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Fig. 27.15 Dissected
aps, appreciate the
extension of the tissue
removed from the patient
C. A. Ríos et al.
a
Fig. 27.16 (a) Resection of granulomas located between muscle fascicles. We do not resect muscle bers. (b) Appreciate the deepens reached to extract biopolymers
b
Depending on the muscular compromise evidenced in the MRI, we perform
dissection of granulomas located between the muscular fascicles, reaching deepness of 7–8cm (Fig.27.16). Then, we perform rigorous hemostasis and progres-
sive tension sutures over the entire ap. Finally it is sutured in three planes
more: fascia with 2–0 vicryl. Subcutaneous with monosyn 2–0 and skin with
monosyn 3–0.
27.9.1.4 Reconstructive Surgery
At least 6months after the retirement surgery, we assess the patient with a new MRI
and compare it with the preoperative MRI.Additional resections are planned if
necessary, we evaluate the volume decit, as well as the presence of excess body fat.
The possibility of using gluteal implantsit’s tangible, whether there is skin accidity, gluteal ptosis, orthe location and nal shape of the scars.
In this way, we can arrange for hybrid reconstructions with two or more techniques to be usedat the same time: Liposuction + Lipoinjection, local aps, silicone
implants, liftings, scar correction, and relocation (Fig.27.17).
27 Management ofPatients withASIA Syndrome inPlastic Surgery
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a
b
401
Fig. 27.17 A 37-year-old, female patient that underwent for large incisions surgerytowards biopolymers remotion. (a) Notice in the preoperative photography the anatomical deformities caused
by the biopolymers and the sick aspect of the area. (b) 12weeks postoperative of reconstructive
surgery, in this case we performed liposuction and hybrid gluteal augmentation with 300cc of fat
grated plus implants of 150cc in each gluteus, observe the natural and athletic appearance of the
buttocks and specially the healthy appearance
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Chapter 28
Complications inButtock Implants
Surgery: How toPrevent andTreat Them
PatricioCovarrubias, PauloGodoy, andNicolásFlores
28.1 Introduction
The rst buttock implant surgery was reported in 1969 [1], then fully described by
Gonzalez-Ulloa [2]. By that time, implants in a subcutaneous plane were used,
which obviously led to a high rate of complications, for having less natural results
and implant extrusion. Later, it experienced a peak in the 1980s thanks to Robles
with his submuscular technique in which he places the implants in a space under the
Gluteus Maximus muscle [3, 4]. De la Pena describes the implants with subfascial
technique [5, 6] and Vergara describes the intramuscular technique [7, 8] (which is
systematized by Raul Gonzalez, achieving more reproducible results) [9, 10].
Recently, the description of a real intramuscular anatomical space described by
Rodriguez-García has made it easier to better dene the range of dissection in this
surgical technique [11].
There are silicon elastomer implants and cohesive gel implants. Although both
fulll the same objective, they are very different in their behavior once implanted.
This would explain the difference on complications rates in different publications
[12–18].
The variety of techniques and implants has also inuenced the rate of complications to be very varied in literature and has not accomplished the management of
buttock remodeling to be uniform. The pocket locations for gluteal augmentation
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 13802- 7_28.
P. Covarrubias (*) · N. Flores
Clínica, Santiago, Chile
e-mail: patricio@drcovarrubias.cl
P. Godoy
Clínica, Sao Paulo, Brazil
© 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_28
405
406
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P. Covarrubias et al.
surgery with implants complications rate are the following: intramuscular (XYZ)
method (13.18%), submuscular (17.60%), intramuscular (18.05%), and subfascial
(54.84%) [19]. Probably, the most commonly used technique nowadays is the intramuscular one, along with the use of cohesive gel implants, which have made it a
much safer and more reproducible technique.
We will assess the major complications one by one, with a focus in the intramuscular technique and see in this chapter how to prevent and treat them.
28.2 Wound Dehiscence
28.2.1 Prevention
It is the most frequently reported complication in literature and it is described
between 8% and 40% [12, 14, 18, 24].
Some factors that affect in dehiscence are the following
– The zone where the incision is made (above the sacrum) is an area with a limit
irrigation.
– Excessive dissection of the subcutaneous space, which increases the possibility
of seromas in this area.
– Skin trauma when introducing the implant and dissecting the pocket.
– Closure with excessive pressure.
– Wound infection.
In order to prevent it, there are various alternatives that, when combined, can
help to reduce this risk.
– Dissection of limited subcutaneous space: It is not necessary to make a bigger
space than necessary to visualize the muscle, the dissection of this space must
not be exceed 4cm, from the middle line (Fig.28.1).
