Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

372
PART | 6  Thigh, buttock and lower extremity contouring
9. Antithrombotic therapy, early mobilization, pressure
garment support.
10. Avoid drains.
11. Antibiotic prophylaxis.
12. Scar control measures: Topical silicone gel therapy;
suggest optional manual lymphatic drainage techniques.
POSTOPERATIVE CARE
Patients are mobilized immediately postoperatively with
nurse supervision initially. The patient can be showered
after 48 hours, carefully drying using towels or a hairdryer
for the groins. Topical BetadineTM is advised for the groin
wounds and applied twice daily until wound “continence”
is achieved, usually about a week later. Personal hygiene
is important to aid wound healing. Cefuroxime (250 mg,
bd, oral) is given as antibiotic prophylaxis for 5 days.
Pressure support garments are important in preventing
postoperative swelling and thus reducing the risk of infec­
tion. There are no sutures to be removed, but wound
care and scar control advice are carried out in the follow
up clinic.
COMPLICATIONS AND
THEIR MANAGEMENT
The complication rate should be less than 2%. Careful
patient selection and prophylaxis are important in reducing
the risks. Diabetics, patients with bleeding disorders and
patients with poor personal hygiene are the high risk
patients. Smoking and obesity increase the risks.
Hematoma
Small – Leave and aspirate as required.
Large – Evacuate and resuture, closing any “dead space”.
Infection
Superficial cellulitis – Antibiotics. Metronidazole and
cefuroxime until microbiology is known. The most
likely organism, within the first week, is Staphylococcus
aureus, but thereafter mixed flora and later Gram-
negative bacteria are the main culprits. The area is
potentially heavily contaminated. BetadineTM applied
topically to the wounds assists in the control of super­
ficial sepsis.
Deeper tissue infection – An abscess requires drainage
via a reasonably generous incision through the healing
wound, or simply blunt penetration of the thinning
tissue over the abscess will give early relief of symp­
toms, and reduce the risk of septicaemia and venous
thrombosis.
FIG. 36.15  Left medial thigh lift scar at 3 months.
FIG. 36.16  Right medial thigh lift scar at 3 months.
3. Starting distally, excise redundant tissue and suture
the wounds as the operation proceeds in a proximal
direction.
4. At the apex of the excision go slightly deeper and
excise a subcutaneous “cuff” to avoid a “dog-ear” in
closing.
5. Excise only to Scarpa’s fascia and excise by the “trac­
tion and counter-traction” technique.
6. Close the dead space by deep quilt suturing and
inverted knots. Use monofilament ProleneTM or braided
EthibondTM. If any infection risks, use Vicryl-PlusTM
2-0 or 4-0 or 5-0.
7. Hitch the Scarpa’s fascia to the fascia below the adduc­
tor origin.
8. If there is significant skin redundancy elect to use a
short horizontal scar and advance the wounds verti­
cally to excise tissue within the mons pubis.

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Chapter | 36  Short vertical scar medial thigh lift
Wound Dehiscence
Minor – This is usually secondary to poor surgical tech­
nique, with comparative tissue hypoxia encouraging
sepsis and tissue breakdown. Suture knot infection does
occur, particularly with braided sutures. These may
settle with the use of antibiotics and topical BetadineTM
or InadineTM dressings. Twice daily showers and
“drying” of the wound using a hairdryer, followed by
InadineTM or an absorbent dressing will be needed for
some weeks.
Major – This is a disaster and is often accompanied
by a state of relative malnutrition, with poor wound
healing. Initially, the large wounds should be managed
con­servatively until the edges of the wound show
re-epithialization, and then an attempt at closure, using
excision and local flap or partial thickness skin graft,
may speed up the healing process.
Seroma/Lymphocele
These are not strictly the same pathology but these terms
are both loosely applied to cases where a progressive swell­
ing occurs in the deep excisional dissection plane. A seroma
is really only a collection of serum from a liquefying hema­
toma, whereas a lymphocele is the progressive accumula­
tion of lymph caused by damage to lymphatics during the
dissection. The swelling and discomfort progresses until the
“internal pressure” within the developing and organizing
space exceeds the closing lymphatic pressure on the endo­
thelium that constitutes the free end of the cut lymphatic
vessel. To alleviate discomfort, and reduce the space-
occupying collection of lymph, an aseptic aspiration may
be required, frequently at first, then reducing in frequency
as the rate of collection decreases over weeks. It is impor­
tant that aspirating does not lead to any abscess. Very rarely
a chronic lymphocele that is symptomatic may require exci­
sion, and the fresh tissue edges approximated in layers.
Open lymphatics can be identified using blue dye lymphan­
giography and thence ligated as necessary.
Poor Scar
Any wound closed under tension results in hypertrophy. A
hypertrophic scar also contracts in a longitudinal direction
and may be symptomatic in the vicinity of the groin. Any
banding that occurs can be treated simply using a 60o/90o
Z plasty. This often speeds up the maturation phase of the
hypertrophic scar. Topical silicone gel treatment is impor­
tant and, whilst pressure pants/garments are advised, there
is often not a sufficient pressure on the scar to significantly
speed up the maturation phase. The scar often takes 2 years
to cosmetically improve.
CONCLUSION
The idea of a short vertical scar medial thigh lift is to
tighten the loose skin over the femoral triangle and beneath
the groin crease. There can be serious morbidity in cases
where excessive deep tissue damage is created by the
unwary surgeon, who forgets the importance of preserva­
tion of the medial thigh lymphatics. Balancing the benefits
to the patient with these potential complications is the basis
of informed consent. Generally, patients should be discour­
aged from this type of surgery unless clear benefit can be
seen by the surgeon, and the patient is prepared to take the
risk of complication. This is not primarily a cosmetic
surgery procedure because the scar may be worse than the
skin redundancy in appearance.
ACKNOWLEDGMENTS
I am very grateful to David Head for his invaluable assistance in
preparing this chapter.
REFERENCES
1. Hurwitz DJ. Approach to the medial thigh after weight loss. In: Rubin
PJ, Matarasso A, editors. Aesthetic Surgery after Massive Weight
Loss. Philadelphia: Saunders Elsevier; 2007. p. 113–30.
2. Heden P. Plastic Surgery and You. Stockholm: Silander and Fromholtz
Forlags; 2003. p. 219–22.
3. Graf R, de Araujo LR, Rippel R, et al. Lipoabdominoplasty: Liposuc­
tion with reduced undermining and traditional abdominal skin flap
resection. Aesth Plast Surg 2006;30(1):1–8.
4. Vordermark JS, Jones BM, Harrison DH. Surgical approaches to
block dissection of the inguinal lymph nodes. JPRAS 1985;37(3):
321–5.

Part 6  Thigh, buttock and lower extremity contouring
374
© 2013 Elsevier Inc
Chapter 37 
Key Points
●
Brief review of surgical techniques for gluteal
augmentation.
●
Explanation of the details of our surgical technique
designed to provide autologous gluteal augmentation.
●
Highlighting of common errors and pitfalls of this
surgical technique and how to avoid them.
●
Highlighting of possible surgical complications and
how to approach them.
●
Highlighting the methods of assessment of gluteal
projection after gluteal augmentation with mid-pedicle
superior pole perforator flaps.
Autologous gluteal augmentation with
mid-pedicle superior pole perforator flaps
Cassio Eduardo Raposo-Amaral
INTRODUCTION
Gluteal augmentation has become increasingly common
due to a rise in bariatric surgery in North America as well
as because of ingrained cultural ideals, combined with
increasingly easy access to esthetic surgery in South
America. Projection of the gluteal region has become a sign
of a well-sculpted body, and consequently, is a goal of
individuals who seek body contouring procedures. While
Bartels et al were the first to report silicone gluteal augmen­
tation in 1969,1 more recently, numerous autologous proce­
dures have been developed, including fat grafting, dermal-fat
grafting, and, more recently, dermal-fat flaps.2–10 Indeed, fat
grafting plays an important role in gluteal augmentation in
selected patients with low complication rates; however, it
may not work well in patients after weight loss. Excess of
skin combined with muscle hypotonia and skin flaccidity
in patients after significant weight loss may contraindicate
fat grafting procedures. For these patients, Agris,11 based
on the work of Pitanguy,12,13 proposed the use of dermal-fat
suspension flaps for thigh and buttock lifts. In addition,
Gonzalez-Ulloa,14 Guerrerosantos15 and many others have
proposed several types of adipocutaneous flaps to improve
contours in this region.16,17
Flaps proposed in the past have provided little projec­
tion to the upper gluteal region and are based on
de-epithelialization of the gluteal region commonly dis­
carded after major body contouring and circumferential
body lift procedures. Pascal and Le Louarn18 should be
credited for noticing the importance of preserving the
de-epithelialized upper excess of soft tissue to better shape
the gluteal region, avoiding the hollow aspect of the upper
pole seen in patients with a lack of gluteal muscle tone.
Progressive understanding of perforator anatomy in the
gluteal region allows surgeons to respond appropriately to
patient complaints and desires.19 The superior gluteal
region, which is either discarded in body contouring proce­
dures or simply de-epithelialized, can now be used to offer
additional augmentation to the gluteal sagittal projection,
treating the ptotic and sagging buttock. The edges of the
superior gluteal dermal-fat flaps can be rotated to the
midline to add volume to the gluteal region.
The purpose of this article is to describe our 8-year
experience with gluteal augmentation using dermal-
fat rotation flaps and to discuss the indications, proper
location of the flaps, pitfalls of preoperative markings, post­
operative complications, and instruments to both determine
the success of surgery and to evaluate the flaps
postoperatively.
PREOPERATIVE PREPARATION
With the patient in a standing position, we pull the excess
skin cephalad with our open hand on the hip region. Then,
beginning about 4 cm above the coccyx, a line is marked
in the direction of the iliac region, usually a little bit
below the anterior iliac spine. This line will join a classic
abdominoplasty scar at some position where it curves
anterolaterally. When an abdominal scar does not exist,
the line is marked on the projected scar of a supposed
abdominoplasty. With the fingers pinching the skin at the
lumbar region, we determine the amount of skin excess to
be resected. Next, on the lumbar region, we mark a second

375
Chapter | 37  Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
FIG. 37.1  Preoperative markings. (A) The pinch test is used as a helpful maneuver in the preoperative markings section. (B) The markings are
based on the preoperative excess of skin in each patient and may change according to individual patient characteristics.
A
B
line at the superior aspect of the skin excess. The second
line is initially parallel to the first, but then continues later­
ally to the upper anterior iliac spine to be joined with the
first line at either the classic abdominal scar or its supposed
projected position. These markings result in a long fusiform-
shaped area between two points, both beginning and finish­
ing inferior to the anterior superior iliac spine (Fig. 37.1).
The direction of this line depends on the skin excess and is
usually asymmetric. Occasionally, the union point of these
two lines extends as far as the hemiclavicular line or even
into the pubic region.
SURGICAL TECHNIQUE
Under general or epidural anesthesia, the patient is placed
in a ventral decubitus position. The fusiform-shaped area is
de-epithelialized, and an incision is made along the inferior
edge of this area to the gluteal muscle fascia and then
in a direction near the gluteal fold, producing an
adipocutaneous flap (a pocket to receive the dermal-fat
rotation flaps) (Figs 37.2 and 37.3). Next, incisions are
made along the superior edge of the fusiform-shaped area
down to the lumbar–hip musculature aponeurosis. A sagittal
incision along the midline of the fusiform-shaped area is
then made. The medial and lateral segments of the dermal-
fat flaps are undermined, maintaining a large pedicle in the
region corresponding to the position of the gluteal perfora­
tor’s vessels. The two segments are rotated and either
sutured together in the muscle plane or alternatively fixed
with a Reverdin needle, and transcutaneous fixation sutures
are tied to gauze and buttoned over the transfixed skin near
the gluteal region (Fig. 37.4). The inferior adipocutaneous
flaps are brought over the dermal-fat flaps in an upward
direction and sutured to the upper lumbar–hip skin border
using biplanar wound closure. The same procedure is per­
formed on the contralateral side. We also perform numerous
quilting sutures to fix the gluteal skin flaps to the aponeu­
rosis after rotation of the dermal-fat flaps. This maneuver

376
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 37.2  (A) Illustration of the fusiform-shaped area being de-epithelialized. (B) Intraoperative photograph showing the dermal-fat flaps before
elevation.
A
B
has proven to be efficient in diminishing the seroma rate in
abdominoplasty and has similar effects in the gluteal region.
Another maneuver used during the undermining of the
dermal-fat skin flaps is to leave a fat layer over the gluteal
fascia to decrease seroma formation. These technical details
have been responsible for decreasing the duration of
drainage.
In cases in which the preoperative marking lines reach
the anterior abdominal wall, the operation is begun with the
patient in the dorsal decubitus position, and after rotation

