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

Implant Size Selection
Selecting implant size requires a fine balance of trying to please the patient with her
desired size and trying to prevent the complications of implant exposure and wound
dehiscence. Often these goals conflict: the tissues will not allow as large an aug-
mentation as the patient desires. In these cases, fat grafting can be combined to fur-
ther increase volume.
Decreasing Implant Exposure
In attempts to decrease implant exposure, I spoke with my mentor in gluteoplasty,
Dr. Jorge Hidalgo, and revisited the operation. Once the implant is in place, the mus-
cle edges should almost be opposing (“kissing” edges); this way, very little tension
is placed on the muscle closure. Some patients have a very lax or loose muscle and
can easily accommodate large implants, whereas others have very tight, fibrous at-
tachments with dense muscle fibers that can barely tolerate medium-sized implants.
Interestingly enough, the degree of athletic build or activity has nothing to do with
the degree of muscle tension. I have seen body builders with lax muscles and seden-
tary patients with very dense, tight fibers. There seems to be a genetic and cultural
predisposition with individuals of African descent having the tightest attachments.
Because each patient’s anatomy is unpredictably different and implant exposure rates
rise as tension increases, implant size cannot be guaranteed or determined before
surgery. Sizers are used intraoperatively to identify the largest implant the body will
accommodate without creating excessive muscle tension at closure. If the patient de-
sires a larger augmentation, in 3 to 6 months the surgeon can either place larger im-
plants (the muscle having been stretched), or can perform fat transfers. Fat grafting
can also be performed at the same time as the implant augmentation.
Intramuscular Surgical Procedure Technique
Preparation
Preoperatively dexamethasone (Decadron) 10 mg and clindamycin (Cleocin) 600 mg
are administered intravenously. Pneumatic compression stockings are placed and
functioning before anesthesia is induced. Because the surgical procedure takes only
11⁄2 to 2 hours, placement of a Foley catheter is unnecessary.
Anesthesia and Positioning
The procedure can be performed under general anesthesia, or with spinal or intra-
venous sedation. The patient is placed in the prone position with a pillow under the
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Chapter 85  Gluteal Augmentation
pelvic bones to jackknife the pelvis and aid in muscle visualization and dissection.
The elbows are flexed with the arms out to the sides at less than 80 degrees (the
beach position), and all pressure points are padded. The pneumatic compression de-
vices are rechecked.
If the procedure is to be done with the patient under general anesthesia, I suggest
placing a draw sheet under the patient before induction. Once the airway is secured,
with aid of the draw sheet, anesthesia in control of the airway, and staff assisting
with arm positioning, the patient is rotated to the prone position. The arms are se-
cured and the pillow placed under the pelvic bones. It is important to ensure that all
pressure points are well padded and that the pneumatic compression devices are
functioning.
Once satisfied with positioning, the buttocks and back are prepared and draped. The
gluteal area is prepared from the knees to the upper back and as far laterally as pos-
sible. Draping should leave the entire gluteal zone and lower back exposed; a gauze
soaked in povidone-iodine (Betadine) solution is placed over the anus and secured
with 2-0 silk to avoid contamination (left). A sterile towel is placed over the gauze
to cover the anus and the inner gluteal zone (right). This towel is secured to the skin
with 2-0 silk so that there is no space between the towel and skin. All gloves and
gowns are changed.

Markings
Preoperatively the areas to have liposuction or fat transfers are marked with the pa-
tient in the standing position. The intraoperative markings are minimal, identifying
only the tip of the coccyx and infragluteal crease (this helps to identify the drain exit
points). Most of our markings relate to incision placement.
Incision Design/Selection
In 1969 Crocket used a unilateral infragluteal incision for reconstructive purposes.
González-Ulloa used a bilateral infragluteal approach for his subcutaneous tech-
nique, but given the visibility of these scars, they were never in favor. Robles placed
the implants in the submuscular position through a hidden single intergluteal inci-
sion. This became the incision of choice because of its inconspicuous nature.
Performing gluteal augmentation with implants has been very humbling, because
complication rates have remained high, although we have explored many avenues to
decrease wound dehiscence and implant exposure: fibrin glue; platelet gels; quilting
sutures; drains; variations of the central intergluteal incision; scalpel dissection ver-
sus cautery dissection; immobilization; a variety of postoperative care techniques,
including fewer office visits (to decrease wound irritation); changes in antibiotics; a
variety of garments, and more. No matter how our preoperative, intraoperative, and
postoperative care was manipulated, we saw no improvement. Other investigators
published articles, and I saw that they did not share my high wound dehiscence rates
or issues. However, it became clear that the single midsacral incision was not the
best approach in my series, so I began to use bilateral parasacral incisions, which
I later learned had already been described by González-Ulloa. These incisions avoid
the sacral midline, with its poor circulation. In my last 12 cases, no dehiscence has
occurred.
These incisions are designed as follows: with the patient in the prone position, the
tip of the coccyx is palpated and marked; staying exactly in the sacral midline the
central intergluteal crease is drawn from the tip of the coccyx 8 cm cephalad. The
future incisions are marked 1 cm from this midline so that both incisions are 2 cm
apart in the inferior and middle portions. If these lower distances are not respected,
central skin necrosis may occur. As the incision reaches the upper buttock, it follows
the upper gluteal curvature (this occurs at about the 6 cm mark from the coccyx).
This design produces two 8 cm incisions that parallel the midline from the tip of the
coccyx and extend cephalad following the upper gluteal curvature.
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The incisions at their inferior and middle portions have a 2 cm separation; in their up-
per portion, a 4 to 5 cm separation. The eventual scars remain hidden in the gluteal
cleft. Although the upper incision may be seen in some patients, it is hidden in bikinis.
Skin Flap Dissection
The incision sites are infiltrated with 10 ml of 1% lidocaine with epinephrine
1:100,000. Tumescent fluid is injected into the intramuscular and subcutaneous tis-
sues, as well as the areas to be suctioned. With the surgeon approaching one side at
a time while standing on the opposite side of the gluteus to be worked on, the inci-
sion is made down to the gluteal fascia. The tissues are placed under upward trac-
tion with hooked retractors. The beginning of this dissection is tricky, because the
muscle fascia comes up relatively quickly and takes an upward, sloping turn. Care
must be exercised to avoid getting into the muscle and losing the plane. With the aid
of deeper retractors, the dissection is continued, making certain to preserve the fas-
cia on the muscle (a key point in this approach; if the fascia is not preserved on the
muscle, there will not be enough good closing tissue for implant coverage). The dis-
section can be done with electrocautery or, for a less heated dissection, with a gauze
pad wrapped around the thumb, digitally elevating the subcutaneous tissues with an
upward, sweeping motion. The goal of the initial subcutaneous dissection will be to
expose just enough of the muscle and fascia to allow implant placement (this usu-
ally means about 5 to 6 cm of subcutaneous dissection).
Muscle Dissection
Before beginning the dissection, it is important to understand the anatomy. The ma-
jor muscles in this zone are the gluteus maximus, minimus, medius, and piriformis.
The maximus has transversely oriented fibers and is one of the largest muscles in the
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body; its superior half covers the medius, which has vertically oriented fibers. The
plane between these muscles is more distinct in its superior portion (at the level of
the posterior superior iliac crest). Moving caudally, the fibers integrate and become
indistinguishable. Because our dissection is performed at the gluteal midlevel, there
will not be clear identifiable planes, muscle groups, or layers. It is a blunt intramus-
cular procedure with components of direct visualization, the goal being to maintain
a 2 to 3 cm muscle thickness of coverage for the implant. The gluteus muscle is about
4 to 6 cm thick, so maintaining a 3 cm intramuscular dissection allows the muscle
to remain and still provide coverage over the crucial nerves and vessels.
Using the midsacral level as the reference point, the fascia is opened following the
direction of the muscle fibers for a length of 5 cm.
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The intramuscular dissection is started by using a long hemostat and spreading per-
pendicular to the muscle for a depth of 1 cm. At this point, the surgeon switches to
a ring forceps and continues the perpendicular muscle spread for another 2 cm (a
total of 3 cm coverage). During the forceps dissection, one can see glistening fascia
fibers that are present at different levels of the dissection. If the 3 cm depth has not
been reached, the fascia is incised and dissection continues until the 3 cm mark is
reached. The forceps dissection creates only a small muscular opening that must be
enlarged. With the use of cautery, the muscle incision is opened medially and laterally
to its full fascial incision length. Once this depth is achieved, the Deaver retractors
are introduced on both sides of the muscle and spread. Up to this point, the procedure
has been relatively bloodless; the dissection now becomes blunt, and some blood loss
(about 50 ml) will occur. Remember, this is an intramuscular procedure; there is no
real areolar plain, as in breast augmentation. The closed ring forceps is used to bluntly
push and create the muscle pocket; the muscle pocket should be kept 3 cm thick
throughout. It is best to start the pocket dissection in the superior lateral direction.
A key point to this portion of the dissection is to tilt the tip of the ring forceps down
to about 45 degrees, because the surgeon’s tendency will be to unconsciously tilt the
forceps upward and pierce through the muscle. If this happens, one can dissect deeper
or convert this part of the implant to a subcutaneous position (it is better to dissect

