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Fig. 23.3 Silicone present in capsule of the prostheses
G. Ramos-Gallardo et al.
evaluate the extension of the disease, the possible use of chemotherapy, and other
treatments as brentuximab that has proved to be helpful in advanced cases [1].
23.3 Treatment
As the number of gluteal implants is not as big as the breast implants, we have
less information of GIA-ALCL. Unfortunately, in the rst case, the patient had
an advanced stage with a not good outcome. In the second case, after removal of
the capsule, chronic seroma came later with the diagnoses. For this reason we
should consider the possibility of this pathology and the possible presence in the
capsule.
It is true that lymphoma has been reported in other type of prostheses, in the case
of Anaplastic Large Cell Lymphoma the symptoms are related to local swelling and
inammation but location of the prostheses may vary symptoms as different as, for
example, endovascular prostheses or gastric band for bariatric procedures [12, 13].
What is important to mention is that once the diagnoses is conrmed by puncture
of seroma it is important to perform a complete en block capsulectomy that is different from the planning and the margins that regular capsulectomy have [7].
We must mention that plastic surgeons help with the diagnoses but the management of this pathology as well as the BIA-ALC should be multidisciplinary, where
additional studies should be ordered. PET scan has been useful to know the extension and to plan a better en block capsulectomy. In the case of BIA-ALCL,
23 Gluteal Implant Associated withAnaplastic Large Cell Lymphoma
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317
chemotherapy has been reported in some patients, the most common is CHOP [6].
Radiotherapy has been used in some patients as well. Guidelines from NCCN to
treat BIA-ALCL can help clinicians and surgeons worldwide to know what to do in
these patients [7]. As there are ve cases reported of this pathology, information
from BIA-ALCL can help know the best care for a possible case. As the number of
patients increase more data can be known and differences with BIA-ALCL can be
identied.
23.4 Records
It is important to keep a record of patients with implants. Breast and gluteal cases
used not to be followed by our clinics [10]. It is true, no cases have been reported
with smooth implants, although we do have cases of patients that used to have textured and changed to smooth implants. At this moment it is not necessary to replace
asymptomatic patients from textured implant to smooth implants. If it is the case,
we need to evaluate the role of capsulectomy. In the case of BIA-ALCL the capsulectomy in patients with implants under the muscle, the risk of possible affection to
the pleura should be considered. As in BIA-ALCL in the case of GIA-ALCL reconstruction after treatment may be considered [14].
A record of every patient that we have with implants is important. We need to
explain to them that implants are not a lifetime device and it is important to replace
them. The possibility of rupture increases after 10years. A record should be enforced
by every surgeon in their practice as well as every plastic surgery society and
country.
An algorithm is shown of the management of chronic seroma in a patient with
gluteal implants.
23.5 Conclusion
GIA-ALCL have similarities to BIA-ALCL.Although the number of reports is not
the same as in BIA-ALC.Asymmetry due to chronic seroma has been the common
onset. Delay in diagnoses can make the worst prognoses. Once a positive case is
conrmed in the sample of seroma, en block capsulectomy should be done in conrmed cases. In case of chronic seroma with no positive result, total capsulectomy
should be planed. It is important to work with an experienced pathologist.
Multidisciplinary treatment is the best way to approach these cases. NCI guidelines
can help to treat possible cases of GIA-ALCL.National records of breast and gluteal cases can help to nd an etiology of this pathology.
Conict of Interest Statement The authors declare no conict of interest or any commercial
relationship with any industry or laboratory.
318
G. Ramos-Gallardo et al.
References
1. Shauly O, Gould DJ, Siddiqi I, Patel KM, Carey J.The rst reported case of gluteal implantassociated anaplastic large cell lymphoma (ALCL). Aesthet Surg J. 2019;39(7):253–8.
2. Mendes J, Mendes V, Frascino L, Zacchi FF. Gluteal implant associated anaplastic
large cells lymphoma. Plast Reconstr Surg. 2019;144(3):610–3. https://doi.org/10.1097/
prs.0000000000005910.
3. Ramos-Gallardo G, Cuenca-Pardo J, Cardenas-Camarena L, Duran-Vega H, RodríguezOlivares E, Bayter-Marin JE, etal. Is Latin America ready to identify anaplastic large cell
lymphoma in breast implants patients? Regional encounter during the National Plastic Surgery
Meeting in Cancun, Mexico. Aesthet Plast Surg. 2018;42(5):1421–8.
4. Collins MS, Miranda RN, Medeiros LJ, Silva de Meneses MP, Lyer SP, Butler CE, Liu J,
Clemens MW.Characteristics and treatment of advanced breast implant: associated anaplastic
large cell lymphoma. Plast Reconstr Surg. 2019;143(3S):41–50.