377
Chapter | 37  Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
FIG. 37.3  Bilateral gluteal pockets are created above the gluteal
muscle fascia plane to receive the dermal-fat rotation flap.
of the two anterior dermal flaps to the back, the patient is
changed to the ventral decubitus position, and the lumbar-
hip dermal-fat flaps are fashioned. Two large suction drains
are placed in each side at the end of both the dermal-fat flap
insertion and adipocutaneous flap rotation, and the patient
is kept in the hospital in either the ventral or lateral decu­
bitus position until at least the first postoperative day.
Overall, patients were satisfied with the surgical outcomes
as well as the longevity of the new shape of the gluteal
region achieved with this operation (Figs 37.5–37.11).
OPTIMIZING OUTCOMES
Avoiding Pitfalls in Preoperative Markings
Preoperative errors during patient demarcation may occur.
The first common error is putting the initial mark high in
the coccyx region (higher than 6 cm), which leads to an
increase in the vertical dimension of the gluteal fold. This
is especially noticeable in oblique photographs and results
in an unnatural and ungracious appearance in the patients,
specifically for those who may want to use a Brazilian
bikini. The second error is marking less skin than the pinch
test has shown, aiming to avoid tension in the final suture.
Although it becomes easier to close at the end of the surgery
with less tension on the skin, early recurrence of skin flac­
cidity has been seen, especially in patients with massive
weight loss.
Understanding the Geometric Shape
of the Gluteal Region
The beauty of the gluteal region involves the sagittal pro­
jection associated with the relative volume of and
satisfactory fat distribution along the lower limbs. Several
authors have developed a comprehensive classification
system for the ideal fat distribution in the posterior
region.20–22 In patients with weight loss, skin flaccidity, and
muscle hypotonia, we favor augmentation of the upper
gluteal pole only. Long-term follow up has demonstrated
its benefits (Fig. 37.12).
Understanding the Relevance of the Upper
Gluteal Pole Perforator Anatomy
In 2003, criticism was raised during the early conceptual­
ization and development of dermal-fat flaps for autologous
gluteal augmentation.23 The main concern was the perfu­
sion of the flaps and the potential chance of ischemia and
necrosis during the follow up period. Interestingly, Kankaya
and co-workers classified the gluteal region into three vas­
cular zones based on an anatomic study. This group found
(in a cadaver study) that the superior gluteal zone contained
48.5% of perforators, whereas the central gluteal zone was
noted to be the most poorly vascularized region.24 These
findings corroborate our empirical and initial concern about
the lack of gluteal perforators in the medial aspect, which
may jeopardize dermal-fat flaps based on pedicles from this
zone. For this reason, we always favor superior pole gluteal
augmentation rather than mid-level gluteal augmentation.
Our concern about the vascular supply of the dermal-fat
flap has driven our choice of the superior pole mid-pedicle
flaps.
The second reason we favor the augmented upper pole
is that it seems to be more sought-after and attractive to
Brazilian women. The third and final aspect for favoring
the upper pole is the relative descent of the gluteal region
with aging. A mid-level gluteal augmentation may become
a lower level augmentation 5 years after surgery, leading to
a convex-shaped gluteal region instead of a natural long-
lasting concave shape that brings harmony and beauty.
POSTOPERATIVE CARE
The drains are used for 3 or 4 days and are removed when
output is less than 20 ml over 12 hours. Elastic garments
are applied to the legs and buttocks, as well as to the
abdomen at the level of the umbilicus, with a gauze dress­
ing over the incision. Compression bandages are then
applied over the elastic garments. If we are concerned about
skin perfusion, we postpone the use of elastic garments
until late in the postoperative period. Patients are seen every
day until postoperative day 10 to 15, when the skin flaps
can be monitored. If any sign of lack of perfusion is noticed,
patients must remain in prone position for 10 consecutive
days. Hemoglobin and metabolic profile are checked for at

378
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 37.4  (A) Intraoperative photograph showing the edges of the
dermal-fat rotation flaps being elevated and prepared for rotation to provide
projection to the upper pole of the gluteal region. (B) Illustration of the
rotated dermal-fat flaps being sutured to the gluteal muscle fascia.
A
B
least 2 to 3 postoperative days. Patients are meticulously
monitored for general clinical status (O2 saturation, EKG,
urine output, and blood pressure). Patients are instructed to
not stand without professional assistance because of the
potential risk of orthostatic hypotension and they are usually
discharged at 3 to 4 days after surgery.
COMPLICATIONS AND
THEIR MANAGEMENT
We experienced both transient and major complications.
We define transient complications as an event without
serious consequences such as seroma, paresthesias, aug­
mentation of the vertical dimension of the gluteal fold, and
hypertrophic and malpositioned scars.
Seroma formation has decreased significantly with the
routine use of drains and quilting sutures. Paresthesias of
the gluteal region usually last from 2 to 3 months and are
attributable to the wide undermining of the skin flaps. Their
incidence also decreases when more selective undermining
is performed, especially in patients after significant
weight loss.
An increased vertical dimension of the gluteal fold is a
common error and it is not considered a complication.

379
Chapter | 37  Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
A
B
FIG. 37.6  Same patient as in Fig. 37.5: same photographic sequence: profile view.
C
A
B
FIG. 37.5  (A) Preoperative photograph of patient showing small gluteal projections. (B) Postoperative view after dermal-fat rotation flap gluteoplasty.
Notice the projection and shape of the buttocks. (C) Long-term follow up (6 years after surgery) of the same patient. Notice the long-lasting results as
well as improvements in the quality of the scar.
C
When photographs are taken of patients in their under­
wear, either the vertical dimension of the gluteal fold or
the positioning of the scar cannot be appropriately appre­
ciated. Both problems are related to preoperative mark­
ings. While a little redundant, it is of paramount importance
to emphasize that the initial demarcation should never be
started 6 cm above the coccyx region. The positioning of
the upper marking should be slightly bowed toward the
iliac region below the anterior iliac spine. In patients with
skin flaccidity, scar descent may occur; we believe that its
positioning, hidden by the underwear, is the final impor­
tant detail of this technique. Dehiscence is also related to

380
PART | 6  Thigh, buttock and lower extremity contouring
A
B
FIG. 37.7  Same patient as in Fig. 37.5: same photographic sequence: oblique view.
C
poor blood supply and high tension during placement of
the suture.
We define major complications as events with serious
consequences, mainly when related to systemic complica­
tions, infection, and ischemia of either the skin or dermal-
fat flaps. Besides systemic complications, a lack of perfusion
of the overlying skin of the gluteal region and dermal-fat
flaps is the most significant and feared complication. With
the mid-pedicle superior pole bilateral dermal-fat flaps, we
reduce the undermining area (i.e., increasing the number of
flap perforators) as well as decrease the area of the arc
of rotation of the dermal-fat flaps. Verification of perfusion
for each of the flap edges may reduce complications
related to ischemia that may lead to fat necrosis and post­
operative calcifications. Intraoperative resection of regions
with limitation of dermal-fat flap perfusion is important for
the reliability of this procedure, and although rare, such
complications may occur in the extremities of the lateral
segments of the dermal-fat flaps.
During our 7-year experience using this technique, we
had only one patient with low perfusion of the skin flaps.
Infection, even when proper antiseptic technique is per­
formed, can be related to lack of blood supply and it was
never seen in our patients. In order to avoid complications,
procedures combined with gluteoplasty augmentation are
rarely done. Liposuction of the lateral thighs might be per­
formed to improve the shape of the gluteal region in selec­
tive patients (Fig. 37.13).
Assessment of Gluteal Projection and
Possible Dermal-Fat Complications
and Calcifications
The surgical outcomes of gluteal augmentation techniques
have been assessed by clinical observations and compari­
sons between preoperative and postoperative photographs,
which in many cases have not been standardized. We rou­
tinely photograph our patients using three or four spotlights
and without any underwear to show the upper gluteal region
as well as the position of the final scar. Three-dimensional
photography is a good alternative to determine the final
projection achieved by surgery, although not used in our
practice.
Babuccu was the first to describe anthropometric mea­
surements for gluteal morphology analysis after time,
aging, and weight gain.25,26 Radiographic and anthropo­
metrical tools, however, have not been routinely used for
surgical outcome validation.
We recently studied the accuracy and applicability of
three different measurement methods (two radiological:
computed tomography (CT) scan and ultrasound; one
anthropometrical: goniometer) to assess gluteal projections
after augmentation with bilateral dermal-fat rotation flaps
from the lumbar–hip region. The CT scan and ultrasound
measured the thickness of the subcutaneous tissue in the
major gluteal region in the superior gluteal pole, and the
goniometer measured the sagittal distance that corresponds

381
Chapter | 37  Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
FIG. 37.8  (A) Preoperative oblique view of a 52-year-old woman after a weight loss of 170 kg. Note the enormous amount of lax skin in the gluteal
region. (B) Postoperative results, exhibiting the superior pole gluteal projection achieved by surgery.
A
B
FIG. 37.9  Same patient as in Fig. 37.8: same photographic sequence: oblique view.
A
B

382
PART | 6  Thigh, buttock and lower extremity contouring
A
B
FIG. 37.10  (A) Preoperative photograph of a patient after weight loss, with redundant skin in the posterior region and gluteal muscle hypotonia, seeking
gluteal augmentation procedures. (B) Postoperative view at 4 years after surgery. The patient returned to our clinic, desiring additional projection of the
gluteal region; thus, a repeated dermal-fat rotation flap was performed. (C) Final postoperative photograph at 3 years after the second procedure and 7
years after the first gluteal augmentation with autologous flaps.
C
FIG. 37.11  (A) Preoperative photograph of a patient with a very dysmorphic gluteal region after a bariatric procedure. The patient has a high accu­
mulation of fat in the superior gluteal pole with flaccidity and hypotonia. (B) A challenging operation in which the patient benefited by the dermal-fat
rotation flaps procedure. Postoperative view of the same patient in whom liposuction of the lateral thighs was performed as an ancillary procedure to
improve final esthetic results. Restricted area where liposuction was performed should be preoperatively delineated to avoid complications.
A
B

383
Chapter | 37  Autologous gluteal augmentation with mid-pedicle superior pole perforator flaps
FIG. 37.12  (A) Illustration of the nonharmonic distribution of fat in patients seeking body contouring procedures. (B) Illustration of ideal fat redis­
tribution, leading to a more harmonic, well-shaped body.
A
B
to the major gluteal projection of the lumbar–hip region as
determined by anatomic landmarks.
A simple equation was proposed to quantify the postop­
erative gluteal projection:
the gluteal projection measurement achieved
by the operation =
−
postoperative gluteal projection
measurement
preoperative gluteal projection
measurement
Although the three methods of measurement were tech­
nically different, the results should theoretically be the
FIG. 37.13  Photograph of another patient in the prone position, 2 days
after surgery, showing the lack of perfusion on the skin flap, marked with
a blue pen. Ischemia of the flaps is indeed a major complication that can
possibly result in a wide area of necrosis. This particular patient improved
during follow up, and no major consequences occurred, besides an area
of hyperchromia in the center of the gluteal region.
same. Nevertheless, the ultrasound method showed a lack
of correlation between preoperative and postoperative
gluteal projection measurements. This lack of accuracy
using the ultrasound technique was probably due to a
radical change in the soft tissue position when the patients
were put in a prone position for the ultrasound examina­
tion. Standardized anatomic landmarks were difficult to
establish clinically by the surgeon, and errors tended to
occur. Recorded gluteal soft tissue changes were fewer
when the patients were standing. The measurements
taken by the goniometer in the standing position tended
to avoid these errors, bringing higher accuracy to the
measurements.
The overall conclusion of this study is that the gonio­
meter method is preferred, since it shows less variability in
each measurement (both before and after surgery). These
measurements (both before and after surgery) correlated
with each other and were equal to those measurements
obtained using the CT scan method, which is much more
expensive.27 We did not observe calcifications and/or any
sign of fat necrosis during the postoperative period. We
conclude that the goniometer is a simple and reliable device
for measuring gluteal projections after any type of gluteo­
plasty technique (Fig. 37.14).
CONCLUSION
As gluteoplasty evolves, surgeons will no doubt face new
challenges that require a refinement of current approaches.
Rotation-flap gluteal augmentation represents an additional
option for gluteoplasty, particularly in an ever-growing
population of postgastroplasty patients.

384
PART | 6  Thigh, buttock and lower extremity contouring
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22. Mendieta CG. Classification system for gluteal evaluation. Clin Plast
Surg 2006;33:333–46.
23. Raposo-Amaral CE, et al. Gluteal augmentation with dermal-fat
flaps. Awarded Ivo Pitanguy-Ethicon Prize for best paper presenta­
tion at the 41st Annual Brazilian Congress of Plastic Surgery, in
Florianópolis, Brazil, November 19–22, 2004.
24. Kankaya Y,Ulusoy MG, Oruç M, et al. Perforating arteries of gluteal
region. Anatomic study. Ann Plast Surg 2006;56:409–12.
25. Babuccu O, Kargi E, Hosnuter M, et al. Morphology of the gluteal
region in the female population 5 to 83 years of age. Aesth Plast Surg
2004;28:405–11.
26. Babuccu O, Gozil R, Ozmen S, et al. Gluteal region morphology:
the effect of the weight gain and aging. Aesth Plast Surg 2002;26:
130–3.
27. Raposo-Amaral CE, Ferreira DM, Warren SM, et al. Quantifying
augmentation gluteoplasty outcomes: a comparison of three instru­
ments used to measure gluteal projection. Aesth Plast Surg 2008;
32:333–8.
FIG. 37.14  (A) Preoperative imaging (CT scan) of a patient in prone
position. (B) Postoperative imaging of the same patient 10 months after
surgery showing the dermal-fat flaps. This is one of the CT images per­
formed in a series of 10 patients to screen flap status during the postopera­
tive period. Although not routinely performed as a tool for flap screening,
in this series, it was important to verify calcification and fat necrosis in
addition to modifications of both gluteal shape and contour. In all exams,
the dermal-fat flaps were integrated to local adipose tissue, confirming that
the technique offered satisfactory and reliable results with low complica­
tion rates.
A
B
REFERENCES
1. Bartels RJ, O’Malley JE, Douglas WM, et al. An unusual use of the
Cronin breast prosthesis. Case report. Plast Reconstr Surg 1969;44:
500–9.
2. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined
gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg
1999;104:1524–31.
3. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation
with fat grafting. Aesth Plast Surg 2000;24:412–7.
4. Raposo-Amaral CE, Cetrulo Jr CL, Guidi M de C, et al. Augmenta­
tion gluteoplasty using dermal fat autografting from the lower
abdomen. Aesth Surg J 2006;26:290–8.
5. Coban YK, Uzel M, Celik M. Correction of buttock ptosis with
anchoring deepithelialized skin flaps. Aesth Plast Surg 2004;28:
116–9.

