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28 Complications inButtock Implants Surgery: How toPrevent andTreat Them
Fig. 28.10 Patient with a
herniated gluteal implant
Fig. 28.11 Patient with
gluteal implant rotation
and ipping
411
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P. Covarrubias et al.
28.3.3.1 Treatment
In case of presenting an excessively wide pocket, we must remove the implant from
the pocket, measure the adequate width of the implant and, based on this measure,
close its lateral edge with barbed sutures obliterating it and then placing a polypropylene mesh on the edge we have created to achieve the appropriate support in that
area. The mesh is xed with Prolene 2–0 stitches. Then the implant must be placed
again on site (Videos 28.6 and 28.7).
28.4 Periprosthetic Seroma
It is the second in incidence according to literature, being reported between 3% and
19% of the cases [12, 14, 18]. It is mainly presented when using texturized implants;
therefore we recommend the use of smooth or nanosurface implants. The study
requires MRI images. Some authors recommend the use of drainage to reduce its
incidence, but according to our experience we do not use them and have not seen the
appearance of seromas.
28.4.1 Treatment
If there are no signs of infection in the cavity and the seroma has formed early
(within the rst postoperative month), the use of negative pressure therapy (i.e.,
VAC) can be tried, which is placed in the cavity with the implant. The sponge is
removed in repeated sessions until there is no outow of liquid, then the muscle and
wound are closed. In the event that the seroma is chronic or of late appearance, it is
recommended to remove the implant, place hydrogen peroxide to obliterate the cavity, and after 3–6months try a new surgery (Fig.28.12).
Fig. 28.12 Use of negative
pressure system (VAC) to
manage periprosthetic
seroma
28 Complications inButtock Implants Surgery: How toPrevent andTreat Them
413
28.5 Implant Infection
It is described between 1% and 4% [12, 14, 18]. This is a surgical emergency in
which the patient could present from local signs of infection to severe sepsis cases.
Immediate hospitalization must be done, with general laboratory tests as hemogram, white blood count, and infection markers. CT scan or MRI must also be performed to evaluate the presence of uid collection and its extension. The indication
is the immediate implant removal, washing the cavity thoroughly. Cultures are taken
and drainages must be made for at least 72h, along with starting antibiotic therapy
with ceftriaxone and metronidazole, until the results of the culture are obtained for
adjusting the therapy. The patient must stay hospitalized to be kept under observation and infectology management. The gluteal augmentation could be performed
after 6months.
28.6 Sciatic Nerve Compression
The associated pain to buttock augmentation has an incidence of about 1% [10, 12,
18]. It is presented as paresthesias and pain on the posterior face of the inferior
extremity. Its appearance is frequent during the rst days after the surgery and it is
mainly due to the swelling in the pocket’s dissection lower zone.
28.6.1 Treatment
It is treated by using Pregabalin in doses of 75–150mg/per day for 3weeks, also
methylprednisolone can be added. In addition, supporting the implant must be prevented, for which pillows can be used when lying or thigh pillows when sitting.
In case they were extended for more than a month, they could cause chronic
problems. In such case, it is convenient to assess changing it by a smaller implant
as, in such case, it could be the implant the one that directly compresses the nerve,
another alternative is to remove the implant and try another surgery after 3–6months.
28.7 Capsular Contracture
As in breast implants, cases of capsular contracture have been described, which
present strengthening and asymmetries at rest or in movement [20].
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P. Covarrubias et al.
28.7.1 Treatment
The management consists in removing the implant with capsulectomy. They must
be sent to studies of anaplastic large-cells lymphoma [21–23].
References
1. Bartels RJ, O'Malley JE, Douglas WM, Wilson RG.An unusual use of the Cronin breast prosthesis. Case report. Plast Reconstr Surg. 1969;44(5):500.
2. Gonzalez-Ulloa M.Gluteoplasty: a ten year report. Aesthet Plast Surg. 1991;15:85–91.
3. Robles J, Taglipietra J, Grandi M.Gluteoplastia de aumento: implante submuscular. Cir Plast
Iberolatinoamericana. 1984;102:4.
