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14 S -C urve® Gluteal Augmentation
Venus dimples is aggressively liposuctioned. The back is contoured following anatomic barriers of the latissimus and the erector spinae as well as bra strap region and
deltoid adjacent regions. Liposuction is performed on the upper arm and back as one
contiguous unit and the arm is placed in several positions to ensure the continuity of
the upper back and shoulder with the upper posterior arm. Further dening of the
triceps and deltoid borders may be achieved if desired. Failure to address the arms
and upper back transition (width/volume) may lead to an odd and dysmorphic body
shape, with larger outer arms and a thin upper back. Any weight gain postoperatively and this appearance will become exaggerated and revision surgery may be
sought out and indicated. Similarly access points for liposuction of the back should
be carefully chosen. We utilize an incision in the crease in the posterior axilla so it
hides well and allows women to wear any number of backless dresses without worrying about a scar. All too often in revision cases the senior author has seen, the
surgeon has used too many access points along the back, and these cannot be hidden
in most garments and swim wear.
211
14.3.1 Fat Processing
Minimal manipulation is encouraged, the fat is placed into a strainer for removal of
the liquid component of the tumescent solution [6–12]. The strainer is gently moved
in circles to strain excess liquid. Once the extra uid and blood, etc., is removed,
Clindamycin saline solution is used as the last irrigant. The senior author prefers the
fat grafts to be dehydrated for injection to aid in more accurate assessment of end
goals in augmentation and shaping without interference of excess liquid and aqueousness of the grafts. The fat is then gently moved to 60cc Toomey syringes.
14.3.2 Fat Grafting
Both authors utilize 60cc syringes with hand control for fat grafting. The use of
Luer Lock systems is discouraged as these bend at the hub and this exibility can
inadvertently misguide the cannula submuscular in certain patients. It should be
noted that the senior author does use power-assisted lipo-injection using basket tip
cannulas for the nal 25% or so of the case in about 30% of patients in which
regions of the buttock are resistant or dense for nalizing the fat grafting phase.
However, a roller pump is not used to propel the fat grafts into the cannula, rather a
manual direct injection method is utilized.
NOTE: It is the senior author’s contention that roller pump action: (1) necessitates more aqueous quality of fat to be injected; and (2) the roller pump may injure
fat cells, which are delicate and require little to no manipulation for highest survival.
Either scenario is undesirable, and this is why direct power-assisted injection of
dehydrated strained fat grafts is performed.
212
y
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Danger
zone
Gluteus medius
Superior and
inferior gluteal
vessels
Sciatic nerve
Gluteus maximus
2
Danger
⁄
3
zone
D. Gould and A. Ghavami
2
⁄
3
1
1
⁄
⁄
3
3
Ischial tuberosit
Ischiocutaneous
ligament
Fig. 14.6 Danger zone of the buttock
The patient is then placed in the 30°–45° jackknife as well as placed on a bolster,
to position for safe access to the supercial and deep planes of fat that are “supramuscular.” This allows for total control of the pressure and distribution of fat. It is a
tedious process that requires focus, intrinsic hand strength, and time. The angle of
cannula and hand positioning as well as knowing where the tip of the cannula is at
all times are all critical in safety for avoiding danger zone or deep submuscular
injection. The S in S Curve also represents “Subcutaneous Only” injection. No new
technologies have yet been proven safer than this, and in this practice, we continue
to implement these techniques as our experience with safety has been without catastrophic complications, particularly fat embolism in thousands of cases. There are
new approaches with promising sensory technology, though these are expensive and
unproven [13]. Only knowledge of the underlying anatomy and tactile feedback will
allow safe delivery of this or any surgery [14, 15]. We believe that starting and in
many cases completing this operation with the use of manual injection cannula
without power assistance will give better feedback as to where the injections are
being placed. Albeit the greater difculty with syringe injections may lead to greater
prudence. Without proper training and anatomical adherence, power-assisted only
injection can allow for easier injection and gliding, and therefore easier injection
also into dangerous submuscular and subfascial planes. The eye does not see what
the mind does not know so all surgeons should familiarize themselves with the
many chapters on gluteal safety [16, 17]. Several cases are depicted below to demonstrate the power of gluteal fat grafting with liposculpture and the S Curve
(Fig.14.6).
