The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

3020
Part XII  Body Contouring
The postoperative results at 8 months reveal the impressive, almost circumferential
correction. The scar is once again low centrally and hidden throughout. The im-
provement at the upper chest, back folds, thighs, and waist is evident.
Her preoperative markings are shown.

3021
Chapter 83  Abdominoplasty

3022
Part XII  Body Contouring
Concluding Thoughts
A well-conceived and well-executed high-tension abdominoplasty, with the addition
of the fleur-de-lis or reverse principles, defines a truly comprehensive abdominoplasty,
which is a surgical antidote to the shortfalls of more traditional approaches. In
essence, comprehensive abdominoplasty is a more complete treatment of the ante-
rior trunk aesthetic unit from the submammary and lateral chest area to the pubic,
thigh, and buttock zones, with a greater overall aesthetic result and margin of vas-
cular safety.
Clinical Caveats
Key Principles of the High Lateral Tension Abdominoplasty
 The HLTA is driven by the concerted effort to treat not only the tissues above the
incision but also those below. This treatment is as much excision of redundancy
as it is a far-reaching body lift through a relatively anterior incision. The pubis and
anteromedial thighs as well as the hips, anterolateral thighs, and even buttocks can
be aesthetically improved by this technique.
 This procedure is fundamentally and philosophically different in that the skin is
considered more redundant at the lateral trunk than in the midline. Therefore the
anterolateral thigh can be more effectively treated. In addition, the redundant up-
per abdominal skin emanates more from the chest and demonstrates more of a hor-
izontal laxity compared with the vertical laxity of the lower pannus. Thus the rel-
atively oblique pull of the HLTA can more effectively treat this epigastric excess.
 This approach, in contradistinction to the traditional abdominoplasty, is not driven
by the usually mandatory excision of all the skin between the pubis and umbili-
cus. Therefore the pubic/median portion of the incision can be naturally lower and
more hidden and the closure can be under less tension, improving the chances for
healing by first intention and a more natural looking result.
 The HLTA often mandates that the incision be longer laterally. However, it is also
true that the longer the lateral incision, the better the result. This approach allows
the excision of a greater extent of skin, and what is more important, affords an
impressive body lift of the surrounding tissues. This balance between scar length
and result must be negotiated with the patient.
 As a corollary, if there is not a significantly redundant skin envelope at the lateral
thigh, the HLTA should be “tempered,” and the scar can and should be shorter.

3023
Chapter 83  Abdominoplasty
 This technique, although often more effective at treating the upper abdominal skin
excess, should be supplemented by a second-stage reverse abdominoplasty proce-
dure when necessary or even “converted” to a fleur-de-lis initially.
 The HLTA is predicated on preservation of the flap blood supply first and fore-
most. As part of this philosophy, for a patient with a medium to high BMI the sur-
geon should seriously consider a staged liposuction of the central and superior ab-
dominal flap instead of either liposuction or direct excision. Only then can a zero
tolerance for skin necrosis truly be honored.
 The entire anterior trunk should be considered as one aesthetic unit. Thus not just
the traditional lower abdominal pannus is treated but all of the areas surround-
ing this deformity as well.
Fleur-de-Lis Abdominoplasty
 The excess skin (particularly when first applying this technique) should be tailor-
tacked in the vertical and horizontal directions to more safely conduct the skin
excisions.
 Tacking should always be started at the inverted-T junction to ensure that enough
skin is preserved for the suprapubic closure.
 Surgery beyond the xiphisternum should be avoided to avoid the scar’s riding up
between the breasts.
 The surgeon should imagine the excision as a fleur-de-lis skin template, never un-
dermining the skin flaps.
Reverse Abdominoplasty
 All patients undergoing significant routine abdominoplasties (especially weight-
loss patients considering possible breast rejuvenation) should be informed that a re-
verse abdominoplasty might be desirable at a later time.
 The position of the future crease should be accurately determined with the patient
in the upright position on the operating table.
 The abdominal flap should always be doubly secured to the defined inframam-
mary crease to create a platform on which the breast can rest and the abdominal
flap can hang.
 The relative mobility of the umbilicus and the extent of excision must be assessed
to help determine how much umbilical displacement may occur. The tissue above
the umbilicus should be left undissected in an effort to block excessive superior
movement.

3024
Part XII  Body Contouring
Annotated Bibliography
Baroudi R, Keppke EM, Carvalho CG. Mammary reduction combined with reverse ab-
dominoplasty. Ann Plast Surg 2:368, 1979.
These investigators were the first to publish a report in the English-language literature of
the combined technique of reduction mammoplasty and reverse abdominoplasty. They
give credit to Rebello and Franco for originally describing the approach in 1972 in the
Brazilian literature.
Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg 9:27-32, 1985.
This is the first description of the fleur-de-lis technique. Dellon emphasizes the advan-
tage of combining a vertical and a horizontal resection in restoring abdominal contour.
Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspen-
sion. Plast Reconstr Surg 9:603-615, 1995.
This seminal article describes the principles and surgical results of this new approach to
abdominoplasty.
Suggested Readings
Babcock W. The correction of the obese and relaxed abdominal wall with special reference to
the use of buried silver chain. Am J Obstet 74:596, 1916.
Burget G, Menick F. The subunit principle in nasal reconstruction. Plast Reconstr Surg 76:
239-247, 1985.
Castanares S, Goethel J. Abdominal lipectomy: a modification in technique. Plast Reconstr
Surg 40:378-383, 1967.
Duff C. Fleur-de-lys abdominoplasty: a consecutive case series. Br J Plast Surg 56:557-566,
2003.
Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a more superficial plane: de-
creasing the need for drains. Plast Reconstr Surg 125:677-682, 2010.
Grazer F. Abdominoplasty. Plast Reconstr Surg 51:617-623, 1973.
Huger W Jr. The anatomic rationale for abdominal lipectomy. Am Surg 45:612-617, 1979.
Kelly H. Excision of the fat of the abdominal wall. Surg Gynecol Obstet 10:229, 1910.
Le Louarn C. Partial subfascial abdominoplasty. Aesthetic Plast Surg 20:123-127, 1996.
Le Louarn C, Buis J, Buthiau D. Treatment of depressor anguli oris weakening with the face
recurve concept. Aesthet Surg J 26:603-611, 2006.
Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined
abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg 15:111-121, 1991.
Nahai F, Brown RG, Vasconez LO. Blood supply to the abdominal wall as related to plan-
ning abdominal incisions. Am Surg 42:691-695, 1976.

3025
Chapter 83  Abdominoplasty
Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive
cases. Plast Reconstr Surg 40:384-391, 1967.
Ramsey-Stewart G. Radical “fleur-de-lis” abdominal after bariatric surgery. Obesity Surg
3:410-414, 1993.
Rebello C, Franco T. [Abdominoplasty with inframammary scar] Rev Bras Cir 62:249, 1972.
Regnault P. Abdominal dermolipectomies. Clin Plast Surg 2:411-429, 1975.
Rosenfield LK. High tension abdominoplasty 2.0. Clin Plast Surg 37:441-465, 2010.
Saldanha OR, de Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective
and safe undermining. Aesthetic Plast Surg 27:322-327, 2003.

