Fat Injection From Filling to Regeneration

850
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 46-3
T e morning o surgery, the patient is photographed. T is must be a three-dimensional procedure: every
aspect o the buttock will look dif erent rom dif erent angles, so it is important to capture these views
preoperatively. T is also allows the surgeon to discuss the areas to be treated with the patient. T e pa-
tient is asked to rotate a ull 36 degrees, using quarter turns, so I can capture the ront and back rom
a variety o angles. Nine photographic positions are used, including the “diver’s” position, to assess the
triangular lower gluteal crease zone.

851
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Markings
Fig. 46-4
1
2
4
3
2
3
5
5
ZONES 1 THROUGH 5 FOR LIPOSUCTION
Also on the day o surgery, in the holding area, the patient is marked while standing. T e areas to be li-
posuctioned are identif ed; these always include zones through and the areas over the oblique zones.2
Zone has cultural ramif cations: some patients desire at added in that area, whereas others request that
at be removed rom this region.
Although there are aesthetic units to the posterior region, there are important zones that truly de-
f ne the buttock rame and shape (zones to and zone ) that I will discuss here.
Fig. 46-5
Narrow A

Wide A
T e patient is reminded that in our state (Florida) we have a L supernatant at limit, and there ore it is
possible that not all the areas being marked will be suctioned. Markings o these areas are in case I need
to harvest more lipoaspirate. My main ocus and priorities are zones through . I more at is needed
or reshaping, I turn to the outer aspect o the legs (zone , i excess is present), abdomen, inner legs,
inner knees, lateral chest wall, and in extreme cases, the arms, until enough at has been obtained or at
gra ing, staying within the L limit and my com ort level.

852
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 46-6, A and B
A

B
T ree landmark areas are identif ed in the buttocks:

. T e f rst is the posterior superior iliac spine (dimples in the parasacral areas); this represents the
height o the gluteal muscle I am trying to achieve.

. With these points marked, it is easy to identi y and mark the V zone (zone 1). T is is the presacral
space, identif ed by the superiormost point o the intergluteal old and both posterior iliac spine
dimples. Connection o these points creates a V, which is zone 1. When this zone is suctioned, it
adds signif cant aesthetic contour to the buttocks.
Fig. 46-6, C and D
C
D

3. Any depressions in the midlateral buttock (white arrow, zone 8) are identif ed.

853
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
E

F
G
H
ZONE 8 FOR LIPOSUCTION
Fig. 46-6, E-H
Sometimes these depressions extend all the way to the anterior leg. T ere ore care is taken to mark the
lateral extent o the def ciency, and any dimples or irregularities are marked. Zone is evaluated and an
attempt is made to quanti y the amount o at to remove: very little, none, or a lot. T e markings are pho-
tographed; these photos become extremely help ul during the procedure, because the marks are o en
erased during surgery.
Medications
Be ore the procedure begins, 1 L o intravenous uid is administered. Preoperative medicines given
include clindamycin (Cleocin) 00 mg intravenously. I the patient is at high risk or postoperative nau-
sea, ondansetron (Zo ran OD [orally disintegrating tablet]) mg is given sublingually be ore surgery.
Dexamethasone (Decadron) 10 mg is given intravenously toward the end o the procedure to reduce
postoperative swelling and to help prevent nausea and vomiting. I the patient has a history o re ux,
metoclopramide (Reglan) 10 mg and ranitidine (Zantac) 0 mg are added intravenously, especially since
the patient will be lying in the prone position.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Operating Room Preparation and Initial Patient Positioning
With below-the-knee ED hose and pneumatic stockings in place, the patient is prepped circum eren-
tially while she is in the standing position with room-temperature Hibiclens or Betadine solution.
Patient Positioning on the Table
T e patient is now ready to be placed supine on the operating table; her arms are kept above the head
while one assistant continues to keep all the tubing out o the way and the other assists her in lying down
by holding her leg and supporting her upper back. T e patient is asked to gently lie down; she is then
asked to place her arms on the arm boards. T e pneumatic tubing is kept inside the stockings.
At this point, the pneumatic stocking compression tubing is brought out and connected. It takes two
assistants to do this: one remains sterile while the other connects the tubes.
All pressure points are padded. T e patient is then covered, and induction o anesthesia may begin.
Following induction, and with the assistant prepared and gowned using a new set o sterile gloves, a
Foley catheter is inserted. T e patient will be going home with the Foley catheter still in place so that
she does not have to get up every hour to urinate. T is eature becomes extremely convenient or the
patient; the catheter also helps in monitoring uid status. T e catheter is removed the next day, during
her ollow-up appointment. T e patient is once again prepared with precautionary measures, and the
inf ltration process begins.
TECHNICAL GUIDELINES
Tumescent Fluid Mixture
T e uid mixture that I use is composed o the ollowing:
• 1 L o lactated Ringer’s solution
• ml o 1% lidocaine
• Epinephrine 1:100,000 (1 ampule or the ront but when working hard dense back and waist areas,
I add ampules)
Box 46-2 Reference Values When Using the Tumescent Approach
• to 5 L o tumescent uid usually injected
• to 5 L o intraoperative intravenous uids used
• to 6 L o lipoaspirate ( uid and at) required to obtain 2 to 3 L o supernatant at

855
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Harvesting
Fig. 46-7
T e areas rom which I harvest at depend on the amount o the patient’s available at, as identif ed pre-
operatively, and the amount o at needed or contouring, reshaping, and augmentation.
Harvesting by Zones
1
2

2
3

3
4
5
5
8
8
Fig. 46-8
My goal is to reshape and recontour the body rame; there ore at will be removed rom areas that will
accentuate the entire gluteal zone. In almost every case, regardless whether at or implants are used or
volume expansion, I per orm liposculpting o zones 1 through . Zone requires less suctioning. As
noted previously, this zone carries cultural signif cance; some patients eel very strongly that they want
to preserve the contour o this area, whereas other patients request reshaping o this zone.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
T e midlateral buttock (zone ) is o particular interest, because it is the only zone out o the that may
require at gra ing to smooth the contour. T is zone has no muscle; there ore at gra ing will be to the
less vascularized subcutaneous tissues and will require more care and precision with the gra ing tech-
nique.
What other areas will be contoured depends on the amount o at present. In large- or extra-large- ramed
individuals, because I have a state-imposed 4 L supernatant at extraction limit, my goal is to shape the
waist and rame, so I may be limited in suctioning other areas, such as the abdomen or back. T e patient
is advised o these limits.
However, i the patient has a small to medium rame, I contour the abdomen f rst, then the waist and
rame, and then move on to other areas: the lateral chest wall, upper back, inner legs, inner knees, and
perhaps the arms.
Selecting the Harvesting Technique Based on Fat Characteristics
My harvesting technique varies, depending on the patient’s presenting at characteristics and available
at. I usually start the procedure by introducing a mm cannula into the deep layers. T is allows me
to assess the characteristics o the at that I am about to extract and answer the ollowing questions: Is
the at hard or so ? Does it extract quickly or slowly? Is it di cult to extract, or does it come out like
butter? Does it have a propensity toward leaving sur ace irregularities? Is the superf cial layer thick or
thin, compact or loose? Can the deep layer be easily distinguished rom the superf cial layer, or does it
all seem to blend in?
From the results o my assessment, I adjust my approach and technique. I the patient has extremely
dense at, in that particular dense zone I pre-tunnel (using the power-assisted cannula) to help so en the
at (this is usually in the upper and lower abdomen and linea alba/midline). T is is the Simeon Wall, Jr.,
technique called “SAFE” Lipo (separation, aspiration, equalization).
Liposuction is per ormed with the patient in the supine, lateral decubitus, and prone positions. Each po-
sition has a specif c purpose and technical goal that has become more apparent to me as I have learned
to contour the body and buttock areas.
T e supine position is used to address the ollowing areas:
• T e abdomen
• T e zones overlying the external/internal oblique zones
• Some o the posterior triangle
• T e lateral chest wall
• T e inner legs (i needed)
T e abdomen is contoured, but this does not a ect the buttock rame or gluteal contour; it is merely a
ancy harvesting approach. However, when contouring in the supine position, it is important to avoid
accidently disrupting the rame shape.

