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242

A. Hoyos and M. Perez

– Liposuction starts on the deep layer using either Power-X (2018 Solta

Medical–Bausch Health Companies) or MicroAire Systems (MicroAire Surgical Instruments, LLC, Charlottesville, VA).

– We use 3- or 4-mm straight/curved Mercedes cannula over the lower back and

upper gluteal area through the intergluteal crease access.

– The inner thigh, the lower and lateral gluteal areas are carved using the infra-

gluteal midpoint access, bilaterally, and in distal-to-proximal fashion.

– The upper gluteus maximus line and lower internal must be thoroughly

dened in men, while soft transitions are preferred for women.

– Negative spaces previously marked as triangles are smoothly dened to create

transitions between concavities and convexities over the upper border of the gluteus maximus, the trochanteric depression, and the medial infragluteal crease.

– Thorough liposuction is performed in the lower ank areas to overlap its de-

nition with the upper portion of the gluteus medius in men, while the immediate supragluteal region should be carefully carved in women, to allow a soft transition toward the waist.

– The sacral dimples must be carved in all women, since they enhance the

youthful appearance of the gluteal region. Women tend to have greater fat deposits over this area compared to men.

– Rude transitions over the inner thigh are preferred for the male but avoided for

the female patient. On the lower lateral gluteal region, a negative space allows us to blend the deep extraction in the lateral thigh and the gluteus to create a rounded shape.

– The lower midline must be dened at the end depending on the grade of mus-

cular denition.

– Once the posterior zones are completed, liposuction of the inner thigh can be

completed with the patient in the supine position.

TIPS

• Small-diameter cannulas are preferred for the female transition zones.

• The sharper for the squared male, the smoother for the round female.

• No Trochanteric depression for the Female but enhances it in the Male!

• The supragluteal region is critically different between men and women,

sharp for the former, and soft for the latter.

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16.8 Fat Grafting

First of all, we need to differentiate large-volume fat grafting for body contouring from that of small-volume from face and hand rejuvenation. Although they have just about the same purpose, the entire process for fat grafting widely differs since the amount needed to restore the anatomical contour from either of their specic segments could be considered disproportionate. Large-volume lipoinjection aims to restore the body contour by increasing the size of some body segments that lack volume or simply need more projection with the use of autologous adipose tissue, which is why micro-fat grafting or nano-fat grafting would not be suitable techniques.

Lipograft harvesting, processing, and injection techniques have been widely

studied, still there is a lot of controversy in which would be the best process to achieve the optimal adipose graft. Low-speed centrifugation and low negativepressure aspiration with large-bore cannulas have shown to minimize the adipocyte damage during fat harvesting, when it comes to separate the fat from any watersoluble solution associated with the fat, however studies show that the adipocytes are not capable of surviving just by themselves, no matter how purely they are grafted, which means the recipient area and its dynamics also play important roles on fat graft survival, and so it would account for the unpredictability of the results.

Buttocks augmentation through fat grafting has increasingly taken over the pre-

vious implant-based tendency, since studies reported an effective and predictable way to remodel the gluteal region with lipoinjection; however, the procedure is not awless and mortality due to fat embolism has lately become a concern. It is recommended that small-volume fat injections at the recipient site should be performed using small-gauge cannulas in a fanning out pattern over multiple sessions, yet this is not considered an option for body contouring. From the anatomic point of view, avoiding gluteal vessel damage may prevent those feared complications, yet skilled surgeons with an accurate anatomical analysis and a systematization of the procedure have also reported cases of fat embolism.

16.8.1 So, What Should WeDo?

Various studies with large case series report that proper patient selection, favorable instrumentation, patient positioning, proper technique, and knowledge of the local anatomy are critical to improving the safety and lasting outcomes of large-volume fat grafting.

We have safely grafted 50–500cc of processed adipose tissue to multiple body

areas including: the deltoids, biceps, triceps, breasts, pectorals, trapezius, latissimus dorsi, buttocks, quads, calves, and even hamstrings; all over a long learning curve, which unfortunately includes the multiple complications that we have all suffered from.

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A series of studies evaluating the effects of injection techniques on invitro fat

viability and invivo volume retention, in addition to the effects of injection mechanics on material properties of fat demonstrated that either a minimal manipulation approach or using an adipose tissue injector were superior compared to the modied Coleman technique. Through the years, we did notice a remarkable increase of fat retention rates after we implemented some strategies in order to preserve most of the cellular fraction of the lipoaspirate supernatant (Fig.16.9), by avoiding centrifugation and rather allow its passive decantation within the sterile cannister (High volume harvesting cannister™– ©2021 Wells-Johnson– Tucson, AZ). These could be probably explained by the higher concentration of both the cellular vascular stromal fraction (cSVF) and the adipose-derived stem cells (ASC), which are well known to improve fat survival in clinical reports.

Fig. 16.9 Wells-Johnson harvesting cannister (3000cc) with lipoaspirate after 1-h passive decantation

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245

On the other hand, the grafted adipose tissue is also subject to eventual adverse

events after its placement. The majority of them are related to fat necrosis and require minimal diagnostic or therapeutic intervention, though the larger the graft volumes the higher the incidence (e.g., fatty necrosis). Likewise, the oncologic safety of fat grafting has been supported by multiple clinical studies of breast cancer patients.

As a result, we established a fat grafting protocol for HD2, which could be summarized as follows

– Use VASER in continuous mode and a mid-power conguration when lipo-

aspirating the thighs and the abdomen.

– Use low-powered liposuction over these areas as well. – Decantation and minimal manipulation over the fat graft are a must. – Nano-fat and micro-fat grafting is reserved for small-volume contour decits. – It is mandatory to follow the postoperative recommendations for long-lasting

results.