deeper). The dissection continues in a sweeping counterclockwise motion from a su-
perolateral to superomedial direction by a back-and-forth pushing motion of the
ring forceps. At this point, with a pocket somewhat created, under direct visualization
and with the aid of retractors, the surgeon further defines the pocket with the Aiache
gluteal muscle dissector, a serrated instrument. If this dissector is not available, the
surgeon can use an index finger or a curved Van Buren sound to push the fibers. At
this point little dissection will be done inferiorly. A lap pad is placed in the wound
to clear out any blood.
Expander
To help define the pocket further, the surgeon places a breast implant expander and
overinflates it until no further expansion can be obtained. The expander will stretch
the muscle and help to indicate areas that require further dissection. It will also help
define the inferior dissection. In the past, the inferior dissection was limited to an
imaginary line that spanned from the tip of the coccyx to the greater trochanter of
the femur; this limitation placed the implant in a very high and unattractive posi-
tion. As surgeons have gained familiarity with this procedure, the inferior dissection
has been refined so that the dissection extends 3 to 5 cm below the coccyx, placing
the implant in a more anatomic location with improved aesthetic contour. To ensure
safety, the inferior dissection is performed with the aid of the expander in place;
blunt finger dissection is used to push muscle fibers away from the implant in an in-
ferior direction. The majority of the inferior dissection is done using finger dissec-
tion to maintain the muscle thickness and avoid instrument injury to any structures.
On occasion, the surgeon may encounter some very dense and tough fibers that can-
not be broken with finger manipulation. In these cases, the expander is removed and
under direct vision these fibers are freed using the Aiache or Van Buren dissectors or
even cautery.
It should be kept in mind that the sciatic nerve is deeper than this dissection. An im-
portant landmark is the acetabulum of the femur, which is easily palpated and some-
times seen. If the acetabulum can be palpated, the nerve lies in a groove that is im-
mediately lateral to this structure and is well protected. Occasionally one may
encounter the inferior gluteal or superior gluteal arteries; rarely are these cauterized
or ligated. However, if this is necessary, it will not create a problem, because the max-
imus is a type III muscle with excellent blood supply.
Sizers and Implant Size
Once the surgeon is satisfied with the dissection, a sizer is inserted to determine the
appropriate implant to be used. When the implant is in place, the muscle edges should
be in close proximity, with very little tension at closure (this is one of the key steps
in the procedure). Every patient will exhibit different muscle thickness, tightness, and
characteristics; this is not related to an athletic build or body size. It is difficult to
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predict whose tissues will be lax or tight. Therefore it is often helpful to have a va-
riety of sizes available in the operating room to help assess the largest implant that
this particular patient’s muscle will accommodate with minimal tension.
Drains
After the implant size has been determined, a Jackson-Pratt drain is introduced in the
pocket and brought out through a separate stab incision in the infragluteal crease.
Use of the drain has decreased the incidence of seroma. At this point the pain pump
and catheters can be placed; these are brought out through the upper medial buttock.
Implant Placement/Closure
The implant pocket is irrigated with 10 ml of 1% lidocaine with epinephrine
1:100,000 mixed with 5 ml of bupivacaine (Marcaine) 0.5% plain. All gloves are
changed, the implant is soaked in antibiotic solution, and the incision is thoroughly
scrubbed with a scrub brush using Hibiclens. A new sterile towel is placed over the
buttock; the implant is rolled into a cigar shape and introduced. A sterile sleeve may
come with the implant; this is used to introduce the implant and help avoid implant
contact with the skin—the surgeon should be prepared to struggle. Sometimes, if the
muscle is tight, it will have to be incised at its insertion along the sacrum for about
0.5 cm to create more space. (The surgeon should try to avoid having to do this, be-
cause it does make it more difficult to close). Care is taken to leave a cuff of tissue
so that it can be closed over the implant. Any irregularities are corrected with fur-
ther pocket refinement utilizing a curved dissector. The drains are checked for any
kinking to ensure that they are in a good position. The muscle is closed with 2-0
Vicryl. The subcutaneous wound is closed in layers with a final running 3-0 Vicryl.
The opposite side is now completed in a similar fashion.
Postoperative Care
Activities
 For the first 2 to 3 weeks the patient is instructed not to sit, to sleep on the stom-
ach, and when relaxing (watching TV, visiting with friends, reading the paper), to
be in the prone position or standing. The patient may conservatively ambulate
around the house but is asked to limit activities to avoid wound friction and
trauma. When traveling to the office, the patient is asked to lie prone in the back
seat of the car.
 Most wound dehiscence occurs about the fourteenth postoperative day; wounds
are checked on this day. If the wound is intact, the patient is seen for follow-up a
week later. At the third postoperative week, the patient is cleared for sitting and
driving and is encouraged to start stretching exercises. If the wound is marginal,
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the patient is followed closely but is not allowed to sit or drive for at least 2 more
weeks until the wound appears stable, or, if the wound dehisced, until granula-
tion tissue has developed.
 The patient can usually return to work 2 to 3 weeks postoperatively.
 Return to the gym will depend on wound status. If all is well, the patient can re-
sume exercise 6 weeks postoperatively. If the wound is compromised, it may be 2
to 3 months before workouts are appropriate.
 After 3 months the patient is cleared for all types of activities (bungee jumping,
motorcycle riding, or any other vigorous activity). At first, the implants will feel
very firm (like sitting on rocks); it will take 3 months for them to “soften up.” Af-
ter that time, they feel like a well-worked-out buttock.
Garments
 If liposuction was performed, the patient wears a body garment for 4 to 6 weeks.
 If no liposuction was performed or the liposuction was limited to the waistline,
an abdominal binder that wraps around the upper buttock and waist line is used
for 2 weeks. This binder seems to give patients more comfort and less pain than
not having any garment.
 After the third week, if all is well, the patient is cleared to start sitting.
Bathroom
 Privileges are given, but the patient is encouraged to urinate in the shower while
in the standing position.
 Since the patient is usually constipated (because of pain medications), bowel move-
ments are not likely to be an issue until a week postoperatively.
 Nevertheless, if the patient must defecate, it is permissible to sit, but with assis-
tance. The patient is instructed to use baby wipes and to wipe in the standing po-
sition while leaning forward on a countertop, wiping once (repeating with a fresh
towelette) from top to bottom until clean.
Postoperative Visits
To avoid excessive ambulation, the patient is seen on the third postoperative day for
a wound and drain check. The drains are removed when there is less than 30 ml of
drainage per 24 hours, usually about 1 week postoperatively. Oral cephalexin 500 mg
three times a day is used until the drains are removed. If the amount of drainage re-
mains high at 1 week after surgery, the surgeon must consider balancing the risk of
infection from the prolonged presence of drains against possible seroma formation
resulting from early drain removal. If drainage persists, tetracycline is placed through
the drain and the tube is clamped for 3 hours. This sclerosing agent helps to decrease
output. The patient is seen the following day and the process is repeated if necessary.
If drainage persists after 10 days, the drains are removed regardless.
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Postoperative follow-up visits are scheduled for the third, seventh, tenth, and four-
teenth postoperative weeks. If the wound’s condition is questionable, the patient is
seen either daily or every other day between postoperative days 14 and 21. If the
wound is intact by the third week, the patient is seen 1 month later, then 3 months
postoperatively, and finally at 6 months. If the wound has dehisced, the patient is
usually seen daily until the wound is stable (with granulation tissue forming), then
weekly or every other week.
Problems and Complications
As the technique and procedure have evolved, implant complications have been de-
creased by attention to the following principles:
 Incisions are placed in the intergluteal fold, but as separate bilateral incisions,
each placed 1 cm from the center midline.
 Using sizers, the correct implant size is determined based on muscle tightness.
 The muscle edges should be almost kissing when the implant is placed, before
muscle closure.
Individuals with a large or extra-large frame seem to have a higher implant compli-
cation rate, because they usually require larger implants, which can lead to greater
tension at closure and a greater potential for complications. In these individuals aug-
mentation is best done with fat or dermal flaps. With these modifications, this pro-
cedure has worked well.
Wound Dehiscence
Most dehiscence will occur near the fourteenth postoperative day but can occur as
late as 3 weeks postoperatively. In our original series, published in 2003, the rate of de-
hiscence was 30%. The central single sacral incision had the higher dehiscence once
the bilateral intergluteal incisions were performed. One dehiscence occurred in 18 cases.
Although the case number is small, the procedure shows tremendous promise.
If the wound does dehisce, it can be locally explored at the bedside to see whether
the implant is exposed. If it is not exposed, traditional wound care and management
are implemented. Closure may take 1 to 3 months. If the implant is exposed, sec-
ondary surgery is required using implant salvage techniques (posterior capsular flaps
for coverage).
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Implant Exposure
If no tension is placed during muscle closure, the incidence of exposure is low (about
2% to 3%). If an excessively large implant is placed or in patients with extremely
tight muscle fibers with very little stretch, the incidence is higher. Patients are in-
formed that implant size cannot be determined preoperatively, because the most sig-
nificant variable to implant size is the patient’s particular muscle tightness, which
can only be determined intraoperatively. I attempt to place the largest implant the
patient’s buttock can accommodate. If a larger size is desired, an implant exchange
can be performed 3 to 6 months later, and at this time a fairly large implant can be
used, since the muscle has been expanded and stretched. Complication rates in such
instances are very low, and recovery is extremely quick, with return to work in 5 to
7 days.
If the implant is exposed and secondary surgery is required, the wound is irrigated
and the implant usually is exchanged. If the exposure is large, posterior capsular flaps
can be used to aid in implant coverage. Patients are advised that these are implant
salvage techniques and may be unsuccessful, requiring implant removal.
Infection
Postoperative infection is rare, with an incidence of 1% to 2%. If an infection does
develop, removal of the implant may be required. Infections most commonly occur
around the tenth to fourteenth day but have been seen as late as 3 months. However,
implants have been salvaged through secondary surgery to exchange implants and
the use of a closed antibiotic irrigation system. The pocket is irrigated for several
days until the infection resolves. Again, patients are advised that these are salvage
techniques and that implant removal may be necessary.
Seroma
The use of drains has decreased the incidence of immediate seroma. Late seroma has
an incidence of 3% and is usually seen approximately 6 months postoperatively, al-
though it can occur several years later. Late seroma has mainly been seen with the
use of textured implants. Resolution has required surgery with implant exchange
(substituting smooth implants), partial capsulectomy, and drainage.
Capsular Contracture
Capsular contracture has a 1% incidence; it is improved with implant exchange and
partial capsulectomy. It may recur.
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Neurapraxia
No sciatic nerve injuries have occurred in my patients. Patients will complain of
sciatic-type discomfort in the first month after surgery because of swelling. In these
patients symptoms are improved with stretching exercises and administration of vi-
tamins B12 and B6, methylprednisolone (Medrol Dosepak), and oral gabapentin (Neu-
rontin) 100 mg given twice daily. After 1 week, if symptoms have not improved, the
dose of gabapentin is increased to 200 mg twice daily. Most of these symptoms will
improve and disappear over the next 1 to 3 months.
Implant Rotation
Implant rotation is not an issue with round implants; however, there is a small (less
than 1%) incidence of implant rotation with anatomic implants. This can be cor-
rected by placing internal capsulorrhaphy sutures.
Chronic Pain
Chronic pain usually does not occur. When it does, possible causes include myosi-
tis, fasciitis, capsular contracture, nerve impingement, and scarring. Sometimes the im-
plant may be too large and cause pain when the patient sits, because it forces itself
onto the muscle attachment at the posterior iliac crest. In such a case, changing to a
smaller implant may help; in a patient with an anatomic implant, changing to a round
implant may help.
AUGMENTATION WITH FAT GRAFTING
There are three main components to be considered in fat grafting: fat harvesting, fat
preparation, and fat injection. There are many different approaches to harvesting
and preparation and physicians regularly debate which one is superior. To date, there
is no scientific evidence that one approach is demonstrably better than another for
fat survival. Although the debate continues as to the best harvesting method (ma-
chine versus syringe aspiration, syringe size, cannula size, and other factors) and the
best fat preparation method (straining, centrifuge, decanting), there is little debate
on the best injection technique. It has been clearly established that small amounts of
fat need to be placed in layers using multiple repeated passes, as opposed to single
globular-type injections. This basic layering technique is what makes fat grafting
work. This technique has been well demonstrated for small-volume transfers and re-
mains the cornerstone for large-volume transfers as well. However, large-volume aug-
mentations are very different from small-volume augmentations. The primary dif-
ference is the recipient site. In large-volume placement, the surgeon is injecting into
very large muscle groups with excellent blood supply as opposed to smaller, tighter,
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less-vascularized spaces. This is where my technique to harvesting, preparing the fat,
and choosing the infiltration syringe and cannula size differs from that of many of
my colleagues. The layering principle remains the same.
Technique
The large-volume fat grafting technique is straightforward, cost effective, and time
efficient. There is no need for expensive or fancy equipment. The simplicity and speed
are related to three factors:
1. Fat harvesting is performed with a larger-bore cannula (4 mm and on occa-
sion 5 mm for the deep layer).
2. The aspirate is separated into its components by the use of a very large metal
strainer (600 microns).
3. The pure fat injections are done with large-volume syringes (10 and 60 cc sy-
ringes) and 2.4 to 3 mm cannulas.
Nearly all the procedures are performed with the patient under general or intra-
venous sedation in my office-based AAAASF-approved surgical center (only ASA 1
and 2 patients). The procedure takes 21⁄2 to 3 hours to perform. The surgical team is
very small, consisting of me, my surgical assistant, and a circulator; my assistant
helps position, turn the patient, and prepare the fat.
Infiltration
The tumescent fluid is infiltrated through the access incisions; the exact locations for
these are determined when the patient is on the operating room table. On average,
4 to 5 L of tumescent fluid is used per case.
Tumescent Mixture
The fluid consists of 1 L of prewarmed Ringer’s lactate solution mixed with 1 am-
pule of 1:1000 epinephrine. The amount of lidocaine used will vary, depending on
the type of anesthesia being used. If the patient is under general anesthesia, then
20 ml of 1% lidocaine with 1:100,000 epinephrine is used. If the patient is under
intravenous sedation, 50 ml of 1% lidocaine with 1:100,000 epinephrine is used;
10 ml of bupivacaine (Marcaine) 0.25% is used as well.
Harvest
Liposuction is performed with the power-assisted machine using a 4 mm cannula
with the fat being collected in 1500 ml glass bottles that work much like a large
Lukens trap.
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Part XII  Body Contouring
One connector tube goes from the handpiece into the glass bottle and another from
the glass bottle to the liposuction machine. The liposuction machine is set at a suction
power of 22 to 23 mm Hg.
Once the bottle is full, it is emptied into a regular strainer that has been sterilized.
The strainer will separate all fluid (lactated Ringer’s solution, blood, triglycerides,
and emulsified fat) from the intact fat cells.

