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ac
A. Cansanção and A. Condé-Green
b
Fig. 30.2 Subcsion® procedure to release retracted fasciocutaneous ligaments. (a) Preoperative
view of a secondary defect to the buttock caused by a retracted fasciocutaneous ligament not
treated in the rst gluteal fat grafting procedure. (b) Subcision
®
performed with a 18G needle. (c)
Immediate postoperative view
30 Secondary Defects oftheButtock
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30.2.3.2 Oil Cysts andFat Necrosis
When a part of the injected fat does not survive, the dead adipocytes can turn into
oil. This oil can accumulate in oily cysts, which are often small, with no clinical
repercussion. Sometimes, they can form large oily lakes with cellular debris that can
serve as a culture medium and can lead to infection [19].
Small oily cysts can be treated conservatively, with regular clinical and radiological monitoring (Fig.30.3). However, large oily cysts must be drained using a
blunt cannula guided by ultrasound to prevent contamination of the material and
formation of a gluteal abscess. These abscesses can be serious and lead to sepsis and
necrotizing fasciitis that can culminate in death. When faced with these bulky oily
cysts, if the drainage is done correctly, the risk of contamination and the formation
of abscess are low. However, they may result in aesthetic deformities that must be
addressed in a secondary surgical procedure with additional fat grafting.
Fig. 30.3 Small and asymptomatic oily cyst in the buttocks identied by ultrasound (1year
post-op)
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A. Cansanção and A. Condé-Green
30.3 Conclusion
Gluteal fat grafting is a safe procedure with high satisfaction rates when performed
by experienced plastic surgeons. However, numerous causes can lead to unsatisfactory outcomes that can result in secondary defects in the gluteal region. Every surgeons interested in this type of surgery must be attentive to avoid, or at least decrease
the chance of unwanted events that can lead to unsatisfactory results in this region
of the body that is important to women sexuality.
References
1. De La Peña JA, Gallardo GJ.History of gluteal fat grafting. In: Cansanção A, Condé-Green A,
editors. Gluteal fat augmentation, best practices in Brazilian butt lift. Cham: Springer Nature;
2021. p.157–60.
2. American Society of Plastic Surgeons. Plastic surgery statistics. 2016. https://www.plastic-
surgery.org/documents/News/Statistics/2016/plastic- surgery- statistics- fullreport- 2016.pdf.
Accessed 13 Jan 2018.
3. Condé-Green A, Kotamarti V, Nini KT, etal. Fat grafting for gluteal augmentation: a systematic review of the literature and meta-analysis. Plast Reconstr Surg. 2016;138:437e–46e.
4. Mod MM, Teitelbaum S, Suissa D, etal. Report on mortality from gluteal fat grafting: recommendations from the ASERF task force. Aesthet Surg J. 2017;37:796–806.
5. Urgent warning to surgeons performing fat grafting to the buttocks (Brazilian Butt Lift or
BBL). https://www.surgery.org/sites/default/les/URGENTWARNING- TO- SURGEONS.
pdf. Accessed 24 July 2018.
6. Villanueva NL, Del Vecchio DA, Afrooz PN, etal. Staying safe during gluteal fat transplantation. Plast Reconstr Surg. 2018;141:79–86.
7. Cansancao AL, Condé-Green A, Rosique RG, etal. Brazilian butt lift performed by board
certied Brazilian plastic surgeons: reports of an expert opinion survey. Plast Reconstr Surg.
2019;144:601–9.
8. Cansanção A, Condé-Green A, Kalaaji A. Safety in gluteal augmentation. In: Cansanção A,
Condé-Green A, editors. Gluteal fat augmentation, best practices in Brazilian butt lift. Cham:
Springer Nature; 2021. p.157–60.
9. Roberts TL 3rd, Weinfeld AB, Bruner TW, etal. “Universal” and ethnic ideals of beautiful
buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plast Surg.
2006;33:371–94.
10. Del Vecchio DA, Villanueva NL, Raja M, etal. Clinical implications of gluteal fat graft migration: a dynamic anatomical study. Plast Reconstr Surg. 2018;142:1180–92.
11. Cansanção A, Condé-Green A, Vidigal RA, etal. Gluteal fat injection standardization: the gluteal codes. In: Cansanção A, Condé-Green A, editors. Gluteal fat augmentation, best practices
in Brazilian butt lift. Cham: Springer Nature; 2021. p.119–27.
12. Cansanção A, Condé-Green A.Strategy and planning of gluteal reshaping. In: Cansanção A,
Condé-Green A, editors. Gluteal fat augmentation, best practices in Brazilian butt lift. Cham:
Springer Nature; 2021. p.47–55.
