Operative Technique in Plastic Surgery – Kevin C.Chung

OUTCOMES
■ The primary goal of the morbidly obese panniculectomy may vary depending
on the patient population.
■ Restore ability to ambulate
■ Functional access for other surgical interventions
COMPLICATIONS
■ Infection
■ Fat necrosis
■ Skin necrosis
■ Hematoma
■ Asymmetry of scar
REFERENCES
1. Natarajan B, Pallati PK, Bertellotti RP, Forse RA. Panniculectomy as a pre-
bariatric surgery procedure. Plast Reconstr Surg. 2011;127:169e.
2. Manhan MA, Shermak MA. Massive panniculectomy after massive weight
loss. Plast Reconstr Surg. 2006;117:2191.
3. Brown M, Adenuga P, Soltanian H. Massive panniculectomy in the super
obese and super super obese: retrospective comparison of primary closure
versus partial open wound management. Plast Reconstr Surg. 2014;133:132.

15
CHAPTERButtock Lift
Michele Shermak
DEFINITION
■ Buttock lift describes excision of lax and/or redundant lower back tissue to
improve lift and shape to the buttocks, as well as posterior waist contour. It is
the basis for the posterior element to lower body lifting for individuals who
have sustained massive weight loss. The procedure may be performed in
combination with augmentation of the buttock using fat, autologous flaps, or
implants or with lifts of adjacent body regions such as the abdomen or thigh to
globally improve the lower body region.
ANATOMY
■ The 10 gluteal aesthetic units, identified by Mendieta,1 while not all in the
buttock proper, impact the appearance of buttock (FIG 1A):
■ Sacrum
■ Flank
■ Upper buttock
■ Lower back
■ Outer leg
■ Gluteus
■ Diamond zone
■ Midlateral buttock
■ Inferior gluteal/posterior leg junction
■ Upper back
■ Anatomic layers of the lower back/buttock (FIG 1B)
■ The skin can demonstrate varying degrees of redundancy, vertical excess,
laxity, and collagen strength as manifested by striae. Thin skin may have

greater recoil after surgery resulting in exacerbated loosening of the surgical
result.
■ Subcutaneous fat varies in thickness. A thinner fat layer is more appropriate
for buttock lift than a thick one, which might be more suitable for a
liposuction contouring procedure or recommendation for weight loss. If
subcutaneous fat is limited, an augmentation with autologous flaps, fat, or
implant may be considered.
■ Scarpa fascia is the pseudofascial plane in the subcutaneous fat that varies in
strength and is relied upon for closure and lift and may need more sutures to
provide greater tension or better support for weak tissue.
■ Subscarpal fat is the layer in which dissection is performed for buttock lift.
■ Deep muscular fascia should not be cut during buttock lift. This layer
protects the muscles and vital vessels and nerves.
■ Muscles of significance in this region include the paired gluteus maximus
muscles, which should not be invaded during surgery so all structures deep to
the gluteus maximus are not dissected or visualized. Attenuated muscle may
account for buttock deflation and may be improved with fat augmentation.
■ Circulation of greatest importance is provided by the superior gluteal arterial
system and inferior gluteal artery system. Perforators from these arteries
should be preserved, particularly when performing autologous gluteal
augmentation2 (FIG 1C).
PATHOGENESIS
■ With skin laxity and/or weight loss of varying degrees, individuals can suffer
from excess vertical dimension of skin in the lower back with deflation and
flatness of the buttock area, an ill-defined infragluteal crease, cellulite, and lack
of fullness.
■ Ptosis may occur in the buttock and lateral thigh. This is associated with an
aged look or with difficulty in wearing clothing.
■ Lower backlift/buttock lifting surgery improves the posterior waist and shape
and tautness of the buttock, in conjunction with improving adjacent areas, like
the upper posterior thigh, outer thigh, and back.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history should be probed for significant weight loss, and if present in
the history, the mode and degree of weight loss, as well as nutritional
challenges that may exist.

■ Weight should be stable at the time of surgery at least 3 months.
■ Medical conditions that may impact outcome of backlift surgery should be
queried, such as diabetes, peripheral vascular disease, heart disease, sleep
apnea, autoimmune and endocrinological disorders, and coagulation
disorders and venous thromboembolic history.
■ Physical findings should note skin quality and degree of excess and
redundancy, as well as adiposity.
■ Adjacent body regions such as the upper back, abdomen, and thigh anteriorly
and posteriorly are examined to see if addressing these regions will improve
overall lower body aesthetics.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning depends on patient preference and deformities present.
■ Limitations in patient state of health or finances may curtail extensive surgical
procedure and mandate a staging plan.

FIG 1 • A. The 10 gluteal aesthetic units are shown. The
diamond zone includes the inner gluteal/leg injection. B.
From superficial to deep, anatomy of the buttocks
includes the skin, fat, pseudofascial plane in the fat,
muscle fascia, and muscles. The subcutaneous fat

layer may vary in thickness and deposition, and fascial
layers may have varying degrees of strength. Thickness
of each of these layers affects gluteal contour. C.
Arterial supply of the gluteal region is primarily provided
through the superior and inferior gluteal artery
perforators. The autologous flap is primarily supplied by
the superior gluteal artery perforator system as it is
within the angiosome.
■ Buttock lift is typically performed in continuity with abdominoplasty and
may be performed either at the time of abdominoplasty or at a later stage.
■ Planning and discussing possible augmentation in conjunction with buttock
lifting should take place prior to surgery.3
■ Prediction needs to be made by the surgeon to determine whether excision of
lower back tissue alone will provide adequate improvement to buttock
position and contour or if additional tissue in the form of autologous flap
tissue or fat graft should be harvested from the tissue that would otherwise be
discarded to help amplify and shape a severely deflated buttock.
■ Liposuction of the outer thigh also may be considered if it will improve
contour and allow greater tissue resection.
Positioning
■ Prone positioning is most optimal for buttock lift. It allows a symmetrical,
safe, and stable approach.
■ The patient is laid on two gel rolls laid horizontally across the OR table, one
under the upper chest and axillae, and the other under the lumbar area (FIG 2).
■ Axillae and elbows are positioned at no greater than 90 degrees to limit
traction on nerves and vessels.
■ The neck is in neutral position, and the face should be protected in a prone
pillow, avoiding any pressure to the eyes.