5. Collett DJ, Rakhorst H, Lennox P, Magnusson M, etal. Current risk estimate of breast implantassociated anaplastic large cell lymphoma in textured breast implants. Plast Reconstr Surg.
2019;143:30S–40S.
6. Ramos-Gallardo G, Cuenca-Pardo J, Rodríguez-Olivares E, Iribarren-Moreno R, ContrerasBulnes L, Vallarta-Rodríguez A, et al. Breast implant and anaplastic large cell lymphoma
meta-analysis. J Investig Surg. 2017;30(1):56–65.
7. Clemens MW, Jacobsen ED, Horwitz SM. 2019 NCCN consensus guidelines on the diagnosis and treatment of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).
Aesthet Surg J. 2019;39:S3–S13.
8. Clemens MW, Brody GS, Mahabir RC, Miranda RN. How to diagnose and treat breast
implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg. 2018;141:586e–99e.
9. Van Natta BW.Determining the true incidence of breast implant-associated anaplastic large
cell lymphoma (BIA-ALCL): the need for accurate data. Aesthet Surg J. 2019;39:NP230–1.
10. McCarthy CM, Loyo-Berríos N, Qureshi AA, Mullen E, Gordillo G, Pusic AL, Ashar BS,
Sommers K, Clemen M.Patient registry and outcomes for breast implants and anaplastic large
cell lymphoma etiology and epidemiology (PROFILE): initial report of ndings, 2012–2018.
Plast Reconstr Surg. 2019;143(3S):65S–73S.
11. Loch-Wilkinson A, Beath KJ, Knight RJW, Wessels WLF, etal. Breast implant-associated anaplastic large cell lymphoma in Australia and New Zealand: high-surface-area textured implants
are associated with increased risk. Plast Reconstr Surg. 2017;140:645–54.
12. Umakanthan MJ, McBride CL, Greiner Y, Yuan J, Sanmann J, Bierman PJ, Lunning MA,
Bociek RG. Bariatric implant-associated anaplastic large-cell lymphoma. J Oncol Pract.
2017;13:838–40.
13. Menter T, Ballova V, Caspar C, Wolff T, Kasend B, Singer G, Juskevicius D, Tzankov A,
Dirnhofer S. ALK-negative anaplastic large cell lymphoma arising in the thrombus of an
aortic prosthesis preceded by clonally related lymphomatoid papulosis. Virchows Arch.
2019;474(6):763–7.
14. Lamari GA, Butler CE, Deva AK, Miranda R, Hunt KK, Connell T, Lipa JE, Clemens
MW. Breast reconstruction following breast implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg. 2019;143(3S):51S–8S.
Part VI
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The Post-Bariatric Buttock
Chapter 24
Advanced Techniques forButtock
Restructuring, Reshaping, andLifting
EduardoUlisesGóngora Alejandre andCynthiaCatalinaSolis López
24.1 Introduction
In recent years the desire to improve the gluteal aesthetics has been constantly
increasing. The popularity of the buttock surgical interventions, both to increase its
size and to improve the shape and contour, has shown an important increase. Due to
this, multiple techniques have been developed in order to obtain an excellent aesthetic result. In a joint effort we have managed to purify compound techniques. In
addition to improving the aesthetic results, the techniques are safer, reduce the risk
of complications, and decrease recovery time.
24.2 Concept ofGlute andBody Aesthetics
The concept of aesthetics is a subjective matter. Aesthetics depends on the perspective of each individual and the concept of what is beautiful varies between different
people, societies, and even between different races. In addition to those factors,
aesthetics preferences change over time and with the different fashions. For example, it is observed that in Latin and African American societies there is a marked
preference for big buttocks, with large volume, projection, and pronounced hips. In
European populations it is more popular the preference for buttocks with less projection and more athletic appearance. Therefore, it is difcult to generalize the canons of beauty in what is a “beautiful” buttock and even more complicated to describe
E. U. Góngora Alejandre (*)
Private Practice in “Clinica Genesis”, Rosarito, Baja California, México
C. C. Solis López
Private Practice in “Clinica Genesis”, Rosarito, Baja California, México
Guadalajara, Jalisco, 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_24
321
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a surgical plan as a “prescription” that can be applied to all patients. However, as a
plastic surgeon, there are general characteristics that should be sought when performing the buttock contour modication.
Among the general characteristics observed in a beautiful silhouette are those
already described previously by Mendieta and Centeno [1, 2].
(a) Absence of excessive adipose tissue in the lumbosacral region, which produces
a soft depression of the region forming a triangle that marks the transition
between the back and the buttocks.
(b) Presence of presacral dimples, which anatomically demarcates the posterior
superior iliac spines.
(c) In some occasions a mild lateral depression corresponding to the trochanteric
region can be observed, which should not be very marked and is present mainly
in athletic bodies and can be very marked in males.
