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11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
179
Fig. 11.8 Marking before and 20days after the procedure 8
marking in green the subunits with excess volume and in yellow the subunits with
volume deciency. Once the subunits are marked, they are listed, and photographs
are presented to the surgeon during surgery with the objective of conrming the
surgical plan details during the procedure (Fig.11.8).
Before surgery, the patient is informed about risks and complications. Patient
authorization is obtained with signed consent.
11.12 Surgical Preparation andSurgical Technique
Preoperatively, ciprooxacin single dose iv, omeprazole single dose 40mg iv, and
etamsylate 500mg iv is provided to patients 1h before surgery.
General anesthesia is applied, and I apply sodium hypochlorite as an aseptic and
antiseptic.
The superwet inltration technique is performed with Hartmann’s solution,
1000cc epinephrine (1:1000), and lidocaine (20 mg/kg) (the solution is heated to
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A. N. Mendez
38–40°C prior to the procedure). The solution is inltrated with an infusion pump,
and power-assisted liposuction (PAL) with a basket-type 5mm cannula is used for
the procedure.
Asepsis and antisepsis measures are applied in the standing position. The surgical bed is covered with waterproof sterile drapes. The patient receives a calf-pump
for deep vein thrombosis prophylaxis, and a Foley catheter is placed during the
surgical procedure. A Foley catheter is removed 1h after the surgery has concluded.
It is important to seal the area, as shown in Fig.11.5, as part of the preoperative
preparation.
11.13 Surgical Technique
Once the evaluation has been performed, the subunits with excess volume colored
green and the subunits with volume deciency colored yellow, the treatment plan
can be schematized (Fig.11.8). Liposuction is performed in four steps, and fat grafting is performed in three stages (Table11.2) (Video 11.2, Step 2; Video 11.3, Stage
1; Video 11.4, Step 3; Video 11.5, Stage 2; Video 11.6, Stage 3).
I perform the procedure with a PAL with a MicroAire instrument. After fat grafting, I separate the fat with a 5-mm basket-type cannula in each subunit; once the fat
is separated, suction is started. Then, I tighten the cutaneous tissue with a 980-nm
diode laser (if that patient presents loose skin). Fat grafting is performed with a
Wells-Johnson infusion pump with a high volume precision (HVP) system after
PAL and a 5-mm basket-type cannula applied in a retrograde direction.
Table 11.2 Surgical steps and stages
Liposuction Fat grafting
Step 1: Supine position (B7, B6, B5, B4, B3) left
and right sides
Step 2: Prone position (B7, B6, B5, B4, B3, B2,
B1, A) left and right sides
Step 3: Right lateral decubitus (B7, B6, B5, B4,
B3, B2, B1, C1, C4, C2, C)
Left lateral decubitus (repeated)
Step 4: Prone position
No suction
Note: The surgeon can decide which side to start with (left or right side); however, it is important
to follow the surgical plan in a sequence
None
Stage one: (D1, D2, D3, D4, D5, D6, C2, C3)
Stage two: Right lateral decubitus: D4, D5,
D6, C2, C3, C4, C1, E3, E4
Left lateral decubitus (repeated)
Stage three: E2, E3, E4, E1
Use a leveling device
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
181
11.14 Description ofper Aesthetic Units Obtained
fromNajar Marking
Before liposuction, 12 access ports/incisions are made: 7in the posterior part and
5in the anterior part. They are located at strategic points to facilitate fat extraction/
removal and fat grafting (Fig.11.9).
11.14.1 Unit A(Lumbosacral Area)
Liposuction in this area is essential to achieve beautication/enhancement of the
cephalic portion of the buttocks/gluteal area [13].
This unit is defatted in only the prone position using incision access number 1.
Fig. 11.9 Incision
access 9
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A. N. Mendez
The procedure is initiated once liposuction has been performed in subunits B7,
B6, B5, and B4 and during step 2 of liposuction.
The recommended thickness ratio of the subcutaneous cellular tissue of the lumbar area to the sacral area is 1:1.
11.14.2 Unit B
This unit corresponds to the trunk, which is divided into the superior back, middle
back, and anks (waist). It contains six or seven subunits depending on the number
of back rolls.
Subunits B1 and B2 are in the posterior part at the level of the anks. These
subunits undergo liposuction in step 2 through incision access numbers 2, 3, 4,
and 5 (Fig.11.9). Subunit B2 must not be suctioned entirely since it is best to treat
this section during step 3 of liposuction (lateral decubitus position).