385
© 2013 Elsevier Inc
Part 6  Thigh, buttock and lower extremity contouring
Chapter 38 
Key Points
●
The procedure of circumferential lower truncal
dermatolipectomy is described and compared to
alternative techniques.
●
Main technical aspects and refinements are highlighted
and described in the clinical context.
●
The prevention, reduction and management of
complications is demonstrated for this specific
procedure.
●
The different intraoperative steps are explained and
how these enable procedure enhancement.
●
The combination of liposuction and lower body
contouring procedures has to be performed cautiously
and restricted. Therefore, limitations are emphasized.
Liposuction and circumferential lower
truncal dermatolipectomy
Dirk F. Richter and Alexander Stoff
INTRODUCTION
The worldwide population of obese and morbidly obese
individuals is growing faster than any other group. Conse­
quently, we have a rapid increase in patients after weight
loss, some of them through diet and exercise, and others
who undergo a bariatric procedure with more or less irre­
versible gastrointestinal changes. Therefore, this new sub­
field of plastic surgery is gaining worldwide acceptance and
there are many participating surgeons around the world.
Following the establishment of modern body lift proce­
dures by Ted Lockwood in the early 1990s1–5 and the
progress in this surgical field, we nowadays benefit from
different innovative approaches, which are all based on
Lockwood’s philosophy. The main technical aspect, similar
to modern face-lifting procedures, is the reconstruction of
the superficial and deep connective tissue layers compara­
ble to the superficial musculoaponeurotic system (SMAS)
of the face. Nevertheless, it is essential to perform large-
area tissue undermining and separation to allow a sufficient
tissue mobilization and tightening of the affected areas with
respect to an optimal result.
Since patients after bariatric weight loss can be more
challenging candidates than nonbariatric patients, it should
be mandatory for every post-obesity surgeon to have thor­
ough knowledge of different post-bariatric procedures,
including their side effects, and all available body contour­
ing procedures, consequently being able to deal with their
specific perils and pitfalls.
We carried out our first lower body lifts in 1999, con­
sistently improving our standards and technique. During
the following years we were able to detect and solve
problems and complications, and consecutively implement
refinements, which nowadays enable us to perform our
circumferential lower truncal dermatolipectomy within
2.5 to 3.5 hours. Nevertheless, we should keep in mind
that these surgical procedures are performed on formerly
morbidly obese patients and particularly on postbariatric
patients, who may present with malabsorption and nutri­
tional deficiencies. Despite the fact that we deal with the
largest body surface area, it is possible to perform these
procedures with manageable risks when preoperative plan­
ning and operative performance are carried out meticu­
lously and conscientiously. During our first years, we
refused to carry out simultaneous liposuction in circumfer­
ential body contouring procedures, in order to avoid any
risk of impaired tissue perfusion. Currently, adjuvant lipo­
suction is widely accepted in tissue mobilizing procedures
and can safely be included into lower circumferential con­
touring procedures; however, one must always be aware of
its various limitations.
PREOPERATIVE PREPARATION
A precise physical examination and assessment of the
medical history is mandatory in every patient. The exami­
nation of the lower body should include the upper and lower
abdomen, the umbilical region, the midline region in stand­
ing and supine position, the flank and hip region with lateral
thigh, the inner thigh, and additionally, the entire lower

386
PART | 6  Thigh, buttock and lower extremity contouring
total resection height lies superior to the red scar line while
the lower three quarters are inferior to it. The proposed
inferior line of excision is an estimate that may need to be
adjusted at the time of surgery. If avoidable, the anal cleft
should not be elevated, since an elongation may result in
patient dissatisfaction. It has been worthwhile to allow the
upper incision line to run at a sharper angle into the anal
cleft, in order to achieve an optical accentuation of
the buttock form (Fig. 38.1).
Next, the anterior markings are performed based on the
frontal red line previously marked (Fig. 38.2). We routinely
instruct the patient to firmly and symmetrically pull up the
entire abdominal tissue, while we initially mark the midline,
a minimal distance of 6 cm from the vulvar commissure
(or base of the penis), and next the lower incision line from
the midline point laterally, where they are connected to the
lower dorsal line. Often the resulting scar line is placed too
far cranially due to a lower incision line marked in the
abdominal skinfold. Consequently, the mons pubis, which
is often sagged and slackened, is not lifted. In more severe
cases the lower incision line can be extended caudally in
an elliptical or triangle shape into the mons pubis region
for an effective local skin tightening. Nevertheless, it is
essential to leave a distance of 6 cm to the upper vulvar
commissure (or base of the penis) (Fig. 38.3). The upper
incision line is then continued from the lateral aspect of the
dorsal upper line medially to the height of the umbilicus.
In cases of distinct tissue surplus in the upper abdomen we
routinely inform the patient about the option of a fleur-de-
lis incision pattern during the first consultation. If the
patient agrees to this additional scar line, we draw the
midline cranially to the xiphoid. The vertical incision line
is then evaluated by pinching and marked in an elliptical
shape, starting two finger breadths below the xiphoid. This
is mandatory to avoid a further cranial scar ending. Also, it
is advisable to mark the vertical incision lines in standing
position, since the tissue tends to drop laterally and back­
wards in supine position. The upper horizontal incision line
is then marked approximately one finger breadth below the
height of the umbilicus.
Importantly, dorsal vector lines are marked to allow a
mediocranial rotation of the gluteal and thigh region and a
consequent sculpturing of the waist (Figs 38.3 and 38.4). A
final check of the markings should be performed in the
patient’s supine and prone positions.
For additional liposculpturing of the flank, back or
lateral thigh regions, the markings are made in the typical
manner. We advise refraining from excessive liposuction in
the undermined gluteal area, since any additional impair­
ment of microcirculation in this area may result in skin
necrosis. Patients after massive weight loss frequently
present with significant adipose tissue redundancy in the
area of the circumferential thighs, we routinely perform
back region. For grading we recommend the Pittsburgh
Rating Scale, published by Song et al.6
The ideal patient for circumferential reconstructive
surgery meets the following criteria:
● BMI below 25
● Non-smoker or to quit smoking 6 weeks prior to surgery
● Weight stabilized for at least 6 months prior to surgery
● Highly motivated, athletically and socially stable
● Weight loss through diet and exercise
● Physically and mentally stable
● Circumferential tissue excess
● Maximal deflation of adipose tissue
● Adequate reduction of intraabdominal fat
● Strengthened abdominal wall muscles.
The first consultation should further include a thorough
and detailed explanation of the entire procedure, preferably
on PowerPoint® presentations. It is essential to demon­
strate complications on images to visualize and emphasize
possibilities such as wound separation and impaired scar­
ring. The translation-test by Aly has proven to be worth­
while in clinical practice. The patient is instructed to grasp
his tissue surplus at the height of his waist and pull the
excess tissue firmly upwards. The visible skin lift and body
contour improvement obtained in this way reliably fore­
casts the outcome of the thigh appearance after lower body
lift operations. Optimal results can be achieved with a
normal BMI < 25. With a higher preoperative BMI the
patient must be informed about an exponentially limited
postoperative result. The upper limit for massive weight
loss surgery should not exceed a current BMI of 32.7
Further, we endeavor to enhance the patient’s under­
standing of impaired skin quality due to weight loss and
bariatric surgery. In this context, we cite the latest article
on this issue and inform every patient about secondary skin
relaxation in this specific patient group. Therefore it is not
uncommon to perform a secondary tightening procedure in
particular cases.8
Markings
Initially, the boundaries of the patient’s preferred undergar­
ment are marked in the standing position. The desired scar
course is marked in red and double-checked by the patient.
Dorsal markings are performed first. The posterior upper
incision line runs about two to three finger breadths above
the desired scar line and is marked in blue. The blue line,
along its entire length, is then pulled caudally using the
surgeon’s palm and is checked to make sure that it will
reach the proposed red line of closure. In general, it should
be at the lateral height of the umbilicus. The inferior pro­
posed line of excision is estimated by strongly pinching the
skin cranially, ensuring that approximately a quarter of the

387
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
antibiotic to every patient. In specific cases the postoperative
continuation of antibiotic prophylaxis may be considered.11
SURGICAL TECHNIQUE
We routinely perform the operation with two teams of one
surgeon and one medical assistant. The leading surgeon
performs all the markings and is responsible for the entire
performance. Preparation, dissection, and wound closure
are performed simultaneously on each side of the patient’s
body. After endotracheal intubation and the installation of
a urinary catheter the patient is turned to the prone position
on a padded operating table. Next, the patient is scrubbed
and covered with sterile drapes, followed by a wide-area
infiltration of tumescent solution (1 liter of Ringer solution
including 1 ampule of Suprarenin) between the superior and
inferior line, which is performed until a satisfactory tissue
turgor is achieved. In cases of additional flank, back, or
thigh contouring, additional tumescent infiltration is
performed.
Dorsal Preparation
The initial skin incision (utilizing the cold blade or alter­
natively the Colorado® Microdissection needle) is made
along the superior marking line and is carried out down
to the level of the underlying superficial fascia, which is
widespread tissue reduction by vibration-assisted liposuc­
tion in this area during the initial circumferential lower
truncal dermatolipectomy.9
General Considerations
We advise every patient to perform an extensive body scrub
with antiseptic soap the night and morning before surgery.
Massive weight loss patients with bariatric therapy may
have an increased risk of aspiration, so an experienced
anesthesia team should be involved. Hypothermia may
occur in these operations because of extended operation
times and large wound areas, which may lead to shivering,
crouching, and inappropriate cramping postoperatively
causing increased wound tension. Preheated infusions,
heated blankets and preheated beds can optimize patients'
comfort and safety.
Accurate patient positioning is essential for avoidance
of scar asymmetry and impairment of tissue perfusion in
the areas of maximal pressure. The entire team, including
anesthesiologists, surgical nurses and surgeons must con­
stantly and conscientiously check the patient’s positioning.
Pressure necrosis can arise around the periorbital regions
and at the breasts, particularly in the prone position.10
We routinely install a urinary catheter and wrap the lower
legs with compression bandages for deep vein thrombosis
(DVT) prevention. Further, we administer a single-shot
FIG. 38.1  Upper and lower incision line (blue) and resulting scar line (red) in the anterior (left) and dorsal view (right).

388
PART | 6  Thigh, buttock and lower extremity contouring
dissection is continued to the lateral thigh, where the prep­
aration level is above the aponeurosis of the tensor fascia
lata muscle. Further distal mobilization of the lateral thigh
can be carried out bluntly using the Lockwood under­
miner. With completion of dissection, the waist and gluteal
fatty tissue is widely mobilized and covered with robust
superficial fascia. This is particularly suited for autologous
gluteal augmentations, since patients after massive weight
loss frequently suffer from flattened buttocks. For this
purpose, two to three 1×0 Ethibond threads (Ethicon,
USA) are sutured from lateral to medial, grasping the
stable fascia and consequently displacing the gluteal fatty
tissue to the middle of the buttock. For cranial reposition­
ing, three to four 1×0 Ethibond threads (Ethicon, USA)
are sutured from caudal to cranial at the medial aspect of
the buttocks. By reconstruction and tightening of the
gluteal adipose tissue, the gluteal flaps are lifted cranially
with a consequent final skin closure under less tension.
Further, this maneuver is able to improve the shape of the
waist (Fig. 38.5).
The detachment in the zones of adherence combined
with an extended mobilization allow an enormous tighten­
ing of the skin. The stage of resection should always be
supervised by the “leading” surgeon in terms of symmetri­
cal resection. We advise to utilize bullet forceps for deter­
mination of the amount of resection. The marked vector
lines (Fig. 38.4) are incised from medial to lateral and
adjusted for maximum tension. The redundant medial,
central and lateral gluteal flaps arising in this way are mea­
sured precisely in tensed condition for symmetrical resec­
tion, which is subsequently carried out between the clamps
(Figs 38.6 and 38.7).
Reconstruction of the superficial fascia system (SFS) is
then performed with PDS 2×0 (Ethicon, USA). The SFS is
extremely stable, allowing avoidance of any suturing of fat
tissue in terms of consequent fat necrosis. After readapting
the SFS, wound closure is performed in layers with resorb­
able suture material (see below). Two suction drains are
placed in each gluteal/back and lateral thigh region and
buried in the wound for sterile turning of the patient.
Before patients are turned into the supine position we
perform a temporary closure of the lateral skin surplus
utilizing a stapler and occlusive Opsite® foil.9
Anterior Preparation
Standard Technique
The inferior incision is checked and re-marked before the
patient is scrubbed, adjusting the initial inferior line to the
laterally ending gluteal incision line. Infiltration of tumes­
cent solution is then performed in the marked areas.
Vibration-assisted liposuction, however, is performed at the
exposed using the Colorado® Microdissection needle or
alternatively the Harmonic™ ultrasound scalpel, both of
which easily separate the superficial lamellar from the
subfascial lobular fat. Next, the dissection is continued
inferiorly just above the robust white superficial fascia.
The dissection level above the superficial fascia differs
considerably from the original technique by Lockwood,
who dissected subfascially. The preservation of fascia to
the deep gluteal fat as the “gluteal SMAS” is conception­
ally similar to the “facial SMAS” used in face-lifts. The
superficial fascia is dissected at the height of the inferior
resection line, before flap mobilization is continued cau­
dally. Further, this allows a reconstruction of superficial
fascia upon wound closure. Lateral gluteal adhesions
are released caudally up to the gluteal fold height, before
FIG. 38.2  Anatomical landmarks. Normal abdominal anatomic pro­
portions. The approximate measurements for an average female abdomen
are listed. These vary according to individual height and bone structure.
The umbilicus is located in line with the most superior point of the iliac
crest in 99% of patients. (A) Distance between top of mons and anterior
vulvar commissure. Average height is 5–7 cm. (B) Distance between
umbilicus and top of mons. Average height is 11–13 cm. (C) = (A + B)
Distance between umbilicus and top of anterior and vulvar commissure
(C = D) (from Richter DF, Stoff A. Abdominoplasty procedures. In: Plastic
Surgery 3rd edition (Neligan P ed.) Elsevier, Saunders, St. Louis, 2012,
with permission from Elsevier).
D
R
W
H
E
C
A
B

