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Fig. 14.6 Venous traction theory. Fat injected deep into the gluteal fascia can further migrate in the muscle towards the submuscular area.
Submuscular pooling of the adipose tissue exerts a strain on the gluteal
vein or its branches, leading to tearing and siphoning of the fat into the
lacerated vessel. Drawing by Lisa Ramaut
14.6 New Guidelines Led toanImproved
Safety Prole
Following the recommendations to graft subcutaneously, the
ASERF Task Force survey was repeated in 2019 and sent
again to ASAPS and ISAPS members. This second study
corrected the ratio of fatal pulmonary fat embolisms to 1 out
of 14,952 [54]. To date, the mortality numbers are unfortunately based on data gathered through anonymous surveys,
and, thus, they remain mere estimates. A lower mortality risk
after gluteal fat grafting procedures was also calculated by
Cansancao, based on ISAPS statistics. He estimated the risk
at 1:20,117 (0.005%) [14]. Non-fatal fat embolism occurred
in 1 out of 9530 (0.01%) [14]. Interestingly, abdominoplasty,
which was previously thought to be the highest-risk aesthetic
procedure, carries a fatal complication risk of approximately
1 out of 13,000, which is mainly related to a different mechanism, i.e., deep venous thrombosis [22]. Thus, abdominoplasty and gluteal fat grafting have a similar mortality risk
but a very different reputation.
M. Geeroms et al.
The decreased risk for fatal fat embolisms in a period of
only 2years underlines the combined efforts of the plastic
surgery community in raising awareness, conducting
research, providing practical guidelines, offering training,
and adopting surgeons who switched from intramuscular
injection to subcutaneous injection. Rios showed that 94% of
the participants were aware of the guidelines to inject in the
subcutaneous layer only [54]. Eighty-six percent of surgeons
who in 2016 performed intramuscular fat grafting switched
to subcutaneous- only fat grafting [22, 54]. Only 0.8% of the
surgeons in 2019 still injected in the deep muscle, compared
to 13.1% in 2017 [54]. Sadibeen recently concluded from his
survey among British Association of Aesthetic Plastic
Surgeons (BAAPS) members that 96.9% of the surgeons
inject only subcutaneously [55]. Overall, this proves the efcacy of the message that was sent out by several plastic surgery societies to stay subcutaneous to graft in a safe manner.
It has to be said that, in these anonymous surveys, it cannot
be veried whether the surgeon uses objective tools to
describe the plane of fat injection. Consequently, these data
are arbitrary because the majority of plastic surgeons perform this intervention as a blind procedure.
Most participants in the mentioned surveys are boardcertied plastic surgeons. Unfortunately, this procedure is
also being performed by inadequately trained providers in
unlicensed or unaccredited cosmetic clinics. They are driven
by the elegance and the protability of the procedure, but can
be deceived by the apparent ease of it. So we still have uncertainty about the real mortality and the current awareness
among these “non-core physicians” [22, 56]. Even though
86% of female patients value board certication highly (the
most important parameter for 54% of patients), there are still
20% of gluteal fat graftings performed by non-plastic surgeons, facial plastic surgeons, and dermatologists [22, 57].
14.7 Preoperative Guidelines
Apart from the standard history and physical examination,
attention can be given to the presence of varicose veins as it
increases the risk of venous lacerations with subsequent
embolization. Symptoms from sciatic nerve compression or
irritation should be noted since they can be associated with
venous varicosities in proximity to the sciatic nerve [20].
Correctly informing the patient and including fat embolism as a potentially fatal complication in the informed consent, with an estimation of this risk, is correct preoperative
management to allow well-informed and unbiased decisionmaking [32, 58]. A recent survey demonstrated that 78% of
adult females underestimate the mortality risk related to gluteal fat grafting [57]. Seventy percent of women who were
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willing or neutral to undergo surgery were converted to
unwilling after education about complications. No less than
one out of ten patients would tolerate a mortality risk greater
than 0.1%. Notably, patients with body dysmorphia and
“social media dysmorphia” had more tendency to accept
higher risk [57]. These results underline the general unawareness among our clientele as well as the patients’ poor risk
assessment capability. It also emphasizes our role as informers or educators during the preoperative consultation.
To avoid directly targeting the vessels, the preoperative
marking of danger areas has been described in which fat
grafting is discouraged or solely injected subcutaneously.
Villanueva marks a danger triangle on each buttock, between
the posterior superior iliac spine, greater trochanter, and
ischial tuberosity, which delineates the regions of the main
gluteal vessels and the sciatic nerve [38]. However, because
of new insights from the discussed dissection studies, topographical thinking has become obsolete. The danger area
should be redened and encompasses the area beneath the
deep gluteal fascia, which was corrected in a reply [48, 59].
14.8 Perioperative Guidelines
14.8.1 Positioning ofthePatient
Villanueva recommended in his 2017 paper to position the
patient in a prone jack-knife position with exed hips while
performing the gluteal fat grafting. Because this position
allows lowering your dominant hand, it would direct the cannula into a supercial plane [38]. While this can help guide
the cannula from the inferior gluteal incision (Fig.14.7), it
might create a false feeling of safety.
