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20 Round Implants forButtock andHip Augmentation
sitting or lying on their buttocks at any time. A correct and fair dissection of the
intramuscular bag is enough to keep the implant in place without displacement.
285
20.9 Complications
No aesthetic surgical procedure has had such a rough evolution as buttocks implants.
But it has also become increasingly important within the surgical practice of body
contouring.
What was once neglected, now has a good present and a better future. There is no
doubt that lipotransfer to the buttocks is currently much more widely used than
prosthetics. However, the difference between both procedures is abysmal if we talk
about trans or postoperative complications. I have seen very severe lipotransfer
infections whose treatment is really complicated, long, and expensive, if not fatal.
And this is due to the fact that fat inltrates and spreads irregularly in the cellular
tissue and even to the gluteal muscles, making it almost impossible to extract the
transferred fat. Unlike implants that become infected, their handling is easier than
the above. Implants are removed, the dissected bag is washed generously, and drains
are placed. This, therefore, makes treating the infection in buttock implants much
easier. Another advantage of buttock prostheses is that thromboembolism due to
implant placement has not been reported so far. While in the lipotransference, this
is one of its main complications.
According to my perception, this also marked the impasse to revert to buttock
implant surgery again. Of course, the highest rate of complications of lipotransference is given by the high number of said procedure against the poorer number of
implant surgery.
However, the difference in the treatment and prognosis of the complications,
once installed, in both procedures, remains. In other words, implant surgery has
fewer severe or life-threatening complications. In this, complications are more often
of an aesthetic nature. While in the lipotransference the complications are more
serious for life, but without the aesthetic complications of the implants [4].
20.10 The Future ofButtock Implants
As I mentioned earlier, the perfect implant does not exist. So we have to resort, on
many occasions, to a hybrid lipotransfer and implant procedure. And on other occasions, implant placement and buttock pexia with skin resection. Today, commercial
companies that make buttock implants, which are the same companies that make
breast implants, have a very poor portfolio of gluteal implants compared to their
portfolio of breast implants. In breast implants there are different projections of the
same, in which the relationship projection diameter varies considerably. Most of the
plastic surgeons are familiar with the different types of projection of breast implants
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G. G. Blanco and B. B. Orozco
for each particular case according to the problem of each patient, low, medium,
high, extra high, or ultrahigh prole. All of them with different diameter and projection according to the problem to be solved.
However, when it comes to buttock prostheses, only one line of implants exists,
round with a single projection or oval with a single projection. Here I will deal with
round implants which is what concerns us.
Just as there is a choice in the selection of breast implants, so should there be a
wider range of buttock implants. A patient with a wide hip and who only requires a
projection of the buttock where we require a high-projection implant with a more
discreet diameter, is not the same as another patient, which requires hip augmentation and little projection of the buttock, where an implant with more diameter and
less projection is required. Or another patient who requires a buttock and hip where
we would use a prosthesis with a large diameter and high projection. Or a male
patient, which requires only projecting the buttock, using for this a high-projection
implant with a smaller diameter. But this does not exist.
Therefore, buttock implant surgery presents a challenge and a relatively high
degree of difculty, due to the current limited choice of implants, for those of us that
have made this procedure a routine procedure in our surgical practice. This means
that this surgery still does not have the best results that can be obtained due to limitations in the selection of the implant. Additionally, it also goes to show that this
procedure, although we have found the appropriate technique for its easy reproduction thanks to the anatomical study of the gluteal region, must also now be focused
on the manufacture of a new generation of buttock implants to obtain the best results
this procedure can offer.
References
1. Mendieta CG. Classication system for gluteal evaluation. Clini Plast Surg. 2006;33(3):
333–46. https://doi.org/10.1016/j.cps.2006.04.006.
2. Durán-Vega HC. Composite gluteal augmentation: implant+ fat grafting: getting the best of
both worlds. Gluteal Fat Augmentation: best practices in Brazilian butt lift. 175–9.
3. Frank K, Casabona G, Gotkin RH, Kaye KO, Lorenc PZ, Schenck TL. Inuence of age, sex,
and body mass index on the thickness of the gluteal subcutaneous fat: implications for safe
buttock augmentation procedures. Plast Reconstr Surg. 144(1):83–92.
4. Cárdenas-Camarena L, Gerardo LPA, Durán H, Bayter-Marin JE. Strategies for reducing fatal
complications in liposuction. Plastic and reconstructive surgery Global open. 5(10).