The deep medial third of the buttock is the area of greatest risk of gluteal vessel
injury and possible fat embolism. This can be due to direct submuscular injection
or fat migration from submuscular injection adjacent to the danger zone. It is possible that migration into this zone from other subfascial placed fat grafts can also
theoretically lead to fat entering lacerated or “blown” deep veins (DDV paper)
(Fig.14.7).
crease ligamen
vein (IGV)
14 S -C urve® Gluteal Augmentation
213
Gluteal
IGV
t
Inferior
gluteal
Fibrous
ligaments
SN
SF
DF
Sciatic
nerve (SN)
Superficial fat
(SF)
Pillow - jackknife 45˚ position
Deep fat
(DF)
Superior gluteal
ligament
Fig. 14.7 Here is a depiction of the safe orientation of the patient and cannula for injection of the
supercial and deep subcutaneous fat planes in the buttock
14.3.3 Outcomes
The S Curve remains safe with relatively few complications including seroma,
infection, and unsatisfactory results. These are almost all treated nonoperatively;
revision surgery is very uncommon unless the patient wants to gain additional fat to
return for additional rounds of fat grafting after volume loss or weight gain. It is not
uncommon to return after pregnancy weight gain for a “round 2” S Curve.
Below are several before and after images of S Curve patients (Figs. 14.8
and 14.9).
14.3.4 Perioperative Management
In the post-op period we recommend 2–4weeks of no to limited sitting and no direct
compression on the gluteal surface augmented. Patients who had mostly, or only hip
dip augmentation are less limited in positioning and may lay on their back as well
as sit easier since hip dips will remain unharmed by added compression. Compression
garments with compression padding over the skin in areas of liposuction, can be
worn if modied to ofoad the buttock pressure. The goal is to maintain the maximal yield and thus there is no reason not to use supportive nutritional interventions
214
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D. Gould and A. Ghavami
Fig. 14.8 This is a 27-year-old female patient with follow-up photos at 1 year post-op with no
change in her weight. She had improvements in her waist to hip ratio from 0.72 to 0.61in the
before and afters shown here. She also has better overall shape, and transition between her buttock
and thigh junction is also improved
14 S -C urve® Gluteal Augmentation
215
Fig. 14.9 This 29-year-old female is shown at 14months post-op with improvements in her projection and shape, notably with dramatic improvements in contour from the back with c point
improvements and a much softer transition from waist to hip to lateral thigh. This represents a
dramatic improvement in projection and shape. Her waist to hip ratio actually went from a 0.71 to
a 0.56, which represents a dramatic transformation
and even hyperbaric oxygen therapy though there is not good human clinical data
yet on this intervention. Animal studies and invitro studies show good data [18–22].
14.4 Conclusion
S Curve is a modern adaptation of advanced lipocontouring with fat grafting to
provide safe and subcutaneous gluteal contouring in a reliable, not overdone fashion. The techniques are time tested since 2008 and the outcomes have been well
received with minimal revisions necessary. The modern techniques of SAFE
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D. Gould and A. Ghavami
liposuction along with advances in fat grafting (Egro and Coleman) have all helped
to change the paradigms of classical liposculpture [23−29].
References
1. Nahai F, Nahai F.The art of aesthetic surgery, three volume set, third edition: principles and
techniques. Stuttgart: Thieme; 2020.
2. Centeno RF, Mendieta CG.Gluteal augmentation, an issue of clinics in plastic surgery, e-book.
Amsterdam: Elsevier Health Sciences; 2018.
3. Mendieta C, Stuzin JM.Gluteal augmentation and enhancement of the female Silhouette:
analysis and technique. Plast Reconstr Surg. 2018;141(2):306–11.
4. Mendieta C.The art of gluteal sculpting. NewYork: Thieme Medical Publishers; 2011.
5. Klein JA. Tumescent technique: tumescent anesthesia and microcannular liposuction. St.
Louis: Mosby Inc; 2000.
6. Shiffman MA.Autologous fat transfer: art, science, and clinical practice. NewYork: Springer
Science & Business Media; 2009.
7. Green AC. Optimized autologous fat grafting: effects of harvesting, manipulation on live
mesenchymal stromal cells. Plast Reconstr Surg. 2010;126:57–8. https://doi.org/10.1097/01.
prs.0000388779.99220.70.