(d) Infragluteal crease that does not exceed 2/3 of the buttock’s entire width and at
an angle of 45° to form a diamond-shaped space between the crease and the
medial region of the thighs.
(e) Absence of excessive adiposity in the medial region of the thigh, anks, tro-
chanteric region, or in the region of the “banana roll”.
(f) Maximum projection of the buttock in the central region, which generally
matches the height of the pubic bone.
(g) Similar volume between the upper and lower quadrants of the buttocks, and the
medial quadrants in regard to the lateral quadrants.
(h) Other characteristics that are observed in what is considered a beautiful buttock
are adequate quality and texture of the skin, rmness in the tissues, absence of
depressions, dimples, cellulite looking skin or stretch marks.
E. U. Góngora Alejandre and C. C. Solis López
24.3 Classication ofPatients andSurgical
Management Proposed
Next, in Table24.1 we describe the different types of patients that are usually seen
in consultation, their general characteristics, and the proposed surgical management.
Next, each of the proposed surgical techniques will be described.
24.3.1 Lipoinjection
Buttock augmentation with fat injection is the most popular technique, which has
evolved since its beginnings in which the intramuscular inltration was described,
to the more recent ndings and relevant changes among which are the suggestions
made by the “Gluteal Fat Grafting Task Force” [3] whose recommendations have
concluded that fat should be applied only in the subcutaneous plane and avoid the
cd
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
323
Table 24.1
characteristics and the proposed surgical management
Type 1 Usually these are young patients, under
Type 2 This type of patient is similar to the previous
Type 3 These type of patients are generally over
Type 4 This type of patient is similar to the type 3
The different types of patients that are usually seen in consultation, their general
25years old, with adequate skin quality,
without cellulite, stretch marks, or sagging.
With a desire to increase their buttocks and
with areas of localized lipodystrophy
(Fig.24.1a)
one, the difference is that the areas of
lipodystrophy are not suitable for harvesting an
adequate amount of adipose tissue (Fig.24.1b)
25years old, have signicant sagging of the
tissues and gluteal ptosis, cellulite areas, may
present the “double buttock deformity” and
important body lipodystrophy (Fig.24.1c)
patient. The difference is that it has localized
areas of lipodystrophy, but adipose tissue
reserves are not sufcient to achieve an optimal
result only through lipoinjection (Fig.24.1d)
ab
Liposuction + lipoinjection
Buttock implant + lipoinjection in the
peri-implant area and in the gluteal
frame
Lipectomy in “seagull
wings”+cellulite release and “double
buttock” correction if necessary +
lipoinjection
The same procedure is performed as
in type 3 patients + gluteal implant
placement with lipoinjection in the
peri-implant area and gluteal
framework
Fig. 24.1 (a–d) The different types of patients usually seen in consultation (a) Type 1: young
patient with good quality tissues and with localized lipodystrophy areas. (b) Type 2: young patient
with good quality tissues but the localized lipodystrophy areas are not enough to get an adequate
fat graft. (c) Type 3: usually an older patient with sagging tissues, buttock ptosis, important lipodystrophy areas. (d) Type 4: usually an older patient with sagging tissues, buttock ptosis, the localized lipodystrophy areas are not enough to get an adequate fat graft
intramuscular location in order to prevent complications such as the absorption of
fatty emboli, which can lead in extreme cases even to death due to macroembolism.
Also it has been demonstrated by Del Vecchio etal. [4] that despite seemingly application at the supercial level in the intramuscular plane, the fat suffers a process of
deeper intramuscular migration even toward the submuscular plane, with the subsequent risk of complications. For these reasons we consider that we should avoid
intramuscular application to safeguard the life of our patients.
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E. U. Góngora Alejandre and C. C. Solis López
24.3.2 Surgical Technique
All surgical patients begin with a mixed block consisting of the use of a high peridural block + lumbar subarachnoid spinal block. To ensure the airway we use “light
general anesthesia,” which consists of placing an endotracheal tube in the patient,
and a mechanical ventilator. The difference with respect to traditional general anesthesia is that the concentration of anesthetic gases administered is much lower since
analgesia is provided by the peridural and subarachnoid blocks so there are no painful stimuli that require a high MAC (minimum alveolar concentration), which refers
to the concentration of gases that are administered regularly so that the patient does
not respond to painful stimuli.
With regard to uids restitution, this is based practically on the uresis and vital
signs of the patient. It is done conservatively due to the large volumes of solution
inltrated by the tumescent technique for liposuction.
