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Intravascular fat (high
vein wall
Gluteus maximus m.
31 Complications ofFat Transfer
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Fig. 31.21 Illustration of
injury to a gluteal vein wall
by fat grafting cannula and
transit of macroscopic fat
particles from within the
extravascular space into the
lumen of the vein. (a)
Depiction of a preinjury
schematic of the gluteal vein
wall and (b) depiction of an
injury to the vein wall
allowing intraluminal entry of
fat (Mod MM, Teitelbaum S,
Suissa D, etal. Report on
mortality from gluteal fat
grafting: Recommendations
from the ASERF task force.
Aesthetic Surg J. 2017;37
(7):796–806. doi:10.1093/asj/
sjx004, with permission) [36]
Fig. 31.22 Illustration of
superior and inferior gluteal
vessels and their tributaries
leading into the internal iliac
vein and inferior vena cava.
(Mod MM, Teitelbaum S,
Suissa D, etal. Report on
mortality from gluteal fat
grafting: Recommendations
from the ASERF task force.
Aesthetic Surg J. 2017;37
(7):796–806. doi:10.1093/asj/
sjx004, with permission) [36]
487
pressure to low pressure)
ab
Tear in
Gluteus medius m.
Internal iliac v.
Superior gluteal a.
Inferior gluteal v.
Superior gluteal v.
Superior and inferior
gluteal arteries
(cut)
488
Posterior superior
iliac spine
Landmarks
Superior gluteal v.
Greater
trochanter
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L-5
Inferior gluteal v.
Fig. 31.23 Posterior coronal illustration of superior and inferior gluteal
vessels relative to bony anatomic landmarks. (Mod MM, Teitelbaum S,
Suissa D, et al. Report on mortality from gluteal fat grafting:
Recommendations from the ASERF task force. Aesthetic Surg J. 2017;37
(7):796–806. https://doi.org/10.1093/asj/sjx004 with permission) [36]
S. Santareno et al.
31.12 Miscellaneous Events intheBreast
In the systematic review from Jan-Willem G. and colleagues
[39], a total of 17 studies (3409 patients) were analyzed. The
overall complication rate of fat transfer to the breast was
17.2% (95% CI 15.9–18.5) after a mean follow-up period of
34.5 months. Palpable indurations were seen in 33.3%,
persistent pain was reported in 25.0%; hematoma was seen
in 16.4%. New nodules were reported in 11.0% of the cases,
and cytological analyses of the aspirated or surgically
removed material showed fat necrosis in all cases. In 8.3% of
the patients, abnormal breast uid, lymphadenopathy, and
pus discharge were seen. Other complications were dysesthesia in 7.7%, fat necrosis in 6.6% and calcications in
4.47%. Striae of the breast were seen in 4.3% and cyst formation in 3.3%. Infection of the breast was seen and treated
with oral antibiotics, drainage, and/or ice packing in 0.9% of
the cases, and donor site infection was seen in 0.6% (95% CI
0.0–3.9) of the cases. Donor site deformation was seen in
0.4% of the cases; pneumothorax, another rare complication,
was seen in two patients.
The proposed management of these complications may
include the following strategies [39]:
Fig. 31.24 Sagittal illustration of the sciatic nerve and superior and
inferior gluteal veins with perforators through the gluteus musculature.
(Mod MM, Teitelbaum S, Suissa D, et al. Report on mortality from
gluteal fat grafting: Recommendations from the ASERF task force.
Aesthetic Surg J. 2017;37 (7):796–806. https://doi.org/10.1093/asj/
sjx004, with permission) [36]
pened in response to emergency cases in Florida. Actually
it is required that all cases of gluteal fat grafting performed
in the ofce based facility should be undertaken by a physician with a hospital; furthermore, the use real-time ultrasound technology prior to and during the injection
technique, since it improves the precision of their understanding of the location of the canula. Also, there should
be a limit of 3 brazilian butt lift (BBL) cases as the maximum number of total operative cases per day by a single
surgeon [38].
Sciatic nerve
Gluteal veins
– Striae of the breast—daily application of tretinoin.
– Fat necrosis/oil cyst formation—extirpation and radio-
graphic follow-up.
– Infection—topical and oral antibiotics, minor incision
with drainage, surgical drainage.
– Pneumothorax—pleural drain placement.
– Donor site deformity —aspiration of fat necrosis and
additional fat grafting.