4. Hidalgo J.Submuscular gluteal augmentation: 17 years of experience with gel and elastomer
silicone implants. Clin Plast Surg. 2006;33(3):435–7.
5. De La Pena JA, Lopez-Momjardin H, Gamboa LF.Augmentation gluteoplasty: anatomical and
clinical considerations. Plast Cosmet Surg. 2000;17:1–12.
6. Mendieta C.The art of gluteal sculpting. 1st ed. St. Louis: Quality Medical Publishing; 2011.
7. Vergara R.Gluteal augmentation with silicone implants: a new proposal for intramuscular dissection. Aesthet Plast Surg. 2017;41(4):872–7.
8. Vergara R.Intramuscular gluteal implants 15 years experience. Aesthet Surg J. 2003;23(2):86–91.
9. Gonzalez R.Gluteal implant: the “XYZ” intramuscular method. Aesthet Surg J. 2010;30:256–64.
10. Gonzalez R.Buttocks reshaping posterior contourn surgery: a step-by-step approach including
thigh and calf implant. Rio de Janeiro: Indexa ed; 2006.
11. Rodriguez-García F, etal. Surgical anatomy of gluteus maximus muscle: FROD’S intramuscular space. Cir Plást Iberolatinoam. 2016;42(2):149–56.
12. Horn G.Gluteoplasty with intramuscular silicone cohesive gel implants: a retrospective study
of 50 cases. Ann Chirurg Plast Estet. 2009;54:467–76.
13. Senderoff DB. Buttock augmentation with solid silicone implants. Aesthet Surg
J. 2011;31(3):270–7.
14. Sinno S, et al. Determining the safety and efcacy of gluteal augmentation: a systematic
review of outcomes and complication. Plast Reconstr Surg. 2016;137(4):1151–6.
15. Cardenas Camarena L, Trujillo-Mendez R, Diaz-Barriga JC.Tridimensional combined gluteoplasty: liposuction, buttock implants and fat transfer. Plast Reconstr Surg. 2020;146(1):53–63.
16. Cardenas Camarena L, Silva-Gavarrete JF, Arenas-Quintana R.Gluteal contour improvement:
different surgical alternatives. Aesthet Plast Surg. 2011;35(6):1117–25.
17. Godoy PM, Munhoz AM.Intramuscular gluteal augmentation with implants associatted with
immediate fat grafting. Clin Plast Surg. 2018;45(2):203–15.
18. Asserson DB, etal. Differences in complication rates of gluteoplasty procedure that utilize
autologous fat grafting, implants, or local aps. Ann Plast Surg. 2019;82:342–4.
19. Flores-Lima G, Eppley BL, Dimas JR, Navarro DE. Surgical pocket location for gluteal
implants: a systematic review. Aesthet Plast Surg. 2013;37:240–5.
20. Moreira G, Ferreira L.Capsular contracture in gluteal implants patients: case report. Plast
Reconstr Surg. 2006;117(3):1070–1.
21. Piubelli Mario LM, Ferruno-Schmidt MC, Miranda RN.Gluteal implant-associated anaplastic large cell lymphoma (ALCL) is distinct from systemic ALCL ALK negative in a patient
with gluteal implants. Aesthet Surg J. 2019;39(10):NP441–2.
28 Complications inButtock Implants Surgery: How toPrevent andTreat Them
22. Orr Shauly BS.The rst reported case of gluteal implant-associated anaplastic large cell lymphoma (ALCL). Aesthet Surg J. 2019;39(7):NP253–8.
23. Mendes J Jr, etal. Gluteal implant-associated anaplastic large cell lymphoma. Plast Reconstr
Surg. 2019;144(3):610–3.
24. Serra F, etal. Reducing wound complications in gluteal augmentation surgery. Plast Reconstr
Surg. 2012;130(5):706e–13e.
415
Chapter 29
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Infection intheOperated Buttock
GuillermoRamos-Gallardo, MiguelÁngelLeónHernández,
JesúsCuenca- Pardo, DavidOrozco-Rentería, LazaroCardenas-Camarena,
andHéctorDurán
29.1 Microbiology
Infection with this procedure is related with contamination by gram negative most
commonly Escherichia coli, Bacteroides fragilis, Microaerophilic strep, pseudomo-
nas, enterococcus, non-gas forming Clostridium. Other possible causes are
Peptostreptococcus and Staphylococcus aureus [1]. That can be related with the
ora of the surrounding skin. The symptoms related with this problem are swelling,
inammation, redness, local hyperemia, or fever. At the beginning it may be consider part of the normal postoperative course even in the absence of any
complication.