FIG 2 • Prone positioning helps provide the best access
to the lower back, allowing symmetrical treatment.
Safety measures must be followed to avoid blindness,
stroke, neurapraxia, and pressure phenomena. A. Face
in prone pillow with goggles protecting eyes from
pressure and desiccation. B. Arms at 90 degrees and
bumps under chest and lumbar region. C. Bump under
lumbar region. Patient is warmed with forced warming
blanket intraoperatively.
■ These maneuvers in the head and neck limit the risk of kinking of arteries in
the neck to prevent dissection and stroke, as well as blindness.
■ The legs and arms should be padded with pillows or foam to avoid pressure to
superficial nerves.4
Approach
■ Landmarks including the posterior superior iliac crest and sacral depression
guide markings for skin removal.
■ The buttock down to the infragluteal fold should be marked and prepared in
the field.
■ Skin undermining and laxity is greatest laterally and extremely limited
centrally.
■ Markings made preoperatively with the patient standing allow for this and aim
to create an incision that resembles a gull wing over the buttock to define and
improve aesthetics of the buttock region.
T E C H N I Q U E S

■ Buttock Lift
■ The patient is marked while standing.
■ Excision is determined by movement and laxity of the skin, as well as goal
of creating a symmetric, curvilinear incision that will border the upper
gluteal region (TECH FIG 1A).
■ Skin is grasped, and pinching skin closed will guide the marks.
■ Midline should be marked.
■ Little will be excised centrally where there is strong tissue adherence, with
increasing removal planned moving laterally.
■ Cross-hatches are made vertically across the proposed excision to aid in
approximation.
■ The patient is intubated on a stretcher and turned to the prone position with
careful padding and protection of all potential pressure points.
■ The patient is prepared with Betadine.
■ If liposuction is planned in the outer thigh, tumescent solution is infused.
■ Incision is made superiorly in skin, through subcutaneous fat to deep fascia.
■ Dissection is then directed inferiorly toward the lower marked incision
(TECH FIG 1B,C).
■ Minimal undermining is performed.
■ Careful hemostasis is performed, and the wound is irrigated.
■ Local anesthetic is injected above and below deep fascia; long-acting
Marcaine is preferable.
■ Prior to definitively determining the skin excision, if liposuction is going to
be performed, it should be performed at this stage, as tissue may mobilize
further and allow greater excision.
■ Tailor tacking is performed to aid in precise skin removal, using the hatch
marks as a guide.
■ The areas are stapled as skin is excised.
■ Tailoring often needs to take place at the sacral hollow in the middle of the
incision, closing as a V in the cleft.
■ A no. 10 flat Jackson-Pratt drain is placed within the wound and exited out
laterally under the incision on each side. It is sutured to the skin.
■ The wound is closed. No. 1 braided nylon is used to approximate Scarpa
fascia, taking a bite of deep tissue with the fascial layer to close dead space.

(Trang không có chữ)

TECH FIG 1 • A. The patient is marked while standing.
Markings are based on skin laxity as well as incision
placement goal through a grasping technique and
putting the skin on traction. B. Incision is made in the
skin to the level of the deep fascia, leaving soft tissue
intact, and dissection proceeds inferiorly. C. Skin
removal is determined with tailor tacking. D. Closure
of the lower back incision looks like a gull wing over
the buttocks.
■ The skin is closed with 3-0 monofilament absorbable suture to approximate
deep dermis and running 4-0 monofilament absorbable suture as a running
subcuticular suture.
■ Skin is then better approximated with interrupted 4-0 nylon simple
interrupted sutures (TECH FIG 1D).
■ The wound is washed and dressed with cyanoacrylate glue.
■ Attention can then be turned to another body region, such as the posterior
thigh or abdomen.
■ Buttock Lift With Autologous Gluteal
Augmentation
■ The patient is marked standing.
■ A mirror image of the buttocks is drawn within the upper and lower
markings of excision.
■ Err on the side of removing less over more to allow for closure over the
flaps and avoiding undue tension on the closure or pressure on the flaps.
■ Also err on the side of elevating the lower incision to allow ease of closure
over flaps.
■ Incision closure will be more transverse than gull wing at the end of the
procedure.
■ Cross-hatches are made vertically across the proposed excision, particularly
in the midline and along the lateral buttock, to aid in approximation during
closure (TECH FIG 2A).
■ The patient is intubated on a stretcher and turned to the prone position with

careful padding and protection of all potential pressure points.
■ After preparing the area with Betadine, the areas marked for the buttock
reconstruction flaps are de-epithelialized bilaterally and symmetrically.
■ Superior incision marked on the back is made to deep fascia, whereas the
lower incision is made to the subcutaneous fat.
■ Tissue marked outside the flaps medially and laterally is then resected to
deep fascia full thickness around the flaps.
■ Deep fascia around the flap is incised, not to muscle, to allow release and
movement of the flaps (TECH FIG 2B,C).
■ Gluteal artery perforator blood supply is based on the superior gluteal artery,
and this must be preserved when releasing the fascia around the flaps.
■ Dissection of the skin flap over the buttock follows to create a pocket for the
flap. Maintain subcutaneous fat on the skin flap and dissect inferiorly as
marked to create a pocket for the flap (TECH FIG 2D).
Video p5-c015_01
■ Careful hemostasis is performed.
■ Local anesthetic is injected above and below deep fascia.
■ The flap may then be moved without rotation under the skin.
00:00 / 00:00

Video p5-c015_02
■ The flap is tacked into position on deep fascia with 2-0 absorbable braided
suture.
■ A 10-mm flat drain is then placed on each side in the dead space. It is
sutured to the skin (TECH FIG 2E).
00:00 / 00:00

E

TECH FIG 2 • A. Autologous gluteal augmentation flap
is marked in mirror image to the buttocks in the lower
back skin excision marked. B,C. The tissue marked is
de-epithelialized, and tissue between and lateral to the
flaps is excised full thickness to deep muscular fascia.
D. The pocket for the gluteal flap is dissected,
maintaining subcutaneous fat under the skin to
maintain circulation (see Video 1). The pocket must be
dissected inferiorly toward the fold so the flap is not
too highly placed. E. The flap freely descends under
the skin designed for the flap pocket (see Video 2),
and the flap is secured in place with 2-0 Vicryl sutures,
prior to closing skin. F,G. Skin is closed in layers over
the flap, with drains in place bilaterally.
■ The wound is closed.
■ No. 1 braided nylon is used to approximate Scarpa fascia, with 3-0
monofilament absorbable suture to approximate deep dermis and running
4-0 monofilament absorbable suture as a running subcuticular suture.
■ Skin is then better approximated with interrupted 4-0 nylon simple
interrupted sutures (TECH FIG 2F,G).
■ The wound is washed and dressed with cyanoacrylate glue.
■ Attention can then be turned to another body region, such as the posterior

thigh or abdomen.
PEARLS AND PITFALLS
Optimizing
scar
■ The best scar results from reduction of tension on the wound, assured
by limiting over-resection, and by scar location and symmetry.
Without gluteal augmentation, the gull wing scar leads the eye to a
focused, well-contoured gluteal region. Maintaining adequate
subcutaneous fat on the skin flap for autologous augmentation is
critical to avoid wounds.
Optimizing
wound
healing
■ Avoid high-tension closure and proactively address intraoperative
issues such as hypothermia and anemia. Wounds are extremely
common in the midportion of the incision at the lower sacrum and
respond well to gentle cleansing and petrolatum application.
Seromas
■ These are not uncommon with this procedure, most often associated
with large tissue removal. Maintaining a layer of tissue over deep
fascia to assist in lymphatic and venous egress as well as limiting
undermining and maintaining drains in place until output is low will
best protect against seromas.
To
augment
or not to
augment
■ This question needs to be addressed preoperatively as the most
optimal tissue for augmentation will otherwise be discarded. This is a
judgment call based upon the quantity of existing gluteal tissue: if
there is very minimal tissue and significant flattening, then
autoaugmentation should take place. This is a much bigger procedure
from which to recover and requires hospital overnight stay and
monitoring for anemia.
POSTOPERATIVE CARE
■ Patients are followed on a weekly basis after surgery to assure optimal wound
healing and drain care.
■ Drains can be removed when drainage is 30 to 40 cc or less per day.
■ Wounds that develop are typically superficial and respond well to gentle
cleansing and topical petrolatum, with modification to topical antimicrobial
medications for superficial wounds that may be infected, or debridement and
packing for deeper wounds.