The surgery begins with the patient in the ventral position. We perform inltration with tumescent technique to minimize blood loss. Inltration solutions consist
of 1L of Hartmann solution together with 1cc of adrenaline. A traditional liposuctor is used to perform liposuction, the dimensions and types of cannula used are
determined according to the needs of each case. I generally use multi-hole cannulas,
3.5–5mm. Liposuction is performed all over the high back, anks, shoulders, and
arms. Subsequently, the harvest of the fatty tissue to inltrate is performed from the
waist, lower back, and sacral region in the same way using traditional cannula but
performing the aspiration with a Tummy syringe. This is done with the aim of minimizing the trauma caused to the fat cells by the negative pressure of the liposuctor.
Generally, to perform the lipoinjection, a single incision is placed above the
intergluteal crease below the sacral triangle with which we obtain excellent access
to the buttock in addition to hiding the scar. In some cases, if more incisions are
necessary, we place them in the infragluteal crease to prevent them from being
visible.
In my practice, I use the “minimal exposure technique” for fat tissue handling
(Fig. 24.2a–c), which consists in making immediate application of the fat to be
grafted, after liposuction with a Tummy syringe and decanted for a few seconds
inside the same syringe. To perform the inltration, I use the same cannula with
which I perform the harvest of the fat graft and place the fat only in the subcutaneous plane.
Fig. 24.2 (a–c) Minimal exposure technique for fat tissue handling
abcd
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
Fig. 24.3 (a–d) Lateral and oblique views of a patient before and after buttock augmentation with
lipoinjection only
325
I usually put between 500 and 600cc of fat in each buttock as this depends on the
patient’s tissues presenting a complacent expansion and not getting too much tension in the buttock. I believe that the fact of using methods for the preparation of fat,
such as the use of lters, centrifugation, decantation with devices, or the different
processing methods are not a determining factor that increases the survival or integration of fat cells and on the contrary they can contribute to an accidental contamination of the graft. With this technique, an excellent survival of the graft is obtained
and by decreasing the manipulation of the fat, its viability is increased in addition to
decreasing the risk of contamination and infections.
The fat is inltrated according to the needs of each patient, mainly in the central
region of the buttock, accompanied by an inltration of point C (according to
Mendieta’s classication) at the level of trochanteric depression. In patients who
present with cellulite or some type of irregularity in the contour, a Toledo cannula is
used to release the cutaneous retraction bands. Then lipoinltration is performed in
the treated area. In selected patients, with adequate tissue quality, excellent results
are obtained through this technique (Fig.24.3a–d).
24.4 Compound Technique (Implants+Lipoinjection)
We live in an era in which the buttocks of large dimensions or with marked projection are increasingly popular. To meet the expectations of this type of patients we
have two options:
1. Perform gluteal augmentation with inltration of huge amounts of fat.
2. Use of large volume gluteal implants.
Despite the large increase in popularity of the gluteal augmentation with autologous fat, this procedure is accompanied by high rate of complications, and according to the reports made by the “fat grafting task force,” [3] this is the plastic surgery
procedure with the highest rate in mortality among any other aesthetic surgery
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E. U. Góngora Alejandre and C. C. Solis López
procedure, and with multiple complications ranging from mild ones such as fat
reabsorption, fat necrosis, or infections to fatal complications and even death caused
by a fat macroembolism. On the other hand, the use of gluteal implants also is a
procedure that is not free of complications. The possibilities include a high rate of
wound dehiscence, seroma, and implant malposition. In addition to the fact that the
implant does not provide us with a three-dimensional improvement, it mainly gives
us anteroposterior projection, not an improvement of the entire gluteal frame. For
these reasons the compound technique is an excellent option, which in recent years
has increased its popularity and has been widely described [5].
The technique consists of placing gluteal implants in the intramuscular plane
together with lipoinjection in the subcutaneous plane, which is performed both in
the gluteal region mainly in the peri-implant zone and in the entire gluteal frame.
The placement of buttock implants is an excellent resource to achieve an adequate
volume without having to resort to the inltration of massive amounts of fat, thus
avoiding the complications inherent to this procedure, as well as being a valuable
resource in thin patients in whom there are not large amounts of fatty tissue to
harvest.
24.4.1 Markings
Marking is done with the patient in standing position. First the areas of liposuction
and lipoinjection in the gluteal frame are marked. The implant pocket is planned to
place the implant in the area in which it is planned to give the greater projection,
which coincides with the pubic symphysis height, we place the implant in a slightly
oblique position to take advantage of it and provide a slight increase in lateral projection at the level of trochanteric depression according to the needs of the patient.
Finally, de peri-implant lipoinjection is marked in order to make a smooth and
homogeneous transition between the implant and surrounding tissues.
24.4.2 Surgical Technique
For the placement of implants, two types of approaches can be performed. One is
through the incision of “seagull wings lipectomy” that is used in cases of buttock
lift, which will be discussed later, and a second in which a single incision is used in
the intergluteal region as described by Vergara [6].
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