389
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
FIG. 38.3  Anterior (left) and dorsal (right) vectors for medial tissue advancement.
FIG. 38.4  Intraoperative marking of vectors and intraoperative
positioning in prone position (with permission from Elsevier).9
FIG. 38.5  Intraoperative view of the transposition-gluteoplasty
procedure.
time of wound closure, again avoiding excessive liposuc­
tion in the areas to be undermined.
With all techniques the dissection level is performed
above Scarpa’s fascia (Figs 38.8–38.10), entailing a number
of key advantages: long-lasting swellings can be prevented
because the underlying lymphatic vessels are preserved,
and the stretching of the SFS craniomedially provides an
additional “inner traction” on the deep penetrating fascia
system of the thigh. The SFS may then be fixated with 1/0
Ethibond sutures (Ethicon, USA) to the anterior rectus
fascia (Fig. 38.11). Approximately three finger breadths
below the umbilicus, Scarpa’s fascia is dissected and further
mobilization of the abdominal flap is performed cranially
on the anterior rectus fascia (Fig. 38.12). The central supra­
umbilical adhesion zone is sharply dissected between both
rectus muscles, preserving the laterally incoming perforator
vessels (Fig. 38.13).

390
PART | 6  Thigh, buttock and lower extremity contouring
Rectus diastasis and/or abdominal fascial laxity are cor­
rected by vertical anterior rectus fascia plication (Figs
38.13 and 38.14). In simple cases, midline plication is suf­
ficient; in more pronounced cases of fascial laxity addi­
tional oblique infraumbilical plications may be indicated.
Lateral extended release of the abdominal flap may be nec­
essary to prevent tissue bulging in the midline. Since the
umbilicus is often prolonged in patients after massive
weight loss, we shorten the entire umbilical stalk with a
remaining 2–3 cm deep umbilical tunnel. The umbilicus
base is now fixated at 3, 6, 9, and 12 o’clock to the anterior
rectus fascia. The new position of the umbilicus is marked
on the abdominal flap and a small distally based triangular
or U-shaped pedicular flap is incised, followed by an exten­
sive periumbilical fat removal, and continued cranially in
the midline for accentuation of a “Champagne groove”.
Temporary wound closure is performed with bullet forceps,
followed by reconstruction of the SFS with PDS® 2×0
(Ethicon, USA). A multilayer wound closure with 2-0 and
3-0 Monocryl® (Ethicon, USA) follows prior to intracuticu­
lar suturing. Because of the wound length, 2-0 Monocryl®
(Ethicon, USA) is advisable (Fig. 38.15). Finally, Steri-
strips are applied as described later. Alternatively, wound
closure at the subdermal level may be performed with a
FIG. 38.8  Intraoperative view of Scarpa fascia preparation and
mobilization.
FIG. 38.9  Intraoperative view of Scarpa fascia preparation and
mobilization.
FIG. 38.10  Intraoperative view of Scarpa fascia preparation and
mobilization.
FIG. 38.6  Intraoperative demonstration of flap dissection to ensure
symmetrical resection (with permission from Elsevier).9
FIG. 38.7  Each flap should be measured in comparison to the con­
tralateral side (with permission from Elsevier).9

391
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
FIG. 38.12  Supraumbilical abdominal flap mobilization.
FIG. 38.13  Anterior rectus fascia tightening starting at the cranial
midline.
A
B
FIG. 38.11  Schematic demonstration of rectus diastasis and Scarpa fascia preservation (A) and fascial tightening and Scarpa-lift (B).

392
PART | 6  Thigh, buttock and lower extremity contouring
Fleur-de-lis Technique
Initial preparation and dissection of a Fleur-de-lis lipec­
tomy is equal to a standard abdominal lipectomy. On com­
pletion of the abdominal flap mobilization we check the
horizontal resection utilizing bullet forceps, followed by an
incision and resection of the midline tissue excess. After
meticulous hemostasis the temporary vertical wound
closure is performed, following any fascial tightening. Sub­
sequently, the vertical tissue excess is checked in regard to
the horizontal superior incision line prior to its resection.
The umbilical insertion is performed after closure of the
entire vertical wound. We routinely mark the midline of the
future umbilical position and bilaterally excise a small tri­
angle or semicircle, depending on the preferred incision
pattern of the umbilical stalk. Umbilical reinsertion is then
performed with 5-0 Prolene™ (Ethicon, USA), considering
a small vertical umbilical diameter. We advise performing
excisions at the umbilical level conservatively, since our
first cases presented with postoperative increased umbilical
diameters.
In patients with extreme weight loss (>120 kg) and
consecutive skin redundancy the abdominal tissue tighten­
ing mostly requires fleur-de-lis resections, which signifi­
cantly reduce the lower abdominal circumference. In the
thigh area these patients additionally present extensive
circumferential tissue redundancies, which we prefer to
remove by a medial scar approach, beginning from the
lower abdominal scar at the mons pubis and descending
caudally to the medial thigh region. In this regard, we rec­
ommend performing the closure of the abdominal region
while shifting the lower lateral and anterior thigh tissue
medially. This allows a circumferential tightening of the
entire thigh circumference. Immediately and in the first
weeks postoperatively, patients have to deal with a signifi­
cant skin surplus at the lateral mons pubis region, which
will be eliminated by the following inner thighplasty.
Taking this maneuver into account, this modification
allows an optimal tightening of the entire thigh simply by
two procedures. Representative case studies are shown in
Figs 38.16–38.27.
OPTIMIZING OUTCOMES
We evaluated our results retrospectively from the years
1999 to 2010 and collected data from more than 1100
lift operations. The list of the main problems and solutions
is as follows:
1. Operation time
2. Symmetry
3. Wound healing disorders, perfusion disorders
4. Scarring
5. Seroma
FIG. 38.14  Anterior rectus fascia tightening continued caudally to
the symphysis.
FIG. 38.15  Skin closure in an everting manner with postoperative
progression (upper) and schematic demonstration of the three-level
suturing (lower). (From DF Richter & A Stoff, Chapter 25, Abdomi­
noplasty procedures. In Neligan, PC, Plastic Surgery, Third edition,
Volume Two, Aesthetic, Copyright Elsevier 2013.)
Dermis
Subcutis
SFS suture
Subcutaneous suture
Intracutaneous running suture
B
A
single resorbable barbed suture (PDO 3-0, Quill®) in
running manner. Skin closure may then be performed with
an intracuticular monofil or barbed suture and alternatively
with a two component skin closure system (refer to section
Operation Time).

393
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
FIG. 38.16  Preoperative anterior view of a 34-year-old patient after
48 kg weight loss.
FIG. 38.17  Preoperative lateral view of a 34-year-old patient after
48 kg weight loss.
FIG. 38.18  Preoperative posterior view of a 34-year-old patient after
48 kg weight loss.
FIG. 38.19  Six-months postoperative anterior view after circumfer­
ential lower truncal dermatolipectomy.

394
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 38.20  Six-months postoperative lateral view after circumfer­
ential lower truncal dermatolipectomy.
FIG. 38.21  Six-months postoperative posterior view after circumfer­
ential lower truncal dermatolipectomy.
FIG. 38.22  Preoperative anterior view of a 42-year-old patient after
81 kg weight loss.
FIG. 38.23  Preoperative lateral view of a 42-year-old patient after
81 kg weight loss.

395
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
FIG. 38.24  Preoperative posterior view of a 42-year-old patient after
81 kg weight loss.
FIG. 38.25  Three-months postoperative anterior view after circum­
ferential lower truncal dermatolipectomy and breast reshaping.
FIG. 38.26  Three-months postoperative lateral view after circum­
ferential lower truncal dermatolipectomy and breast reshaping.
FIG. 38.27  Three-months postoperative posterior view after circum­
ferential lower truncal dermatolipectomy and breast reshaping.

396
PART | 6  Thigh, buttock and lower extremity contouring
6. Buttock projection
7. Waist formation
8. Blood loss
9. Infections
10. Thrombosis.
Operation Time
Depending on the findings for each patient, the initial oper­
ations last from 6 to 9 hours. Since unpredictable risks can
arise from extensive operation times (e.g., long periods of
susceptibility to contamination, surgeons' fatigue, long
anesthesia, drying out of the wounds) it was our first inten­
tion to reduce this problem.
We perform the procedure with only two turns, starting
in the prone position and completing in the supine position.
This enables a considerable decrease in operation time and
allows one team to operate simultaneously on each half of
the patient’s body. However, one surgeon has to take the
leading position, controlling for an equal resection and
standard operative performance. Further, the application of
running barbed sutures for subdermal closure and the two
component wound closure systems, including an adhesive
mesh tape and a next generation cyanoacrylate (PRINEO™
Skin Closure System), may decrease the operation time
markedly.12
Symmetry
To achieve a symmetric result regarding scar course and
umbilical position we endeavor to comply with the follow­
ing instructions:
● Patient positioning has to be checked precisely after
each position change. Redundant tissue resection and
umbilical insertion should be performed prior to bending
patients for wound closure.
● Formerly, with three positions, including three patient
turns, we observed asymmetric scar courses, since the
lateral positioning inhibited effective control of sym­
metry during the operation.
● In prone/supine positioning we advise a “leading”
surgeon ensures simultaneous and comparable resection
and wound closure tension. In this regard it has proved
to be useful to divide operation areas into precisely
defined sectors using suitable vector lines (Fig. 38.4).
Wound Healing Disorders
Circumferential lower truncal dermatolipectomies include
extended tissue mobilization with a corresponding impair­
ment of tissue perfusion. Therefore, it is essential to have
precise knowledge of the vascular anatomy and the restric­
tions implicated by this procedure.
For this reason we advise respecting the following
instructions:
● Supraumbilical mobilization should include the entire
midline up to the xiphoid and should not extend to the
costal margin. Perforators should be preserved to the
maximal tension, especially in smokers. With adequate
reconstruction of the SFS, wound closure on skin level
should be performed tension free with respect to the flap
perfusion.13 In thicker abdominal flaps, the distal portion
of the sub-Scarpal fatty tissue (inferior to the new umbi­
licus) can be resected with ease.14
● In fleur-de-lis resection we refrain from lateral under­
mining of both abdominal flaps. Again, the distal sub-
Scarpal fatty tissue of abdominal flaps can be resected.
We recommend avoiding any mobilization inferior to
the lower incision line.
● Profound knowledge of the gluteal and thigh perfusion
is very important for a complication-free outcome, since
discontinuous undermining may be carried out all the
way caudally to the knee area. If necessary, the upper
lateral and anterior thigh can be mobilized from the
muscle layer without significant consequences, and dis­
sected precisely by preserving the subcutaneous vascu­
lar plexus. If patients present with excessive adipose
tissue redundancy in the lateral thigh area, we recom­
mend liposuction of the deep fat layer prior to the
gluteal dissection. In these particular cases we constrain
lateral and gluteal dissection.9,15
Wound healing problems represent the most frequent
complication after circumferential operations. Erroneous
postoperative repositioning or excessive mobilization may
cause wound dehiscences. Procedure-related staff training is
therefore mandatory for optimal perioperative patient care.
Suture granulomas due to the large number of resorb­
able sutures occur frequently and may cause local infec­
tions with wound openings. In patients with bariatric
surgery we endeavor to monitor proteins, vitamin C, zinc,
blood glucose, as well as hemoglobin levels.10,16
Scarring
Patients who have had massive weight loss are less fastidi­
ous in terms of optimal scarring and scar sparing tech­
niques. It is advisable to extend scars in advantage of an
optimal tissue removal with corresponding tissue tension.
Publications on the superficial fascial system by Lock­
wood in the early 1990s have brought a new understanding,
including with respect to scar formation.1–3 Dissection on
the level of the superficial fascia in the buttock area pre­
serves a stable layer for reconstruction and tissue transposi­
tion of the gluteal fatty tissue. Further, the reconstruction
of the SFS enables a tension free closure on skin level, in