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Lipoabdominoplasty

OSVALDO RIBEIRO SALDANHA,
SÉRGIO FERNANDO DANTAS DE AZEVEDO,
FÁBIO MASSARU KUROYANAGI,
VINÍCIUS COSTA E SILVA DE FREITAS,
OSVALDO RIBEIRO SALDANHA FILHO,
CRISTIANNA BONETTO SALDANHA,
LUIS HUMBERTO URIBE MORELLI
CHAPTER 84

3028
Part XII  Body Contouring
T
he abdomen is one of the regions of the body that is most susceptible to aes-
thetic and functional deformity as a result of genetic characteristics or because
of acquired problems associated with obesity, weight loss, pregnancy, or other causes.
Abdominal deformity may present as cutaneous flaccidity, localized fat accumula-
tion, or diastasis of the abdominal rectus muscle. Such deformity has long had a neg-
ative psychological and physiologic impact on patients who seek a more aesthetic ab-
dominal appearance. Lipoabdominoplasty has proved an excellent procedure for
solving this problem and providing patients with the cosmetic contouring they desire.
100
90
80
70
60
50
40
30
20
10
0
Undermining area (%)
1899
1957
1990
1992
2000
2009
Year
Kelly
Vernon
Illouz
Saldanha
Lipoabdominoplasty
Lipoabdominoplasty combines two traditional techniques—liposuction and ab-
dominoplasty. This new, conservative concept is based on preservation of the ab-
dominal perforating vessels (subcutaneous pedicle), which are branches of the deep
epigastric vessels. As stated previously, this preserves about 80% of the blood sup-
ply of abdominal flap compared with traditional abdominoplasty. The nerves and
lymph nodes are also preserved, maintaining the flap’s cutaneous sensibility to su-
perficial pain and superficial touch by temperature, vibration, and pressure—also an
improvement on traditional abdominoplasty.
Evolution of Technique
Traditional plastic surgery of the abdomen results in a high rate of morbidity, be-
cause the perforating vessels must be sectioned during undermining of the large flaps.
As demonstrated by Munhoz in a postoperative Doppler ultrasound study, these per-
forators represent 80% of the blood supply of the abdominal wall. Consequently,
the vascularity of the remaining flap is supplied only by the intercostal, subcostal
and lumbar perforating branches situated in the back and flank regions. Multiple in-

vestigators have noted the incidence of ischemia, with tissue necrosis and suture de-
hiscence, associated with abdominoplasty with liposuction, so surgeons have been
reluctant to perform this procedure.
Techniques for undermining the abdominal wall evolved from 1899 to 1957, when
Vernon published a standardized technique for extensive undermining of the ab-
dominal wall to facilitate umbilical transplantation.
In previous decades surgeons developed innovative techniques to reduce the surgical
morbidity associated with abdominoplasty, obtain a faster recovery, provide a more
aesthetic body contour, and produce lower rates of abdominal wall necrosis. The in-
troduction of liposuction by Illouz in 1980 led to the development of techniques that
reduced the need for abdominal undermining.
The mini-lipoabdominoplasty described by Hakme in 1985 involved liposuction of
the entire abdomen and flanks, with an elliptical resection of the suprapubic skin,
plication of the supraumbilical and infraumbilical rectus muscles, without relocat-
ing the umbilicus. The complications associated with combined liposuction and ab-
dominoplasty methods are vascular related and were presented by Matarasso in 1991
and 1995. He considered the back and flanks safe areas for liposuction. He did not
regard the lateral region of the abdomen as safe, and he cautioned that no liposuction
should be done in the central region of the abdomen.
In the 1990s Illouz decreased the extent of undermining and the rate of complica-
tions (seroma, hematoma, and most of all, necrosis), reaching zero undermining in
1992 with an article on “abdominoplasty mesh undermining.” The trend toward
“abdominolipoplasty,” with or without a small amount of undermining, continued
until 1999, when Shestak and Avelar presented the partial abdominolipoplasty
method, with no undermining. In 1995 Lockwood reported using Scarpa’s fascia to
decrease the tension of the skin closure.
Superficial liposuction, introduced by de Souza Pinto in 1996, became the first fun-
damental principle of lipoabdominoplasty, because this technique allows more mo-
bility of the abdominal flap so that it can slide down easily and reach the suprapu-
bic region. The second principle is the preservation of abdominal perforator vessels
(see p. 3035).
Lipoabdominoplasty was developed by Saldanha and published for the first time
in 2001 as a safe option to correct both functional and aesthetic abdominal defor-
mity while achieving better aesthetic results with technical simplicity for surgeons.
Saldanha outlined a standardized method for selective undermining between the in-
ternal borders of the rectus abdominis muscles.
3029
Chapter 84  Lipoabdominoplasty

Indications and Contraindications
Lipoabdominoplasty can be used for any patient with flaccid abdominal skin, adi-
posity, and diastasis of the rectus muscles. It can be used in smokers and in over-
weight and postbariatric patients.
Pertinent Anatomy
The abdominal wall skin comprises two elements: the epidermis and the dermis. Be-
yond the dermis is the subcutaneous cellular tissue, which is made up of two layers
of fat separated by the superficial fascia. The deeper fat layer is intimately related to
the muscles of the anterior abdominal wall through which the vascular, lymphatic
end and nervous systems penetrate.
The abdominal muscles are the rectus abdominis, external oblique, internal oblique,
transverse, and pyramidal.
Lipoabdominoplasty is based on the vascular anatomy of the abdominal wall, es-
pecially of the perforating vessels of the rectus abdominis muscles. The main arter-
ies of each part of the abdominal wall are two superior arteries, the superior epi-
gastric artery and the musculophrenic artery (branches of the internal thoracic
artery); and two inferior arteries, the inferior epigastric artery and the deep cir-
cumflex artery of the ilium (branches of the external iliac). Branches of the lumbar
and intercostal arteries also help to supply the abdominal wall. The veins follow the
arteries’ paths and nomenclature.
Lymphatic drainage flows caudally to the umbilicus toward the superficial inguinal
nodes and cranially to the axillary nodes. Innervation is by the thoracoabdominal,
iliohypogastric, and ilioinguinal nerves.
3030
Part XII  Body Contouring

3031
Chapter 84  Lipoabdominoplasty
Rectus
abdominis
muscle
Deep fat
layer
Scarpa’s
fascia
Perforating
vessels
Location of
rectus abdominis muscle
under Scarpa’s fascia
and deep fat layer
Scarpa’s
fascia and
deep fat layer
Perforating
vessels
Scarpa’s fascia and part of the deep fat layer are preserved to achieve a complete re-
construction of the abdominal wall in the entire lower abdomen—between the um-
bilicus scar and pubis. Reconstruction is completed when the superior flap is brought
down to the pubis.
The upper abdomen is undermined exactly between the internal borders of the rec-
tus muscles that correspond to the area of diastasis, preserving the perforating ar-
teries, veins, lymphatics, and nerves. Munhoz’s postoperative Doppler ultrasound
study demonstrated that 81.21% of the perforating vessels mapped in the preoper-
ative period were preserved. This validates the hypothesis that this technique results
in a lower percentage of complications from flap ischemia.
De Frene et al showed that it is possible to raise perforator flaps after liposuction of
the donor sites; they performed breast reconstruction using perforator flaps in pa-
tients who had previously undergone abdomen liposuction.
The skin and rectus abdominis muscle are innervated by the anterior branches of the
sixth to the twelfth intercostal nerves, which run along the abdominal perforating
vessels. Many studies have shown that the loss of sensitivity is significant after clas-
sic abdominoplasty.

