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64
D. Del Vecchio
the anticipated liposuction volume, volume and location of transplanted fat, anes­thesia route, facility type, and the patient’s overall health status.
The management of the postoperative period is critical to the outcome of BBL.Qualied staff provide the appropriate post-anesthesia and postoperative care. Particularly in larger-volume cases, management of uid and electrolyte balance, pain management, and monitoring for complications are important and the use of home-monitoring devices shows early promise as future potential standards of care.
Research ndings over the past 6years have demonstrated safe and unsafe ana­tomic depths to transplant fat in the gluteal region. With the advent of a practical ultrasonic technique that is time-efcient, surgeons can now safely and accurately reach the correct depth to insert fat. With this nal breakthrough, we expect BBL mortality rates to drop over time, commensurate with or better than those of abdom­inoplasty and liposuction.
When performed by a surgeon with a thorough knowledge of the pathophysio­logic implications of this surgery, and by a surgeon who understands and respects his or her own physical and cognitive limitations, gluteal fat grafting can be a safe procedure that results in signicant patient satisfaction.
References
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advocacy/key- issues/fat- grafting- to- the- buttocks. Accessed 10 Oct 2021.
2. Mod MM, Teitelbaum S, Suissa D, etal. Report on mortality from gluteal fat grafting: rec­ommendations from the ASERF Task Force. Aesthet Surg J. 2017;37(7):796–806. https://doi.
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3. Thorne CH Matarasso A, Richter D, Coleman SR, Magalon G.Gluteal fat grafting advisory.
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4 Practice Advisory onGluteal Fat Grafting
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13. History of the Brazilian Butt Lift in Brooklyn—Dr. Leonard Grossman. https://www.youtube.
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14. Del Vecchio DA, Rohrich RJ.A changing paradigm: the Brazilian butt lift is neither Brazilian nor a lift—why it needs to be called safe subcutaneous buttock augmentation. Plast Reconstr Surg. 2020;145(1):281–3. https://doi.org/10.1097/PRS.0000000000006369.
15. Del Vecchio DA, Rohrich RJ. A classication of clinical fat grafting: different problems, different solutions. Plast Reconstr Surg. 2012;130(3):511–22. https://doi.org/10.1097/
PRS.0b013e31825dbf8a.
16. Coleman SR.Fat grafting to the buttocks, live surgical demonstration. The Aesthetic Meeting 2013—ASAPS/ASERF Annual Meeting, NewYork, NY.April 11, 2013–April 16, 2013.
17. Abd-Elfattah HM, Abdelazeim FH, Elshennawy S. Physical and cognitive consequences of fatigue: a review. J Adv Res. 2015;6(3):351–8. https://doi.org/10.1016/j.jare.2015.01.011.
18. Del Vecchio DA, Wall SJ.Expansion vibration lipolling—a new technique in large volume fat transplantation. Plast Reconstr Surg. 2018;141(5):639e–49e. https://doi.org/10.1097/
PRS.0000000000004338.
19. Cansancao AL, Condé-Green A, Vidigal RA, Rodriguez RL, D'Amico RA. Real-time ultrasound- assisted gluteal fat grafting. Plast Reconstr Surg. 2018;142(2):372–6. https://doi.
org/10.1097/PRS.0000000000004602.
20. Grazer FM, De Jong RH.Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 1990;105(1):436–46. https://doi.org/10.1097/00006534- 200001000- 00070.
21. Wall S Jr, Del Vecchio D, Teitlebaum S, et al. Subcutaneous migration: a dynamic ana­tomical study of gluteal fat grafting. Plast Reconstr Surg. 2019;143(5):1343–51. https://doi.
org/10.1097/PRS.0000000000005521.
22. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H, Cuenca-Pardo J. Deaths caused by glu­teal lipoinjection: what are we doing wrong? Plast Reconstr Surg. 2015;136(1):58–66. https://
doi.org/10.1097/PRS.0000000000001364.
23. Cárdenas-Camarena L, Durán H, Robles-Cervantes J, et al. Critical differences between microscopic (MIFE) and macroscopic (MAFE) fat embolism during liposuction and glu­teal lipoinjection. Plast Reconstr Surg. 2018;141(4):880–90. https://doi.org/10.1097/
PRS.0000000000004219.
24. Nissar S. Emergency management of fat embolism syndrome. J Emerg Trauma Shock. 2009;2(1):29–33. https://doi.org/10.4103/0974- 2700.44680.