Authors have suggested certain angles which are safer
than others from certain entry ports, and, as a general and
logical observation, an obtuse angle between the patient’s
skin and the cannula is dissuaded [42, 60]. However, maintaining the cannula at a certain angulation is hard to control during the process of fat grafting, as a small vertical
motion of the handpiece can change the angulation considerably [61].
179
Fig. 14.7 Ergonomic advantage of jack-knife position, as depicted in
the lower image. Fat grafting through an inferior incision while the
patient is installed in a prone position with exed hips, allows the practitioner to keep the dominant hand in a lower position, and points the tip
of the cannula up into a more supercial plane. Drawing by Lisa
Ramaut
Fig. 14.8 The sacrum as a ramp: the bony prominence of the sacrum
guides the cannula into the supercial tissues. Drawing by Lisa Ramaut
14.8.3 Volume
14.8.2 Incisions
Risk-free access sites do not exist, as gluteal vein fat embolism has been seen regardless of the incision location. An
often preferred [14] high intergluteal incision overlying the
sacrum is considered safer because the sacrum can act as a
ramp: its bony prominence steers the cannula into the subcutaneous plane and prevents it from pointing or bending down
into the deeper tissues (Fig.14.8).
To overcome tissue loss and volume reduction due to fat
graft resorption after gluteal fat grafting, overcorrection has
been applied and advocated by clinicians, which means the
injection of a volume that exceeds the requirement for correcting a volume depletion or contour defect. However,
based on scientic evidence [62] and clinical experience
[63], it has been concluded that overgrafting does not
improve outcomes. On the contrary, increased interstitial
pressure will restrict capillary perfusion to the adipocytes,
leading to apoptosis, necrosis, and oil cyst formation. If a
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M. Geeroms et al.
large volume is required to achieve the aesthetically desired
result, which is more than what the subcutaneous tissue can
accommodate, it is preferable to perform staged grafting procedures [32, 52].
Regarding fat embolism, a large-volume fat grafting procedure carries a higher risk compared to small-volume fat
grafting. This increased risk is simply attributed to a more
frequent cannula passage in order to inject the whole graft, as
b
every axial movement can potentially penetrate the muscle
fascia. Also, the risk for fat embolism can be theoretically
attributed to the increased pressure which forces intramuscular fat into already lacerated vessels (laceration-siphon theory), or which can push the fat submuscularly where it can
tear vessels (venous traction theory).
However, it is of greater importance to keep in mind that
a small but inaccurately performed fat grafting procedure
(i.e., intramuscular) is more hazardous than a large-volume
subcutaneous-only graft. Therefore, the focus should be
given to the position of cannula at every stroke. This belief is
Fig. 14.9 (a) Manual fat graft injection by means of a syringe con-
nected to a cannula is often performed, but a stable interface should be
guaranteed. Loosening of the connection could angle the cannula
towards deep tissues and lead to penetration of the deep gluteal facia.
(b) The concept of exibility misguidance. A slight bend in a cannula
continues to curve further in the direction of the initial bend, leading to
inadvertent deep injections. Drawing by Lisa Ramaut
supported by extensive patient series in which no fatal fat
embolisms were detected, even though volumes up to
4400mL of subcutaneous fat were reported [49, 64]. In addi-
tion, autopsy reports of patients who died after gluteal fat
grafting show relatively low volumes of fat grafts [25].
However, fat embolism and cardiac instability can arise suddenly during the operation, which urges the surgeon to stop
the procedure.
If the injection is performed manually with syringes
attached to a cannula, a stable connection should be ensured
to avoid angulation of the cannula, and we should be aware
of possible loosening or bending of connecting pieces
(Fig.14.9) [46]. Unstable interfaces than can pivot or angle
at the junction with the syringe should be avoided.
Power-assisted devices for liposuction and fat grafting
will be associated with less aggressive shoulder and elbow
movements for axial motion, less fatigue-induced decrease
14.8.4 Device
in proprioception, and does not require the thumb generating
fat ow by pushing the plunger of the syringe, which allows
The cannula should be held parallel to the skin surface and
muscle fascia, with the tip, directed upwards. Alternatively,
an angled cannula can be used to aim for the supercial
tissues.
Most surgeons prefer a cannula with a diameter of 3 or
4mm [14]. Theoretically, it is easier to penetrate the deep
gluteal fascia with a narrow cannula tip. ASERF found that
the surgeon to be completely focused on the orientation and
direction of the cannula tip [38, 49]. The non-dominant hand
is free to monitor the position of the cannula underneath the
skin. These are valid arguments for the use of power-assisted
devices in order to inject in a controlled manner. Although,
deaths following grafting with automated devices have been
reported as well.
using large-bore cannulas of 4.1mm and more are correlated
with less fatalities [22]. According to Rios’ survey, 30% of
ASAPS and ISAPS surgeons use cannulas of at least 4.1mm,
14.8.5 Extensive Liposuction
compared to 4% in 2016 [22, 54]. Importantly, changing surgical tools and starting to use 5-mm cannulas will not guarantee grafting in the subcutaneous plane.
Larger-bore cannulas have the additional advantage of
being more rigid, allowing a more reliable orientation. Thin,
long, exible or bendable cannulas have a higher propensity to
lead to exibility misguidance: a slight blend of the instrument
continues to curve in the patient toward the bend (Fig.14.9)
[23, 49]. By consequence, the cannula tip will be located in the
deeper tissue planes, even when a supercial direction of the
syringe is attempted by the misguided surgeon.