13. Ghavami A, Villanueva NL, Amirlak B.Gluteal ligamentous anatomy and its implication in
safe buttock augmentation. Plast Reconstr Surg. 2018;142:363–71.
14. Cunha MG, Cunha ALG, Machado CA. Hypodermis and subcutaneous adipose tissue—two
different structures. Surg Cosmet Dermatol. 2014;6:355–914.
30 Secondary Defects oftheButtock
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15. Hexsel D, Siega C, Schilling-Souza J, etal. A comparative study of the anatomy of adipose
tissue in areas with and without raised lesions of cellulite using magnetic resonance imaging.
Dermatol Surg. 2013;39:1877–86.
16. Cansanção A, Condé-Green A, Viaro MSS. Anatomy of the gluteal region applied to the
Brazilian butt lift. In: Cansanção A, Condé-Green A, editors. Gluteal fat augmentation, best
practices in Brazilian butt lift. Cham: Springer Nature; 2021. p.29–35.
17. Hexsel D, Dini TDF, Hexsel CL.Subcision® for the treatment of cellulite. In: Cansanção A,
Condé-Green A, editors. Gluteal fat augmentation, best practices in Brazilian butt lift. Cham:
Springer Nature; 2021. p.251–7.
18. Cansancao AL, Condé-Green A, Vidigal RA, etal. Real-time ultrasound-assisted gluteal fat
grafting. Plast Reconstr Surg. 2018;142:372–6.
19. Ramos-Gallardo G, Durán-Vega HC, Cárdenas-Camarena L.Complications of gluteal fat augmentation. In: Cansanção A, Condé-Green A, editors. Gluteal fat augmentation, best practices
in Brazilian butt lift. Cham: Springer Nature; 2021. p.151–5.
Part VIII
Postoperative Management of Buttock
Chapter 31
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Drains inGluteal Augmentation
CarlosOaxaca
“Meticulous surgical technique and obliteration of dead space
eliminates the need for drains”.
—William Stewart Halsted
31.1 History ofDrains inPlastic Surgery
Hippocrates 370 BC described the use of cannulas. Celsus in the second century,
conical bronze tubes. Leonardo Da Vinci in the fteenth century described capillarity. Kellogs in 1885 and Heaton in 1889 described constant suction by means of
vacuum. And Penrose in 1890 and 1897 described the cylindrical tube. From here
began the evolution of drains to the more sophisticated ones used today.
31.2 Classication
There are simple passive drains without aspiration such as: Penrose, Kher tube,
Cistocath.
Active drains with aspiration such as Blake, Jackson-Pratt, Drenovac, etc.
The ideal characteristics of a drain, according to the postulate of Jackson and
Fleming in 1972 is that they should have a smooth and slippery surface, exible,
radio opaque to allow its identication, with reservoirs to collect secretions (blood,
serum), to be kept in place, of homogeneous consistency that allows its easy
removal.
These are xed with nonabsorbable suture, connected to a vacuum system, with
a wide exit orice to avoid obstruction.
C. Oaxaca (*)
Private Practice, Plastic Surgery, Leon, Gto., Mexico
© 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_31
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C. Oaxaca
31.3 Indications
The drains have specic indications such as avoiding hematoma or seroma besides
obliterating dead spaces, in the specic case of plastic surgery.
Among the main discomforts that are frequently asked in the preoperative consultation in buttock augmentation surgery is the placement of closed drains. In consensus, the majority of plastic surgeons, with wide experience in this procedure,
perform the placement of closed drains in the buttock, to subsequently assess the
daily cost and the characteristics of the same, in order to perform their removal in a
timely manner. However, in recent years, the trend of not placing them is increasing,
thus having a recovery with fewer difculties and discomfort for our patients, as
well as reducing the likelihood of infection at the surgical site secondary to the presence of them.
Multiple articles for different areas in aesthetic surgery mention the use of drains
necessary to avoid uid collection (seroma). For example, it is clear that, in abdominoplasty, the dissection is very wide and despite the placement of stitches that
decrease tension to the ap at the site of the wound, they also decrease the dead
space and in theory would decrease the possibility of drains, but they are still used
for this body area. Vinicius [1] in 2002 reports the need for drains also due to the
excessive use of electrocautery for hemostasis management, this could be another
factor for which an excessive amount of serum is produced in the postoperative
period, which does not happen in gluteal augmentation surgery.
Acosta [2] establishes that, preserving Scarpa’s fascia, reduced the expense and
time of drainage in the abdomen.