Subunits B7, B6, B5, B4, and B3 have two surfaces or sides including the posterior, lateral, or anterior sides. They undergo liposuction in steps 1, 2, and 3
through incision access numbers 2, 3, 4, 5, 9, 10, 11, and 12. During step 3 (right
and/or left), 90% of liposuction is performed through incision access numbers 9,
10, 11, and 12. This is preferable since the rib cage and iliac crest protect the abdomen in the lateral decubitus posterior position, so there is a decreased risk of
abdominal perforation.
The waist is represented by subunits B1, B2, B3, and B4. I have found that most
of the patients’ fat is located in subunits B1 and B4 and that the subunits with the
lowest volumes are subunits B2 and B3, where the transition zone is located.
Therefore, subunits B1 and B4 must be thinned considering that the lowest point of
waist concavity is located at the line that separates subunits B1 and B4 from subunits B2 and B3. Suctioning of this area is performed in step 3 of liposuction. I
recommend suctioning subunits B2 and B3 after fat grafting subunits D and C to
account for the transition between the hip convexity and concavity of the waist, as
long as the patient’s goal is to achieve a round buttocks and waist with a good waisthip proportion.
11.14.3 Unit C
Unit C corresponds to the waist and has four subunits: C1 and C2, located in the
lateral and posterior portions and next to E4 and E3, respectively, and C4 and C3,
which have anterior and an anterolateral surfaces.
Liposuction is performed in steps 2 and 3 (Table11.2).
In the case of a square or a round pelvic frame with excess volume, suction
should be performed in C1 and C4 through incision access numbers 6 and 7.
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
Fat should be distributed according to the patient’s pelvic frame. Normally, the
zone with the largest volume deciency is the central hip zone. This zone is considered by many to be a determinant of gluteal attractiveness [10] and is where four
subunits of the hip meet (Fig.11.2). To obtain a round buttocks and a better waist
line, fat manipulation in this zone is required.
Fat grafting in C subunits is performed in stages 1 and 2.
Fat grafting in these subunits (C) will be individualized depending on the
patient’s goals and surgical plan; for example, if the patient has a type V pelvic
frame and desires a round buttocks, subunits C2 and C3 should be fat grafted, but
only after subunits D4, D5 and D6 have previously undergone fat grafting.
Subunits C2 and C3 (part of the gluteal support) undergo fat grafting using incision access numbers 2 and 3, and the anterior portion of subunit C3 is accessed from
incision access numbers 9 and 10, regardless of the side treated.
183
11.14.4 Unit D (Gluteal Support)
This unit corresponds to the proximal one-third of the thigh and its point of joint with
the caudal part of the pelvic frame (buttocks and hips). This is an important inferior
transition in the caudal position of the gluteus. The infragluteal fold, which is one of
the main determinants for gluteal attractiveness, is located in this unit [10].
Unit D has six subunits (D1–D6). D2 and D3 are located in the posterior portion.
D1 has a posterior and a posteromedial surface. The diamond zone, described by Dr.
Centeno [14] in his esthetic units classication, is located in this zone. The greater
the rmness of this area is, the greater the gluteal attractiveness will be.
Fat grafting in these subunits is performed through incision access numbers 5
and 6. Occasionally, a 13th incision is made in the middle and under subunit D2 to
graft fat toward subunit D1in a longitudinal direction (Video 3, Stage 1).
Subunits D3, D5, and D6 are grafted through incision access number 5 and 6
according to the corresponding side.
Subunit D4 is grafted through incision numbers 2 and 3 according to the corresponding side.
11.14.5 Unit E
Aesthetic unit E has four subunits; E1 and E2 are medial, while E3 and E4 are external or lateral.
The treatment of this aesthetic unit is performed during stage 3 fat grafting.
Subunits E1, E2, E3, and E4 are grafted through incision access number 1 (this
is the safest port according to the International Survey on Aesthetic/Cosmetic
Procedures (ISAPS) [15]. Subunits E3 and E4, which are in the greater caudal portion, are occasionally grafted from incision access numbers 6 and 7 according to
entry/access (Video 6, Stage 3).
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11.15 Postsurgical Treatment andCare
Once surgery is concluded, two drains are placed, and the patient is dressed in a soft
compression long sleeved-top and a bandage with a cotton cover.
The patient can be discharged 24h later and should be prescribed the antibiotic
ciprooxacin (1 g orally every 24h) and the analgesics paracetamol (1 g every 12h)
and dexketoprofen (12mg every 8h).
It is recommended to perambulate at home and drink plenty of liquids.
