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Part I
Anatomy and Aesthetic Concept
Chapter 1
Modern and Integral Anatomy oftheGluteal
Region: FROD’S Intramuscular Space
FreddyRodriguezGarcia
1.1 Historical Aspect
Without underestimating the multiple advances that Science and Technology have
contributed to the modern development of Medicine and Surgery in recent decades,
we consider a fundamental and essential factor for obtaining excellent results in any
of the different surgical areas of medicine, wide and deep knowledge of the body
anatomy. The learning and teaching of human anatomy have been strongly related
to the vertiginous advance of medical thought, and simultaneously to the method of
direct observation, based on the dissection of human corpses.
It is therefore necessary to mention in this chapter, a brief summary of the development of this discipline and some of the most important characters in the history
of medicine and human anatomy, who have made great contributions to these areas.
Beginning in ancient Greece with Hippocrates, describing great vessels, special
senses, systems, and his Hippocratic oath, Aristotle and his contributions to comparative anatomy, Herophilus and his public dissections on human bodies [1], then
moving on to the Roman Empire with Galen and his contribution to physiology, in
addition to the work “De usu partium,” which highlights the parts of the human
body [2].
The Feudal period continued with very few anatomical discoveries due to the
inuence of Christianity, and in the Middle Ages the Bible predominated over anatomy texts [3].
In the Renaissance, discoveries such as the compass, gunpowder, and the
American continent, among others, changed the vision of the world, and then Da
Vinci appeared, standing out in the Arts and Philosophy, who decided to dissect
corpses to better draw the human body [4]. In one of his diaries he designed “The
F. R. Garcia (*)
Centro Medico Vital, Barranquilla, Colombia
Sociedad Colombiana de Cirugia Plastica, Bogotá, Colombia
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_1
3
4
F. R. Garcia
Fig. 1.1 Leonardo da Vinci’s Vitruvian man, represents the ideal proportions of the human body
Vitruvian Man” famous drawing for studying in it, the ideal proportions of the
human body [5] (Fig.1.1). In this same period we highlight Vesalius, who begins
modern Anatomy with his great work “De Humani Corporis Fabrica, Libri Septem”
known as “la Fabrica,” correcting many of Galen’s errors [6].
Already in modern times from the sixteenth century onward, considered as a
“period of scientic conrmation,” many characters contributed to the advancement
of Science, Medicine, and Anatomy, describing organs and tissues, in addition to the
publication of recognized texts and atlases. Some of these important names from
different countries that made their contributions are: Harvey, Henle, Malpighi, Bell,
Broca, Testut, Roentgen, and Pirogof, among others [6].
Toward the end of the nineteenth century and the rst half of the twentieth century, a promising technological era appeared that focused on the visualization of
organs and tissues, and also on medical diagnosis. This is how in the second half of
the century, ultrasound [7], nuclear magnetic resonance [8, 9] and computed tomog-
raphy [10, 11] were discovered successively. In 1975 laparoscopic surgery began in
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
Fig. 1.2 Plastination,
technique of preservation
of biological tissue, of the
German professor Gunther
Von Hagens
5
Brazil, and a few years later the laparoscopic technique was also published for diagnosis, as a revolutionary ally of anatomy due to the internal images obtained [12]. A
little more recent, the German professor Von Hagens in 1977 disclosed the technique of preservation of biological tissues, called plastination, replacing water and
technical lipids with polymers, resulting in exible, dry, odorless, and very durable
corpses for study [13] (Fig.1.2).
We can observe in this brief summary of the development of Anatomy over the
years that after the era called “Modern Anatomy,” where practically all organs and
body anatomical structures were discovered and described, little has been published
or described on new ndings related to the already known macroscopic anatomy.
Even so, Science, Medicine, and Anatomy maintain a progressive evolutionary
state, increasingly sophisticated and complex.
Without a doubt, we can afrm that the domain of Anatomy provides the surgeon
with security, tranquility, and the ability to modify, repair, mold, and prevent complications of tissues or organs, which are subjected to surgical procedures of different kinds.