Dening gluteal enhancement as making the buttocks bigger
is a big understatement. As the surgeon’s main objective is to
accentuate the buttocks’ shape instead of merely pumping
volume to the buttocks, one has to take into account the
patient’s complete morphology. Through extensive liposuction of the waist and lower back, a visually enhanced contour
of the upper gluteal region can be achieved, which can reduce
the need for massive fat grafting. The rst and most important donor site for the adipose tissue is by consequence the
patient’s anks and lower back.
Subcutaneous
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14.8.6 Ultrasound-Guided Gluteal Fat Grafting
We are taught to use our non-dominant hand to palpate and
assess the location and the depth of the cannula tip at all
times. However, autopsies and dissection courses have made
us realize there is a discrepancy between what a surgeon
claims and what is seen on dissection. Even though a complete subcutaneous injection has been attempted, fat can
appear in the intramuscular or submuscular plane.
Ultrasound-assisted fat grafting has been described as a
reliable technique to enable objective and real-time localization of the cannula tip and provide a means to verify subcutaneous injection [37, 65]. With little training, the ultrasound
probe helps to distinguish the different layers under the skin.
From supercial to deep, a rst dense white line indicates the
supercial gluteal fascia, and a second dense white line identies the important deep gluteal fascia (Fig.14.10) [65]. The
acoustic shadow of the cannula on the portable screen can
reliably indicate the cannula’s position. It can warn us when
the cannula tip is deeper than expected because of exibility
misguidance:
• the cannula is located in the supercial subcutaneous tissue if the acoustic shadow starts above the rst dense
white line (supercial gluteal fascia)
• the cannula is located in the deep subcutaneous tissue if
the acoustic shadow starts between both white lines
• fat grafting should not be performed if the acoustic shadow
starts below the second dense white line (deep gluteal fascia), as the cannula is positioned intramuscularly
Cansancao demonstrated the safety of ultrasound-guided
fat grafting, as it did not lead to grafts unintentionally placed
in the intramuscular plane in his series of 35 patients [37].
In addition, ultrasound allows us to evaluate the thickness
and appearance of the subcutaneous fat layer [37, 66], which
is useful for:
• Intraoperative measurements
– To measure the depth of the deep gluteal fascia relative
To the skin surface
– To measure the expansion of the subcutaneous layer
• Postoperative follow-up
– Resorption of the grafted fat
– Appearance of cysts, necrosis, hematoma, or seroma
Skin
superficial fat
Superficial gluteal
fascia
Subcutaneous
deep fat
Deep gluteal
fascia
Gluteus maximus
muscle
Fig. 14.10 With ultrasound the different layers from skin to muscle
can be reliably identied. The important deep gluteal fascia is the second dense white line which is seen under the skin. If the acoustic
shadow of the cannula starts below this level, the injection should be
stopped in order to avoid intramuscular grafting
In general, the ultrasound device has been proven to be a
helpful appliance for gluteal fat grafting, both for beginners
as well as experts. The latter group can benet from this
device since it allows precise targeting of the supercial subcutaneous space to correct small deformities and concavities,
or the deep subcutaneous space for diffuse reshaping and
projection. The subcutaneous tissues and its brous septa
can be evaluated and can be released with the cannula under
ultrasound visualization.
However, an extra hand is required to hold the device, or
a learning curve exists to simultaneously manipulate the cannula and the ultrasound probe yourself and interpret the
ultrasound images. It inevitably slows down the procedure:
the reported additional operative time was approximately
25min [65]. Therefore, it is cumbersome to perform a complete procedure under ultrasound guidance.
Several brands exist that produce portable ultrasound
devices with different resolutions and different prices. The
device should have a high frequency to visualize supercial
structures since great depth of penetration is not required.
Some of them are wired and can be connected to smartphones or tablets. Other devices are wireless and can be
introduced in a sterile cover, which increases intraoperative
practicality and sterility.
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14.8.7 “Smart” Sensing Cannula
Recent work by Turer and Rubin led to the innovation of a fat
grafting cannula which measures electrical impedance in different tissue types [66]. Through this modality, the cannula
tip can be reliably located in the subcutaneous fat or in the
muscle throughout the procedure. The feedback from the
device to the surgeon is both visual and audible (Fig.14.11).
The surgeon will be alarmed with red indicator lights and an
audible signal as soon as the cannula touches the deep gluteal fascia and will stop us when we are misguided by the
exibility of the cannula or by our own proprioception.
When connected to certain devices, the fat grafting ow can
instantaneously be stopped as soon as the cannula tip enters
the muscle.
Prototypes have been tested on exvivo porcine models
and on fresh cadavers [66]. With simultaneous ultrasound, it
was conrmed that the smart sensing cannula is able to
differentiate between fat and muscle with sub-centimeter
accuracy. From the rst demonstrations, the smart sensing
cannula looks very easy to use and does not require additional skill such as simultaneously analyzing ultrasound
images while performing ultrasound-guided fat grafting. It
would also not add additional time to the intervention
(Fig.14.11).