857
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
External oblique muscle
Do not direct cannula
below iliac crest
Latissimus dorsi
muscle
Fig. 46-9
While the patient is in the supine position, the surgeon should avoid suctioning below the iliac crest
(marked by an X in the photo). T is zone below the crest corresponds to point A on the rame.
A
B
C
Fig. 46-10
I this small technical point is not ollowed, oversuctioning o the upper buttock may occur, creating a
step-of that does not ow smoothly.

858
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Contouring
Lateral Decubitus Position
Contouring o the gluteal rame and gluteal zone begins with the patient trans erred to the lateral decu-
bitus position. T e ollowing areas will be treated:
• Aesthetic unit 2: T e posterior f ank triangle; the waistline
• Frame point A: T e upper lateral buttock
• Zone 3
• Frame point B: T e outer legs, i needed
• T e posterior lateral chest wall zone and back
Aesthetic Unit 2 Contour
2

2
Fig. 46-12
Setting up the gluteal rame is per ormed by creating a smaller waist. o help create a smaller waistline,
suctioning o the lower back and sacrum are needed, but the most important zone is the posterior f ank
triangle, aesthetic unit 2. T ese areas begin to set up the aesthetics o the rame shape and are best ap-
proached with the patient in the lateral decubitus position.
T e areas below the iliac crest and zone 3 (white arrow) should be
suctioned under direct vision with the patient in the lateral decu-
bitus position.
Fig. 46-11

859
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Fig. 46-13
T e posterior ank triangle is def ned in eriorly by the superior iliac crest, superiorly by the twel h rib,
medially by the lumbar muscle, and laterally by the internal oblique muscle (lef , above).
A very distinct at pad exists in this triangular zone. T is at pad is highly movable and tends to shi
around when the patient is placed in di erent positions, thereby giving the illusion that the at has been
completely suctioned, whereas in reality it has shi ed.
Fig. 46-14, A
A
o truly contour this at pad zone, the surgeon must approach it not only with the patient in the lateral
decubitus position but also in the prone position. In the past, I tried addressing the waistline when the
patient was supine and prone, but the contour was never really as ref ned as desired. It looked good while
the patient was on the table, but the results 3 to months later le something to be desired.

860
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 46-14, B-D
B
C
Posterior approach
D
Anterior approach
It was not until I learned how to really suction the posterior triangle in the lateral decubitus position that
I started to see tremendous changes. T is area requires a three-dimensional approach. It is started with
the patient supine, then the patient is trans erred to the lateral decubitus position and suctioning contin-
ues. However, these positions alone will not be su cient to achieve the result I am seeking; the posterior
triangle also has to be suctioned with the patient in the prone position.
Upper Lateral Buttock (Point A) and Zone 3 Contour
Fig. 46-15, A and B
3
3
B
A
Point A: Upper lateral flap
Point C: Midbuttock
Point B: Lateral leg
Point A and aesthetic unit 3 are closely associated but dif erent. T e rame point A corresponds to a
point along the midaxillary line; it is located between the anterior and posterior axillary lines. Aesthetic

861
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
unit 3 is located over the gluteus medius muscle and is there ore lateral to the posterior axillary line and
medial to the gluteus maximus muscle. T e contouring approach is very dif erent in these two areas.
C
D
E
Fig. 46-15, C-E
T e posterior triangle (aesthetic unit 2) is best approached rom all positions: supine, lateral decubitus,
and prone; zone 3 should be contoured rom the lateral decubitus and prone positions under direct vision.
F
G
Fig. 46-15, F and G
T is zone 3 is still a great challenge or me. I too much suctioning is per ormed here, an un attering
step-of is created (black arrows); by contrast, undersuctioning makes the buttock appear ar too square
(white arrows). T e goal is to contour this zone to allow the buttock to transition smoothly all the way

862
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
up to the iliac crest. I have learned to use the preoperative photos to determine how much suctioning
will be done; o en the results may look excellent on the table, but months later it is evident that more
at should have been removed, or the zone was oversuctioned. T is is not a very orgiving zone; it has a
steep learning curve, which I am still on.
Prone Position
Fig. 46-16
1
2
4
3
2
3
5
5
T e prone position will help with contouring o the ollowing areas:
• V zone: Aesthetic unit zone 1
• T e remaining at in the posterior ank triangle: Aesthetic unit zone
• T e remaining at in the upper buttock: Frame point A
• Aesthetic unit zone 3
• T e lower sacrum/lower back: Aesthetic unit zone 4
• I present, excess in the lower inner gluteal old: Aesthetic unit zone 7
Zone 1 Contour
A

B
Fig. 46-17, A and B
Once the patient is in the prone position, the V zone is def ned through an access incision placed at the
superior intergluteal crease. Contouring this zone requires a cross-suction approach; there ore a second
incision is placed somewhere in the ank, usually at the superior posterior iliac crest (not the iliac spine).

863
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
C
Fig. 46-17, C
With the patient in the prone position, the posterior ank triangle is urther def ned; it is much easier
to f nalize the contour with the patient in this position. T e lateral upper buttock (zone ) sometimes
has excess at that could not be appreciated while the patient was in the lateral decubitus position. I this
excess is visible, it should be removed. On occasion, the lower inner gluteal old has excess at, and this
is suctioned as well.
D
E
Fig. 46-17, D and E
Although volume will add gluteal projection, it is this aggressive contouring that will create the aesthetic
buttock rame. Adding volume alone does nothing but create a big buttock.
F
Fig. 46-17, F
Creating gluteal contour requires more aggressive suctioning than most surgeons are used to, in partic-
ular in the V zone (sacrum) and the posterior ank triangle.