There is absolutely no fluid in the fat. The fat is then transferred to 60 cc syringes.
The well-established methods of centrifuging and decanting work well for facial fat
grafting procedures, but the face requires small volumes that can easily be handled
with these methods. For fat transfer in the buttocks, on the other hand, large vol-
umes (4 to 6 L) are used, and while large centrifuge machines exist, they are very
bulky, require additional personnel, and add a tremendous amount of time to the
procedure. Decanting is not efficient with such volumes. The most efficient method for
me has been straining. The straining process is remarkably easy. It requires a large
metal strainer (which can be purchased at the local grocery store, Target, Wal-Mart,
or kitchen accessory store for approximately $6 to $10), a wooden tongue blade to
help swirl the aspirate, two or three sterile bowls (one to collect the strained fluid
and the others to place the supernatant fat), and one large, nonsterile bowl for the
discarded strained liquid. Critics of this open straining technique argue that the
process is not closed and therefore exposes the cells to air, potentially increasing fat
cell trauma and death. I have not noticed this to be an issue in assessing the results.
Passive straining takes far too much time; the dense fat will frequently clog the fine
mesh holes, slowing the process further. To expedite this process, my assistant picks
up the strainer and repeatedly shakes it back and forth, much like a chef would strain
spaghetti. If this active straining technique is not working well and the fluid refuses
to strain, a tongue blade is used to swirl the aspirate and let the fluid flow through.
Care is taken not to forcefully scrape the tongue blade on the bottom or sides of the
mesh to avoid destruction of fat cells. The swirling must be gentle and at midstrainer
level, the idea being to avoid squeezing the fat cells. Once all the fluid is sieved, the su-
pernatant fat is placed in a 1000 cc collecting metal bowl and covered with a sterile
towel. The entire process is repeated until all currently available aspirates have been
strained.
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Part XII  Body Contouring
Once the bowl is full, 10 cc of antibiotic solution (clindamycin 600 mg mixed in
20 ml of saline solution) is added and the fat is swirled again.
If I am still harvesting, my assistant will proceed with syringe loading. Because we
are working simultaneously, there is no down time between harvesting and prepar-
ing fat. This entire process moves smoothly and quickly, like a well-coordinated two-
person orchestra.
The following reference values should be noted:
 The amount of tumescent fluid injected is usually 5 L.
 The amount of intraoperative fluids required is usually 4 to 5 L.
 It takes 5 to 6 L of aspirate (fluid and fat) to obtain 2 to 3 L of supernatant
fat.
Syringe loading depends on fat density. My transfers are
done using a 10 cc syringe connected to a Tulip Luer-
Lok 2.4 by 20 cm cannula (for subcutaneous injections)
and a 60 cc Luer-Lok syringe using a 3 by 15 cm Luer-
Lok Byron cannula (for intramuscular injections). A
cannula thinner than 2.4 mm is too flimsy and may
bend during injections.