Chapter 21
Natural Look inButtock Implants: Eight
Step Hybrid Gluteoplasty
HumbertoUribeMorelli
21.1 Introduction
Gluteal aesthetic surgery is probably one of the surgeries with the most growing
potential in aesthetic plastic surgery. The gluteal area represents a very important
part of the female sexuality, reason why it should be one of our most performed
procedures. Many techniques have been described, but only two have shown efcacy in the long term with low complications rates and risks: implant-based gluteoplasty and gluteal fat transfer [1–3].
But there are four situations that have put this surgery in check today. (1) Recent
ndings related to patient safety in intramuscular fat transfer and its association
with serious complications, (2) The collective fear of the population to use buttock
implants due to fake aesthetic results, (3) Lack of training of plastic surgeons to
perform this technique, and (4) The use of inappropriate substances for gluteal augmentation (biopolymers) and its derived complications that have scandalized the
population [4–6]. We can really change all these situations by showing that this is a
safe surgery with excellent results.
The lack of consistency in results from a single technique added to the versatility
of fat, has recently motivated the combination of the two techniques (fat and
implants) to obtain the benets of both and reduce risks associated with a single
technique. The adequate surgical technique facilitates the inclusion of implants in a
dened intramuscular anatomical plane, the possibility of adding fat to gluteal
implant surgery, brings the benet of reducing the size of the implants, which
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 13802- 7_21.
H. U. Morelli (*)
Private practice, HUM Cirugía Plástica and SPA, Cucuta, Colombia
e-mail: hum@uribemorelli.com
© 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_21
287
288
• Excess of skin flaccidity.
Inclusion criteria:
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H. U. Morelli
translates into less risk of the classical complications that have been associated with
this surgery, in addition to offering a more natural and practically imperceptible
result, which is what our patients are looking for.
If we nd the balance between an adequate surgical technique and a harmonic
aesthetic and natural result, we can increase the demand for this surgery.
In this chapter we will describe the eight step hybrid gluteoplasty with the objective to obtain natural, consistent, and long-lasting results but specially with a
reduced rate of complications.
21.2 Methodology
One hundred and forty-four patients have been operated from March 2013 to
December 2020 with the eight step hybrid intramuscular gltuteoplasty. The average
age was 29years, the most used size of implants was the 305cc Demi projection of
Motiva Gluteal Armonic (From Establishment labs) and the average amount of fat
transferred to the subcutaneous tissue after the implant inclusion was 120cc per
side (240cc total). All patients were discharged from the hospital 4h after nishing
the surgical procedure. See inclusion and exclusion criteria in Table21.1.
Table 21.1 Inclusion and exclusion criteria
• Age: 18–50
• BMI: 18–28
• Patients desiring the inclusion of implants and fat
• Patients without large volumes of fat to harvest and transfer
• Patients demanding a longer lasting results and more predictability on the result
• Patients with gluteal lipodystrophies
• Patients with higher expectations on gluteal results
Exclusion criteria:
• Patients desiring only fat transfer
• Patients with comorbidities such us: blood disorders, history of DVT/PE, uncontrolled
Diabetes Mellitus or Hypertension.
21 Natural Look inButtock Implants: Eight Step Hybrid Gluteoplasty
289
21.2.1 Surgical Technique
Great surgical techniques emerge from the combination of maneuvers learned from
different experts in the eld, and this is not the exception. My surgical technique
consists in putting together some tips and tricks learned from other authors plus
some steps added by myself. This technique was the result of observation, experience, and trial and error.
We divided the technique into eight steps to simplify the procedure and to better
learn the tips to be done in each of them. See Video 21.1 for the full technique.
21.2.1.1 Adequate Markings
Adequate markings are mandatory to every aesthetic surgery. To better understand
the markings please see Image 21.1 and Video 21.1.
Two incisions of 5cm each are drawn bilaterally in the inter gluteal crease starting from cephalic to caudal. Start the drawings 1cm below the superior portion of
the crease to hide them properly. Place the drawings 1cm bilaterally from the midposterior inter gluteal line.
Draw a semicircle bilaterally over the incisions markings with a radius of 2.5cm.
(This will correspond to the subcutaneous dissection of the pocket).
Draw the dimensions of the implant chosen just immediately after the subcutaneous dissection semicircle. (This will correspond to the intramuscular pocket of the
implant).