397
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
addition to an everting skin closure for optimal scar forma­
tion (Fig. 38.15).
Patients have to be informed in detail about the planned
scar course, the consequences of the operation and any
esthetic limitations and problems that might arise and
finally about the preferred postoperative scar treatment.
Seroma
Because of the large area of the wounds, accumulations of
wound fluid (seromas) may cause postoperative problems.
Particularly at the lateral thigh, seroma may occur down to
the knee region due to gravity. Seroma formation cannot be
prevented with any degree of certainty.17–19 Suction-assisted
drains in the area of the lateral outer thigh are left until drain­
age is less than 30 ml within 24 hours. Progressive tension
sutures are helpful tools for the reduction of dead space and
may limit accumulation of fluids.20 The potential of the ultra­
sonically activated Harmonic™ scalpel for reducing seroma
formation in circumferential body lift procedures has been
demonstrated in studies.21
Buttock and Waist Formation
After massive weight loss patients often present with a
flattened buttock. Circumferential lower body contouring
procedures remove redundant skin and adipose tissue,
which may prohibit any contour improvement in the gluteal
region. For this reason, it is of huge importance in
certain cases to restore gluteal adipose tissue for gluteal
enhancement with autologous tissue transpositioning
(transposition-gluteoplasty) during circumferential lower
truncal dermatolipectomy. This maneuver enables an
enhancement of gluteal projection, gluteal shape and waist
formation22 (Figs 38.28–38.36).
Infection
The risk of widespread infections in lower body contouring
procedures is fortunately extremely low. The huge wound
cavities and the disconnected adhesion zones that prevent
any transgression to neighboring sections, allow microor­
ganisms to spread unimpeded in a large operative wound.
Therefore we advise the following principles: swift operat­
ing, careful operating, avoidance of tissue drenching,
single-shot antibiotic therapy, preoperative antiseptic
scrubbing of patients, antiseptic intraoperative lavage
before wound closure, preoperative thorough umbilical
scrubbing.
With these principles we are able to keep the risk of
serious infections lower than 0.1%. The immediate surgical
wound revision as well as the installation of a suction
and irrigation system generally preserve from further
aggravation.
FIG. 38.29  Schematic demonstration of gluteal adipose tissue pres­
ervation followed by suture placement in vertical and horizontal
directions (with permission from Elsevier).9
FIG. 38.28  Schematic demonstration of gluteal adipose tissue
preservation during dorsal preparation (with permission from
Elsevier).9

398
PART | 6  Thigh, buttock and lower extremity contouring
Blood Loss
Patients with bariatric weight loss may suffer from malab­
sorption and nutritional deficiencies. We advise every
patient to have their blood clotting status examined and to
preclude any postbariatric anemia. Patients with greater
BMI-drop regularly present a higher number and diameter
of blood vessels, which may cause increased intraoperative
bleeding. Further, particularly at the level of the anterior
rectus fascia, we recommend ligating vessels with a diam­
eter larger than 3 mm, since insufficient coagulation may
lead to a postoperative clot removal with consequent bleed­
ing, induced by hypertension or muscular contraction. Dis­
section of the wide and well-perfused wound areas as well
as any indirect undermining, for example using the Lock­
wood underminer, can already cause greater blood loss.
Any postoperative bleeding should be revised at the very
earliest opportunity. Any unresolved venous hemorrhage
will prolong drainage time and volume and consequently
increase the risk of seroma formation. All along, patients
have to be informed preoperatively about the possibility of
blood transfusions. Autohemotherapy may be considered,
but is usually refused by most experienced clinicians. For
legal reasons, however, the patients must be informed about
FIG. 38.31  Preoperative anterior view of a 49-year-old patient after
55 kg weight loss.
this option. Patients who will not consent for any possible
blood transfusion must be refused from treatment.
Thrombosis
The patient’s medical history has to be checked in terms of
former thrombosis, family history, and personal habits such
as smoking or oral contraceptive pill. In all cases appropri­
ate prophylaxis should definitively be considered. Prior to
body contouring procedures, patients with any degree of
varicosis are encouraged to have duplex sonography and,
if necessary, any kind of variceal stripping.
Our standard thrombosis prophylaxis is performed with
preoperative beginning low molecular weight heparin,
intraoperative compression treatment of the lower legs and
a postoperative beach chair position as well as early patient
mobilization. In the United States intermittent compression
stockings are considered a standard of care and can be
considered as an alternative to compression stockings.
FIG. 38.30  Vertical and horizontal suturing for maximal tissue accu­
mulation in the medial and cranial direction (with permission from
Elsevier).9

399
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
To date, we have observed three DVTs with a single
pulmonary embolism event in our patient collective, without
any fatality.
POSTOPERATIVE CARE
The patient is monitored for the initial 24 hours postopera­
tively on an intensive or intermediate care unit. In order to
ensure an optimal tissue perfusion and appropriate micro­
circulation, 2500 ml of Ringer solution is provided in the
initial 48 hours postoperatively. Dressings during the initial
48 hours postoperatively include compression girdles sur­
rounding an adult patient diaper. Furthermore, laboratory
checks for electrolytes and hemoglobin are performed mul­
tiply during the initial 48 hours. Patients are positioned in
the beach-chair position, on an air mattress with electroni­
cally adjustable positions, if available. Thrombosis pro­
phylaxis is administered using low molecular weight
heparins and compression stockings. Patients are instructed
to move their feet consistently without crossing legs. All
FIG. 38.33  Preoperative posterior view of a 49-year-old patient after
55 kg weight loss.
FIG. 38.32  Preoperative lateral view of a 49-year-old patient after
55 kg weight loss.
patients receive pain treatment within the initial 48 hours
postoperatively,
utilizing
an
individualized
patient-
controlled analgesia pump. Patients are mobilized on the
first postoperative day and instructed to obtain deep-
breathing exercises to prevent pneumonia. Drains are
removed when drainage is less than 30 ml per 24 hours.
The urinary catheter is removed after 2–3 days postopera­
tively for better mobilization.
The average duration of hospitalization is 6 days. Before
discharge we individually adapt a compression garment,
which has to be stringently worn for at least 8 weeks post­
operatively. The immediate postoperative compression
therapy is intended to reduce shearing forces for adhesion
support of different tissue layers. In this context, drains are
left for a minimum of 4 days postoperatively for negative
intracavitary pressure.
For reduction of superficial wound tension, we intraop­
eratively apply transverse vectored Steri-Strips™ for the
initial 3 weeks postoperatively. Any nonresorbable suture
or wound closure material is removed at the latest 3 weeks

400
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 38.35  Twelve-months postoperative lateral view after circum­
ferential lower truncal dermatolipectomy, breast reshaping, inner
thigh lift and brachioplasty.
FIG. 38.34  Twelve-months postoperative anterior view after circum­
ferential lower truncal dermatolipectomy, breast reshaping, inner
thigh lift and brachioplasty.
postoperatively. For at least 3 months postoperatively we
recommend our patients to cover the scars entirely with
silicone sheets for improved scar formation.
COMPLICATIONS AND
THEIR MANAGEMENT
Complications in body contouring procedures have to be
differentiated into minor and major types. Since the proce­
dure results in large wound areas and wounds are closed on
a length of 100 up to 200 cm, minor complications cannot
be precluded.
Since wounds are closed with deep and superficial sub­
cutaneous sutures, we commonly observe minor complica­
tions such as local wound reactions on resorbable suture
material. Due to this, we emphasize a reduction in the total
number of knots, and an everted skin closure with attention
to maximal suture shortening and deep positioning. Further,
we currently utilize barbed sutures in a running subdermal
manner, which allows us to do away with superficial sub­
dermal single knots. Primary treatment of local wound
healing disorders is conservative wound management. In
persistent cases we suggest a local excision with secondary
closure, to be performed under local anesthesia. In rare
cases, patients suffer from allergy to suture ingredients,
which has to be excluded in cases of multiple wound
healing disorders in the same patient.
Other minor complications such as local wound separa­
tion, asymmetry of the scars or umbilicus can be corrected
by a secondary revision. Wound separation is mainly caused
by local infection, impaired perfusion in smokers, seroma
formation, or increased wound tension, therefore is more
likely to occur in the gluteal wound area.
Fortunately, in spite of the fact that we treat formerly
morbidly obese patients, the risk of life-threatening major
complications such as DVT followed by pulmonary embo­
lism, severe infection, or bleeding, is rare.

401
Chapter | 38  Liposuction and circumferential lower truncal dermatolipectomy
For prevention and risk minimization of seromas we
recommend the following:
● Preparation with a Colorado® microdissection needle
● Alternative preparation with an ultrasonic scalpel
(Harmonic™)
● Intraoperative tissue cooling and dampening with wet
compresses and initial infiltration
● Reduced operation time and minimal heat development
● Preservation of Scarpa’s fascia
● Meticulous coagulation for minimal bleeding, ligation
of arterial perforators
● Anesthesiological-induced increase of blood pressure
during hemostasis
● Early revision of postoperative hemorrhage
● Insertion of 5–7 drains in lower circumferential
procedures
● Drain removal with drainage volume of maximum
30 ml per 24 hours
● Progressive tension sutures
● Perioperative protein, zinc and vitamin substitution for
wound healing enhancement
● Individually adapted compression garments to reduce
shearing forces postoperatively.
We recommend weekly wound inspections per manual
and ultrasonic examination within the first 4 weeks postop­
eratively. The sooner a seroma is detected, the earlier it can
be evacuated. If patients are inadequately guided during the
postoperative phase, they might present with an unexpected
wound separations with deflation of an undetected seroma.
Once a seroma has been detected it should be evacuated
under sterile conditions and checked at least twice a week.
For persisting seroma we recommend the intracavitary
injection of 200 mg doxycycline.9
Larger skin necrosis is an extremely rare complication
and should be primarily treated by conservative debride­
ment followed by wet wound care. In cases of smaller skin
necrosis we recommend an early excision and secondary
closure, if wound tension allows a complete closure.
Patients with extensive liposuction in the lower trunk
regions prior to the circumferential procedure have an
increased risk for skin necrosis. In these cases we advise
minimizing tissue undermining and ensuring reduced
tension during wound closure.
CONCLUSION
Patients with moderate to massive weight loss are ideal
cases for lower circular body contouring procedures. Plastic
surgeons may choose from numerous techniques, including
circular abdominoplasty, lower body lift, belt lipectomy,
and circumferential lower truncal dermatolipectomy.
Depending on the surgeon’s philosophy and preferences an
In cases of major postoperative bleeding, we recom­
mend an early revision, since the wound cavity may gather
a large and life-threatening blood volume and any hema­
toma consequently leads to a seroma formation. For this
reason, we emphasize the use of donated blood transfusions
for cases with serious blood loss. To prevent postoperative
bleeding the anesthesiologist should induce a controlled
hypertension before wound closure and perform the patient’s
awakening from anesthesia as calmly as possible.
Severe infections are extremely uncommon, prophy­
laxis is maintained by single-shot antibiotics, and therapy
should be performed adequately by early aggressive wound
debridement. The installation of an infusion–aspiration
drainage may be beneficial.
Of higher clinical relevance is the occurrence of seroma
formation and consequent complications. This includes sec­
ondary wound healing and wound separation. In cases of
simultaneous liposuction of the abdominal, flank, thigh or
gluteal region we observe a prolonged drainage time and
increased risk of seroma formation.
FIG. 38.36  Twelve-months postoperative posterior view after cir­
cumferential lower truncal dermatolipectomy, breast reshaping, inner
thigh lift and brachioplasty.

402
PART | 6  Thigh, buttock and lower extremity contouring
11. Richter DF, Stoff A. Lower body contouring procedures. Chirurg
2011;82(9):797–800, 802–806, [German].
12. Richter DF, Stoff A, Blondeel PN, et al. A comparison of a new skin
closure device and intradermal sutures in the closure of full thickness
surgical incisions. Plast Reconstr Surg, in press.
13. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am
Surg 1979;45(9):612–7.
14. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia: Saun­
ders Elsevier; 2009.
15. Richter DF, Stoff A, Uckunkaya E, et al. Perils and pitfalls in lower
body lifts. Int J Adipose Tissue 2007;1(1):12–6.
16. Agha-Mohammadi S, Hurwitz DJ. Enhanced recovery after body-
contouring surgery: reducing surgical complication rates by optimiz­
ing nutrition. Aesth Plast Surg 2010;34(5):617–25.
17. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: The University of Iowa experience. Plast Reconstr
Surg 2003;111:398.
18. Kenkel JM. Body contouring surgery after massive weight loss. Plast
Reconstr Surg 2006;Suppl 117:1–86.
19. Rohrich RJ, Gosman AA, Conrad MH, et al. Simplifying circumfer­
ential body contouring: the central body lift evolution. Plast Reconstr
Surg 2006;118(2):525–35; discussion 536–538.
20. Baroudi R, Moraes M. Philosophy, technical principles, selection,
and indications in body contouring surgery. Aesth Plast Surg 1991;
15:1–18.
21. Stoff A, Reichenberger M, Richter DF. Comparing the ultrasonically-
activated scalpel (HarmonicTM) versus high-frequency electrocautery
on postoperative serous drainage in massive-weight-loss surgery.
Plast Reconstr Surg 2007;120(4):1092–3.
22. Richter DF, Stoff A. Autoaugmentation of the buttocks during circum­
ferential body lift without flaps. Plast Reconstr Surg. in preparation.
FURTHER READING
Gonzales-Ulloa M. Belt lipectomy. Br J Plast Surg 1961;13:179.
Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann
Plast Surg 2004;52(5):435–41; discussion 441.
Richter DF, Stoff A. The Scarpa-Lift – a novel technique for minimal
invasive medial thigh lifts. Obes Surg 2011;21(12):1975–80.
Malinowski SS. Nutritional and metabolic complications of bariatric
surgery. Am J Med Sci 2006;331(4):219–25.
Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
Surg 2006;117(2):414–30.
Song AY, Rubin JP, Thomas V, et al. Body image and quality of life in
post massive weight loss body contouring patients. Obesity (Silver
Spring) 2006;14(9):1626–36.
Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the post-
bariatric surgery patient. Plast Reconstr Surg 2006;117(7):2200–11.
Xanthakos SA, Inge TH. Nutritional consequences of bariatric surgery.
Curr Opin Clin Nutr Metab Care 2006;9(4):489–96.
optimal result can be achieved, improving multiple areas of
the lower body.
We recommend every postbariatric surgeon to be famil­
iar with different techniques, since patients differ in their
type of local adipose tissue and skin redundancy, and
consequently show various benefits from different
procedures.
Since skin quality is deficient in patients after weight
loss and bariatric surgery, the primary result with optimal
skin tone and tension may change during the postopera­
tive months by secondary skin laxation. It is essential to
inform patients of this preoperatively and emphasize this
phenomenon.
Adjuvant liposuction of the thigh, back or flank region
may be performed simultaneously. The patient and surgeon
must be aware of an increased risk for postoperative
complications; nevertheless, the results may be optimized
through adaptational contouring. In patients with increased
local, resistant adipose tissue redundancy in the thigh region,
we routinely perform a primary liposuction for circular
volume reduction during lower body lift procedures.
REFERENCES
1. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg 1991;87(6):
1009–18.
2. Lockwood TE. Transverse flank-thigh-buttock lift with superficial
fascial suspension. Plast Reconstr Surg 1991;87(6):1019–27.
3. Lockwood TE. Lower body lift with superficial fascial system sus­
pension. Plast Reconstr Surg 1993;Nov;92(6):1112–2112.
4. Lockwood TE. The role of excisional lifting in body contour surgery.
Clin Plast Surg 1996;23(4):695–712.
5. Lockwood TE. Maximizing aesthetics in lateral-tension abdomino­
plasty and body lifts. Clin Plast Surg 2004;31(4):523–37.
6. Song, AY, Jean RD, Hurwitz DJ, et al. A classification of contour
deformities after bariatric weight loss: the Pittsburgh Rating Scale.
Plast Reconstr Surg 2006;116(5):1535–44.
7. Aly AS. Body Contouring after Massive Weight Loss. St.Louis:
Quality Medical Publishing; 2006.
8. Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content
of abdominal skin after surgical weight loss. Obes Surg 2010;
20(4):480–6.
9. Richter DF, Stoff A, Velasco FJ, et al. Circumferential lower truncal
dermato-lipectomy. Clin Plast Surg 2008;35(1):53–71.
10. Rubin JP, Nguyen V, Schwentker A. Perioperative management of
the post-gastric-bypass patient presenting for body contour surgery.
Clin Plast Surg 2004;31(4):601–10, vi. Review.