On rare occasions the fat is extremely fibrous and will not pass through the small sy-
ringe Luer-Lok opening. In these cases, the fat is transferred using a large-bore 60 cc
Toomey syringe connected to a large-bore 4 mm harvesting Toomey cannula.
It is important to assess the quality of the fat as it is being strained. Occasionally it
is difficult to tell whether the fat density will be an issue; in these cases, the Luer-
Loks are loaded, and if an issue develops, the Luer-Lok syringe is emptied into the
Toomey syringe, and for that syringe only, the Toomey system used. Rarely, the en-
tire aspirate is fibrous in which case the entire injections are done with the Toomey
system. I always have these syringe and cannula readily available since I never know
when I might need them.
Loading
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Chapter 85  Gluteal Augmentation
The 60 cc Luer-Lok syringes are loaded in the following manner: the syringe plunger
is temporarily removed while the fat is poured using a small 50 cc metal cup.

All four 60 cc syringes are loaded while the 10 cc syringes are loaded quickly and
easily using the transfer tool connected to the 60 cc syringe.
At this point I am still harvesting, so my assistant is on hold until the next batch of
fat comes through. He or she will repeat the emptying and straining process, col-
lecting the fat in the 1000 cc bowl and adding antibiotic solution to each new batch
until we are done harvesting. If the bowl becomes full, we have a spare bowl wait-
ing. The strained fluid is periodically poured into a large plastic nonsterile 3 or 4 L
bowl and the fluid is discarded.
The advantage of this technique is that the total procedure time is about 3 hours,
compared with following the small fat-transfer principles (harvesting with a smaller
cannula, followed by centrifugation, then injection with 1 or 3 cc syringes), which
would take about 6 to 8 hours.
The straining system I use is efficient, cost effective, easy to perform with retention
rates equal to those published. My experience is clinically based and not scientific;
however, it is my impression that I retain 70% to 80% of the fat injected.
The disadvantage to this technique is that I do lose about 10% of cells that are very
tiny and sieve through the strainer. The quality of these very small fat cells is un-
known; some hypothesize that those are the best cells (stem cell rich); others think
that these are not great cells for transfer. In an effort to salvage some of these smaller
cells, I have tried using a smaller strainer with 300-micron sizes but even so, I still
do not manage to capture many more cells, because these cells are almost liquid in
form.
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Part XII  Body Contouring

The other disadvantage to my approach is that one needs to do some searching to
obtain the necessary equipment. The glass bottle can be obtained through Wells John-
son (Tucson, AZ); it is the 1500 cc model with a rubber stopper. This glass bottle
can be resterilized; its initial cost is about $350. After about 30 cases a new rubber
stopper must be ordered. The bottle is sterilized in a regular autoclave, and the rub-
ber tubing by gas sterilization, to make it last longer. (If autoclaved, the rubber starts
to break down and will last for only 10 to 15 cases.) Another option is to gas-sterilize
the 1500 to 2000 cc plastic containers, which cost about $2 or less. Some compa-
nies may have these already presterilized. Finally, the strainer can be obtained at any
store (Target, Wal-Mart) and costs about $6 to $10; it is sterilized regularly.
There are many new disposable collection systems coming to the market that will
further simplify and speed the process, but currently some of these systems are flawed
because they retain too much fluid with the transferred fat-containing fluid, which
will be reabsorbed, falsely elevating the absorption rate. With time these issues will
be worked out, but in the meantime the system I am using has worked extremely
well.
Postoperative Care
Care for patients after fat transfer is the same as that following circumferential ab-
dominoplasties or buttock lifts. If no abdominal work has been performed, the patient
is instructed to sleep on her stomach for 2 weeks. This means watching TV, reading,
and relaxing in the prone position. For travel to the office, patients are asked to stay
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Chapter 85  Gluteal Augmentation

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Part XII  Body Contouring
in the back seat, lying on the stomach. Bathroom privileges are given, but patients
are asked to urinate in the shower in the standing position. Bowel movements, al-
though welcomed, usually do not occur for 1 week because of constipation from
pain medications. If at 1 week the patient remains constipated, one bottle of mag-
nesium citrate is recommended.
If an abdominal procedure has been performed, postoperative care is the same as
that provided for abdominoplasty patients. Patients sleep on the back, not on the
stomach. Although it may seem contradictory, it is better to tolerate some fat loss
than to have to deal with abdominal skin pressure necrosis. A body garment is worn
for 4 to 6 weeks, and the patient is able to return to work in 2 to 3 weeks and to the
gym in 4 to 6 weeks. No ultrasonography of the buttock area is performed, because
this can destroy fat cells. An antibiotic (such as cephalexin) is used until the drains
are removed (when drainage is 30 ml or less in 24 hours). Patients may shower on
the third postoperative day. The final results can be evaluated in 6 months.
Problems and Complications
Complications associated with fat transfer are rare.
Gluteal Asymmetry
Gluteal asymmetry is not a complication, but rather a preoperative anatomic fact.
No two buttocks are the same; patients must be educated about this reality. One side
is always larger and different from the other. This disparity was present preopera-
tively, and it will be present postoperatively.
Infection
The incidence of infection after gluteal augmentation is approximately 1% to 2%.
This is usually seen by the seventh to the fourteenth postoperative day. It will pre -
sent with increased gluteal pain, mild to severe swelling, and erythema that is mild
to severe (rare). The usual presentation begins with the patient complaining of some
discomfort and tenderness in the gluteal area. On physical examination the surgeon
may not see much. Over the next few days the patient develops a fever and possibly

some mild erythema; however, redness may still be difficult to discern. Over the en-
suing days a localized area or a gluteus that is more swollen becomes evident, and
the patient complains of increasing tenderness, especially to the touch. If this is just
cellulitis, it can be treated with antibiotics; however, if an abscess is present, it will
need to be drained. Usually this does not require extensive incisions; sometimes nee-
dle aspiration will suffice, along with administration of antibiotics. In other cases, if
the area is not that obvious, CT-guided drain placement may be needed. If the area
is obvious, a small incision is made and a drain is placed. The area can be irrigated
daily with an antibiotic solution.
If the diagnosis is uncertain, ultrasound examination or a CT scan is performed.
Treatment of the infection will vary: in some patients, it can be managed on an out-
patient basis; in others, it may require hospitalization. A word of caution: the scan
may show areas of questionable fluid accumulation, but often this is just the trans-
ferred fat. Therefore the scan has to be correlated with the clinical picture. At the first
sign of possible infection, or if there is any doubt, antibiotic therapy is instituted
(covering for Staphylococcus, Streptococcus, Bacteroides, and Escherichia coli).
Other Potential Complications
There have been no incidents of sciatic nerve injury, seroma, or fat necrosis among
my patients. Irregularities and lumpiness have also not been problems; the injections
are deep to the muscle. Patients who are simultaneously undergoing a body lift and
fat transfers must be educated on the postoperative need for ambulation. If they have
poor pain tolerance and refuse to move during the postoperative period, they will
sit on the dissected flaps and injected fat, creating ischemia to the areas and subse-
quent wound necrosis. I have instituted several steps to help minimize problems:
 A mini–bowel preparation solution is given the day before surgery, with a liq-
uid diet after 12 noon.
 Patient ambulation starts the morning after surgery. A patient who refuses to
ambulate is placed in the lateral decubitus position and turned regularly, if
possible.
 No more than 600 cc of fat is placed in each buttock during the first proce-
dure. More fat can be injected later.
 The patient is positioned in a lateral decubitus position on an eggcrate mat-
tress or air mattress bed.
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Chapter 85  Gluteal Augmentation

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Part XII  Body Contouring
Results
This 26-year-old nulliparous patient is 5 feet 5 inches tall and weighs 59 kg (130
pounds); she had round, smooth, solid silicone 290 cc implants placed intramuscu-
larly. Liposuction of the inner legs and waist was also performed. She is shown
10 months postoperatively.
This 22-year-old nulliparous patient is 5 feet 6 inches tall and weighs 69 kg (152
pounds); she had liposuction of the abdomen, flank, back, and upper buttock. Five
liters of tumescent fluid was infiltrated and 5400 cc was removed, containing tumes-
cent fluid, blood, destroyed fat, and intact fat. Thirty percent was acceptable for
transfer; 780 cc was placed in each buttock. She is shown 1 year postoperatively.