31.13 Conclusion
Although fat grafting procedures have an established
safety record and are classied as minimally invasive surgeries, reports of adverse outcomes are uncommon; however, they do occur, as with any surgical procedure. Fat
necrosis, which results in undercorrection, reabsorption,
brosis, calcications, and oil cysts, is one of the most
common complications. Preventing cysts formation is paramount, since once established, they are very difcult to
manage. The surgeon who is performing the fat graft must
have a full knowledge of the vascular and muscular anatomy on the receipt sites. Aesthetic and technical strategies
about the placement of the entry points, the size of cannulas (both for harvest and injection), the preferred donor
sites, are key to prevent both donor and receipt sites aesthetic complications.
31 Complications ofFat Transfer
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489
Catastrophic major complications such as blindness, skin
necrosis, stroke, and death are avoidable with an accurate
and atraumatic technique and an anatomical knowledge by
the surgeon, specially the arterial network in the face, breast
and buttocks.
Facial fat grafting will likely continue to grow in popularity as an adjunct to facial rejuvenation, contouring, or even
for regenerative surgery. The knowledge of local anatomy
and mastery of safe technique is paramount in prevention of
minor or severe complications. In the management of severe
complications following facial fat grafting, it is more important to avoid complications than to treat them. There have
been reports of atypical mycobacterial infections after facial
fat grafting. However, the dreaded complications result from
embolic phenomenon to local end organs, such as the skin
and eye, and the central nervous system. It is imperative to
adhere to the safe and efcacious techniques previously outlined in order to minimize such complications. The authors
encourage every surgeon who performs facial fat grafting to
establish a systematic method to deliver safe, consistent, and
long-term results for their patients.
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18. Wang L, Luo X, Lu Y, Fan ZH, Hu X.Is the resorption of grafted
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28. Teimourian B. Blindness following fat injections. Plast Reconstr
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29. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri
S. Blindness following cosmetic injections of the face. Plast
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31. Tansatit T, Apinuntrum P, Phetudom T.Facing the worst risk: confronting the dorsal nasal artery, implication for non-surgical procedures of nasal augmentation. Aesthet Plast Surg. 2017;41(1):191–8.
https://doi.org/10.1007/s00266- 016- 0756- 0.
32. Filip C. Response re: “autologous fat grafting for the treatment
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bjps.2014.02.001.
33. Wang DW, Yin YM, Yao YM.Internal and external carotid artery
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35. Tagkalakis P, Dionyssopoulos A, Karkavelas G, Demiri E.Topical
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Aesthetic Surg J. 2017;37(7):796–806. https://doi.org/10.1093/asj/
sjx004.
37. Mills D, Rubin JP, Saltz R. Multi-society gluteal fat grafting task
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38. https://www.plasticsurgery.org/for-medical-professionals/
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39. Groen JW, Negenborn VL, Twisk JWR, Ket JCF, Mullender MG,
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sjw105.
Spiral Lift
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TarickSmiley andRaniaAgha
32
32.1 Introduction
Achieving the desired body shape is essential to many people. Weight loss programs, including diet and exercise programs, and bariatric surgery have become common place.
Although patient satisfaction is high, the disappointment
in the body shape after massive weight loss is also very
high. To address the unsightly skin laxity that results from
weight loss, patients resort to plastic surgeons for the total
body or the spiral lift. In combination with other plastic
surgery procedures, spiral lifts are of particular interest to
patients who have the so-called pear- or guitar-shaped contours of their bodies. It is frustrating, discouraging, and
simply disguring to some. A bathing suit or pants are not
an option for such patients to enjoy. Fortunately, advances
in plastic surgery techniques permit safe and effective correction of such contour deformities by adding spiral lifts as
an option to treat these deformities that result from weight
loss. We will discuss our technique for spiral lift in this
chapter.
32.2 History oftheSpiral andThigh Lifts
Originally described by Lewis in the 1960s, the medial thigh
lift did not gain much popularity due to numerous postoperative complications including scar widening, skin necrosis,
vulvar broadening, and deformation and recurrence of ptosis.
A couple of decades later, several surgeons including worldrenowned Ivo Pitanguy, Lockwood, and le Louarn and Pascal
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_32].