8. Smith P, Adams WP Jr, Lipschitz AH, etal. Autologous human fat grafting: effect of harvesting and preparation techniques on adipocyte graft survival. Plast Reconstr Surg.
2006;117(6):1836–44.
9. Katz AJ.Tissue processing considerations for autologous fat grafting. In: Autologous fat transfer. Berlin: Springer; 2010. p.403–5. https://doi.org/10.1007/978- 3- 642- 00473- 5_52.
10. LLQ P.Fat grafting to the face for rejuvenation, contouring, or regenerative surgery, an issue of
clinics in plastic surgery e-book. Amsterdam: Elsevier Health Sciences; 2019.
11. LLQ P.Fat grafting: current concept, clinical application, and regenerative potential, an issue
of clinics in plastic surgery, e-book. Amsterdam: Elsevier Health Sciences; 2015.
12. Botti G, Pascali M, Botti C, Bodog F, Cervelli V.A clinical trial in facial fat grafting: ltered
and washed versus centrifuged fat. Plast Reconstr Surg. 2011;127(6):2464–73.
13. Pazmiño P. ultraBBL: Brazilian Butt Lift using real-time intraoperative ultrasound guidance. In: Ultrasound-assisted liposuction. Berlin: Springer; 2020. p. 147–72. https://doi.
org/10.1007/978- 3- 030- 26875- 6_10.
14. Oranges CM, di Summa PG, Giordano S, Kalbermatten DF, Schaefer DJ. 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;146(4):502e–3e. https://doi.
org/10.1097/prs.0000000000007200.
15. 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. https://doi.
org/10.1093/asj/sjaa098.
16. Ghavami A, Villanueva NL, Amirlak B.Gluteal ligamentous anatomy and its implication in
safe buttock augmentation. Plast Reconstr Surg. 2018;142(2):363–71.
17. Ghavami A, Villanueva NL.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.
18. Kato H, Araki J, Doi K, etal. Normobaric hyperoxygenation enhances initial survival, regeneration, and nal retention in fat grafting. Plast Reconstr Surg. 2014;134(5):951–9.
19. Shahzad F, Mehrara BJ.The future of fat grafting. Aesthet Surg J. 2017;37(suppl_3):S59–64.
20. Shoshani O, Shupak A, Ullmann Y, etal. The effect of hyperbaric oxygenation on the viability
of human fat injected into nude mice. Plast Reconstr Surg. 2000;106(6):1390–6.
14 S -C urve® Gluteal Augmentation
21. Yoshinoya Y, Böcker AH, Ruhl T, et al. The effect of hyperbaric oxygen therapy on human
adipose-derived stem cells. Plast Reconstr Surg. 2020;146(2):309–20.
22. Engel P, Ranieri M, Felthaus O, etal. Effect of HBO therapy on adipose-derived stem cells,
broblasts and co-cultures: invitro study of oxidative stress, angiogenic potential and production of pro-inammatory growth factors in co-cultures. Clin Hemorheol Microcirc.
2020;76(4):459–71. https://doi.org/10.3233/CH- 209222.
23. 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.
24. Egro FM, Coleman SR.Facial fat grafting: the past, present, and future. Clin Plast Surg.
2020;47(1):1–6.
25. Coleman WP. Structural fat grafting. Dermatol Surg. 2005;31(12):1714. https://doi.
org/10.1097/00042728- 200512000- 00015.
26. Coleman SR, Mazzola RF. Structural fat grafting and fat injection-two volume set. Boca
Raton: CRC Press; 2009.
27. Coleman K, Coleman WP 3rd. Update on nonfacial fat transplantation. Dermatol Surg.
2020;46(Suppl 1):S38–45.
28. Coleman SR.Long-term survival of fat transplants: controlled demonstrations. Aesthet Plast
Surg. 2020;44(4):1268–72.
29. Coleman SR, Tucker CJ.Autologous fat injection: afrmation of longevity. Aesthet Plast Surg.
2020;44(4):1273–7.
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Chapter 15
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The Lipocontour Technique
HéctorDurán
15.1 Introduction
The goals of liposuction have changed over the last 20years. Previously, the
goal of liposuction was based on fat suction in areas with lipodystrophia [1]
than on dening anatomical structures, removing lumps and achieving large
homogeneous areas. Currently, however, at least in Latin America, patients
demand that liposuction reveals anatomical structures while producing aesthetic
relationships between different regions such as the back, buttocks, and legs.
