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Fig. 13.3 On table before and after large volume fatgrafting versus 6 months after results (Emily)
A. Aslani and M. G. Bravo
anterior iliac spine. Regarding incision placement, we recommend bearing two factors in mind: an additional incision has the unquestionable disadvantage of additional scarring, though small. But on many occasions, this may be outweighed by
the advantage of an extra inltration angle, which may be much more signicant
(Fig.13.4).
Inltration starts aiming at the central buttock projection zone. The central point
of the highest projection corresponds to the crossing point of a horizontal line
through the center of the natal cleft line, and a vertical line connecting the posterior
iliac spine through the ischiatic tuberosity. When aiming for the central projection
zone, we make sure that the cannula is passed through the subcutaneous space only,
which is easy to control since the tip of the cage cannula is palpable below the skin
at all times. Preoperative ultrasound to measure the thickness of subcutaneous tissues maybe useful to create awareness of how much subcutaneous tissue is actually
available as recipient tissue. Real-time ultrasound can be used too, though at the
disadvantage of ratherstatic inltration.
Inltration starts pedal-controlled, at 200–300mL/min with the continuous toand- fro movement of the cannula in the subcutaneous space. We prefer to angle the
cannula perpendicular to the skin surface and maintain palpation control with the
palm of the nondominant hand at all times (Fig.13.5).
13 Preferred Surgical Techniques inFat Transplant totheGluteal Region
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Fig. 13.4 Ischiocutaneous
ligament
201
Care is taken to always feel some tissue resistance so as to make sure the grafts
nd sufcient recipient tissue. Loss of tissue resistance signals the need to stop the
injection immediately. It means loss of scaffold and therewith heralds the risk of
creating fat cysts and blow out deformities. On the other hand, in patients with high
tissue density, we prepare the recipient bed with vibrating cannula expansion only,
without injection, to loosen up tissue prior to the actual inltration. This is especially helpful in patients with very tight skin in the trochanteric area like often found
in male-to-female gender reassignment patients. In most cases, expansion/inltration ratio will be approximately 1:1.
The inltration is stopped once the grafted area hardens up and further expansion
of the subcutaneous space seems impossible. Patients typically maintain around
50% of the transferred volume. It is important to understand that the anticipated
volume loss is not only due to fat resorption but also to the absorption of the water
that a high-volume fat graft still contains. We call this percentage of water the
“uid-phase.” Without a uid-phase, fat would have a block like consistence comparable to butter, and injection would be impossible. This is also one of the reasons
why we moved away from purifying fat too much, since too low a percentage of
uid will make the graft “viscous “and make the graft vulnerable to friction trauma.
202
A. Aslani and M. G. Bravo
Fig. 13.5 Hip expansion AP
The targeted volume increase in the central hip area is a powerful tool to change the
patient’s waist to hip ratio to a more feminine relation (see Fig.13.5).
13.2 Complications
Fat necrosis and fat cysts are known complications of large volume fat grafting. Fat
necrosis can be caused by shear damage to fat cells, over-injection, and failure to
place the fat graft into sufciently vascularized recipient tissue. Also, patient incompliance after surgery by undue pressure on grafted areas prolonged unprotected sitting may be a contributing factor. It has been an essential part of our learning curve
with EVL to nd the right balance of expansion vibration fat grafting and preservation of soft tissue scaffold. Overexpansion can lead to fat blow out and cysts. To
avoid these complications, we encourage EVL beginners to start with a slightly
slower ow rate of 150mL/min and with more cases and experience gradually
increasing to 300mL/min, taking care to immediately stop the injection upon loss
of tissue resistance.
13 Preferred Surgical Techniques inFat Transplant totheGluteal Region
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203
Apart from all of the above, the key advantage of EVL fat grafting is maximum
safety against fat embolism.
Fat embolism has been the main issue in public discussion of BBL safety in
recent years [6] and has led to a high degree of public awareness of this problem.
There are two main theories as to the pathogenesis of fat embolism. The rst
mechanism is through direct injection into the venous system. For example, a cannula injection into the superior gluteal vein has a high risk of causing a fat embolism. The second mechanism is through an injury to a main vein through venipuncture
or an indirect tear. As a result, fat may pass into the lower pressure areas as the
transplantation process is carried out. It would, therefore, be important for the individual undertaking the procedure to consider the measures that would effectively
eliminate the possibility of these risks. With EVL the risks of fat emboli are signicantly reduced. Using the basket cannulas ensures the surgeon’s maximum control
over the correct positioning of the cannula tip in the subcutaneous space. The blunt
tip design makes inadvertent puncture of vulnerable structures very unlikely.
13.3 Conclusion
The EVL procedure is a relatively new technique that utilizes the available instrumentation in an innovative way, and which has better outcomes in shape change,
volume increase, and safety.
EVL is not only the standard of care as to prevention of fat embolism, it also
achieves superior aesthetic results and decreases surgery time as well as better longterm results in the use of autologous fat grafting in aesthetic plastic surgery.