■ Seromas are not uncommon and should be aspirated if there is concern about
seroma presence to avoid chronic scar and possible abscess.
■ Strenuous activity may be resumed about a month after surgery as long as
healing is uncomplicated.
■ Longer-term care is provided for scar management, including topical therapies
to reduce scar visibility and massage to assist in dysesthesias and edema.
■ Compression with a pull-up girdle assists in reducing swelling through the
day.
COMPLICATIONS
■ Seroma is one of the most common risks with this surgery and is best
minimized by maintaining a layer of connective tissue over deep fascia to
assure venous and lymphatic drainage, as well as maintaining drain tubes until
output is less than 30 to 40 cc/d.
■ If a seroma develops, it is best to aspirate with a needle to assure no long-
term pseudobursa and scar or abscess. More advanced techniques are helpful
with chronic seromas.5
■ Wound healing problem: Addressing and planning how to compensate for
preoperative risk factors like malnutrition, diabetes, peripheral vascular disease
and smoking, and downstaging procedures for morbidly obese patients or
patients with multiple medical problems.
■ Careful surgical technique and attention to maintaining circulation to the
tissues and avoiding undue tension optimize wound healing.
■ Unsatisfactory scarring is best avoided by minimizing risk of wound healing
problems, reducing tension, and closely monitoring postoperatively to innovate
scar management depending on progress
■ Venous thromboembolism: It is necessary preoperatively to check on any
history or elevated risk as per the modified Caprini scale.6
■ Infection is not common, and risk can be reduced by optimizing surgical
conditions like addressing efficiency with reduced operative time and
hypothermia, as well as initial dose of antibiotics prior to making incision.
■ Seromas can become sources of infection and should be treated.
REFERENCES
1. Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg.
2006;33(3):333-346.
2. Georgantopoulou A, Papadodima S, Vlachodimitropoulos D, et al. The

microvascular anatomy of superior and inferior gluteal artery perforator (SGAP
and IGAP) flaps: a fresh cadaveric study and clinical implications. Aesthetic
Plast Surg. 2014;38(6):1156-1163.
3. Centeno RF. Autologous gluteal augmentation with circumferential body lift
in the massive weight loss and aesthetic patient. Clin Plast Surg.
2006;33(3):479-496.
4. Shermak M, Shoo B, Deune EG. Prone positioning precautions in plastic
surgery. Plast Reconstr Surg. 2006;117(5):1584-1588.
5. Shermak MA, Rotellini-Coltvet L, Chang D. Seroma development following
body contouring surgery for massive weight loss: patient risk factors and
treatment strategies. Plast Reconstr Surg. 2008;122(1):280-288.
6. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of postoperative
venous thromboembolism risk in plastic surgery patients using the 2005 and
2010 Caprini Risk score. Plast Reconstr Surg. 2012;130(2):343-353.

16
CHAPTERCircumferential Body Lift
Joseph Michaels and Jennifer Capla
DEFINITION
■ A lower body lift is a combined procedure consisting of an abdominoplasty,
lateral thigh lift, and buttock lift.
■ Addresses the lower truncal skin redundancy in the massive weight loss
patient in a circumferential fashion by removing skin excess from the
abdomen, hips, lateral thighs, flanks, and buttocks.
ANATOMY
■ Excess skin can distort a patient’s anatomy.
■ Knowledge of the superficial fascial system (SFS) as described by Ted
Lockwood is important (FIG 1).1
■ The SFS has zones of adherence. Posteriorly, this is to the spine; anteriorly, it
is to the lower borders of the pelvis.
■ The bony landmarks of the pelvis are commonly used as reference points,
specifically the anterior superior iliac spine (ASIS) and the ischium.
■ Preservation of the inguinal lymph node basin and knowledge of the course of
the lateral femoral cutaneous nerve is important to minimize complications.
■ Abdomen
■ The borders are the costal margins and xiphoid superiorly, the pubic
symphysis inferiorly, and the ASIS laterally.
■ The blood supply to the abdomen is classically described as three zones (FIG
2):2
• Zone 1: midabdomen supplied by the deep epigastric arcade
• Zone 2: lower abdomen supplied by the external iliac artery

• Zone 3: flanks and lateral abdomen supplied by the intercostal, subcostal,
and lumbar arteries
■ Buttocks
■ Landmarks include the posterior superior iliac spine, the ischial tuberosities
inferiorly, and the greater trochanter laterally.
■ The gluteal fascia will serve as an anchor point for rotational flaps used to
preserve and restore buttock volume.
■ Thighs
■ This region overlies the greater trochanter and tensor fascia lata. Anteriorly, it
extends to the ASIS.
■ The saddlebag deformity that is commonly seen is a combination of residual
adiposity and loose skin.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients generally present with massive weight loss (weight loss greater than
75 lb).
■ This can lead to various degrees of skin laxity depending on the extent of
weight loss, the rate of weight loss, and the patient’s skin elasticity.
■ Physical examination is focused on the abdomen, lateral thighs, flanks, and
buttock.
■ Patients often present with excess skin in the abdomen and may have an
intertriginous rash (erythema intertrigo) in the skinfold. There is also
commonly mons ptosis. Excess skin extends to the lateral thigh (saddle bag)
region and continues onto the buttock. There is often a sense of deflation in the
buttock region.
■ Abdomen should be evaluated for degree of rectus diastasis, previous
incisions, and any associated hernias.

FIG 1 • The superficial fascial system between the
superficial and deep fat compartments of the abdomen.
FIG 2 • Blood supply to the abdomen.

IMAGING
■ An abdominal CT scan may be helpful if there are any concerns for an
abdominal hernia—umbilical, ventral, or incisional. This will allow for better
intraoperative planning and the possible need for a general surgeon.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients should be at or close to their goal weight and weight stable for a
minimum of 3 months.
■ All massive weight loss patients should undergo a full preoperative evaluation
in addition to a nutritional assessment.
■ Nutritional assessment is an important factor in wound healing and should
include albumin, prealbumin, B12, folate, iron, and total iron binding capacity.
■ Understanding and assessing the patient’s goals is of primary importance.
■ In front of a mirror, with the patient unclothed, the pinch technique can help
provide the patient with a sense of how the tissues will translate and what will
be achieved with this procedure. This can also be done with the patient lying
down and showing them a picture of the projection (FIG 3).
■ Determine whether the patient needs added volume in the buttock.
■ A lower body lift inevitably will flatten the buttock. Gluteal
autoaugmentation is considered in patients who desire increased buttock
volume and projection.
■ The markings are the key to the procedure.
■ Prewarm the operating and all IV fluids to minimize patient hypothermia.
Positioning
■ The patient is intubated on a stretcher.
■ The patient is transferred to the operating room table in the prone position with
appropriate padding.
■ Arm boards can be placed on the lower part of the table to widen the bed and
to allow for additional abduction of the legs. This will help obtain the maximal
lateral thigh lift.
■ After the lower body lift is performed, the lateral dog-ears are tucked, stapled,
and covered with a sterile dressing.
■ The patient is then repositioned into the supine position for the

abdominoplasty portion of the procedure.
Approach
■ The determination of whether the patient requires additional buttock volume
will ultimately determine the approach for the lower body lift.
■ If none is required, this procedure is simply a circumferential removal of
skin, also known as a belt lipectomy.
■ If increased gluteal projection and volume is necessary, gluteal
autoaugmentation or fat transfer will be required.
FIG 3 • Pinch test to evaluate buttock projection for
whether autoaugmentation is needed during a lower
body lift.
T E C H N I Q U E S
■ Lower Body Lift With Gluteal Autoaugmentation
Flaps
Markings (TECH FIG 1)
■ Patients are asked to bring an undergarment, and upper and lower borders
are marked to try and keep the incisions hidden within these lines. Most
people wear their undergarments at the level of the anterior superior iliac
spine (ASIS).