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Chapter 85  Gluteal Augmentation
This 26-year-old patient is 5 feet 6 inches tall and weighs 64 kg (140 pounds). She
has had one child. Liposuction was performed on her abdomen, flanks, back, and
upper buttocks. Five liters of tumescent fluid was infiltrated and 5400 cc was re-
moved. Fat grafting was performed in which 780 cc was placed in each buttock. She
is shown 11⁄2 years postoperatively.
This 36-year-old nulliparous patient is 5 feet 6 inches tall and weighs 70 kg (155
pounds); she had liposuction of the abdomen, inner legs, flanks, back, and upper but-
tocks. Five liters of tumescent fluid was infiltrated and 5400 cc was removed, con-
taining tumescent fluid, blood, destroyed fat, and intact fat. Thirty percent was ac-
ceptable for transfer; 800 cc was placed in each buttock. She is shown 9 months
postoperatively.

This 31-year-old nulliparous patient is 5 feet 6 inches tall and weighs 61 kg (135
pounds); she had liposuction of her abdomen, flanks, back, and upper buttocks. Five
liters of tumescent fluid was infiltrated and 5400 cc was removed. Fat grafting was
performed in which 780 cc was placed in each buttock.
Concluding Thoughts
In deciding whether to augment the gluteus with fat or implants, the surgeon first
needs to determine how much fat is available for transfer. In some patients this ques-
tion often cannot be answered preoperatively, because the quality and quantity is
not apparent until liposuction is underway. To make a difference with fat transfers,
400 to 800 cc of fat per side should be used. The actual volume will depend on the
patient’s size, anatomy, and aesthetic goals. However, some generalizations can be
made: small-framed individuals will require implants for gluteal augmentation;
medium-framed patients present a dilemma, since they may not have enough donor
fat and require implants; and patients that have a large or extra-large frame are best
contoured and augmented through liposuction and fat transfers.
In intramuscular implant augmentation the size is determined intraoperatively with
the aid of sizers so there will be no muscle tension at closure. Implant shape selec-
tion involves determining the muscle height-to-width ratio: a tall buttock (2 to 1
height-to-width ratio) is best augmented with an anatomic implant; a short buttock
(1 to 1 ratio) is best augmented with a round implant; and an intermediate buttock
(1 or 2 to 1 ratio) may require assessment of the lateral view to make the final de-
termination.
Complications have been reduced tremendously by following three principles: the
use of bilateral gluteal incisions, the use of sizers for proper implant size selection,
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Chapter 85  Gluteal Augmentation
and proper patient selection through the use of body-frame classification to match
the appropriate procedure. The implant gluteal augmentation operation has become
safe, reproducible, and more acceptable to physicians but remains selective only for
patients who do not have the fat to spare. The primary mode of augmentation is fat
grafting, because this avoids all the possible complications that can occur with im-
plants.
Clinical Caveats
 The volume of distribution in all four quadrants of the buttock should be deter-
mined.
 The V zone is evaluated for lack of muscle volume and excess fat in the presacral
space.
 The inner gluteal fold zone is assessed: does it have a downward 45-degree slope,
a nearly horizontal character, or an upward slope?
 The lateral midbuttock zone is evaluated to determine whether it is adequate, has
excess tissue, or is deficient.
 The presacral space–inner gluteal fold relationship is assessed to determine whether
it is ideal, short, or long.
 The inner gluteal crease length is measured.
 On lateral view, one must determine where most of the gluteal volume lies: the up-
per, mid, or lower buttock.
 Fat grafting is the least problematic form of gluteal augmentation.
 The fat harvest should be limited to approximately 2 to 3 L.
 Fat should be placed in all available layers, starting in the muscle and moving up,
even in subcutaneous tissues.
 Proper implant selection is important: oval, anatomic, or round.
 Implant size is determined by the patient’s muscle anatomy. This should be deter-
mined intraoperatively so there is no muscle tension on closure.
 If the patient is still overweight, an implant is not the best form of augmentation.
 Implant augmentation is best for very thin patients for whom augmentation with
fat is not an option.
 If possible, a bilateral paramedian incision should be used unless the patient al-
ready has a midsacral scar. In that case, the existing scar should be used.

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Part XII  Body Contouring
Annotated Bibliography
González-Ulloa M. Gluteoplasty: a ten-year report. Aesthetic Plast Surg 15:85, 1991.
The author presents several cases that are follow-ups to the type of gluteoplasty de-
scribed in the author’s 1979 article in which he discusses torsoplasty and reconstruc-
tion and augmentation of the deformed gluteal region. It was found that there was con-
siderable postoperative improvement for the patient and satisfaction for the surgeon.
Mendieta CG. Gluteoplasty. Aesthet Surg J 23:441-455, 2003.
Although gluteoplasty employing silicone implants has been performed for more than
30 years, little has been written about how to evaluate and reshape the area or how to
select and place the various implants available. In this article the clinical anatomy of the
buttocks area is reviewed, the properties of silicone elastomer gluteal implants are sum-
marized, and an approach to evaluation and augmentation of the gluteal area involving
solid silicone elastomer implants is presented. An understanding of implant shapes, sizes,
and firmness will aid the surgeon in the selection of the most appropriate implant on
the basis of the individual patient’s gluteal anatomy. Intramuscular implant placement
will result in a more natural shape, help prevent implant migration, and, most impor-
tant, help reduce implant removal rates.
Perén PA, Gómez JB, Guerrerosantos J, et al. Gluteus augmentation with fat grafting. Aes-
thetic Plast Surg 24:412-417, 2000.
This study presents the authors’ experience with gluteal augmentation with autologous
fat grafts and liposuction methods; they review the evolution of gluteal reshaping with
autologous intramuscular fat graft injections for the previous 5 years. Preoperative shape
is discussed and patient evaluations, operative techniques, postoperative management,
and long-term results are emphasized.
Roberts TL III, Toledo LS, Badin AZ. Augmentation of the buttocks by micro fat grafting.
Aesthet Surg J 21:311-319, 2001.
Requests for buttock augmentation are increasing in the United States because of changes
in lifestyle and fashion that emphasize the “gluteal aesthetic unit.” The authors review
the use of microfat grafting for enhancing the buttocks in a series of 566 patients. But-
tock augmentation by microfat grafting is a safe, simple procedure. Compared with im-
plant placement, the advantages of microfat grafting include greater flexibility in the
size and placement of augmentations, less pain and faster recovery for the patient, and
less risk of complications. The technique is limited only by the amount of donor fat
available.
Suggested Readings
Badin AZ, Vieira JF. Endoscopically assisted buttocks augmentation. Aesthetic Plast Surg
31:651-656, 2007.
Bartels RJ, O’Malley JE, Douglas WM, et al. An unusual use of the Cronin breast prosthesis.
Case report. Plast Reconstr Surg 44:500, 1969.

Colwell AS, Borud LJ. Autologous gluteal augmentation after massive weight loss: aesthetic
analysis and role of the superior gluteal artery perforator flap. Plast Reconstr Surg
119:345-356, 2007.
Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques.
Clin Plast Surg 33:321-332, 2006.
de la Peña JA, Lopez MH, Gamboa LF. Augmentation gluteoplasty: anatomical and clinical
considerations. Key issues. Plast Cosmetic Surg 17:1-12, 2000.
de la Peña JA, Rubio OV, Cano JP, et al. History of gluteal augmentation. Clin Plast Surg
33:307-319, 2006.
Gonzalez R. Late intracapsular seroma in subfascial buttock augmentation: a case report.
Aesthetic Plast Surg 30:599-604; discussion 605, 2006.
Harrison D, Selvaggi G. Gluteal augmentation surgery: indications and surgical manage-
ment. J Plast Reconstr Aesthet Surg 60:922-928, 2007.
Hwang K, Nam YS, Han SH, et al. The intramuscular course of the inferior gluteal nerve in
the gluteus maximus muscle and augmentation gluteoplasty. Ann Plast Surg 63:361-365,
2009.
Le Louarn C, Pascal JF. Autologous gluteal augmentation after massive weight loss. Plast Re-
constr Surg 121:1515-1516; author reply 1516-1517, 2008.
Lee EI, Roberts TL, Bruner TW. Ethnic considerations in buttock aesthetics. Semin Plast Surg
23:232-243, 2009.
Mendieta CG. Buttocks aesthetics: shaping, contouring, and enhancing. In Aly AS, ed. Body
Contouring After Massive Weight Loss. St Louis: Quality Medical Publishing, 2006.
Mendieta CG. Classification system for gluteal evaluation. Clin Plast Surg 33:333-346, 2006.
Mendieta CG. Gluteal reshaping. Aesthet Surg J 27:641-655, 2007.
Millard DR Jr. Principlization of Plastic Surgery. Boston: Little Brown, 1986.
Raposo-Amaral CE, Cetrulo CL Jr, Guidi Mde C, et al. Bilateral lumbar hip dermal fat ro-
tation flaps: a novel technique for autologous augmentation gluteoplasty. Plast Recon-
str Surg 117:1781-1788, 2006.
Raposo-Amaral CE, Ferreira DM, Warren SM, et al. Quantifying augmentation gluteoplasty
outcomes: a comparison of three instruments used to measure gluteal projection. Aes-
thetic Plast Surg 32:333-338, 2008.
Roberts TL III, Mendieta CG. Buttocks augmentation by micro fat grafting or implants. In
Proceedings of the American Society for Aesthetic Plastic Surgeons. Vancouver, Canada,
April 2004.
Robles JM, Tagliopertra JCY, Grandi MA. Gluteoplastia de aumento: implante submuscu-
lar. Cir Plast Iberolatinoamer 10:365-375, 1984.
Serra F, Aboudib JH, Cedrola JP, et al. Gluteoplasty: anatomic basis and technique. Aesthet
Surg J 30:579-592, 2010.
Vergara R, Marcos M. Intramuscular gluteal implants. Aesthetic Plast Surg 20:259-262, 1996.
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Female Aesthetic
Genital Surgery

GARY J. ALTER
CHAPTER 86

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Part XII  Body Contouring
T
he demand for female genital aesthetic surgery has increased as women and
men have become more aware of genital appearance and as successful proce-
dures have been developed to achieve patients’ goals. The widespread proliferation
of sexually explicit material in print and video, along with the popularity of genital
hair removal, has led to women defining and seeking an aesthetic genital ideal. If a
woman believes she has unattractive genitalia, she may avoid intimacy for fear of
rejection or ridicule. The definition of a female genital ideal varies among individu-
als. Most consider the following traits as ideal:
1. Symmetrical labia minora (inner lips) that do not protrude past the labia ma-
jora (outer lips) when the woman is standing.
2. A clitoral hood that is short and nonprotruding, with few folds.
3. Full labia majora that are not overly fatty without excess hanging skin so that
there is no bulge or protrusion when tight clothes are worn.
4. A mons pubis fat pad that does not protrude in clothing.
These improvements can be achieved in almost all cases. In addition to aesthetic con-
cerns, the vast majority of women have some discomfort with clothes, exercise, or
sex caused by enlarged labia minora (singular labium minus), labia majora (singular
labium majus), and the clitoral hood. Hypertrophy can also interfere with hygiene.
Indications, Advantages, and Disadvantages
Enlargement of the labia minora is usually congenital. It may appear in childhood
but becomes more obvious in adolescence. Occasionally, enlargement of the labia
minora will increase as a result of pregnancy, birth control pills, aging, or exogenous
hormones. Ideally, the labia minora should be thin, straight, light-colored, nonre-
dundant, and symmetrical.
Labia minora reduction has traditionally been performed by trimming the protrud-
ing labia along the entire labial length. The trimming is performed using a scissor,
knife, clamp, or laser. The labial edge is closed with either interrupted or running
external sutures or a running subcuticular suture. This procedure has the advantages
of a short operative time and of eliminating some of the dark pigmentation that is
disliked by some women. However, the disadvantages are elimination of the natu-
ral labial edge, which is replaced by an incision line and often a wide, irregular, scal-
loped scar; difficulty creating symmetrical labia; an often unnatural transition be-
tween the labium, clitoral frenulum, and clitoral hood; the possibility of overresection

3099
Chapter 86  Female Aesthetic Genital Surgery
of the labia; and the potential for a higher incidence of postoperative and chronic
discomfort from irritation of the scar line. Because of the disadvantages, the extended
central wedge technique was developed, which may also include partial reduction
of the clitoral hood.
Youthful labia majora have fullness, but overabundant fat protuberance can be con-
genital or may occur with weight gain. Obesity causes labia majora fat and skin en-
largement. After pregnancy or weight loss, or as a result of aging, the majora can
lose fat but have excess skin and wrinkling. This causes the majora to hang lower,
with more redundancy. The labia majora can be reduced, depending on the cause—
excess fat or skin, or a combination of both. Before hair removal became the trend,
physicians traditionally placed the incisions in the midlabium. However, those scars
can be very visible if genital hair is removed, so the incision line should now be placed
medially in a less noticeable location.
Pubic lipodystrophy is often seen as a congenital deformity, which will not resolve
with weight loss alone. The woman may complain of an unsightly bulge or protru-
sion; the bulge may lead her to avoid wearing tight clothes or bathing suits, citing
embarrassment and loss of self-esteem. If there is no excess skin or if a lift is not nec-
essary, pubic liposuction can be used to eliminate the fat deposit. Usually the lipo-
suction is performed through small stab incisions in the groin creases. The upper
labia majora are usually also suctioned.
The epidemic of female obesity and the trend toward massive-weight-loss proce-
dures have resulted in the common complaints of an excessive mons pubis fat de-
posit and descent of the escutcheon, introitus, and labia majora. A large mons pu-
bis fat deposit is often associated with large, protuberant labia majora as a result of
fat excess and stretched skin. Weight loss rarely eliminates these deformities, so sur-
gical treatment is required.
Traditional reduction of an enlarged mons pubis fat pad with skin descent has been
a horizontal skin excision and fat resection with a skin lift. This has often been com-
bined with an abdominoplasty. However, a skin lift is usually not adequate, because
the escutcheon often descends again. A second unsuccessful lift is often attempted,
which can cause an unnatural shortening of the escutcheon. Surgeons have also per-
formed a vertical excision of pubic skin, which can lead to an unsightly T scar in the
mons. A pubic lift with fat removal and tacking sutures to the rectus fascia performed
through a curvilinear incision below the panniculus line gives a natural, lasting cor-
rection to the mons pubis.

Pubic symphysis
Anterior labial commissure
Posterior labial commissure
Glans of clitoris
Frenulum of clitoris
Vaginal orifice
Urethral orifice
Labium minus
Ischium
Labium majus
Prepuce of clitoris
Hood of clitoris
Pubic symphysis
Glans of clitoris
Vaginal orifice
Urethral orifice
Ischium
Crus of clitoris
Vestibular bulb
Corpora cavernosa
of clitoris
Anal orifice
Dorsal neurovascular
bundle of the clitoris
Pertinent Anatomy
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Part XII  Body Contouring
A clear understanding of clitoral anatomy is mandatory to prevent injury. No change
in sexual sensation should occur if the clitoris is uninjured. The glans clitoris is vis-
ible underneath an overlying extension of the clitoral hood, the prepuce. The body or
corpora of the clitoris is attached to the pubic symphysis by the suspensory ligament
of the clitoris. The corpora diverge inferiorly and laterally and are attached bilater-
ally to the ischium.

A fold of skin (frenulum) extends from the ventral glans bilaterally to meet with an
extension of the clitoral hood to form a labium minus. The labia minora may meet
at the posterior introitus or gradually taper down.
Injury will not occur if mons fat resection is performed superior to the pubic sym-
physis and if labia majora fat is excised lateral to the pubic symphysis and superfi-
cial to the ischium. The glans and body of the clitoris can be palpated and protected.
LABIA MINORA
Preoperative Assessment
Labioplasty can be performed on almost any woman with enlarged labia. Labial
protrusion is evaluated with the patient standing. She then is asked to lie in the li thot -
omy position, and the labia are examined for thickness, symmetry, and both anterior
and posterior length. The clitoral hood is examined to determine protrusion, sym-
metry, the location of hyperkeratotic, darkened skin, the presence of extra folds, and
the clitoral glans size and exposure. The posterior introitus should be evaluated for
a high posterior lip or an open introitus resulting from a previous episiotomy.
A wedge or V will be excised from the most protuberant portion of each labium.
Because the labia are often asymmetrical, the amount of the wedge is varied to achieve
symmetry. With the patient holding a mirror and lying in the lithotomy position, the
surgeon holds the amount to be excised in each hand by bringing the anterior to the
posterior portion of the V together.
There may be a color mismatch between the anterior and posterior labium at the
anastomosis, but this is rarely an issue with the patient if she is told preoperatively,
and the color difference usually lessens with time. The surgical plan and anticipated
postoperative result must be explained to the patient to prevent any misconceptions
or false expectations.
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Chapter 86  Female Aesthetic Genital Surgery

3102
Part XII  Body Contouring
Medial incisions
Lateral incision
The anterior incision line is usually at or just posterior to this convergence. Forceps
are used to determine the appropriate amount of excision in each labium to create a
straight line without causing tension on the incision line or a tight introitus (which is
uncommon). Markings on the opposite labium are made to achieve symmetry. The
medial portion of the V extends internally to end distal to the hymeneal ring. The ex-
tended lateral markings are made in an anterior hockey-stick manner for excision of
redundant lateral clitoral hood or lateral hood folds. Therefore the medial and lateral
wedge excisions are asymmetrical. Usually the darkest labial skin is excised with the
V. If there is extreme posterior labial asymmetry or enlargement, a second V may need
to be excised from one or both sides to achieve symmetry or adequate reduction.
Preoperative Planning
Patient Positioning and Markings
The patient is placed in the lithotomy position in the operating room; usually a gen-
eral anesthetic is administered. The clitoral glans frenulum converges with the lower
clitoral hood to form the labium minus; the nature of this convergence varies among
women.