864
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
TECHNIQUE
Goals
Fat injections to the buttock accomplish two purposes: they help shape and contour the gluteus muscle,
and they add volume to the buttock. Liposculpture involves working on the rame o the buttock by
creating a well-def ned and aesthetically contoured rame, but the gluteus itsel also has to be shaped.
Access Incisions or Fat Graf ing
A
B
Fig. 46-18, A and B
For at gra ing, I use f ve standard incisions through which most o the at gra ing is per ormed: the
intergluteal crease, bilateral upper posterior superior iliac spine dimple areas and bilateral in ragluteal
creases. I try to place the in ragluteal crease incisions in the old but i no old is present, I place them in
a position that will allow me the greatest exibility in adding volume in all areas, which is usually at the
same lateral biceps emoris–to–gluteus maximus muscle junction. Other incisions are added i certain
areas cannot be reached through these standard access ports.
Which incisions are added will depend on the patient’s presenting anatomy, the severity o the de ormity,
the ease o access, and the degree o recontouring required.
Fig. 46-18, C and D
C
D
On many occasions I need to f ll the triangular space ound between the biceps emoris and the vastus
lateralis. In these cases, I place bilateral outer leg incisions. T is lateral leg incision is extremely versatile:
through this incision I can suction the saddlebags, the upper point A (upper lateral buttock), and trans-
er at to the in ragluteal crease and point C o the rame. I can also use this incision to widen the gluteal
muscle base and work on the transition zones between muscle and rame. T is incision is not always
required, but i I need to address all the areas mentioned and the in ragluteal crease does not allow me to
address them or whatever reason (too medial, patient anatomy, and so on), this access incision is used.

865
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
E
Fig. 46-18, E
On many occasions I cannot suction the waistline rom the intergluteal crease incision; in such cases, a
liposuction access incision is made at the posterior iliac spine. T is incision is sometimes used to help
gra the upper portion o point C and/or the upper lateral buttock transition zone. On other occasions
I also use the lateral border o tattoos as access points, because the scar at this site is seldom seen and
remains extremely well hidden in the tattoo.
Level o Fat Graf ing
T e two most requently asked questions about at gra ing in this area are:

1. Exactly what level is the at injected into: at, muscle, or both?

2. How can you avoid injuring the sciatic nerve during injections?
On principle I pre er to inject into the muscle as much as I can. However, there are certain circumstances
that limit one’s ability to inject into the muscle, and I am orced to trans er the at more superf cially in
three di erent groups o patients.
Fig. 46-19
T e f rst group consists o patients with limited at available or harvest. Because the main goal is to
work on shape and contour, the more superf cial the injection, the more direct the in uence on the skin
sur ace, and the more projection will be achieved. In other words, 10 cc placed in the superf cial tissues
(above muscle ascia) translates to a greater projection than 10 cc placed deep in the muscle. T ere ore,
i I think the available at is limited, I purposely place the at in the superf cial muscle and subcutaneous

866
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
layer, with 0% to 70% placed in the subcutaneous layer and 30% to 40% in the intramuscular layer.
Once the desired shape is obtained, volume is then added deeper in the muscle. However, i plenty o at
is available, a er contouring and reshaping, volume is added into the muscle, making the ratios higher in
the muscle, with 0% to 70% added to the muscle and 30% to 40% to the subcutaneous layer.
Fig. 46-20
Patients with a at gluteal sur ace area may be classif ed as a second group, where I may place at more
superf cially. In some patients the muscle may be round, but the subcutaneous layer is def cient in such
a way as to have a depression or at gluteal zone (white arrows). For these individuals, the only way to
round out the buttock is by increasing the volume at the subcutaneous tissue level to o set the def ciency.
Increasing muscle volume will not a ect the at zone, because the issue is not the muscle but rather the
subcutaneous tissues. Fat gra ing to the subcutaneous layer is the solution.

867
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and Torso
Skin and superficial fat
contoured
Fat-to-muscle ratio
85%
15%
70%
30%
Dimpled
surface
50%
50%
Fig. 46-21
Patients with sur ace irregularities are a third group; at gra ing to the areas o def cit or irregularities is
the only way to improve these issues. Adding volume to the muscle will only augment the buttock with-
out addressing the irregularities.

868
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Avoiding the Sciatic Nerve During Graf ing
Fig. 46-22
T e sciatic nerve lies in a groove lateral to the ischial tuberosity and is well protected and deeper than
one might think. T e nerve is under the hamstring muscle, which urther protects the nerve. o avoid
injury to the nerve, at gra ing is done parallel to the table; this means at will be placed in the midlevel
o the muscle and more superf cial. By staying parallel, the injections will be nowhere near the lateral
ischial tuberosity groove.
Fig. 46-23
Although the incision is placed at the crease, the nerve is well below the access point.
Precision in the Placement o Fat
Fat gra ing is always done with a repetitive back-and- orth motion, layering the at at multiple levels
with multiple passes (see Chapter 1). T e vibrating 5 mm basket cannula is in constant motion while the
at is slowly injected in a linear, threading ashion (no injections o stagnant globs).

869
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Fat Graf ing Sequence
Fig. 46-24
Point A: Upper lateral flap
Point C: Midbuttock
Point B: Lateral leg
T e areas to be suctioned and gra ed are addressed in this order: the waist, suction point A (the upper
lateral hip area), suction, add, or do nothing to point B (lateral leg area) and i needed, add at to point
C. So an easy way to remember this sequence is to think f rst o contouring the waistline, then working
on the ABCs o the rame.
T e sequence or this procedure is to work rom the outside in, meaning start with the rame, then tran-
sition zone, then muscle, so move rom lateral to medial as ollows:

1. Harvest and process at

2. Reshape the rame: Suction point A, possibly suction or add to point B, and assess point C or at
gra ing.

3. Once the rame has been addressed, the next step is to improve the gluteal transition zones, espe-
cially the lower outer gluteus-to-leg junction and the gluteus maximus-to-medius transition.

. Next, the surgeon adjusts the volume o distribution, reshapes the muscle, and modif es gluteal
height, ideally to the posterior iliac spine.

5. Only a er all o these alterations are complete does augmentation o the buttock begin.
Supine and Lateral Decubitus Positions
T e f rst goal o gluteal at gra ing is to work on improving the rame. Although nearly all o the at
injections are done while the patient is in the prone position, some at gra ing needs to be per ormed in
the supine and lateral decubitus positions.

870
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 46-25
T e midlateral buttock depression sometimes swings all the way around to the anterior lateral leg.
Fig. 46-26, A-C
A
B
C
T e anterior portion o the midlateral buttock depression is between the anterior iliac spine and where
the rectus emoris inserts. T is depression of en goes unrecognized when the patient is standing; I al-
ways notice it, but it is best appreciated when the patient is supine on the operating table. T is depression

871
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
is f lled with 0 cc syringes while the patient is supine; the at is layered using multiple repeated passes,
placing the at in the mid-deep level, then moving to a more superf cial level, until the de ect is f lled.
D
E
Fig. 46-26, D and E
T e lateral portion o this depression corresponds to rame point C. T ere ore rame reshaping contin-
ues with at gra ing while the patient is in the lateral decubitus position.
Improving the Frame Shape by Adding Fat at Point C
Fig. 46-27
An interesting aspect o this procedure is that each new angle reveals something that could not be seen
in one position only. T ere ore each area needs to be evaluated rom the supine, prone, oblique, and
lateral decubitus positions. Although modif cation o the rame might appear to have been completed
while the patient is in the lateral decubitus position, once she is placed prone, the surgeon may be sur-
prised to f nd that the def cit persists, and more at gra ing needs to be per ormed.