■ The ASIS is also marked, and this height is also transposed to the back as a
reference point.
■ The next mark is made with the patient lying down. The lower abdominal
incision is marked at 6 cm above the vulvar commissure in women or the
pubic symphysis in men.
■ The patient is then asked to stand up, and the posterior markings are done
first. The posterior midline is marked, and the midaxillary line is marked.
This represents the lateral extent of the posterior excision.
■ In the midline, a mark is placed several centimeters above the gluteal cleft.
This point will represent the top of the new gluteal cleft and should lie below
the level of the ASIS.
■ The superior marking is drawn as a gull wing from the midline mark to a
point on the midaxillary line that lies below the ASIS on downward traction.
■ A conservative pinch test is performed every 5 to 6 cm up to the superior
line. These points are connected and represent the lower posterior marking.
■ The area for autoaugmentation is marked. These flaps are designed within
the area of resection and nearly encompass the entire area of resection except
for the lateral few centimeters over the lateral thighs.
■ The patient is then asked to turn around, and the anterior incision is marked
with superior traction on the abdomen.
■ The previous marked lower abdominal incision is connected to the lower
posterior marking at the midaxillary line.
■ This incision should also remain below the level of the ASIS on upward
traction of the abdominal skin.
Gluteal Autoaugmentation
■ The procedure starts in the prone position (TECH FIG 2A,B).
■ A towel clip is first used to approximate the upper and lower markings to
confirm the area of resection. If too tight, adjust the lower marking
superiorly.
■ The area marked for autoaugmentation is de-epithelialized (TECH FIG 2C).
■ The flaps are further dissected with electrocautery to dissect down through
the superficial fascial system (SFS) and down to the deep fascia at the
superior and inferior margins.
■ Laterally, dissection continues through the SFS until the deep fat pockets
are exposed; there is no deep fascia laterally.
■ The tissue between the midaxillary line and the lateral extent of the flap is

excised.
■ Inferior to the flap, a pocket for the flap is dissected just above the gluteal
fascia (TECH FIG 2D).
■ The gluteal tissue is elevated from the lateral aspect leaving a broad base to
supply the flap.
■ The flap is raised just enough that it can be rotated inferiorly into the
pocket to provide the desired projection.
■ A Lockwood underminer is used to release the lateral thigh attachments to
the greater trochanter allowing for additional upward movement of the lateral
thigh and correction of the saddlebag deformity.
■ Liposuction can be used to remove any residual adiposity from this region
at this time. Liposuction can also be performed in the lower back region as
necessary.
■ The SFS is reapproximated with 0-Vicryl sutures. The skin is closed in
layers with 3-0 Monocryl (TECH FIG 2E,F).
■ The lateral dog-ears are temporarily stapled and closed.
Abdominal Lift
■ The patient is transferred to the supine position on the operating room table
(TECH FIG 3A), dependent areas are again padded, and the patient is
sterilely draped.
■ The lower abdominal incision is made and connected to the posterior
incision laterally.
TECH FIG 1 • A. Transposition of ASIS to posterior
aspect as a reference point. B. Superior and inferior
markings of the resection with area of
autoaugmentation marked. C. Lateral view of the
markings showing the extent of the posterior excision,

as well as the lateral aspect of the autoaugmentation
flaps. D. Anterior markings of the lower abdominal
incision connecting to the posterior markings. This line
should remain below the ASIS. E. Anterior markings
with the abdominal skin flap relaxed.
TECH FIG 2 • A,B. Patient in the prone position with
superior and inferior body lift markings. C. De-
epithelialized and dissected buttock flaps. D. Pockets
made for the inferior rotation of the gluteal flaps. The
left side shows the pocket dissected just superficial to
the gluteal fascia. The right side shows the gluteal
flaps inferiorly rotated and sutured to the gluteal
fascia. E. Closure of the posterior incision line. F.
Lateral view after gluteal autoaugmentation showing
the change in gluteal projection. Compare with A.
■ As this incision may lie below the level of the inguinal canal, care must be
taken to avoid injury to the inguinal lymph node basin and the round
ligament/spermatic cord during elevation of the abdominal flap.
■ Care is taken to leave soft tissue on the deep fascia lateral to the rectus

abdominis muscle. This helps preserve lymphatics and decreases the risk of
seroma.
■ Superior dissection continues to the level of the umbilicus.
■ The umbilicus is circumscribed, leaving adequate perforators, and
dissection of the abdominal flap continues up to the level of the xiphoid
process and costal margins.
■ Any hernias are repaired along with repair of the diastasis recti with
permanent sutures (0-Ethibond).
■ The patient is sat up in the semi-Fowler position, and the skin excess is
marked and excised. The new umbilical position is marked.
■ Two no. 15 drains are placed and brought out laterally through the incision.
These drains are placed in a crisscross fashion and extend to the opposite side
to drain the back.
■ The abdomen is closed in a similar manner as the back, and the umbilicus is
sutured to the abdominal wall flap with 4-0 Monocryl sutures in layers
(TECH FIG 3B).
■ The markings are similar to the markings described above, except that there
are no markings for the autoaugmentation flap (TECH FIG 4).
■ This procedure is performed similarly to the above procedure except no
dermoadipose flaps are dissected to provide added buttock volume.
■ For this procedure, the tissue between the superior and inferior incision lines
is removed at the level just deep to the SFS. There is no dissection performed
outside the areas of resection.
■ Posterior closure and the anterior steps are the same as described for the
lower body lift with autoaugmentation.

TECH FIG 3 • A. Patient now in supine position. Dog-
ears from the back can be seen laterally on the
abdomen. B. Closed abdomen following completion of
the abdominoplasty and lateral dog-ear excision.
■ Lower Body Lift Without Autoaugmentation (also
Known as a Belt Lipectomy)
TECH FIG 4 • A. Anterior, posterior (B), and lateral
views (C) of preoperative markings for a lower body lift
without autoaugmentation flaps.
PEARLS AND PITFALLS
Lower body lift
■ Creating a dartoid point at the gluteal crease helps to avoid the
appearance of the gluteal crease extension above the incision.
Lateral thigh lift
■ Dividing the zones of adherence with the Lockwood
underminer allows for a greater pull and redistribution of the
tissues.
Mons pubis
ptosis
■ In marking the lower abdominal incision, be sure to lift the
mons and resuspend at the time of closure.

