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22 Combining Fat andImplants forGluteal Augmentation
Fig. 22.2 On table
marking of subiliac
liposuction area
305
Timing of fat-grafting versus implant pocket dissection to our view depends
largely on the preference of the surgeon. It can be done before or after implant
placement, we recommend to combine both, transfer the larger amount of graft
before implant placement and leave a smaller quantity for nal touch-ups. The
important thing is not whether to place the fat graft before or after implant placement, the important thing is to do it at all.
The common areas that receive fat grafts are the hip, the lateral third of the buttock, and transition are found between the hip and the gluteal [6]. The fat is injected
into the marked areas by positioning the cannulas in the subcutaneous planes via
small incisions made on the anks and infragluteal folds. The preoperative topographic marking is key for the success of the fat transfer. During this process, graft
is injected subcutaneously through several passes using EVL (expansion vibration
lipolling) as described by Del Vecchio. Care is taken to nd the perfect balance
between passes for just vibration tissue expansion to loosen up the tissue scaffold
and the actual fat inltration. We recommend to focus on the lateral perigluteal
areas and avoid the incisional zone for pocket access. Aesthetic focus is grafting
into the trochanteric depressions (hip-dips) where volume replacement is highly
desired and implants do not really provide any extra volume.
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A. Aslani and M. G. Bravo
22.1.2 Silicone Implant Placement
For the preparation process for this we do an additional, second skin-prepping with
iodine. Additionally, a betadine-soaked compress is sutured over the anus using a
number 0 silk stitch, to achieve a watertight separation from the surgical eld.
The procedure entails making a 5cm skin incision on both sides of the intergluteal cleft (Fig. 22.3). The dissection begins at 45° aiming at preservation of the
sacrocutaneous ligament until the gluteus maximus is identied. The muscle is then
dissected leaving a 2cm cuff on the medial side. Enough muscle dissection should
be made to leave a thick muscle ap of around 3cm. A blunt dissector is rst used
to create a submuscular space for the implant in the upper half of the implant pocket
(Fig.22.4). When the dissection approaches the height of the sciatic foramen, the
dissector is beveled to a atter angle to switch into an intramuscular plane (Video
22.1). Thus the implant is submuscular in the cranial half of the pocket and intramuscular in the lower half of the pocket. We call this approach “Dual-plane” technique and the idea is to combine the best of both approaches, totally submuscular
versus totally intramuscular. Dual-plane dissection achieves maximum muscle coverage, both gluteus maximus and medius, and still brings a protective layer of muscle tissue between sciatic nerve and implant. Double muscle ap cover gives a
signicantly more robust tissue cover in the upper pocket half as compared to the
single muscle cover only (Fig.22.5a, b).
A sterile surgical compress is immersed with adrenaline solution and placed
inside the pocket during the dissection process to prevent excessive bleeding.
Fig. 22.3 Upper half of
the pocket with double
muscle ap cover,
markings in cadaver lab
22 Combining Fat andImplants forGluteal Augmentation
Fig. 22.4 Upper half of
dual plane implant pocket
in cadaver specimen
307
abc
Fig. 22.5 (a–c) Cadaver dissection upper half dual plane pocket
Determining accurate height and width of the implant ensures an adequate pocket is
created to avoid the implant from rotating.
The implant insertion procedure begins with soaking the implant in an antibiotic
solution. The implant is then inserted using the plastic funnel devices that have been
sterilized. As a measure of preventing excessive uid from accumulating in the pocket,
a number 14 suction drain is placed on each pocket. An dynamic suspension suture is
used to anchor each gluteal fascia to its contralateral side to achieve mutual
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A. Aslani and M. G. Bravo
contralateral stabilization and avoid early gluteal implant ptosis. The concept of mutual
stabilization is similar to the columns of an “Arabic arch” and this is why the approach
has been labeled “Arabic-arch-suture-suspension” (Video 22.2). The subcutaneous
layer is closed using a long-term absorbable monolament suture and a negative-pressure wound therapy device is used as a dressing for 7days.
a
b
Fig. 22.6 Before and 6months after composite buttock augmentation with 330cc dual plane buttock implants and perigluteal fat grafting (Fig.22.6)
22 Combining Fat andImplants forGluteal Augmentation
Fig. 22.7 Posterior view. Before and after 3 months after composite buttock augmentation
(Fig. 22.7)
309
22.2 Postoperative Care
The postoperative care entails preventing bacterial infections and improving the
scarring to facilitate quick healing. We recommend twice daily skin wash with hibitane shower gel. Patients receive intravenous antibiotics during the procedure and
oral antibiotics for 7days after. Early ambulation helps to minimize the occurrence
of venous thrombosis, so pain control is key in order to have the patient walking.