872
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Widening the A Frame by Adding Fat at Point B
Point A
Point C
Point B
Fig. 46-28
A
B
C
T e frame is further contoured with the patient in the prone position. If the patient desires a wider
A frame, this is the stage in which volume is added to point B to widen the zone. Frame reshaping is
three-dimensional: it has to be done in the supine, oblique, lateral decubitus, and prone positions. If this
is not done, the reframing portion of the procedure will be less than optimal.

873
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Transition Zone Improvements and Volume of Distribution
Fig. 46-29
1
2
3

4
a
b
c
d
All our transition zones (shown on lef buttock) will require attention. Some o the work is per ormed
while the patient is in the lateral decubitus position, and some in the prone position. By improving
the transition zone volumes, the surgeon is incidentally and simultaneously working on all our gluteal
quadrant volumes (quadrants 1 through ).
By adding at to the lower lateral gluteal leg junction (region a), the surgeon is also expanding the glu-
teal muscle base and changing its shape. T ere ore, by working on the transition zones, the surgeon is
addressing two other issues: muscle shape and volume o distribution. During this entire process, while
volume is being added, the primary ocus is on correction o the contour o the buttock, not on volume.
Fig. 46-30
In the lateral decubitus position, the surgeon begins at trans er to the muscle transition zones. In par-
ticular, at is injected in the lower lateral gluteal muscle to leg junction, which is the union between the
biceps emoris and vastus lateralis (the triangular zone). T is is per ormed through the in erior gluteal
crease incision, and on many occasions through the lateral leg incision (region b in Fig. -29). T e tech-
nique is to approach it rom a superior and an in erior cross-graf ing approach.

874
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
T e inferior gluteal leg junction is particularly important, because adding volume to this zone will do
several things:
• It starts to widen the base o the gluteal muscle, changing it to a wider, more aesthetic shape. T is
is not to be con used with point B on the rame shape (located more laterally at the midaxillary
line), which is responsible or the saddlebags.
• It adds volume to the triangular space between the biceps emoris and the vastus lateralis to help
support the in erior gluteal zone and li the buttock.
• It so ens the transition between the muscle and the leg.
A
B
Fig. 46-31, A and B
T e next transition zone treated is the midlateral buttock-to-frame junction. I approach it rom an in e-
rior direction through the in erior gluteal crease incision, and rom a lateral position, using the interglu-
teal crease incision. Fat is placed with a anning, cross-gra ing technique.
C
D
Fig. 46-31, C and D
Improvement o the transition zones continues with at trans er to the junction between the gluteus max-
imus and medius. T e def cits here can o en be appreciated by palpation.

875
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
E
F
Fig. 46-31, E and F
Next, the inner gluteal transition zone is approached rom the intergluteal crease incision and rom the
in ragluteal crease incision.
Muscle Height
T e gluteal muscle height should be up to the posterior iliac crest, once the rame, transition zones, and
muscle volume o distribution have been improved. I work on raising the muscle height to the posterior
iliac spine.
A
B
Fig. 46-32, A and B
Muscle height is increased by approaching the gra ing rom an in erior gluteal incision and rom the
intergluteal incision, ensuring a cross- anning gra ing technique. Volume is added until the muscle
reaches the intended height (the posterior iliac spine).3
Fig. 46-32, C and D
D
C
Once I am satisf ed with the muscle height, I step back and reevaluate the entire shape and volume. I
gluteal volumes must be adjusted in any o the quadrants, it is done at this time.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Gluteal Volume Augmentation
Fig. 46-33
When I have the best rame shape, muscle shape, transition zones, volumes o distribution, and overall
shape, I can add gluteal volume. As can be seen above, most o the at gra ing is or reshaping and recon-
touring. T e amount o at used or augmentation is minimal.
Fig. 46-34
T e recontouring work does add some volume, but it is now in the right places. T is creates a more aes-
thetic buttock.
On occasion there are def cits to the midlateral buttock, and these need to be f lled as well. O en patients
have a attening in the outer midgluteal muscle area, and the tissue in this region can be quite adherent,
tight, and di cult to expand. A second at gra ing session may be required at a later date, and in some
individuals this area will always remain at. Fat gra ing in the lateral decubitus position is initiated to
help expand the zone. When the patient is trans erred to the prone position, the surgeon attempts to
ree up some o these very strong ascial dermal attachments by per orming pretunneling with the lipo-
suction cannula or by using a oledo pickle ork in the deep plane. Sometimes I have used an 1 -gauge
needle to try to release this, but the area would end up overcorrected and was very di cult to improve
(see Complications section). T ere ore it is important to be conservative with these releases and to come
back at a later date i more release or gra ing is required.

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Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Drains
I no longer use drains but rather leave the groin and posterior intergluteal crease incisions open to allow
or drainage, and I place a pressure pad in the lower back/sacral zone. T e seroma rate is less than 5%
with this technique.
POSTOPERATIVE CARE
Garments and Pressure Pads
A regular body garment is used or to weeks. I do not use any special ones, but a triangular pressure
pad is placed in the sacrum.
Recovery Room
T e patient is kept in the supine position until awake and able to control the airway; at that point, the
patient is placed in the prone position. In the recovery room the ocus is on maintaining body tempera-
ture and monitoring uid status. Because there are ongoing uid shi s, it is imperative that uid status
be aggressively monitored in the early recovery phase.
Postoperative Instructions
Pressure will destroy the trans erred at, so the patient must be instructed to keep pressure o o the
buttocks or at least weeks (this is an arbitrary number that I use but may be readjusted). T ere ore the
patient can sit with modif cations: a pillow is placed beneath the posterior hamstrings (not touching the
buttock). T e pillow keeps the buttock in the air and avoids pressure on the newly gra ed tissue. With
this technique patients can return to work, drive, and go to the movies at 10 days postoperatively, but
sitting without a pillow is not allowed or weeks.
Fig. 46-35
Alternatively, or sitting, patients can purchase a cane chair, which doubles as a cane and a sitting device.
T ey are very inexpensive. While sitting, the buttocks actually hang o the back o the chair, so no pres-
sure is placed on them. However, i the patient had at trans ers to the in ragluteal crease, I pre er that
the pillow technique be used.
When transported home or or a postoperative ollow-up, the patient should be in the prone or lateral
decubitus position. T ese positions should also be used to maneuver and stand or the f rst 3 days.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Patients are instructed to wear a compression garment or 4 to 6 weeks. O en Endermologie lipomas-
sage therapy is suggested or the areas o liposuction, starting a er the f rst postoperative week. Patients
are advised not to shop or clothes to f t their new contours or 3 months and that the f nal results will be
realized at about 6 months postoperatively.
R esul ts
Fig. 46-36
T is 22-year-old woman, 5 eet 1 inch tall and 62 kg (136 pounds), was an ideal patient or at gra ing,
because she was slightly overweight but otherwise in good health. Her abdomen, internal and external
oblique zones, posterior triangle, and sacrum (V zone) were liposuctioned; 550 cc o purif ed at was
trans erred to each buttock. She is seen months postoperatively.