Preoperative Assessment
 The surgeon evaluates the amount of excess abdominal skin and its flaccidity, not-
ing the presence of any striae and their extent.
 The thickness and volume of subcutaneous fat are estimated.
 The rectus abdominis muscles are evaluated for diastasis.
 The surgeon palpates for ventral, lumbar, or femoral hernias. Abdominal wall ul-
trasound is essential.
 The presence of any scarring is recorded, as is a history of previous endoscopic
procedures because of the risk of weakness in the abdominal aponeurosis.
 A history of previous liposuction should raise a warning flag because of the like-
lihood of decreased flap mobility.
 The surgeon should begin with a high suprapubic incision if there is any question
whether a mini-lipoabdominoplasty or full lipoabdominoplasty is indicated.
Preoperative Planning
Marking
3032
Part XII  Body Contouring
The abdomen is marked with the “bicycle handlebar” shape described by Baroudi
and Ferreira. The horizontal suprapubic line is 12 to 14 cm long and 6 to 7 cm from
the vulvar furcula.
Two oblique lines 6 to 8 cm long are
drawn in the direction of the iliac crest
to complete the incisional line. The ar-
eas that will be liposuctioned and from
which the abdominal flap will be raised
are marked. When appropriate, the dor-
sal region is also marked for liposuction.

Operative Technique
Infiltration
3033
Chapter 84  Lipoabdominoplasty
For better orientation at the beginning of tunnel
undermining, the rectus abdominis muscle dias-
tasis is marked (shown here in another patient).
Surgical Steps in Lipoabdominoplasty
1. Marking
2. Infiltration
3. Liposuction of the upper abdomen
4. Liposuction of the lower abdomen
5. Preservation of Scarpa’s fascia
6. Selective undermining
We use the tumescent technique, infiltrating the abdominal region with 1 to 1.5 L
of saline solution with 1:500,000 of epinephrine.
7. Removal of the infraumbilical strip
8. Plication of the rectus muscle
9. Omphaloplasty: star-shaped technique
10. Suturing of the layers
11. Placement of drains
12. Dressings
7
84-1
Lipoabdominoplasty
with selective
undermining

Upper Abdomen Liposuction
3034
Part XII  Body Contouring
So that liposuction can be performed safely, the patient is placed in a hyperextended
position on the operating table. Liposuction begins on the supraumbilical region
with a 3 or 4 mm cannula; the fat of the deep and superficial layers is removed, ex-
tending to the flank and reaching the submammary fold. The thickness of the fat is
maintained at about 2.5 cm to avoid vascular impairment and contour deformities as
in traditional liposuction.
Lower Abdomen Liposuction
Scarpa’s fascia is an important anatomic structure of the abdomen and should be
preserved in the lipoabdominoplasty. So that the fascia can be seen and preserved,
all of the superficial fat layer and part of the deep layer in the lower abdomen should
be aspirated with a 6 mm cannula. After the surgeon evaluates the flap descent, the

umbilicus is isolated and the infraumbilical skin resected as in traditional ab-
dominoplasty. If necessary, complementary open liposuction can be performed to
remove fat above and below the Scarpa’s fascia and create a homogeneous surface
to accommodate the superior flap, which becomes thinner in its descent.
Preservation of Scarpa’s Fascia
3035
Chapter 84  Lipoabdominoplasty
Preservation of Scarpa’s fascia is important for a number of reasons: to reduce bleed-
ing because the inferior perforating vessels are spared; to provide homogeneous sup-
port for the upper flap, which becomes thinner in its descent; it causes the contention
of scars laterally offering better adherence between the flap and the deep layers.
Selective Undermining
The preservation of the abdominal perforating vessels and nerves during the proce-
dure is the second principle of lipoabdominoplasty.
Selective undermining is performed in the median line of the upper abdomen be-
tween the internal edges of the rectus abdominis muscles. Undermining laterally be-
yond this area may damage the perforating vessels, increasing the potential for mor-
bidity and abdominal flap necrosis.

Tunnel undermining may reach the xyphoid process, depending on the need for rec-
tus muscle plication. The tunnel width may vary with the extent of diastasis, because
the perforating vessels follow the muscle’s separation. The wider the diastasis, the
wider the tunnel. The perforating vessels are not damaged if undermining does not ex-
tend laterally beyond the internal edges of the rectus abdominis muscles.
3036
Part XII  Body Contouring
The Saldanha retractor can be used to enlarge the surgical site, thus improving vi-
sualization of the anatomic structures, which facilitates muscle plication and helps
to prevent trauma to the edge of the flap.
The dislocation caused by the liposuction cannula facilitates descent of the flap. Re-
lease of the trabecular ligament (as described by de Souza Pinto) in the upper ab-
domen should be performed to extend the transposition of the abdominal flap to the
pubic region, preventing excessive tension on the suture.
Removal of the Infraumbilical Strip
In the median infraumbilical line, a vertical strip that contains Scarpa’s fascia and
adipose tissue should be removed to expose the internal edges of the rectus abdom-
inis muscles and to facilitate plication from the xyphoid process to the pubis.

Resection of Excess Skin
3037
Chapter 84  Lipoabdominoplasty
All excess skin of the lower abdomen should be removed after making certain that
the flap easily transposes to the pubic symphysis.
Omphaloplasty
The star-shaped omphaloplasty design is marked on the abdominal wall and a
lozenge shape is created on the umbilical pedicle. The cardinal points of the umbil-
ical pedicle are sutured to the cardinal points of the cruciform incision of the ab-
dominal wall. The scar results in a continuous Z-plasty that offers little possibility
of retraction.

3038
Part XII  Body Contouring
Suture of the Layers
The surgical site is sutured in two layers, with 3-0 Monocryl on the deep layer and
4-0 Monocryl on the subdermis. The skin is sutured with 5-0 mononylon separate
stitches. At this point, the scar can be lowered by resecting a cutaneous strip (1 to
2 cm) without risk of harming the flap or causing too much tension on the sutures.
A continuous-aspiration drain is placed for 1 or 2 days.

Dressing
The wound is covered with Micropore surgical tape, and the dressing is placed while
the patient is still on the operating table.
Postoperative Care
The aspiration drain is removed 1 or 2 days after surgery. The dressing is changed
on the third and eighth postoperative days when the horizontal sutures are removed.
The sutures on the umbilicus are removed on the twelfth postoperative day. A medium
compression belt is used until the twentieth postoperative day.
The recovery time for patients who undergo lipoabdominoplasty is midway between
that of abdominoplasty and liposuction because it is less invasive, causes little vas-
cular and nerve injury, and presents a discrete dead space. Preserving Scarpa’s fas-
cia decreases the dead space, reducing the possibility of seroma formation. These
factors result in lower morbidity and enable the patient to return quickly to social
and professional activities.
Problems and Complications
3039
Chapter 84  Lipoabdominoplasty
60
50
40
30
20
10
0
Seroma
(p 0.0001)
Epitheliolysis
(p  0.0007)
Dehiscence
(p  0.0001)
Necrosis
(p  0.0004)
Hematoma
DVT/PE
(Percent of complications)
Traditional abdominoplasty (N  495)
Lipoabdominoplasty (N  520)
60.0
0.4
3.8
0.2
4.0
0.2
0.2
0.2
0.2
5.1
0.4
0.6
DVT, Deep venous thrombosis; PE, pulmonary embolism.
If the surgical steps described are followed systematically, the potential for compli-
cations is reduced. The graph above provides data on our 9-year experience with
lipoabdominoplasty with selective undermining, comparing the complication rate
with that of the traditional abdominoplasties performed. The reduced incidence of
seroma, epitheliolysis, dehiscence, and necrosis is statistically significant. Although
the reduced incidence of hematoma and deep venous thrombosis/pulmonary em-
bolism remained the same, we cannot consider them statistically because of the small
number of cases in which these complications occurred.

