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422
G. Ramos-Gallardo et al.
There is an increase of reports about mycobacteria infections in medical tourism
[18]. It is important to maintain suspicion with a patient that arrives with infection
after been operated in another country.
Another possible cause of mycobacteria infection is from the injection of an
unspecied substance in unauthorized stores as spas and gyms. Patients may be
injected months before the surgery. Once the fat has been harvested the mycobacteria is inoculated in the gluteus [19]. It is important to ask the patient about any possible treatments to lose weight and improve shape. As well important information of
injections of other types of substances in order to improve the shape of the buttock
should be documented [20]. If suspicion of injection of mineral oil or other substances is high, it will be important to discuss the possible complications with the
patient from high risk of infection to embolism.
29.2.2 Seroma andFat Necrosis
Seroma is more common in the zone where fat is harvested [13]. We have decreased
the risk of seroma with the use of drains and compression with a lap pad as soon as
the surgery has nished for 5days. If seroma persists, direct aspiration can improve
this problem. Compression with pressure of a lap pad and compression garments
should help to decrease and improve this situation. Also, the use of a closed system
for drainage should be considered. Advantages are a more objective quantication
of volume of drainage, more control over spillage of blood, and also less contamination (Figs.29.3 and 29.4).
Seroma is multifactorial phenomena related with lymphatic disruption and nonviable tissue or fat debris [21, 22]. Equipment related with this procedure as laser
can decrease the inammation and swelling but it should be carefully monitored
during the procedure (Figs.29.5 and 29.6).
Fig. 29.3 Infected case of
gluteoplasty
ab
29 Infection intheOperated Buttock
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Fig. 29.4 (a, b) Adequate debridement and VAC placement
Fig. 29.5 Infected case of
fat grafting with
mycobacteria
423
424
Fig. 29.6 First
postoperative day of
liposuction buttock fat
injection. Redness, edema,
and inammation.
(Recovered without any
complication)
G. Ramos-Gallardo et al.
Minor drainage of liqueed fat has been reported. In our experience in the last
years this phenomenon has not been seen. Absence of signs of infection and cultures
can help to rule out contamination by bacteria. Reabsorption of fat is expected [23].
Recent reports in animals have seen similar survival of fat in the subcutaneous tissue as well as the muscle. We have conducted studies in pigs where fat in deposits
of 60cc has survived in the subcutaneous tissue. More evidence is required. Good
surgical and realistic planning that combine liposuction in the lower back plus fat
injection in the hips and gluteus can obtain better results with less complications.
29.3 Conclusion
Complications related with infectious disease in gluteoplasty can be a difcult problem to handle. Meticulous procedures should be encouraged. Gram negative and
staph are the most common organisms involved. In case of fat grafting serious and
devastating consequences can appear with an infection. The failure of a sterilization
process can cause severe and fatal complications. Mycobacteria infections are difcult to diagnose and to treat with long-lasting antibiotic treatment with multiple
surgical procedure required. Implants procedures should be done following the
same principles as for breast implants. Seroma can predispose dehiscence of the
surgical incision and exposure of the implant. An implant that is exposed should
consider the removal and replacement after a 6month period.
29 Infection intheOperated Buttock
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425
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6. Ramos-Gallardo G, Medina-Zamora P, Cardenas-Camarena L, et al. Where does the transplanted fat is located in the gluteal region? J Invest Surg. 2019;32(3):228–31.
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8. Deva AK, Adams WP Jr, Vickery K.The role of bacterial biolms in device-associated infection. Plast Reconstr Surg. 2013;132(5):1319–28.
9. Oishi N, Miranda RN, Feldman AL.Genetics of breast implant-associated anaplastic large cell
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12. Cuenca-Pardo JA, Ramos-Gallardo G, Contreras-Bulnes L. Factores relacionados con las
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13. Fischer JP, Wes AM, Serletti JM, Kovach SJ.Complications in body contouring procedures:
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surgical quality improvement program databases. Plast Reconstr Surg. 2013;132(6):1411–20.
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gluteal deformities: a systematic review and experience of four cases. J Plast Surg Hand Surg.
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16. Cusumano LR, Tran V, Tlamsa A, Chung P, Grossber R, Weston G, Sarwar UN.Rapidly growing mycobacterium infections after cosmetic surgery in medical tourists: the Bronx experience
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17. Ruegg E, Cheretaks A, Modarrest A, Harbarth S, Pittet-Cuenod B.Multisite infection with
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18. Ramos-Gallardo G.How I can suspect of mycobacteria infection in breast implant surgery.