References
1. Wall SH Jr, Lee MR.Separation, aspiration, and fat equalization: SAFE liposuction concepts
for comprehensive body contouring. Plast Reconstr Surg. 2016;138(6):1192–201. https://doi.
org/10.1097/PRS.0000000000002808.
2. Abboud M, Dibo S, Abboud N. Power-assisted gluteal augmentation: a new technique for
sculpting, harvesting, and transferring fat. Aesthet Surg J. 2015;35(8):987–94. https://doi.
org/10.1093/asj/sjv161.
3. Del Vecchio D, Wall S. Expansion vibration lipolling. Plast Reconstr Surg.
2018;141(5):639e–49e. https://doi.org/10.1097/prs.0000000000004338.
4. Chopan M, White J, Sayadi L, Buchanan P, Katz A. Autogenous fat grafting to the breast
and gluteal regions. Plast Reconstr Surg. 2019;143(6):1625–32. https://doi.org/10.1097/
prs.0000000000005617.
5. Ghavami A, Villanueva N.Gluteal augmentation and contouring with autologous fat transfer.
Clin Plast Surg. 2018;45(2):249–59. https://doi.org/10.1016/j.cps.2017.12.009.
6. Mod M, Teitelbaum S, Suissa D, Ramirez-Montañana A, Astarita D, Mendieta C, Singer
R.Report on mortality from gluteal fat grafting: recommendations from the ASERF task force.
Aesthet Surg J. 2017;37(7):796–806. https://doi.org/10.1093/asj/sjx004.
Chapter 14
S-Curve® Gluteal Augmentation
DanielGould andAshkanGhavami
14.1 Introduction
Other chapters have focused on the history of gluteal fat grafting and the science
behind it. The purpose of this chapter is to describe the techniques behind S-Curve®
Gluteal Contouring and to prescribe several pearls for those interested in delivering
high quality long-lasting buttock fat grafting to their patients.
14.1.1 Surgical Planning
As with any surgery, most of the case outcomes start with proper preoperative planning. Preoperative photographic analysis as well as physical exam helps to identify
several key points. The physician should ask several questions:
1. What is the bony shape of the patient? Underlying bony anatomy including the
lowest rib position and the height of the iliac crest will help dene the depth of
the excavation or “snatch” possible, as well as the shape of the abdomen in the
end [1]. Shorter torsos may still be able to provide an excellent prole if the bony
anatomy is amenable [1, 2]. Palpate the ASIS and mark the distance from this to
the lower rib to visualize the area of greatest contouring and fat reduction.
Figure14.1 illustrates this concept.
2. What is the elastic quality and volume of the skin and underlying fat? Palpation
and pinch testing yields an idea of the density of the fat, and the rebound of the
skin gives an approximation of how much it will contract after surgery versus
how much will become ptotic and loose. Exercise caution in patients with very
D. Gould · A. Ghavami (*)
Beverly Hills, CA, USA
© 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_14
205
206
l
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Fat excess
Distance between
12th rib and iliac
crest
Fat transfer
Fat recipient site
Fig. 14.1 Flank shape potential. The distance between the caudal ribs and iliac crest along with
iliac crest height and shape inuence the potential depth of the ank and waist excavation and
degree of waist to hip ratio possible
D. Gould and A. Ghavami
Post-liposuction
Depth and distance
determined potentia
for ‘S’ - curve
lax skin, and multiple or large striae, especially those with recent weight loss as
this may lead to dissatisfaction. Keep in mind the posterior anks as well as the
outer thigh bulges (“saddle bags”) hold much of the best fat for transfer and offer
key targets for “snatching” the total waist width and improving waist–hip ratio.
It is not uncommon to harvest most of the usable dense fat from the anks even
in those with paucity of donor fat.
3. What is the shape and size of the current buttocks? Mendieta has written about
the different anatomical shapes (Fig.14.2), augmenting the C points to improve
the shape, or to change from a V to an A [2–4]. Regardless of how you analyze
the buttock, keep in mind that each gluteal envelope can only accommodate a
certain volume of fat. Avoid overlling and focus on the transformation possible
with liposculpture as well as appropriation of the fat lobules to where best serves
the patients as well as dictated by patient goals. As with all contouring surgery
what we leave behind is just as critical as what we add. A smooth uniform layer
of subcutaneous fat (especially the supercial fat compartments) should be left
behind. A less is more philosophy and use of the SAFE technique will help avoid
postoperative donor site contour deformities (Fig.14.3).