3040
Part XII  Body Contouring
The percentage of surgical revisions decreased from 20% to 10% when we began to
perform lipoabdominoplasty-only procedures, remaining so for 8 years. The table
shows the percentage of surgical revisions required in this lipoabdominoplasty se-
ries. The cases of surgical revision required because of complementary liposuction
and postoperative skin flaccidity (3.2%) correspond to patients who had undergone
previous bariatric surgery and had a great amount of flaccidity. There was a need
for scar revision in 6%, which represents 63% of surgical revisions.
Surgical Revision in Lipoabdominoplasty
2000
2001
2002
2003
2004
2005
2006
2007
2008
Primary Cases
(N = 520)
15
45
55
64
62
65
68
71
75
Scars
3
5
4
3
4
3
3
4
2
Skin flaccidity
—
—
1
2
1
1
1
2
—
Insufficient liposuction
—
—
1
2
2
1
1
1
1
Excessive liposuction
—
—
—
—
—
—
—
—
—
Infection
—
—
—
—
—
—
—
—
—
Other causes
—
—
—
—
1
—
—
—
—
TOTAL
3
5
6
7
8
5
5
7
3
Percentage
20
11
11
11
13
8
7
10
4
Pitfalls
 Initially, the surgery requires more than 30 minutes.
 The procedure should not be performed on patients with a large hernia or even-
tration.
 A short learning curve is required to assimilate the new procedure.
Outcomes
The learning curve for this technique is short, because the plastic surgeon performs
both liposuction and abdominoplasty. As the surgeon gains familiarity with this tech-
nique, he or she can produce a harmonious body contour with a shorter postoper-
ative recovery time. A safe liposuction technique in abdominal and costal areas leads
to excellent results in almost all cases. In lipoabdominoplasty, preserving Scarpa’s
fascia reduces the length of the suprapubic scar, compared with the initial marking,
in 30% of the cases. This occurs because Scarpa’s fascia has a direct relationship
with the skin. This can be observed when it is reapproximated, after the removal of
the vertical infraumbilical strip. Complication rates are decreased, the aesthetic re-
sults are satisfactory, there is less postoperative morbidity, and the need for late sur-
gical revision is reduced.

3041
Chapter 84  Lipoabdominoplasty
Results
The combination of liposuction and abdominoplasty at the same surgical setting im-
proves the results, providing greater reduction in abdominal volume and better body
contour. In addition, patients’ satisfaction with their abdominal rejuvenation results
in a decreased need for surgical revisions—and an increased demand for such pro-
cedures as they share news of their experience with others.
The table compares the incidence of complications in traditional abdominoplasty to
that of lipoabdominoplasty in the 1015 patients in our series who underwent ab-
dominal surgery and were followed by the senior author (O.R.S.) from 1979 to 2008.
Total Abdominal Surgeries, 1979-2008
1979-
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
TOTAL
Traditional
469
25
—
—
—
—
—
—
1
—
495
abdominoplasty
Lipoabdominoplasty
—
15
45
55
64
62
65
68
71
75
520
TOTAL
1015
From 1979 to 2000 the senior author performed 494 traditional abdominoplasties.
In 2007 one traditional abdominoplasty was performed in a case of skin excess in
a postbariatric patient, bringing the total to 495 traditional abdominoplasties. In
2000 the senior author began to develop lipoabdominoplasty, performing 520 pro-
cedures through 2008. In the first 9 years of implementing this technique, there was
a 100% increase in abdominal surgeries by the senior author (before 2000, the av-
erage was 35 patients per year; from 2004 to 2008, the average was 75 patients per
year). There was a 50% reduction in the need for surgical revisions during the same
period.
We observed a decrease in final scar extension when compared with the initial mark-
ing in 30% of patients. The initial line always measured 28 cm in length: 12 cm hor-
izontal and 8 cm oblique on each side. In the 520 patients, 156 had a final scar of
25 to 27 cm, with an average reduction of 2 cm from the initial marking. This is a
result of the traction of Scarpa’s fascia on the skin.
The graceful shape of the umbilical scar has been deemed good to excellent by the
team and the patients.

3042
Part XII  Body Contouring
This 42-year-old patient, who had two children, was slightly overweight, with re-
dundant abdominal skin, an abdominal bulge, and stretch marks. She is shown
6 months postoperatively with a lower abdominal scar and a much better contour
as a result of liposuction.

This 39-year-old woman, who had one child, had flaccid skin and moderate lipodys-
trophy, which made her appear older. The rejuvenating effect of lipoabdominoplasty,
seen 12 months postoperatively, has provided a contour more appropriate to her age.
3043
Chapter 84  Lipoabdominoplasty

This 30-year-old patient had one child. Despite her relative youth, she had a very
disharmonious abdominal shape. She is seen 10 months postoperatively; lipoab-
dominoplasty has produced a more harmonious contour with a natural-looking pro-
file and umbilical scar.
3044
Part XII  Body Contouring

Similar to the previous patient, this 28-year-old woman, with one child, presented
with an unattractive abdominal contour. Six months postoperatively, the improved
contour is evident. The lower scar accommodated the patient’s desire to wear bikinis.
3045
Chapter 84  Lipoabdominoplasty

3046
Part XII  Body Contouring
This 50-year-old woman, who had two children, desired a more harmonious body
contour. She had redundant abdominal skin and a horizontal umbilical shape that
bothered her. Her postoperative photos, 10 months after the procedure, reveal a
much-improved shape with a uniform profile that pleases the patient.