25. Del Vecchio DA, Villanueva NL, Mohan R, etal. Clinical implications of gluteal fat migra­tion: a dynamic anatomical study. Plast Reconstr Surg. 2018;142(5):1180–92. https://doi.
org/10.1097/PRS.0000000000005020.
26. Macias AA, Ramos-Gallardo G, Durán H.Macro fat embolism after gluteal augmentation with fat: rst survival case report. Aesthet Surg J. 2019;39(9):NP380–3. https://doi.org/10.1093/
asj/sjz151.
27. Wang NN, Panda N, Jeong S, etal. Cerebral fat embolism in a trauma patient with captured imaging of echogenic emboli in the inferior vena cava. J Med Ultrasound. 2016;24(1):162–5.
https://doi.org/10.1016/j.jmu.2016.08.006.
28. Dayan E, Theodorou S, Del Vecchio D. Nanotechnology and articial intelligence: a novel technique for patient assessment after radiofrequency assisted liposuction and gluteal fat trans­fer. Submitted for publication. Aesthet Surg J. 2022.
29. Brown S, Lipschitz A, Kenkel J, et al. Pharmacokinetics and safety of epinephrine use in liposuction. Plast Reconstr Surg. 2004;114(3):756–63. https://doi.org/10.1097/01.
prs.0000131021.17800.be.
30. Del Vecchio D. Common sense for the common good: staying subcutaneous during fat transplantation to the gluteal region. Plast Reconstr Surg. 2018;42(1):286–8. https://doi.
org/10.1097/PRS.0000000000004541.
31. What is awake Brazilian butt lift? https://millardplasticsurgery.com/liposuction- info/awake-
bbl/. Accessed 10 Oct 2021.
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32. Hyman MC, Vemulapalli S, Szeto WY, et al. Conscious sedation versus general anesthe­sia for transcatheter aortic valve replacement: insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy. Circulation. 2017;136(22):2132–40. https://doi.org/10.1161/
CIRCULATIONAHA.116.026656.
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org/10.1097/PRS.0000000000005067.
35. Iverson RE, Lynch DJ. Practice advisory on liposuction. Plast Reconstr Surg. 2004;113(5):1478–90. https://doi.org/10.1097/01.prs.0000111591.62685.f8.
36. Beidas OE, Gusenoff JA.Update on liposuction: what all plastic surgeons should know. Plast Reconstr Surg. 2021;47(4):658–68. https://doi.org/10.1097/PRS.0000000000007419.
37. Chow I, Alghoul MS, Khavanin N, etal. Is there a safe lipoaspirate volume? A risk assess­ment model of liposuction volume as a function of body mass index. Plast Reconstr Surg. 2015;136(3):474–83. https://doi.org/10.1097/PRS.0000000000001498.
38. Gladwell M.Outliers. Boston: Little, Brown and Company; 2008.
39. How much is a Brazilian butt lift in NewYork? https://www.google.com/search?client=refox-
b- 1- d&q=how+much+is+a+BBL+in+New+York+City. Accessed 10 Oct 2021.
40. How much is Brazilian butt lift in Miami? https://www.google.com/search?q=how+much+is+
a+BBL+in+Miami&client=refox- b- 1- d&sxsrf=AOaemvLWMjelsB_oWAUCqJYMo4ougU WFJA%3A1635345300597&ei=lGN5YdTfI7moqtsPwNmZeA&ved=0ahUKEwjU- ef95- rzA hU5lGoFHcBsBg8Q4dUDCA0&uact=5&oq=how+much+is+a+BBL+in+Miami&gs_lcp=C­gdnd3Mtd2l6EAMyBQgAEIAEMgYIABAWEB4yBggAEBYQHjIGCAAQFhAeMgYIABA WEB4yBggAEBYQHjIGCAAQFhAeMgYIABAWEB4yBggAEBYQHjIGCAAQFhAeOg­cIABBHELADSgQIQRgAUMC0AlimvAJgy84CaAFwAngAgAGGBogB8hySAQM2LTWY AQCgAQHIAQjAAQE&sclient=gws- wiz. Accessed 10 Oct 2021.
41. Denson JL, McCarthy M, Fang Y, Evans L.Increased mortality rates during resident handoff periods and the effect of ACGME duty hour regulations. Am J Med. 2015;128(9):994–1000.
https://doi.org/10.1016/j.amjmed.2015.03.023.