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Chapter 86  Female Aesthetic Genital Surgery
Operative Technique
After marking, the area is infiltrated with lidocaine and bupivacaine (Marcaine) with
epinephrine. Loupe magnification is usually required to get an excellent closure and
anastomosis.
The medial labium is approached first, and only the mucosa is removed. The under-
lying subcutaneous tissue should be preserved. The lateral skin is then excised, also
removing only skin and no subcutaneous tissue.
The subcutaneous tissue is then approximated with 5-0 Monocryl on an atraumatic
TF needle, in two layers whenever possible. A good subcutaneous closure helps pre-
vent wound dehiscence or fistula formation. Any excess subcutaneous tissue is re-
moved medially or laterally during the closure to eliminate dog-ears or an overly
thick labium. The skin is then closed from distal to proximal with interrupted ver-
tical mattress 5-0 Monocryl sutures. Running sutures can be used on the deepest
portion of the medial incision line or occasionally on the lateral labium. The subcu-
taneous tissue of the clitoral hood is closed with a running 5-0 Monocryl suture,
and the skin of the hood is closed with a running subcuticular 5-0 Monocryl suture.
Minor defects may be closed with 6-0 Monocryl.

Once one side is completed, the markings on the opposite side are checked and pos-
sibly remarked for symmetry. The procedure is then repeated. In the very unusual
situation in which a second wedge is required on one or both sides, this is performed
after the bilateral anterior wedges are closed.
3104
Part XII  Body Contouring
Extending the lateral labial V to the anterior hood can reduce redundant clitoral
hood folds or excess lateral skin. However, if the excess folds or hypertrophic skin are
more medial, the lateral V excision can stop at the lateral labium, and a vertical el-

lipse can be excised from one or both sides of the medial-lateral clitoral hood. (Ex-
cess perineal skin was also excised in this patient lateral to the posterior labia.) If
there is asymmetry of the clitoral hood folds, these are adjusted accordingly. If no
excess clitoral hood is present or if the patient does not want this excised, then the
lateral V ends at the lateral labium or clitoral hood to prevent a dog-ear.
If the patient has redundant transverse folds of the clitoral hood, a small amount
can be excised in a transverse ellipse on rare circumstances. Closure is done with in-
terrupted vertical mattress 6-0 Monocryl. Care must be taken not to overly expose
the glans, because patients can be hypersensitive or dislike the aesthetic appearance.
More aggressive clitoral hood reduction requires clitoral repositioning (clitoropexy),
which is beyond the scope of this chapter. Clitoral enlargement of the shaft and glans
can be reduced, but this is also beyond the scope of this chapter.
The introitus should fit two fingers without significant tension to prevent overtight-
ening. If there is a high posterior lip or overly tight introitus, a posterior midline in-
cision may need to be made to prevent difficulty with intercourse. If the lip is in-
cised, the vaginal mucosa is sutured to the perineal skin. This creates dog-ears
bilaterally that need to be trimmed and aesthetically closed.
If a vaginal tightening procedure is performed at the same time as the labia reduc-
tion, the tightening procedure should be performed first. If the patient has very large
labia requiring very large V excisions extending up to the hymen, the introitus and
perineal closure distal to the hymen should not be completed until the labioplasty
is finished. The large V excision can elevate the posterior lip and cause introital tight-
ness. This is best adjusted at the time of distal vaginal and perineal closure.
Postoperative Care
The patient should use ice packs and antibiotic ointment for 2 days. Cephalosporin
is given prophylactically for several days. The patient should avoid exercise for
3 weeks, but yoga and horseback and motorcycle riding should not be done for
8 weeks. Sexual intercourse is allowed at 6 weeks. Usually 80% of the swelling is
resolved by 6 weeks, with all swelling and induration commonly gone in 4 months.
The sutures start disappearing in 2 weeks and are usually gone by 6 weeks. The
Monocryl sutures may cause itching and discomfort after several weeks; this can be
alleviated with Vagisil or a very weak cortisone cream.
3105
Chapter 86  Female Aesthetic Genital Surgery

Problems and Complications
Complications are extremely uncommon if meticulous surgery is performed with
the above sutures and techniques. Approximately 2% of patients will have a slight
separation at the labial edge. Most of the visible small separations will resolve in
4 to 6 months and will not require revision. A fistula or major dehiscence occurs in
less than 1% of cases. Surgical revisions may need to be performed for asymmetry
of the labia minora or lateral clitoral hood, unsightly or stretched scars, separations
or dehiscence of the labial edges, or fistulas. Revisions are delayed a minimum of
4 months after the initial surgery to allow healing and resolution of induration.
Rarely, a patient will have some persistent discomfort lasting over several months.
This is usually resolved with a several-week course of a potent cortisone cream such
as clobetasol 0.05%.
Outcomes
A recent study in 407 patients revealed an average patient satisfaction rate of 9.2
on a scale of 10 (10 indicating most pleased). Patients reported improvement in self-
esteem (93%), sex life (71%), and reduction of discomfort (95%), with a low sig-
nificant complication rate (4%).
Results
3106
Part XII  Body Contouring
This 23-year-old woman is shown before a labia minora reduction and lateral cli-
toral hood reduction.

The patient is shown 3 months after a labia minora reduction and lateral clitoral
hood reduction. The appearance is very natural, with a slight color mismatch that
is inconsequential.
3107
Chapter 86  Female Aesthetic Genital Surgery
This 50-year-old woman is shown before and 3 months after a labia minora reduc-
tion and lateral clitoral hood reduction. There is significant reduction of her labia
and clitoral hood, with a natural appearance. The scars are almost invisible.
LABIA MAJORA
Women wish to recreate the youthful full labia majora. However, excessively protu-
berant or low-hanging labia majora can cause an unsightly bulge in clothes, often
with a central crease from the introitus. The protuberance can be from either an
overly fatty, full majora or a fat deficient, stretched majora with excess skin, or a
combination. The woman should also be evaluated for significant mons pubic de-
scent and pubic lipodystrophy, which could affect the approach for the majora sur-
gery as well as results (see the next section). Labia minora and labia majora surgery
can be performed in the same operation, with the minora performed first.

Preoperative Assessment
The patient’s complaints are evaluated. It is helpful to have her shave on the morn-
ing before arriving for surgery, or it must be done at the time of marking. The ma-
jora are evaluated for symmetry with the patient standing and lying down in the
lithotomy position. The patient uses a hand mirror to view herself during this process.
Sometimes the excess may only be loose, redundant skin, whereas in others the ex-
cess may be fat. The skin or fat excess may be diffuse or more anterior or posterior.
Patient Education
The patient must be told that reduction of the majora can result in more prominence
of the clitoral hood and labia minora. Occasionally, majora reduction may later lead
to the patient’s desire for a labia minora and/or clitoral hood reduction. She must
also be told that the suture line may show a contrast between lighter and darker tis-
sue or between coarse and fine skin. If these issues are described and shown preop-
eratively, the woman is usually not concerned.
Preoperative Planning
Markings
3108
Part XII  Body Contouring
Landmarks are noted and marked, including the medial thigh creases and the lat-
eral color differentiation of each labium. The skin excess is marked as a crescent ex-
cision from the medial labium extending from the anterior to the posterior labial
commissures. The medial incision line is usually placed just lateral to the medial hair-
line of the labium. The amount of labial skin to be removed is determined by the
amount of excision desired by each woman. However, it is usually mandatory to
leave at least 2 cm of pigmented labium lateral to the lateral excision line. This usu-

ally ensures preservation of enough skin to prevent gaping of the introitus while the
legs are fully abducted, which must be tested with a cotton swab pushing in the
marked area. The surgeon should err on the conservative side. The crescent excision
of each side is adjusted to achieve symmetry and to excise more anterior or poste-
rior skin depending on the deformity. The medial anterior and posterior incision
lines from each side do not meet in the midline but are moved laterally in a fusiform
manner if necessary. Fat excision is performed in only a minority of cases. If fat is
to be excised, the location and amount is noted on the markings. With fat removal,
overresection must be avoided, because it gives an aged appearance.
3109
Chapter 86  Female Aesthetic Genital Surgery
Proposed
incision
Excess fat
removed
Once the markings are made, the woman
stands and the location of the lateral
markings are viewed for symmetry. Cot-
ton swabs are used to push in the excess
skin or fat to coapt the medial and lateral
markings, which allows the surgeon and
patient to view the expected postoperative
labial size. It is not unusual to perform pu-
bic liposuction during the operation.
The patient is placed in the lithotomy position. The areas of excision are infiltrated
with lidocaine and bupivacaine with epinephrine. The crescent skin excisions are
performed and checked for symmetry. If fat is excised in an area, the superficial Colles
fascia is opened. The fat is conservatively removed with electrocautery. Meticulous
hemostasis is maintained, or hematomas can occur. The skin on each side is tem-
porarily stapled closed to check for symmetry. The wounds are then reopened.
Operative Technique