This 29-year-old patient, after having two children, requested a better abdominal
contour. She had abdominal lipodystrophy, stretch marks, a significant diastasis, pro-
trusion, and a noticeable umbilical diversion. Three months postoperatively, the ex-
cellent rejuvenative effects of the procedure are already evident, including a new,
higher, centered position of the navel.
3047
Chapter 84  Lipoabdominoplasty

Concluding Thoughts
The initial objective of lipoabdominoplasty was to reduce the complication rates in
abdominoplasty patients. As the technique evolved, other advantages became ap-
parent. Aesthetic results were improved, because reduced abdominal measures pro-
vided better abdominal contour. Recovery of suprapubic sensitivity was faster, be-
cause the nerves were preserved. This technique represents an important advance in
plastic surgery, improving patient safety. The adoption of lipoabdominoplasty is easy
for surgeons who are accustomed to performing both liposuction and abdomino-
plasty. Patient satisfaction increases, and the need for surgical revisions decreases,
leading to a greater demand for the technique.
Clinical Caveats
 With lipoabdominoplasty, a better body contour is achieved because liposuction
decreases the abdominal measurement.
 Morbidity is decreased because the perforating vessels are preserved and there is
no dead space.
 The incidence of complications is lower with this procedure.
 Lipoabdominoplasty is easy to perform because surgeons are already accustomed
to liposuction and classic abdominoplasty.
 The abdomen is rejuvenated with a more natural profile.
 Suprapubic sensitivity is preserved.
 Postoperative recovery is faster, and the scar is shorter.
 Vibroliposuction or ultrasound liposuction can be used.
 The procedure is safe for smokers, obese patients, and postbariatric patients or
those who have undergone reversal abdominoplasty.
 Surgeons should perform their first lipoabdominoplasties in patients with excess
skin flaccidity and extensive fat volume.
 Ultrasonography of the abdominal wall should always be performed to identify
any asymptomatic hernias and to prevent abdominal perforation by the cannula.
 This technique should not be performed in patients with large hernias and even-
trations, because bleeding can increase liposuction time. Patients who have had
previous laparoscopic procedures also have this risk.
3048
Part XII  Body Contouring

 Extra care must be taken in patients who have had previous liposuction and in pa-
tients with abdominal scars that suggest previous surgeries.
 A high suprapubic incision is recommended if there is any question whether a
mini-lipoabdominoplasty or full lipoabdominoplasty is indicated.
3049
Chapter 84  Lipoabdominoplasty
Annotated Bibliography
Illouz YG. A new safe and aesthetic approach to suction abdominoplasty. Aesthetic Plast
Surg 16:237-245, 1992.
Suction abdominoplasties are associated with a number of surgical complications, mainly
in obese patients and those with diabetes. A neoumbilicoplasty, described there, can be
situated in the “right position” with good aesthetic results.
El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a
microdissection study on the deep inferior epigastric vessels and the perforators branches.
Plast Reconstr Surg 109:1539-1543; discussion 1544-1547, 2002.
The inferior epigastric artery provides the main blood supply to the lower abdominal
wall. The authors performed microdissections of the inferior epigastric artery, its main
branches, and the perforator vessels in 20 cadavers.
de Souza Pinto EB. Superficial liposuction. Aesthetic Plast Surg 20:111-122, 1996.
In this paper the author describes superficial liposuction and explains the benefits of this
technique, including flap mobilization in lipoabdominoplasty.
Saldanha OR, ed. Lipoabdominoplasty. Rio de Janeiro: Di-Livros, 2006.
This book describes the anatomic concepts, history, and evolution of lipoabdomino-
plasty. The surgical technique is described step by step.
Saldanha OR, de Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective
and safe undermining. Aesthetic Plast Surg 27:322-327, 2003.
This paper describes the aesthetic treatment of the abdominal region using the princi-
ples of liposuction associated with traditional abdominoplasty. Lipoabdominoplasty is
distinguished from other techniques because it has the advantage of conserving the per-
forator vessels of the abdominal wall.
Saldanha OR, Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty without undermining.
Aesthet Surg J 21:518-526, 2001.
First publication by this author group about the development of lipoabdominoplasty.
Taylor GI, Watterson PA, Zelt RG. The vascular anatomy of the anterior abdominal wall:
the basis for flap design. Perspect Plast Surg 5:1, 1991.
The authors note that refinements in tissue transfer, from pedicled to free flaps and mus-
culocutaneous to perforator flaps, have required increasing understanding of finer levels
of the vascular anatomy.

Suggested Readings
Avelar JM. Abdominoplasty: a new technique without undermining and fat layer removal.
Arq Catarinense Med 291:147-149, 2000.
Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J 18:439-
441, 1998.
Callia WEP. Dermolipectomia Abdominal. São Paulo: Carlo Erb, 1963.
De Frene B, Van Landuyt K, Hamdi M, et al. Free DIEAP and SGAP flap breast reconstruc-
tion after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 59:1031-1036,
2006.
Dillerud E. Abdominoplasty combined with suction lipoplasty: a study of complications, re-
visions, and risk factors in 487 cases. Ann Plast Surg 25:333-338, 1990.
Fodor PB. Defining wetting solutions in lipoplasty. Plast Reconstr Surg 103:519-520, 1999.
Hakme F. Technical details in the lipoaspiration associate with liposuction. Rev Bras Cir
75:331-337, 1985.
Illouz YG. Une nouvelle technique pour les lipodystrophies localisées. Rev Chir Esthet 6:9,
1980.
Kelly HA. Report of gynecological cases. Johns Hopkins Med J 10:197, 1899.
Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspen-
sion. Plast Reconstr Surg 96:603-608, 1995.
Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined
abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg 15:111-121, 1991.
Matarasso A. Liposuction as an adjunct to full abdominoplasty. Plast Reconstr Surg 95: 829-
836, 1995.
Munhoz AM, Kamamoto F, Saito FL, et al. Anatomical mapping of the perforant abdomi-
nal vessels and clinical application in the treatment of aesthetic deformities of the ab-
dominal wall through lipoabdominoplasty. In Saldanha OR, ed. Lipoabdominoplasty.
Rio de Janiero: Di-Livros, 2006.
de Souza Pinto EB. Our experience in liposuction. Ann Cong Bras Plast Surg 1:9, 1983.
Pitanguy I. Abdominoplasty: classification and surgical techniques. Rev Bras Cir 85:23-44,
1995.
Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concept. Plast Re-
constr Surg 103:1020-1031; discussion 1032-1035, 1999.
Vernon S. Umbilical transplantation upward and abdominal contouring in lipectomy. Am J
Surg 94:490-492, 1957.
3050
Part XII  Body Contouring

Gluteal Augmentation

CONSTANTINO G. MENDIETA
CHAPTER 85

T
he ability to augment the buttock has existed since 1969, when Bartels et al first
described the reconstruction of a unilateral gluteal agenesis by placing a Cronin
breast silicone implant above the gluteus muscle. Over subsequent years, other au-
thors described similar reconstructive procedures for the treatment of asymmetry
and gluteal depressions. However, it was not until 1973 that the first successful aug-
mentation for cosmetic purposes was published by Cocke and Ricketson from
Nashville, Tennessee.
Despite its U.S. origins, gluteal augmentation did not develop a following in the
United States, and it was the Latin-American plastic surgeons who popularized and
refined the technique as a cosmetic procedure. In 1981 González-Ulloa developed an
interest in gluteal augmentation and placed gluteal implants above the muscle through
bilateral infragluteal crease incisions (at the bottom of the buttock). He was among
the first to develop an implant line that was specifically designed for the buttock,
marking the birth of the almond-shaped gluteal implant. Until then, breast implants
had been used for buttock augmentation. González-Ulloa published his 10-year ex-
perience in 1991 describing his technique as well as a new incision approach, the bi-
lateral intergluteal incision (moving the incision from the bottom of the buttock to
the inside of the midline gluteal crease).
Until that time, only subcutaneous buttock augmentation had been described, but
in 1984 Robles et al of Argentina published a landmark article in which they de-
scribed the intramuscular technique through a central single intergluteal incision.
Robles also introduced his own line of round gluteal implants, making the choices
for gluteal implants more intriguing.
Unfortunately, gluteal augmentation as a procedure lay dormant for the next
10 years, with very few advancements or publications until 1994, when Vergara pub-
lished his experience with an anatomic implant that he developed for the intramus-
cular plane. Then in 2000 de la Peña published his work describing a new surgical
plane and described the new implant he designed specifically for the subfascial plane.
Gluteal augmentation was now developing apace: we had different incision locations,
different implants to choose from, and different planes of placement. However, de-
spite its 30-year history, the procedure remained in its infancy and had not flour-
ished as other procedures had, such as breast augmentation, face lifts, and body con-
touring, about which many articles had been written. Physicians’ interest remained
low, since they remained unfamiliar with the anatomy, they perceived a high com-
plication rate, and there were few articles in the literature.
This all began to change in the early 2000s as public interest began to peak with the
appearance of Jennifer Lopez, Serena Williams, and other personalities who accen-
tuated and flaunted their curves. As patients began to inquire what could be done to
give them more-curvaceous buttocks, physicians’ interest began to increase—yet the
vast majority remained hesitant because the operative techniques were not well un-
3052
Part XII  Body Contouring