42. Kato H, Jena AB, Tsugawa Y.Patient mortality after surgery on the surgeon’s birthday: obser­vational study. Br Med J. 2020;371:4381. https://doi.org/10.1136/bmj.m4381.
43. Aylin P, Alexandrescu R, Jen M, Mayer E, Bottle A.Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. Br Med J. 2013;346:f2424. https://doi.org/10.1136/bmj.f2424.
44. Neal DJ.Fatal Brazilian butt lift was day’s 7th illegal surgery by coral gables doctor. Miami Herald. 2021. https://www.miamiherald.com/news/health- care/article256016237.html. Accessed 27 Nov 2021.
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www.iii.org/fact- statistic/facts- statistics- distracted- driving. Accessed 10 Oct 2021.
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50. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2–3):70–8.
D. Del Vecchio
Chapter 5
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting Procedure Safe
PatPazmino
5.1 Introduction
Gluteal contouring and augmentation has proven to be a powerful and extremely popular addition to the body contouring armamentarium of the plastic surgeon.
This has been driven largely by patient demand as over the last 10–20 years soci­ety’s ideals of beauty have continued to expand. Beautiful is now possible at any size and in many shapes. Patients are specically requesting fuller hips and buttocks both as stand alone procedures, and to complement other breast and body contour­ing surgeries [1–4].
It is possible to emphasize gluteal contours with liposuction and fat extraction alone. Mild asymmetries and depressions can also be effectively corrected with fat separation and fat shifting [5–7]. However, true gluteal augmentation can only be done with fat grafting.
Gluteal augmentation with fat grafting has been proven to be effective in the plastic surgery literature and memorialized by patients and surgeons throughout social media [2, 8]. This is a powerful technique, but it must be performed cautiously.
Over the last 10 years, there has been an excessively high number of complica­tions and patient deaths after gluteal fat grafting. Fat pulmonary emboli are the most common fatal complication that can occur when fat grafting is performed intramuscularly into the gluteus maximus and the fat graft is inadvertently injected into the gluteal veins [3, 9–11]. The now intravascular fat graft travels to the heart, lungs and brain with fatal results. Deaths from fat pulmonary emboli have occurred throughout the world, but in the United States, South Florida has been the epicenter of these tragedies. In the last 10 years, in South Florida alone, 20 deaths from fat
P. Pazmino (*) Division of Plastic Surgery, University of Miami, Miami, FL, USA e-mail: ultra@miamia.com; dr@miamia.com
© 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_5
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P. Pazmino
pulmonary emboli have been identied by the Medical Examiner of Miami Dade County [12]. The postmortem results conrmed a two hit hypothesis for this fatal complication: fat must be injected into the muscle and a gluteal vein injury must occur. These events most commonly happen when fat is injected into the gluteus maximus or deeper muscles and the fat grafting cannula inadvertently injures the gluteal veins, creating an opening for the fat graft to enter the venous system with fatal results [3].
These autopsy results were reviewed by the Multi-Society Task Force for Safety in Gluteal Fat Grafting (Rubin, Mills, Saltz, etal) as they designed cadaver research to further study this issue. The Task Force was able to delineate the vascular gluteal danger zone and describe safer cannula angles and lengths to avoid these injuries. The Task Force issued guidelines for safe gluteal fat injection which included con­stant vigilance of the cannula tip during fat grafting, a rigid cannula system, and most importantly to avoid intramuscular fat injection by staying above the deep gluteal fascia that lies on the external surface of the gluteus maximus at all times [13].
The South Florida surgeons who had the fatal fat pulmonary emboli mortalities used different fat graft volumes, different patient positions, different access inci­sions, and different cannula styles, but the one factor all of these deaths had in com­mon was that every surgeon insisted that they were subcutaneous and above the deep gluteal fascia at all times. Unfortunately, the autopsies disagreed [14]. The South Florida experience demonstrates that surgeons currently do not have a consis­tent and reliable way to always know the position of their cannula tip during gluteal fat grafting. Furthermore, surgeons have no way to prove that they only injected fat subcutaneously and to document that they never injected fat into the gluteal muscles to protect themselves for medicolegal reasons.