879
Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
Fig. 46-37
T is 2 -year-old woman, 5 eet 3 inches tall and 5 kg (12 pounds), underwent liposuction o the abdo-
men, f ank, back, upper buttocks, and inner and outer legs; 50 cc o at was trans erred to each buttock.
She is seen 11 months postoperatively.
Fig. 46-38
T is 31-year-old patient is 5 eet 5 inches tall and kg (1 0 pounds). Liposuction was per ormed on her
waist, abdomen, and upper buttocks; 00 cc o at was trans erred to each buttock, her C-point, and her
outer legs. She is seen 11 months postoperatively.

880
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
C om p l i ca ti on s
Complications are rare and are similar to those seen in liposuction, including skin sur ace irregularities,
hyperpigmentation, and hypertrophic scars.4 Neuropathy o the ulnar nerve can occur rom resting the
elbow on the bed. Patients are placed prone, so pressure can be placed on the ulnar nerve. A pillow
should be placed under the elbows, and patients are instructed to keep their arms at their sides i they
need relie rom the “beach” position (prone, elbows bent, arms at 9 degrees). Most neuropathies will
resolve with time, but i this does occur, I prescribe gabapentin (Neurontin) and vitamins B12 and B6. I
remind patients to place a pillow under the elbows or keep their arms at their sides. Neurapraxia o the
sciatic nerve has not occurred in my patients.
Fig. 46-39
Although my patients have not had any gluteal hematomas that I am aware o , one patient presented or
an evaluation 3 months af er gluteal at graf ing per ormed by another physician. Blood was aspirated,
and the issue resolved without recurrence.
Fig. 46-40
Oil cysts are extremely rare. Other possible complications include at necrosis, at embolism, deep ve-
nous thrombosis, hypovolemia, and anemia.

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Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
NECROSIS
Fig. 46-41
Liquef ed at necrosis can occur. riglyceride cysts are very rare; they appear pale milky white and look
like pus. T e patient seen here required three aspirations be ore resolution. Rarely, hard, indurated at
necrosis can occur (less than % o cases). I have had our cases o signif cant tissue necrosis, with areas
as large as 0 by 0 cm; I injected these areas with 0 mg o triamcinolone (Kenalog). All o these pa-
tients were asked to wait about year. In only one was the necrotic tissue excised, an area by cm; this
did leave an upper buttock scar. T e other three patients did not return to have the necrotic area treated.
Had they returned, I might have tried liposuction f rst to see whether the necrotic tissue could be broken
up and aspirated. I this did not correct the problem, excision would have been my next choice, or per-
haps serial injections o a steroid.
Fig. 46-42
Encapsulated at necrosis can also occur. T is mass was removed rom a patient who had undergone at
gra ing by another physician. She had an by 0 cm mass in her outer gluteal zone. It was reely mov-
able and well encapsulated.
INFECTION
In ections occur in approximately % to % o patients. T e presenting signs are o en vague. T e patient
starts to complain o increasing gluteal pain at about days to 0. On examination there is no redness,
and only mild discom ort on palpation. T is makes it di cult to discern whether the patient is experi-

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
encing postoperative discom ort or has an in ection. A ever may be present but usually is not. Erythema
typically does not appear or 3 to 4 weeks, since the collection lies deep; it takes some time be ore skin
sur ace signs appear. T ere ore the trigger or suspicion o in ection is a patient who underwent gluteal
augmentation to 10 days previously and presents complaining o increasing unilateral buttock pain,
especially on ambulation. In this scenario, I palpate the area o greatest discom ort, and using a 0 cc
syringe with an 1 -gauge needle, I try to localize a collection. I there is no collection, I may obtain an
ultrasound or wait to see whether the patient improves on antibiotics.
Fig. 46-43
T e in ection can be mild, simple cellulitis and may be treated with oral antibiotics.
Fig. 46-44
I the collection is identif ed, I make a small incision with a No. 11 blade using a local anesthetic; I ir-
rigate the pocket and clean the areas as best I can. A small wick or gauze is placed to keep the incision

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Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
open. Cultures are taken, and the patient is placed on a broad-spectrum antibiotic, usually clindamycin
(Cleocin) and ciprof oxacin to cover Escherichia coli, Staphylococcus, and occasionally Pseudomonas un-
til the results o the cultures are back rom the laboratory. T en targeted antibiotic therapy is used. T e
patient is ollowed daily to make certain the symptoms are resolving. I they are not, the site is incised
with the patient under anesthesia and exploration and drainage are per ormed. T is may require urther
small incisions with drain placements. Most in ections are treated with a local anesthetic and do not
require aggressive drainage in an operative setting.
Fig. 46-45
I the in ection is more extensive, a more aggressive incision and drainage are required. I no collection
is ound, I send the patient or ultrasound evaluation. On several occasions in my experience, ultraso-
nography yielded negative results when in act there was a collection o pus. I the ultrasound results are
negative, I nevertheless prescribe antibiotics as prophylaxis (usually clindamycin 00 mg orally every
hours). I have the patient return every 2 to hours or observation. I symptoms worsen, I repeat the
needle localization. I that also yields negative results, the patient is sent or a C evaluation.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 46-46
Others may present 1 or 2 months postoperatively with erythema and more typical signs o in ection;
in such an instance, a collection should be sent or traditional culture and to evaluate or the presence
o Mycobacterium as well. Some patients have returned 3 months a er surgery complaining o localized
and increasing pain in one buttock. In such cases I ollow the protocols described. I send the cultures
or Mycobacterium and ungus. T e typical presentation or these patients is increasing buttock pain, but
there may be several raised, red areas the size o a dime or quarter; these areas are usually not draining
but may be uctuant. Aspiration may produce a serous-colored uid. Whatever uid is collected should
be sent or standard Gram stain, culture, and sensitivity testing as well as or the presence o Mycobacte-
rium and ungus. Culture and sensitivity must be specif ed or these organisms as well. On several occa-
sions, laboratories have not sent the specimens or sensitivities despite my having ordered this; there ore,
i tests are positive or Mycobacterium, the laboratory should be called to conf rm that they sent the
specimen or sensitivity testing. O en these organisms take several weeks to grow out, and when they
yield a positive result, the lab may miss sending them or sensitivities. T is organism is being seen on an
increasing basis in plastic surgery.
NEED FOR BLOOD TRANSFUSION
Early in my series, I had to give a blood trans usion in about 10% o my patients, because postoperative
anemia was common. oday the incidence is 3% to %. Presenting hemoglobin levels a er this proce-
dure are usually 10 g/dl, but on occasion can range rom 7 to 9 g/dl. Blood is trans used i the hemoglo-
bin level is below 7 g/dl and on an individual evaluation basis (that is, we f rst determine whether the
patient is symptomatic, tachycardic, has intractable headaches, severe weakness, or shortness o breath).
SEROMAS
Seroma or micro uid collections can be an issue in the anterior abdomen. T ese are treated with re-
peated needle aspirations (usually two or three times). However, i the a ected areas are larger, drain
placement may be required.
FAT EMBOLISM
Although at embolism has been described, it has been a diagnosis o exclusion. T is is most likely
to occur i injections were done at an angle, aiming to the pubis or deep pelvis with the patient in the
prone position. T e injections should be done parallel to the operating table and into the midmuscle
and above. T e true incidence o at embolism is not known, but several deaths in the United States and
around the world have implicated at embolism a er a gluteal augmentation procedure.

