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26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
369
palpated and marked. The superior incision is marked on the axillary line, 2cm
above the level of the undergarment, since it will shift downward with the traction
of closure. This mark lies generally 7–9cm below the level of the iliac crest. The
inferior incision is marked using the pinch test. In certain cases there will be more
tissue excess on one side than the other and resection needs to be adjusted. It is
important to mention that with the patient standing, we can appreciate a distinct
boundary in the buttocks between smooth skin above and wrinkled skin below. The
smooth skin above is the lower back and the inferior wrinkled skin is the true buttock that needs to be placed in its proper position. The inferior incision line needs to
be marked at least at this boundary to have and adequate lifting effect.
Finally the top of the intergluteal crease is marked along the posterior midline.
We estimate the tissue to be resected with a pinch test with the patient standing
and in a bent over posture, simulating the Semi Fowler postoperative position. This
helps us simulate the tension placed on the incision after closure and adjust resection width to avoid wound dehiscence.
Once the markings are done in the standing position, the patient is placed prone.
Using the previously marked superior limit of the intergluteal crease as a reference, the amount of tissue resection in the posterior midline is double checked.
Performing both superior and inferior traction, the amount of skin to be removed
is estimated and marked. The amount of skin resected in the midline goes a couple
of cm into the actual intergluteal crease. This helps avoid lengthening of the crease
and it’s negative aesthetic result. It is worth mentioning that lengthening of the intergluteal crease is not always due to a high resection. In a lower body lift, we are
trying to match the lower and usually longer gluteal incision with the superior and
generally shorter lower back incision. The length discrepancy of these two incisions
requires the lower ap to be compensated toward the midline, to match the superior
ap. This mismatch and compensation causes the lower back skin to get bunched up
in the posterior midline, even when the resection area is placed low and includes
part of the crease.
Afterward, the superior and inferior lateral marks are joined with the corresponding ones in the posterior midline to dene the transverse section to be resected.
We try to place the inferior gluteal incision line 16–18cm above the infragluteal
fold. While mobilizing the skin in a cephalic direction, a straight line is drawn from
the lateral inferior mark to the inferior midline mark. When traction is released, the
result is a curved line with a superior concavity. The superior incision is marked
while pulling the skin in a caudal direction. This results in a slightly curved line with
a superior convexity, since the lower back skin is not as mobile. Ideally the resulting
scar will lie at the junction between the lower back and buttocks, where it is most
aesthetically pleasing. This is checked by pulling down and observing where the
proposed upper incision line lies, since this incision determines scar position [11].
The posterior midline markings are adjusted drawing superior and inferior
inverted triangles, to dene de sacral region as described by Centeno [3, 12].
With cephalic traction on the buttocks we visualize the estimated point of maximum gluteal projection at the level of the mons pubis and make a mark. The lipolled autoaugmentation ap must go beyond that mark to deliver adequate contour.
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R. Munro-Wilson
The area of resection has to be placed low so enough tissue is removed to correct
gluteal ptosis and the aps can reach the inferior pole of the buttocks.
In the medial buttock area care must be taken not to remove too much skin to
avoid intergluteal spreading and exposing the anus and posterior perineum. At the
level of the external buttocks and trochanteric region, resection width can be more
liberal [11].
A simple maneuver that we nd very useful when tissues are thick and a pinch
test is not possible, is to traction the ap inferiorly and have an assistant hold a pen
at the level of the marked incision and keep it in that position while the skin is pulled
in the opposite direction. We can then observe if our inferior marking reaches the
point where the pen is being held and adjust the drawing accordingly.
The buttock augmentation ap is designed 2–4cm laterally from the posterior
midline and its lateral edge reaches the third vertical line that was drawn in the
standing position (16–18cm from the midline). The distance of this line from the
midline will increase with the patient lying prone. The height of the ap can include
the complete resection area since its base lies caudal to the iliac crest, centered on
the gluteus maximus muscle with a rich blood supply. Doppler ultrasound can be
used to identify the superior gluteal artery perforators [13]. The two major perforators are always within the demarcated ap. I strongly recommend that the novel
surgeon starting with these operations identify the perforators beforehand. It will
keep you safe and do a lot for your peace of mind.
