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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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348
Image 25.3 Grade IV
ptosis
M. Morales-Olivera
Image 25.4 Grade V
ptosis
25 The Post-Bariatric Buttock
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349
25.4 Irregularities andAdherences Zones
Irregularities and adherence zones of the gluteal surface (also known as retractions),
are depressions caused by tissue changes in the subcutaneous cell tissue, fascia or
muscular bers, and which are exacerbated by modications from post-bariatric
weight loss (previously described histological alterations).
25.4.1 Presentation Plane
When it occurs in the subcutaneous tissue or fascia, it corresponds to alterations of
the adipose tissue in its function as a structure of the connective tissue network in
the region.
However, when its origin is in the depth of a muscular structure, it is due to the
application of injections, which is constant in patients undergoing a bariatric procedure (especially iron), and sometimes becomes chronic, causing an inammatory
process in the injection zone, which will eventually manifest as retraction.
25.4.2 Presentation Topography
In conventional patients, they usually appear in the lower third of the buttock as
depression/brotic atrophy zones, or in areas of previous isolated injections.
In a post-bariatric patient, it is observed in any zone: in the upper third (specically in the upper external quadrant where injections are applied chronically), but as
they lose weight and more ptosis is generated, retractions now manifest in the middle third, in addition to those of the lower third, which were always present even
without a history of intramuscular injection (Image 25.5).
In patients with a history of morbid obesity or super obesity, the “Massive” presentation of adherence occurs not only in all thirds of the gluteal area, but also
toward the trochanteric and posterolateral thighs (Image 25.6a, b).
25.4.3 Importance ofClinical Identication
25.4.3.1 Superior Third
Because surgical planning of a post-bariatric gluteoplasty will involve performing
an en bloc tissue resection (when there is not enough fat component to perform a
gluteal fat ap), or only cutaneous (with the caudal mobilization of the fatty tissue
for a gluteal ap), the superior third is the zone that represents the best prognosis, as
no matter the technique used, it will completely eliminate retraction and its stigma
(Image 25.7).
350
Image 25.5 Postbariatric
adherences and
irregularities
M. Morales-Olivera
a
Image 25.6 Massive adherences: They are localized depressions of adipose tissue in any third of
the gluteal anatomy. They are the result of irregular fat loss when losing weight
b
25 The Post-Bariatric Buttock
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Image 25.7 Adherences
and irregularities in
superior third
25.4.3.2 Mid andInferior Third
351
In these areas, adherences and irregularities will generally be subcutaneous; therefore, when performing the buttock lift (as part of a circular abdominoplasty or a
single procedure), and/or an increase with autologous fatty tissue or implant, they
will have a considerable improvement by applying tension to the skin surface.
However, if retraction is deeper (muscular or at the fascia), it will be necessary
to perform a rigotomy to eliminate skin memory in that brotic zone, in addition to
fat grafting (Image 25.8).
25.4.4 Massive Presentation
It is the indication to perform a gluteal lift associated with liposuction of the trochanteric region sequentially.
It means that this type of patient presents severe sequelae not only in the gluteal
region but also in the thighs and the femoral region, requiring at least two sequential
surgical procedures, since planning an aggressive resection in a single surgical procedure with excessive tension (trying to improve irregularities) poses high risk of
dehiscence due to the great counterweight of legs.
And on the other hand, performing a single conservative procedure will deliver
suboptimal outcomes.
352
Image 25.8 Adherences
and irregularities in mid
and inferior third
25.5 Infragluteal Echoes
M. Morales-Olivera
When the patient presents a dysfunctional ptosis (Grade V ptosis), every tissue component is damaged, and if the patient also had a loss greater than 50kg, parallel and
transversal lines (cephalic or caudal) are clinically presented in the true infragluteal sulcus.
These lines are the result of the “excessive” accumulation of loose skin in the
lower gluteal third, and sometimes with adherence zones from the middle third,
which appear as what I have called “infragluteal echoes“(given the image reected
as ripples on the skin surface (Image 25.9a, b).
