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Chapter 32
Gluteal Lipografting: Technique
andTransoperative Care
AndresFernando, DuranPinilla, andAndresVillateHernández
32.1 Introduction
Gluteal augmentation procedure has become more popular in recent years, according to ISAPS statistics, and it is now the tenth most performed procedure, with a
65% increase over the last 5years [1]. However, as a result of complications, such
as fat thromboembolism, fat injection in the submuscular plane has fallen into disuse and has been mostly replaced by injection in the subcutaneous plane. This plane
offers advantages as it reduces the possibility of fat injection in the large gluteal
vessels; however we must be extra cautious when injecting large amounts, to avoid
infections, seromas, fat necrosis, or irregularities. Multiple techniques for fat harvesting have been developed; however, complications associated with gluteal lipografting continue to be reported, of which fat embolism is one of the most severe
[2–6]. Therefore, the surgeon’s anatomic knowledge of the gluteal region must be
comprehensive and recognizes the individual needs of each patient to achieve the
desired contour, as well as control the structures involved in gluteal shape. Mendieta
describes four types of gluteal contour frames, focusing on deciency zones and
contour modiable zones [3, 4, 7].
Fat harvesting is usually obtained from the abdominal region and the dorsum.
With the introduction of new ultrasound and vibration-assisted liposuction technologies, fat harvesting is now facilitated but may affect the integration of the fat
graft. For this reason, in practice, when I am performing liposuction procedures on
patients who need gluteal lipotransfer, I keep the vaser energy at no higher than 60%
and usually with a 2–3 ring probe to avoid fat lipolysis. Depending on the desired
A. Fernando · D. Pinilla (*) · A. V. Hernández
Private practice, Atlántico, Colombia
© 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_32
445
446
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volume and the patient’s build, volumes ranging from 400 to 1000cc of transferred
fat can be used [3–5].
As described before, we understand that gluteal fat grafting is not an innocuous
procedure and that it requires an adequate training curve and precise anatomical
knowledge. Also, of no less importance, proper intraoperative and postoperative
management is needed to avoid fat resorption, which as noted in some articles is
evidenced in up to 35% of cases. Postoperative care is not standardized worldwide,
therefore, the strategies to obtain better results depend on the surgeon’s individual
experience, and is accompanied by a multidisciplinary team including professionals
such as anesthesiologists, nurses, and therapists, all performing a comprehensive
care not only from the medical aspect, but also using strategies such as massage and
noninvasive procedures.
A. Fernando et al.
32.2 Trans-Operative Care
32.2.1 Preoperative Evaluation
The initial consultation with the patient is important to discuss the expectations and
possible outcomes of the procedure, as well as to identify abdominal hernias, previous surgeries, skin alterations, and/or a body dysmorphic syndrome. The multidisciplinary evaluation also helps to identify and control possible pathologies that may
lead to postoperative complications. Body contouring surgery offers better results in
nonobese patients with minimal skin laxity [8–10].
The surgeon is responsible for clarifying any doubts that the patient may have
and for proposing a realistic outcome. Also, from the rst consultation we initiate
the postoperative plan and the treatment that the patient should follow.
In patients with advanced age, obesity (body mass index >30kg/m2), and cardiopulmonary disease, adequate medical and metabolic control by the multidisciplinary team should be indicated to identify patients at high risk of complications
such as pulmonary embolism [11]. The Caprini scale should be calculated in all
patients who will undergo liposuction and gluteal liposuction-gluteal transfer to
stratify the risk and assess the possibility of preoperative antithrombotic prophylaxis [12–15].
32.3 Postoperative Management
Regarding leaving the operating room, continuous monitoring of vital signs is mandatory for at least the rst 24h, in order to identify alterations in oxygenation and/
or hypothermia, which should be evaluated and corrected immediately [10, 16, 17].
32 Gluteal Lipografting: Technique andTransoperative Care
447
32.3.1 Postoperative Analgesic Control
Postoperative pain management is crucial to any surgical procedure and can condition the outcome and patient satisfaction. The traditional use of systemic drugs for
analgesic control is not immune to complications and adverse effects, such as nausea, altered state of consciousness, narcotic dependence, constipation, or respiratory
depression. New alternatives for control and reduction of possible adverse effects,
such as analgesic pumps, have been crucial in analgesic management in the rst
postoperative days [12, 13].
32.3.2 Postoperative Analgesia: Epidural Infusion Pumps
Epidural analgesia has gained popularity in recent years, demonstrating superiority
to systemic management with opioids, decreasing the mortality rate in major surgery by 15%; however, in plastic surgery there is insufcient evidence of decreased
mortality [15, 18].
