Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_994_Библиотеки_им_академика_М_И_Перельмана
.pdf
358
Image 25.16 Buttock
with fat component
Image 25.17 Buttock
without fat component
M. Morales-Olivera
25 The Post-Bariatric Buttock
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Table 25.2 Buttock evaluation
Buttock evaluation
Type of buttock A B C
Type of sequelae Mild Moderate
Fat component With fat component Without fat component
Severe
359
25.7 Planning theSurgery
After examining the gluteal region, we can dene our surgical plan where the rst
thing to assess is whether we will perform region management in a single procedure, or combined with another procedure.
It is worth noting that in post-bariatric reconstruction (and after massive weight
loss in general), it is very common to approach the abdomen jointly with the gluteal
region (as long as gluteal implants are not placed in that surgical procedure).
Therefore, performing a circular abdominoplasty would be ideal (eur-de-lis in
most cases), where a gluteal lift is to be performed in the posterior approach, which
is technically the same as the single procedure, with or without gluteal fatty ap, as
allowed by patient characteristics (fat component in the sacral and suprasacral
region).
Otherwise, when the patient warrants the placement of a gluteal implant due to
the absence of sufcient fatty component, suggestion is rst to perform the circular
abdominal approach and, second, place the prosthesis through the posterior scar
access route.
In summary, in a post-bariatric patient, the gluteal lift (or posterior component of
circular abdominoplasty) is the focus of the gluteoplasty. Marking will be
described below.
25.8 Buttock Lifting Marking (Images 25.18–25.23)
Buttock lifting marking is performed as part of the planning for a lower body contouring surgery, i.e., for a circular abdominoplasty. For this, the patient must be
marked standing, for a better identication of anatomical structures involved.
With the patient standing and facing you
1. Mark the anterior midline.
2. Mark the horizontal anterior abdominal incision 6cm above the beginning of the
vaginal introitus (maximum tension) and 6cm toward each side.
3. Locate the anterior superior iliac spine (ASIS) and join it to the initially marked
horizontal lines.
360
M. Morales-Olivera
Images 25.18–25.23 Buttock lifting marking
25 The Post-Bariatric Buttock
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
361
With the patient standing in prole
4. Locate the trochanter of the femur.
5. Locate the posterior axillary line (PAL).
6. Mark a line that connects the PAL with the trochanter.
7. Perform a maximum skin tension from the trochanter in a cephalic orientation.
8. With the skin taut, mark a point that will connect horizontally to the ASIS (lat-
eral point “L”).
9. From point “L,” mark with a pinch test in a cephalic orientation the dimension of
the redundant skin to be resected in the circular abdominoplasty. Point “L.”
Regardless of whether Fleur-de-Lis will be performed or not, here is where
the marking of the posterior approach begins.
With the patient standing and from behind
10. Mark the posterior midline.
11. Mark a point 2 cm above the start of the interglute cleft/groove (posterior
point “P”).
12. From point “P,” mark with a pinch test in a cephalic orientation the dimension
of the redundant skin to be resected. Point “P”.
13. Identify the true infragluteal sulcus (gluteal groove).
14. Mark a point 20 cm in a cephalic orientation from said sulcus (superior gluteal
point “SG”).
15. Mark a line connecting the points “L,” “SG,“and “P“to both sides.
16. Mark a line connecting the points “L,” “P,” and “L” contralateral.
25.9 Important Aspects ofMarking
1. When the patient presents a mild laxity in the posterior midline (when perform-
ing step 12), resection of more than 5cm is not recommended, as it is a high
tension zone of the suspension system, and a tense wound would be an imminent
cause of dehiscence.
2. When marking the superior gluteal point (SG), the standard dimension of 20cm
(average measure of an ideal gluteal from the infragluteal sulcus), may vary
considerably according to the patient-specic characteristics. What is important
is to schematize that the resection should be extended in this zone with a curved
line (unlike the superior incision “L”, “P,” “L,” where the line is completely
straight).
3. In case a gluteal ap is planned, marking is the same, only delimiting the lateral
dimension of the ap (according to the intended effect: decrease or maintain the
size of the hip), as well as the skin pocket, which in general should be dissected
with caution without reaching the true infragluteal sulcus, as it increases the
development of seromas in that dissection plane.
4. If a gluteal implant is decided, marking does not change, as the access route is
through the segment of skin to be resected. Only dissection limits of the intramuscular pocket should be marked.
362
M. Morales-Olivera
25.10 Special Considerations inPost-Bariatric
Buttock Surgery
Post-bariatric patients present a wide range of clinical, metabolic, and nutritional
disorders that are widely described, identiable through paraclinical testing and
physical examination.