Staging
procedures
■ Do not perform a vertical medial thigh lift or an upper body lift
at the same time as a circumferential body lift because of the
opposition of vectors on the pull of the tissues.
Lower body lift
■ In the prone position, flex the table 5 to 10 degrees to take the
tension off the posterior incision when the patient is in the semi-
Fowler position.
Abdominoplasty
■ Preserve tissue on the deep fascia to minimize the risk of
seroma.
Lower body lift
■ If patient has very heavy thighs, consider thigh debulking
liposuction first to decrease pull on incisions.
POSTOPERATIVE CARE
■ Patients should be maintained in the semi-Fowler position.
■ Patients should ambulate the evening of surgery.
■ Plan for hospital admission for 1 or 2 nights.
■ Recommend postoperative venous thromboembolism chemoprophylaxis.
■ No lifting over 10 lb for 6 weeks.
OUTCOMES
■ Patients will see immediate improvement, but swelling will persist for up to 3
to 6 months.
■ Long-term patient satisfaction is high (FIG 4).
FIG 4 • Preoperative (A–C) and postoperative (D–F)
views of patient who underwent a lower body lift with
autoaugmentation.

FIG 4 •
COMPLICATIONS
■ Seroma
■ Wound dehiscence
■ Infection
■ Scarring
■ Hemorrhage
■ Residual laxity
■ Skin loss
■ Residual laxity
■ Incomplete correction
■ Need for revision
■ Venous thromboembolism
REFERENCES
1. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a
new concept. Plast Reconstr Surg. 1991;87:1009-1018.
2. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg.
1979;45:612-617.

17
CHAPTER
Lower Posterior Torso and
Buttock Sculpting
Dennis J. Hurwitz
DEFINITION
■ Harmonious sculpturing of a feminine lower back, waist, and buttocks is a
new frontier in body contouring surgery. Because less attention has been
focused on these regions than the breasts and abdomen, many plastic surgeons
need training in advanced approaches to achieve femininity of the lower
posterior torso.
■ Although the public is increasingly requesting buttock enlargement, adjacent
areas such as the flanks, hips, and lateral and posterior thighs should be also
addressed when performing buttock augmentation. As there is minimal demand
for augmentation of the male buttocks, the male situation will receive limited
attention.
■ A summary of this author’s approach follows:
■ Back rolls with undersized buttocks are treated by third-generation
ultrasound-assisted lipoplasty of the torso with lipotransfer to the buttocks in
the young overweight female.
■ Posterior torso tissue laxity with flank rolls and buttock ptosis is the
indication for lower body lift with de-epithelialized adipose fascial flap
buttock augmentation. Liposuction harvest of fat from the flanks and
abdomen followed by fat transfer to the inferior buttocks may be helpful to
complete the lower torso buttock reshaping.
■ Maximum narrowing of the waist in the older female, especially when none
ever existed and the most effective safe correction of oversized love handles
in all males is achieved with direct oblique excision of the flanks, ie, a oblique
flankplasty.
■ Silicone elastomer implants are reserved for buttock augmentation when

harvestable fat stores are inadequate.
■ The drawbacks of commonly accepted approaches have limited their use in
favor of innovative solutions to be presented in this chapter.
■ Traditional liposuction is rather traumatic when applied to the fibrous
posterior torso.
■ Hip-hugging circumferential lower body lifts with and without adipose
fascial flaps for gluteal buttock augmentation often sag along the lateral
gluteal region and fail to narrow bulging waists.
ANATOMY
■ A sensuous woman’s lower posterior torso, upper thigh, and buttocks and the
procedures to create them are based anatomically (see FIG 1 for an artistic
rendering of role of underlying anatomy to feminine shape). The photographic
results of the four case presentations of this chapter approximate aesthetic
ideal.
■ A subtle feminine S-shaped curvilinear midline is centered on the curving
lumbar spine. Along with its paraspinous muscular ridges, this concavity
bridges the convexities of the lower thoracic spine and sacrum.
■ A tapering lower thoracic rib cage narrows to the pelvic brim. This gap is
spanned by the latissimus dorsi and external oblique muscles with overlying
adipose.

FIG 1 • Anatomy relationships in the aesthetic lower
back and buttocks. The musculoskeletal structure and
relationships are responsible for the underlying shape

of the lower back, waist, and buttocks. Adipose fullness
about the hips and buttocks accentuates femininity. The
paramedian vascularity clearly nurtures advanced
buttock flaps.
■ At an ideal 0.7 transverse diameter, waist-to-buttocks ratio, the waist abruptly
expands laterally over the posterior iliac spines to adipose rounded hips that
are wider than her shoulders.1
■ The maximal projection of the midbuttocks combines adiposity with the
gluteus maximus muscle bulk and lies directly on a horizontal plane to the
mons pubis.
■ Buttock projection abruptly extends from back lordosis.
■ From their widest diameter, lateral buttocks smoothly taper to slightly convex
upper lateral thighs.
■ Posterior medially, the curved buttocks abruptly end in horizontal folds about
the ischial tuberosity to border the upper posterior thighs.
■ Within those essential features, there are a variety of sensually pleasing sizes
and shapes, but overall, the ideal 0.7 ratio of waist-to-buttock transverse
diameter holds true.
■ Preserved generous paramedian perforating blood supply allows for high-
tension closures and limited mobilization of adipose fascial flaps for buttock
augmentation.
■ Android body build, massive weight gain and loss, aging, and lower body lifts
may result in masculinization and/or undesirable contours.
■ Reducing of the curvilinear midline features
■ Dampening of lumbar lordosis
■ The lower back and waist undulating concavities are straightened and may
even bulge.
■ Increased breadth of the back and waist dominates over the narrowing
buttocks.
■ Lateral buttocks are flattened and even depressed.
■ Inferior buttock fold separations from the posterior thighs are obliterated.
NATURAL HISTORY
■ The shape of the posterior torso and buttocks can be distorted by congenitally
flared posterior costal margins, wide and high pelvic rims, localized flank

adiposity, weight gain, weight loss, pregnancy, and menopause.
■ Most commonly, aging with weight gain broadens the midtorso, deposits, and
transverse rolls and narrows and flattens the buttocks. Buttock ptosis may
obliterate the fold at the medial posterior thighs and leave sagging, wrinkled
skin.
■ Once acquired, increased girth of the flanks is hard to lose through exercise
and weight loss, and narrow buttocks rarely expand.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ For the back and buttocks, women usually request elimination of sagging back
rolls and filling flat buttocks. On occasion, they specifically mention a smaller
back, a narrower waist with smooth contours bridging the lower chest and
buttocks, and rounder buttocks. More commonly, they complain of sagging
abdomen and/or breasts.
■ They either ignore the back, waist, or buttocks or simply feel that little can be
done to improve bulging or masculine features. Because of that, women
considering breast reshaping or abdominoplasty should have their posterior
torso, thighs, and buttocks examined. If those areas are sensually alluring, she
should be complimented.
■ As a rule, in all but morbidly obese patients or after extreme weight loss, the
central back is feminine and need no correction. Her figure faults are
presented, and if there is interest, the means for their correction are offered.
■ In Western Pennsylvania and probably throughout most of America,
candidates for body contouring of the back and waist rarely request
improvement. Instead, they inquire about breast reshaping and are pleased to
learn that the lateral breast roll and upper back can be reduced.
■ They request a tummy tuck and are pleased to learn that their waist can be
reduced by liposuction or direct excision. A deep and defined waist with
rounded buttocks during youth suggests fertility, which is an aphrodisiac.
■ With buttock augmentation requests, patients are pleased to learn that fat
removed from around the buttocks not only can be processed to augment it but
also the perimeter reduction can picture frame buttock prominence. Because
their companions better see the posterior view, they tend to be enthusiastic
about the anticipated improvement. For some, a lower body lift is the best
approach to suspend the thighs and buttocks.
■ The examination while standing exposes the entire aesthetic complex.
■ Overall and localized excess adiposity and skin laxity are noted.