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19. Zhang J, Lui L, Liang L, Bai X, Chen M. Mycobacterium avium infection after acupoint
embedding therapy. PRS Glob Open. 2017;5(9):e1471.
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G. Ramos-Gallardo et al.
Chapter 30
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Secondary Defects oftheButtock
AlvaroCansanção andAlexandraCondé-Green
30.1 Background
Gluteal fat grafting, also known as Brazilian Butt Lift was rst presented by Raul
Gonzales [1] at the 1984 ASAPS meeting in Hawaii and was published in 1986.
Gonzales then started to use intramuscular gluteal implants since he did not achieve
the results he expected with fat grafting. In 1985, Luiz Toledo [1] started injecting
larger amounts of fat to the face and body, up to 450mL to each buttock and published his results in 1988.
Gluteal fat grafting became very popular in Brazil and in other Latin American
countries in the early 1990s, but was initially met with skepticism in North America
and Europe. This started to change in the beginning of the second decade of the
twenty-rst century with the popularity of Latin celebrities in the USA, showing the
importance of the buttocks in the woman sexuality. The popularity of the Brazilian
Butt Lift started to grow, making gluteal fat grafting a hot topic and the surgery with
the fastest growth in demand in the world [2].
This popularity was further increased because the results were great, there was a
relatively quick recovery, and low number of complications [3].
From there, internationally renowned plastic surgeons began to improve the surgical technique adapting it to the beauty standards of different populations and ethnic groups.
A. Cansanção (*) · A. Condé-Green
Hospital da Plástica, Rio de Janeiro, RJ, Brazil
Private Practice, Boca Raton, FL, 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_30
427
428
A. Cansanção and A. Condé-Green
30.2 Causes ofSecondary Defects totheButtocks
Despite the low incidence of reoperations in gluteal fat grafting, there are causes
that can lead to unsatisfactory results.
For didactic purposes, we can divide the causes of reoperation in gluteal fat grafting into three groups:
1. Surgeries scheduled to be performed in two steps.
2. Surgeries with poor surgical planning.
3. Surgical complications.
30.2.1 Surgeries Planned tobePerformed inTwo Steps
Besides the increase in demand for gluteal fat grafting, we observed an increase in
the complications ratio, especially deaths [2].
In order to understand the cause of deaths and address safety measures, an international multi-society task force was created. This task force made a series of recommendations to make gluteal fat grafting safer [4]. One of them was to avoid
large-volume fat grafting to the buttocks and if a large volume was desired, the
surgery should be divided into two stages [5].
This recommendation generated controversy, since no study had found scientic
evidence that large-volume fat grafting increased the risk of death [6–8].
Still, many surgeons started to perform gluteal fat grafting in two stages in order
to increase safety or to avoid legal problems.
30.2.2 Surgeries withPoor Planning
Poor surgical planning is the main cause of reoperation in gluteal fat grafting.
Secondary surgery can occur for several reasons:
30.2.2.1 Incorrect Identication ofthePatients’ Dissatisfaction
For many years, gluteal surgery was neglected and not thought in plastic surgery
training. It is common to see young plastic surgeons nish their training without
having performed and often not even seen any gluteal fat grafting or gluteal implant
surgery [7].
Many experienced plastic surgeons are well aware of the beauty criteria and
anatomy of the breasts, abdomen, and face, but they are not accustomed to the
beauty criteria and anatomy of the gluteal region and are often unaware of the different patterns of gluteal beauty in different ethnic groups [9] (Table30.1).
30 Secondary Defects oftheButtock
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Table 30.1 Main characteristics of each buttock shape according to patients’ ethnical and cultural
preferences
Buttocks:
characteristics X
shape
Caucasian
(Type I)
Caucasian
(Type I)
African descent As full as
Hispanic Very full
Asian Small
(Need permission from: Cansanção A, Condé-Green A, Vidigal RA, etal.: Gluteal Fat Injection
Standardization: The Gluteal Codes. in A. Cansanção, A. Condé-Green (eds.), Gluteal Fat
Augmentation, Best Practices in Brazilian Butt Lift. Springer Nature Switzerland 2021:119–127)
Buttock
size
Full
Projected
Not
extremely
large
Full
Projected
Not
extremely
large
possible
Not as
much as
African
descent
shaped
Lateral
buttocks
fullness
Athletic
shape
Lightly
rounded
Rounded No lateral
Very full Lateral
Very full
Not as
much as
African
descent
No No 60/40% 3:2:1:1:1
Lateral
thigh
fullness
No lateral
thigh
lling
thigh
lling
thigh very
full
Slight
fullness
Gluteal volume
distribution
superior/inferior
60/40% 3:2:1:1:1
60/40% 3:2:2:1:1
50/50% 3:2:2:2:1
60/40% 3:2:2:1:1
Proportions of fat
between gluteal
subunits
429
Not knowing the purpose of the surgery and where we have to intervene on the buttocks, is the rst step toward unsatisfactory results and unsightly and defective buttocks.
