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24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
327
In the latter, a vertical midline incision of approximately 6–7cm in length is
made above the intergluteal crease, depending on the size of the implant and the
patient’s buttock dimensions. Subsequently lateral dissection of approximately
5–6cm is performed with electrocautery at the level of the suprafascial space trying
to preserve the fascia of the gluteus maximus muscle, and then blunt dissection of
the muscle bers is performed with metzembaum scissors. This is done following
the direction of the muscle bers, which are not sectioned, they are only separated.
After this, the dissection of the intramuscular pocket is performed, for which a
series of blunt dissectors are used (Fig. 24.4); these are used sequentially until
obtaining a pocket of adequate dimensions. When dissecting the pocket, it is important to try to preserve an adequate muscle thickness (usually about 2–3cm) in both
portions of the pocket, that is, the muscle thickness must be similar in the pocket
walls to obtain adequate coverage above the implant and to get coverage of neurovascular structures under the implant.
Once the pocket is made, the hemostasis is veried, irrigation of the cavity with
saline solution and antibiotic application is performed both in the intramuscular
pocket and on the implant, an anatomical gluteal implant is placed, being generally
small to moderate in size, which will depend on the dimensions of the bony framework of the patient. Once the implant is placed, a 4mm Jackson Pratt drain is placed
in the base of the pocket and then the closure is performed, rst of the muscle tissue
with separated stitches of vicryl 2/0; once closed, the subcutaneous tissue is left
open in order to perform the lipoinjection through this access, which is performed
subcutaneously, mainly in the central region of the gluteus to provide more projection, in the peri-implant area to create a smooth transition between the implant and
the surrounding tissues and in the gluteal framework, in addition to combining with
liposuction of the surrounding areas if necessary. By performing lipoinjection in the
subcutaneous plane, the risk of damaging the implant is totally avoided, since the
implant was placed in the intramuscular plane. The compound technique is an
excellent resource in thin patients, in which we would get an unsatisfactory result if
we only performed lipoinjection (Fig.24.5).
Fig. 24.4 Blunt dissectors
used for dissection of the
intramuscular pocket
328
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E. U. Góngora Alejandre and C. C. Solis López
c
Fig. 24.5 (a, b) Oblique and posterior views of a patient before composite buttock augmentation
with implants and fat grafting. (c) Immediate result of the patient after composite buttock
augmentation
ab
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
329
24.5 Buttock Lifting by Lipectomy in“Wings ofSeagull”.
In older patients, patients with poor skin quality, overweight, or with a history of
weight loss, it is common to observe different degrees of skin laxity and sagging, as
well as gluteal ptosis (Fig.24.6a). In this type of patients, lipectomy is usually performed in the form of “seagull wings.”
This is the technique that I most frequently use in gluteal contour surgery. In my
25years’ career, I have observed that the only way to achieve a signicant buttock
lift in this type of patients is by performing cutaneous excision and repositioning of
the buttock. This technique allows to reshape the buttock and the surrounding frame
in the way that I want, managing to place the buttock in an adequate position, raising it as much as desired, in addition to allowing to modify its dimensions, shortening or lengthening it according to the needs of the patient (Fig. 24.6b). The
modication of the length of the buttock will depend on the site where the lower
segment of the lipectomy is placed, the modication of the buttock’s width is also
possible, widening by lipoinltration or narrowing its dimensions by performing
liposuction; with this technique we can give the buttock as much projection as
desired by lipoinjection and/or implant placement according to the need and desire
of each patient.
Fig. 24.6 (a, b) Oblique view of a patient before and after buttock makeover with lipectomy and
lipoinjection
330
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Fig. 24.7 (a, b) Double buttock deformity: refers to an accumulation of fat in the inferomedial
quadrant of the buttock
E. U. Góngora Alejandre and C. C. Solis López
Frequently, especially in patients who are overweight, with antecedent of weight
loss and gluteal ptosis, we observe what I have called “the double buttock deformity,” (Fig.24.7) which is an accumulation of fat in the inferomedial quadrant of
the buttock, lateral to the intergluteal crease and above the infragluteal crease; this
“double buttock” gives a ptosic, aged, and irregular appearance. It is important to
perform lipoaspiration of this fatty tissue and to reshape the periphery of this region
through lipoinjection to achieve an aesthetic and regular contour.
24.5.1 Markings
This type of surgery is regularly performed in conjunction with a tummy tuck, that
is, a circumferential abdominoplasty is performed and the incisions of the “lipectomy in seagull wings” are continued with the incisions of the tummy tuck.