T. Smiley (*)
California Surgical Institute, Beverly Hills, CA, USA
R. Agha
Dermatology, Summit Dermatology and Aesthetic Surgery,
Oakbrook Terrace, IL, USA
revised the procedures to avoid abovementioned complications. Pitanguy proposed anchoring the anterior thigh ap to
the mons pubis and the muscle fascia, while Lockwood’s
technique involved suspension of the skin ap’s dermis to
Colles’ fascia. Le Louarn and Pascal’s incision was made
horizontally along the inguinal fold without descending into
the gluteal crease; they also treated the excess fat with liposuction and the skin laxity with serial resections. In the late
1980s, Baroudi etal. published their technique of performing a simultaneous medial, anterior, and lateral thigh lift and
upper inner thigh lift, combined with a ank-plasty and
optional lipoplasty [1–5].
32.3 Procedure Rationale
Spiral lifts are designed to address deformities of the trunk,
buttocks, and thighs at the same time. It is imperative for the
surgeon to understand the etiology of such deformities.
Although not fully understood, a pear- or guitar-shaped body
deformity (Fig.32.1) can be a result of lipodystrophy; dysmorphic adipose tissue distribution; cellulite; excessive skin
of the thighs, buttock, and waist; buttock ptosis; and trochanteric lipodystrophy.
More often than not, the upper and lower abdominal area
is devoid of such lipodystrophy (Fig.32.2). Genetics play a
role in the development of this contour as well as lack of
exercise, alterations in body weight, and possibly poor diet
habits. Such deformities represent a challenge to treat.
Traditional treatment options such as liposuction, liposculpture, noninvasive modalities with radiofrequency- and heatbased devices, diet, and exercise are all futile. In fact,
liposuction may worsen the condition and the result could be
aesthetically detrimental; excessive weight loss will only
increase skin laxity and exercise may result in muscle hypertrophy, which can lead to worse overlying skin texture. If
liposuction is selected as a treatment option, it must be performed in a conservative way, as aggressive liposuction of
the lateral thighs can result in irreversible irregularities.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_32
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Fig. 32.1 A pear-shaped or a guitar-shaped body with excess skin in the medial thighs, front and lateral thighs, and also the abdomen
T. Smiley and R. Agha
Fig. 32.2 A pear-shaped or a guitar-shaped body with excess skin in the medial thighs, and front and lateral thighs. Abdomen does not have excess
skin
Therefore, spiral lifts can address and treat pear-shaped
deformities of the lower trunk in conjunction with an almost
circumferential thigh lift.
32.4 The Spiral Lift [6–8]
The term spiral lift stems from the shape of the incision that
is performed. A spiral lift is a combination of a lower body
lift (which includes the lateral thigh lift and buttock lift) posteriorly and a medial thigh lift anteromedially connected
together. Contour deformities of the abdomen should be
addressed separately with an abdominoplasty.
A spiral incision can achieve two goals: removal of excess
skin and tissue, and reshaping the body to a more aesthetically pleasing silhouette. In the late 1980s, Baroudi et al.
published their technique of performing a simultaneous
medial, anterior, and lateral thigh lift and upper inner thigh
lift, combined with a ank-plasty and optional lipoplasty.
This technique along with a buttock lift combined with a
dermal fat ap is a more favored option to treat tear-drop
deformities.
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493
In this chapter, we will describe our technique to correct
the pear-shape deformities, with special focus on pearls,
complication, and pitfalls.
32.5 Patient Selection
As with any cosmetic procedure, a thorough physical, medical, surgical, and social history is performed. Typically,
patients seeking the spiral lift have a pear-shaped body, have
dermatolipodystrophy, moderate skin laxity, and rippling of
the skin and subcutaneous tissues in the inner and later thighs
with a ptotic buttock.
32.6 Preoperative Marking [4, 5]
This is one of the most crucial steps for a successful surgery.
Marking is performed while the patient is in the standing
position with hands stretched out in front of them, close to a
wall for support with the lower extremities abducted.
The surgeon pinches the skin to estimate the amount of
skin to be excised. Starting posteriorly, the superior portion
of the buttocks is marked starting from the buttock cleavage
at the sacrum proceeding laterally along the superior margins
of the buttocks and then around the hips toward the ASIS and
then anteriorly down toward inguinal ligament continuing
toward the medial thigh lift incision (Fig. 32.3). The surgeon’s hand is then applied with rm pressure to the lower
aspect of the buttocks lifting medial and superiorly as much
as possible. With the buttock lifted, a pen is used to mark the
newly lifted incision line at 2cm intervals keeping the vector
orientation superior and medial (Fig. 32.4). The incision
should dip downward toward the medial buttock cleavage
along the sacrum so as not to connect the two incisions in the
midline unless there is too much excessive redundant skin
(Fig.32.5). Anteriorly, the medial thigh lift incision line is
marked as usual ensuring that the femoral triangle is well
demarcated to avoid any injury to this area (see Sect. 32.11 at
the end of the chapter).