Technique for the male

• The subcutaneous plane is preferred for the adipose graft placement: We use a 4-mm basket cannula attached to a MicroAire and peristaltic pump device (expansion vibration lipolling) to delicately place the graft in the subcutaneous layers by the infragluteal crease access on each side.

• The superior and middle thirds usually need the most projection.

• The gluteus medius is reached through the intergluteal crease access to place a selective intramuscular fat graft using a blunt-tip 4-mm 30-degree-curved cannula, attached to a 50-cc syringe lled with processed adipose-graft.

Technique for the female

• We use a 4-mm basket cannula attached to a MicroAire and peristaltic pump device (expansion vibration lipolling) to delicately place the graft in the subcutaneous layers by the infragluteal crease access on each side. A fanning motion is performed from deep to supercial.

• The middle third is the one requiring the most projection from the lateral perspective.

• The trochanteric depression and the superior third may need subcutaneous fat grafting to achieve a round contour from the posterior perspective.

Warning!

• Do NOT graft the trochanteric depression in the male.

• Always evaluate symmetry with anatomical references and from different

angle views.

• Do NOT graft the gluteus maximus IM plane.

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A. Hoyos and M. Perez

Discipline and strict following of our protocol has allowed us to achieve remark-

able aesthetic outcomes and high satisfaction rates among our patients (Figs.16.10 and 16.11). The entire team at the OR is aware about the procedures and methods that must be followed to prepare and optimize the adipose graft, which in fact is subject to a subtle manipulation.

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Fig. 16.10 A 34-year-old female patient who underwent HD2 gluteal liposculpture. A new improved projection of the buttock is seen in the postoperative photos (d–f) compared to the at and loose appearance of the preoperative ones (a–c)

16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...

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247

Fig. 16.11 A 36-year-old man who underwent HD2 gluteal liposculpture. Notice the round and fatty appearance of the preoperative photos (a–c) compared to the new athletic and muscular looking in the postoperative pics (d–f)

16.9 General Postoperative Procedures

• Postoperative garments and foam vests are used since the immediate till 8–12weeks postoperative.

• Patients are enrolled in the postoperative CARE program, which includes daily lymphatic drainage and massages. Ultrasound therapy is NOT recommended over fat grafted areas.

• Drains are left at the intergluteal incision and removed after minimal drainage (approx. 7days postop).

• Although the supine position is recommended during resting, there is no strict contraindication on positioning, provided that there was no pain. Some patients actually prefer to use a donut pillow or the prone position while resting.

• Early mobilization is encouraged at 6h post-op.

• Follow-up period should be but not limited to 2years after surgery.

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16.10 Conclusions

Our anatomical approach to contouring the gluteal region in men and women has resulted in excellent aesthetic outcomes with minor complications and no major complications. The development of our technique was designed to accomplish not only an ideal muscular and athletic appearance for the masculine buttocks, but also a slim and round contour for the female.

The step-wise division of the gluteal region into four distinct zones and sub-

zones, for both genders, has improved our understanding of the anatomic regions that need specic treatments to achieve optimal aesthetic outcomes.

Fat grafting has become the cornerstone of buttock augmentation due to its less

invasive technique with a lower rate of complications compared to those from implant-based procedures. Although female techniques have been thoroughly studied and multiple approaches have been described, still some challenges exist when facing some anatomical variations that do not t the regular patient. In contrast, men gluteal aesthetics are changing the paradigm of what to do, by including new anatomical landmarks that strongly differ from women standards.

Current social tendencies have challenged us plastic surgeons to become even

more critical when analyzing aesthetic standards. As so, patients’ preferences have changed as the society moves forward to a more inclusive one, where men and women are not required to dress, behave, and show a stereotype but rather do what they truly prefer or desire. In that sense, some patients with a masculine phenotype could request for a soft and rounded feminine shape of their gluteal area (Fig.16.12), while others with a feminine phenotype could ask for a more muscular and squared one (Fig.16.13).

Fig. 16.12 A 29-year-old male patient with a feminine appearance of his buttocks

16 Buttocks Dynamic Denition (HD2) Liposuction: for Adipose Harvesting...

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Fig. 16.13 A 27-year-old woman with a masculine appearance of her gluteal area

249

In comparison, current research on tissue engineering and stem cell cultures is

making great progress in a radical solution to avoid intraoperative graft manipulation, donor site complications, while increasing the long last of the outcomes. However, the use of stem cell therapies to expand and to grow tissue for reconstruction must evaluate the different variables that imply the execution of an optimal process. Nonetheless, there is much hope in the evaluation and implementation of multimodality approaches for autologous fat transplant, including the later inclusion of new methods for fat processing and harvesting that incorporate the preservation of the cSVF and the ASC, which seem to be our “best bet” to guarantee a long-last fat graft survival whatsoever.

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Highlights

• Surgeons should pick the technique for harvesting at which they feel the

most comfortable with.

• VASER technology has the advantage of preserving an optimal cellular

SVF, adipocytes and ASC.

• We do recommend using low-pressure suction when harvesting the low

abdomen and thighs for graft harvesting.

• When large volumes of fat grafting are necessary, use the main collecting

canister to process your adipose graft.

• Use curved cannulas with small syringes and small amounts for fat graft

placement.

• Be aware of the anatomy to avoid vascular injury and contour defects.

• The less you manipulate the graft the better!

• Adherence to key principles in fat grafting techniques should allow a safe

procedure and its continued practice in the setting of increasingly high demand.

• Tissue engineering could be the answer to avoid donor site complications,

decrease even more the rate of complication rate and why not, prolong graft survival rates.

• Future of gluteal contour should not be guided by gender approaches but

rather by the patient desires and behavior: female curves could probably t better to a homosexual man, while sharp muscular buttocks could be preferred in the homosexual female counterpart.