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Chapter 46 • Aesthetic Liposculpting and Fat Gra ting or the Buttock and orso
GLUTEAL ASYMMETRY
Gluteal asymmetry is present in every patient a er an augmentation procedure; there ore this is not a
complication. T e at absorption that occurs is usually equal on both sides. However, preexisting asym-
metries should be documented and pointed out to patients preoperatively so they do not ocus on them
ollowing the procedure.
BLOODY ASPIRATE
Some patients, despite the use o epinephrine, have a bloody aspirate that limits the extraction. I the
patient is too bloody, I will f rst add more tumescent uid with 2 ampules o epinephrine 1:1000, but i
the aspirate remains bloody, I end the procedure be ore reaching my L limit. T is may lead to a lim-
ited amount o available at or trans er, and the buttock may lack volume. A repeat procedure may be
required at a later date (usually about 3 months later).
OVERCORRECTION OF DEPRESSED ZONES
Fig. 46-47
In cases in which I have tried to release indentations or tight gluteal zones with a subdermal release us-
ing an 1 -gauge needle, I have created an overcorrection. T is is very di cult to treat; it requires several
at gra ing sessions, liposuction o the excess, and on occasion, skin excision.
D i scussi on
HOW MUCH TRANSFERRED FAT WILL SURVIVE?
I ask patients to wait months be ore assessing how much at has survived. Although there is no current
scientif c reproducible way to ascertain how much o the transplanted at has survived, it is my subjective
observation that on average, 0% to % o the at trans erred using this technique survives.
We must also keep in mind that 0% o this procedure involves contouring the surrounding gluteal
rame, and this alone will create tremendous changes in shape. With the rame well def ned, the but-
tocks are accentuated, whether or not volume is added with at or implants. Even i all the trans erred
at is lost—which has never happened in my experience—the gluteal shape always remains signif cantly
altered.

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Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
C oncl usi on
When per orming gluteal contouring and augmentation, the surgeon must start working rom the out-
side in; that is, starting with the outermost portion o the buttock. T is is what I call “the rame” (delin-
eated by points A, B, and C); then I move medially to work on the transition between the muscle and the
rame. Next I move more medially and work on the muscle itsel by f rst setting the right dimensions.
Expand the upper part o the muscle cephalad to the posterior iliac spine (this is the upper limit or
height o the gluteal muscle), next work on equalizing volume in all our quadrants o the gluteal muscle,
and f nally you can work on the augmentation. Most o our work is in reshaping the buttock area—and
only one ourth is dedicated to augmentation.
REFERENCES
1. Medication guide or Remicade. Available at
information.pdf.
2. Mendieta CG. Classif cation system or gluteal evaluation. Clin Plast Surg 33:333, 200 .
3. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg 33:423, 200 .
4. Mendieta CG. T e Art o Gluteal Sculpting. St Louis: Quality Medical Publishing, 2011.

LOWER EXTREMITY
AND GENITAL AREA
Reconstructive
S e c t i o n E i g h t

(Trang không có chữ)

C h a p t e r 4 7
T s v d c s f . B c us
v scu z d ssu x y, s p f d s w. F f c b
us u s c y p s y, dd v u b j vu v s uc u s, d
u c y p s y, sc s, d d s, p y, p , d x y.
P ri nci p l es
FEMALE GENITAL ANATOMY
Fig. 47-1
Mons pubis
Prepuce of clitoris
Glans of clitoris
Urethral opening
Vestibule of vagina
Labia majora
Labia minora
Hymenal caruncle
Vestibular fossa
Frenulum of labium
Posterior labial
commissure
Perineal raphe
Anus
Fat Gr a t ing o t he Femal e
Genit al Ar ea
Massimiliano Brambilla
889

890
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Labia Majora
Fig. 47-2
Posterior labial
artery
Transverse perineal
artery
Perineal artery
Internal pudendal
artery
Inferior hemorrhoidal
artery
Dorsal artery
of clitoris
Deep artery
of clitoris
Inferior fascia of
urogenital diaphragm
Artery of
clitoris
Deep transverse
perineal muscle
Ischiocavernosus
muscle
Bulbospongiosus
muscle
Superficial transverse
perineal muscle
External anal
sphincter muscle
Urogenital diaphragm
Levator ani
muscle
Gluteus maximus
muscle
Fig. 47-3
T e labia majora are 7 to cm long, 3 to 4 cm wide, and 2 to 5 cm thick; they extend between the pubis
and approximately 3 cm from the anus. T e subcutaneous tissue consists of loose areolar tissue that

891
Chapter 47 • Fat Gra ting o the Female Genital Area
is rich in at, and superf cially, sebaceous glands. Vascularization is provided by a rich anastomosis o
branches o the internal pudendal artery: posterior labial branches, branches o the pudendal artery, and
branches o the perineal artery. No major vessels are ound in the labia majora.
Ilioinguinal nerve
Genital branch of
genitofemoral nerve
Posterior cutaneous
nerve of thigh
Pudendal nerve
Perineal branch of
pudendal nerve
Fig. 47-4
Innervation o the labia majora is rom the perineal and labial branches o the perineal nerve. Lymphatic
drainage is to the superf cial inguinal lymph nodes.
Interlabial Sulcus
T e interlabial sulci, le and right, separate the labia minora rom the labia majora.
Labia Minora
T e labia minora are to 6 cm long and to cm wide; they extend o the vestibule o the clitoris,
next to the prepuce o the clitoris. T e subcutaneous tissue consists o f rm connective tissue, erectile
tissue, and elastic f bers, with no adipose tissue. T e nervous and vascular ascicle underlies all o the
labium. Vascularization is provided by the labial artery and vein, which run at the base o the labia and
give branches to the labial crest that anastomizes superiorly with the periclitoral branches o the dorsal
artery o the clitoris.1 Innervation is by the labial nerve, which runs with the vessels and gives terminal
branches to the labial crest and the labial walls.2
Clitoris
T e clitoris, a double-arch–shaped erectile organ, is to cm long. T e f rst arch is composed o three
parts (three corpora cavernosa, the clitoral crura, and a ooting with the suspensory ligament), whereas the
second arch is composed o two bulbs ( to cm long) located in the lateral superior portion o the vagina.
Arterial supply to the clitoris is provided by the deep arteries that supply the corpus cavernosum; the arter-
ies o the bulb supply the bulb o the vestibule. T e dorsal artery o the clitoris runs on the dorsum o the
clitoris to the glans, where it divides into branches that supply the glans and prepuce.
T e dorsal veins are the most relevant and drain into the internal pudendal veins. Innervation to the
clitoris is provided by the in erior hypogastric plexus and the pudendal nerve.3
Vagina
T e length o the vagina is approximately .5 to cm. T e vaginal lumen varies in size, with some ana-
tomic variations, and alterations resulting rom vaginal delivery o a baby. T e vagina is an elastic, mus-