As we know, despite not being obese anymore, they continue with several pathologies in different systems, and their tissue quality is below than that of conventional
(non-post-bariatric) patients, thus they are always at an increased risk of presenting
postoperative local or systematic complications.
That is why I always insist on making use of the technology available as a safety
measure, both in preventing systemic (e.g., intermittent pneumatic compression to
reduce the risk of thromboembolism events), or local (sutures and special tissue
adhesives that reduce the risk of dehiscence) complications.
However, throughout their transformation process (from obesity, through bariatric surgery, to the reconstructive process), there will be psychological changes that
may affect their mental health and with it, their compliance with treatment and
postoperative care.
What is even more serious are high expectations (sometimes unrealistic), not
identied or ignored during the preoperative period, which will directly contribute
to an unsatisfactory result.
As such, it is essential to remember the mandatory psychological evaluation in
this particular patient population, in addition to planning the surgical procedure
(protocol and preoperative evaluations).
It is important to remember that clinical changes developed (in the gluteal region
and in the rest of the body contour) pose a real surgical challenge, and only when
taking every measure will we achieve a successful result.
Further Reading
Capella JF, Oliak DA, Nemerofsky RB.Body lift: an account of 200 consecutive cases in the mas-
sive weight loss patient. Plast Reconstr Surg. 2006;117(2):414–30.
Centeno RF.Autologous gluteal augmentation with circumferential body lift in the massive weight
loss and aesthetic patient. Clin Plast Surg. 2006;33:479–96.
Duparc F, Thomine JM, Dujardin F, etal. Anatomic basis of the transgluteal approach to the hip-
joint by anterior hemimyotomy of the gluteus medius. Surg Radiol Anat. 1997;19(2):61–7.
Echo A, Menn ZK, Friedman JD.A minimally invasive approach for the correction of a traumatic
buttock deformity via wire subcision and volume replacement. J Plast Reconstr Aesthet Surg.
2012;65:e163–5.
González R. Etiology, denition and classication of gluteal ptosis. Aesthet Plast Surg.
2006a;30(3):320–6.
González R. Gluteal retractions: classication and treatment techniques. Aesthet Surg
J. 2006b;26(5):537–50.
González R.Gluteoplasty. 1st ed. Río de Janeiro: Indexa Editora; 2008.
25 The Post-Bariatric Buttock
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
363
Halawi A, Abiad F, Abbas O.Bariatric surgery and its effects on the skin and the skin diseases.
Obes Surg. 2013;23:408–13.
Mendieta CG.Classication system for gluteal evaluation. Clin Plast Surg. 2006;33(3):333–46.
Morales-Olivera JM.Histological dermal changes after massive weight loss and its impact on
surgical wound after abdominoplasty. Cir Plast Iberolatinoam. 2019;45(3):275–84.
Morris H.Morris’ human anatomy. Philadelphia: Blakiston; 1943. p.525–6.
Pereira O, Bins-Ely J, Machado E, et al. Treatment of skin depression with combined upward
suture traction and percutaneous subcision. Plast Reconstr Surg Glob Open. 2015;534(3):1–9.
Rincon-Rubio L, Cemborain M, Gil B, etal. Evaluation of histopathological changes secondary to
bariatric surgery. Cir Plást Iberolatinoam. 2018;44(4):379–87.
Schmitt T, Jabbour S, Makhoul R, etal. Lower body lift in the massive weight loss patient: a new
classication and algorithm for gluteal augmentation. Plast Reconstr Surg. 2018;141:625–36.
Shikora SA, Kim JJ, Tarnoff ME.Nutrition and gastrointestinal complications of bariatric surgery.
Nutr Clin Pract. 2007;22:29–31.
Chapter 26
The “Buttock Augmentation Lipolled
Flap”: ANovel Approach forGluteal
Contour inthePost Bariatric Body Lift
RodrigoMunro-Wilson
26.1 Background
The body lift or Circumferential Lipectomy is the work horse operation to restore
contour and improve quality of life in the after massive weight loss patient population [1].
These patients have generalized skin redundancy, lipodystrophy, and signicant
gluteal deformities that cannot be corrected by skin resection alone [2].
The gluteal area should be augmented during the lower body lift to avoid loss of
volume and projection due to aggressive skin removal [3].
Liposuction and fat transfer can be used as adjuncts to improve the results of the
excisional procedure but are limited to the availability of subcutaneous tissue and
better suited for patients in a higher BMI range.
Buttock augmentation aps are an important tool to improve the gluteal area and
can deliver adequate results provided enough soft tissue is available. They also have
shortcomings that have been addressed by several authorities [4].