1.2 General Considerations
The concept of body beauty has been constantly evolving, through the different
times or stages of humanity. At present, the increase in the volume of the buttocks
has been synonymous with femininity, sensuality, and eroticism, considering it as
an essential element in the shaping of body beauty and powerful sexual attractiveness. Gluteal implants and lipoinjection of the area are currently the “gold standard”
worldwide to obtain volumetric augmentation of this anatomical region [14].
6
F. R. Garcia
According to the annual statistical reports prepared by the American Society
of Plastic Surgeons (ASPS) on the frequency and type of cosmetic surgeries most
performed in that country, gluteal augmentation with fat graft has been presented
in the last 5years, a continuous increase in the percentage of surgeries performed
compared to the immediately previous year, despite a slight decrease in frequency
in the last 2years, probably due to its low or doubtful safety prole [15–19]. On
the contrary, gluteal augmentation with implants presented a signicant increase
in surgeries performed in 2015 [15] and 2016 [16], presenting a worrying drop in
2017 [17] and 2018 [18] due to the volume of complications, recovering these
falls with a slight increase in frequency, in 2019 [19], closely related to the fall in
the safety prole of gluteal fat transfers in recent years. According to the annual
and global statistics of the International Society of Aesthetic Plastic Surgery
(ISAPS), in 2017, contrary to the ASPS statistics, gluteal augmentation surgery
ranked third among the surgeries with the highest rapid growth with 17%, only
surpassed by vaginal rejuvenation and belt lipectomy, but even surpassing rhinoplasty, which was placed in fourth place with 11% growth. It did not appear in
this group in 2018, and the 2019 and 2020 records have not been published [20].
Due to this uncertain situation of both procedures when performed in isolation,
some authors such as Cárdenas [21] and del Vecchio [22] propose the combination of both techniques using less volume of fat and implants, to try to reduce
complications presented in isolation, and obtain a more complete and attractive
aesthetic result.
And it is precisely in this gluteal region, very fashionable due to modern
beauty parameters in recent decades, strongly favored by the inuence of the
Internet and Social Networks, where we have found several important anatomical ndings in the macroscopic structure of the gluteus maximus muscle, which
will be thoroughly described in this chapter. These discovered anatomical ndings are considered very valuable for all Medical Science, but mainly for plastic
surgeons who use the tissues of this area, to perform surgical procedures aimed
at improving congenital or acquired aesthetic defects, using autologous tissues
or implants.
We begin the study of this important body region, defining its anatomical
limits, to then proceed to describe from the covering skin, each of the planes
that make it up with their respective tissues and fasciae or aponeurosis present
there and the muscular and neurovascular structures belonging to each one of
them, which must be taken into account for the effect of the surgical procedures performed there. We will present a modern anatomical chapter, based on
concepts from the texts of Descriptive and Functional Anatomy, more complete and updated today, complemented with an important study of surgical
anatomy carried out by the author of this chapter, in fresh and formalized
cadavers, with novel findings such as the FROD INTRAMUSCULAR
SPACE [23], essential for the placement of implants in gluteal augmentation
surgeries.
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
7
1.3 Anatomical Limits
The gluteal region constitutes in the back, a great transition zone between the trunk
and the lower limbs, and although physically it is part of the trunk, functionally it is
undoubtedly part of the lower limb. It occupies exactly the posterior part of the hip,
and is limited superiorly by the iliac crest, inferiorly by the gluteal sulcus that separates the buttock and thigh, medially by the intergluteal cleft, and laterally by a
vertical line of the anterior superior iliac spine, anterior border of the greater trochanter. The groove or lower gluteal fold does not correspond to the lower border of
the gluteus maximus muscle, which crosses it obliquely. It is formed mainly in its
medial part, due to the presence of brous tracts (suspensory ligament or ischiocutaneous ligament), which keep the deep face of the skin attached to the ischium [24].
Then we will make a basic description of the surface anatomy and descriptive
anatomy of the area, to nish with a detailed detail of the surgical anatomy, where
we will highlight the ndings found a few years ago, in a study carried out by the
author of the chapter, in 20 cadavers fresh and formalized [23].
1.4 Surface Anatomy
During the physical examination of the patient and also during surgery, the bone
landmarks are very useful to assess normal development, detect and evaluate dislocations or fractures, and locate important vascular-nerve structures.