Drains are removed 4days after the rst medical appointment, and a low-level
compression bandage is applied a week of the surgery (at the second medical visit).
Sleeping face down is recommended as long as breast surgery has not been performed, and the patient should not sit for 21days to enhance the speed of gluteal fat
transfer.
Ten days after surgery, I recommend initiating rehabilitation therapy every other
day based on ultrasound results, lymphatic drainage (not manual) with a soft pneumatic compression system and electrostimulation.
11.16 Complications
I performed 413 surgeries with this technique from September 2016 to June 2019.
There were a total of seven complications: ve involved liponecrosis that was
addressed without hospitalization, one involved liponecrosis that required hospitalization, and two involved anemia requiring transfusion. One patient was diagnosed
with adult respiratory distress syndrome within 11days of surgery.
As a result, the complication rate was 0.016%.
11.17 Conclusion
Antigravitational liposculpture is a systematic detailed and three-dimensional technique that is based on Najar marking to improve the waist–hip ratio and the beautication of the buttocks; it includes liposuction steps and processes and fat grafting
of only subcutaneous cellular tissue (safe zone) distributed in the hips (unit C),
gluteal support regions (unit D), and buttocks (unit E). This technique reduces the
volume that is applied in the gluteal area (unit E); the volume must be optimized to
reduce fall and complications while considering the aesthetic result desired by the
patient.
11 Preferred Surgical Techniques in Fat Transplantation to the Gluteal Region…
185
References
1. 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;145:281–3.
2. Hoyos AE, Millard JA. VASER-assisted high-denition liposculpture. Aesthet Surg
J. 2007;27:594–604.
3. Wall S, Del Vecchio D, Teitelbaum S, Villanueva NL, Dayan E, Durand P, etal. Subcutaneous
migration: a dynamic anatomical study of gluteal fat grafting. Plast Reconstr Surg.
2019;143:1343–51.
4. 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;143:447–51.
5. Frank K, Casabona G, Gotkin RH, Kaye KO, Lorenc PZ, Schenck TL, etal. Inuence of age,
sex, and body mass index on the thickness of the gluteal subcutaneous fat: implications for safe
buttock augmentation procedures. Plast Reconstr Surg. 2019;144:83–92.
6. Del Vecchio D, Wall S.Expansion vibration lipolling: a new technique in large-volume fat
transplantation. Plast Reconstr Surg. 2018;141:639e–49.
7. Coleman SM, Jacobs J.Chapter 47: Fat grafting in body conturing surgery. In: Rubin JP,
Jewell M, Richter DF, Uebel CO, editors. Body conturing liposuction. New York: Elsevier;
2013. p.513–20.
8. Cardenas-Camarena L, Arenas-Quintana R, Robles-Cervantes JA.Buttocks fat grafting: 14
years of evolution and experience. Plast Reconstr Surg. 2011;128:545–55.
9. Ghavami A, Villanueva NL, Amirlak B.Gluteal ligamentous anatomy and its implication in
safe buttock augmentation. Plast Reconstr Surg. 2018;142:363–71.
10. Cuenca-Guerra R, Quezada J.What makes buttocks beautiful? A review and classication of
the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthet Plast
Surg. 2004;28:340–7.
11. Wong WW, Motakef S, Lin Y, Gupta SC.Redening the ideal buttocks: a population analysis.
Plast Reconstr Surg. 2016;137:1739–47.
12. Rosique RG, Rosique MJ, De Moraes CG.Gluteoplasty with autologous fat tissue: experience
with 106 consecutive cases. Plast Reconstr Surg. 2015;135:1381–9.
13. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A.Combined gluteoplasty: liposuction
and lipoinjection. Plast Reconstr Surg. 1999;104:1524–31.
14. Centeno RF.Gluteal aesthetic unit classication: a tool to improve outcomes in body contouring. Aesthet Surg J. 2006;26:200–8.
15. American Society of Plastic Surgeons (ASPS), American Society for Aesthetic Plastic Surgery
(ASAPS), International Society of Plastic Surgery (ISPS), International Society of Plastic
Regenerative Surgeons (ISPRES), International Federation for Adipose Therapeutics and
Science (IFATS). Multi-society gluteal fat grafting task force issues safety advisory urging
practitioners to reevaluate technique [letter]. ASPS, ASAPS, ISPS, ISPRES. 2018. https://
www.surgery.org/sites/default/les/Gluteal- Fat- Grafting- 02- 06- 18_0.pdf. Accessed 26
Feb 2020.