4. What are the patient’s goals? Petite S Curve patients (those already thin and
many in good t shape) may have different expectations than larger S Curve
patients. There is a demand for this surgery even for just a few hundred ccs of fat
transfer, in thin patients. In this patient group, a little goes a long way particularly in the upper pole of the buttocks for projection and lling of the lateral
gluteal depressions (aka: “hip dips”). In this as in many practices, it is common
to request patients to gain weight prior to surgery to allow for more fat lobule
size available for future harvest. Caution against discouraging patients, many
come in and state they have seen other doctors who have said they don’t have
enough fat for the surgery, however with nesse and attention to detail with
meticulous 360° pinch testing, it is possible to safely reduce the areas of lesser
ab
cd
14 S -C urve® Gluteal Augmentation
207
Fig. 14.2 Mendieta’s frame shapes to evaluate overall bony frame and the consequent buttock–
body relationship. (a) A-frame (b) V-Frame (c) Square (d) Round. A—upper lateral hip; B—midbuttock; C—Lateral leg (From the art of gluteal sculpting. NewYork, Thieme; 2011:11)
lipodystrophy and to increase projection and contour volume in areas where
most desired. There may be a slightly higher risk of contour abnormalities so it
is recommended to take additional time in the fat equalization steps and to provide postoperative liposuction massage. Use of smaller cannulas and
interchanging of size as well as “basket” type tips for Mercedes tips is warranted. Release of the fat layers with basket cannulas of various diameters off
suction and on high vibration with power assistance will reduce contour issues
as well as provide more liberated fat lobules for acquisition (Fig.14.4).
208
Conca
Tr
Con
y
y
Conca
Tr
Con
a
b
Athletic - Curve (posterior) Athletic - Curve (lateral)
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D. Gould and A. Ghavami
vity
ansition
vexity
vity
ansition
‘S’ - Curve (posterior) ‘S’ - Curve (lateral)
Concavit
Transition
Convexity
Concavit
Transition
vexity
Fig. 14.3 (a) The modern preference for an S-curvilinear female body contour. Patients vary in
their preference for waist to hip ratio. (b) Some patients desire a more athletic silhouette line,
whereas others may prefer a wider lateral buttock/hip dimension. Almost all request as narrow a
waist as possible
Convexity
Sacrocutaneous
Gluteus
maximus
s
14 S -C urve® Gluteal Augmentation
Fig. 14.4 Two main
regions are important to
prioritize especially when
there is a lack of donor fat
available. Zone A is the
key mandatory graft donor
site for projection, whereas
zone B can remain limited.
Some patients prefer
enhanced waist to hip ratio
over projection and
therefore will express the
importance of zone B over
A.Zone B1 may also be
desired in some who need
greater buttock lift and
B1
need lateral thigh width
enhancement. A thorough
discussion is necessary
preoperatively
209
B B
A A
B1
Fig. 14.5 Gluteal
ligaments and zones of
medius
Sacrum
ligament
adhesion
Superior gluteal
adhesion
Gluteus
Ischiocutaneou
ligament
Gluteal crease
adhesion
14.1.2 Anatomy
Ischium
Gluteal anatomy including fasciocutaneous attachments and adhesion zones has
previously been described at length. Below is a gure depicting these anatomic
structures though they do vary in size and position in patients depending on their
physical shape and ethnic background (Fig.14.5).
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D. Gould and A. Ghavami
14.2 Preoperative Consultation
All patients are provided with consistent preoperative protocols. They are instructed
to purchase special pillows for ofoading to sleep and they are told they will not be
allowed to apply extra pressure to the buttocks for 2–3weeks post-op. Patients are
encouraged to go to aftercare and in the senior author’s practice the majority are
required to particularly if multiple areas of liposuction are performed. If going to
aftercare, their IV and foley are left in for transport, to be later removed once good
PO and ambulation is demonstrated. Caution against sitting on the areas as they are
at risk for vascular compromise especially in revision surgery, as the post-op sensation is less after fat grafting. More importantly sitting can cause movement of the
newly grafted fat, which can alter the results and diminish the quality.
14.3 Operative Steps
Patients are all marked standing in order to better appreciate the natural fascial connections to the skin as well as the “hills and valleys” to be dened in their abdomen
(High-Denition techniques). The back, arms, and buttock are also marked while
pointing out native asymmetries in bone, muscle, and fat distribution. Note the
emphasis is on deepening the preexisting anatomy, no new anatomic relations are
generated, as this creates an overdone or overoperated appearance.
Patients are then escorted to the operative suite where they are placed under general anesthesia in the supine position. The rst step is tumescence (1:1 Super Wet
technique) with a traditional Klein needle [5] or basket tip cannula followed by pretunneling with a 4- or 5-mm basket cannula. The anterior abdomen is lipo contoured
again typically using a 4 and/or 5mm basket cannula. Markings help serve as a
guide, though often intraoperative decision making is required to more aggressively
liposuction areas under the ribs and along the linea in order to achieve an athletic
look. Throughout the liposuction, pinch testing is performed to provide feedback on
the equalization in fat layers and subcutaneous volume distribution. The S curve
follows many principles dealing with overall 360° contouring of the buttock–body
relationships, but safety is at its core, so efforts are made to avoid contour abnormalities at all costs. After liposuction of the anterior abdomen, equalization is performed with the same cannula for approximately equal amount of time as the
liposuction. Contour regions such as the infraumbilical region and around the umbilicus, as well as the inner thighs, are regions most susceptible to postoperative
untoward contour abnormalities even in the best of hands. It is prudent to demonstrate greater caution in these areas and to consider smaller caliber cannulas with
emphasis on a longer “off suction” fat lobule release time.
Patients are then placed in the prone position and liposculpture is performed on
the lower back (sacral triangle) rst, to set the height of the new upper and mid-pole
gluteal mound. Next the sacral “diamond” region bordered by the cleft and the
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