In the nal and posterior part of the iliac crest, we nd the posterior superior iliac
spine (PSIS), sometimes difcult to palpate, but easily located because it is located
at the bottom of a cutaneous depression located about 3.5–4.0cm lateral to the line
medio-sacral, and formed by the xation of the skin and fascia underlying the PSIS.
In the inferior-internal part of the gluteal area, we easily palpate the ischial tuberosity, especially when the thigh is exed. When the thigh is extended, the buttock
covers and conceals the tuberosity.
The laterally located greater trochanter projects superior to the femoral neck and
can be palpated on the outer aspect of the thigh, 10cm below the iliac crest. It forms
a prominent anterior to the depression of the lateral aspect of the buttock. The width
of the adult pelvis is determined by the prominences of the greater trochanters. This
prominence is located in the middle of a line drawn from the anterior superior iliac
spine (ASIS), to the apex of the ischial tuberosity. Due to its lateral location close to
the skin, it causes discomfort when we lean in lateral decubitus on a hard surface.
The prominent area posterior to the pelvis and inferior to the iliac crests, extending laterally to the posterior border of the greater trochanter, is called the Buttock,
and another area that extends supero-lateral to the greater trochanter, and anteriorly
to the postero-superior iliac spine, is called the Hip. The buttocks are generally
convex, and their relief or projection varies according to the anatomical constitution
of each individual [25] (Fig.1.3).
8
INTERGLUTEAL
CLEFT
F. R. Garcia
HIP
BUTTOCK
THIGH
Fig. 1.3 Surface anatomy: we observed the main bone landmarks, and the areas corresponding to
the buttock and hip of the gluteal region
GREATER
TROCHANTER
ISCHIAL
TUBEROSITY
GLUTEAL
FOLD
1.5 Descriptive Anatomy
From the skin to the posterior skeleton of the pelvis in depth we will describe the
most relevant anatomical aspects of the tissues and anatomical structures present in
each of the planes of the region.
Under the thick and exible skin covering of the gluteal area, we nd a layer of
fatty tissue made up of adipose accumulations, separated from each other by brous
tracts of the supercial gluteal fascia, which are inserted in the deep face of the
dermis and in the aponeurosis underlying. This fatty tissue decreases in thickness
and disappears at the level of the ischial tuberosity and the greater trochanter, originating a laminar tissue that frequently results in a serous bag (Velpeau). In this layer
of subcutaneous fat, perforating and cutaneous branches of the nerves are located:
XII dorsal (Subcostal), abdominogenital major, sciatic minor, femoroccutaneous
and sacral nerves. We also nd supercial arterial and venous branches, not very
important [24].
Below the subcutaneous fat, the regional aponeurotic layer or deep gluteal fascia
can be seen, with a pearly, dense and thick appearance, continuation of the lumbar
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
9
fascia, and covering the upper portion of the gluteus medius muscle that protrudes
above the gluteus maximus. Starting from the iliac crest, upon reaching the superior
border of the gluteus maximus muscle, the regional aponeurosis is divided into three
sheets: a supercial sheet that covers the posterior or supercial aspect of the gluteus maximus, a middle sheet that covers the anterior or deep aspect of the gluteus
maximus, and a deep thin and cellular sheet that lines the posterior or supercial
aspect of the gluteus medius muscle, extending inferiorly over the pyramidal, superior gemellus, internal obturator, inferior gemellus (Triceps Coxae), and quadratus
femoris muscles, continuing below with the femoral aponeurosis [26]. At the time
when the supercial and middle sheets of the regional aponeurosis cover the supercial and deep aspects of the gluteus maximus muscle, they originate or emit resistant brous septa, which are located between the thick and cylindrical muscular
fascicles, joining them strongly (Fig.1.4).
Beneath the deep gluteal fascia or regional aponeurosis, we nd numerous muscles, ligaments, vessels, and nerves in the area, which we will mention in the following. There are several classications of the gluteal muscle planes, but we will
describe the one by Rouviere–Delmas, due to the evident coincidence in the multiple dissections in cadavers performed by us [24].