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© 2013 Elsevier Inc
Chapter 39 
Key Points
●
Rates of surgical intervention to contour and
rejuvenate the gluteal region have been rapidly
increasing in recent years.
●
The gluteal esthetic has largely been codified and
varies across ethnicities.
●
A systematic approach to the evaluation of the gluteal
region is critical as one designs an appropriate and
individualized operative plan.
●
Modalities including the utilization of prosthetic
implants, liposculpture and autologous tissue flaps
may be employed alone or in combination to contour
the gluteal region.
●
These procedures may be performed safely and
reliably if careful attention is paid to patient selection,
operative design and technical execution.
●
Complications of gluteal contouring procedures are
generally infrequent and minor.
Gluteal contouring and rejuvenation
Robert F. Centeno and Ronald P. Bossert
INTRODUCTION
Evaluation of female beauty and esthetics varies across
cultures, but tends to focus on the breast and buttocks as
key elements of investigation, evaluation and surgical inter­
vention. Plastic surgical trends have largely focused on the
breast; however, over the past 10 years augmentation and
rejuvenation of the gluteal region have far outpaced inter­
vention upon the breast and abdominal region. According
to the American Society of Plastic Surgery trends, from
2000 to 2010, procedures which aim to enhance the esthetic
of the gluteal region, including lower body lifting and spe­
cifically buttock lifting, have seen increases of 4550% and
143% respectively.1
These procedures come in many forms, with intricacies
and variations too numerous to expound upon in any
text. There are currently three main avenues for rejuvena­
tion and augmentation of the gluteal region: alloplastic
implantation, autologous fat injection, and autologous
tissue transposition/flaps. All of these techniques (and
combinations thereof) are powerful tools in surgically
improving the gluteal esthetic. Key to achieving the full
potential of these techniques is a thorough understanding
of the regional anatomy, as well as variations therein which
predispose patients to one technique versus another. One
must also consider these techniques to be utilized for per­
sonalized definitions of the gluteal esthetic, as various eth­
nicities define this differently. Furthermore, an understanding
of anatomic changes in certain patient populations, such as
the massive weight loss patient, is critical in designing the
appropriate procedure for gluteal rejuvenation.
In this chapter, the authors set out to assist the reader in
defining the relevant gluteal anatomy, in addition to tar­
geted regions found to be of critical importance in defining
the gluteal esthetic. With this background, the various tech­
niques will be described in detail to address specific sites
of deficiency, excess or derangement. Critical maneuvers,
both inside and outside the operating room, will
be expounded upon to help optimize results. Procedure-
specific postoperative care will be discussed along with
common complications and their successful management.
It is the aim of this chapter to allow the reader to success­
fully evaluate, treat and manage the patient presenting for
gluteal rejuvenation while minimizing complications and
maximizing patient satisfaction.
PREOPERATIVE PREPARATION
The characteristics of the ideal gluteal esthetic must first be
defined prior to the determination of an appropriate surgical
plan for the patient presenting for gluteal contouring
surgery. The gluteal esthetic was largely codified in 2006
by Cuenca-Guerra and colleagues.2 Their analysis of over
2400 images of the gluteal area revealed four of the most
recognizable characteristics of an esthetically pleasing
gluteal region: (1) Two mild lateral depressions that cor­
respond to the femoral greater trochanter; (2) A short infra­
gluteal fold lying in the horizontal crease under the ischial
tuberosity which does not extend beyond the medial two-
thirds of the posterior thigh; (3) Two supragluteal fossettes
(or dimples) on either side of the medial sacral crest which
correspond to the posterior superior iliac spines (PSIS); and
(4) A V-shaped crease (sacral triangle) which arises from
Part 6  Thigh, buttock and lower extremity contouring

404
PART | 6  Thigh, buttock and lower extremity contouring
serve as useful sites for incision placement during exci­
sional procedures. Mendieta has subsequently divided these
esthetic units into more discrete subunits.5 One must also
consider the surrounding regions of the abdomen,
anterior thigh, medial thigh, and lateral thigh. Derange­
ment, overcorrection, or undercorrection of these areas may
create overall disharmony as the gluteal region is surgically
approached.
Proper evaluation of the gluteal region is critical when
planning surgical intervention. Mendieta has devised a clas­
sification system analyzing the underlying bony frame­
work, gluteus maximus muscle, subcutaneous fat topography
and overlying skin to assist in operative planning.5 It is the
interplay of these variables that assists in selecting the
appropriate procedure on an individual basis.
Mendieta begins with classification of the “frame”,
which he defines as the bone, skin, and fat of the buttock
region. Frame types are defined based on the location of
three topographical landmarks: the “A” point representing
the most protruding point in the upper lateral hip, the “B”
point representing the most protruding point in the lateral
thigh, and the “C” point representing the depression at
the lateral mid-buttock (Fig. 39.3). The square buttock,
most commonly seen, is defined as equal protrusion of
points A and B. The round shape is similar, but is char­
acterized as having excess fat deposition at point C.
A-shaped frames are characterized as having more fat in
the lateral upper thigh (B point); this is contrasted with the
V-shaped frame which is characterized as having more fat
in the upper lateral hip region (A point). These A-shaped
and V-shaped frames have colloquially been referred to as
“pear shaped” and “apple shaped”, respectively. Targeted
the proximal end of the gluteal crease and extends toward
the sacral fossettes (Fig. 39.1).
It is critical for one to understand the variations across
ethnicities in defining gluteal esthetics. Roberts has out­
lined very specific variations of this basic framework
between ethnic groups in the United States.3 The short
infragluteal fold, supragluteal fossettes and sacral triangle
are generally universally accepted, whereas mild lateral
depressions tend not to be preferred by Hispanic or African-
Americans. This population tends to prefer a fuller lateral
gluteal region along with increased projection compared to
Asian-Americans, who prefer a short buttock with a high
point of maximum projection. United States Caucasians
tend to prefer a more athletic ideal with greater muscular
and bony anatomy definition with less anterior-posterior
projection.
With these regions of a pleasing buttock region defined,
one must have a systematic way to define the anatomy of
the patient presenting for gluteal contouring. Centeno has
described eight esthetic units that must be evaluated in
order to design an appropriate, individualized surgical
plan.4 From the posterior-anterior view, the gluteal region
consists of two symmetrical flank units, a sacral triangle,
two symmetrical gluteal units, two symmetrical thigh units,
and one infragluteal diamond unit (Fig. 39.2). These regions
should be individually considered and addressed in the sur­
gical planning process. The junctions between these units
FIG. 39.1  Characteristics of esthetically pleasing buttocks: a mild
lateral depression at the femoral greater trochanter, a short infraglu­
teal fold, the supragluteal fossette corresponding to the posterior supe­
rior iliac spine and a V-shaped sacral triangle. (Cuenca–Guerra, R and
Lugo–Beltran I. Beautiful buttocks: characteristics and surgical tech­
niques. Clini Plast Surg 2006;33:321–332.)
PSIS
IT
T
1
2
3
4
5
6
7
8
FIG. 39.2  Eight esthetic units described by Centeno utilized for
individualized surgical planning: two symmetrical flank units, a sacral
triangle, two symmetrical gluteal units, two symmetrical thigh units,
and one infragluteal diamond unit.

405
Chapter | 39  Gluteal contouring and rejuvenation
FIG. 39.3  Mendieta’s frame evaluation utilizing three critical landmarks. (Mendieta C. Classification system for gluteal evaluation. Clin Plastic
Surg 2006;33:333–346.)
liposculpture tends to be very effective in reshaping these
frames to achieve a more esthetically pleasing gluteal
region.
The gluteus maximus muscle can then be evaluated.
Mendieta classifies the gluteal musculature based on its
height-to-width ratio with 1 : 1 being defined as a short
muscle, 2 : 1 being defined as a tall muscle, and those in
between defined as an intermediate muscle (Fig. 39.4). This
classification scheme is particularly critical when one is
evaluating a patient for gluteal implant placement. Patients
with short gluteus maximus muscles are best augmented
with round implants, whereas those with tall muscles
require an anatomic implant. For those with intermediate
gluteal muscles, evaluation of projection and shape from a
lateral view assists in determining the appropriateness of a
round, anatomic or oval implant shape.
A gluteal ptosis classification scheme has also been
devised by Mendieta, which is similar in design to that of
breast ptosis described by Regnault.6 Those patients with
some buttock volume and skin falling slightly below the
infragluteal fold are described as having Grade I ptosis.
Patients with an apparent and angular infragluteal fold
with skin drooping below it are classified as having Grade
II ptosis. Those patients with severe skin laxity, along with
a laterally extending infragluteal fold with an angle of
greater than 30° are classified as having Grade III ptosis
(Fig. 39.5).
It is critical to appropriately and systematically analyze
the complex regional anatomy of the buttocks prior to
moving forward with surgical intervention. The interplay
between the framework, musculature, fat deposition and
skin envelope may be analyzed as above to assist in design­
ing the appropriate surgical plan for the patient presenting
for gluteal contouring.
Special consideration must be given to the massive
weight loss population, who generally present with severe
soft tissue deflation and excess skin. While circumferential
body lifting assists in eliminating skin and soft tissue
excess, it tends to flatten the gluteal region. Contouring and
autologous augmentation of the buttocks in these patients
is best achieved using de-epithelialized gluteal flaps.
SURGICAL TECHNIQUE
Implantation of prosthetic devices, liposculpture with a
combination of targeted suction-assisted lipectomy with
lipoinjection, and rejuvenation utilizing autologous tissue
flaps form the basis of surgical intervention. Combinations
of these techniques have been described to fine-tune resto­
ration of the gluteal esthetic. Below, the authors detail
the appropriate techniques for utilizing these treatment
modalities.
Prosthetic Gluteal Augmentation –
An Overview
Gluteal augmentation for reconstruction was first described
by Bartels in 1969.7 Cosmetic correction of lateral gluteal

406
PART | 6  Thigh, buttock and lower extremity contouring
abandoned secondary to unacceptably high complication
rates and utilization of more appropriate tissue planes.
Prosthetic Gluteal Augmentation –
Submuscular Approach
In 1984, Robles and colleagues described gluteal augmen­
tation utilizing the submuscular space.10 This approach suc­
cessfully addressed the capsular contracture and palpability
complications seen with the subcutaneous approach.
However, the anatomy of the submuscular space limits the
augmentation that may be achieved. Because the sciatic
nerve exits on the underside of the piriformis muscle at its
depressions was subsequently undertaken by Cocke and
Ricketson in 1973 with their utilization of mammary
implants.8 Specific gluteal implants are now available in
various shapes and textures. Numerous options for pros­
thetic implantation exist in Mexico and South America.
Cohesive gel implants with a polyurethane textured surface
allow implants to have a natural feel with less capsular
contracture and a tendency to maintain their position.
Unfortunately, the soft solid elastomer prostheses available
in the United States are more rigid, leading to increased
palpability and firmness.
Subcutaneous implant placement was originally
described by Gonzalez-Ulloa.9 This approach has been
FIG. 39.4  Mendieta’s muscle evaluation utilizing muscle height and width to assist in selecting appropriate gluteal implants. (Mendieta C.
Classification system for gluteal evaluation. Clin Plastic Surg 2006;33:333–346.)