While the smart sensing cannula is a very promising
appliance for the future of gluteal fat grafting, its accessibility, usability, and safety should be studied in clinical trials.
Time will tell whether the smart sensing cannula is costeffective: what is the price of the cannula, and importantly, is
it disposable or can it be sterilized and re-used?
The question arises whether this cannula is still reliable
when a passage through the deep gluteal fascia has already
occurred and fat grafts are located intramuscularly. The cannula tip might detect adipose tissue even though it is deep to
the fascia, leading to no alarm signal, and leading to further
injecting fat in the muscle.
14.8.8 Local Anesthesia
A series of 47 gluteal fat grafting procedures on awake
patients has been described [67]. The patients could give
immediate feedback to the surgeon when they experience
pain. This would implicate that the cannula hits a non-anesthetized region, that is, the muscle. During deep gluteal fascia penetration, it is likely that sensitive nerves are being hit
or stretched. The anesthetic protocol consisted of oral medication (hydrocodone 5 mg or acetaminophen 300 mg, and
diazepam 10–20 mg), local inltration of the access sites
(lidocaine and epinephrine) and tumescent inltration of the
donor sites and gluteal subcutaneous tissues (for every liter
of lactated Ringer solution: lidocaine 800–1000mg with a
maximum of 35 mg/kg body weight, epinephrine 1.5 mg,
and sodium bicarbonate 12mL) [67].
Additional advantages are the lack of inconveniences
related to general anesthesia such as nausea, vomiting, possible overnight admission, deep venous thrombosis, aspiration, pneumonia, urinary retention, and corneal lesions [68].
Absorption of the tumescent solution into the gluteus
muscles might theoretically numb the muscle and limit the
usefulness of this technique [33]. However, in the authors’
Fig. 14.11 The “smart”
sensing cannula. When the
cannula tip is located in the
safe subcutaneous layer, a
green light is shown. As soon
as the cannula touches the
deep gluteal fascia or enters
muscle, the device gives a
warning signal and shows a
red light. The blue light
indicates the cannula tip is not
touching any tissue. Drawing
by Lisa Ramaut
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183
experience, the tumescent inltration is inadequate to anesthetize the deep gluteal fascia and underlying muscle, and
every hit with the fascia causes a pain response [67]. The
thickness and rmness of the deep gluteal fascia also make it
a relative barrier to diffusion [68].
Another limitation to this technique is the tumescent inltration in the recipient site, which expands and distorts the
buttock and might complicate a correct perioperative evaluation of the shape and projection. The authors recommend
inltrating the buttocks rst so that the anesthetic product is
absorbed and edema decreases by the time the fat grafting is
done [67].
This approach under local anesthesia slows down the procedure because of the gentle injection and the waiting time
for the tumescence to fully induce anesthesia. On the other
hand, no time is spent on induction of general anesthesia, on
patient position changes, or on awakening.
In our experience, not every patient is physically or mentally able to comfortably undergo liposuction and fat grafting
awake, and often this is only clear during the procedure.
Because of anxiety or pain, the liposuction and/or grafting
volume can be limited, and the operation can be stopped
before the desired result has been achieved.
14.9 Postoperative Guidelines
andAdministrative Guidelines
During the surgery and immediately postoperative, it is imperative to recognize signs of acute right-sided cardiac failure due
to mechanical obstruction caused by fat embolism: hypoxemia, bradycardia, and (severe) hypotension [25]. This characteristic triad can arise during the process of gluteal fat grafting,
which is especially true for macroscopic fat embolism, or can
develop several hours later in the recovery area, which is more
likely to happen in case of microscopic fat embolism [18, 25].
When fat embolism is suspected, inotropic and vasopressor
support should be put into action as soon as possible.
Dobutamine is the therapy of choice [69]. Aggressive resuscitation being our only available treatment at this moment,
underscores the importance of prevention [69–71].
Safety in gluteal contouring should stay an item of ongoing study, given its frequency in today’s plastic surgery practice and the severity of potential complications [72]. An
online General Registry of Autologous Fat Transfer (GRAFT)
has been established in which plastic surgeons from the
USA, Brazil, and Canada can introduce patient demographics, procedural variables (graft volume, injection device,
cannula length, cannula diameter, injection plane,…) and
outcomes or complications (including fat embolism) [73].
The accurate analysis of these data can help us in understanding and limiting adverse events.
14.10 Alternatives forHigh-Volume Gluteal
Fat Grafting
Gluteal augmentation by performing excisional and lifting
techniques, by redistributing the patient’s own tissues, or
by using implants, reduces the risk of fat embolism related
to intramuscular injection. Depending on the surgeon’s
preference, implants can be placed submuscularly, intramuscularly or subcutaneously, which have a different complication prole compared to fat grafting (among others:
migration of the prosthesis, capsular contracture, seroma,
hematoma, dehiscence or infection of the access site,
unsightly scarring, thinning of native tissues, implant palpability or exposure) [16, 50, 74]. A hybrid technique combines the use of implants (for reliable projection) with
supercial fat grafting (for hip widening and transitional
ll) [44, 75]. Alternatively, suspension threads or loops
have been described by Abboud to modulate the buttocks’
footprint and to create fullness [11]. These options reduce
the required fat volume and, consequently, the number of
cannula passages. Theoretically, these strategies decrease
the potential risk of inadvertently penetrating the deep gluteal fascia and can be discussed with the patient preoperatively [58].