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
M. Á. L. Hernández
Nuevo Hospital Civil de Guadalajara, Juan I.Menchaca, Universidad de Guadalajara,
Guadalajara, Mexico
J. Cuenca-Pardo · D. Orozco-Rentería · L. Cardenas-Camarena
Comite de Seguridad, Asociacion Mexicana de Cirugía Plastica, Estética y Reconstructiva,
Mexico City, Mexico
H. Durán
Merida, Yucatán, 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_29
417
418
G. Ramos-Gallardo et al.
29.1.1 Antibiotic Prophylaxis inGluteoplasty andMeasures
toPrevent Infection
Prophylaxis in case of infection is recommendable. For this area taking into account
the normal ora and the most common agents for gluteoplasty that includes liposuction with fat graft, combining implant placement or not, we may suggest second- or
third-generation cephalosporin. The most important part of prophylaxis is that antibiotics can be in the blood stream before surgical incision is done, following for a
coverage for 24h [2]. In case of implant placement alone or combining liposuction
with fat injection, timing should be considered. Special attention must be done to
the drain and seroma collection [3], if it is true that no evidence is available to prolong antibiotic until drainage is removed, on the other hand, seroma can be risk of
infection, for this reason antibiotic may justied (Fig.29.1).
29.1.2 Measures toDecrease Infection inFat Injection
Shower the day of the surgery is recommendable [4]. As a routine we don’t shave
the area. We keep lap pad soaked with povidone/iodine in gluteal cleft at the beginning of surgery that will be removed at the end of the procedure. In the case of
liposuction, we performed minimal handling of the fat. No washing and no centrifugation of the fat are done but only decantation. After fat harvesting, by simple use
of lap pad fat is separated from additional uid. But also use of a closed system is
desired. In this system, once the fat is recollected, uid is drained (decanted) through
the lower opening and after, we can graft the fat with the use of 60cc syringes for
small areas, or if the volume is more than 500cc the closed pump system to inject
Fig. 29.1 System used to
collect fat
29 Infection intheOperated Buttock
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Fig. 29.2 Implant exposed
after gluteal augmentation.
(Courtesy Dr. Martin Lira)
419
the fat (Fig.29.2). The fat is injected keeping angle less than 45° as much as possible in retrograde mode, trying to avoid danger zones, especially deeper structures.
Photographs in the operating room help to evaluate fat donor and recipient zones at
the time of the surgical procedure [5, 6]. In the case of gluteal implant, it is important to follow the same principles as breast implant placement.
29.1.3 Principles ofBreast Implants Applied
toGluteal Implants
We want to mention the proper care in gluteal implant placement.
It is suggested to follow 14 steps for proper placement of breast implants [7].
These principles should be applied to gluteus implants. We want to focus on the following aspects. The right evaluation of the patient, measuring and knowing according to the anatomy of the patient the gluteal implant. About the implant relevance
done in the surface. It is true, there is no clear etiology about breast implant associated to anaplastic large cell lymphoma [8, 9]. Some hypotheses say they come from
420
G. Ramos-Gallardo et al.
outside as biolm and some bacteria. Texture surfaces nowadays are more related
with BIA-ALC [10]. Smooth implants can be a better choice but adherence to tissue
is not the same as in texture.
About surgical technique, keeping exposure of the implant to a minimum possible can help. For this reason, removing the talc from the gloves, irrigation of the
implant inside the package, irrigation of the pocket, only one surgeon manipulates
the implant, as well as the introduction of the implant through the kenel funel, can
help reduce exposure and potential contamination. Placement of the drain is important. Drain tube can be colonized after 24h of placement, some measures have been
proved to be helpful to prevent complications with it, as impregnated gauze with
antiseptic to reduce bacterial colonization [11]. Meticulous techniques with proper
dissection, avoiding overuse of cautery, not exceeding the surgical time, and proper
care in the operating room will help decrease the possibility of an infection.