892
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
cular tube paved by mucosa with an underlying lamina propria o connective tissue, then a thin layer o
smooth muscle, ollowed by the adventitia, a thin layer o dense connective tissue. T e lamina propria
o the mucosa contains elastic f bers as well as a dense network o blood vessels, lymphatics, and nerves.
ransudate rom blood vessels, combined with cervical mucus secreted by glands, provides lubrication
during sexual arousal and intercourse.
T e vagina is divided into our ornices: one anterior, one posterior, and two lateral. In the anterior
ornix, deep to the mucosa, a thin layer o loose areolar tissue can be ound in the midline that runs
rom the urethra and is covered by the urethral sphincter. Posteriorly, the rectovaginal space hosts the
rectum muscle and the rectal ascia. In the f rst to cm, the space is thicker ( to cm) and progres-
sively becomes thinner. T e mucosa o the two lateral ornices is f rmly attached to the bulbocavernosus
muscle by a network o f bers T e bulbocavernosus muscle is thin, 0. to 1. cm thick. Laterally, the
ischiorectalis ossa hosts a at pad that separates the pubococcygeal muscle rom the ischiocavernosus
muscle. Inside the at pad run small branches o the perineal artery, and more posteriorly, o the internal
pudendal artery.4
T e arterial supply to the vagina arises rom three sources:

1. Vaginal branches o the uterine artery or the upper vagina

. T e vaginal arteries, branches o the hypogastric artery, to the middle vagina that penetrate the
vaginal tube perpendicularly

3. T e middle hemorrhoidal and clitoral arteries that send branches to the in erior portion o the
vagina
T e nerve supply to the vagina is rom the autonomic nervous system. Sensory f bers arise rom the pu-
dendal nerve, and pain f bers are rom sacral nerve roots.
Lymphatic drainage o the vagina is generally to the internal and external iliac nodes and the superf cial
inguinal and perirectal nodes.
PHYSIOLOGY: THE EFFECTS OF HORMONES, SENESCENCE, AND
VAGINAL DELIVERIES
Vulvovaginal tissues are highly a ected by changes in estroprogestinic levels, resulting in their trophism
and imbibition. Poor hormonal levels there ore cause senescence in tissues.5 T e aging process causes
a diminished trophism o the vulvovaginal structures: reduction o at deposits o labia majora, with a
“sagging bag” aspect, and reduced trophism o the labia minora; reduction o the at pad o the ischiorec-
talis ossa; and reduction o trophicity o the vaginal mucosa and lamina propria.6 T e complex myoten-
dinous system loses power and volume with aging.7,8
IDEAL APPEARANCE OF THE FEMALE GENITALIA
A canon o beauty o the emale genitalia has never been def ned. However, despite the wide anatomic
variation o the vulva, it is still possible to outline an ideal o emale genital beauty by re erring to the
genital eatures o young women, as or the canon o beauty o the breast, ace, eyelids, and so on. T e la-
bia majora should appear pu y and turgid; the labia minora must be partially hidden by the labia majora
and protrude by 1. to 3 cm; the clitoris should not be excessively prominent, and its prepuce should be
in continuity with the labia minora. T e vaginal ostium should not be exposed.

893
Chapter 47 • Fat Gra ting o the Female Genital Area
M
ethod s o f F a t G ra f ti n g o f the F ema l e G eni ta l i a
PREOPERATIVE EVALUATION: GENERAL CONSIDERATIONS
A candidate or at gra ing o the genitalia must demonstrate good general and local health, and the
genital area must be in good condition, without signs o in ammation. It is use ul to restore the vaginal
pH i it is altered.
T e least invasive procedures can be carried out under local anesthesia with or without sedation; spinal
or general anesthesia is used or the most complex procedures. Most procedures can be per ormed in
1-day surgical settings.
A solution o saline plus epinephrine plus ropivacaine (Naropin) is inf ltrated in a 1:1 ratio to the volume
o the area to be treated. T e purpose is to obtain vasoconstriction, reducing the caliber o the vessels.
Injection is per ormed with blunt 1 -gauge cannulas.
INDICATIONS AND SPECIAL CONSIDERATIONS
Fat gra ing is indicated to improve emale genitalia in the ollowing cases:
• Poor volumes
• Retracted scars rom surgery
• Cutaneous and mucous atrophies and dystrophies
• Pain syndromes
A distinction should be made between sa e, moderate, and high-risk areas or at injection to avoid po-
tential complications.
Safe Areas for Injection
• Labia majora
• Periclitoral area: Superf cial layers around the clitoris are sa e areas to inject, with care to avoid the
nervous-vascular bundle running perpendicular to the clitoris
• Lateral-anterior portion o vaginal walls
• In erior rectovaginal space ( to 5 cm rom the introitus)
Moderate-Risk Areas: Injections Must Be Performed With Great Care
• Labia minora: T e labial artery courses at the base o the labia; the surgeon placing at gra s in the
labia minora should be aware o this vessel and should avoid the use o small cannulas and needle.
• Anterior vaginal wall: No at should be placed close to the urethra, unless treatment o urinary incon-
tinence is considered, to avoid potential per orations and urethral distortions.
• Lateral to the bulbocavernosus muscle: T e ischiorectalis ossa contains branches o the perineal and
internal pudendal artery.
• Perineal area close to the rectum: T ere is a risk o per orations.