However, gluteal enhancement through fat grafting
remains the favored option among surgeons [14].
Liposuction of the waist and lower back, combined with
gluteal grafting, allows to reshape the buttock and the silhouette of the patient, contributing to an overall improved
shape of a body in harmony with a desirable waist-to-hip
ratio [11]. In addition, fat grafting is an optimal tool to correct lateral hollowness or “hip dips,” which cannot be
improved with gluteal implants.
14.11 Conclusion
Gluteal fat grafting exhibited an increase in demand year
after year, and expanded from Brazil to be a globally performed procedure. The main technical guideline in gluteal
fat grafting to adhere to is the sole injection in the subcutaneous plane. The danger zone is the area beneath the deep gluteal fascia. Over the last few years, we have learned that one
errant passage and inadvertent fat injection through the fascia can be sufcient for venous injury and fat embolization.
Autopsy images showing macroscopic fat particles in the
heart and lungs are carved into our minds [18, 21]. It is recommended to invest in cadaver dissection to truly understand
the anatomy, technique and the required precision. For the
same reasons, assisting the coroner in the autopsy after a
fatal complication is a learning opportunity to become familiar with gluteal anatomy.
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Plastic surgeons who want to provide optimal care in
accordance with what is currently known regarding safety
should never intentionally inject through the deep gluteal
fascia. Studies have shown that an increasing percentage of
plastic surgeons embrace the new guidelines and adapt their
techniques, which has contributed to safer practice. However,
gluteal fat grafting is most commonly performed as a blind
procedure. An operation performed by a highly experienced
surgeon with accurate knowledge of the gluteal and vascular
anatomy, after proper patient selection and with the recommended tools and positioning, cannot guarantee a risk-free
procedure. We should stay humble as we can inject in a deep
(intramuscular) plane without realizing this.
Therefore, two helpful intraoperative risk-reduction tools
are being discussed which can move us from cannula tip
awareness to cannula tip conrmation. Technological
advances will not bring the complication rate down to zero,
but especially, the “smart” sensing cannula could be the
game changer which can drastically improve outcomes,
while not adding additional operation time.
References
1. Matsudo PK, Toledo LS. Experience of injected fat grafting.
Aesthet Plast Surg. 1988;12(1):35–8.
2. Chajchir A, Benzaquen I.Fat-grafting injection for soft-tissue augmentation. Plast Reconstr Surg. 1989;84(6):921–34; discussion 35.
3. ISAPS international survey on aesthetic/cosmetic procedures;
2018. https://www.isaps.org/.
4. The American Society for Aesthetic Plastic Surgery's cosmetic
surgery National Data Bank: statistics 2018. Aesthet Surg J.
2019;39(Suppl_4):1–27.
5. Wong WW, Motakef S, Lin Y, Gupta SC. Redening the
ideal buttocks: a population analysis. Plast Reconstr Surg.
2016;137(6):1739–47.
6. Wang J, Thornton JC, Bari S, Williamson B, Gallagher D,
Heymseld SB, etal. Comparisons of waist circumferences measured at 4 sites. Am J Clin Nutr. 2003;77(2):379–84.
7. Vartanian E, Gould DJ, Hammoudeh ZS, Azadgoli B, Stevens WG,
Macias LH. The ideal thigh: a crowdsourcing-based assessment
of ideal thigh aesthetic and implications for gluteal fat grafting.
Aesthet Surg J. 2018;38(8):861–9.
8. Singh D. Universal allure of the hourglass gure: an evolutionary theory of female physical attractiveness. Clin Plast Surg.
2006;33(3):359–70.
9. Lewis DMG, Russell EM, Al-Shawaf L, Ta V, Senveli Z, Ickes W,
et al. Why women wear high heels: evolution, lumbar curvature,
and attractiveness. Front Psychol. 2017;8:1875.
10. Heidekrueger PI, Sinno S, Tanna N, Szpalski C, Juran S, Schmauss
D, etal. The ideal buttock size: a sociodemographic morphometric
evaluation. Plast Reconstr Surg. 2017;140(1):20e–32e.
11. Abboud M, Geeroms M, El Hajj H, Abboud N. Improving the
female silhouette and gluteal projection: an anatomy-based, safe,
and harmonious approach through liposuction, suspension loops,
and moderate lipolling. Aesthet Surg J. 2020;41:474.
12. Analysis of sampled English language tweets mentioning the peach emoji; 2016. https://blog.emojipedia.org/
how- we- really- use- the- peach/.
13. Conde-Green A, Kotamarti V, Nini KT, Wey PD, Ahuja NK,
Granick MS, etal. Fat grafting for gluteal augmentation: a systematic review of the literature and meta-analysis. Plast Reconstr Surg.
2016;138(3):437e–46e.
14. Cansancao AL, Conde-Green A, Gouvea Rosique R, Junqueira
Rosique M, Cervantes A. "Brazilian butt lift" performed by boardcertied Brazilian plastic surgeons: reports of an expert opinion
survey. Plast Reconstr Surg. 2019;144(3):601–9.