After surgery it is important to have a daily shower and cleaning of the surgical
incision; more studies are needed to know the best postoperative care [12]. Family
members or a nurse can assist the patient due the difculty to take care of this part.
Surgical incisions should be kept clean and covered with a gauze. Resting is recommendable, special care and position should be considered for an appropriate period
(10–14days). It is recommendable to prevent dehiscence of the surgical incision.
Exposure of the implant is not recommendable. In case this event happens removal
should be considered.
In the case of liposuction and fat graft, swelling and inammation can be part of
the normal recovery. Use of drains can help seroma, and pressure garment can make
immediate postoperative care more comfortable. Proper care and washing of the
pressure garment is important to keep it as clean as possible, it is acceptable to have
some uid related with the surgery to be present in the garment; for this reason
constant washing is recommendable.
29.2 Clinical Symptoms
If after following all the past instructions we notice redness, inammation, increase
of pain or purulent discharge, fever, chills, and malaise we should consider the possibility of an infection. It is important to keep record of complications in order to
know the incidence of this kind of event [13].
Initial lab test as complete blood cell count, blood chemistry, serum electrolyte,
and liver function tests should be ordered. Preexisting conditions as noncontrolled
hyperglycemia in diabetic patients or hypo-albuminemia in malnourished patients
may require management as well as the infection being treated. Also, borderline
patients with insulin resistance might in these conditions behave as immunosuppressed diabetic patients.
About the medical treatment empiric antibiotics can help. Antibiotic combination
of metronidazole or clindamycin with a second- or third-generation cephalosporin
should be initiated, taking in account the possibility of enterobacteria or skin ora.
29 Infection intheOperated Buttock
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421
Once the result of the cultures is conrmed, nal adjustment can be done. It is
desirable to take cultures before starting an antibiotic [1].
As any infected wound, drainage and irrigation are very important steps. Open
approach to allow the discharge of purulent uid should be performed. Debridement
of any nonviable tissue can be helpful as well, later reconstruction can be considered once source of infection is treated [14, 15]. Cultures should be taken at the time
of the surgical exploration.
Once the purulent discharge has been controlled and viable granulation tissue is
identied, the use of VAC can help to reduce the size of the open wound [14].
If implant is exposed, early removal can be convenient. Although is not well
accepted by the patient in the beginning.
We would like to mention that infection can be associated with another part of
surgery as, for example, sides where liposuction was done. Reports of severe infection associated with liposuction exist. Contamination of the surgical equipment taking into account as a source of infection the cannulas used. It is important to verify
the adequate sterilization process as well as cultures of the operating room (basin
work). Nontraditional methods to sterilize the equipment are associated with an
important source of infection causing devastating consequences. It is important to
rule out any past history of injection of unspecied treatments as mesotherapy that
can be an important source of bacteria or mycobacteria.
29.2.1 Mycobacteria
It is important to discuss the infection by mycobacteria. This type of infection in fat
grafting is a complex problem because of resistance to medical treatments and it is
difcult to make diagnoses with normal cultures [16]. Initially the infection is nonevident. The clinical symptoms start a few weeks after the procedure is done with
zones of erythema and swelling that evolve in a purulent discharge. More than one
site is affected [17].
Often, only routine bacterial cultures are obtained, which are not designed to
identify Mycobacterium species. For example, acid-fast (Ziehl–Neelsen) stains are
superior to routinely used Gram stain for detecting Mycobacterium species.
Although RGM rapid growth mycobacteria (RGM) grow on conventional bacterial
culture media, Lowenstein–Jensen or other mycobacterial culture media should be
used when Mycobacterium species are suspected [16, 17].
Polymerase chain reaction (PCR) is important to conrm the diagnoses [18].
Medical treatment is key. It is important to take precautions and identify the
source of the infection. Many cases have been related with decient water system in the hospital [18]. Rigorous sterile techniques must be followed, and all
surgical equipment should be veried and continuous cultures in the facility
should be encouraged. Most of the cases that are reported are seen in outbreaks.
We have seen outbreaks related with contamination in the cannula system in a
single hospital.
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