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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_994_Библиотеки_им_академика_М_И_Перельмана
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232
A. Hoyos and M. Perez
ab
Fig. 16.1 Pictures from the ideal gluteal shapes for the male (a) and the female (b) patients: a
squared muscular shape is seen in men while a round smooth contour is preferred for women
compared to that from fat grafting, although fatalities have been associated with the
latter, mainly after large-volume intramuscular techniques. One could believe that
the increasing demand from patients requesting the procedure as well as more plastic surgeons performing it have derived in those disastrous incidents; yet numerous
surgeons have safely performed gluteal fat grafting on an even larger number of
patients with zero mortality. Indistinctly, the surgeon has to determine the best
approach for each patient and agree with them what would best suit their expectations.
Multiple scientic reports have evaluated the effectiveness of fat grafting not
only for buttocks augmentation but also for breast enhancement (alone or in combination with reconstructive techniques), face and hand rejuvenation, arthritis, among
other treatment options. Overall complications are rather low, still reabsorption
rates are a big concern for most plastic surgeons, in addition to the chronic behavior
of the grafted tissue, due to fat necrosis, oil cysts, and calcications.
There is substantial variation among fat grafting reported results regarding the
handling techniques, the harvesting methods, and the grafting placement procedure
itself. Literature reviews and metanalysis have attempted to achieve consensus on
these matters but not enough evidence has been obtained to support a unique
approach to either optimize the donor site, the lipograft processing, or technique.
In this chapter we will describe the outcomes after fat grafting from the Dynamic
Denition Liposculpture (HD2) point of view, and we will revise the updated evidence on what the best techniques for fat graft processing are.
16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...
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233
16.2 Art andAnatomy
The gluteal area cannot be considered as an isolated segment, but rather a continuum from the lower back to the thighs. This contour uniformity and the adequate
projection of the mid and upper thirds have been constant ndings in the many
attempts to dene objective parameters of an attractive buttock. Still, the gluteal
beauty must also consider tangible parameters including tissue softness, skin
smoothness, and its elasticity. Anthropometrical studies have identied the common
sites prompt for fat accumulation that actually distort the ideal gluteal shape, of
which the perigluteal area plays the most important role for buttocks denition.
Over the next paragraphs we will describe the anatomical features that differ
between the male and the female gluteal region, but also discuss the artistic point of
view behind the correct carving of this zone.
16.3 Female
The female buttocks have the shape of a hemisphere where the only dened edge is
on the inferior-medial zone whereas the other borders smoothly diffuse with the
body continuum of the leg and torso at the bottom and the top, respectively. Those
limits are even more important than the volume itself as over-denition could distort
the natural appearance of the entire segment.
Muscles in the lower back as well as the hamstrings are determinant in outlining
the convex curvature of the buttocks, while their lateral border runs continuous with
both the anterior thigh and the pelvis. The point of maximum indentation of the waist
is critical in order to get a youthful and symmetric perception of the gluteus as it marks
the limit of the negative zones for deep and supercial liposuction. The trochanteric
depression is another critical anatomical reference as it marks the only point to avoid
deep liposuction and should be only subject to fat grafting (if needed) in women.
The “banana roll” at the inferior edge of the buttock needs a specic mention
since some women develop anatomical features in which the inferior gluteal crease
resembles a reel and over-resecting this zone may end up in a prosthetic-like appearance of the buttock. Moreover, liposhifting and fat grafting have to improve the
round shape but also smoothen the transitions between the gluteal edges to achieve
the most natural results.
16.4 Female Markings
• Deep liposuction: anks, sacral fat pad, hips, and lateral and medial thighs. The
sacral dimples are marked for pure framing. The roll below the gluteal fold:
Inferior projection of the gluteus (smooth transition).
• Green zones (negative spaces): Free fat extraction.
234
A. Hoyos and M. Perez
• Red zone: Zero to minimal extraction to avoid rude contour changes.
• Smooth transitions between red and green zones (shading effect).