It is because of the possible dangers with this procedure that plastic surgeons must not abandon gluteal fat grafting. Gluteal fat grafting is a powerful tool that can augment tissue, correct deformities, and create impressive results that cannot be produced any other way. Because of this, high patient demand for this procedure will continue. If board certied plastic surgeons stop performing this procedure, interested patients will simply go to the non board certied practitioners who have had the majority of the complications (Lew 2018) and even more deaths will occur. As researchers and patient advocates, plastic surgeons must study this technique and determine how gluteal fat grafting can be performed safely and consistently.
Ultrasound can help plastic surgeons achieve these goals. Ultrasound can be used to evaluate the thickness and quality of the subcutaneous envelope pre-operatively. In the last 3 years, ultrasound equipment has become portable, wireless, and afford­able opening the door for its use in the sterile eld of the OR. Ultrasound visualiza­tion can be used with any cannula style or injection system [15]. Real time intraoperative ultrasound visualization can help the surgeon perform fat harvesting and accurate fat grafting into the unique spaces of the subcutaneous region. This will not only make for a safer surgeon, but a better surgeon—a surgeon who can manipulate subcutaneous anatomy not appreciable without ultrasound.
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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5.2 Gluteal Anatomy andUltrasound
Ultrasound can help us accurately analyze and measure the unique subcutaneous anatomy of each individual patient. The pelvic bony framework, gluteal muscles, gluteal fat, and skin have been well described in the plastic surgery literature [2, 16,
17]. Cadaver dissections have actually identied two gluteal fascias (Fig.5.1).
The external surface of the gluteus maximus muscle is covered with a fascial plane, the deep gluteal fascia. The Multi Society Task Force has recommended sur­geons never place fat graft under the deep gluteal fascia [9, 13]. However, there also exists a second fascial layer (the supercial gluteal fascia) within the subcutaneous zone above the deep gluteal fascia and below the dermis. The supercial gluteal fascia is thick, impregnated with fat and can only be appreciated in an open dissec­tion or with ultrasound visualization.
The supercial gluteal fascia is part of the supercial fascial system of the trunk and is analogous to Scarpa’s fascia in the abdomen. The supercial gluteal fascia divides the subcutaneous zone into two subcutaneous spaces: the supercial subcu­taneous space (between the dermis and the supercial gluteal fascia) and the deep subcutaneous space (between the supercial gluteal fascia and the deep gluteal fas­cia) [18] (Fig.5.2).
Fig. 5.1 Transverse cross section of female buttocks. The deep gluteal fascia (green) lies on the external surface of the gluteus maximus muscle. The supercial gluteal fascia (yellow) is above the deep gluteal fascia and below the dermis and divides the subcutaneous region into two spaces
70
Fig. 5.2 Transverse cross section of female buttocks. The supercial gluteal fascia divides the subcutaneous region into two spaces. The supercial subcutaneous space (yellow) is below the skin and above the supercial gluteal fascia. The deep subcutaneous space (green) is below the supercial gluteal fascia and above the deep gluteal fascia. Ultrasound allows the surgeon to accu­rately enter each space and manipulate it while always remaining above the deep gluteal fascia
P. Pazmino
It is important to remember that the entire subcutaneous zone (including both the supercial and deep gluteal spaces) ranges in thickness from 1cm (outer hips) to 3 to 4cm (central gluteal dome). This means that gluteal surgeons must graft in a thin space under a curving dome of varying thickness. This small variable target may account for the inadvertent deep intramuscular injections by well intentioned sur­geons grafting without ultrasound visualization.
More important clinically, if the supercial gluteal fascia remains intact, it can retain the fat graft that is specically injected above or below it, like the casing of a sausage. Fat graft injected into the deep subcutaneous space (above the deep gluteal fascia and below the supercial gluteal fascia) can create excellent volume and central dome projection, similar to a subfascial implant. Fat graft precisely injected into the supercial subcutaneous space (above the supercial gluteal fas­cia and below the skin) can correct supercial contour deformities and depres­sions. The consistent accurate injection of fat graft to either the supercial or deep subcutaneous spaces can only be performed with real time intraoperative ultra­sound visualization.
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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A surgeon can use real time intraoperative ultrasound to not only avoid an intra­muscular fat graft injection but to accurately target fat graft into the supercial or deep subcutaneous spaces. Neither of these techniques is possible without ultra­sound. Real time intraoperative ultrasound guided gluteal fat grafting can not only make fat grafting safer but much more powerful and accurate as well.