In patients with low BMI the buttocks are so attened and ptotic that autologous
aps are insufcient to improve buttock aesthetics. This patient group where subcutaneous tissue is in short supply is better suited for implant augmentation [5].
While gluteal augmentation with implants has advanced enormously in recent
years, we still encounter patients that will refuse alloplastic material [6–8].
What can we offer a low BMI patient that does not want an implant but desires
to improve buttock contour?
To optimize the results of our Circumferential Body Lifts in such candidates we
developed the Buttock Augmentation LipoFilled Flap.
R. Munro-Wilson (*)
Private practice, San Pedro Garza García, Nuevo León, Mexico
e-mail: drmunro@perfecta.com.mx
© 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_26
365
366
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
abc
def
R. Munro-Wilson
Fig. 26.1 (a–d) BALF in a low BMI patient. Adequate volume, projection, and lifting was
achieved in the gluteal region. (e, f) Postoperative outcome after the surgery
In this technique we combine skin removal with liposuction and fat grafting of
the buttock augmentation aps in order to increase their volume. These procedures
coupled with additional fat transfer to key areas help us deliver adequate outcomes
in a patient population that is very challenging but demands good results nonetheless (Fig.26.1).
26.2 Patient Selection andIndications
In order to obtain optimal results, improve patient satisfaction, and minimize morbidity in a patient population that already has a higher complication rate, only nonsmoking patients in good health with a BMI less than 30kg/m2 are considered for
circumferential lipectomy [9]. The method of gluteal augmentation is chosen in a
case by case basis and discussed with the patient.
26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
367
Fat deposits in the upper and lower back are evaluated, as well as the sacral
region and lateral thighs. Patients have different body types and should be analyzed
individually and treated accordingly.
Schmitt and associates published an algorithm for gluteal augmentation in the
massive weight loss patient that I have adopted in my practice with good results [10].
The lower back skin is pinched to asses if the tissues have a thickness greater
than 5cm.
Post-bariatric patients with good soft tissue volume and adequate gluteal projection are candidates for a Circumferential Body Lift plus liposuction and fat transfer.
Some patients in this class might choose no gluteal augmentation at all [4].
Patients with a pinch test of 5cm or more that present with deated buttocks are
ideal candidates for gluteal augmentation aps. In these cases that have enough soft
tissue to create an acceptable gluteal contour, aps can still be lipolled to increase
volume and meet personal or ethnic preferences.
On the other hand, patients with a low BMI and a pinch test of less than 5cm
don’t have sufcient soft tissue for ap augmentation and are better candidates for
gluteal implants, but as we mentioned earlier, the patient might refuse for diverse
reasons.
In these cases, valuable fat can be harvested from other areas to improve contour
and then be transferred to the ap to increase volume.
The “Buttock Augmentation LipolledFlap”(BALF) is a good tool to have in
our armamentarium (Fig.26.2).
abc
Fig. 26.2 (a–e) BALF in a post-bariatric patient that desired large gluteal volume. (f) Postoperative
outcome after ap surgery
368
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. Munro-Wilson
def
Fig. 26.2 (continued)
26.3 Preoperative Markings
Careful preoperative markings are important to achieve scar symmetry. Ideally scars
should lie between the anatomical units and be concealed by most undergarments.
Our markings as well as preoperative photos and video are done the night before
the operation. The process is started with the patient in the standing position. I like
to sit in a stool with wheels and be able to move freely around the patient. The
patient is asked to use his or hers preferred underwear for the initial stage of the
markings since it can serve as a reference. In some cases with excessive loose skin
where the use of a garment is not practical, we rely on bony structures.
We start drawing ve vertical lines, following Pascal’s description [11].
First the posterior midline is drawn. Then the midaxillary line is carried down to
the trochanteric region on both sides, to determine the division between the dorsal
and ventral areas, since ap movement is different. In the ventral area the inferior
pubic incision is xed and the superior abdominoplasty ap moves downward. In
the back the opposite occurs where the superior dorsal ap is less mobile and the
inferior buttock ap moves upward. It is important to simulate this ap movement
while making the marks to try and estimate the amount of tissue to be resected and
also the nal scar placement.
Finally, two vertical lines are drawn 16–18cm lateral from the posterior midline,
depending on the patient’s body habitus. These lines are generally three quarters of
the distance between the posterior midline and the midaxillary line and mark the
lateral aspect of the infragluteal fold. These lines will also represent the lateral edge
of the buttock augmentation ap and the pocket to be undermined.
Once the vertical lines are drawn, we have to decide the amount of tissue to be
resected laterally. The intersection between the midaxillary line and the iliac crest is
Соседние файлы в папке Библиотека им академика М.И. Перельмана