■ Tightly bound skin expanded by underlying fat is noted as the contour can be
improved by liposuction with the expectation of reasonable skin retraction.
■ Hanging tissues and rolls are described by location (lateral breast, scapular,
midback, flanks, and hips) and magnitude.
■ Back rolls are characterized by transverse accumulations of adiposity within
loose skin bordered inferiorly by transverse dense fibrous adherence from the
dermis to the underlying muscular fascia through relatively thin subcutaneous
fat.
■ Ptotic rolls, in most over 50 years of age, are best treated with direct or
superior excisions.
■ Sagging and flat buttocks are congenital, age related, or the aftermath of
severe weight loss.
■ Laxity with lateral flattening and even indentation are common with aging.
■ While pointing out figure faults in front of a full-length mirror aids
communication, reviewing standardized digital images is usually less
awkward. In either case, lines can be drawn that indicate proposed excisions,
liposuction or lipoaugmentation, and resulting scars.
IMAGING
■ There are no supportive radiologic or other diagnostic studies.
NONOPERATIVE MANAGEMENT
■ If the posterior torso and buttocks are obese, then a weight loss program is
indicated.
■ There are a variety of noninvasive treatments that apply energy to cause lysis
of adipose for reduced volume. Topical treatments of proven but limited and
somewhat variable reduced shaping are CoolSculpt, Thermage, VelaShape,
Liposonix, and VASER Shape.
■ They are intended to reduce small selected areas over repeated and rather
painful treatments. Large contour adipose excess is difficult to reduce.
■ The appeal is nonsurgery and minimal to no downtime.
■ Smartlipo with YAG laser energy leads the list of recognized minimally
invasive adipose lysis with some skin retraction, but this costly technology
has not been widely embraced among plastic surgeons.
■ Recently, minimally invasive treatments with subcutaneous thin probes
delivering controlled radiofrequency energy, Thermi and InMode BodyTite,
have shown consistent lipolysis with some shrinkage of the lower torso.

SURGICAL MANAGEMENT
Indications
■ Patient recognizes correctable deformity of the lower posterior torso and
buttocks.
■ Patient is reasonable in goals and accepts the therapeutic recommendations
and risks.
■ Patient is in good health with control of chronic disease.
Preoperative Planning
■ Medical, mental, and psychological conditions must be evaluated and
acceptable for elective surgery.
■ The roles of liposuction, fat grafting, tissue excision, adipose fascial flaps, and
silicone implants toward reaching their aesthetic goals
■ The functional working order of all equipment with special attention to high-
technology instrumentation
■ An awareness of the areas to be liposuctioned, lipoaugmented, and excised and
the resulting scars
■ The trade-off of scars for unwanted contour deformities
■ Understanding of the unpredictable quality of scars and the likelihood of faded
scars over many years
■ The planned areas for liposuction and incisions for skin and fat excisions are
drawn on the awake patient either the evening before or immediately prior to
the operation.
■ Patient understands the unpredictable magnitude of fat graft take.
■ Patient understands the risks of implant malposition, exposure, and infection.
■ Immediately prior to the procedure, the tissues are pushed together to simulate
closures. Excessive width of resection is avoided. When closures are planned
over buried adipose fascial flaps, the width of resection is appropriately
reduced.
■ Following neighboring liposuction and flap undermining, manual assurance of
the proper width of resection is made during the operation for the final time
with the plan to tangentially resect more tissue if needed to obtain mild tension
at closure.
Positioning

■ Surgery only on the posterior trunk is performed with the patient prone. The
table is airplane towards lateral for deep liposuction of the flanks.
■ When an abdominoplasty is part of the plan and fat harvest in the prone
position is estimated inadequate for the buttock augmentation, then the
operation starts supine with the lipoabdominoplasty followed by a turn prone
with strategic placement of gel body rolls to obtain a jack-knife position.
Approach
■ Some combination of the following advanced techniques are considered:
■ VASERlipo with optimal probe, mode, power, and cannula selections for
extraction and harvesting of fat
■ Lower body lift with adipose fascial flap augmentation
■ Direct oblique excision of flank excess selectively replaces lower body lift.
■ Silicone soft elastomer gluteal implant augmentation
T E C H N I Q U E S
■ VASERlipo of the Posterior Torso With
Lipoaugmentation of the Buttocks (Video 1)
Video p5-c017_01
■ The demand for gluteal fat augmentation has increased in recent years, with
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9993 reported procedures in 2013 and 11 505 in 2014 in the United States.
■ VASERlipo is best indicated for flatten buttocks with mild to moderate torso
adipose deposits in a previously well-shaped young woman (TECH FIG 1A-
D).
■ The 1 year result of 3500-cc VASERlipo and 300 cc of lipofill of each
lateral buttock reveals more pleasing feminine contours (TECH FIG 1E-
H).
Markings
■ Through visual and palpable cues, bulging and moderately ptotic back rolls
are mapped with purple marker from one to three pluses for the extent of
adiposity to be removed via liposuction.
■ Excessive removal or etching is indicated in black. Depressed areas, such as
adherences, should be avoided and are marked in red. Inadequate and
depressed buttock projection is encircled with green marker with dashes
indicating the extent of deficiency.
Power-Assisted Lipoplasty
■ The densely fibrous adipose of the posterior torso makes traditional suction-
assisted liposuction (SAL) arduous and traumatic. Popular power-assisted
lipoplasty (PAL) reduces the surgeon’s effort but not the damage to the
retained tissue.
■ Excessive disruption of the connective tissue and neurovasculature
intensifies the trauma and disrupts tissue elasticity.
■ With large volume removal, the patients are traumatized and intrinsic skin
contraction damaged. Recovery can be prolonged for weeks.
■ Nevertheless, traditional liposuction and PAL are the most common means
of fat shaping and the results can be dramatically excellent.
Fat Emulsification and Harvest
■ VASER provides for the preliminary application of internal focused
ultrasound. VASER is the acronym for Vibration Amplification of Sound
Energy at Resonance.