• The maximum point of indentation (PMI) at the waist is delimited by the lower
border of the rib cage and the iliac bone. Lines traced from the coccyx to both of
these references create an upper triangle for deep resection a lower triangle for
careful smooth transition.
• The trochanteric depression must be marked for either careful or no liposuction.
• The inferior gluteal area is divided into four zones by tracing a vertical line into
the center of the gluteus and a horizontal line that crosses through the infra-
gluteal midpoint (Fig.16.2):
Fig. 16.2 General
markings for the female
gluteal region: Point of
maximum indentation
(PMI) and Iliac bone (IB).
Trochanteric Depression
(TD) and negative zones in
the perigluteal region
(Zones 1–4) require
smooth transition in
lipoplasty. The adhesion
zone (AZ) from the inner
thigh should be avoided
16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...
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235
– Zone 1: The lower internal gluteal area must form an acute angle in an aes-
thetically pleasant buttock in order to achieve a round-like buttock.
– Zone 2: The lower external gluteal area, it is the transition between the lateral
leg and the buttock. A line from the infra-gluteal midpoint to the inferior edge
of the trochanteric depression was drawn. A careful extraction must be done
to avoid rude contour changes.
– Zone 3: The inner thigh is divided in thirds; the middle one is an adhesion
zone, which contains only supercial fat, so over resection should be avoided
in this area. From the upper limit of the adhesion zone a line is drawn up to
the infra-gluteal midpoint. The resulting area is safe for extraction and has the
advantage of holding a high stem cell concentration.
– Zone 4: The outer thigh, it is extended from the lateral portion of the gluteal
area to the lateral tight. It requires deep liposuction to remove the extra fat that
deforms the hips, so the markings will go up to the inferior portion of the
trochanteric hollow.
• The lower gluteal edge should normally end in the infragluteal midpoint; how-
ever, it is important to identify the entire border of the gluteus maximus m. on the
lateral side. By making an internal rotation of the thigh this border can be easily
seen and drawn. This maneuver allows identifying the extra fat on the lateral
buttocks.
• The gluteal area itself was then divided into horizontal thirds. The major projec-
tion zone must be located over the middle third. The superior limit is the red
zone, and the inferior limit is the infragluteal crease (Fig.16.3). These zones will
be determinant for volume projection and enhancement by means of fat grafting.
236
Fig. 16.3 Horizontal
thirds of gluteal projection:
upper (U), mid (M), and
lower (L). References are
made by the perigluteal red
zone at the top limit and
the infragluteal crease at
the bottom (green)
A. Hoyos and M. Perez
WARNING!
Remember the female red zones where little or no liposuction should be done:
• Immediate supragluteal zone
• Trochanteric depression
• Lateral distal thigh
16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...
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237
16.5 Male
The male gluteal shape is mainly determined by the underlying gluteus maximus and
gluteus medius muscles with little adipose tissue, and sharp edges producing a distinctive slim and muscular appearance. Because of hormonal receptors and estrogenrelated fat deposits, compared to women, men do not accumulate signicant
amounts of adipose tissue in the gluteal area, but rather in the central abdomen
and torso.
The trochanteric depression is important to keep the masculine appearance, as it
is more pronounced in men than in women. Thus, misshaping over this area ends up
in poor aesthetic outcomes.
The gluteus medius is a fan-shaped muscle bounded by the tensor fasciae latae
muscle and lies lateral to the gluteus maximus. Deep and below the gluteus medius
lies the iliac bone, where no noble structures are found; this will allow the potential
fat grafting of the muscle, which constitutes one of the most important athletic features of the masculine buttocks. Below the gluteus medius muscle lies the trochanteric depression (an adhesion zone) where little or no fat is accumulated in men, its
careful denition will outline the square-shaped lateral border of the male buttocks.
16.6 Male Markings
• Deep liposuction: ank zones, supragluteal zone, medial and outer thighs.
• Trochanteric depression is marked on the lateral side and a line is traced from its
upper limit to the top of the intergluteal crease, creating a triangular area (red
zone) for complete (deep and supercial) fat removal.