15. Cardenas-Mejia A, Martinez JR, Leon D, Taylor JA, GutierrezGomez C.Bilateral sciatic nerve axonotmesis after gluteal lipoaugmentation. Ann Plast Surg. 2009;63(4):366–8.
16. Sinno S, Chang JB, Brownstone ND, Saadeh PB, Wall S Jr.
Determining the safety and efcacy of gluteal augmentation: a
systematic review of outcomes and complications. Plast Reconstr
Surg. 2016;137(4):1151–6.
17. Oranges CM, Tremp M, di Summa PG, Haug M, Kalbermatten DF,
Harder Y, etal. Gluteal augmentation techniques: a comprehensive
literature review. Aesthet Surg J. 2017;37(5):560–9.
18. Rapkiewicz AV, Kenerson K, Hutchins KD, Garavan F, Lew EO,
Shuman MJ.Fatal complications of aesthetic techniques: the gluteal region. J Forensic Sci. 2018;63(5):1406–12.
19. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A.Combined
gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg.
1999;104(5):1524–31; discussion 32–3.
20. Astarita DC, Scheinin LA, Sathyavagiswaran L.Fat transfer and
fatal macroembolization. J Forensic Sci. 2015;60(2):509–10.
21. Cardenas-Camarena L, Bayter JE, Aguirre-Serrano H, CuencaPardo J.Deaths caused by gluteal lipoinjection: what are we doing
wrong? Plast Reconstr Surg. 2015;136(1):58–66.
22. Mod MM, Teitelbaum S, Suissa D, Ramirez-Montanana A,
Astarita DC, Mendieta C, etal. Report on mortality from gluteal
fat grafting: recommendations from the ASERF task force. Aesthet
Surg J. 2017;37(7):796–806.
23. Wall S Jr, Del Vecchio D.Commentary on: report on mortality from
gluteal fat grafting: recommendations from the ASERF task force.
Aesthet Surg J. 2017;37(7):807–10.
24. Pronovost PJ, Ishii LE.Commentary on: report on mortality from
gluteal fat grafting: recommendations from the ASERF task force.
Aesthet Surg J. 2017;37(7):811–3.
25. Bayter-Marin JE, Cardenas-Camarena L, Aguirre-Serrano H,
Duran H, Ramos-Gallardo G, Robles-Cervantes JA.Understanding
fatal fat embolism in gluteal lipoinjection: a review of the medical records and autopsy reports of 16 patients. Plast Reconstr Surg.
2018;142(5):1198–208.
26. Teitelbaum S. Discussion: understanding fatal fat embolism in gluteal lipoinjection: a review of the medical records
and autopsy reports of 16 patients. Plast Reconstr Surg.
2018;142(5):1209–11.
27. 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.
28. BAPRAS Statement on 'Brazillian Butt Lift' Surgery. https://
www.bapras.org.uk/media- government/news- and- views/view/
bapras- statement- on- %27brazillian- butt- lift%27- surgery.
29. Namgoong S, Kim HK, Hwang Y, Shin SH, You HJ, Kim DW, etal.
Clinical experience with treatment of Aqualling ller-associated
complications: a retrospective study of 146 cases. Aesthet Plast
Surg. 2020;44(6):1997–2007.
30. Oam GS, Paddle A.Invited discussion on: clinical experience with
treatment of aqualling ller-associated complications: a retrospective study of 146 cases. Aesthet Plast Surg. 2020;44(6):2008–10.
31. Multi-Society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique. https://www.sur-
gery.org/sites/default/les/Gluteal- Fat- Grafting- 02- 06- 18_0.pdf.
14 New Concepts forSafe Gluteal Fat Grafting
https://t.me/medicina_free
185
32. Multi-Society Task Force for Safety in Gluteal Fat Grafting.
Urgent warning to surgeons performing fat grafting to the buttocks
(Brazilian Butt Lift or “BBL”). https://www.surgery.org/sites/
default/les/URGENT- WARNING- TO- SURGEONS.pdf.
33. Del Vecchio D. Common sense for the common good: staying
subcutaneous during fat transplantation to the gluteal region. Plast
Reconstr Surg. 2018;142(1):286–8.
34. Chopan M, White JA, Sayadi LR, Buchanan PJ, Katz
AJ.Autogenous fat grafting to the breast and gluteal regions: safety
prole including risks and complications. Plast Reconstr Surg.
2019;143(6):1625–32.
35. Teitelbaum S. Discussion: clinical implications of gluteal fat
graft migration: a dynamic anatomical study. Plast Reconstr Surg.
2018;142(5):1196–7.
36. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA,
Deos M, Diaz P.Long-term survival of free fat grafts in muscle: an
experimental study in rats. Aesthet Plast Surg. 1996;20(5):403–8.
37. Cansancao AL, Conde-Green A, David JA, Vidigal
RA.Subcutaneous-only gluteal fat grafting: a prospective study of
the long-term results with ultrasound analysis. Plast Reconstr Surg.
2019;143(2):447–51.
38. 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.
39. Toledo LS.Gluteal augmentation with fat grafting: the Brazilian
buttock technique: 30 years' experience. Clin Plast Surg.
2015;42(2):253–61.
40. Ali A.Contouring of the gluteal region in women: enhancement
and augmentation. Ann Plast Surg. 2011;67(3):209–14.