TECH FIG 1 • A–D. Preoperative frontal, right lateral,
right posterior oblique, and posterior view presentation
for 4400 cc VASERlipo of the torso, followed by 330-
cc lipoaugmentation of each buttock. A 33-year-old
woman desires a smaller, more sensual body with
buttock roundness. E–H. One-year postoperative
result of VASERlipo of the torso with lateral
lipoaugmentation of the buttocks.
■ Resonance is a natural phenomenon referring to the possibility to amplify
up to nine times the input resonance versus the energy released. The use of
ultrasound frequencies at resonance means that the energy release is most
efficient, translating to less power needed to create the same effect,
resulting in reduced adverse effects.
■ VASERlipo emulsifies fat woven in dense connective tissue, with maximum
preservation of supporting structures, neurovasculature, and adipose viability
for immediate transplantation to the buttocks.
■ Using a multiholed blunt cannula saline with Xylocaine and epinephrine is
diffusely and meticulously infiltrated throughout the targeted fat until the
tissues are turgid. Through a skin protector, a multiringed ultrasound probe is

uniformly drawn back and forth to disrupt the fat through cavitation of
microscopic bubbles introduced through the preliminary infusion of the
wetting solution.
■ The thrusts are lengthy and slower and more gentle than during typical
liposuction. The concept is to achieve an even and thorough disruption of the
fat.
■ With the energy on, the push through the tissues is met with mild to
moderate resistance. The cannula is then pulled back. Disruptive energy is
being applied with both the push and pull of the cannula.
■ The flattened helping hand stabilizes the skin and adipose, while the
thrusting cannula traverses each level, usually from superficial to deep, as if
the subcutaneous tissues were laminated.
■ Solid titanium probes are available with 1, 2, 3, and 5 rings etched near the
distal rounded tip. The greater the number of rings, the more the dispersion of
energy. Initial ring selection is made based on the anticipated tissue
resistance.
■ Firm or scarred tissue requires one ring, whereas soft fat is rapidly
emulsified with 5 rings.
■ When fat is being harvested for lipoaugmentation, the more gentle multiple
rings are chosen if possible.
■ Three- and five-ring cannulas tend to have just enough focused energy to
traverse the tissue with minimal thrusting force. The power is set at 80%.
■ When the adipose is soft, I prefer the speed of the 5-ringed probe set at
90%.
■ The VASER mode, which rapidly alternates ultrasound energy, exudes
negligible heat and is preferred when traversing the subdermis.
■ Superficial liposuction with retention of elasticity best leaves skin able to
recontour to a smaller volume.
■ When the extracted fat is planned for lipofill, VASER mode is used
throughout the procedure.
■ Ultrasound is applied approximately 1 minute for every 100 cc of infiltration
or until there is no longer resistance to the moving probe.
■ Fat for discard is aspirated at one atmosphere (about 22 in. of mercury)
through specially vented 3.0-, 3.7-, or 4.6-mm diameter VentX 4-holed
cannulas. When the fat is being harvested for lipoaugmentation, the vacuum
pressure is lowered to 18 inches of mercury, and a 24-holed grated cannula is

chosen to aspirate fat into a 2200-cc capacity cylindrical glass harvester.
■ The 24 two-millimeter openings reduce the vacuum pressure per opening
and the size of the adipose particles able to enter each opening. Providing
smaller fat packets that can be more easily injected through 1.5-mm diameter
Coleman cannulas. When both intakes of the vacuum canister are used, the
harvest is quickened and the pressure lowers to 18 in.
■ Turning off the vacuum stops the agitation, allowing gravity to separate the
denser fluids to the bottom of the canister (TECH FIG 2).
TECH FIG 2 • Harvester for aspirated adipose. In-line
reusable glass collector with a heavy base traps
sterile aspirate. After the suction is turned off, gravity
settles the liquid, which is drained through a spout at
the bottom. While the remaining fatty emulation can
be syringe aspired through the spout, we prefer and in
this case removed the harvester lid and then poured
the contents through a kitchen colander for drainage
of excess liquid. The moist fat is then spoon-fed into
10- and 20-cc syringes. Through several stab wound
incisions along the designated perimeter, fat is
treadlike injected into the buttocks through 8-in.-long
blunt Coleman cannulas. Initially, infiltration is fanned
throughout the subdermis. Then the fat is evenly
injected through the subcutaneous and superficial
muscular layers, until a distinct firmness is palpated

throughout the target.
Fat Processing and Injection
■ Through a dependent spout, the infranate liquid is released. Then there are
two reasonable ways to process fat for injection.
■ Commonly, the canister lid is removed. The fat emulsion is awkwardly
poured into a kitchen colander for drainage of the remaining fluid through
multiple small holes. Within the open colander, long tissue strands are
sliced and diced before the drained fat is spooned into 10- or 20-cc.
syringes. The moist fat is pasty and may be difficult to pass through
standard Coleman injection cannulas.
■ Alternatively, the decanted adipose slurry is withdrawn through the
dependent spout into 20- to 60-cc syringes, which are left standing in a tray.
When ready to use, the dependent fluid is pushed out, and the syringe is
attached to Coleman cannulas for fat injection. In the demonstration, 3200
cc of fatty emulsion was removed.
■ Through stab wounds, fat is injected in a weavelike manner throughout the
subcutaneous fat and superficial musculature of the buttocks. As deep, high-
tension injections and sharp-pointed cannulas may be the source of fatal
venous injections, they are avoided; 600 cc of fat was injected into each
buttock.
■ The diminution of the back and waist with shapely buttock augmentation is
seen one year later (see TECH FIG 1B,D,F-H).
■ The aesthetic male buttocks are narrow and centrally projecting, suitable for
lipoaugmentation that includes infiltration into the gluteal musculature.
■ Gluteal Augmentation Through Lower Body Lift
With Adipose Fascial Flaps and Lipotransfer From
Flanks to Inferior Buttocks
■ Following significant weight loss, sagging, flat buttocks are reshaped with
de-epithelialized adipose fascial island flaps isolated within the lower body
lift posterior tissue resection.1 At the same time, reduction of flank adiposity
by liposuction not only narrows the waist but also shortens apparent excess
buttock height. Fat harvested from the flank is processed and then transferred

to the lower buttocks by injection, where the de-epithelialized adipose fascia
flap cannot reach.
■ In this demonstrative case, a prior abdominoplasty has been done many
years earlier, and so a circumferential lower body lift was not indicated. Due
to a high rate of complications, there is a trend toward performing these two
operations independently.2
Island Flap Harvesting and Placement
■ A transverse anchor line is drawn along the posterior iliac crests over the
lower lumbar midline. The width of resection, as determined by tissue
gathering, leaves a transverse curvilinear line along the midbuttocks. Island
flaps for augmentation are centered over the superior portion of each buttock
(TECH FIG 3A-C).
■ Reliable double set of paramedian perforator vessels vascularizes the tissues.
The anticipated resection distance between the superior and inferior incisions
is reduced about 20% to accommodate for the increased subgluteal volume
created by the buried augmentation flap.
■ The harvested island flaps are de-epithelialized and isolated for positioning
under the gluteal skin flap (TECH FIG 3D). The perimeter of the flaps is
undermined several centimeters. Restricting fascial bands are cut while trying
to preserve perforating vessels.
■ There are a variety of successful ways to advance the flaps. In this case, the
adipose fascial flap was suture advanced to the gluteus muscle as distal under
the gluteal skin flap as possible (TECH FIG 3E). The lateral fourth of the
flaps are completely undermined so that tissue can be either rotated or flipped
over the main body of the advanced flap to increase projection (TECH FIG
3F). Then the gluteal skin flap is sewn to the lower back and hip anchor
incision line in two barbed suture layers (TECH FIG 3G).
Completion
■ A Jackson-Pratt suction drain is inserted into each buttock pocket. Even a
small seroma may allow re-epithelialization of the buried de-epithelialized
flap, requiring an operation to decorticate the skin.

