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22
Table 1.3 Average of measurements of the muscle thickness of the gluteus maximus
AVERAGE OF MEASUREMENTS OF THE
MUSCLE THICKNESS OF THE GLUTEUS
MAXIMUS, ACCORDING TO REGIONS
3
2,5
2
F. R. Garcia
1,5
1
THICKNESS CM.
0,5
1,45
0
III III IV
1,95
2,65
2,32
1,92
VVI VII VIIIIX
MUSCLE REGIONS
2,31
2,71
2,73
2,6
Fig. 1.15 Fascia of the gluteal region: Supercial, deep, and muscular
placement of prostheses of medium to large volume, with a base diameter greater
than 10cm. It is undoubtedly a good surgical plane for patients who need small or
slightly medium implants, and surgeons with very good anatomical knowledge, due
to the proximity of important neurovascular structures (Fig.1.16a–c).
ab
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
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23
c
Fig. 1.16 (a–c) Submuscular space. Measures for implant placement. [“Original image published
in Cir. Plast. Iberolatinoam, 2016, 45(2):149–156 and reproduced with permission”]
1.8 Important Morphological Findings intheGluteus
Maximus Muscle
A macroscopic study of the gluteus maximus was carried out, where, fortunately,
we were able to identify anatomical structures of great morphophysiological interest and some ndings of great scientic value, such as the intramuscular space of
FROD, ideal for making the pocket in gluteal augmentation surgeries with implants,
not previously described in any publication or basic text of human anatomy, or plastic surgery [23].
One of the striking ndings was the observation that the gluteus maximus muscle, as described by some important anatomy texts, is not a homogeneous mass
“with the thickest muscle bers in the whole body” [25], or “formed by different
fascicles separated by ne conjunctive septa” [24]. By carefully removing the muscular fascia itself, it was veried that the muscle bers are grouped into indepen-
dent, longitudinal, voluminous eshy cylinders, of variable thickness depending
on the area, adjacent, joined by strong brous or broaponeurotic septa, with two
different insertions and directed in parallel toward down and out, from its supercial
to the deep part [23] (Fig.1.17a, b).
24
ab
Fig. 1.17 (a, b) Muscle cylinders: independents, longitudinals, voluminous eshy cylinders, of
variable thickness, joined by strong brous or broaponeurotic septa, from its supercial to the
deep part
This anatomical conformation with multiple independent, eshy longitudi-
nal cylinders would explain the reason for its enormous muscular power due to the
sum of numerous force vectors, instead of a single vector, displayed during the
action it performs when it takes the femur as a xed point and extends the trunk over
the lower limb by straightening the pelvis in the bipedal station in the act of standing
up when sitting and when running or climbing stairs [25]. Analogous action to that
used by suspension or cable-stayed bridges, with multiple resistant support cables
tied to main cables or pillars, developing large traction and compression forces
respectively, capable of supporting or balancing enormous weight loads [36]
(Fig. 1.18). Coincidentally, an interesting article was published last year in the
FILACP scientic journal where this mechanism of distribution of forces of suspension bridges is used for the closure of fasciotomies and complex wounds [37]. This
special anatomical characteristic, of independent eshy cylinders in the gluteus
maximus, would also explain the reason for the functionality present in this muscle,
despite severe lesions with necrosis due to different causes, signicant surgical
trauma, or section of an important part of the gluteal muscle tissue, during the making of aps in reconstructive surgeries. Being the most powerful extensor muscle of
the hip, it acts preferably when strength is needed.
Simultaneously with the discovery of the muscular cylinders in the anatomical
constitution of the gluteus maximus muscle, we were able to verify the presence of
powerful brous or bro-fascial septa, resistant to any digital dissection
maneuver, which hold the muscle cylinders tightly together, from the surface to the
depth. These septa can only be dissected with sharp instruments, electrocautery, or
traumatic blunt disclosure, which generally causes unwanted inammatory or hemorrhagic processes (Fig.1.19). Only at the level of the intramuscular space of
FROD, these brous septa do not exist, so the easy digital dissection of their
approach ensures the location of the space and at the same time provides us with
less morbidity.
F. R. Garcia
a
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
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25
b
Fig. 1.18 (a, b) Analogous action, to that used by suspension or cable-stayed bridges, with multiple resistant support cables tied to main cables or pillars, developing large traction and compression forces respectively
Fig. 1.19 Powerful brous
or bro-fascial septa,
resistant to any digital
dissection maneuver,
which hold the muscle
cylinders tightly together,
from the surface to the
depth. [“Original image
published in Cir. Plast.
Iberolatinoam, 2016,
45(2):149–156 and
reproduced with
permission”]
Finally, we nished our study, with the most important nding of all at the level
of surgical anatomy, represented by the discovery of an intramuscular anatomical
space of the gluteus maximus muscle, located deeply as a virtual space, between the
supercial and deep fascicles of said muscle, not described in the world literature,
and that we come to call as “FROD Intramuscular Space” [23] (Fig.1.20).