41. Murillo WL. Buttock augmentation: case studies of fat injection
monitored by magnetic resonance imaging. Plast Reconstr Surg.
2004;114(6):1606–14; discussion 15–6.
42. Alvarez-Alvarez FA, Gonzalez-Gutierrez HO, Ploneda-Valencia
CF.Safe gluteal fat graft avoiding a vascular or nervous injury: an
anatomical study in cadavers. Aesthet Surg J. 2019;39(2):174–84.
43. Ghavami A, Villanueva NL. Gluteal augmentation and contouring with autologous fat transfer: part I. Clin Plast Surg.
2018;45(2):249–59.
44. Rosique RG, Rosique MJ. Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg.
2016;137(3):641e–2e.
45. Wolf GA, Gallego S, Patron AS, Ramirez F, de Delgado JA,
Echeverri A, etal. Magnetic resonance imaging assessment of gluteal fat grafts. Aesthet Plast Surg. 2006;30(4):460–8.
46. Ghavami A, Villanueva NL, Amirlak B. Gluteal ligamentous
anatomy and its implication in safe buttock augmentation. Plast
Reconstr Surg. 2018;142(2):363–71.
47. Cardenas-Camarena L, Duran H, Robles-Cervantes JA, BayterMarin JE. Critical differences between microscopic (MIFE) and
macroscopic (MAFE) fat embolism during liposuction and gluteal
lipoinjection. Plast Reconstr Surg. 2018;141(4):880–90.
48. Villanueva NL, Del Vecchio DA, Afrooz PN, Rohrich RJ.Reply:
staying safe during gluteal fat transplantation. Plast Reconstr Surg.
2018;142(4):594e–5e.
49. Del Vecchio D, Wall S Jr. Expansion vibration lipolling: a new
technique in large-volume fat transplantation. Plast Reconstr Surg.
2018;141(5):639e–49e.
50. Ordenana C, Dallapozza E, Said S, Zins JE. Objectifying the
risk of vascular complications in gluteal augmentation with
fat grafting: a latex casted cadaveric study. Aesthet Surg J.
2020;40(4):402–9.
51. Del Vecchio DA, Villanueva NL, Mohan R, Johnson B, Wan
D, Venkataram A, et al. Clinical implications of gluteal fat graft
migration: a dynamic anatomical study. Plast Reconstr Surg.
2018;142(5):1180–92.
52. Wall S Jr, Delvecchio D, Teitelbaum S, Villanueva NL, Dayan E,
Durand P, etal. Subcutaneous migration: a dynamic anatomical study
of gluteal fat grafting. Plast Reconstr Surg. 2019;143(5):1343–51.
53. Donovan DL, Schmidt SP, Townshend SP, Njus GO, Sharp
WV. Material and structural characterization of human saphenous
vein. J Vasc Surg. 1990;12(5):531–7.
54. Rios L, Gupta V.Improvement in Brazilian Butt Lift (BBL) safety
with the current recommendations from ASERF, ASAPS, and
ISAPS.Aesthet Surg J. 2020;40(8):864–70.
55. Sadideen H, Akhavani MA, Mosahebi A, Harris PA. Current perceptions of 'Brazilian butt lift' (BBL) surgery in the UK: a BAAPSled survey of BAAPS members. J Plast Reconstr Aesthet Surg.
2020;73(11):1966–75.
56. Singer R. Commentary on: improvement in Brazilian Butt Lift
(BBL) safety with the current recommendations from ASERF,
ASAPS, and ISAPS.Aesthet Surg J. 2020;40(8):871–3.
57. Fadavi D, He W, Kraenzlin F, Darrach H, Shetty P, Xun H, et al.
Risk and reward: public perception of gluteal fat grafting safety.
Aesthet Plast Surg. 2020;44(5):1628–38.
58. Nahai F. Acceptable risk: who decides? Aesthet Surg J.
2017;37(7):852–3.
59. Villanueva NL, Del Vecchio DA, Afrooz PN, Rohrich RJ.Reply:
staying safe during gluteal fat transplantation. Plast Reconstr Surg.
2018;142(4):596e.
60. Ramos-Gallardo G, Orozco-Renteria D, Medina-Zamora P, MotaFonseca E, Garcia-Benavides L, Cuenca-Pardo J, etal. Prevention
of fat embolism in fat injection for gluteal augmentation, anatomic
study in fresh cadavers. J Investig Surg. 2018;31(4):292–7.
61. Turer DM, Rubin JP.Commentary on: safe gluteal fat graft avoiding a vascular or nervous injury: an anatomical study in cadavers.
Aesthet Surg J. 2019;39(2):185–6.
62. Eto H, Kato H, Suga H, Aoi N, Doi K, Kuno S, etal. The fate
of adipocytes after nonvascularized fat grafting: evidence of
early death and replacement of adipocytes. Plast Reconstr Surg.
2012;129(5):1081–92.
63. Mineda K, Kuno S, Kato H, Kinoshita K, Doi K, Hashimoto I, etal.
Chronic inammation and progressive calcication as a result of
fat necrosis: the worst outcome in fat grafting. Plast Reconstr Surg.
2014;133(5):1064–72.