Surgical trauma generates a stress response, associated with pain triggers that
can lead to the appearance of cardiac alterations, such as atrial brillation, supraventricular tachycardia. Postoperative epidural analgesia has been shown to reduce
these complications. Few complications have been described with epidural infusion
analgesia, such as hypotension, urinary retention, and pruritus [19].
32.3.3 Compression Therapy withGirdles
Compressive therapy uses a type of girdle, which goes from the thighs covering the
buttocks and abdomen, and may be accompanied or not by a bra, depending on each
case. It should be used for periods of 6–8weeks postoperative, as it helps the girdle
of intermediate-low compression (8–15mmHg) the rst 4–6days, and then increases
to a high compression (15–20mmHg). However, special care should be taken to
verify the measure of the girdle, as an incorrect measure can cause pressure areas,
hyperpigmentation, or pain.
Special care should be taken in the gluteal region, since discrepancies in the size
of the girdle can cause unwanted compression in the gluteal region; however, the
use of these is not restricted in patients who have been taken to lipografting, associated with another procedure such as abdominoplasty and liposuction. The patient is
asked to remain in prone position initially, having the ability to return to daily activities after the rst week. We recommend patients to use donut-shaped cushions when
performing activities that generate direct pressure on the gluteal area, such as
driving.
448
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A. Fernando et al.
32.3.4 Antithrombotic Prophylaxis
Determining the risk of thromboembolic event in plastic surgery is not a simple
task. Widely used scales such as Caprini/Pannucci do not take into account variables
that are common in patients undergoing cosmetic procedures, which should be identied by the treating surgeon and anesthesiologist. Airplane or bus travel may be
precursors to the occurrence of embolic events.
The combination of procedures can be deleterious to the patient and are associated with a higher rate of complications due to prolonged operative times.
Low molecular weight heparins are considered in all patients who will require
some type of immobilization or inactivity for a period not exceeding 7days. In
patients who are identied with high risk of thrombosis, it should be continued for
a period of 4weeks. It is recommended to start its application 8–12h after surgery
[10, 16, 17].
32.3.5 Elastic Compression Stockings
These stockings offer constant compression in the calf region, avoiding venous stasis and favoring venous return. They are useful when combined with intermittent
pneumatic compression, which acts based on two mechanisms, rst by reducing
blood stasis, improving drainage to the deep venous system and second by increasing brinolytic activity; and are recommended for use in the postoperative period.
32.3.6 Antibiotic Prophylaxis
Reports of gluteal lipotransfer infections vary from 0.3 to 1.96% [19, 20]. Bruner’s
early publications reported a 14% infection rate associated with autologous fat augmentation [21], and his observations led to the following conclusions about possible
causes and sources of contamination: inltration near the anal region, lipograft collection, and decanting systems in contact with the external environment, and the
hypoxic environment [6, 20, 21]. The latter is due in part to the early stages of fat
graft integration, before neovascularization begins, which starts in a period of
approximately 4–7days, while the transferred fat depends on the nutritional supply
of the recipient’s environment.
These observations have led to the development of antibiotic prophylaxis
schemes, starting from the preoperative period (with a minimum injection period of
30min prior to surgery), as rst line rst-generation cephalosporins, or gentamicin
if the patient is allergic.
Robertes recommends the use of antibiotic schemes in the intraoperative period,
based on the volume extracted, in which he mentions the application of sulbactam
32 Gluteal Lipografting: Technique andTransoperative Care
ampicillin, gentamicin, and rst-generation cephalosporins, for each 200cc of fat
extracted.
Within our protocol the antibiotic scheme is continued for 5days, or until the
drains are removed.
449
32.3.7 Monopolar Radiofrequency
The liposculpture improves the body contour; however, there can be areas of inltration accumulation, hematoma areas, or early seromas. The noninvasive procedures such as monopolar radiofrequency (RF) are one of the most used as a
coadjuvant for skin retraction, in areas where liposuction was performed. RF uses
frequencies above 1MHz, by transmitting energy in a monopolar manner to the tissues. It has been observed that it promotes changes in tissue composition, inducing
the formation of collagen type I, III, and elastin [11–26], helping skin retraction,
decreasing the formation of seromas, and decreasing edema of the liposuctioned
tissues [23, 24, 26].
The use of RF is reserved for areas where liposuction was performed; it is not
recommended for use in areas of gluteal lipografting, due to the thermal remodeling
that occurs; the elevation of tissue temperature in the area to be treated could cause
lysis of the adipocyte [11–13, 24].
