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D. Del Vecchio
the anticipated liposuction volume, volume and location of transplanted fat, anesthesia route, facility type, and the patient’s overall health status.
The management of the postoperative period is critical to the outcome of
BBL.Qualied staff provide the appropriate post-anesthesia and postoperative care.
Particularly in larger-volume cases, management of uid and electrolyte balance,
pain management, and monitoring for complications are important and the use of
home-monitoring devices shows early promise as future potential standards of care.
Research ndings over the past 6years have demonstrated safe and unsafe anatomic depths to transplant fat in the gluteal region. With the advent of a practical
ultrasonic technique that is time-efcient, surgeons can now safely and accurately
reach the correct depth to insert fat. With this nal breakthrough, we expect BBL
mortality rates to drop over time, commensurate with or better than those of abdominoplasty and liposuction.
When performed by a surgeon with a thorough knowledge of the pathophysiologic implications of this surgery, and by a surgeon who understands and respects
his or her own physical and cognitive limitations, gluteal fat grafting can be a safe
procedure that results in signicant patient satisfaction.
References
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4 Practice Advisory onGluteal Fat Grafting
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technique for patient assessment after radiofrequency assisted liposuction and gluteal fat transfer. Submitted for publication. Aesthet Surg J. 2022.
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31. What is awake Brazilian butt lift? https://millardplasticsurgery.com/liposuction- info/awake-
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D. Del Vecchio
Chapter 5
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Real Time Intraoperative Ultrasound
Guidance Can Make Any Gluteal Fat
Grafting Procedure Safe
PatPazmino
5.1 Introduction
Gluteal contouring and augmentation has proven to be a powerful and extremely
popular addition to the body contouring armamentarium of the plastic surgeon.
This has been driven largely by patient demand as over the last 10–20 years society’s ideals of beauty have continued to expand. Beautiful is now possible at any
size and in many shapes. Patients are specically requesting fuller hips and buttocks
both as stand alone procedures, and to complement other breast and body contouring surgeries [1–4].
It is possible to emphasize gluteal contours with liposuction and fat extraction
alone. Mild asymmetries and depressions can also be effectively corrected with fat
separation and fat shifting [5–7]. However, true gluteal augmentation can only be
done with fat grafting.
Gluteal augmentation with fat grafting has been proven to be effective in the
plastic surgery literature and memorialized by patients and surgeons throughout
social media [2, 8]. This is a powerful technique, but it must be performed cautiously.
Over the last 10 years, there has been an excessively high number of complications and patient deaths after gluteal fat grafting. Fat pulmonary emboli are the
most common fatal complication that can occur when fat grafting is performed
intramuscularly into the gluteus maximus and the fat graft is inadvertently injected
into the gluteal veins [3, 9–11]. The now intravascular fat graft travels to the heart,
lungs and brain with fatal results. Deaths from fat pulmonary emboli have occurred
throughout the world, but in the United States, South Florida has been the epicenter
of these tragedies. In the last 10 years, in South Florida alone, 20 deaths from fat
P. Pazmino (*)
Division of Plastic Surgery, University of Miami, Miami, FL, USA
e-mail: ultra@miamia.com; dr@miamia.com
© 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_5
67
68
P. Pazmino
pulmonary emboli have been identied by the Medical Examiner of Miami Dade
County [12]. The postmortem results conrmed a two hit hypothesis for this fatal
complication: fat must be injected into the muscle and a gluteal vein injury must
occur. These events most commonly happen when fat is injected into the gluteus
maximus or deeper muscles and the fat grafting cannula inadvertently injures the
gluteal veins, creating an opening for the fat graft to enter the venous system with
fatal results [3].
These autopsy results were reviewed by the Multi-Society Task Force for Safety
in Gluteal Fat Grafting (Rubin, Mills, Saltz, etal) as they designed cadaver research
to further study this issue. The Task Force was able to delineate the vascular gluteal
danger zone and describe safer cannula angles and lengths to avoid these injuries.
The Task Force issued guidelines for safe gluteal fat injection which included constant vigilance of the cannula tip during fat grafting, a rigid cannula system, and
most importantly to avoid intramuscular fat injection by staying above the deep
gluteal fascia that lies on the external surface of the gluteus maximus at all times [13].
The South Florida surgeons who had the fatal fat pulmonary emboli mortalities
used different fat graft volumes, different patient positions, different access incisions, and different cannula styles, but the one factor all of these deaths had in common was that every surgeon insisted that they were subcutaneous and above the
deep gluteal fascia at all times. Unfortunately, the autopsies disagreed [14]. The
South Florida experience demonstrates that surgeons currently do not have a consistent and reliable way to always know the position of their cannula tip during gluteal
fat grafting. Furthermore, surgeons have no way to prove that they only injected fat
subcutaneously and to document that they never injected fat into the gluteal muscles
to protect themselves for medicolegal reasons.
