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24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
337
c
Fig. 24.12 (continued)
24.7 Postsurgical Management
d
The patient must remain at the surgical facility for a minimum period of 24h for
surveillance, antimicrobial coverage, analgesia, anti-inammation, antiemetics, and
measures for prevention of DVT such as the use of pneumatic intermittent compression stockings and enoxaparin, the latter begins 8h after surgery. In the immediate
postsurgical period a postsurgical garment is not used, only a noncompressive bandage so as not to compromise the viability of the aps and it is important to use a
cushion to reduce the pressure in the gluteal region. The wounds are inspected the
next day and assisted ambulation begins. The patient is instructed to perform proper
wound care and is scheduled for revision every 5days.
The drains are removed once the expense has decreased to 25cc in 24h for 3
consecutive days. Once the drains have been removed, the postsurgical garments are
placed and rehabilitation therapy with ultrasound, lymphatic drainage, radiotherapies, etc., is started according to the needs and evolution of each patient. One week
after drain removal the stitches are removed. The patient is instructed to avoid pressure in the area, avoid sitting for long periods of time, and continue using a special
cushion or donut to avoid pressure in the buttock area. In case of performing lipectomy the donut use begins 10days later to avoid pressure in the wound region and
its use continues for at least 2months.
338
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E. U. Góngora Alejandre and C. C. Solis López
In case of making an incision above the intergluteal crease for implant placement, it is important to instruct the patient to maintain a meticulous cleaning of the
area and to take a shower after each bowel movement.
24.8 Complications andIts Management
This section will discuss the complications of the buttock reshaping and lifting with
lipectomy since the complications of buttock augmentation with lipoinjection or
implants have been widely discussed by several authors and are widely known.
Therefore, we will only discuss the complications of lipectomy in “seagull wings”
with gluteal augmentation in its different modalities.
24.8.1 Transitory Ischemia ofFlaps
This complication occurs mainly in patients in whom aggressive liposuction of the
back is performed, patients whose large dermal-fat aps are resected and in which
the wound may present a certain degree of tension, or in patients in which secondary
to wide tissue resection is necessary to perform a cephalic dissection of the lumbar
ap to achieve adequate advancement and closure of the wound. Although this complication is not frequent, it is important to keep a close postsurgical surveillance in
order to establish the management as soon as possible and avoid any transient ischemia that can progress toward a partial necrosis of the ap (Fig.24.13a).
Among the general measures for the management of this complication are to
avoid any type of pressure that can be exerted in the area, remove compressive bandages, application of local heat in the area, supplement with oxygen in nasal tips,
and local application of 2% nitroglycerin ointment in the affected area with a plastic
cover over the region. This is repeated every 12h according to the evolution of the
Fig. 24.13 (a) Transient ischemia of the ap in a patient. (b) Supercial eschar formation after
7days of evolution
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
patient. It is important to warn the patient about possible adverse effects of the
nitroglycerin ointment (dizziness, nausea, headache, redness of skin, fainting,
sweating, etc.). We have also found helpful the use of oral pentoxifylline 400 mg
every 12 h.
Usually, after starting this treatment, transient ischemia remits after approximately 5–7days and there is a favorable evolution in most cases. However, in some
cases, there is blister formation and partial necrosis of the dermis, which is presented clinically as a supercial eschar and which usually evolves favorably with
epithelialization (Fig.24.13b).
339
24.8.2 Non-Aesthetic Scars
Since this procedure involves large incisions it also involves large scars. In some
cases, they can be irregular, asymmetric, hyper pigmented, or, in the worst case,
hypertrophic or keloid. In case of requiring scar revision this is done 6months after
surgery.
24.8.3 Skin Necrosis
It is a rare complication, if it occurs, conservative management and surveillance
begins until the damage is delimited, which occurs in a period of 1 or 2weeks. Once
the area of necrosis is delimited excision of the area of necrosis is made and direct
closure is performed.
24.8.4 Wound Dehiscence
When dehiscence cases occur these are generally limited to small areas of a few
centimeters in the areas of greatest tension such as the central regions of the aps.
