming Fear inGluteal Surgery
placed with its widest part touching the horizontal line (line C), and the medial part
of the implant touching the line B.
The superior limit of the dissection is determined by the superior edge of the
implant, as well as the lateral limit which is also determined by the lateral portion
of the implant.
The advantage of using the implant dimensions to determine the limits of pocket
design allows a safe and precise plane dissection and avoids an over undermining of
the plane. This maneuver aims to obtain a tight pocket that keeps the implant in denite position and prevents its rotation or mal position.
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18.3 Patient Positioning andAntisepsis
A 12cm high silicone cushion is positioned below the patient, in the iliac crests.
The purpose of this positioning is to keep the maximum gluteal muscle horizontal
and facilitate its access.
As it is close to the anal region, the gluteus is an area with an increased potential
for the risk of infection therefore strict antisepsis is paramount. It is recommended
to start with a brushing of the skin with chlorhexidine degerming soap solution followed by rinsing with alcoholic chlorhexidine solution.
18.4 Anal Isolation
One of the biggest concerns of the surgeon who starts performing gluteal surgery is
the increased potential for infections. It is known that the anal region is a highly
infectious risk area. For this reason, in addition to a previous cleaning with chlorhexidine solution, physical isolation of the region is essential.
The anal isolation is initiated with the introduction of a 4 × 3cm transparent lm
adhesive dressing placed directly over the anus.
Next, a rolled surgical compress is xed with 5 stitches on the skin: 1 superiorly
and 2 on each side. The main function of xing the compress to the skin is to prevent
it from dislocating during the insertion of the implant or inadvertently being used in
surgery. Above the compress, another adhesive bandage is positioned to cover, protect, and isolate the entire anal area.
18.5 Incision
The incisions are planned in parallel lines bilaterally, each one distancing 0.5cm
from the midline of the intergluteal cleft. The length of the incisions varies from 4
to 7cm according to the distance between the upper border of the anus and the
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upper limit of the intergluteal crease. In addition to facilitating the inclusion of the
silicone implant in the gluteus, the use of a double incision helps the preservation of
the sacrocutaneous ligament and, consequently, minimizes the chances of wound
local dehiscence. The difcult management of dehiscence is one of the factors that
discourage surgeons from performing gluteoplasty with implants. Mastering
maneuvers that aim the minimization of potential dehiscences are essential to overcome fear in performing these procedures.
An improvement in the quality and enlargement of the two incisions was observed
when compared to a single incision over time. With two incisions there is no need
for resection of a skin island as recommended by other authors. With a single incision, once the implants are placed, the tension on the incision may increase, and if
the skin island is resected, the tension on the scar tends to be higher and lead to
dehiscence.
P. Go doy
18.6 Precise Subcutaneous Tunnel Dissection
As previously demonstrated by Serra e col., a supra-fascial dissection tunnel should
be kept to a minimum, sufcient to include the implant in the intramuscular plane.
The 5 × 2cm dissection tunnel, when compared with a 6 × 6cm one, proved to be
large enough for implant inclusion without difculties. The group that used a smaller
dissection tunnel also showed lower rates of dehiscence and complications.
18.7 Tight Intramuscular Pocket
The dissection of the intramuscular plane must obey the precise limits of the implant.
The implant, once inserted in the correct anatomical plane, must remain precisely
accommodated in the created pocket. Excessive dissection of the intramuscular
plane can facilitate displacement, rotation, or malpositioning of the implant, culminating in an unsightly appearance over time.
To avoid an over displacement of the intramuscular plane, it is mandatory to
restrict the dissection of the plane according to the preoperative marking.
Sizers with the correct dimensions of the implant or the implant itself are used to
mark the skin and determine the precise limits for dissecting the implant site.
18.8 Rapid Muscle Incision Synthesis
A common fear in performing gluteoplasty is complications related to muscle synthesis. With the implant introduced in the intramuscular plane, the application of
sutures to close the muscle incision may inadvertently cause perforation of the
implant shell by the needle. One option to avoid this complication is to perform a
18 Overcoming Fear inGluteal Surgery
running suture to close the muscle incision before including the implant. However,
this suture is made without its traction, keeping its tension loose. In this way, the
implant can be inserted between the suture wefts and, after its inclusion, a simple
traction of the suture can quickly close the muscle incision.
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18.9 Inclusion Film Funnels
Compared to the breast implant, the introduction of the gluteus implant is more
challenging. The use of facilitating devices for the inclusion of implants is very
benecial in gluteal surgery. They facilitate the introduction of the implant even
with smaller incisions and decrease the contact of the implant with the skin. One
popular option is the lm funnel. Film funnel is a shaped sleeve constructed of a
exible, polymeric lm and has a lubricious hydrophilic coating on the inside surface. It is intended to assist the delivery of silicone gel implants by providing a
shell-tissue interface with less friction during insertion of the implant.
18.10 Protective Supercial Fat Layer Flap
In addition to the aforementioned feared wound dehiscence, one of the factors of
concern is certainly the exposure and extrusion of the implant. In order to prevent
and maintain a greater layer of protection, we propose a ap of the supercial fat
layer of the gluteal subcutaneous layer.
Supercial to the gluteus maximus muscle, ve different layers are consistently
identied in both male and female: dermis, supercial fat (fatty layer between dermis and supercial fascia), supercial fascia, deep fat (fatty layer between supercial fascia and deep fascia), deep fascia (the investing fascia of the gluteus maximus
muscles).
The main idea for this ap is to release the supercial layer of fat from the dermis
and supercial fascia.
This layer is then rotated and xed anteriorly and deeply in the fascia of the glu-
teus maximus muscle.
This ensures an anterior layer of protection. Thus, in the event of wound dehis-
cence, the implant is kept protected. The same occurs in the other direction: if there
is a rupture of the muscle’s sutures, the implant does not tend to come out and externalize through the subcutaneous tissue.
18.11 Tapping
In the immediate postoperative period, a topical adhesive that provides resistance to
maintain the integrity of the barrier and wound closure is applied over the skin
suture. In order to limit movement and maintain a stable implant position in the rst
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P. Go doy
days after surgery, an elastic cotton and rayon bandage with permeable rubber adhesive is applied in horizontal parallel bands over the entire gluteal surface. This bandage remains during the rst 5 days after surgery, its prolonged use should be
avoided due to the possibility of blisters and erythema on the skin.
After removing this bandage, kinesio tapes are applied directly to the gluteal
skin. The strips are arranged in a “C” shape as a frame around the implant in order
to optimize muscle support and limit the movement of the implants.
18.12 Postoperative Management
The postoperative analgesic control is performed with the administration of 30mg
of codeine every 8h for 7days. The muscle relaxant carisoprodol is associated for
5 days. Antibiotic coverage is achieved with cefadroxil 500 mg every 12 h for
7days, a jet rifocin spray is splashed daily on the scar after cleaning.
Patients are encouraged to sit from the rst postoperative day; however, they use
pillows below their thighs thus avoiding pressure directly on the implants. Squat
muscle exercises are postponed for 3months to avoid potential misplacement of the
implant.
18.13 Conclusion
Overcoming fear is achieved through the acquisition of knowledge, security, and
good experiences. The popularization of gluteoplasty in the world, especially in
Latin American countries, and medical education focused on this subject, contributed to the dissemination of knowledge and reduction of complications. The didactic segmentation in 11 steps facilitates the performance of this procedure in a
reproducible and safe way.
References
1. Cárdenas-Camarena L, Gerardo LPA, Durán H, Bayter-Marin JE. Strategies for reducing fatal
complications in liposuction. Plastic and reconstructive surgery Global open. 5(10).
2. Durán-Vega HC. Composite gluteal augmentation: implant+ fat grafting: getting the best of
both worlds. Gluteal Fat Augmentation: best practices in Brazilian butt lift. 175–9.
3. Frank K, Casabona G, Gotkin RH, Kaye KO, Lorenc PZ, Schenck TL. Inuence of age, sex,
and body mass index on the thickness of the gluteal subcutaneous fat: implications for safe
buttock augmentation procedures. Plast Reconstr Surg. 144(1):83–92.
4. Cárdenas-Camarena L, Durán H. Improvement of the gluteal contour: modern concepts with
systematized lipoinjection. Clin Plast Surg. 45(2):237–47.
Chapter 19
Anatomical Implants
PatricioCovarrubias
19.1 Introduction
When deciding to perform a gluteal augmentation surgery with implants, we have
different alternatives in terms of surgical techniques, dissection planes, and also the
type of implant to be placed, in this case, round and anatomical implants [1–3].
In this Chap. 1 describe the characteristics of the latter, as well as its advantages
and disadvantages.
19.2 Characteristics oftheImplants
Among the characteristics of this type of implants are:
19.2.1 Material
There are cohesive gel and silicone elastomer implants [4–6]. Behavior of both
could inuence the different rates of complications associated with the use of these
implants described in the literature [7], as well as their visualization and palpation,
especially with the gluteus in movement.
P. Covarrubias (*)
Clínica Dr. Covarrubias, Santiago, Chile
e-mail: patricio@drcovarrubias.cl
© 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_19
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19.2.2 Surfaces
There are smooth, nanotextured, microtextured, and macrotextured implants on the
market. The use of macrotextured implants is associated with a higher incidence of
periprosthetic seroma as well as some anecdotal cases of Anaplastic Giant Cell
Lymphoma [8–10]. Today the use of microtextured, smooth, or nanosurface implants
is preferred.
19.2.3 Base andProjection
The main characteristic of this type of implant is the asymmetrical base, with one
side wider than the contralateral side [11]. They also have at least two different
projections for each base measurement, which ultimately translates into the different volumes to be placed.
This feature of the implant makes it more versatile in relation to where to locate
the maximum projection (up, down, or lateral) depending on what is sought in each
patient; but it is also the main problem if the pocket is not designed properly, or an
implant wider than the base of the buttock is chosen, as we will see later.
To be more sure that the direction in which the implant is placed is correct, the
different commercial companies place both visual (which can be radiopaque) and
palpable position markers, to verify the correct position of the implant before closure (Figs.19.1, 19.2, 19.3 and 19.4).
19 Anatomical Implants
273
Figs. 19.1–19.4 Anatomical implant features: asymmetrical base, increased projection on the
widest side, and position markers
19.3 How toChoose theRight Implant?
Depending on the technique to be used (subfascial, intramuscular, or submuscular)
we choose the implant in relation to the base of the gluteal muscle. This implant is
not suitable for use in those buttocks whose width–height ratio is very similar (buttocks with a more square frame), but if they have a good indication in which the
shape is more elongated.
Once the base has been measured, we proceed to look for an implant that does
not exceed these measurements and, depending on the result sought, we proceed to
choose the appropriate projection.
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19.4 Implant Position
Since the implant is asymmetric, it allows us to place the maximum projection
where we need it most, that is, in the upper, lower, or even somewhat lateralized
portion. Most of the cases correspond to the posterior projection of the pubis,
although it must be dened on a case-by-case basis. Personally, I leave the maximum projection in the upper part in patients with a atter posterior pelvis, also in
patients who want that hyper-projected area or in patients who need a gluteal pexy
associated with implants. In cases where the patient has a more curved pelvis or
wants a more natural result, I leave the maximum downward projection. In cases
where some projection is sought on the hips, the widest part can be left a little to the
side to achieve this effect (Figs.19.5 and 19.6).
Fig. 19.5 Position marker
that is displayed before
closing the wound
Fig. 19.6 Implant versatility: implant positioning with greater projection in the superior portion
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