It is because of the possible dangers with this procedure that plastic surgeons
must not abandon gluteal fat grafting. Gluteal fat grafting is a powerful tool that can
augment tissue, correct deformities, and create impressive results that cannot be
produced any other way. Because of this, high patient demand for this procedure
will continue. If board certied plastic surgeons stop performing this procedure,
interested patients will simply go to the non board certied practitioners who have
had the majority of the complications (Lew 2018) and even more deaths will occur.
As researchers and patient advocates, plastic surgeons must study this technique
and determine how gluteal fat grafting can be performed safely and consistently.
Ultrasound can help plastic surgeons achieve these goals. Ultrasound can be used
to evaluate the thickness and quality of the subcutaneous envelope pre-operatively.
In the last 3 years, ultrasound equipment has become portable, wireless, and affordable opening the door for its use in the sterile eld of the OR. Ultrasound visualization can be used with any cannula style or injection system [15]. Real time
intraoperative ultrasound visualization can help the surgeon perform fat harvesting
and accurate fat grafting into the unique spaces of the subcutaneous region. This
will not only make for a safer surgeon, but a better surgeon—a surgeon who can
manipulate subcutaneous anatomy not appreciable without ultrasound.
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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69
5.2 Gluteal Anatomy andUltrasound
Ultrasound can help us accurately analyze and measure the unique subcutaneous
anatomy of each individual patient. The pelvic bony framework, gluteal muscles,
gluteal fat, and skin have been well described in the plastic surgery literature [2, 16,
17]. Cadaver dissections have actually identied two gluteal fascias (Fig.5.1).
The external surface of the gluteus maximus muscle is covered with a fascial
plane, the deep gluteal fascia. The Multi Society Task Force has recommended surgeons never place fat graft under the deep gluteal fascia [9, 13]. However, there also
exists a second fascial layer (the supercial gluteal fascia) within the subcutaneous
zone above the deep gluteal fascia and below the dermis. The supercial gluteal
fascia is thick, impregnated with fat and can only be appreciated in an open dissection or with ultrasound visualization.
The supercial gluteal fascia is part of the supercial fascial system of the trunk
and is analogous to Scarpa’s fascia in the abdomen. The supercial gluteal fascia
divides the subcutaneous zone into two subcutaneous spaces: the supercial subcutaneous space (between the dermis and the supercial gluteal fascia) and the deep
subcutaneous space (between the supercial gluteal fascia and the deep gluteal fascia) [18] (Fig.5.2).
Fig. 5.1 Transverse cross section of female buttocks. The deep gluteal fascia (green) lies on the
external surface of the gluteus maximus muscle. The supercial gluteal fascia (yellow) is above the
deep gluteal fascia and below the dermis and divides the subcutaneous region into two spaces
70
Fig. 5.2 Transverse cross section of female buttocks. The supercial gluteal fascia divides the
subcutaneous region into two spaces. The supercial subcutaneous space (yellow) is below the
skin and above the supercial gluteal fascia. The deep subcutaneous space (green) is below the
supercial gluteal fascia and above the deep gluteal fascia. Ultrasound allows the surgeon to accurately enter each space and manipulate it while always remaining above the deep gluteal fascia
P. Pazmino
It is important to remember that the entire subcutaneous zone (including both the
supercial and deep gluteal spaces) ranges in thickness from 1cm (outer hips) to 3
to 4cm (central gluteal dome). This means that gluteal surgeons must graft in a thin
space under a curving dome of varying thickness. This small variable target may
account for the inadvertent deep intramuscular injections by well intentioned surgeons grafting without ultrasound visualization.
More important clinically, if the supercial gluteal fascia remains intact, it can
retain the fat graft that is specically injected above or below it, like the casing of
a sausage. Fat graft injected into the deep subcutaneous space (above the deep
gluteal fascia and below the supercial gluteal fascia) can create excellent volume
and central dome projection, similar to a subfascial implant. Fat graft precisely
injected into the supercial subcutaneous space (above the supercial gluteal fascia and below the skin) can correct supercial contour deformities and depressions. The consistent accurate injection of fat graft to either the supercial or deep
subcutaneous spaces can only be performed with real time intraoperative ultrasound visualization.
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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A surgeon can use real time intraoperative ultrasound to not only avoid an intramuscular fat graft injection but to accurately target fat graft into the supercial or
deep subcutaneous spaces. Neither of these techniques is possible without ultrasound. Real time intraoperative ultrasound guided gluteal fat grafting can not only
make fat grafting safer but much more powerful and accurate as well.