Awf A. Quaba [3] in the United Kingdom, in 2015, also established Scarpa’s
fascia preservation without the use of quilt sutures with reduced discomfort and low
rate of seroma complications.
Jefrey in 2016 [4] evaluated 75 studies comprising 7173 patients. Strategies to
prevent seroma were: use of closed drains, maintaining them until the outow was
minimal; use of ultrasound dissection instead of using electrocautery; dissection of
the abdomen above Scarpa’s fascia; ligating vessels with sutures or clips; use of
progressive tension sutures; use of brin, thrombin, or talc; immobilization of the
surgical site; use of compression garments, preventing seroma formation. In fact,
the use of sclerosants at the beginning of surgery increased the risk of seroma.
The ndings were that drains with a vacuum of 500–750mmHg resulted in fewer
seromas than drains with low vacuum (100–250mmHg).
Andrades etal. [5] found that post-abdominoplasty seroma is an inammatory
exudate and compared the drainage uid of patients with closed suction who developed seroma, against the uid collected from patients who did not develop seroma,
and in the former the characteristics of the uid were inammatory, with a lower
pH. These ndings suggested that transudation comes from damaged lymphatic
channels and exudation from inamed tissues and these two factors contribute to
seroma formation. Inammation of damaged tissues plays an important role in
seroma formation. One strategy to obliterate dead spaces and prevent traction forces
was the use of progressive tension sutures.
31 Drains inGluteal Augmentation
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Another situation that should be taken into account is the one mentioned by
Rincon [6] in 2018, regarding the albumin levels with the greater production of
liquid. In his study the patients presented levels below 4 g/dL, showed greater average of liquid through the drains; although this association was not statistically signicant, it is recommended the determination of albumins preoperatively.
Now, after having made these anatomical and physiological considerations in the
abdomen, regarding the possible causes of seroma, we know that in the gluteal area
it is very different due to the following aspects:
1. The implants are placed between the muscle space.
2. The dissection spaces are very limited.
3. The friction forces generated when smooth implants are placed are minimal,
compared to the textured surface implants used in the past, which had a high
tendency to seroma formation, even in late stages (after 1year).
4. Electrocautery dissection is not performed, since the dissection is blunt, which
leads to think that, since there is no thermal damage, the inammatory effect will
be lower.
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31.4 Objective
The objective of our study is to determine the indications and decide in which
patients we should or should not perform the placement of closed drains in primary
gluteal augmentation surgery and leave aside the protocol of always placing them,
even when there is no reasonable justication to do so, regardless of the clinical or
trans-surgical situation of our procedures in order to achieve the lowest percentage
of infection or dehiscence in our surgical site.
31.5 Drains
Drains can be made of rubber, plastic, or silicone. However, despite the different
types of drains, the care is similar.
Normally a drain should remain in place for a period of 3–7days.
31.6 Personal Experience
Fourteen patients were operated on from 2018 to 2020, ranging in age from 24 to
62years old. The average operative time was 2h. Physiological solution 1000mL
was inltrated plus 50mL of simple xylocaine plus an ampoule of epinephrine for
both gluteal regions, where 250mL were inltrated on each side.
442
In all cases hybrid augmentation with fat grafting was performed, with an average lateral area of 240mL per side. In some cases, due to depressions in the inferolateral area, 120mL were grafted. In addition, it is worth mentioning that smooth
prostheses were used in all cases. Only in the last four cases, drains were not placed.
These patients did not present seroma with follow-up at 6months. In the patients
that drains were placed [7], they were left 7–8 postoperative days, with an average
removal time of 5days, where the drainage was less than 50mL in the rst 3days,
being of hematic content at the beginning and serohematic the following day.
All patients wore a girdle from the immediate postoperative period and continued up to 1month day and night and another month during the day resting at night.
C. Oaxaca
31.7 Results
No patient where drains were not applied developed seroma with follow-up up to
6months postoperatively. Only two cases with supercial surgical dehiscence in the
upper area of the wound, which was repaired 5days after its presentation.
In two patients, due to pain at 4weeks and slight asymmetry, ultrasound was
performed, which ruled out the presence of seroma.
31.8 Conclusion
Although the use of drains has been described to avoid seroma or hematoma accumulation in breast reduction, breast augmentation, abdominoplasty, and buttock
augmentation, the current trend is to avoid their use.