Both the denition of the gluteal marking [2] and the hip-to-waist ratio [3] have
been important contributions to these goals and have helped us to improve the
aesthetic criteria. Liposuction requires several critical elements for its execution, from adequate patient selection to appropriate postoperative care. A doctor
must be a surgeon and an artist at the same time to ensure that a patient has a
good outcome and recovery and to achieve the desired contours, shapes, and
volumes [4]. Therefore, preoperative marking of a patient is a vital step to dene
parts of the body that do not provide aesthetic benet.
The aim of this chapter is to describe a technique called Lipocontour, which is a
liposculpture technique based on standardized preoperative marking, providing the
surgeon with an aesthetic reference points based on anatomy to dene a female
silhouette.
H. Durán (*)
Merida, Yucatán, Mexico
© 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_15
219
220
H. Durán
15.2 Materials andMethods
This study is a retrospective evaluation of data collected over a period of 5years
from January 2014 to January 2019. In this case series of 210 patients, liposuction
was performed with the Lipocontour technique in the author’s private practice, and
all patients were asked about their satisfaction with the result of the procedure on a
5-point Likert scale 6months after surgery. To standardize the report, we followed
the Preferred Reporting of Case Series in Surgery (PROCESS) checklist for a surgical case series of the Equator network [5].
15.2.1 Marking (Fig.15.1)
The patients were marked 1 day before or on the day of surgery with a permanent marker.
15.2.1.1 Front
First, the linea alba is marked, as well as two lateral lines corresponding to the linea
semilunaris. These lines start from above the mammary lines, are aligned vertically
with the nipples, and are extended to the level of the lateral inguinal fold. One can
usually palpate these lines. We mark an upper and lower anterior triangle. The linea
semilunaris should not cross the costal margin superiorly. An upper vertical midline
(never below the umbilicus) is also marked.
Fig. 15.1 Lipocontour marking, front, lateral and back
15 The Lipocontour Technique
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221
15.2.1.2 Side
The mid-axillary line is identied, and a vertical descending line is drawn. The pelvic border is also marked, and the anterior and posterior lines are joined. The incisions are placed in the mid-axillary line at the height of the bra-line mark and
beneath another landmark where the midline with the greater gluteal projection and
the vertical mid-axillary line converge.
15.2.1.3 Back
The midline is marked, and a line extending from the posterior axillary line to the
highest point of the intergluteal line is drawn in the shape of a V.Subsequently, at
the height of the elbows, the 12th rib is marked transversely. From the convergence
point between this transverse line and the V-shaped marking, a vertical line is drawn
down the middle of the buttock and extended to the thigh. A diamond shape is
drawn above the intergluteal line. On the buttock, in the middle of the intergluteal
line, a transverse line joining the two trochanters is marked. At the intersection of
this transverse line and the vertical gluteal midline, the greatest projection of the
buttock should be identied. An intergluteal incision is placed along with one midline incision at the height of the bra line.
15.2.2 The Surgical Procedure
Once the patient is ready for surgery and after signing informed consents, is directed
to the operating room. Each patient is given intravenous ceftriaxone or ciprooxacin
as a prophylactic antibiotic 1h before starting surgery. Antisepsis of the standing
patient is performed before starting the procedure while the operating table is covered with sterilized sheets. Liposuction is performed under general anesthesia or a
regional block. We place a Foley catheter and pneumatic compression boots. A modied Fodor solution, which is a crystalloid solution plus 1.5 adrenaline ampules per
1000cc, is inltrated using power-assisted liposuction (PAL) with a 4-mm basket
cannula as well as an inltration pump according to previously described methods
[6]. We do super-wet inltration, wait 7min, and then begin the liposuction procedure. The procedure requires four positions; generally, the order is dorsal decubitus,
followed by both sides, and then ventral decubitus. In the anterior position, the abdomen is treated with an emphasis on removing the greatest volume of fat according to
preoperative planning and marking. Liposuction should be performed in the lateral
position such that the transverse line marked along the 12th rib denotes the narrowest area. Liposuction and fat inltration is performed in all positions except for the
rst position. We do not use any special positioning of the surgical table. The tissues
shift once the patient is rotated, but the markings indicate where we should perform
liposuction despite the position change (Images 15.1 and 15.2).
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