If the tissues are in suitable conditions, conservative debridement and direct closure
are performed.
24.8.5 Asymmetry ofButtocks
It is a very rare complication. It refers to the difference in the height and/or position
of the buttocks when augmentation is performed with implants and is attributed to
malposition due to rupture of the intramuscular pocket and displacement of the
340
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E. U. Góngora Alejandre and C. C. Solis López
implant. If presented, surgery renement is performed to reposition the implant
6months after surgery.
24.8.6 Neuropathic Pain
This complication is very rare, and occurs in cases of buttock augmentation with
implants of signicant volume and occurs by compression of the sciatic nerve. This
complication is extremely rare and has occurred in only two patients in my 25-year
career. The patient presents pain and paresthesia in the pelvic limb, as well as weakness of the musculature. Initial management has been carried out in both cases with
analgesics, anti-inammatories, steroids, physiotherapy, etc., with torpid evolution.
The denitive management was the withdrawal of the gluteus implant.
24.8.7 Insatisfaction withtheResult
It is important to note that patients never complain about the length of the “seagull
wings lipectomy” scar in the postoperative period. The patient should be thoroughly
explained in the presurgical consultation that the only way to obtain an adequate
buttock lift and reshaping in order to obtain an aesthetic result is through this big
incision and that an exchange will be carried out. That is, we will obtain the silhouette that the patient has always dreamed of in exchange for making a very large
incision. The scar generally has an adequate evolution and is easily hidden under
clothes and even under a bathing suit (Fig.24.14). A patient satised with the shape
abc
Fig. 24.14 (a–c) The scar can be easily hidden even under a tiny bathing suit
24 Advanced Techniques forButtock Restructuring, Reshaping, andLifting
341
and volume of her buttocks will never complain about the scar. When there is some
kind of dissatisfaction in the result it is usually because they want a greater volume.
In 25years I have only presented one case in which the patient reported dissatisfaction with a volume that seemed excessive for her and requested that the implants be
removed.
References
1. Mendieta CG, Sood A.Classication system for gluteal evaluation: revisited. Clin Plast Surg.
2018;45(2):159–77.
2. Centeno RF.Gluteal aesthetic unit classication: a tool to improve outcomes in body contour-
ing. Aesthet Surg J. 2006;26(2):200–8. https://doi.org/10.1016/j.asj.2006.01.001.
3. Mod MM, Teitelbaum S, Suissa D, etal. Report on mortality from gluteal fat grafting: recom-
mendations from the ASERF task force. Aesthet Surg J. 2017;37:796–806.
4. Del Vecchio DA, Villanueva NL, Mohan R, Johnson B, Wan D, Venkataram A, Rohrich
RJ. Clinical implications of gluteal fat graft migration: a dynamic anatomical study. Plast
Reconstr Surg. 2018;142(5):1180–92. https://doi.org/10.1097/PRS.000000000000502.
5. Aslani A, Del Vecchio D. Composite buttock augmentation: the next frontier in gluteal
aesthetic surgery. Plast Reconstr Surg. 2019;144(6):1312–21. https://doi.org/10.1097/
PRS.0000000000006244.
6. Vergara R, Marcos M.Intramuscular gluteal implants. Aesthet Plast Surg. 1996;20:259. https://
doi.org/10.1007/s0026699000306.
Chapter 25
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The Post-Bariatric Buttock
MartínMorales-Olivera
25.1 Introduction
The lower body contour is the region of greatest clinical stigma after massive weight
loss. This contour includes the abdomen, thighs, and gluteal region, and are also the
topography of greatest concern and most popular for reconstruction.
We should keep in mind that patients who lose weight after bariatric surgery
(postbariatric patient), present a series of nutritional, histological, and clinical
changes, placing them in a very particular study group as compared to a conventional cosmetic patient.
The severity of these changes (also called sequelae) depends on the bariatric
surgery performed, as there are very signicant differences between restrictive (gastric sleeve, adjustable gastric band, intragastric balloon), and malabsorptive procedures (Roux-en-Y gastric bypass, biliopancreatic diversion, duodenal switch). The
most common and performed worldwide are the bypass and gastric sleeve
(Table25.1).