There are few contraindications to the use of RF, as it has proven to be a safe and
effective procedure in the clinical and histologic setting; however it should be
avoided in patients with thin skin, vascular disease, collagen disorders, and chronic
corticosteroid use.
32.4 Massage Therapy andLymphatic Drainage
Manual lymphatic drainage is a special type of massage, recommended for the treatment of postoperative edema caused by surgical trauma and inltration of tumescent solution in liposuction areas; some authors use massage together with
postoperative ultrasonography, however it is only recommended to use these techniques in liposuction areas; no type of massage should be applied in lipograft
areas [25].
32.5 Complications
The reported complication rate varies between 7 and 10%, most of which are minor
complications. Minor complications include seroma, infection, fat necrosis, contour
irregularity, and sciatica. The main major complication is pulmonary fat embolism.
450
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A. Fernando et al.
There are two mechanisms for pulmonary fat embolism, the rst is circulatory
blockage by macroscopic fat particles, the second is pulmonary inammation
caused by hydrolyzed fatty acids from the microemboli, which causes edema and
hemorrhage [17, 22].
References
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2. Mendieta CG, Sood A. Classication system for gluteal evaluation. Clin Plast Surg.
2018;45(2):159–77. https://doi.org/10.1016/j.cps.2017.12.013.
3. Villanueva NL, Del Vecchio DA, Afrooz PN, Carboy JA, Rohrich RJ. Staying safe during
gluteal fat transplantation. Plast Reconstr Surg. 2018;141(1):79–86. https://doi.org/10.1097/
prs.0000000000003934.
4. Ghavami A, Villanueva NL.Gluteal augmentation and contouring with autologous fat transfer.
Clin Plast Surg. 2018;45(2):249–59. https://doi.org/10.1016/j.cps.2017.12.009.
5. Khouri RK, Rigotti G, Cardoso E, Khouri RK, Biggs TM.Megavolume autologous fat transfer.
Plast Reconstr Surg. 2014;133(3):550–7. https://doi.org/10.1097/01.prs.0000438044.06387.2a.
6. Che DH, Xiao ZB.Gluteal augmentation with fat grafting: literature review. Aesthetic Plast
Surg. 2020;45(4):1633–41. https://doi.org/10.1007/s00266- 020- 02038- w.
7. Wong WW, Motakef S, Lin Y, Gupta SC.Redening the ideal buttocks: a population analysis.
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8. Turin SY, Fracol M, Keller E, Markl M, Collins J, Krochmal D, Kim J.Gluteal vein anatomy:
location, caliber, impact of patient positioning, and implications for fat grafting. Aesthet Surg
J. 2020;40(6):642–9.
9. Astarita DC, Scheinin LA, Sathyavagiswaran L.Fat transfer and fatal macroembolization. J
Forensic Sci. 2015;60:509–10.
10. Cardenas-Camarena L, Bayter JE, Aguirre-Serrano H, etal. Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg. 2015;136:58–66.
11. Dayan E, Burns AJ, Rohrich RJ, Theodorou S. The use of radiofrequency in aesthetic
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GOX.0000000000002861.
12. Pöpping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Tramèr MR.Impact of
epidural analgesia on mortality and morbidity after surgery. Ann Surg. 2014;259(6):1056–67.
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13. Gramigni E, Bracco D, Carli F. Epidural analgesia and postoperative orthostatic haemodynamic changes: observational study. Eur J Anaesthesiol. 2013;30:398–404.
14. Abu-Ghname A, Perdanasari AT, Reece EM.Principles and applications of fat grafting in plastic surgery. Semin Plast Surg. 2019;33(3):147–54. https://doi.org/10.1055/s- 0039- 1693438.
15. Yoshimura K, Coleman SR. Complications of fat grafting: how they occur and how to
nd, avoid, and treat them. Clin Plast Surg. 2015;42(3):383–8. https://doi.org/10.1016/j.
cps.2015.04.002.
16. Duncan DI.Improving outcomes in upper arm liposuction: adding radiofrequency-assisted
liposuction to induce skin contraction. Aesthet Surg J. 2012;32(1):84–95. https://doi.org/1
0.1177/1090820x11429549.
17. Kaoutzanis C, Gupta V, Winocour J, etal. Cosmetic liposuction: preoperative risk factors, major
complication rates, and safety of combined procedures. Aesthet Surg J. 2017;37(6):680–94.
32 Gluteal Lipografting: Technique andTransoperative Care
18. Mendez BM, Coleman JE, Kenkel JM.Optimizing patient outcomes and safety with liposuction. Aesthet Surg J. 2018;39(1):66–82. https://doi.org/10.1093/asj/sjy151.