894
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
High-Risk Areas
• Major vessels can be ound in the deep layers. T e surgeon must avoid at gra ing where major vessels
run and exercise special care injecting close to the rectum, urethra, and peritoneum.
• Superior vaginal walls can present problems or at gra ing, as a result o the very short distance
between the vaginal walls and the bladder and peritoneum; ultrasound-guided injections are recom-
mended.
• T e superior part o the rectovaginal septum requires caution because o the thinness o the septum
itsel .
C l i ni ca l A p p l i ca ti on s
GENERAL CONCEPTS
Di erent indications call or specif c techniques o harvesting, processing, and placement o at gra s.
Volume Enhancement
• Harvesting with 2 mm cannulas
• Centri ugation at 3000 rpm or 2 minutes
• Fat gra ing with 1.20 mm (1 -gauge) 1.60 mm (16 g) blunt cannulas
Scar Release
• Harvesting with 2 mm, multihole ( 00-micron) cannula
• Centri ugation at 3000 rpm or 1 minute
• Fat gra ing with 1 - to 21-gauge blunt cannulas or 1 - or 21-gauge sharp needles (a rigottomy is per-
ormed with a needle or scar release)
Regenerative Ef ect
• Harvesting with 2 mm ( -gauge), multihole ( 00-micron) cannula
• Centri ugation at 3000 rpm or 1 minute
• Fat gra ing with 1 - to 21-gauge blunt cannulas
• Both cutaneous and mucous dystrophies at their initial phase can also benef t rom intradermal-
intramucosal injection o nano at gra s.9

895
Chapter 47 • Fat Gra ting o the Female Genital Area
SPECIFIC AREAS AND INDICATIONS
Augmentation of the Labia Majora
T e at compartments o the labia majora are important or achieving vulvar aesthetic balance. Enhance-
ment o the labia majora has been reported with the use o dermo at graf s.10 T e purpose is to correct
a volume naturally depleted by the aging process, to improve a contour that is congenitally poor, or to
mimic the reduction o excessively protruding labia minora by increasing the volume o the labia majora.
Gauge of the cannula for fat harvesting
Gauge of the cannula for fat grafting
Amount injected
Level of placement
Number of procedures
2 mm
16- or 18-gauge blunt cannula
5 to 15 cc on each side
Subcutaneous multilayer for 3 cm of depth
1 or 2
Fig. 47-5
Atrophy o the labia majora is shown in this patient be ore she underwent surgery. Note the changes
months af er cc o at was graf ed to each side o the labia majora and cc in the labia minora (re-
duction o the labia is an optical illusion).
Augmentation of the Labia Minora
T e purpose o this procedure is to augment an atrophic labia minora or to mimic the reduction o its
protrusion by enhancing the base o the labia itsel . Fat is graf ed to the oot o labia minora to atten
mild hypertrophy o the labia minora. T is requires care to avoid injury o the artery that runs at the
base o the labia minora itsel . o avoid injection inside the vessel, a cannula o . mm is needed.
Gauge of the cannula for fat harvesting
Gauge of the cannula for implantation
Amount injected
Level of placement
Number of necessary procedures
2 mm
16 g at the base and 0.8 mm to 18-gauge needle over the base
1 to 3 cc per side
Subcutaneous
1 or 2

896
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
lm

lm

lm
LM

LM
lm
Fig. 47-6
T e drawing demonstrates the optical reduction o a protruding labia minora by gra ing adipose tissue
into the oot o the labia minora.
Fig. 47-7
T e photo shows at gra ing into the labia minora.
Vaginal Lumen Reduction
T e vaginal lumen changes over time as a result o natural aging and particularly vaginal delivery o an
in ant,8 which stretches skin, mucosa, muscles, and the whole ascial system, thus modi ying both the
thickness o tissues and the contractile capability o muscles.
T e purpose o vaginal at gra ing includes the ollowing:

1. Reduction o the vaginal lumen by increasing the thickness o its walls; per ormed as a unique
procedure in moderate laxity cases

2. Reduction o the need o a high-tension suture perineoplasty and aggressive mucosal resection in
mild and severe laxities, combining at gra ing and a ascial suture technique

3. Regeneration o vaginal tissues
Placement Sites
• Posterior vaginal wall: Fat is gra ed in the perineal area and in the in erior rectovaginal septum, 4 or
5 cm rom the vulvar ostium upward, while care ully avoiding injecting the superior portion o the
septum. Use o a f nger inside the anus during the injection is advisable.
• Anterior wall: Fat can be injected along all the length o the lumen, maintaining a distance at least o
2 cm rom the urethral line. For this purpose, it is use ul to insert a catheter.
• Lateral: Fat can be injected in the space between the mucosa and the bulbocavernosus muscle, inside
the bulbocavernosus muscle (extremely thin and adherent to the mucosa), and into the ischiorectalis
ossa. (NO E: T is is a high-risk area i at is injected with a sharp needle.)

897
Chapter 47 • Fat Gra ting o the Female Genital Area
Uterus
Rectum
Bladder
Labia minora
Pudendal nerve
Unsafe
Safe
Fig. 47-8
Fat grafting of anterior and posterior vaginal wall
Fig. 47-9
Fat grafting of lateral vaginal wall and perineum
Between mucosa
and bulbospongiosus
muscle 5-10 cc
In bulbospongiosus
muscle 3-10 cc
In lateral fat
compartment 10-15 cc
In proximal perineal
space between vagina
and rectum 40-80 cc
Fat gra ing o the lateral walls o the vagina requires employing several principles or sa ety and e -
ectiveness. Hydrodissection is per ormed (with injection o saline plus epinephrine plus ropivacaine
[Naropin] 0.5%) o 10 cc per side o the space between the mucosa and bulbocavernosus muscle (to
separate muscle rom mucosa gaining space or the gra ). Inf ltration o 10 cc is placed inside the bulbo-
cavernosus muscle (to vascular constriction o the f ne vessel crossing the muscle perpendicularly), and
15 cc is placed inside the lateral at pad (to produce hydrodissection and vasoconstriction o small-
caliber vessels that might pass through the pad). Blunt cannulas o 0. mm are used to inject the submu-
cosal space, and 1.5 mm cannulas or intramuscular and lateral at pad injection.
Gauge of the cannula for fat harvesting
Gauge of the cannula for fat grafting
Amount injected
Level of placement
Number of necessary procedures
2 mm
16- to 18-gauge blunt cannulas
Lateral walls 8/20 cc
Posterior wall 5/10 cc
Anterior wall 10/15 cc
Subcutaneous, submucous, intramuscular
1 to 3

898
Part III • Clinical Applications • Lower Extremity and Genital Area: Reconstructive
Fig. 47-10
A

B
C
T is patient is shown be ore at gra ing o the lateral wall (A), 3 months postoperatively (B), and
months postoperatively (C).
Fig. 47-11
A
B
T is patient underwent at gra ing to correct vaginal laxity. T e vagina is shown be ore surgery (A), and
year a er at gra ing and a perineoplasty with skin mucosa resection and ascial suturing (B).
Vulvovaginal Scars
Vulvovaginal scars can be congenital (congenital anular stenoses), be o autoimmune origin (as a result
o lichen sclerosus and lichen planus), may occur as a sequela o in ections, or be iatrogenic in origin
( rom episiotomies, mutilations, radiodermatitis, in ections, or corticosteroid therapies). T ey result in
increased sti ness o tissues, increased ragility o the skin and mucosa, and a reduced contractile capa-
bility. All o these actors can lead to dyspareunia and ulceration.
T e purpose o at gra ing in the presence o vulvovaginal scars is to address the lysis o the adhesions,
to add so tissue (“pillow action”), and to produce a regenerative e ect on the scar. T e benef ts o at
gra ing or radiodermatitis have been previously described.11