Chapter 12
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Gluteal Fat Augmentation– Our Personal
Approach
RodrigoG.Rosique andMarinaJ.F.Rosique
12.1 Introduction
Buttock fat grafting became extraordinarily popular around the globe over the last
decade and is consistently ranked among the fastest growing procedures year after
year in annual surgical statistics published by several plastic surgery societies [1, 2].
This recent trend had a different impact on the buttock’s aesthetic goals within
each country. In countries where buttock augmentation is a novelty, populational
preferences shows a waist-to-hip ratio (WHR) lower than the constant ratio along
with human mankind’s history of 0.7 [3], indicating the sought for more articial
body contour [4].
Buttock fat grafting was rst published in Brazil in 1986 [5], just a few years
after the publication of the liposuction technique by Illouz [6], probably because
buttocks aesthetics were already valorized in Brazilian culture and patients start
questioning the possibility of using its own fat to enhance the buttocks.
Along history, the exaggerations present in each aesthetic trend vanishes away,
melting into the classic preferences [7]. Working mainly with Brazilian patients and
international ones that desire to have the real Brazilian look, our buttock fat graft
technique that will be described in the following, is a product of the experience
accumulated, not only during our professional years of experience [8] but also on all
that the Brazilian plastic surgeons have taught us.
R. G. Rosique (*) · M. J. F. Rosique
Private Practice, Junqueira Rosique Plastic Surgery Clinic, Ribeirão Preto, Brazil
e-mail: Rodrigo@rosique.com.br
© 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_12
187
188
R. G. Rosique and M. J. F. Rosique
12.2 Preoperative Period
12.2.1 Patient Selection
Proper patient selection is pivotal to ensure good results. The four main points to
consider during the pre-operative consultation are:
• Body fat percentage (BF)
• Body shape and
• Skin quality
When the patient has a BF lower than 20%, there is not enough fat to work with.
If the BFP is high, above 30%, we often ask the patient to lose weight and exercise
to increase the muscle mass, ensuring more athletic results.
Patients are instructed to avoid losing weight 4weeks before surgery, in order to
prevent trans operative anemia and low protein conditions.
We never ask thin patients to gain weight, but to maintain their regular weight,
otherwise when patients lose weight postoperatively, the fat grafted will be
jeopardized.
Certain body shapes are difcult to work with and may be challenging to obtain
the desired hourglass gure. Patients with banana or apple body shapes are advised
preoperatively of the limitations of their body frames, and the expectations should
be lowered.
Lastly, the skin must be of good quality and elasticity, otherwise there will be
accid skin and laxity, requiring skin excision procedures (Buttock Lift), especially
in massive weight loss patients.
12.2.2 Surgical Planning
With the patient standing, the donor and recipient areas are marked. The donor sites
vary with each patient, but usually comprise the anks, the torso, the sacral region,
and, occasionally, the arms, saddlebags, and inner thighs.
It is important to build a transition zone between the lower torso and the buttocks
in a wide opened arc shape over each buttock beginning at the apex of the intergluteal cleft. This 1-inch wide line should not be suctioned or grafted (Fig.12.1).
The area to be grafted is usually a transverse oval shape, pointing outward and
slightly displaced toward the superior part of the buttocks (to lift) and the lateral part
(to ll the lateral curve). This area overlaps the gluteus maximus and the fossa between
the gluteus maximus, gluteus medius, and tensor fasciae latae, from the lateral border
of the sacrum to the femoral neck. In some patients, we also perform fat grafting in
the greater trochanter depression to achieve a harmonious contour (Fig.12.2).
Supercial depressions usually are present over the ischial tuberosity but may be
present in any other locations and should be marked for a subcutaneous lling.
12 Gluteal Fat Augmentation– Our Personal Approach
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Fig. 12.1 Transition zone
between the lower torso
and the buttocks. With the
patient in standing
position, we mark the most
pronounced points or lines
to be suctioned or grafted
and draw concentric areas
around them. Fat
harvesting sites upper body
(green), Fat harvesting
sites lower body (yellow),
Grafted areas (black). The
blue line is the transition
area, or “no touch” area.
Most of the fat is grafted
over the gluteus maximus
muscle (black). In some
patients, fat is also injected
over the great trochanter
(red), especially if this area
shows some depression
during hip exion
189
Therefore, each patient present individual needs, background, and history that should
be addressed, making it difcult to apply a standardized map for grafting (Fig.12.3).
12.2.3 Positioning ofthePatient
The patient is placed prone as we think that this position is more stable than the
lateral decubitus. This prevents an extra change in position and allows the placement of entry ports for the cannulas in well-dened and hidden anatomical
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