The position of the lower incision of the lipectomy will be determined by the
length that is desired to be given to the buttock, in case of having a short buttock, the
incision will be placed more cephalic to give it greater length. If we have a very long
buttock, we will place the incision lower in order to make the buttock look shorter
(Fig.24.8a).
Usually this is an area in which it is difcult to perform a pinch test unless the
patient has a history of a massive weight loss. If possible, the amount of tissue to be
resected is determined by performing a pinch test; however, in most patients this is
a zone of adherence and in many cases this is not possible. In order to determine the
point at which the upper incision will be made is by means of a maneuver in which
gluteal traction is performed simulating the lifting that is desired to achieve with the
surgery. In this way it is determined the point at which the buttock will be xed to
and where the placement of the incision is planned (Fig.24.8b).
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
331
ab
Fig. 24.8 (a) The lower incision is the rst to be marked. Its position is determined by the length
that is desired to be given to the buttock. (b) The upper incision is determined by a maneuver in
which gluteal traction is performed simulating the lifting that is desired to achieve with the surgery,
the line will be drawn at the point that we wish to x the new buttock position
24.5.2 Surgical Technique
With the patient in the ventral decubitus position liposuction of the areas to be
treated is begun in the manner previously described, performing tumescent inltration to minimize bleeding, the fat graft harvesting is performed with the “minimal
fat exposure technique” described previously. In case we are only performing buttock augmentation by lipoinjection, this is done immediately.
Subsequently, with scalpel, the incision of the lipectomy in “seagull wings” is
made going through planes, making a section of supercial and deep fascia until we
reach the thoracolumbar aponeurosis. At this level it is important to preserve a layer
of deep fascial tissue to preserve the lymphatic ow of the area and decrease the
presence of postsurgical seromas. We perform exhaustive hemostasis with electrocautery nishing the resection of the aps according to the surgical plan. After performing the buttock augmentation and the resection of the aps of the lipectomy,
washing and irrigation with saline is performed to eliminate cellular debris and
impurities of the surgical material such as cloth bers, talcum powder from gloves,
etc. (Fig.24.9). We apply rifamycin in the area and nally two closed drains are
placed, a Jackson Pratt of 10mm and a drenovac of ¼ inch. To perform the closure
of the lipectomy we start at the level of the midline, performing closure of supercial and deep fascia with vicryl 1 and making an anchorage to the thoracolumbar
332
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E. U. Góngora Alejandre and C. C. Solis López
fascia. This anchor point is of paramount importance to achieve an adequate repositioning of the buttocks; as we advance laterally with the closure of the wound, it is
important to perform adequate compensation and xation of aps to achieve adequate tissue distribution and thus avoid excessive remnants at the lateral level.
Subsequently deep dermal closure is performed with continuous vicryl 2/0 stitches
and we end closure with an intradermal suture with nylon 2/0. At this point the buttock restructuring surgery has been completed and the abdominal lipectomy is continued (Fig. 24.10). With this technique we can get excellent, consistent and
long-lasting results (Fig.24.11).
Fig. 24.9 Irrigation of
surgical area after
lipoinjection and resection
of aps. Before drain
placement and closure
Fig. 24.10 Immediate result of the same patient in Fig.24.8, after lipectomy, buttock reposition-
ing and augmentation with lipoinjection
a
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
333
b
c
Fig. 24.11 (a–l) Oblique view of different patients before and after buttock lifting by lipectomy
and lipoinjection
d
334
ef
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E. U. Góngora Alejandre and C. C. Solis López
Fig. 24.11 (continued)
ij
kl
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
335
Fig. 24.11 (continued)
336
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E. U. Góngora Alejandre and C. C. Solis López
24.6 Buttock Lifting by “Lipectomy inSeagull Wings” +
Placement ofButtock Implants
When performing this technique, liposuction is performed in the manner previously
described, the difference is that the fat graft obtained is similarly decanted within
the same Tummy syringe, but is reserved in a sterile container for later use. The
incision of the lipectomy is made in in the manner already described and after completing it, the same approach is used to perform the placement of the implants. The
gluteus major muscle bers are located, the blunt dissection is performed, and the
formation of the intramuscular pocket is made in the manner already described, the
implant and the drains are placed, and the closure of the intramuscular pocket is
performed with vicryl 2/0, leaving the subcutaneous tissue intact in order to perform
the lipoinjection in the peri-implant area and in the entire buttock framework according to the surgical plan. This technique is reserved for patients who desire a very
signicant increase in the dimension of the buttocks, or very thin patients with different degrees of ptosis and sagging tissues (Fig.24.12a–d).
ab
Fig. 24.12 (a–d) Oblique and posterior views of a patient before and after buttock makeover by
lipectomy, augmentation with implants and lipoinjection
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