derstood. Patient selection remained a mystery, and no evaluation system existed to
universalize the approach. Consequently, surgeons continued to avoid performing
procedures on this area of the anatomy.
In 2003 I published my experience with intramuscular implants in which patients
described a tremendously high satisfaction rate, but clinically there was a 30% wound
dehiscence rate. Up to this point, no article had addressed complications, complica-
tion rates, patient selection, implant selection, plane selection, and so on. My focus
turned from simply trying to master the technique to trying to decrease the compli-
cation rates and make the procedure safer and more appealing to surgeons.
The procedure has evolved significantly over the past 8 years. In this chapter I will
focus on how to augment the buttocks safely with implants or with fat. It includes
guidelines for patient selection, implant selection, incision location, and surgical
plane selection. In addition, information is provided on identifying patients who are
at a greater risk for developing complications. Mastery of this procedure requires
both knowledge of relevant clinical anatomy and familiarity with the properties of the
various implants available to the surgeon.
Patient Profiles: Who Is a Candidate for Gluteal
Augmentation?
Gluteal augmentation is not just about making the buttock bigger, but rather ac-
centuating, contouring, and reshaping. The focus becomes volume redistribution,
shifting volume from an unattractive zone to a more desirable curvaceous position.
3053
Chapter 85  Gluteal Augmentation
With this perspective, even a full-figured woman becomes a candidate, because on
closer examination, the large buttock has poorly distributed fat with deficient vol-
ume in pertinent aesthetic zones. Liposuction was also performed on this patient’s
back, waist, and abdomen.
Preoperative and 5-month postoperative views after 1100 cc of fat grafting to the buttocks

The question is no longer who is a candidate for buttock surgery, but rather what
augmentation procedure is best for a particular patient. Liposuction is used for re-
shaping, and fat grafting is used for fat redistribution, but which augmentation
method should be selected becomes our first challenge.
Pertinent Anatomy
A thorough grounding in anatomy and aesthetics is essential for body contouring.
We can all recognize a pretty buttock, but translating this aesthetic into surgical re-
sults becomes a challenge. Millard emphasized in his principles that to be success-
ful in our surgical design, approach, and ultimate results, we must first understand the
beautiful and ideal normal. This is particularly true when dealing with a massive-
weight-loss patient, where normal anatomy and proportions may have become
grossly distorted.
3054
Part XII  Body Contouring
The gluteus maximus muscle originates primarily along the lateral margin of the
sacrum and, to a lesser extent, from the coccyx and sacrotuberous ligament. It con-
tinues in an upward curvilinear direction to the posterior iliac spine (identified as
bilateral dimples in the parasacral zone). Traditional teachings tell us that the muscle
attaches all along the crest, but in reality it only follows the crest for a quarter to a
third of its distance—up to the posterior superior iliac spine. From this point it fol-
lows a ridge inferior to the crest. The distance from this ridge attachment to the pal-
pable superior crest is variable among patients. The gluteus maximus inserts into the
iliotibial tract, and, to a lesser degree, the greater trochanter. The gluteus medius
originates along a ridge in the posterior superior iliac crest and attaches in a man-
ner similar to the gluteus maximus.
Gluteal
muscles
Fat
Iliac crest
Median sacral
crest
Posterosuperior
iliac spine

The superior aspect of the origin of the gluteus maximus plays an important role in
defining the ideal buttock. However, buttock aesthetics are not solely dependent on
the gluteal muscles. The overall shape of the buttocks is also influenced by bony pelvic
anatomy, fat distribution, and, to a lesser degree, skin, if there is laxity or overhang,
as is the case in massive-weight-loss patients. Without a doubt, the most significant
contributor to shape is fat. Excess fat in the sacrum, upper buttock, flank, and outer
legs will distort shape and contour.
The Ideal Buttock
To evaluate the buttock, it is helpful to divide it into quadrants by drawing an imag-
inary line down the center of the buttock. The ideal buttock has equal volumes on
either side of this line and has the shape of a football, but with a slightly wider base.
3055
Chapter 85  Gluteal Augmentation
To assess volume distribution, a horizontal midbuttock line is added to divide the
buttocks into four quadrants. The ideal buttock also has equal volumes above and
below this horizontal line. In determining the best procedure for a particular patient,
the surgeon evaluates all four quadrants as either sufficient or deficient.
There are three other zones surrounding the buttock that are important in this eval-
uation: the upper inner gluteal–sacral junction, the lower inner gluteal fold–leg junc-
tion, and the midlateral gluteal–hip junction.
Horizontal line
1
2
4
3
Mid reference line

Upper Inner Gluteal–Sacral Junction: Ideal Presacral Space Shape
The inner gluteal–sacral space should be well defined so that a V shape is apparent;
this lower presacral space is appropriately called the V zone. As the V zone becomes
more visible, the buttock has greater aesthetic appeal.
3056
Part XII  Body Contouring
In the ideal buttock, the edge of the gluteal muscles should be well defined and have
a semicircular upward turn. The superior edge should culminate a quarter to a third
above the intergluteal crease line.
If this space is not well defined because of lack of muscle volume and excess fat in
the V zone, the buttock becomes blunt and appears flat, especially on lateral view.
Lower Inner Gluteal Fold–Leg Junction
To describe this relationship, the intergluteal crease will be referred to as the mid-
line. The upper aspect of the crease is easily identified; however, the inferior aspect
is defined at the point where the buttock begins to separate from this midline.
Solid line marks end of intergluteal crease line; dashed line marks
end of upper muscle edge; notice V zone with visible muscle fullness
L5-S1
V zone–
presacral
space
14-1 3
Muscle edge
not defined