As such, in addition to these factors, the resulting body deformities will also
depend on the weight loss (the greater the degree of obesity, the greater the loss and
sequelae), but will generally occur in all segments and body areas, including the
gluteal region.
Therefore, in order to better understand the gluteal region changes in a postbariatric patient and conduct their correct evaluation, we should remember that there
are specic anatomical changes in the four anatomical structures involved in “ideal
buttocks”: the skin, fat, muscle, and bone components.
M. Morales-Olivera (*)
Hospital General Tláhuac, 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_25
343
344
Table 25.1 Severity of sequelae
Severity of sequelae
Nutritional
changes
Histological
changes
Clinical changes Great loss of subcutaneous fatty tissue (almost
Iron deciency Uncommon Common
Zinc deciency Uncommon Common
Vitamin B1 deciency Rare Common
Vitamin B12 deciency Very rare Common
Vitamin C deciency Very rare Common
Density changes of elastic bers Uncommon Very
Morphology changes of elastic bers Uncommon Very
Collagen density changes Uncommon Very
Collagen morphology changes Uncommon Common
exclusively skin aps)
Increased cervicofacial contour deformity Uncommon Very
Increased upper body contour deformity Uncommon Very
Increased lower body contour deformity
(including the gluteal region)
M. Morales-Olivera
Gastric
sleeve
Uncommon Very
Uncommon Very
Gastric
bypass
common
common
common
common
common
common
common
25.2 Post-Bariatric Anatomic Changes oftheGluteal Region
25.2.1 The Skin Component
As indicated above, post-bariatric patients present skin histological alterations
depending on the procedure performed, and this will have a direct impact on the
clinical presentation of the skin surface (larger aps, higher degree of rhytidosis,
and greater number of irregularities).
Changes in density and morphology of elastic and collagen bers, as well as
thickening of the epidermis, hyperplasia, and parakeratosis, are very common histological changes in patients who underwent gastric bypass (especially in those who
had class II or greater obesity), and therefore lose viscoelasticity, which is reected
as greater laxity.
Similarly, these histological alterations pose a greater risk of presenting alterations in the surgical site, such as epidermolysis, necrosis, and dehiscence. These
pose a relative risk 14 times greater than for a conventional patient.
As such, the gluteal skin component of a post-bariatric patient must be handled
in a very specic way with surgical accessories that allow us to close with less reactive and stiffer suture material (such as tissue adhesives), while achieving complete
healing of the wound.
25 The Post-Bariatric Buttock
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345
25.2.2 The Fat Component
Buttocks are closely related to all the structures adjacent to the posterior contour to
have a certain shape or projection, where fat plays an essential role, both externally
and internally.
Externally, factors such as the lack of waistline have an inuence, given large
fatty deposits in the sacral or suprasacral region, and internally, providing adequate
tissue rmness by lling the connective-brotic tissue network of the gluteal region.
That is why fat is a fundamental factor for gluteal aesthetics, as much of the
volume, especially in female patients, consists of fat located in the subcutaneous
region. This fat is usually rm because the subcutaneous tissue of this region is
mostly rich in dense connective tissue, resulting in rmness of the local tissue.
Therefore, in thin patients with a lack of fat that lls said connective-brotic tissue, it converts the loose subcutaneous plane and causes gluteal ptosis, which can in
turn come with cutaneous accidity.
In post-bariatric patients, weight loss certainly involves structural alteration of
the adipocytes, presenting interstitial brosis, hypertrophy of the vessel wall, and fat
necrosis.
Therefore, the loss and structural and density modication of collagen bers and
elastin, as well as modications of the adipose tissue in all planes (including the
subcutaneous region), result in severe clinical alterations (ptosis in any degree,
aps, and depressions), regardless of the patient bone and muscle characteristics.