407
Chapter | 39  Gluteal contouring and rejuvenation
inferior border, augmentation is limited to utilization of
smaller round implants placed in a more superior location.
This results in greater projection in the upper gluteal region
with a deficiency in the lower portion (Fig. 39.6). Further­
more, with such superior placement, gluteal ptosis may not
be appropriately addressed. Risk of direct injury to the
sciatic nerve also accompanies this approach. While this
technique may be used today for patients with a well-
developed inferior gluteal region requiring upper pole aug­
mentation, it has largely fallen out of favor with the advent
of intramuscular and subfascial descriptions.
Prosthetic Gluteal Augmentation –
Intramuscular Approach
The intramuscular approach to prosthetic gluteal augmenta­
tion provides padding both above and below the gluteal
implant. Utilization of this space allows for better inferior
placement when compared to the submuscular approach
and decreases the risk of injury to the sciatic nerve
(Fig. 39.7).
The authors prefer the technique outlined by
Mendieta.11 Preoperative Decadron and clindamycin are
administered and intermittent pneumatic compression
stockings are applied. General anesthesia or epidural place­
ment with IV sedation may be utilized. The patient is placed
FIG. 39.5  Mendieta’s ptosis evaluation utilizing skin fold angles for classification.
FIG. 39.6  Submuscular placement of gluteal prosthetics. Because of
anatomic limitations, augmentation is limited to the utilization of
smaller, round implants placed in a superior position. IC, iliac crest;
PSIS, posterior superior iliac spine; IGF, Inferior gluteal fold.
IC
PSIS
GT
IGF

408
PART | 6  Thigh, buttock and lower extremity contouring
subcutaneous dissection is performed and the fascia
opened for a length of 6 cm. Blunt dissection is taken
perpendicular to the gluteus muscle fibers to a depth of
2–3 cm along the corresponding fascial incision. Pocket
dissection with a tissue thickness coverage of 2–3 cm is
created, beginning in a superolateral direction. At this
point, given the lack of natural tissue plane and areolar
tissue, the dissection will no longer be bloodless. Dissec­
tion continues in a sweeping counterclockwise motion
from this superolateral point with little dissection (3–5 cm
below the coccyx) undertaken inferiorly. A breast implant
expander may be placed into the pocket at this time and
over-inflated to assist in dissection. This is then replaced
with a gluteal prosthesis sizer to estimate the volume of
permanent implant to be used. A closed-suction drain is
FIG. 39.7  Intragluteal placement of gluteal prosthetics. Dissection is superficial to the sciatic nerve, thus allowing for more inferior placement
of the prosthetic. A 5–6 cm incision is made in the midline approximately 2.5cm superior to the anus. The depth of dissection, allowing for
2–3 cm of muscle thickness overlying the implant, is established. A closed suction drain is inserted through a separate stab incision. The implant
is then inserted into the pocket and rotated into position. Closure is undertaken without undue tension.
IC
PSIS
IGF
6cm
2.5cm
in the prone jackknife position with the entire gluteal region
prepped and draped. A Betadine-soaked gauze is placed
over the anus to prevent contamination of the surgical field.
While a single midline approach had previously been advo­
cated, two parasacral incisions are now utilized to minimize
postoperative wound dehiscence. The midline is marked
and two paramedian lines are drawn 1 cm lateral to the
midline which curves to follow the upper gluteal curvature
superiorly for a total length of 8 cm.
The incision lines, intramuscular and subcutaneous
tissues are infiltrated with 1% lidocaine with epinephrine
(adrenaline) 1 : 100 000. Incisions are made in the skin and
taken down to the gluteal fascia. It is critical to preserve
the gluteal fascia at this point to allow for closure and
appropriate implant coverage. Approximately 6 cm of

409
Chapter | 39  Gluteal contouring and rejuvenation
natural tissue plane. De la Pena describes his approach to
subfascial gluteal augmentation, which exploits the natural
subaponeurotic space to allow for implant placement.12
This space utilizes the gluteus maximus as a base for the
implant to rest and is limited inferiorly by its fusion with
the infragluteal fold, thus limiting implant migration.
The authors prefer the description of this technique
detailed by De la Pena.13 With the patient in a standing
position, markings are made based on templates designed
to estimate the volume implant to be placed. This template
is centered over the gluteal region with a minimum of 2 cm
separating the inferior margin from the infragluteal fold and
2 cm separating the medial margin from the lateral border
of the sacrum (Fig. 39.8). Preoperative antibiotics are
administered and sequential compression devices applied
placed in the pocket and brought out through a separate
stab incision in the infragluteal fold.
The implant pocket is then irrigated and the implant
rolled and placed within the pocket. The muscle and sub­
cutaneous layers are closed with absorbable braided suture
in a layered fashion. It is critical that this closure be without
undue tension to avoid dehiscence and implant exposure.
The final skin closure is performed after augmentation of
the contralateral buttock to ensure symmetry.
Prosthetic Gluteal Augmentation –
Subfascial Approach
While rewarding and successful, the intramuscular approach
may be frustrating to some surgeons, owing to its lack of a
FIG. 39.8  Subfascial placement of gluteal prosthetics. Dissection is superficial to the sciatic nerve, thus allowing for more inferior placement of
the prosthetic. A minimum of 2 cm separates the inferior margin from the infragluteal fold. A 5–6 cm incision is made in the midline approximately
2.5 cm superior to the anus. Dissection is carried down through the gluteal fascia and a pocket created. A closed suction drain is inserted through
a separate stab incision. The implant is then inserted into the pocket and rotated into position. Closure is undertaken without undue tension.
IC
PSIS
2 cm
IGF
6 cm
2.5 cm

410
PART | 6  Thigh, buttock and lower extremity contouring
to the calves. General anesthesia or epidural placement with
IV sedation may be administered. The patient is placed in
the prone position with the gluteal region prepped and
draped in a sterile fashion. A Betadine-soaked gauze is
placed in the anus and covers the perineal area.
Two paramedian skin incisions are made as described
by Mendieta and beveled toward the gluteal aponeurosis
at the lateral border of the sacrum. Dissection is carried
down through the subcutaneous tissue to the presacral
fascia until the lateral aspect of the sacrum is encountered.
There, an 8–10 cm incision is made in the gluteal fascia
parallel to the lateral edge of the sacrum. Dissection is then
carried out in a subfascial plane; instillation of tumescent
solution facilitates identification and dissection in this
plane. This avascular plane with aponeurotic extensions is
sharply defined with the assistance of long instruments and
lighted retractors. Dissection continues in a superomedial
to inferolateral direction to create a pocket defined by the
preoperative skin markings. Once completed, a sizer is
placed in the pocket to estimate the volume of permanent
prosthesis to be used. Hemostasis is ensured and a closed-
suction drain is placed in the pocket.
The permanent implants are then soaked in antibiotic
solution and inserted into the pocket. The gluteal fascia is
reapproximated with absorbable monofilament suture in a
tension-free fashion. The deep and superficial subcutaneous
tissues are closed separately, followed by final skin closure
and adhesive.
TABLE 39.1  Prosthetic Gluteal Augmentation – Planes of Dissection
Advantages
Disadvantages
Submuscular
Abundant soft tissue coverage
Augmentation limited to smaller round implants
Less palpable/visible
Greater superior projection
Decreased rates of capsular contracture
Deficient inferior projection
Increased risk of sciatic nerve trauma
Fails to address gluteal ptosis
Intramuscular
Soft tissue padding above and below the implant
Technically difficult, indiscrete plane of dissection
Improved inferior placement
More painful postoperative recovery
Soft transition between edge of implant and surrounding soft tissue
Subfascial
Anatomic plane of dissection
Less soft tissue coverage, may result in implant exposure
with wound dehiscence
Limited implant migration
Increased risk of palpable/visible implant
Prosthetic Gluteal Augmentation –
Optimizing Outcomes
When performing prosthetic gluteal augmentation, utiliza­
tion of the intramuscular or subfascial plane produces the
most reliable long-term results with lower rates of morbid­
ity (Table 39.1). The submuscular approach may be appro­
priate for those patients only requiring augmentation of
the upper gluteal region. Paramedian skin incisions are
preferred over midline incisions, which are associated with
higher complication rates. Maintenance of a cuff of fascia
(or gluteus muscle if using the submuscular or intramuscu­
lar approach) is necessary to allow for a deep closure with
little tension. Utilization of long instruments and lighted
retractors assists greatly in visualization and dissection of
the implant pocket. Careful handling of the prosthesis must
be ensured to minimize infectious complications. Finally,
meticulous, tension-free, multilayered closure is paramount
in reducing the risk of wound dehiscence and possible
implant exposure (see Video Attachment 1).
Liposculpture – An Overview
Autologous fat transfer was initially described by Neuber
in 1893; more recently this technique has been refined by
the work of Coleman.13 Success has been attributed to depo­
sition of small aliquots of centrifuged fat in a layered
fashion into a well-vascularized bed. When applied to

411
Chapter | 39  Gluteal contouring and rejuvenation
gluteal augmentation, this may be a powerful and long-
lasting technique.14 When combined with liposuction of
targeted regions of localized lipodystrophy, one may reju­
venate the buttock.
Cuenca-Guerra and Lugo-Beltran have analyzed the
distribution of gluteal fat in elucidating how to better
achieve the gluteal esthetic.2 They state the following:
(1) The ratio of the anterior superior iliac spine to the greater
trochanter and the greater trochanter to the lateral point of
maximum projection of the buttock should not exceed 1 : 2
on lateral view; (2) A visible lumbosacral depression should
aid in distinguishing the back from the buttocks; (3) Excess
fat should be removed from the lumbosacral, subgluteal,
flank, “love handle”, “saddle-bag,” and “banana roll”
regions; (4) The point of maximum gluteal projection
should correspond to the level of the mons pubis. It should
be noted that one must not aggressively remove fat from
the region just inferior to the infragluteal fold (“banana
roll”), as this may exacerbate buttock ptosis.
These points are reflected in Mendieta’s frame classifi­
cation system. As referenced above, patients with a square
shape buttock find improvement with liposuction at the A
and B points with lipoinjection at the C point. Patients with
an A-shape (pear) buttock find improvement with liposuc­
tion at the B point with lipoinjection into the C point
depression. Finally, patients with a V-shape (apple) buttock
require liposuction at the A point and flank regions with
lipoinjection into the upper inner gluteal region.
When one understands the classification systems devised
to characterize the various buttock morphologies, a system­
atic operative plan may be devised. More broadly, the
regions which benefit most from liposuction are the flanks,
presacral region, hips, inner thighs, outer thighs and “banana
roll” areas.15 Lipoinjection may then be utilized to fill
depressions, fill the trochanteric region and augment pro­
jection at the level of the mons pubis.
Liposculpture – Liposuction
with Lipoinjection
Countless descriptions for the handling of harvest fat may
be found in the literature. For the sake of this text, the
authors will outline the technique described by Cardenas-
Camarena in his 2011 publication examining 14 years of
gluteal fat grafting.16 With the patient standing, markings
are made over areas to be liposuctioned and lipoinjected.
Preoperative antibiotics are administered. The patient is
placed in the prone position and epidural block or general
anesthesia is delivered. Liposuction is undertaken first, uti­
lizing a tumescent technique (1 mg epinephrine in 1000 ml
normal saline without the use of an anesthetic). Access
incisions are made in the intergluteal fold, the superior
portion of the posterior iliac crest and the subgluteal fold.
The infiltration to aspiration ratio is approximately 1.5 : 1
and performed with 3–4 mm cannulae. Targeted liposuction
is performed; when employed in the lumbosacral region,
two 2 mm diameter silicone drains are placed and removed
on postoperative day 4.
The lipoaspirate is collected in sterile bottles and
300 mg of clindamycin is added. The fat is then left to
decant and is subsequently placed in 60 ml syringes. If
cannulae larger than 3 mm are used for harvesting, the
resulting lipoaspirate will contain a significant amount of
fibrous tissue. If not removed from the aspirate with an
instrument, this will lead to syringe and injection cannula
clogging. A 3 mm, three opening lipoinjection cannula is
attached and lipoinjection is commenced utilizing the lipo­
suction access sites. The authors advocate instilling injected
fat into all layers of the subcutaneous plane as well as the
superficial intramuscular region. Fat is injected in a linear
retrograde fashion with careful avoidance of deposition of
large aliquots. Approximately 20–30 cm3 of fat is deposited
with each retrograde pass. The fat is then reaccommodated
using manual gluteal massage. Overcorrection is not per­
formed; a combination of palpation and visualization deter­
mine the endpoint for lipoinjection.
Liposculpture – Optimizing Outcomes
A clear surgical plan must be in place with targeted liposuc­
tion and lipoinjection based on the preoperative patient
classification schema. Liposuction is targeted to the flanks,
presacral region, hips, inner thighs, outer thighs and “banana
roll” areas. One must be careful not to be over-aggressive
with liposuction in the “banana roll” region, as this may
potentiate gluteal ptosis. Fat may be isolated utilizing an
array of techniques. Lipoinjection must be performed in a
multilayered fashion utilizing small aliquots in a retrograde
passing motion. High volume lipoinjection may be per­
formed safely with good long-term outcomes if a wide area
is injected in a multiple layer fashion.
Autologous Tissue Flaps – An Overview
Patients presenting with excess truncal, gluteal and lateral
thigh skin are often candidates for excisional procedures
which utilize autologous tissue flaps to augment the gluteal
region. Often, these are patients with significant weight loss
following bariatric surgery or lifestyle changes. It is Lock­
wood’s popularization of the lower body lift, along with his
description of the superficial fascial system (SFS) which
form the cornerstone of today’s autologous gluteal augmen­
tation procedures.17 His original description involved a cor­
rection of the lateral thighs and buttocks with anterior
incision lines merging into the groin crease (Type I). Lock­
wood’s modification to include an abdominoplasty with this