In the images above, the red lines indicate how the fullness increases at the lower in-
ner gluteal fold. Notice how the diamond-shaped zone turns from a 45-degree an-
gle into a straight line.
In the ideal buttock, this point of separation from the midline occurs at about the
bottom two thirds to three fourths of the muscle. The separation widens until it meets
the inner leg junction. At this point the lower gluteal fold has a 45-degree takeoff
from the center intergluteal crease line and the inner gluteal fold–leg junction should
create a diamond-shaped space. This is a key point in gluteal aesthetics. As the lower
inner gluteal fold and inner leg become fuller, the 45-degree sloping line is changed
to a more horizontal position, which causes the diamond-shaped space to turn into
a straight line, losing its aesthetic appeal. As the fullness increases, it develops an in-
verse relationship, creating an upward slope (negative angle). Thus the slant of the
inner gluteal fold has three possible orientations: a downward 45-degree slope with
the inferior gluteal fold ending at the midbuttock or slightly beyond (as seen in the
ideal buttock), a horizontal line, or an upward inverse slope.
3057
Chapter 85  Gluteal Augmentation
Improvement of this zone will depend on the severity of the fullness.
Downward slope
Horizontal line
Upward slope

3058
Part XII  Body Contouring
Lateral Midbuttock–Hip Contour
In the aesthetic buttock, the lateral midbuttock has no depression. In actuality, this
zone may exhibit varying degrees of depression, ranging from no depression to mild
and moderate degrees of depression to severe depression.
With volume well established and these three zones evaluated, the next questions be-
come: Is there an ideal gluteal crease length? How important is this to gluteal aes-
thetics? And what relationship does this have to the gluteus muscle or any of the sur-
rounding areas?
Ideal Intergluteal Crease Length
The intergluteal crease length is usually half the length of the gluteal muscle, but it
is centered on the gluteus so that a quarter to a third of the gluteal volume is above
the highest crease point and a quarter to a third below the termination point—the
takeoff point where the lower inner gluteal fold deviates from the intergluteal crease
line.

Ideal Presacral to Intergluteal Crease Length Relationship
The presacral space extends from the midline dimple of the lower back (L5/sacral
junction) to the superior aspect of the intergluteal crease. It plays an important role
in gluteal aesthetics.
3059
Chapter 85  Gluteal Augmentation
The length of the entire presacral space (green line) should be shorter than the in-
tergluteal crease length (red line). Ideally, the presacral space should be a half to a
quarter the length of the intergluteal crease.
If the presacral space is twice as long as the intergluteal crease length (2:1) (left), the
crease appears extremely short, giving the illusion of a truncated, flat, underdevel-
oped buttock. If the presacral space length is less than a quarter of the intergluteal
crease length and there is excess fullness in the lower inner gluteal zone, this gives
the crease an excessively long, alien appearance (center). However, even with this re-
lationship, if the buttocks have adequate volume, especially in the lower third, the
overall appearance may be adequate (right).

3060
Part XII  Body Contouring
Lateral View Aesthetics
On lateral view, the presacral area should have a nice sweeping curve that has a lazy-
S shape (from the back to the bottom of the gluteus). Most of the gluteal volume is
central and has equal distribution in the upper and lower gluteal zones, providing a
nice C-shaped curve. It has been suggested that the peak of the central mound should
be at the level of the pubic bone.
Determining where most of the volume lies (upper, central, or lower buttock) is im-
portant in selecting the best procedure for buttock augmentation.
Upper buttock zone
Central buttock zone
Lower buttock zone
Upper buttock
Central buttock
Lower buttock

Summary of Key Anatomic and Aesthetic Concepts
3061
Chapter 85  Gluteal Augmentation
One can now easily see that the upper aesthetic unit of the gluteus follows its ori-
gin, beginning at the midsacral line, continuing as a semicircular line that connects
to the posterior iliac spine (identified as bilateral divots in the parasacral zone), and
peaking at 2 to 3 cm above this point. The ideal crease is centered on the gluteus
muscle and is half the length of the muscle. The length of the presacral space should
be shorter than the intergluteal crease length. In a well-developed buttock with very
little lower presacral fat, a visible V zone is apparent that further accentuates the up-
per inner muscle anatomy; the muscle has a football shape, with equal volumes in
all four quadrants. The gluteal unit is marked superiorly by its attachment to the il-
iac ridge (easily palpated) and inferiorly by the inferior gluteal crease. If incisions are
created that fall below the superior insertion point or mark, the shape is distorted.
Without a doubt, the most important contributor to gluteal aesthetics is the volume
of distribution in all four quadrants. When this volume is adequate, all other aes-
thetic points can be overlooked and still produce an attractive buttock.
The other key contributor to gluteal aesthetics is the inner gluteal–leg junction. In-
ferior gluteal aesthetics is defined by a diamond shape at the intergluteal/leg junc-
tion. The medial buttock cheeks have a 45-degree takeoff from the intergluteal line
and flow into the inferior gluteal crease, which terminates at or just beyond the mid-
buttock line. On lateral view there is an S-sweep curve from the lower back as it flows
into the buttock, and most of the gluteal volume is located in the central zone.
Ideal
diamond
space
Pelvis
Gluteal
muscles
Fat
Midreference line
or midgluteal line
V zone
Ideal buttock

3062
Part XII  Body Contouring
Clinical Decision-Making: Implants Versus Fat
As I noted earlier, my initial implant complication rates for buttock augmentation
were published in 2003 in which I had identified a wound dehiscence rate of 30%,
with an implant exposure and infection rate of 2% to 3%. However, in this series,
by far the most frequent patient complaint was that the augmentation was “not big
enough” (see below), and patients demanded larger volumes.
This patient is shown preoperatively and 2 years after intramuscular medium round
implants were placed. The implant augmentation shows minimal difference.
In trying to fulfill patients’ expectations, larger implants were used; however, com-
plication rates soared, with wound dehiscence rates increasing to 40% to 50% and
implant exposure rates rising as high as 30%. This was unacceptable, making it very
clear that not everyone was a candidate for implant gluteal augmentation. But then,
who was?
Through a new retrospective review of 150 intramuscular cases, we noted these fac-
tors: most of the dehiscence and implant exposures occurred in large patients or pa-
tients seeking large augmentations. While at face value this observation seems obvi-
ous, it must be remembered that no guidelines or parameters existed for gluteal
augmentation. Therefore the question became more complex: What patient is too
large? What implant is too big? What is the threshold? To help answer these ques-
tions, we evaluated patients based on body frame size and the degree of muscle ten-
sion at closure.

3063
Chapter 85  Gluteal Augmentation
Wound Dehiscence and Implant Exposure by Body Frame in 150 Patients
Wound
Dehiscence
Body Frame
(%)
No Tension
Tension
Small frame
12*
1-2
12
Medium frame
30†
3-4
12
Large frame
40
10
30
Extra-large frame
80
30
60
Implant Exposure Based on
Muscle Tension at Closure (%)
*Single midline intergluteal incision.
†Two separate parallel intergluteal incisions 2 cm apart.
To assess body size, patients were divided into four groups: those with small, medium,
large, and extra-large frames. Muscle tension was categorized as either having ten-
sion or no tension at closure. Implant exposure and wound dehiscence were com-
pared. The results are shown in the table.