71
5.3 Preoperative Assessment
Like all plastic surgery, careful pre-operative assessment and planning before gluteal contouring and fat grafting is essential. The surgeon should sit with the patient
to understand their goals, priorities, and areas of importance. Asymmetries must be
identied before surgery and a discussion should be held about the pre-operative
shape of the patient’s waist, hips, buttocks, thighs, and back. The surgeon should
ask what kind of shape the patient would like and understand how the patient would
like to specically change their waist, hips, point of maximum hip projection, buttocks, thighs, and back. Within each anatomic zone, the bony framework the muscles, fatty layer, and skin should be assessed to determine how each of these
components affects the contour. Ultrasound can be used to determine the thickness
of the subcutaneous envelope in each region and plan the quantity and location of
the fat graft in each subcutaneous space as well as any areas of adhesion that should
be released.
Digital imaging is helpful to show the patient the effects of liposuction, fat shifting, and fat grafting. It is even more useful in managing expectations and showing
the patient what is not possible. If the patient has requested a very large volume
result but has thin subcutaneous compartments, digital imaging can illustrate what
is reasonable and safe and open a discussion on staging the procedure. Patients
interested in large volume results that would be best served with staged procedures,
can be shown where fat can be left undisturbed and ready for harvest in a second
round of fat harvest and grafting.
Once the nal operative plan has been decided, the surgeon should discuss the
recovery, expected fat resorption rates, and limitations on post-operative activity.
5.4 Surgical Equipment andSet Up
5.4.1 Intraoperative Ultrasound Systems
Over the past 8 years, six different ultrasound systems have been used with gluteal
fat grafting. Real time intraoperative ultrasound can be used with any cannula or
liposuction/fat grafting system. This technique is most comfortably performed
72
P. Pazmino
when the operating surgeon is controlling the fat graft cannula with their dominant
hand and the ultrasound probe with their non-dominant hand. However, when a
syringe fat grafting system is used, both of the surgeon’s hands are occupied. One
hand must hold the syringe while the other hand pushes the plunger to inject the fat.
In this scenario, the surgical assistant or scrub tech must control the sterile ultrasound probe, making coordination with the injecting surgeon difcult. To allow the
surgeon to control the fat grafting system and the ultrasound probe simultaneously,
a power assisted liposuction system (PAL, MicroAire Charlottesville, VA) is used in
conjunction with a peristaltic pump for controlled propulsion of the fat graft. In this
manner, the surgeon can inject fat via expansion vibration lipolling [19] with the
dominant hand and control the ultrasound probe with the non-dominant hand.
Currently, one of two ultrasound systems is being used for real time intraoperative ultrasound: the Clarius Ultrasound (Clarius, $4000) or the Buttery iQ
(Buttery, $1999 with $420 annual subscription). The Clarius is a 4–15MHz high
frequency, portable, waterproof, wireless linear ultrasound probe (maximum depth
of 7cm) that can be placed entirely in a sterile probe cover and can stream via WiFi
a high resolution ultrasound video to Apple iOs or Android tablets. Both systems
will upload their data to the cloud so that ultrasound still images and video can be
accessed on a computer or added to a patient chart (Figs.5.3 and 5.4).
Fig. 5.3 The Clarius
ultrasound probe is a
4–15MHz high frequency
linear L7 portable,
waterproof, wireless
ultrasound probe
(maximum depth of 7cm)
that can be placed entirely
in a sterile probe cover and
can stream a high
resolution ultrasound video
to Apple iOs or Android
tablets
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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Fig. 5.4 The Buttery iQ
ultrasound probe is a new
generation probe that uses
microchips rather than
piezoelectric crystals to
generate and interpret
ultrasound waves. This is a
wired system that is
currently compatible with
iOs devices
73
5.5 Surgical Technique
Liposuction of the torso and fat grafting to the gluteal areas and hips is designed to
be an outpatient procedure performed under general anesthesia. Specic types of
anesthesia do not effectively protect the patient from fatal complications such as fat
pulmonary emboli. What does protect the patient is ensuring that there is no intramuscular fat injection. Ultrasound visualization can continuously conrm the real
time position of the cannula tip and keep the patient safe. The ultrasound guided
gluteal fat grafting is performed under general anesthesia to facilitate comfortable
controlled extraction of deep and supercial fat and for maintenance of the airway
when the patient is in the prone position.
5.5.1 Liposuction andLiposculpture
The anatomic endpoint of liposuction should be to achieve a consistent thickness of
the skin fat ap throughout the torso and to ultimately create the specic anatomic
shape the patient requested. This process begins before surgery when the skin and
fat thickness in all treatment areas are assessed and asymmetries are highlighted. A
strategy should be in place to differentially remove fat until the ap has a consistent
thickness.
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