21.2.1.2 Skin Incision andSubcutaneous Dissection
Incise the skin and the subcutaneous tissues in an oblique fashion until you nd the
muscle fascia. Don’t go beyond the semicircle previously marked (this will reduce
the amount of death space and the seroma formation in the postoperative period).
See Image 21.2.
Image 21.1 Markings
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Image 21.2 Subcutaneous
dissection
H. U. Morelli
21.2.1.3 Split theMuscle
Split the muscle bers with a Kelly forceps (to reduce trauma) on the upper portion
of the subcutaneous pocket. Splitting the muscle high in the pocket was a maneuver
learned from Dr. Juan Diego Mejia from Medellin, Colombia. This will facilitate the
posterior closing of the muscle.
Split the muscle until nding the intramuscular fascia (This is a fascia located in
a virtual space that divides the supercial and deep bellies of the gluteus maximus).
This space is known as the FROD Space (in Honor to the author who found and
described it: Freddy Rodriguez from Barranquilla, Colombia) [7].
21.2.1.4 Dissection oftheIntramuscular Pocket
Once at the intramuscular fascia place your index nger to dissect the previously
marked pocket. In this FROD Space you can easily dissect with your nger and with
little trauma to the tissues. To complement the pocket you can use a Gonzalez gluteal dissector. See Images 21.3 and 21.4. This space is usually free of bleeding. If
bleeding use 1 or 2 compresses for a couple of minutes and it will stop by itself if
you are in the proper plane.
A tip for this step is not to over-dissect beyond the implant dimensions (previously drawn on skin). If over-dissected the implant can dance on the pocket and turn
around, so this pocket must be tight to avoid mal position and ipping.
21.2.1.5 Placing theSutures Before theImplant Placement
After the pocket has been properly dissected and no bleeding on the eld is observed,
we will place three separate closing sutures before placing the implants with 2–0
vicryl on the previously separated muscle edges. I learned this maneuver from Dr.
Carlos Rios, from Cali, Colombia. This step has changed my gluteal practice
because it makes easy the muscle closure after placing the implant (next step) and
will reduce the risk of and implant rupture with the needle (Image 21.5).
21 Natural Look inButtock Implants: Eight Step Hybrid Gluteoplasty
Image 21.3 Intramuscular
pocket
Image 21.4 Cadaver
dissection of the FROD
intramuscular space
291
Image 21.5 Sutures
before implant placement
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Image 21.6 Implant
inclusion
H. U. Morelli
21.2.1.6 Implant Inclusion
Place the diver retractors inside the intramuscular pocket splitting the sutures.
Change gloves and place the implant with either ngers of funnel (currently we are
doing it with the same funnel used for breast implants placement). Use your nger
to accommodate the implant of the pocket if needed (Image 21.6).
21.2.1.7 Muscle Closing, Quilting Sutures, Drains andClosing All
Layers toSkin
Once the implant is placed properly on the pocket proceed to close the muscle with
the previously placed sutures on step 5. Then some quilting sutures to reduce death
space and drains are placed in the subcutaneous pocket. Lastly close all the layers to
skin (sub-cutaneous, sub-dermal, and intra-dermal).
21.2.2 Hybrid Component
After we have closed all the layers and the implants are in place we proceed to place
the fat (in the subcutaneous plane) we have previously harvested from liposuction
and cleared with the ltration pure graft system. We like to use this system to remove
all the contaminants from liposuction, reduce the inammatory response, and
increase retention rate.
21 Natural Look inButtock Implants: Eight Step Hybrid Gluteoplasty
293
We usually transfer between 100 and 150cc of fat in each side.
The fat is placed in all the at areas remained after the implant placement. Since
all women are different they might need fat in different areas. We like to place fat in
the upper pole to reduce and blend the transitions between the lower back and the
gluteal region. Another area to transfer fat is in the lateral and hip dips to improve
contour and reduce transitions.
The idea of transferring fat is to reduce transitions and to make a more natural
appealing buttocks (Images 21.7 and 21.8).
Image 21.7 Fat transfer
Image 21.8 Filtered fat
(puregraft) vs. nonltered fat
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H. U. Morelli
21.3 Results
In general, high satisfaction was obtained after following the eight steps of hybrid
gluteoplasty technique (Images 21.9, 21.10, 21.11, 21.12, 21.13, 21.14, 21.15,
21.16, 21.17, 21.18, 21.19 and 21.20).
Image 21.9 Final on table result
Image 21.10 Before and after (2years follow-up) back view
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