This is why most post-bariatric patients present sequelae at the buttock contour
region, despite having a gradual and controlled weight loss and an adequate muscle
strengthening routine, because the physiological-nutritional-histopathological disorder in the skin and fat components cannot be corrected with exercise.
25.2.3 The Muscle Component
Muscles giving volume to the gluteal region (both supercial and deep) are thinner
and with greater accidity in post-bariatric patients, unlike a conventional patient.
This is because the vast majority are used to a sedentary lifestyle (both before
and after the bariatric procedure), mainly affecting the gluteus maximus muscle,
since daily activities do not require the use of said muscle that much.
The supercial muscle plane is made up of the gluteus maximus and gluteus
medius muscles. The former is the largest and thickest in the region, usually reaching a measure of up to 6–7cm thick at its origin next to the sacrum, becoming thinner toward its lateral limit (2–3cm thick). However, in post-bariatric patients, these
dimensions are considerably reduced, a signicant factor to consider in the placement of buttock implants.
In addition, the supercial gluteal fascia, which is usually quite thick, and which
provides complete coverage to the gluteal muscle region (from the iliac crest and
346
M. Morales-Olivera
tensor fascia lata, covering the gluteus medius and gluteus maximus), also loses
volume and especially rmness (because it is connective tissue, collagen, and elastin bers).
Ultimately, said fascia presents septa-shaped expansions that divide the gluteus
maximus into multiple fascicles, which can be highly resistant (and even inelastic),
causing gluteal retractions, a clinical phenomenon present in most post-bariatric
patients, addressed in the following chapters.
For all these reasons, post-bariatric buttock contouring poses a real surgical
challenge.
In deep muscles (gluteus minimus, pyramidal, upper and lower calves, internal
and external obturator), no important changes have been identied that may have an
impact on the clinical sequelae of these patients.
25.2.4 The Bone Component
The overall image of the gluteal region depends on its shape, volume, and projection. As previously mentioned, these result from the conformation and characteristics of the skin, fat, and muscle components. However, a noteworthy factor (that we
often forget to indicate to the patient during the initial examination), is the bone
structure per se of each individual, as it will give the general proportion of the lower
body contour in relation to the upper body contour.
As such, we should remember that the shape of the gluteal region is dened
mostly by bony structures: the iliac crest in its upper part, and laterally by a line that
goes from the anterior superior iliac spine to the greater trochanter, and then through
an imaginary line from the greater trochanter to the gluteal sulcus.
In post-bariatric patients, we can identify important modications in the bone
structure, but especially in the upper body, given that for people who have been
obese since childhood or are still in development; the ventilation mechanism is
generally dysfunctional (obesity hypoventilation syndrome or obstructive sleep
apnea) that is clinically presented with a large diameter rib cage and a forced inspiration or emphysema.
Such modications cause a disproportionate image of the upper shape in relation
to the lower one, both in an anteroposterior and lateral view (Images 25.1 and 25.2).
For this reason, when a patient presents such bone alterations, it becomes the
most difcult factor to improve, since this component cannot be directly modied,
thus resorting to the other three (skin, fat, and muscle) to offset the disproportion.
For this purpose, we must turn to surgical techniques that generate an actual
increase in the gluteal region, the pelvis, and the lower contour in general.
25 The Post-Bariatric Buttock
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Images 25.1–25.2 Disproportion between the upper and lower body contours
25.3 Post-Bariatric Gluteal Ptosis
347
Gluteal ptosis is skin redundancy and caudal adipose tissue beyond the gluteal sulcus in the midpoint of posterior thigh. Taking Raúl González’s gluteal ptosis classication as reference, post-bariatric patients present Grade IV Ptosis (true Ptosis)
and Grade IV Ptosis (dysfunctional ptosis) (Images 25.3 and 25.4).
It is common that patients who presented a loss greater than 50kg also present a
grade IV ptosis, where the infra-gluteal sulcus exceeds the M line (sagittal line that
crosses the midpoint of posterior thigh), with ptotic tissue beyond that.
In patients with more severe weight loss, grade V ptosis is identied, where there
is complete dysfunction of the gluteal support system.
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