In case of primary buttock augmentation surgery, which is performed with blunt
dissection with bayonet dissector, the presence of bleeding is veried under direct
vision, in addition to not using electrocautery or any other method of dissection
with thermal energy, which would generate greater tissue injury and therefore
greater inammatory process. The usefulness of prepared solution is to achieve
vasoconstriction effect. These two factors make the use of drains unnecessary,
which avoids the risk of infection at the site of placement and discomfort for the
patients.
The usefulness of the compression garment from the end of surgery is also an
important factor in reducing the risk of seroma. No signicant benet has been
demonstrated with the use of surgical wound drainage.
Finally, another factor to consider is that in case there is a seroma of long evolution, meaning longer than 6months, the possibility of anaplastic large cell lymphoma should be ruled out, as cases have already been reported in the literature. It
could be due to chronic inammation or secondary to malignant cell transformation. It could be due to the friction phenomenon of the textured implant, as a possible cause. So a seroma of long evolution should always be submitted to study and
request immunohistochemical evaluation with CD30 of the uid. Mendez in 2019
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443
[8] described the rst case of lymphoma in gluteus, with seroma of long evolution,
due to prosthesis placed 6years before.
References
1. Stojkovic CA, etal. Wound drainage after reconstructive and plastic surgery of the breast.
Cochrane Database Syst Rev. 2016;3:CD007258.
2. Costa-Ferreira A, Rebelo M, Silva A, etal. Scarpa fascia preservation during abdominoplasty:
randomized clinical study of efcacy and safety. Plast Reconstr Surg. 2013;131(3):644–51.
3. Costa J, Costa-Ferreira A, Rebelo M, Valença-Filipe R, Reis J, Silva Á, Amarante J.Scarpa fascia preservation during abdominoplasty: what’s the point? Plast Reconstr Surg. 2011;128(4):61.
4. Quaba AA, Conlin S, Quaba O.The no-drain, no-quilt abdominoplasty: a single-surgeon series
of 271 patients. Plast Reconstr Surg. 2015;135(751):751–60.
5. Janis JE, Khansa L, Khansa I.Strategies for postoperative seroma prevention: a systematic
review. Plast Reconstr Surg. 2016;138(1):240–52.
6. Andrades P, Prado A, Danilla S, etal. Progressive tension sutures in the prevention of postabdominoplasty seroma: a prospective, randomized, double-blind clinical trial. Plast Reconstr
Surg. 2007;120:935–46.
7. Mendez J Jr, Maykeh VA, Frascino LF, Zacchi FF.Gluteal implant-associated anaplastic large
cell lymphoma. Plast Reconstr Surg. 2019;144(3):610–3.
8. Rincon Rubio L, Cemborain-Valarino M, Gutiérrez-Barrozo KU, Gil-Masroua BG,
Bookaman-Salazar AM.Management of aspiration drainage in abdominal dermolipectomy in
post-bariatric patients. Cir Plást Iberolatinoam. 2018;44(1):37–45.
1
Drains in surgery case study: reduction of gluteal implant infection rates with use of retention
sutures.
Postoperatively patients were advised to not sleep in supine position for 3 weeks and avoid
pressure to the area. The 3 patients remained infection free at 2 days and weekly for 6 weeks and
6 months. The surgical drains were removed at 1-week follow-up visit or when drain output was
less than 30 mL in 24 h.
Buttock reshaping with intramuscular gluteal augmentation in an Asian ethnic group a 6-year
experience with 130 patients.
Because the pocket’s size must be an exact t for the implant and muscle dissection area, a
Jackson Pratt drain was introduced in the pocket and removed through a separate stab incision in
the infragluteal crease. The suction tubes were then positioned intramuscularly. The oval-shaped
smooth-surface silicon elastomer (Gusan Inc, Seoul, Republic of Korea; Fig.4) was then inserted.
We removed the Jackson Pratt drain 2 days postoperatively. Owing to our early drain removal
strategy, we often aspirated uid with an 18-gauge needle every 3–4 days.
We administered transamine (coagulant) for a week after drain removal and applied Accolate
for a month postoperatively.
Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients.
The use of drains was identied by 84.2% of respondents (n16), with the majority using drains
for 4 or more days (63.2%, n12).
Secondary gluteal augmentation: surgical technique and outcomes.
Each patient was discharged when vital signs were normalized, the drainage volume was
decreased, and pain and nausea were relieved. The Hemo-vac drain was removed when the drainage volume was less than 20 mL per 24 h.
Gluteal augmentation: technique, indications, and implant selection drains were not used.
Gluteal implant displacement: diagnosis and treatment drains are placed inside the supercial
pocket bilaterally. The subcutaneous layer and the skin are sutured.
1
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