TECH FIG 3 • Operative planning for lower body lift
with harvest of bilateral adipose fascial flaps,
VASERlipo of the flanks, and lipoaugmentation of the
lower buttocks. A,B. Posterior and left lateral standing
views (C). A beltlike excision, resembling the infinity
symbol, starts at the posterior extent of her
abdominoplasty scar. Spanning the posterior iliac
crests, the low back side of the excision will anchor
the advanced buttock skin flap. The width between
incisions, indicated by obliquely oriented cross-
hatched lines, is determined by the gap approximation

of the excess upper buttock skin. Within these two
incision lines lie the adipose fascial flaps for buttock
augmentation. Plus marks within the encircled flanks
indicate moderate depth VASERlipo. The inferior
buttocks are narrow and deflated with loose skin,
which will be lipoaugmented, as designated by the
green rectangle, from fat harvested from the flanks. B.
The same posterior projection of the flanks and
buttocks leaves a flattened mega buttocks. D. The left
side isolated de-epithelialized flap in prone position on
operating room table. The flaps are initially deeply de-
epithelialized manually or with the assistance of an
electric dermatome set to cut thick at 32 000 of an
inch thickness. The lower body lift (LBL) incisions form
the perimeter of the planned buttock augmentation
flaps. Her right LBL with a buried adipose fascial flap
has been completed. The stuffed right buttock projects
far beyond the unstuffed left. The LBL buttock skin flap
needs to be closed over the buried flaps under mild
tension. This left adipose fascial flap is isolated on an
island pedicle with circumferential undermining. E.
The flaps are suture advanced to the depths of the
dissected space in prone position viewing from the
head. After the left flap is fully mobilized, it is sutured
advanced with large branded absorbable suture under
the buttock undermined flap toward the inferior
buttocks. Her right side LBL and buttock plasty have
been completed. F. The lateral flap extension is flipped
over and stacked. Most often, the lateral extensions
are completely undermined in order to flip them over
the more deeply positioned advancement flaps,
providing more projection and lateral fill. G. The
buttock flap is suture advanced to the lower back

incision. The two-layer closure starts at the midline
and progresses laterally with deep bites of double-
armed no. 2 PDO Quill. Similarly, 2-0 Monoderm Quill
closes the dermis. Compare the competed contour on
prone left side with TECH FIG 3F.
■ The final result in this 77-year-old woman shows a narrow waist with raised
buttock and lateral thighs and modest augmentation of the buttocks (TECH
FIG 4). The generalized skin laxity of the lower back and buttocks has been
corrected. Lipoaugmentation of the lower buttocks has reduced the skin sag.
Delayed healing of the left transverse suture line has left a depressed scar that
may need revision.
■ Adipose fascial flaps in men tend to unaesthetically broaden the buttocks
and are prone to complications. The low-lying lower body lift tends to
excessively depress the upper lateral buttocks. Male hirsutism tends to leave
deep hair follicles in de-epithelialized flaps, which may lead to rapid re-
epithelialization, which causes intractable seromas. Well-placed suction
drains may obviate this complication.
TECH FIG 4 • A. The 6-month result in this 77-year-
old patient as seen in posterior and left lateral views
(B). After a limited dehiscence along the left buttock
low back closure, she proceeded to heal with
pleasing, hoped-for buttock shape, turgor, and
projection, along with a deeper waist. The S-shaped
curve from low back to prominent rounded buttocks is
agreeable. C. Right posterior oblique, before and 6

months (D) following her LBL, adipose fascial flaps,
VASERlipo of the flanks and lipoaugmentation of the
inferior buttocks shows the improve contour best.
■ Oblique Flankplasty With Lipoaugmentation of
the Buttocks (Video 2)
Video p5-c017_02
■ Flank rolls widen the waist and lengthen the buttocks.
■ When there is skin laxity, liposuction alone cannot adequately narrow the
waist. Removing both excess fat and skin narrows the waist and reduces
buttock height.
■ A full-thickness obliquely oriented flank excision of broad adiposity covered
by lax skin creates a narrow waist, especially welcomed when none ever
existed. These posterior extensions of an abdominoplasty ascend from
between the posterior iliac crests and posterior costal margins. The tapered
femininity of the lower costal margin is best exposed through this deep and
obliquely oriented resection.
■ As the sagging skin along the lateral thigh and buttocks is pulled up with the
helping hand, the inferior oblique incision line is drawn from the posterior
iliac crests to just short of L1.
■ The excess skin and fat are grasped between that line and the posterior costal
margin for placement of the parallel superior incision. The two lines taper to
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meet near L1 (TECH FIG 5A-E).
■ The inferior perimeter incision is made vertically down along the iliac crests.
■ The superior excision descends vertical to the lumbar fascia. The excision is
deep, leaving some fat over the paraspinous muscles, and bares the fascia
over the latissimus dorsi and external oblique muscles. The thickness of the
specimen can be surprisingly large, like an oversized abdominal pannus.
■ A no. 2 PDO Quill suture three-point closure encircling the most superficial
subcutaneous fascia edges of the wound to the muscular fascia ensures a
tapered deep waist. The quilting aspect of the closure inhibits seroma
formation.
■ Fat VASERlipo harvested from the excision site is processed to lipoaugment
the buttocks.
■ The one-year result shows a sensual posterior torso and buttocks in a 68-
year-old woman, who is for the first time in her adult life pleased with the
appearance of her waist (TECH FIG 5F-J). The smooth transitions across
her hip heightened the aesthetic appeal.
TECH FIG 5 • A–E. Surgical markings for Oblique
flankplasty extension of an abdominoplasty. F–J. The
result of oblique flankplasty extension of an
abdominoplasty. Multiple views show not only deep
waists but also curvaceous transitions from the thorax

and buttocks to the waist.
■ Silicone Soft Elastomer Intramuscular
Augmentation of the Buttocks (Video 3)
Video p5-c017_03
■ Buttock flattening with some skin laxity and normal BMI or less is the
indication for implant augmentation of the buttocks. Often, coincidental
liposuction of the flanks is performed.
■ Based on the patient’s desires and anatomy, an appropriate-sized and
appropriate shape soft silicone elastomer gluteal implant is selected.
■ In closed spaced vertical parallel intergluteal incisions, high intramuscular
placement yields the best chance for complication-free aesthetic success.
■ The case presentation is a 42-year-old, 5′7″, 135 lb self-employed home
cleaner, who lost 100 pounds lb through diet and exercise. She is
disappointed with her sagging breasts and buttocks as well as generalized
loose skin of her torso. She was tormented by her obesity since her
adolescence.4
■ Immediately prior to her buttock implant augmentation, she underwent a
330-cc textured round Sientra implant, Wise pattern implant augmentation
mastopexy, and lipoabdominoplasty (TECH FIG 6A-D).
■ After the gluteal outline is drawn, the perimeter of the chosen implant is
outlined immediately inferior to the superior border of the buttocks (TECH
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