19. Sinno S, Chang JB, Brownstone ND, etal. Determining the safety and efcacy of gluteal
augmentation: a systematic review of outcomes and complications. Plast Reconstr Surg.
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20. Oranges CM, Tremp M, di Summa PG, etal. Gluteal augmentation techniques: a comprehensive literature review. Aesthet Surg J. 2017;37(5):560–9.
21. Bruner TW, Roberts TL III, Nguyen K.Complications of buttocks augmentation: diagnosis,
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23. de Araújo AR, Soares VPC, da Silva FS, da Moreira TS. Radiofrequency for the treatment
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abd1806- 4841.20153605.
24. Abraham MT, Mashkevich G. Monopolar radiofrequency skin tightening. Facial Plast Surg
Clin North Am. 2007;15(2):169–77. https://doi.org/10.1016/j.fsc.2007.01.005.
25. Machado AF, Farcic T, Júnior I, Baldan C, Masson IB, de Oliveira BA.Manual lymphatic
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period. Indian J Plast Surg. 2014;47(1):70. https://doi.org/10.4103/0970- 0358.129627.
26. el-Domyati M, el-Ammawi TS, Medhat W, Moawad O, Brennan D, Mahoney MG, Uitto
J. Radiofrequency facial rejuvenation: evidence-based effect. J Am Acad Dermatol.
2011;64(3):524–35. https://doi.org/10.1016/j.jaad.2010.06.045.
451
Index
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A
Abdominoplasty, 49
mortality rates for, 88, 89
systemic complications, 89
Adequate markings, 289
Adherences, 349, 351
Adipose derived stem cells (ASC), 244
Aesthetics, 321
Ambulatory surgical centers (ASCs), 50
Anatomical implants
advantages, 275
causes, 277
characteristics, 271, 272
disadvantages, 275
implant position, 274
implant rotation, 277
postoperative care, 275
Anesthesia, 57, 58
Anterior superior iliac spine (ASIS), 359
Antibiotic prophylaxis, 448
Antigravitational liposculpture, 169, 174, 184
safe zone, 184
Antithrombotic prophylaxis, 448
B
Biologic mimicry, 32
Bonobos, 33
Brazilian butt lift (BBL), 49, 51, 427, 431
AAAASF mortality data, 96–98
BAAPS decision, 92
gluteus maximus muscle, 90
intra-operative macroscopic pulmonary fat
embolism, 93
materials and methods, 92
national autopsy data, 94
pulmonary fat embolism, 90
Breast aesthetics, 32
Breast augmentation, 442
Breast implant associated anaplastic large cell
lymphoma, 313, 315–317
British Association of Aesthetic Plastic
Surgery (BAAPS), 92
Buttocks, 37–39, 43, 187–190, 193, 194
augmentation, 35, 177, 211, 213, 322, 331,
340, 366, 368, 377
ap, 365
lipoFilled ap, 365
dynamic denition liposuction
anatomy, 233
art, 233
fat grafting, 243, 245
female, 233
female markings, 234, 235
male, 237
male markings, 237, 239
surgery, 241, 242
fat inltration surgery, 120
inltration, 228
lifting, 326, 329, 333, 336, 340
marking, 359, 361
prostheses, 279
round implants
complications, 285
drains, 284
implant selection, 281
incision, 283
marking the patient, 282, 283
postoperative care, 284
surgical technique, 283, 284
waist-buttock-thigh triad, 280
surgery
© 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
453
454
Index
Buttocks (cont.)