After 6–7days following the procedure the drains are removed. It is imperial not to
do this before, since patients often become more mobile 4–5days after surgery and
it is not unusual that they might drain a larger amount of serous uid then, which
would cause pressure increase in the implant pocket space would the drain be
removed before. Patients should also not engage in physical activities immediately
after the implantation to prevent the implant from displacement, seroma, rotation,
and other complications. Immediately after surgery and for 4–6weeks the patients
should wear compression garments to prevent swelling and support the surgical
areas to enhance comfort.
22.3 Complications
Gluteal implants come with a series of procedure-specic complications. It is
important to know that these are very different to issues after breast implants. The
number one cause of problems in buttock implants is seroma. Immediate seroma is
best prevented by using suction drains after surgery. It is also important to be aware
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A. Aslani and M. G. Bravo
of the issue of late seroma, occurring 3–6weeks after the procedure. Late seroma
often leads to uid drainage from a breakdown in the incisional area and is often
confused with primary infection. The difference is important since seroma is usually self-limiting. We recommend prophylactic antibiotics, local wound care, and
observation. Spontaneous resolution occurs as often a 99% of affected cases. We
point this out because often surgeons with little experience in the procedure remove
implants prematurely and unnecessarily.
Using implants of course also carries an increased risk of infection. However, in
buttock implants the risk of a primary infection is actually lower than most practitioners seem to think. To our experience, buttock implants to the robust muscle
cover are very resilient against infection and if infection occurs, it is usually secondary to a superinfected late seroma and secondary contamination.
Sciatic nerve compression is another possible complication. Our current incidence is around 5% of cases. Usually nothing needs to be done, and the problem
tends to resolve with the resolution of swelling. If patients have more intense difculties, a short high dose treatment with prednisolone will usually solve the problem.
22.4 Conclusion
Gluteal augmentation is among the plastic surgery techniques that are becoming
popular in plastic surgery. The two powerful techniques being applied worldwide
are silicone implant placement and fat grafting. We have a very high caseload of
buttock implants yearly and have identied dual-plane dissection and dynamic
pocket suspension as two very strong assets to improve our outcomes and reduce
our incidence of problems.
The addition of fat transfer to the supercial subcutaneous layer avoids visibility
of the implant contour in thin patients and, if enough fat graft as well as recipient
tissue is available, can achieve aesthetically very pleasing volume addition in the
area of the trochanteric depression, leading to clearly better outcomes as compared
to buttock implants alone.
References
1. Sinno S, Chang JB, Brownstone ND, Saadeh PB, Wall S.Determining the safety and efcacy
of gluteal augmentation: a systematic review of outcomes and complications. Plast Reconstr
Surg. 2016;137(4):1151–6.
2. Cárdenas-Camarena L, Trujillo-Méndez R, Díaz-Barriga JC.Tridimensional combined gluteo-
plasty: liposuction, buttock implants and fat transfer. Plast Reconstr Surg. 2020;146(1):53–63.
3. Mod MM, Gonzalez R, de la Peña JA, Mendieta CG, Senderoff DM, Jorjani S.Buttock aug-
mentation with silicone implants: a multicenter survey review of 2226 patients. Plast Reconstr
Surg. 2013;131(4):897–901.
22 Combining Fat andImplants forGluteal Augmentation
4. Auclair E, Blondeel P, Del Vecchio DA.Composite breast augmentation: soft-tissue planning
using implants and fat. Plast Reconstr Surg. 2013;132(3):558–68. https://doi.org/10.1097/
PRS.0b013e31829ad2fa.
5. Aslani A, Del Vecchio DA.Composite buttock augmentation: the next frontier in gluteal aes-
thetic surgery. Plast Reconstr Surg. 2019;144(6):1312–21.
6. Godoy PM, Munhoz AM.Intramuscular gluteal augmentation with implants associated with
immediate fat grafting. Clin Plast Surg. 2018;45(2):203–15.
311
Chapter 23
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Gluteal Implant Associated
withAnaplastic Large Cell Lymphoma
GuillermoRamos-Gallardo, AdriánAlejandroCarballo-Zarate,
DavidOrozco-Rentería, DanielaLeón, JesúsCuenca-Pardo,
andLázaroCárdenas-Camarena
23.1 Clinical Symptoms
The GIA-ALCL is an entity with recent information in the literature. In our population we know from one case. In the last year reports of two cases are in the literature
[1, 2]. Chronic seroma is a common nding as well.
Taking into account the information from BIA-ALCL the following information
is shared.