In the descriptive anatomy part, we report that the gluteus maximus muscle,
thick and quadrilateral, after its strong tendinous origin at the level of the iliac crest
and posterior area of the external iliac fossa, sacrococcygeal crest, posterior sacroiliac ligament and sacrotuberous ligament, is directed laterally to end up inserting
through a thick muscle bundle of approximately three-quarters of the total
thickness of the muscle, in the fascia lata or iliotibial tract, and also through
another thin bundle of more or less a quarter of the total thickness, in the
26
a
LTES
Fig. 1.20 “FROD
Intramuscular Space”:
located deeply as a virtual
space, between the
supercial and deep
fascicles of said muscle,
not described in the world
literature
DEEP FASCICLE OF THE
GLUTEUS MAXIMUS
(1/4 OF THICKNESS)
SUPERFICIAL FASCICLE
OF THE GLUTEUS
MAXIMUS
(3/4 OF THICKNESS)
F. R. Garcia
b
SUPERFICIAL FASCICLE
THE GLUTEUS MAXIMUS
FEMORAL CREST
OR GLUTEAL CREST
ILIOTIBIAL TRACT
DEEP FASCICLEOF THE
GLUTEUSMAXIMUS
Fig. 1.21 (a, b) Gluteus maximus muscle, with its medial origin and two different lateral insertions, through two independent fascicles (supercial and deep), totally identied
gluteal crest of rough femoral line [25] (Fig.1.21). And it is precisely at the site
of the smooth crossover of the bers or muscle cords of the two above mentioned
fascicles, where this virtual space is located that after nding it and digitally
dissecting it, we turn it into real without the presence of brous partitions or nervous vascular structures important, ideal for making the implant pocket in gluteal
augmentation surgeries. It is a clean, deep, safe space, approximately 8–10cm in
diameter, which allows it to be easily expanded in its periphery according to the
size of the base or volume of the implant to be placed (Fig.1.22). Its location and
entry point is made relatively easy and simple through a parasacral muscular
approach incision, which also allows the making of two pillars (upper and
lower), in their entry line to the intramuscular space, which in turn prevent the
implant moves toward the midline, and can produce an extrusion of the prosthesis
or a pressure suture dehiscence (Fig.1.23).
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
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Fig. 1.22 Margins of
FROD’S intramuscular
space
Fig. 1.23 Upper and lower
pillar of FROD’S
intramuscular space.
[“Original image published
in Cir. Plast. Iberolatinoam,
2016, 45(2): 149–156 and
reproduced with
permission”]
27
In addition, these intramuscular spaces of FROD, together with the subfascial
space recommended by Dr. De la Peña [32], and the submuscular space recommended by Dr. Robles [35], are spaces that allow complete visualization during
surgery (Fig.1.24), which provides peace of mind, security, and less possibility of
complications during the trans and post-operative period. This novel anatomical
nding of the intramuscular space of FROD is currently presented in our specialty
of plastic surgery as a good and attractive surgical alternative, for all colleagues who
have ventured into this motivating territory yet to be fully understood, of gluteal
augmentation surgery with implants for its easy access and for its many advantages
during the trans and post-operative period of this type of surgery (Fig. 1.25).
We nish this interesting chapter of Modern and integral anatomy of the gluteal
region leaving in all the colleagues and fans of human anatomy a new concern about
28
Fig. 1.24 FROD’S
intramuscular space, allow
complete visualization of
the pocket during surgery,
which provides peace of
mind, security and less
possibility of
complications during the
post-operative period
F. R. Garcia
a b
Fig. 1.25 (a, b) Implant being easily placed in FROD’S intramuscular space, observing its many
advantages. [“Original image published in Cir. Plast. Iberolatinoam, 2016, 45(2):149–156 and
reproduced with permission”]
the possible morphological classication of the gluteus maximus muscle, as a
bicephalic muscle, with a broad and strong tendon in its medial origin and two different lateral insertions, through two independent fascicles (supercial and deep),
totally identied and with different functions, similar to the morphology of the
biceps or triceps brachii muscle or even the biceps or quadriceps femoral muscles,
which present a tendon strong and single of distal origin, and two, three, or four
heads or muscular portions respectively, with different proximal attachments and
varied functions. Therefore, we could begin to classify and name the gluteus
maximus muscle, as the coxae biceps. Already in the region there is the coxae
triceps, formed by the two gemini muscles (superior and inferior), and the internal
obturator, whose three tendons fuse to join together on the internal aspect of the
greater trochanter (trochanteric fossa).
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F. R. Garcia
Chapter 2
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The Buttocks: Anthropologic andCultural
Evolution
ChrisKhorsandi
Dear Reader, you have chosen to educate yourself regarding the concept of Gluteal
Aesthetics. Contained in the following chapters is a collection of writings on the
current state of the art. The masterful authors contained herein, have endeavored to
elucidate their thoughts and techniques in this eld for the benet of all patients. A
debt of gratitude is owed to these individuals.
To begin this text, one must not simply ask how to proceed with performing
treatments to enhance the look of an individual’s buttocks, but why one should do
so in the rst place. For simply learning to do something without understanding why
we do it, is a disservice to the essence of being a surgeon. So it must be asked: why
do we want to make buttocks look different. Why do we choose to enlarge them, lift
them, and sculp them into forms that are not inherent to the presenting patient. To
understand this, we must rst understand that this concept of enhancing a person’s
buttocks is nothing new. Furthermore, the buttocks has held a place as the object of
desire, and even reverence, as far back as some of the earliest known human records.
Archeological evidence, some 40,000years old, demonstrate that even in the
earliest civilizations, attention to the female form evoked emotion and inspiration.
Statues contemporarily referred to as the “venus statues,” provide evidence for this.
These miniature statues found as far north as Siberia and from the Iberian Peninsula
to the Middle East, unmistakably demonstrate human kind’s fascination with the
female buttocks. The most famous of these, the Venus of Wellendorf demonstrates a
female form with enlarged breasts, a rotund stomach, and generous backside. Yet it
is the Venus of Moruz, dated to about 11,000years ago, which creates the most stylized form of a gluteal admiration. This black lignite stone pendant is devoid of arms,
a face, or any distinguishing features other than a curved, projected buttocks.
Who were these artists? What were these statues were used for? Whether they
were religious relics, fertility totems, satirical depictions, or otherwise, we may
never know. However, it can be said that human beings do not give attention to
C. Khorsandi (*)
Henderson, NV, USA
© 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_2
31
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