To mark the implant pocket, the gluteal skin is held under superior traction and a
line is drawn 5cm above the infragluteal fold to mark the caudal limit of the dissection. This is very important to prevent denervation of the buttock [3, 5].
We call this 5cm wide strip between the infragluteal fold and the caudal limit of
the implant pocket the “lower thirdgap.” After the superior and middle thirds of the
buttocks are lled by the ap, the “lower third gap” can look empty and needs to be
adequately fat grafted to restore volume and enhance the overall contour. This is
especially important in patients with low BMI that will be the most deated. With
the patient lying prone and with superior traction on the buttocks, we again estimate
the point of maximus projection at the level of the mons pubis. Finally the lateral
and medial limits of the pocket are marked matching the width of the ap.
26.4 Operative Technique
All patients receive preoperative prophylactic antibiotics. Compression stockings,
pneumatic sequential compression devices, and Foley catheter are placed. The operation is performed under epidural block and IV sedation unless epidural anesthesia
is a contraindication. In such cases general anesthesia is used.
The operating room is warmed up and a heating blanket over the operating table
helps prevent hypothermia.
We start the operation with the patient placed on the operating table in the prone
position, unless fat needs to be harvested from the abdominoplasty ap. In that case
26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
371
the operation is started in the supine position, fat is harvested, and then the patient
is placed prone. All pressure points, genitalia, and breasts are padded and protected.
The surgery starts with inltration of super-wetting solution in the predetermined
areas (1cc of inltrate to 1cc of aspirate) using 2cc of 1:1000 epinephrine per liter
of lactated Ringer’s [2]. No lidocaine is used in the inltration solution.
The fat is aspirated in the lateral anks, lower back, sacral region, and hips.
Removing fat in the posterior lumbar and supragluteal area gives the impression of
increased gluteal projection, prevents sacral fullness, and also denes the waist.
Only deep plane liposuction is performed to preserve Scarpa’s fascia and to avoid
compromising ap perfusion. In low BMI patients where subcutaneous tissue is in
short demand, supercial liposuction above Scarpa’s fascia is performed in the
areas within the planned resection lateral to the auto augmentation aps. This tissue
would be otherwise discarded and the fat wasted. Harvested fat is kept in a sterile
container and decanted.
Marked incisions are adjusted since ap mobility increases after tissue is released
by liposuction. The incisions are inltrated with a solution made with 1cc of 1:1000
epinephrine diluted in 150cc of saline. Skin incisions are made along the demarcated lines down to the subcutaneous plane. The gluteal aps are deepithelialized
using electrocautery. Flaps have a robust blood supply from superior gluteal artery
perforators, so dermis is preserved for xation purposes since it is not essential for
the ap’s perfusion or survival [13]. Incisions are carried down to Scarpa’s fascia
and the tissue surrounding the aps is removed. Subcutaneous tissue supercial to
the muscle fascia is preserved in the ank and supra trochanteric area to prevent
creating a depression on Mendieta’s point C [14].
Meticulous hemostasis is of paramount importance to avoid complications.
Large bleeding vessels are identied and ligated with 3–0 Vicryl (Ethicon).
The dissection around the ap’s base is carried down to the deep muscle fascia.
It should be perpendicular in the superior, lateral, and medial edges, but must be
beveled in an oblique angle in the inferior border of the ap to obtain a wider base.
This angled dissection not only helps us increase blood ow to the augmentation
ap but also reduces the thickness of the inferior buttock ap. To even out this thickness discrepancy between the lower back ap and the buttock ap will help at the
moment of closure [15].
The deep gluteal and sacral fascia are opened exposing the gluteus maximus
muscle bers so the ap is released from these strong attachments.
Care must be taken to identify the posterosuperior iliac spine and the sacroiliac joint.
The fascia release must be complete and go around those structures.
Once the deep fascia is released, the centrally based ap can be easily mobilized.
The ap pocket is dissected caudally in a plane above the gluteus maximus, leaving the muscle bers exposed and the fascia attached to the ap. The pocket dissection stops 5cm above the gluteal crease to avoid hypoesthesia or dysesthesia of the
overlying buttock skin [3, 5] (Fig.26.3).