64. Pane TA.Experience with high-volume buttock fat transfer: a report
of 137 cases. Aesthet Surg J. 2019;39(5):526–32.
65. Cansancao AL, Conde-Green A, Vidigal RA, Rodriguez RL,
D'Amico RA. Real-time ultrasound-assisted gluteal fat grafting.
Plast Reconstr Surg. 2018;142(2):372–6.
66. Turer DM, Qaium EB, Lawrence AM, Clark WW, Rubin JP. A
smart sensing cannula for fat grafting. Plast Reconstr Surg.
2019;144(2):385–8.
67. Chia CT, Theodorou SJ, Dayan E, Tabbal G, Del Vecchio D.
"Brazilian butt lift" under local anesthesia: a novel technique addressing safety concerns. Plast Reconstr Surg. 2018;142(6):1468–75.
68. Lalonde DH.Discussion: "Brazilian butt lift" under local anesthesia: a novel technique addressing safety concerns. Plast Reconstr
Surg. 2018;142(6):1476–7.
69. Peña W, Cardenas-Camarena L, Bayter-Marin JE, McCormick M,
Duran H, Ramos-Gallardo G, etal. Macro fat embolism after gluteal augmentation with fat: rst survival case report. Aesthet Surg J
2019;39(9):NP380-NP3.
70. Lari A, Abdulshakoor A, Zogheib E, Assaf N, Mojallal A, Lari AR,
etal. How to save a life from macroscopic fat embolism: a narrative
review of treatment options. Aesthet Surg J. 2020;40(10):1098–107.
71. Teitelbaum S, Benharash P. Commentary on: how to save a life
from macroscopic fat embolism: a narrative review of treatment
options. Aesthet Surg J. 2020;40(10):1108–10.
72. Nahai F.No "Quick Fix" for this: an update on the Brazilian Butt
Lift. Aesthet Surg J. 2020;40(8):928–30.
186
https://t.me/medicina_free
M. Geeroms et al.
73. Plastic Surgery Foundation. General Registry of Autologous
Fat Transfer (GRAFT). http://www.thepsf.org/research/clinical-
impact/general- registry- autologous- fat- transfer.htm.
74. Mendes J Jr, Mendes Maykeh VA, Frascino LF, Zacchi FFS.Gluteal
implant-associated anaplastic large cell lymphoma. Plast Reconstr
Surg. 2019;144(3):610–3.
75. Aslani A, Del Vecchio DA. Composite buttock augmentation:
the next frontier in gluteal aesthetic surgery. Plast Reconstr Surg.
2019;144(6):1312–21.
Gluteal Fat Grafting: Technology,
https://t.me/medicina_free
Techniques, andSafety
OnelioGarcia Jr andPatPazmiño
Contents
15.1 History of Gluteal Fat Grafting 187
15.2 The High BBL Mortality Rate in South Florida 191
15.3 Lessons Learned in the Miami Morgue 192
15.4 Optimizing Safety in BBL 194
15.5 Intraoperative Ultrasound Systems 194
15.6 Gluteal Anatomy and Ultrasound 195
15.7 Real-Time Intraoperative Ultrasound Setup 197
15.8 Patient Cases 198
15.9 Why Is Florida an Outlier in BBL-Associated Mortality? 202
15.10 Lessons Learned from the Florida BBL Experience 202
15.11 A Way Forward 202
15.12 Conclusions 203
References 204
15
15.1 History ofGluteal Fat Grafting
Surgeons have been grafting fat for over 100years. The rst
description of a fat grafting procedure was attributed to
German surgeon Gustav Neuber in 1893. He described the
transfer of adipose tissue from the arm for correction of an
osteomyelitis-related, contour deformity in the infra-orbital
region [1]. Two years later, another German surgeon, Vincent
Czerny, published a description of a procedure in which he
transferred a moderate-sized lipoma from the buttock to the
breast, to correct asymmetry resulting from a partial mastectomy [2]. In 1920, Sir Harold Gillies described using fat
grafts to correct various facial wounds and their sequelae [3].
Gluteal enhancement by means of fat grafting has been
performed sporadically for over 40years but gained popular-
O. Garcia Jr (*) · P. Pazmiño
Division of Plastic Surgery, University of Miami, Miller School of
Medicine, Miami, FL, USA
e-mail: oni@ogarciamd.com; author@miamia.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_15
ity among plastic surgeons following the description of the
modern version of the procedure by Toledo [4]. Initially, this
was a strictly subcutaneous operation with a relatively low
associated morbidity and mortality. Typical fat transfer volumes also appear to have been relatively modest in comparison to the average fat transfer volumes associated with the
current version of the operation. The procedure was coined
the “Brazilian Butt Lift” [5] around the turn of the century
and soon after became one of the most sought- after aesthetic,
body contouring procedures in the United States [6].
The aesthetic preferences of American women have
evolved from the t, athletic, “hard bodies” of the 1990s to
fuller, more voluptuous gures after the turn of the century.
Many women now also choose to embrace ethnic backgrounds that nd wider hips and fuller buttocks aesthetically
attractive [7]. Social media has also played a major role in
promoting these concepts.
As fat transfer volumes increased to a level that could
potentially overwhelm the subcutaneous recipient site, surgeons began grafting deeper into the well-vascularized glu-
187
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