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5.3 Preoperative Assessment
Like all plastic surgery, careful pre-operative assessment and planning before glu­teal contouring and fat grafting is essential. The surgeon should sit with the patient to understand their goals, priorities, and areas of importance. Asymmetries must be identied before surgery and a discussion should be held about the pre-operative shape of the patient’s waist, hips, buttocks, thighs, and back. The surgeon should ask what kind of shape the patient would like and understand how the patient would like to specically change their waist, hips, point of maximum hip projection, but­tocks, thighs, and back. Within each anatomic zone, the bony framework the mus­cles, fatty layer, and skin should be assessed to determine how each of these components affects the contour. Ultrasound can be used to determine the thickness of the subcutaneous envelope in each region and plan the quantity and location of the fat graft in each subcutaneous space as well as any areas of adhesion that should be released.
Digital imaging is helpful to show the patient the effects of liposuction, fat shift­ing, and fat grafting. It is even more useful in managing expectations and showing the patient what is not possible. If the patient has requested a very large volume result but has thin subcutaneous compartments, digital imaging can illustrate what is reasonable and safe and open a discussion on staging the procedure. Patients interested in large volume results that would be best served with staged procedures, can be shown where fat can be left undisturbed and ready for harvest in a second round of fat harvest and grafting.
Once the nal operative plan has been decided, the surgeon should discuss the recovery, expected fat resorption rates, and limitations on post-operative activity.
5.4 Surgical Equipment andSet Up
5.4.1 Intraoperative Ultrasound Systems
Over the past 8 years, six different ultrasound systems have been used with gluteal fat grafting. Real time intraoperative ultrasound can be used with any cannula or liposuction/fat grafting system. This technique is most comfortably performed
72
P. Pazmino
when the operating surgeon is controlling the fat graft cannula with their dominant hand and the ultrasound probe with their non-dominant hand. However, when a syringe fat grafting system is used, both of the surgeon’s hands are occupied. One hand must hold the syringe while the other hand pushes the plunger to inject the fat. In this scenario, the surgical assistant or scrub tech must control the sterile ultra­sound probe, making coordination with the injecting surgeon difcult. To allow the surgeon to control the fat grafting system and the ultrasound probe simultaneously, a power assisted liposuction system (PAL, MicroAire Charlottesville, VA) is used in conjunction with a peristaltic pump for controlled propulsion of the fat graft. In this manner, the surgeon can inject fat via expansion vibration lipolling [19] with the dominant hand and control the ultrasound probe with the non-dominant hand.
Currently, one of two ultrasound systems is being used for real time intraopera­tive ultrasound: the Clarius Ultrasound (Clarius, $4000) or the Buttery iQ (Buttery, $1999 with $420 annual subscription). The Clarius is a 4–15MHz high frequency, portable, waterproof, wireless linear ultrasound probe (maximum depth of 7cm) that can be placed entirely in a sterile probe cover and can stream via WiFi a high resolution ultrasound video to Apple iOs or Android tablets. Both systems will upload their data to the cloud so that ultrasound still images and video can be accessed on a computer or added to a patient chart (Figs.5.3 and 5.4).
Fig. 5.3 The Clarius ultrasound probe is a 4–15MHz high frequency linear L7 portable, waterproof, wireless ultrasound probe (maximum depth of 7cm) that can be placed entirely in a sterile probe cover and can stream a high resolution ultrasound video to Apple iOs or Android tablets
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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Fig. 5.4 The Buttery iQ ultrasound probe is a new generation probe that uses microchips rather than piezoelectric crystals to generate and interpret ultrasound waves. This is a wired system that is currently compatible with iOs devices
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5.5 Surgical Technique
Liposuction of the torso and fat grafting to the gluteal areas and hips is designed to be an outpatient procedure performed under general anesthesia. Specic types of anesthesia do not effectively protect the patient from fatal complications such as fat pulmonary emboli. What does protect the patient is ensuring that there is no intra­muscular fat injection. Ultrasound visualization can continuously conrm the real time position of the cannula tip and keep the patient safe. The ultrasound guided gluteal fat grafting is performed under general anesthesia to facilitate comfortable controlled extraction of deep and supercial fat and for maintenance of the airway when the patient is in the prone position.
5.5.1 Liposuction andLiposculpture
The anatomic endpoint of liposuction should be to achieve a consistent thickness of the skin fat ap throughout the torso and to ultimately create the specic anatomic shape the patient requested. This process begins before surgery when the skin and fat thickness in all treatment areas are assessed and asymmetries are highlighted. A strategy should be in place to differentially remove fat until the ap has a consistent thickness.
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