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Since the area of skin resection and the ap are positioned low in the buttocks,
the centrally based ap can be easily mobilized to reach the caudal edge of the subfascial pocket in a patient with square buttocks.
In a tall patient with rectangular or long buttocks, the ap might not be mobile
enough to reach the caudal edge of the pocket without tension. In these cases, the
ap can be easily converted to a split muscle turnover ap as described by Sozer
[16]. To achieve this, dissection is carried into the thickness of the gluteus maximus
to a depth of 1–1.5cm and then the muscle bers are followed in a caudal direction.
The muscle is thus split for 5 or 6cm until it can be turned over itself 180° (Fig.26.4).
Once we are satised with ap mobilization and the way it ts into the pocket,
we can proceed with lipoaugmentation.
The ap is lipolled in the supercial and deep subcutaneous planes, above and
below Scarpa’s fascia to increase its volume. Even though greater volumes can be
grafted into large aps, an average of 150cc of clean decanted fat is injected with a
3mm blunt tip cannula with one orice. This is done under direct vision of the tissue planes, so we are absolutely sure the fat lling is being performed exclusively
in the subcutaneous plane [17]. Care is taken with the volume of fat injected, in
Fig. 26.3 Pocket
dissection
Fig. 26.4 Gluteus
maximus muscle split
26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
Fig. 26.5 Lipolling the
buttock ap
373
order not to compromise circulation or create too much pressure that could negatively affect the fat graft’s take. Active bleeding of the deepithelialized surface and
dermal edges is evaluated as well as ap turgidity (Fig.26.5).
The BALF is then translated or turned over into the pocket and anchored to the
edge of the gluteal fascia using four stitches of 2–0 Vicryl, Ethicon.
The skin and subcutaneous tissue of the inferior buttocks are advanced superiorly over the aps and the wound edges are approximated with staples to check for
tension. If loose tissue remains, the resection is adjusted at this time. The inferior
buttock ap is of greater thickness than the superior ap, which is the thinner lower
back skin. Since the inferior border of the ap was beveled, it usually takes care of
that mismatch. If a thickness difference remains, some fat deep to Scarpa’s fascia on
the inferior ap can be carefully trimmed. It is worth mentioning that in order to
compensate for the difference in length between the inferior and superior incisions,
the caudal ap needs to be pulled toward the midline. In cases where a large discrepancy is encountered, this maneuver causes bunching of the lower back skin that
forms fold in the sacral area above the scar that gives the appearance of a lengthened
intergluteal crease.
With the incision approximated, the overall contour of the gluteal region is
evaluated.
Lipolling of the 5cm wide gap between the implant pocket and the infragluteal
fold helps us prevent an empty lower pole. A stab incision is made in the lateral
aspect of the fold and clean decanted fat is injected exclusively in the subcutaneous
plane using a 4mm blunt single orice cannula. This is done by orienting the cannula upward and always palpating the tip with the nondominant hand [17]. The
volume of fat injected in the gap varies from case to case, with 150cc being average
(Fig.26.6).
The need for additional fat grafting of the thighs is evaluated and performed
depending on patient’s requirements and personal or ethnic preferences. Once we
are pleased with the overall contour and shape of the gluteal region the incision
is closed.
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One 10mm Blake drain is placed across the wound and exits through the incision
in the lateral midline on the left side. The abdominoplasty drain will exit the wound
on the opposite side. I used to exteriorize drains through separate incisions, but now
choose not to give the patient another scar.
Scarpa’s fascia is closed with a spiral running suture using 0V-Loc (Covidien),
the deep dermis is closed with a 2–0V-Loc (Covidien) spiral running suture and the
supercial dermis is closed with a horizontal running Monocryl 3–0 (Ethicon)
suture. No knots are used in the closure. Dermabond skinadhesive (Ethicon) is
applied over the closed incision. The patient is then transferred to the supine position for anterior liposuction and abdominoplasty. A light elastic bandage with cotton dressing is used to drape the patient after surgery. Average operative time is 6h
(Fig.26.7).
Fig. 26.6 Fat grafting of
the “Lower Third Gap”
Fig. 26.7 Tissue resected
in circumferential
lipectomy. Note that only
the skin is removed in the
buttock augmentation
ap area
26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
375
26.5 Postoperative Management
The patient is transferred to the hospital bed in a Semi Fowler position with
knees exed.
Enoxaparin 40mg is injected subcutaneously 8h after the end of the procedure
and once every 24h for a total of 6days.
Oral intake of uids is started once the patient wakes up from sedation and if
tolerated is followed by regular diet.
The epidural catheter is left in place for post op pain management and removed
before the patient is discharged from the hospital. Foley catheter and pneumatic
compression devices are kept for the rst night and removed once the patient mobilizes out of bed.
Patients are ambulated the next morning with the aid of a walker with knees and
waist slightly exed. Patients are allowed to rest and sit in the position they nd
most comfortable.
Compression stockings are used until the patient starts active ambulation after
being discharged from the hospital.
Patients are kept hospitalized for 2 or 3 nights and discharged when they tolerate
pain, regular diet, and are fully ambulatory.
The drains were removed when output was less than 30cc in 24h, generally by
the seventh day after surgery. No compression garments were used until all drains
were removed.
In 50 cases using the lipolled central pedicle or split muscle aps, we have had
no fat of ap necrosis. Our complication rate has not been higher since we started
the lipolling of the gluteal augmentation aps and additional fat grafting of the
lower third gap.
Major complications like deep venous thrombosis and pulmonary embolus have
been absent and no blood transfusions have been required.
We have experienced wound dehiscence in 10% of the cases. All of them were
managed conservatively with dressing changes, healing by secondary intention.
Patient satisfaction was high.
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R. Munro-Wilson
Fig. 26.8 (a–f) Patient in Figs. 26.3, 26.4, 26.5, 26.6 and 26.7. Pre-op, markings and 6
months post-op
26.6 Discussion
We have all witnessed the dramatical increase in demand for aesthetic gluteal contouring surgery. The post-bariatric patient population is no exception.
The gluteal area was frequently overlooked in massive weight loss body lift but
has to be included as an important part of the operation. The anks, buttocks, and
thighs must be seen in conjunction to obtain optimal results.
The techniques available to enhance buttock contour at the time of the
Circumferential Lipectomy include autologous augmentation with aps, fat transfer, and gluteal implants.
Liposuction and fat transfer are adequate only in patients with mild ptosis that
have enough subcutaneous tissue to work with and have not totally lost projection
in the gluteal region (Fig. 26.8).
26 The “Buttock Augmentation Lipolled Flap”: A Novel Approach for Gluteal…
377
Flaps based on superior gluteal artery perforators can be transferred safely during lower body lifts to add volume and projection to the buttocks, but while they
have a reliable blood supply, they can’t be mobilized to reach the lower pole of the
buttocks, so they tend to stay high and only ll the upper third. We are then faced
with high gluteal projection and a lack of volume in the mid and lower thirds of the
buttocks, causing a double bubble appearance [5]. Getting sufcient mobilization to
allow ap descent is achieved by releasing the surrounding deep gluteal and sacral
fascia or converting a centrally based ap to a turnover ap. This way we provide
good projection in the mid portion of the buttocks where it is most aesthetically
pleasing [16, 18].
Even in thin low BMI patients where subcutaneous tissue is in short demand, we
can harvest fat from selected areas and rescue it from the sections that would be
otherwise resected and wasted. Both the centrally based and the turnover aps have
a robust blood supply and can be safely lipolled to increase their volume.
The dissection for the pocket where the ap will be inserted has to stop 5cm
above the infragluteal fold to avoid injury of the medial cluneal and the cutaneous
femoris posterior sensory nerve [3]. This 5cm gap between the caudal edge of the
ap and the infragluteal fold can appear empty. Volume in this area is restored with
careful fat grafting in the subcutaneous plane.
The Circumferential Lipectomy with a buttock augmentation ap is a difcult
procedure because there is a delicate balance between the amount of skin resected
to achieve adequate lift and the volume of the ap required to restore volume. This
produces tension that can lead to wound dehiscence [5]. It is a sound practice to be
conservative on the initial skin removal, since additional tissue can always be
excised once the ap is inserted and the closure approximated with staples.
The Buttock Augmentation Lipolled Flap is a safe procedure that we rou-
tinely perform in combination with the Circumferential Body Lift to rene our
results in selected post-bariatric patients.
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