complications, 135–138
implants, 130–132
types, 353, 354
C
Capsular contracture, 413
Capsulectomy, 315
Cárdenas, 122
Cellular vascular stromal fraction (cSVF), 244
Chronic seroma, 313, 314, 317
Circumferential body lift, 365
Cistocath, 439
Clarius ultrasound, 72
Coleman technique, 51, 57
Compressive therapy, 447
D
Deep intramuscular migration, 93
Deep liposuction, 233, 235, 237
Deep vein thrombosis (DVT), 62
Dehiscence gluteus, 420
Double buttock, 330
Drains, 439, 441
classication, 439
indications, 440, 441
objective, 441
E
Elastic compression stockings, 448
Epidural analgesia, 447
Expansion vibration lipolling (EVL),
52–53, 87, 305
Expansion vibration lipoinjection (EVL), 123
F
Fascial fat transplantation, 55
Fat absorption, 431
Fat component, 357
Fat embolism, 203
Fat embolism syndrome (FES), 121
Fat graft, 67–72, 75–82, 84, 85
Fat grafting, 67, 68, 71–78, 82–85, 134–136,
145, 174–177, 181–184, 187, 188,
192, 205, 210–213, 215, 243,
244, 442
adipocyte viability, 146, 147, 149,
152, 154–156
cannulas, 57
centrifugation, 151–156
decantation, 151–153, 156, 158
processing, 151
Fat inltration technique, 122–124, 223–226
Fat necrosis, 103, 104, 135, 202
Fear, gluteal surgery, 266
anal isolation, 267
antisepsis, 267
lm funnels, 269
incision, 268
patient positioning, 267
postoperative management, 270
preoperative marking, 266, 267
rapid muscle incision synthesis, 269
subcutaneous tunnel dissection, 268
supercial fat layer, 269
tapping, 270
tight intramuscular pocket, 268
Female buttocks, 32
FROD Intramuscular Space, 6, 25
G
Gltuteoplasty, 288
Gluteal aesthetics, 32, 37
Gluteal augmentation, 130–132, 194, 255,
256, 303, 441, 445
complications, 262, 263, 309, 310
fat grafting, 305
liposuction, 304
management, 262
plastic surgery, 310
posterior superior iliac spines, 257
postoperative care, 262, 309
power assisted liposuction, 260
pre-operative photography, 259
silicone implant placement, 306, 307
surgery, 6
surgical anatomy, 256–259
surgical technique, 260, 261
Gluteal contouring, 205, 215
Gluteal fat augmentation
complications, 202–203
concurrent power-aided tunnelization, 198
continous owstream fat-inltration, 198
operative technique, 199–202
patient safety, 188–190
perioperative protocols, 197
SAFE-technique, 197
synergistic approach, 198
vibration lipolling, 198
Gluteal fat grafting, 51, 67, 68, 71, 73, 75, 76,
82–84, 428, 434
Index
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455
anesthesia, 57, 58
Coleman technique, 51
excess, fatigue, 59–63
fat grafting cannulas, 57
fat transplantation process, 51
liposuction volume, 58–59
macroscopic PFE, 55
microscopic PFE, 56, 57
operator distraction, 59–63
pre-early detection, 55
ultrasound assisted fat grafting
technique, 53–55
Gluteal fat grafting safety advisory, 50
Gluteal fat transfer, 287
Gluteal-femoral bursa, 10
Gluteal implants, 5
Gluteal lipoinjection, 110
Gluteal ptosis, 347
Gluteal region, 6, 11, 13–18, 27
anatomical limits, 7
Gluteal Task Force, 90
Gluteoplasty, 287, 288, 294
Gluteus implant, 419, 420
Gluteus implant associated anaplastic large
cell lymphoma, 313, 316, 317
Gluteus maximus, 11, 14, 16
surgical anatomy, 17
Gluteus maximus fascia, 122
Gluteus maximus muscle, 6, 7, 9, 10, 14, 16,
18, 20, 21, 23–28, 90
Google and Ovid databases, 88
H
HIFEM®, 51
Hybrid component, 292, 301
Hybrid gluteoplasty, 288, 294
L
Lipectomy, 323, 330, 331, 336–338
Lipocell transfer, 256
Lipocontour technique
fat inltration, 223–226
lateral oblique muscles, 229
learning curve, 226–227
marking, 220–221
patient satisfaction, 227
single globular bundle, 227
surgical procedure, 221
Liposculpting, 43
Liposculpture, 206, 210, 212
Liposuction, 49, 58, 207, 210, 211, 213, 231, 304
Lower body lift, 365, 369, 377
Lymphatic drainage, 449
M
Macroscopic fat embolism (MAFE), 55,
110–115, 120, 121
patient safety, 124
recommendations, 124
Macroscopic PFE, 55
Margin of error, 95
Microaire, 223
Microscopic fat embolism (MIFE), 55,
110–115, 120, 121
Microscopic PFE, 56, 57
Minimal exposure fat grafting technique, 324
Minor drainage, 424
Modied Coleman "large syringe"
technique, 52
Monopolar radiofrequency, 449
Multi Society Gluteal Fat Grafting Task
Force, 50
Mycobacteria, 421–423
Mycobacterial infection, 106
I
Implant inclusion, 292
Implant infection, 413
Implant malposition, 409, 410, 412
Infection, 417, 418, 420, 421
N
Najar marking, 169, 173, 174, 181–183
Nefertiti, 32
Non-fatal pulmonary embolism, 120
Infragluteal echoes, 352
Interracial marriage, 35
Intramuscular pocket, 290, 291
Intraoperative macroscopic pulmonary fat
embolism, 94
O
Ofce-based surgery suites, 50
Oil cysts, 433
Irregularities, 349, 351
P
K
Kher tube, 439
Patient safety, 124
Penrose, 439
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