– Use of two parallel incisions (parasacral) to intergluteal fold: To perform two
incisions in order to avoid the middle zone that is badly vascularized and leave
Fig. 28.1 Reduced
subcutaneous dissection
around the incision allows
to reduce the subcutaneous
dead space
28 Complications inButtock Implants Surgery: How toPrevent andTreat Them
more space for a possible seroma, this also allows direct access to the muscle
thus avoiding generating a wide subcutaneous space. This decision can be dis-
cussed with the patient (Fig.28.2).
– Use of cutaneous protectors to prevent tissue trauma: The use of plastic cuta-
neous retractor (Pelosi’s device) allows trauma prevention when dissecting the
intramuscular pocket, a maneuver that many times can damage the skin. The use
of a funnel also avoids the friction of the implant with the skin, thus preventing a
trauma by compression (Fig.28.3, Video 28.1).
– Implant choosing: The implant must be chosen in accordance with the anatomic
characteristics of where it will be placed, i.e., the dimensions of Gluteus Maximus
muscle must be measured (this is performed with the contracted muscle) in order
to choose the appropriate base for the implant, which must exceed neither the
width nor the length of the contracted muscle.
– Use of barbed sutures for subcutaneous dead space closure: The use of these
sutures (i.e., Stratax Spiral PDS 2–0) permits a closure of the dead subcutane-
ous space by rmly adhering to both layers, thus preventing the formation of
seromas (Figs.28.4 and 28.5, Video 28.2).
– Use of negative pressure system (VAC Prevena): The use of this negative pres-
sure system allows reducing the tension of the suture on the wound as well as a
faster recovery. Being a closure with negative pressure, it also assists the collapse
of any virtual cavity that might be left, and therefore less collection of uid.
We use it continuously for 2–3weeks with a pressure of −125mmHg (Fig.28.6,
Video 28.3).
407
Fig. 28.2 Two parasacral
incisions that allow direct
access to the gluteus
maximus muscle
Fig. 28.3 “Pelosi”
retractor that allows
reducing skin damage
when inserting the implant
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Figs. 28.4–28.5 Closure
of the subcutaneous space
with barbed sutures
Fig. 28.6 Use of the VAC
Prevena negative pressure
system to reduce skin
tension and accelerate
healing
P. Covarrubias et al.
28.2.2 Treatment
In the presence of a wound dehiscence we must avoid infection; an exploration of
the subcutaneous space must be performed under local or general anesthesia. If the
implant is exposed, explantation must be considered. The implant pocket is isolated
closing the subcutaneous space and the wound as described above and using the
negative pressure system must be done again after surgical cleaning.
28 Complications inButtock Implants Surgery: How toPrevent andTreat Them
409
28.3 Implant Malposition
It can be presented in three forms:
28.3.1 Palpation and/or Implant Visualization
It is produced by a dissection in a very supercial plane, not leaving an appropriate
thickness of the covering Gluteus Maximus muscle or sometimes the implant has
been placed on a subcutaneous space [10]. The study requires MRI to evaluate the
plane where the implant is located (Fig.28.7).
28.3.1.1 Treatment
In order to correct it, we must perform an appropriate pocket in the intramuscular
plane, as if it were a primary surgery, performing the dissection in the intramuscular
plane, without removing the implant before making this dissection; once the pocket
has been accomplished, we remove the implant from the previous pocket. We prefer
closing this pocket with barbed sutures to obliterate the cavity. Next, we apply oxygenated water to get the adhesion of both faces of the capsule (Video 28.4, Figs.28.8
and 28.9).
Fig. 28.7 Magnetic
nuclear resonance showing
implant in the
subcutaneous plane
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Figs. 28.8–28.9 Pre- and postoperative replacement of gluteal implants from subcutaneous to
intramuscular plane
P. Covarrubias et al.
28.3.2 Implant Lateral Herniation
It is caused by not respecting the 45° direction that is recommended to follow the
muscle inclination when creating the intramuscular pocket, which causes an implant
herniation at lateral for breaking the muscle on the dissection [10]. The study
requires MRI to evaluate the implant position (Fig.28.10).
28.3.2.1 Treatment
In case of presenting a herniation in the lateral portion, the way to repair it is the
following: The implant is removed from the intramuscular pocket and then the herniation area is identied. The herniation is closed with barbed sutures, then a polypropylene mesh is placed on the herniated face and xed with polypropylene 2–0
stitches. Next, a capsulotomy is performed in the lateral part and the dissection is
bluntly continued in the appropriate intramuscular plane by following the 45° angle
in order to correctly place the implant (Video 28.5).
28.3.3 Lateralization and/or Implant Rotation
It is produced by an excessive dissection of the pocket, which is not according to the
base of the chosen implant [10]. This allows the implant to ip or rotate easily. The
study requires MRI images (Fig.28.11).
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