412
PART | 6  Thigh, buttock and lower extremity contouring
secondary to the “barrel chest” deformity resultant from
years of rib cage expansion.18
As previously discussed, the eight gluteal esthetic units
and their subsequent derangement following massive
weight loss must be understood and addressed. While
patients who benefit from autologous tissue flaps for gluteal
augmentation generally suffer volume loss, localized
regions of relative volume excess, gluteal hypoplasia and
skin integrity must be evaluated. Centeno has devised a
massive weight loss gluteal contouring algorithm which
assists greatly with this portion of the surgical planning
stage (Fig. 39.9).18
The markings begin with the patient in the supine posi­
tion. With upward tension on the abdominal tissue, a
midline mark 6 cm above the anterior vulvar commissure
is made. This should rise above the pubic symphysis; if not,
it should be moved superiorly until it lies above the sym­
physis. The patient then stands and faces away from the
surgeon. Here, the superior anchor line (superior line of
incision) is drawn as low as possible to allow for reshaping
of the buttocks. This line is extended from the midline to
the mid-axillary line bilaterally. Vertical reference lines are
then drawn at 6 cm intervals. A pinch test is then performed
by rolling the inferior tissues underneath the superior
anchor line to estimate the inferior margin of resection. To
assist in the estimation of the lateral tissues, the patient is
asked to stand with legs slightly abducted. The inferior line
lift, creating a continuous circumferential incision has been
termed a Type II lift. With the correction of posterior tissue
excess, one may augment the gluteal region utilizing local
tissue rotation flaps.
Autologous Tissue Flaps – Lower Body Lift
with Autologous Gluteal Augmentation
Here, the authors prefer the technique described by Rubin.18
It should be noted that the surgical details below refer
strictly to the gluteal augmentation portion of the larger
lower body lift (Lockwood Type II) procedure.
Prior to embarking on markings for the procedure, the
surgeon must understand that specific anatomic landmarks
are of little value. Rather, one will note that a more superior
resection will emphasize the waistline by directly excising
overhanging flank rolls. This approach will elongate the
buttocks, limit flap placement so maximum projection is
more superior than ideal, violate the sacral triangle, and
create a scar which may be visible in some clothing.18 At
the same time, a more inferior incision (preferred by the
author) allows for improved correction of the lateral thigh
and buttocks. However, this incision placement will dimin­
ish waist definition.
It should be noted that in patients who have experienced
massive weight loss after a prolonged history of obesity,
satisfactory waist definition is very difficult to achieve
FIG. 39.9  Gluteal contouring algorithm for the massive weight loss patient.
Loss of volume
Gluteal hypoplasia
Abdomen only
Abdominoplasty
Medial thigh lift
Extended thighplasty
Posterior thigh lift
Circumferential body lift
Infragluteal
diamond lift
Medial thigh
Posterior thigh
Infragluteal diamond
Flanks, back and
buttocks
Skin laxity
STOP
Gluteal augment (auto,
implant, or fat transfer)
Liposuction of lateral/
medial thighs, buttocks
or lumbosacrum
Yes
Yes
No
Volume excess
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes

413
Chapter | 39  Gluteal contouring and rejuvenation
of gluteal tissue marked for autoaugmentation is
de-epithelialized, then circumscribed down to the fascial
level. The lateral margin of resection is incised with exci­
sion of the marked tissues around the dermal pedicle at the
level of the fascia. The circumscribed paddle is then under­
mined laterally at the level of the muscle fascia to allow for
subsequent downrotation. A subcutaneous pocket is then
undermined at the level of the muscle fascia, inferior to the
lower incision line marking. The dermal-fat flaps are then
rotated into this pocket and secured with permanent braided
nylon suture. The surgeon may then elect to plicate the
dermal surface of these flaps to enhance gluteal projection
(Fig. 39.10).
The legs are then abducted on armboards and the Lock­
wood discontinuous undermining device (Byron Medical,
USA) is passed through the subcutaneous tissues along the
lateral thighs to the level of the knee. Two closed-suction
drains are placed in the wound. The wound edges are sub­
sequently reapproximated along the vertical hashmarks. It
is critical to maintain thigh abduction at this point to allow
for decreased tension of closure at the lateral aspect of the
wound. Absorbable braided sutures are placed in the SFS
is drawn in, as well as the lateral margin of resection at the
mid-axillary line, which connects the superior and inferior
incision lines. The regions of adipose tissues which will be
used for gluteal augmentation are marked and symmetry is
checked. At this point, the patient turns to face the surgeon
and markings continue for the abdominoplasty portion of
the operation.
Preoperative antibiotics are administered within 1 hour
of incision and can be redosed if the procedure exceeds 2
hours or if there is excessive blood loss. The patient is kept
under forced air warming blankets in the preanesthesia
area; these are also utilized intraoperatively in order to
prevent hypothermia during the case. After general anes­
thesia is induced, a Foley catheter is placed and the patient
is positioned in the prone position on the operating room
table. Two arm boards are placed at the lower portion of
the table so the legs may be abducted during the procedure.
The buttocks and legs are prepped and draped in a circum­
ferential fashion. Sterile drapes are wrapped around the legs
from knees down to allow for intraoperative manipulation.
A 1 : 100 000 epinephrine solution without anesthetic is
infiltrated into the dermis to aid in hemostasis. The region
FIG. 39.10  The region for autologous gluteal augmentation is circumscribed, de-epithelizalized and dissected laterally at the fascial level. The
flaps may be partially incised or plicated to assist in obtaining projection. A subcutaneous pocket is created over the muscle fascia inferiorly
(dotted line) and the flap is downrotated. The flaps are secured with braided permanent suture and closure undertaken in a layered fashion.
Region
de-epithelized
Subcutaneous pocket

414
PART | 6  Thigh, buttock and lower extremity contouring
sitting be limited to going to the bathroom and sleeping in
a position other than supine for 2–3 weeks postopera­
tively. At that time, clearance for sitting and the initiation
of stretching exercises is undertaken. In the event that the
incision lines have marginal healing, sitting is deferred for
another 2 weeks after interval evaluation. Drainage tubes
are left in place until drainage is less than 30 ml/day.
When the drainage tubes are discontinued, topical
antibiotic ointment may be used until wound closure is
complete. Slowly introduced resumption of exercise is
generally permitted 6–8 weeks after surgery. It is gener­
ally recommended that compression garments be utilized
if liposuction is performed. If no liposuction has been per­
formed, we recommend an abdominal binder be placed to
apply pressure on the upper portion of the buttocks for
2–3 weeks.
Liposculpture
When liposuction is performed in the sacral region, a sili­
cone drain is left in place and removed 4–5 days postopera­
tively. Patients are placed in a panty girdle compression
garment which is worn for 6 weeks. Therapeutic ultrasound
massage is initiated at that time and continued every third
day for a total 1 month course.19 If deemed necessary,
15–20 Endermologie sessions may follow this course of
ultrasonic massage. Normal activities may be resumed at 2
weeks after surgery and gradual initiation of exercise may
begin at 4 weeks postoperatively.
Autologous Tissue Flaps
During the immediate postoperative period, the patient is
maintained in the semi-Fowler’s (beach chair) position,
flexed at the waist. Egg crate foam pads are placed at the
base of bed flexion to minimize pressure on the gluteal
region. The patient is instructed to ambulate with assis­
tance the night of or morning following the procedure.
Sequential compression devices are maintained on the
lower extremities while the patient is in bed and low-
molecular weight heparin is administered twice daily, com­
mencing the night of surgery. When performed as a portion
of the lower body lift, patients undergoing autologous
gluteal augmentation typically spend 2 nights in the hospi­
tal. Drains are maintained until their output is less than
30 ml/day for 2 consecutive days. If retention sutures had
been placed, they may be removed 1–2 weeks after surgery.
Patients are advised that while their posture will be hunched
for the first week or so postoperatively, they will soon
thereafter walk upright without undue discomfort. It is gen­
erally advised that patients may resume their preoperative
level of activity at approximately the 6–8th postoperative
week.
and the dermis is closed in two layers with interrupted
absorbable monofilament suture and a running barbed
suture. Retention sutures using permanent monofilament
sutures may be placed in the sacral region, or other areas
of high tension. Cyanoacrylate adhesive and a layered
gauze with occlusive plastic dressing is then applied
over the incision lines and the lateral dog-ears are stapled
shut prior to placing the patient in the supine position and
continuing with the abdominoplasty portion of the lower
body lift.
Autologous Tissue Flaps –
Optimizing Outcomes
The markings made are critical for operative success; one
must understand that fixed anatomic landmarks should not
be used as immutable guides for surgical planning. The
bony and muscular landmarks differ from patient to patient
and have an impact on gluteal esthetics. Recognition of how
an individual patient’s anatomy differs from the ideal can
guide the surgeon in planning for a more esthetically pleas­
ing outcome while using autologous flaps. Oftentimes,
these findings lead to a variable alteration of the superior
anchor line. Additionally, the origin of the superior gluteal
muscle from the sacral promontory can also serve as a
palpable guide to looking at muscle height and adjusting
the augmentation to either shorten or lengthen muscle
height visually with augmentation. Higher superior anchor
lines will accentuate the waistline, whereas lower superior
anchor lines will allow for greater lateral thigh and gluteal
correction. Abduction of the legs during lateral resection
margin estimation and closure is critical to decreasing the
risk of over-resection and tension of closure. Careful atten­
tion must be paid to meticulous closure of the SFS to insure
strength of closure.
POSTOPERATIVE CARE
Although preoperative planning and operative execution
are critical to long-term success, lack of attention to
appropriate postoperative care can ruin an otherwise sat­
isfactory result. Regardless of which method of buttock
augmentation is employed, all postoperative care proto­
cols call for some degree of gluteal pressure offloading.
Drain and wound care, positioning and activity level are
all aspects of postoperative care which must be closely
monitored.
Prosthetic Gluteal Augmentation
Protocols for postoperative care contain little variation
regardless of the technique employed. Ambulation may
begin the following morning. Most surgeons recommend

415
Chapter | 39  Gluteal contouring and rejuvenation
of the sciatic nerve during intramuscular dissection may
limit the amount of inferior dissection required for optimal
implant placement. However, permanent injury to the sciatic
nerve using this approach is exceedingly rare. Mendieta has
noted transient sciatic parasthesias in approximately 20%
of patients undergoing intramuscular augmentation, which
respond to gabapentin and resolve within 3 weeks.21
Liposculpture
Cardenas-Camarena and colleagues present an excellent
review of the evolution of their gluteal fat grafting tech­
nique over a 14-year timeframe.16 The authors found that
complications such as fat necrosis, gluteal erythema, infec­
tion, and fat embolism syndrome were more common when
fat infiltration volumes were small and localized. The injec­
tion of large volumes of fat into single small areas in one
layer place the patient at increased risk of local complica­
tions and fat necrosis. By increasing the area to be infil­
trated and utilizing multiple layers of deposition, these
complications may be minimized.
Infection rates of 14% have previously been reported by
some groups. This rate has decreased to approximately 4%
by administering systemic antibiotics, clipping (not shaving)
hair in the region, prepping circumferentially with povidone/
iodine solution, placing a gauze pad soaked in povidone/
iodine in the gluteal cleft, decreasing the handling of fat,
coating the grafting cannula with povidone/iodine and
administration of triple antibiotic to each canister of fat
immediately upon harvesting.
Seroma formation at the site of fat harvesting has been
described. This tends to be seen in the lumbosacral region,
a common site of fat harvest given its integral role in creat­
ing an esthetically-pleasing gluteal region. Most surgeons
advocate placing a small silicone drain in this region and
reinforcing with compression garments.
The volume of fat grafted has been a disputable risk
factor for major and minor postoperative complications.
Some authors have described increased complications
with fat injection volumes over 1000 cm3 per buttock,
while others have noted a decrease in complications with
increasing volumes infiltrated. This may be secondary
to the area over which the fat has been deposited, with
large volume deposition in small spaces predisposing to
complications.
More rare, and feared, complications have been
described. These include transient blindness, necrotizing
fasciitis and sepsis.22,23
Autologous Tissue Flaps
Complication rates following procedures utilizing autolo­
gous tissue flaps tend to parallel those of other major body
COMPLICATIONS
As the various modalities utilized for gluteal augmentation
have evolved, refinement of technique has assisted in reduc­
ing postoperative complications. The complications associ­
ated with contouring of the buttocks are often associated
with the unique nature of the procedure. The pressure
applied to the region with sitting, shear force exerted with
movement and close proximity to the fecal stream create
situations which may predispose the patient undergoing
gluteal contouring to various postoperative complications.
Because the procedures performed fall into three broad
categories (prosthetic-based, lipoinjection, and autologous
tissue rearrangement), complications and their management
will be discussed separately.
Prosthetic Gluteal Augmentation
The evolution of prosthetic-based gluteal reconstruction
discussed above has allowed for a decrease in postoperative
complications. As mentioned, the subcutaneous plane has
been fraught with complications and has since been aban­
doned. Wound dehiscence had previously been reported to
occur in approximately 30% of cases. This rate has declined
with the increased popularity of using paramedian instead
of midline incisions. This is felt to be secondary to a number
of factors: (1) The intergluteal crease has an intrinsically
poor blood supply and is considered a “watershed” area;
(2) Prolonged retraction may crush and traumatize the local
tissues; and (3) Inadequate or high tension muscle or fascial
closure.20 Should a wound dehiscence occur without implant
exposure, these wounds will typically heal secondarily
without long-term sequelae. Implant exposure is an indica­
tion for explant. The rate of exposure is quoted at 2–5% but
is significantly higher in patients who are overweight or
receiving implants larger than 350 cm3. