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19 Anatomical Implants
275
19.5 Postoperative Care
In the immediate postoperative period, it is necessary to leave tapes that compress
the implant at its edges to prevent its mobilization and that with its pressure the
pocket is not oversized, thus avoiding the main complication that is its rotation. I
recommend using this for at least a month.
The rest of the care of both the wound and the implant do not differ from any
gluteal augmentation surgery with an implant.
19.6 Advantages oftheAnatomical Implant
The advantages of it are:
– Allows a lling more in line with the space and shape of the gluteus maximus
when it is asymmetrical at its base.
– It is more versatile since, depending on the position in which it is placed, it
allows greater projection in the upper part of the gluteus, or in the lower part it
even allows some projection in the hips (Figs.19.7, 19.8, 19.9 and 19.10).
19.6.1 Disadvantages
– The main disadvantage is the possibility of rotation of the same.
– In case of rotation, the only way to solve it is with a new surgery to repair the
pocket, change the implant plane, or remove them.
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Figs. 19.7–19.10 Pre- and postoperative of anatomical implants
19 Anatomical Implants
277
19.7 Implant Rotation: Its Main Complication
Clinically there is palpable and visible gluteal asymmetry, especially on movement
or when bending forward. Many times patients report that the implant moves and
that they reposition it manually. The diagnosis is conrmed with MRI (Fig.19.11).
Causes of implant rotation are:
– Wrong choice of implant: When choosing implants that exceed the previously
established diameter or with excessive volume.
– Overdissection of the pocket: When dissecting a very wide pocket, it leaves room
for the implant to move and this allows it to be totally or partially rotated. This
effect is seen especially when moving or bending over, being a very annoying
problem for the patient.
– Pressure of the implant on the already dissected pocket: This occurs due to lack
of adequate rest in the immediate postoperative period in which the patient supports the implant and it presses the edges of the pocket, overdissecting it and
giving it room to rotate.
– Appearance of undiagnosed or unresolved seroma in the early or late postopera-
tive period.
The only way to treat this complication is a new intervention with pocket
adjustment, plane change, or implant removal as discussed in another chapter of
this book.
Fig. 19.11 Anatomical
implant rotation
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References
1. Robles J, Taglipietra J, Grandi M.Gluteoplastia de aumento: implante submuscular. Cir Plast
Iberolatinoamericana. 1984;102:4.
2. De La Pena JA, Lopez-Momjardin H, Gamboa LF.Aumentation gluteoplasty: anatomical and
clinical considerations. Plast Cosmet Surg. 2000;17:1–12.
3. Vergara R.Gluteal augmentation with silicone implants: a new proposal for intramuscular dissection. Aesthetic Plast Surg. 2017;41(4):872–7.
4. Horn G.Gluteoplasty with intramuscular silicone cohesive gel implants: a retrospective study
of 50 cases. Ann Chirurg Plast Estet. 2009;54:467–76.
5. Senderoff DB. Buttock augmentation with solid silicone implants. Aesthet Surg
J. 2011;31(3):270–7.
6. Aboudib JH, Serra F, Cardoso C. Gluteal augmentation: technique, indications, and implant
selection. Plast Reconstr Surg. 2012;130(4):933–5.
7. Sinno S, et al. Determining the safety and efcacy of gluteal augmentation: a systematic
review of outcomes and complication. Plast Reconstr Surg. 2016;137(4):1151–6.
8. Piubelli MLM, Ferruno-Schmidt MC, Miranda RN.Gluteal implant-associated anaplastic
large cell lymphoma (ALCL) is distinct from systemic ALCL ALK negative in a patient with
gluteal implants. Aesthet Surg J. 2019;39(10):NP443.
9. Orr Shauly BS.The rst reported case of gluteal implant-associated anaplastic large cell lymphoma (ALCL). Aesthet Surg J. 2019;39(7):NP253–8.
10. Mendes J Jr, etal. Gluteal implant-associated anaplastic large cell lymphoma. Plast Reconstr
Surg. 2019;144(3):610–3.
11. Serra F, etal. Gluteoplasty: anatomic basis and technique. Aesthet Surg J. 2010;30(4):579–92.
Chapter 20
Round Implants forButtock andHip
Augmentation
GustavoGasparBlanco andBrendaBrisenoOrozco
20.1 Introduction
In this chapter we will discuss the importance of proper selection of the buttock
prosthesis for both men and women, as well as the preoperative individual marking
for the best results of our procedure.
The rst results of the placement of buttock prostheses, in which non-cohesive
silicone gel breast prostheses were used, back in the early 1970s, almost completely
discouraged plastic surgeons at that time. This was due to the catastrophic results
obtained, largely due to the poor knowledge of the surgical anatomy of this region
and the little or no experience in surgical management of implant placement in this
area. Furthermore, as if this were not enough for chaos, the subcutaneous dissection
plane that was used for many years came to cause severe buttock ptosis, asymmetries, capsular contractures, and implants visible through the skin. This practically
caused for this procedure to be abandoned and demonized by patients and by plastic
surgeons themselves a few years after its birth.
Buttock lipotransfer was rarely used and liposuction was in gestation. During my
training as a plastic surgeon resident in Mexico in the early 1990s, this surgery
remained almost a conventional prohibition due to the previous results, a taboo.
The chapters in plastic surgery texts at that time were very brief and only made
historical reference to buttock prostheses without showing any safe or proven technique. There was scarce bibliography and it was almost vetoed by the vast majority
of plastic surgeons. Those of us who ventured to work on this procedure had a learning curve that led to serious complications and poor results. That curve brought me
to a point where I also almost abandoned this procedure. And I am sure that many
of my colleagues who also perform this surgery, 1 day thought the same as me.
G. G. Blanco (*) · B. B. Orozco
Private practice, Mexicali, Mexico
e-mail: gustavo@drgaspar.com
© 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_20
279
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G. G. Blanco and B. B. Orozco
During this learning phase I used all possible planes and incisions for the placement of gluteal implants. Therefore, I can assure that in my practice of almost
30years, no plane, except the intramuscular one, justies the aesthetic placement of
buttock implants. Therefore, we can realize that this incipient surgery is increasingly
taking a more important role in our daily activities, particularly in patients who request
buttock augmentation with a small amount of adipose tissue to transfer to the buttocks.
20.2 Waist–Buttock–Thigh Triad
The female silhouette has been determined over time as a balance of the waist, buttock, and thigh ratio [1]. A narrow waist, with full and round buttocks, where the hip
is considered as part of the buttock. And a thick thigh conforms the waist–buttock–
thigh triad, whose proportion between these three elements will have to be adequate
in order to reach a universally accepted standard of aesthetic body contour.
To obtain from this triad the decrease in the female waist, there is liposuction with
various technologies today, giving us satisfactory results in the vast majority of
patients. And for the gluteal area, in the same way, today there is fat lipotransference
in the subcutaneous cellular plane and the placement of a buttock prosthesis in the
intramuscular plane of the gluteus maximus. Or the combination of these last two
procedures called hybrid surgery, as well as the use of vascularized fatty local aps
[2]. All of the above are relatively safe in appropriately selected patients. Here we will
only deal with augmentation with implants for the gluteal area or what I call buttock
implants. The reason for calling it buttock is because by increasing this anatomical
region we are not only emulating the anatomical shape of the gluteus maximus, which
is the most important muscle in the area due to its size and thickness. Rather, we are
giving volume to an entire area made up of other minor muscles that were already
mentioned in the anatomy chapter, as well as the variable presence of subcutaneous
fat, of the pelvic bone structure, which will give us in each individual a wide or brief
hip and very important also, of the quality of the skin that covers the entire region.
The buttock as we see it daily with our eyes, in any patient, is a set made up
mainly of muscle, dermal, bone, and fat mass [3]. In patients with aesthetically balanced buttocks, whether female or male, we nd a round buttock with a greater
amount of fat than muscle, even in athletic patients. That is why we can use signicant volumes of fat on the buttocks as this will improve their appearance, as long as
the technique used and the materials are adequate.
This is where many people without the necessary studies, taking advantage of
this favorable condition for the increase of the buttocks, get to use alloplastic materials, oils, or any other material with the catastrophic results for the inltrated area,
as well as for the health of the affected person.
In people who develop large muscle mass and little presence of fat as in bodybuilders, we can see through the skin a hypertrophied and triangular gluteus maximus muscle, with superior base from its origin in the iliac crest and sacrum to its
insertion in the femur.
20 Round Implants forButtock andHip Augmentation
281
All of the above is what precisely tells us about the importance of an ergonomic
implant, that is, that it has the characteristics to adapt in this case to the aesthetic
conditions of the buttock as a whole, not of a single muscle in particular, which in
the vast majority of cases is a round implant.
Seventy-ve percent of patients requesting a buttock prosthesis, also require hip
augmentation for a better aesthetic result of the waist, buttock, and thigh triad. In
other words, a patient may have a very small waist, but if the hip is the same size as
her waist, the latter will be lost.
And in this case, the surgical solution does not consist of marking the waist with
liposuction since there is not enough fat, but rather a substantial increase in the hip
and buttock to balance the triad in the body contour. It is here where the round
implant plays its most important role.
20.3 Implant Selection
There is no perfect buttock implant. However, we have to nd the most suitable one
in each particular case. In fact, in my surgical practice I have observed at the time of
inltrating the saline solution into the buttock, prior to the placement of the prostheses, that this would be the ideal augmentation, a liquid implant whose characteristics were easy to apply, biocompatible, easily accessible, perhaps reabsorbable for a
period of at least 10years and that had the rmness and elasticity so that it would
not deform over time. But currently, it does not exist. The closest thing to this is
autonomous fat, which we do not have in all cases, so we must give greater importance to round implants for the buttock.
Currently there are basically two types of buttock prostheses, round and oval.
The latter are also erroneously called “anatomical.” The gluteus maximus, which is
the muscle that interests us most in augmentation surgery and which is where the
implant is placed, is triangular, and the buttock is round. An analogy to this is a
completely round piece of pizza. Where a triangular piece of pizza is the gluteus
maximus and the complete pizza is the buttock.
If we wanted to give that pizza uniform volume, we would have to use another
round pizza (round prosthesis) and not only use a triangular piece of pizza (oval
prosthesis called “anatomical” that tends to be triangular).
Therefore, the use of an oval or “anatomical” prosthesis would have to be placed
in the same arrangement as the gluteus maximus. The thicker base of the implant
remains in the superior medial direction and its tip points down and out in the direction of the femur, which would give the implant an unconventional disposition and
is very easy to rotate due to its difference in weight between its upper pole and its
lower pole, being the upper one with more mass and therefore heavier. Throughout
my practice I have removed oval implants that have rotated on their own axis in different directions creating asymmetries and irregularities in the buttocks, and not
infrequently I have found them with their at surface directed toward the skin.
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The reason for this displacement is due to making an intragluteal pouch too large
at the time of dissection. Therefore, the bag that contains the implant must be large
enough so that the implant does not fold on itself, but narrow enough so that it does
not move. To do this, I regularly draw the outline of the prosthesis on the buttock
once we determine the placement site. This is done in order to internally adjust the
dissection to this previously drawn margin. In patients who require not only buttocks but also hip augmentation, the oval implant will not give us enough diameter
to reach laterally and also obtain hip augmentation.
This requires a round prosthesis, which has the advantage of a larger diameter
and a good projection for the buttock, with the benet that if it rotates on its own
axis, it does not deform the buttock due to its own round nature. And because of the
width of its diameter in relation to its projection, it makes it very difcult to turn,
although not impossible.
In men, unlike women, an increase in hip diameter is not normally required,
except in body feminization.
Therefore, a prosthesis with a different diameter-projection ratio than that used
in female patients is used, that is, a smaller diameter, but with the same or greater
projection. In male patients, the oval prosthesis could be used due to its small diameter, but due to its rotational disadvantages, I would always suggest a round prosthesis even in men.
20.4 Marking thePatient
I have always believed that if someone is going to describe a new surgical technique
or modify an existing one, they have to make it as simple as possible or easier than
the respectively modied one, but never more complicated. And I am sure that this
technique has the simplicity that comes from the daily observation of the human
body and the individual aesthetic sensitivity acquired over time. I have never fully
trusted the absolute measurements of the decimal metric system on the human body.
Since, as we know, one person differs from another according to many differences,
which can be ethnic, geographic, social, economic, religious, and cultural.
Mathematicians since ancient times have sought an absolute formula of the anatomical proportions of the human body without satisfying their desire at all. The
closest to it has been the description of the Golden Ration, Phi ratio, or the Divine
Proportion by Fibonacci, which tells us of proportions that exist in painting, architecture, anatomy, and, in general, throughout the universe. But they are not exact or
absolute measurements, just proportions. Patients are marked with this round buttock augmentation and hip augmentation technique in the operating room with the
patient always standing, never sitting or lying down. The patient is placed standing
and in prole to nd a point of convergence between the silhouette of the abdominal
line and the anterior silhouette of the thigh. There, at that junction of those two lines
is a point of deection that sometimes coincides with the symphysis pubis, but not
necessarily. Ideally, the line that forms the silhouette of the body on its front surface
20 Round Implants forButtock andHip Augmentation
should be completely parallel to the line that forms the same silhouette on its back.
These two lines should be kept parallel as far as possible, which should help us to
select the implant volume. From that deection point, a straight horizontal line is
drawn backwards. This line marks the site of greatest projection of the round prosthesis on each buttock. That is, the upper half of the implant placed is above this line
and the lower half of the implant is below this line. In other words, this line should
imaginarily split the prosthesis into two equal parts, top and bottom. And in the
same way, this line marks the point where the hip must project its maximum laterally, that simple.
There we would also inject fat in case of lipotransference for the hip as the maximum point to obtain the best balance in the triad, waist, buttock, and thigh. But in
this case we will use the prosthesis to obtain the hip augmentation. Once this horizontal line on the buttock has been dened, we have then that the prosthesis can be
moved medially or laterally on this line, but not more medial than the line of origin
of the gluteus maximus in the sacrum, nor more lateral than the mid-axillary line.
This gives us several centimeters to be able to move the prosthesis laterally or medially. It should never be medially on the sacrum and laterally up to the iliotibial band.
In thin women who require buttock and hip, the round prosthesis is placed in a
more lateral than medial position, reloading the lateral edge of the implant below
the iliotibial band. In men, the prosthesis will be placed in a more medial position
to avoid hip augmentation, but to project the buttock.
283
20.5 The Incision
I always use a single intergluteal incision for the placement of the prostheses. I
never use two incisions and there are two main reasons for this. The rst one is that,
being cosmetic surgery, we should try to leave as little scarring as possible. And the
middle intergluteal scar, performed with a good closing technique, is obviously
much less noticeable. The second reason is that making two incisions to avoid communication between the two implants is not necessary if we leave the sacrococcygeal ligament on the sacrum where it will be strongly tied.
20.6 Surgical Technique
The surgical procedure is generally performed with spinal block and lasts approximately 45min. With the patient in the prone position, asepsis and antisepsis are
performed. An antimicrobial surgical eld made of plastic that is self-adherent to
the skin (ioban) is placed to completely isolate the anal area from the incision.
One liter of saline solution with adrenaline (1:1,000,000) is inltrated into the
gluteus maximus muscle, 500cc on each side. An intergluteal incision of approximately 6cm in length is made (this can vary in length depending on the volume of
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G. G. Blanco and B. B. Orozco
the implant to be placed) on the sacrum to perform lateral dissection with electrocautery until visualizing the gluteus maximus fascia, which is bluntly opened with
scissors longitudinally in the direction of its bers.
A nger is inserted into the muscle and the dissection of the bag is initiated, supported with a gluteal dissector or malleable separator of an inch and a half wide,
making an intramuscular pocket up to previously established limits. This dissection
is performed relatively quickly and without bleeding when in the proper intramuscular plane. There is no need for hemostasis. Once the bag is made, the selected
round implant is inserted, leaving it tted in said space.
The dissector is then reintroduced to give the pocket enough space until the
round prosthesis rotates freely on its own axis. This will indicate that the implant
has the appropriate bag without displacement beyond our marking. There is no need
to close the gluteus maximus muscle since the implant is about 8–10cm from the
midline completely covered by the same muscle when closing cell tissue and skin.
Each of the two dissected pockets is closed independently. First the subcutaneous cell tissue from one side to the sacrococcygeal ligament and then the same is
done from the contralateral side. Once the above has been done and both cell tissues
on each side are joined, a new suture is made reinforcing the union between the two
with simple stitches in the midline, thus obtaining a strong and secure closure.
Finally, absorbable suture and subdermal points are used to avoid, as far as possible,
the external marking of the suture on the skin and thus avoiding discomfort to our
patients.
20.7 Placement ofDrains
In some patients I do not place a drain, but in some others I do. This decision is
made individually according to each patient. I hardly use them in thin patients with
little fat. In patients with more gluteal fat and that the prostheses are larger, I do
place drainage.
Patients who do not have drainage, even though they are thin, tend to report more
discomfort, inammation, and buttock pain after surgery than those who do have
drainage. However, after 5 days these discomforts become equal between both
drained and non-drained patients.
Once the drain is placed, it is removed approximately 5 days after surgery.
Generally, I would suggest drainage placement for a less bothersome recovery.
20.8 Postoperative Care
Immediately after surgery, a light compression girdle is placed on them. With it,
patients report feeling safer. Patients initiate immediate and assisted ambulation
without limitation once the spinal block has passed. They are not prohibited from
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