In the case of BIA-ALCL the most common presentation is chronic seroma, but
we have reports of capsular contracture as an initial presentation, other ndings are
nodes, local signs of swelling and inammation [3]. As a society of Plastic Surgery
we concentrated these cases in one group of pathologies, in the last year we have
received several samples of possible cases. The most common nding was chronic
seroma, next to capsular contracture. We have one case of gluteal implant- associated
lymphoma that started as chronic seroma. In BIA-ALCL the most common presentation is asymmetry from one side caused by chronic seroma [4]. Although reports
are mentioned about bilateral cases that are advance and as well are more aggressive.
These kind of cases are involved with late diagnoses. Early suspicious of a possible
case can make a difference in recognition of the disease and treatment [5]. The time
line is unclear from unilateral asymmetry to an advanced disease that involves
G. Ramos-Gallardo (*)
Comite de Seguridad, Asociacion Mexicana de Cirugía Plastica, Estética y Reconstructiva,
Mexico City, Mexico
Centro Universitario de la Costa, Universidad de Guadalajara, Puerto Vallarta, Mexico
A. A. Carballo-Zarate
Hospital Español, Mexico City, Mexico
D. Orozco-Rentería · D. León · J. Cuenca-Pardo · L. Cárdenas-Camarena
Comite de Seguridad, Asociacion Mexicana de Cirugía Plastica, Estética y Reconstructiva,
Mexico City, 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_23
313
314
Capsule
+
G. Ramos-Gallardo et al.
spreading out of the capsule and a more aggressive pathology, what is known is the
timing between implant placement and diagnoses, and it is about 10years [6]. In the
case of GIA-ALCL it was in an American patient of 1year and in a Brazilian of
11years [1, 2]. The rst case that was reported appears in California, advanced and
aggressive. The Brazilian case was found in the capsule, even after removal of the
implant. For this reason, capsulectomy should be considered in case of chronic seroma.
23.2 Diagnoses
As chronic seroma is the most common presentation as is the same of breast implant
associated lymphoma the rst step is to obtain a sample of seroma that can be handled by a pathologist with experience in this disease [7]. Most of the reports in the
literature come from well developed countries that count with referral centers [8]. It
is important to notify authorities about the adverse event and work with an experienced pathologist [9, 10]. If the plastic surgeon feels that the uid can be aspirated
without puncture of the implant, an ultrasound guide can help.
It is important to work with a fresh sample, for this reason in countries with no
referral center pathologists should be informed in order to not waste time and to make
diagnoses possible. If the sample will be studied in more than 24h it should be xed
in an equivalent of alcohol of 96%, that means 50% sample and 50% alcohol 96%.
Once the pathologist evaluated the sample, the rst study to consider will be
CD30 [7, 8]. If it is positive, rest of markers should be considered in order to conrm diagnoses (Fig. 23.1). If the case is conrmed additional studies should be
EMA+
Fig. 23.1 Positive case in breast implant patient
CD30
ALK–
ab
23 Gluteal Implant Associated withAnaplastic Large Cell Lymphoma
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Fig. 23.2 (a) In this case mammary asymmetry is illustrated due to chronic seroma. (b) Metaplasia
synovial
requested. A multidisciplinary team should approach the patient with this condition,
where a hematologist should be involved and surgical oncologist should help to plan
a capsulectomy en block [8].
All centers, hospitals, and countries have different epidemiologies about this
condition [11]. The sensitiveness and specicity is different as well. In case a negative result and chronic seroma persists it is important to plan a surgical exploration
to remove the capsule. We don’t know if in future non-lymphoma cases will behave
differently. After evaluating capsules and samples from all the country the most
common nding is chronic inammation, sometimes silicone is present (Fig.23.2).
In this case mammary asymmetry is illustrated due to chronic seroma. Capsulectomy
sample, metaplasia synovial (Fig.23.3).
The removal of the capsule should be as complete as possible. We do understand
that not all the time it is possible to remove the capsule from the small previous incision. Patients should be informed that an extension of the previous incision is
planned in order to remove the complete capsule with the implant. Only by removing the complete capsule, a proper evaluation of the capsule can be done and lymphoma can be ruled out.
Once the capsule is removed the specimen can be kept in formalin. As a routine
in the case of BIA-ALCL we analyze different parts of the capsule, taking 20 parts
from different areas (top, bottom, sides, near the patch).
After the initial evaluation of the pathologist, CD 30 will be considered in rst
place and if it is positive, markers will be ordered to rule out this pathology [7].
Once the diagnosis is conrmed the next step is to know the extension in the
capsule [8]. According to the TNM, we evaluate the extension in the capsule.
Following the work with a multidisciplinary team to complete the work. PET scan,
complete laboratory tests as well as the proper image study to know the extension
into the deep structure in the pelvis if it is the case will be suggested.
If diagnosis is positive since the seroma punction, capsulectomy en block should
be considered. As well as an initial evaluation with a hematologist can help to
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