If fat was excised, the superficial Colles fascia is closed with 4-0 or 5-0 Monocryl. The
subdermal tissue is then closed with a running 5-0 Monocryl suture while including
deeper Colles fascia to eliminate dead space. The skin is closed with a running subcu-
ticular closure of 5-0 Monocryl. Drains are used only for major fat excisions.
3110
Part XII  Body Contouring
Layered closure
of Colles fascia
and subdermis
Subcuticular suture
closes skin
The patient’s labia majora are shown 5 months after surgery.
Postoperative Care
Steri-Strips are applied to the wound for a day or until they fall off. The remainder
of the postoperative instructions are similar to those for the labia minora.
Problems and Complications
Complications are unusual. Hematomas can occur but are rare, unless a massive
amount of fat is removed. The labia can swell considerably postoperatively, but this
starts to resolve within a week. Significant discomfort is unusual. The most common
complications are inadequate reduction or asymmetry of the skin or fat that may
need to be revised in 6 months. Scars are rarely an issue if a subcuticular closure is

performed. Color contrast is not often an issue if this has been discussed with the
patient preoperatively and incision placement is optimal. Persistent pain or sexual
dysfunction is not likely to occur.
The worst potential complication is excessive skin excision, which can lead to a gap-
ing introitus, causing vaginal dryness, discomfort in clothes, and an aesthetic defor-
mity. This complication is more likely to occur if a medial thigh lift has been or will
be performed, because the thigh lift Colles fascia tacking sutures can loosen, caus-
ing posterior migration of the thigh skin, thus pulling the majora and opening the
introitus. If a medial thigh lift is contemplated or recent, skin excision should be
even more conservative.
Outcomes
No series of labia majora reduction has been published. However, patients have ex-
pressed that they are extremely gratified with their result if their expectations were
realistic preoperatively.
Results
3111
Chapter 86  Female Aesthetic Genital Surgery
This 55-year-old woman is shown preoperatively and at 5 months postoperatively
(she is also shown on pp. 3108-3110. She underwent pubic liposuction and labia
majora skin and fat reduction.

MONS PUBIS LIFT
A natural-appearing mons reduction and lift can be achieved with a horizontal skin
excision; undermining of the mons fat pad; liposuction of the mons pubis, upper
labia majora, and inguinal fat; and fat excision of the residual deforming fat pad. It
is imperative that the fibrofatty tissue of the pubic skin flap be tacked to the rectus
fascia to prevent recurrent pubic descent.
Preoperative Assessment
3112
Part XII  Body Contouring
The amount of pubic fat and mons descent is evaluated first with the patient in the
standing position. The enlargement and protrusion of the labia majora are also noted.
If a panniculus is present, it is elevated to determine the amount of pubic skin that
needs to be transversely excised. The anterior labial commissure should be at the
pubic symphysis. The actual skin excision required is usually no more than several
centimeters, because the pubic skin will modestly contract as the fat is removed.
Overresection of skin can elevate the commissure too high and give an unnatural
appearance. The skin incision is placed just below a pannus fold or at a previous ab-
dominoplasty scar line. The skin crescent excision may remove a small amount of
the upper pubic hair. The length of the incision is usually only long enough to elim-
inate the excess skin but can rarely extend to the anterior superior spines. The ap-
pearance of the labia majora with the elevation of the fat pad is also observed, and
the amount of fat removal is estimated, if needed.

Preoperative Planning
Patient Position and Markings
With the patient in the lithotomy position, the labia majora are evaluated for liposuc-
tion or marked for skin or fat excision if this is to be performed simultaneously. The
procedure is the same as outlined previously.
The patient is placed in the supine position if only a pubic lift is performed. If labia
majora skin or fat reduction is to be performed, she is placed in the lithotomy posi-
tion, with the abdomen and genital region prepared.
Operative Technique
3113
Chapter 86  Female Aesthetic Genital Surgery
The upper incision is made and carried down to the rectus fascia. The pubic flap is
elevated to the pubic symphysis between the external inguinal rings. More extensive
dissection is usually not necessary.
Upper incision
Anterior superior
iliac spine
Proposed inferior
skin incision
Skin
marking
Area
undermined
Pubic
symphysis

The inferior incision is then made, and a modest amount of pubic fat is excised. In-
filtration of the mons, upper labia majora, and inguinal region is performed with
tumescent fluid.
3114
Part XII  Body Contouring
Rectus fascia
Ptotic labia majora
Excision of
excess fat tapers
to symphysis
Lower incision removes
excess skin and fat

To maintain the lifted position of the mons pubis, rows of tacking sutures of 1 Ethi-
bond on a CTX needle are placed from the fibrofatty subdermal tissue of the flap to
the rectus fascia. The first row of three sutures is usually placed 1 to 2 cm cephalad
to the anterior labial commissure to the rectus fascia just cephalad to the pubic sym-
physis and between the external inguinal rings. Mild dimpling can occur and is prob-
ably necessary to maintain the lift. These are the crucial sutures, and several attempts
may be required to prevent an abnormal pulled appearance of the majora, to mini-
mize dimpling, and to achieve symmetry.
3115
Chapter 86  Female Aesthetic Genital Surgery
The pubic flap is liposuctioned to a thickness of 1 to 2 cm. The lateral areas are suc-
tioned to prevent a concavity, and the upper labia majora are suctioned. Liposuc-
tion of the flap is preferable to open excision of the pubic fat, because it preserves
the fibrofatty tissue used for tacking. If the labia majora fat is modestly increased,
liposuction of the entire majora can be performed at this time. If labial fat is to be
excised from above, open resection is done, followed by bilateral insertion of closed
suction drains.

Liposuction of upper labia majora, pubis,
and inguinal areas leaving 1-2 cm of fat on skin flap
Skin advanced
cephalad for closure
Initial row of
sutures placed
1-2 cm cephalad
to anterior labial
commissure
Anterior labial
commissure

Usually two more rows of three sutures are placed. A closed suction drain is placed
from the pubic symphysis along the right lateral sutures, and then under the subcu-
taneous closure. The subcutaneous tissue and skin are closed. The thickness of the
subcutaneous tissue on each side of the incision line should be equal, so liposuction
of the lower portion of the abdominal skin flap may occasionally be needed. Rarely,
excess abdominal skin may need to be resected to prevent it from overriding the pu-
bic area.
3116
Part XII  Body Contouring
Rectus fascia
Second and third
rows of sutures
maintain elevated
position of flap
Drain
Subcutaneous
closure
Drain
Second and third row of sutures
maintain elevated position of flap

This patient underwent a pubic lift, labia majora liposuction, and bilateral Z-plasties
to eliminate restrictive medial thigh bands. She is shown preoperatively and imme-
diately after labial liposuction and a mons lift. If the labia majora skin and fat are
to be excised, this is performed at this time (see the labia majora section).
Postoperative Care
The patient’s drains are removed when drainage is minimal. The patient is instructed
to use ice packs on the majora for 2 days.
Problems and Complications
The patient should be told that there might be some concavity in the pubic area.
However, liposuction of the pubic flap with conservative pubic fat resection along
with lateral liposuction helps prevent that. Excess elevation of the pubic area can
result in an unnatural anterior labial commissure and a short escutcheon. This is un-
common if skin resection is conservative.
If the patient has had a previous inner thigh lift, labia majora skin excision should
probably not be performed at the same time as the pubic lift. Theoretically, the skin
between the majora incision and the inner thigh may be at risk if the pubic resec-
tion is performed. Instead, labia majora liposuction or fat excision through the pu-
bic wound can be done first, followed by a later procedure for additional excision
of labia majora fat and skin, if necessary.
3117
Chapter 86  Female Aesthetic Genital Surgery

Outcomes
Patients are generally extremely happy with elimination of the pubic protrusion. It
is uncommon to have an unhappy patient as long as the limitations and potential
results are explained and shown to the patient preoperatively. The need for recur-
rent pubic lift surgery is very uncommon.
Results
3118
Part XII  Body Contouring
This 23-year-old patient (also shown on p. 3112) is seen before surgery and 4 months
postoperatively.