25.5.1 Importance ofClinical Identication
The presence of infragluteal echoes indicates a severe sequelae, regardless of the
type of buttock, of the presence or absence of an adipose component, or if the patient
presents true or dysfunctional ptosis.
This evident sign of severe sequelae provides a guideline to perform an extensive
buttock lift (with or without augmentation with autologous tissue or implant), since
excess skin allows for great traction. It should be noted that this is possible in a postbariatric patient, where viscoelasticity is altered, as long as there is no signicant
countertraction.
25 The Post-Bariatric Buttock
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353
a
Image 25.9 Infragluteal echoes: These cutaneous lines are the result of the “excessive” accumulation of loose skin in the lower gluteal third (as if there were many infragluteal grooves)
b
Therefore, the only contraindication is if the patient is having irregularities and
adherence zones in their massive presentation, where, as previously mentioned,
should be conducted in more than one surgical procedure.
25.6 Post-Bariatric Buttock Classication
After analyzing the four components that make up the gluteal region, we can see
that they all have an inuence, to a greater or lesser extent, in their formation and
clinical presentation.
As such, once the differences between a post-bariatric buttock from a conventional one are understood, a classication can be made depending on three factors.
The rst is the global gluteal shape or presentation (from the bone structure and
the relation of the upper and lower body contours).
The second is the clinical characteristics in the skin (such as retractions) or in the
muscle (ptosis degrees), which will indicate the severity of the sequelae.
And third, the amount of adipose tissue present, as it is the main factor involved
in the prognosis of reconstruction.
1. Type of buttock
(a) Adequate relation of the upper and lower body contours. In other words, rib
cage dimensions are similar to that of the pelvic structure, regardless of the
actual waist, given by the anterior abdominal loose skin and the amount of
fat from the sacral and suprasacral region (Image 25.10).
354
Image 25.10 Buttock
type A
M. Morales-Olivera
(b) The lower body contour is larger than the upper body contour. Large amount
of pelvic-trochanteric fat (Image 25.11).
(c) The upper body contour is larger than the lower body contour. This may be
due to ventilation changes that have affected the rib cage during obesity, or
it may also be a small diameter pelvis per se, clinically exacerbated after
weight loss (Image 25.12).
2. Severity of the sequelae (Images 25.13, 25.14, and 25.15)
• Mild
– Ptosis grade IV.
– Without gluteal adherence or retraction zones.
– No infragluteal echoes.
• Moderate
– Ptosis grade IV–V.
– With zones of gluteal irregularities and adherences.
– No infragluteal echoes.
• Severe
– Ptosis grade V.
– With zones of gluteal irregularities and adherences.
– With infragluteal echoes.
25 The Post-Bariatric Buttock
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Image 25.11 Buttock
type B
355
Image 25.12 Buttock
type C
356
Image 25.13 Buttock
with mild sequelae
M. Morales-Olivera
Image 25.14 Buttock
with moderate sequelae
25 The Post-Bariatric Buttock
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Image 25.15 Buttock
with severe sequelae
3. Fat component
357
(a) With fat component
Presenting fatty tissue in the pelvic girdle (steatopygia), concentrated mostly
in the sacral and suprasacral region, sometimes extending to the trochanteric
region. Specically in gluteal ptosis, the highest concentration is located in the
inferior third (as part of tissues that exceed the infragluteal sulcus) (Image 25.16).
Importance of Clinical Identication: Fat concentration in the sacral and
suprasacral region is useful for reconstruction using pedicled gluteal aps.
Similarly, correct identication of fat in the trochanteric region will allow liposuction and with it, considerably improve results after gluteoplasty.
(b) Without fat component
There is no accumulation of fatty tissue in the sacral, suprasacral region,
or in the brotic connective tissue network of the gluteal network. The result
is a buttock without shape, volume, or projection (Image 25.17).
Importance of Clinical Identication: Despite improving shape with a
gluteal lift procedure, there are no options to improve buttock volume and
projection with autologous fatty tissue, as it is absent (Table25.2).
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