30.2.2.2 Asymmetry Caused by Lack ofStandardization oftheFat
Injection Technique
A second cause of poor surgical planning is due to the surgeon’s inexperience and
the lack of standardization of the fat injection technique. In some cases, even when
the same amount of fat is injected in each buttock, it can be placed in different portions of the buttocks leading to asymmetry. When fat grafting used to be performed
intramuscularly, these cases of asymmetry were less frequent. This can be explained
by the fat migration theory proposed by Del Vecchio [10], who claims that the fat
injected into the muscle migrates to other areas of the muscle, thus augmenting the
whole buttock. With the current recommendation of subcutaneous only gluteal fat
augmentation, the injection of fat should be done in a more standardized way, in
order to reduce the occurrence of asymmetry.
The gluteal fat injection standardization created by the authors, known as Gluteal
Codes [11] can be very helpful to surgeons that are beginning to perform gluteal fat
grafting.
430
A. Cansanção and A. Condé-Green
The concepts of this technique are
– The division of the buttock in ve aesthetic subunits. When fat is injected in
small areas, it is easier to reproduce in the contralateral side (Fig.30.1).
– The creation of preestablished proportions to perform gluteal augmentation in a
customized fashion makes it possible to achieve the desired outcomes according
to the ethnic standards of beauty.
Fig. 30.1 The gluteal
region is divided in ve
gluteal aesthetic subunits:
subunit C (central) in red,
subunit S (superior) in
blue, subunit L (lateral) in
yellow, subunit I (inferior)
in purple, and subunit M
(medial) in green. (Need
permission from:
Cansanção A, CondéGreen A, Vidigal RA,
etal.: Gluteal Fat Injection
Standardization: The
Gluteal Codes. in
A.Cansanção, A.CondéGreen (eds.), Gluteal Fat
Augmentation, Best
Practices in Brazilian Butt
Lift. Springer Nature
Switzerland
2021:119–127)
30 Secondary Defects oftheButtock
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431
30.2.2.3 Poor Assessment oftheAmount ofFat Available
Failure to identify that the patient does not have enough fat to perform a Brazilian
Butt Lift can lead to poor outcomes and dissatisfaction. In cases of small amount of
fat available, other procedures might be proposed to patients such as gluteal augmentation with implants or a hybrid augmentation (implant + fat) [12].
30.2.2.4 Poor Assessment oftheAmount ofSkin Laxity
Failure to identify that the patient has excess skin laxity, which is unlikely to be
lled with fat only, can also be a cause of dissatisfaction and lead to secondary procedures, especially in post massive weight loss or older patients. In these cases,
performing a body lift with its pros and cons has to be discussed with the patient [12].
30.2.2.5 Presence ofCellulite or Gluteal Ligamentous’ Retraction
When we studied the anatomy of the gluteal subcutaneous tissue, we observed the
presence of fasciocutaneous and osseocutaneous ligaments, as well as fascial septae
emerging from the gluteal maximus muscle fascicles and attaching to the skin. All
of these structures have a support function [13–16]. When there is a retraction of
these ligaments, the skin where these ligaments attach is trapped, and does not
expand with the increase in the thickness of the adipose tissue causing deformities
similar to cellulite.
In these areas, Subcisions™ need to be performed to release these ligaments
[17], and allow the skin to expand so that the buttock can have a smoother, harmonious, and regular shape (Fig.30.2).
30.2.3 Surgical Complications
30.2.3.1 Fat Absorption
The absorption of part of the injected fat is not considered a complication since its
occurrence is expected. When injected following the principles enshrined in the
scientic literature, it is expected that around 18% of the fat injected will be absorbed
[18]. However, sometimes this absorption ratio may be higher than expected, due to
other steps in the fat grafting procedure (harvesting, processing, or injection) or due
to lack of care in the postoperative period.
This higher absorption ratio can lead to unsatisfactory results or asymmetry
when the absorption of fat is greater in one buttock than in the other. When fat
absorption is higher than expected in the whole gluteal region or in a specic area,
a secondary surgery can be done to inject fat in these specic areas.
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