• A total of three negative spaces are marked: the proximal portion of the inner
thigh, the supragluteal region, and the trochanteric depression (Fig.16.4).
• The gluteal area is marked and divided into four zones (Fig.16.5):
– Zone 1 (Flank): extends from the posterior lower rib cage margin, to the supe-
rior iliac crest and lateral border of the erector spinae. This area consists of the
thoracolumbar fascia, the latissimus dorsi, and the lateral portion of the external oblique muscle.
– Zone 2 (Central) is subdivided into two areas: the rhomboid of the sacrum
(the rhomboid of Michaelis) and the erector spinae muscles. The area is limited inferiorly by the medial and superior insertion of the gluteus maximus,
creating a V shape. The upper border is delimited by the lateral border of the
erector spinae muscles (i.e., iliocostalis, longissimus, and spinalis). An adipose pad over the sacral prominence is possible, particularly in overweight
and obese patients.
238
Fig. 16.4 Negative spaces
in the male gluteal region:
inner thigh (1), the
supragluteal region (2),
and the trochanteric
depression (3)
A. Hoyos and M. Perez
– Zone 3 (Gluteal) is subdivided into three: gluteus maximus, gluteus medius,
and trochanteric depression. The gluteus maximus depicts convexity,
particularly in slim individuals. A depression over the posterior superior iliac
spines is created by the lack of muscle coverage of this bony structure. The
bulk of the gluteus maximus (posteriorly) and the gluteus medius (superiorly)
create a C-shaped concavity, with the greater trochanter lying as an inverted
vertex between the greater trochanter and the muscle bers of the gluteus
maximus (Fig.16.6).
– Zone 4 (Infragluteal) is subdivided into four areas: the adductors, biceps fem-
oris, vastus lateralis, and iliotibial tract. Muscles of the infragluteal zone form
the posterior compartment of the thigh.
16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...
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Fig. 16.5 Anatomical
zones of the masculine
gluteal region: Flanks (1),
Central (2) and subregions
(a, b), Gluteal (3) and its
subregions (a–c); and
Infragluteal (4) and its
subregions (a–d)
239
• Mark the horizontal thirds of the gluteal region: Volume and projection should be
preferably emphasized over the medial third, using liposhifting/liposuction and
fat grafting.
• Over the thigh, we mark the limits between the anterior and posterior muscular
compartments, emphasizing the lateral border between the quadriceps and biceps
femoris to improve the athletic appearance.
240
Fig. 16.6 C-Shape from
the masculine buttock
lateral view (purple),
delimited by the gluteus
medius m (1), the gluteus
maximus (2) and the
Trochanter (3)
A. Hoyos and M. Perez
WARNING!
Male Adhesion zones in the thigh (where liposuction should be avoided):
• Posterior portion of the lateral intermuscular sulcus, between the quadriceps and the biceps femoris, which should be avoided during liposuction to
prevent contour defects.
• Middle third of the inner thigh.
ab
16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...
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241
16.7 Surgery
• Prone position.
• Stealth incisions: Over each Infragluteal crease and the Intergluteal one.
• Inltration with tumescent solution (1 L of normal saline combined with a
1:1000 ratio of 1% lidocaine (10mL) and epinephrine (1mL), with an approximate 2:1 inltration-to-removal volume).
• VASER (Vibration Amplication of Sound Energy at Resonance) Emulsication
releases adipocytes from its supportive connective tissue (VASER®—2018 Solta
Medical–Bausch Health Companies, Inc., Bridgewater Township, NJ).
• Dynamic Denition (HD2) Liposculpture of the buttocks is carried out by carving
the negative spaces and smoothly changing contours to achieve a female round
shape (Fig. 16.7) and a sharp muscular and square-shaped male buttock
(Fig.16.8).
Fig. 16.7 Preoperative (a) and immediate pop (b) photographs of a 31-year-old woman after
Dynamic Denition Liposculpture (HD
2
) for buttocks contouring
ab
Fig. 16.8 Preoperative (a) and immediate pop (b) photographs of a 42-year-old man after
Dynamic Denition Liposculpture (HD
2
) for buttocks contouring
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