Fig. 32.4 With the buttock lifted, a pen is used to mark the newly lifted
incision line at 2cm intervals keeping the vector orientation superior
and medial
Fig. 32.3 Tissue excision is marked from the inside crease of the buttocks along the inguinal crease and anterior iliac spine, spiraling above
the buttocks and meeting the contralateral incision at the sacrum or dip-
ping down into the buttock cleavage. Please note that in case there is
vertical laxity in the thigh skin, then a vertical excision of the thigh skin
can be planned along the mid lateral line
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Fig. 32.5 The incision should dip downward toward the medial buttock cleavage along the sacrum so as not to connect the two incisions in
the midline unless there is too much excessive redundant skin
Fig. 32.6 Instruments
required for a spiral lift
procedure
T. Smiley and R. Agha
32.7 Surgical Instruments
Surgical instruments include abdominal tray in addition to
demarcator, Kochers, stapler, marker, rakes, and Russian
pickup (Fig.32.6).
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32.8 Technique
32.8.1 Buttock Lift andAugmentation Along
withaLateral Thigh Lift
With the patient in prone position and under general anesthesia, the operation is started with the posterior lower body lift,
which includes lateral thigh lift and buttock lift. A number 10
blade is used to incise the skin of the buttock at the inferior
aspect of what was marked. A 1 cm skin thickness ap is
elevated (Fig.32.7) superiorly toward the lower back pre-
serving the buttocks’ brous and fatty tissue with at least
3cm thick pedicle (Fig.32.8) attached to the gluteal muscles
in order to mobilize it down into the upper buttock in an
open-book formation to create upper pole fullness of the buttock but maintaining its blood supply (Fig.32.9). A 2cm ap
is then developed inferiorly starting from the incision about
half way down into the buttock in order to facilitate the
mobilization of the lower back pedicle. Dissection on the
lateral thighs is undertaken to below the extent of excision
(Fig.32.10).
The lower half of the buttock is not undermined to preserve
the option of fat transfer into that area. The pedicle is now
Fig. 32.7 A 1cm skin thickness ap is elevated superiorly toward the
lower back preserving the buttocks’ brous and fatty tissue
Fig. 32.8 Fibrous and fatty tissue ap is created which is inferiorly
based with at least 3cm thick pedicle attached to the gluteal muscles in
order to mobilize it down into the upper buttock in an open-book
formation
Fig. 32.9 Schematic diagram showing the central area of the excised area (marked in red) being used as a turnover ap to augment the upper buttocks
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Fig. 32.10 Pocket dissection and skin undermining are done on the lateral thigh to achieve a lateral thigh lift. This part of the dissection can be
undertaken using the Lockwood dissector
T. Smiley and R. Agha
Fig. 32.11 The ap is now ipped downward under the inferior skin
ap and sutured with Vicryl 2-0 suture to keep the ap in place
released starting superiorly in downward fashion making sure
to preserve the 3cm pedicle. This is then mobilized and sutured
to the gluteal fascia inferiorly with 2-0 Vicryl (Fig.32.11).
A demarcator is then used to determine the amount of
skin to be marked and excised (Fig.32.12). Skin excision is
performed and closed with deep 2-0 Ethibond and 2-0
Monocryl and 3-0 Monocryl. Steri strip are then applied.
The lateral thigh was undermined inferiorly deep to the
supercial fascial system using a Lockwood underminer
Fig. 32.12 A demarcator is used to mark the excess skin and remarking is done. This can also be done by using towel clips as discussed in
previous chapters. Once the excess skin has been marked, it is excised
and closure done in layers
(Byron Medical, Tucson, AZ; Fig.32.13). The excess skin
was marked (Fig.32.14) and then excised, and the lower ap
was suspended to the periosteum of the iliac crest and the
fascial tissues with a permanent Ethibond suture. The supercial fascial system then was approximated with polyglactin
910 (0 Vicryl) after which the skin and subcutaneous tissue
were closed in layered fashion (Fig.32.15).
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