Analysis of Implant and Fat Options
Before 2003, when patients presented for gluteal augmentation, implants were my
preferred method; 90% of the augmentations were performed with implants and
only 10% with fat injections. My preferred method of augmentation today is autol-
ogous fat grafting, because this method completely eliminates all the implant-related
complications (wound dehiscence, implant exposure, capsular contracture, seroma,
implant rotation, extrusion, and so on). Implants are used only in patients who do
not have enough fat for a significant clinical augmentation (small-framed individu-
als) or borderline patients who cannot gain 4.5 to 9 kg (10 to 20 pounds) (some
small- and medium-framed individuals). The complication rates in these patients,
when using a double parallel intergluteal incision with a no tension on muscle clo-
sure, was only 2% to 3%. However, this means that the exact implant size to be used
can only be determined intraoperatively with the use of sizers. If the patient desires
a larger augmentation, we can perform simultaneous fat grafting to help enhance
volume and shape, but the implant size depends on the patient’s anatomy, meaning
the degree of muscle and skin laxity.
Large- and extra-large-framed individuals are ideal for fat transfers, given that ex-
cess fat and implant complications are far too high in this group. The challenge there-
fore lies in medium-framed individuals, because they may or may not have an ade-
quate amount of fat. It is in these patients that the surgeon’s estimate of the fat that
he or she feels can be extracted plays a crucial role. This estimated amount may vary
significantly, depending on the surgeon’s experience and comfort level. If the surgeon
is in doubt, the patient can be asked to gain weight.
Thus the central question is: Just how much fat is needed to obtain a clinically sig-
nificant buttock augmentation?
The Amount of Fat Needed for Augmentation
Every patient’s desires and goals are different, and often the patient’s anatomy may
limit the amount of augmentation, depending on the laxity of the muscle and skin,
but as a general rule gluteal augmentation with fat requires 400 to 1100 cc of good
transferable fat per side. Obviously, the larger the patient, the larger the required vol-
ume; in a small-framed individual, 300 to 450 cc per side will be needed; in a
medium-framed person, 450 to 850 cc per side; and in large- and the extra-large-
framed patients, 750 to 1100 cc per side. The overall amount that can be placed will
be influenced by the degree of muscle and skin laxity as well as the gluteal muscle
dimensions.
3064
Part XII  Body Contouring

3065
Chapter 85  Gluteal Augmentation
The true amount of fat that will be available for transfer cannot be determined pre-
operatively; there are several variables that are only revealed during the surgical pro-
cedure. We must remember, not all of the aspirated fat is viable, and each patient
has different fat characteristics: some fat is easily destroyed on suctioning, whereas
other fat is very fibrous and resilient. Complicating the issue further, some patients
have a bloodier aspirate, which can further limit the amount of fat we can extract
safely. Other patients have such a strong propensity for leaving cannula track marks
on the skin that it limits the aggressiveness of our suctioning, further limiting the
amount of available fat. These variables cannot be predicted before surgery, which
makes the quantity of transferable fat unpredictable. As a general rule, only half to a
third of the total supernatant aspirate is acceptable for transfer, which means that
1000 to 4000 cc of total supernatant fat is needed to produce 600 to 2000 cc of good
transferable fat. These volumes have been substantiated by others.
Clearly, some patients will not have that volume to spare. A small-framed individ-
ual, as stated before, is best augmented with implants or implants and fat. If in the
surgeon’s opinion a medium-framed individual does not have enough fat or the es-
timated volume is borderline, the patient is asked to gain 4.5 to 9 kg (10 to 20
pounds), depending on the surgeon’s estimate of how much fat the patient will have
available. Often the patient is brought back for a reevaluation after a 4.5 kg (10-
pound) weight gain and is reassessed. If the available volume is still in doubt, the pa-
tient is asked to gain more weight. If the patients cannot gain the weight and the sur-
geon is still in doubt as to whether the needed volume will be available, there are
three options:
1. The patient’s buttocks can be augmented with whatever fat can be harvested,
with the patient fully aware that the procedure may fall short of her expec-
tations, and she may require a second procedure if she desires further aug-
mentation. The second procedure can involve either more fat transfers after
a second weight gain, or placement of implants.
2. The buttocks may be augmented with implants only, but the size of implant
may be limited, depending on her muscle laxity. The goal is to place the largest
implant that does not create muscle tension at closure. This cannot be deter-
mined until surgery, and this may limit the desired size.
3. Therefore a better option would be to use a combination of implants and fat,
the implant size will be determined during surgery, and the fat will be used
to further enhance shape and volume.

3066
Part XII  Body Contouring
IMPLANT AUGMENTATION
There are three main issues that must be decided when selecting implants: shape,
size, and texture. The implant content can be a solid silicone elastomer, or silicone
cohesive gel. The gel implants are used outside the United States, whereas U.S. sur-
geons are limited to the use of elastomer implants.
Implant Shape Selection
The most common shapes are anatomic, oval, and round; the shape selected will de-
pend greatly on which plane is chosen to augment the buttock, subfascial or intra-
muscular. Each plane has different tissue dynamics and responds very differently to
augmentation.
Augmenting the Subfascial Plane
In this plane, tissues are more pliable, but they are thinner. If implants are improp-
erly selected, they may become palpable with visible edges, and over time gluteal pto-
sis may develop.
This patient’s subfascial round implants were placed
too low and descended over time. This is particularly
likely to occur if round or oval implants are used.

The best subfascial implant is the one designed by de la Peña; his implant is specifi-
cally designed for this plane, and he has spent a significant amount of time designing,
engineering, and developing this particular technique. This plane offers a quicker re-
covery with much less postoperative pain. For surgeons outside the United States
who can use silicone-gel implants, palpability is not a big issue. If the patient has
good tissue coverage, with proper patient selection and the use of gel implants, a
nice natural augmentation can be achieved.
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Chapter 85  Gluteal Augmentation
In the subfascial plane, the only decisions that remain are size selection and implant
texture. De la Peña developed some excellent preoperative external templates (above)
that guide the surgeon in size selection. In terms of implant texture, I prefer the
smooth implants, because I have noticed a higher delayed seroma rate with the tex-
tured implants.
Intramuscular Plane
In the United States we are limited to the elastomer implants, and although they have
become softer, these implants are firmer, more palpable, and have less give than gel
implants; therefore obtaining tissue coverage is a priority. Placing the elastomer im-
plants in the muscular plane will help camouflage the firmness of the implant, pro-
ducing a more natural feel and appearance. Given the implant restrictions for U.S.
surgeons, this plane becomes more appealing. The intramuscular implant selection
process involves deciding on implant shape, size, and texture. Again, the smooth im-
plant is preferred, because there seems to be a lower incidence of seroma formation.
The implant shape for the intramuscular plane requires evaluating two aspects: the
muscle height-to-width relationship in the PA view, and the volume of distribution
in the lateral view.

Muscle Height-to-Width Ratio
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Part XII  Body Contouring
To find the muscle height-to-width ratio, the superior and inferior points of the glu-
teus muscle are identified, as well as the most medial and lateral points. At a glance,
one can see a height-to-width relationship that will fall into one of three ratios: short
muscle, 1 to 1; intermediate muscle, 1 to 2 to 1; or tall muscle, 2 to 1. The ideal but-
tock is intermediate but leans more toward a 2 to 1 relationship.
The short muscle is best augmented with round implants, because they have similar
ratios (1 to 1); the tall muscle (2 to 1) is best augmented with an anatomic implant.
The intermediate muscle has the most flexibility, because any of the three types could
be used: round, anatomic, or oval. However, in these cases it is best to use the lat-
eral view to make our final decision.
Upper buttock zone
Central buttock zone
Lower buttock zone
Short: 1 to 1
Intermediate: 1 to 2 to 1
Tall: 2 to 1
The gluteus is divided into three zones: upper, central, and lower