According to the above, there are nine muscles distributed in three planes: supercial, medium, and deep. Based on their origin in the pelvis and their lateral insertion in the greater trochanter, it is stated that all these muscles, with the exception of
the gluteus maximus, are pelvic-trochanteric. We will start the description with the
most supercial of all.
1. Gluteus Maximus or Gluteus Maximus Muscle. The supercial plane is made
up of this thick, quadrilateral, attened muscle, the largest and most supercial
in the area, with multiple fascicles separated by brous septa. It originates medially in the most posterior part of the crest and external iliac fossa, dorsal aspect
and crest of the sacrum and coccyx, posterior sacroiliac ligament and sacrotuberous ligament, inserting laterally in the fascia lata or iliotibial tract, and also in the
Fig. 1.4 Aponeurotic
sheets of the regional
aponeurosis, or deep
gluteal fascia: supercial,
middle, and deep sheets.
[“Original image published
in Cir. Plast. Iberolatinoam,
2016, 45(2):149–156 and
reproduced with
permission”]
10
F. R. Garcia
gluteal crest of the rough femoral line (Fig.1.5). It covers the rest of the muscles
in the region, except the anterior superior third of the gluteus medius. Its deep
face is separated from the rest of the underlying muscles by a layer of adipose
cell tissue that communicates with the superior pelvirectal space through the
greater sciatic notch, and with the ischiorectal fossa through the lesser sciatic
notch. The main deep vessels and nerves of the region are located in this cellulose adipose tissue, which enter between the gluteus maximus muscle and the
deep sheet of the regional aponeurosis, branching out before being lost between
the muscle fascicles. Two serous pockets or bursas develop in the celluloadipose layer, one behind the ischial tuberosity and the other on the external face
of the greater trochanter. Inferiorly we nd a third gluteal-femoral bursa,
separating the iliotibial tract from the upper part of the proximal insertion of the
vastus lateralis [25] (Fig.1.6).
It receives arterial circulation through the superior and inferior gluteal vessels, and innervation by the inferior gluteal nerve (L5, S1, S2). All of these structures enter the muscle through its deep face. The sciatic nerve in the upper part
of its course, passes deep to the gluteus maximus muscle.
This muscle has as its main action, the extension and lateral or external rotation of the thigh. When it is xed distally in the femur, it extends the trunk over
the lower limb, straightening the pelvis, a function it performs in the bipedal
station and in the act of standing up when sitting. It works primarily in the exed
and upright thigh positions, such as when we rise from a sitting position, stand
up from a exed position, run, or climb stairs. Although it is the most powerful
Fig. 1.5 Gluteus maximus
muscle. Supercial large,
with postero-medial pelvic
origin, and lateral
insertions in the iliotibial
tract and gluteal femoral
crest
GLUTEUS
MAXIMUS MUSCLE
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
OBTURATOR
INTERNUS BURSA
ISCHIAL BURSA
TROCHANTERIC
BURSA
GLUTEOFEMORAL
BURSA
11
Fig. 1.6 Serous bursaes: trochanteric, gluteofemoral, ischial and internal obturator
hip extensor, it acts preferentially when strength is needed, and is used briey
during normal walking.
2. Gluteus Medius Muscle. It forms the muscular median plane, it is located in the
upper part of the gluteal region, surpassing the gluteus maximus in height, from
the upper edge of this muscle, to the iliac crest. It is a thick, radiated muscle that
we nd below the gluteus maximus and covering the gluteus minus muscle. Its
lower border is separated from the superior border of the pyramidal muscle, by
the superior gluteal vessels and nerve. Its lateral insertion tendon is separated
from the superior border of the greater trochanter by the trochanteric serous bag.
This Pelvitrochanteric muscle receives innervation from the superior gluteal
nerve (L5, S1). It acts as an abductor or separator, and a medial or medial rotator
of the thigh. If you x your insertion on the femur, it also straightens the pelvis
(Fig.1.7).
3. Gluteus Minor Muscle. Together with six other minor muscles, it constitutes
the deep muscular plane of the area. Located below the gluteus medius that completely covers it, it is attened in a triangular or fan shape. It covers the upper
face of the hip capsule or hip joint. It is also pelvitrochanteric. Its innervation
and muscle action is totally similar to that of the gluteus medius muscle (Fig.1.7).
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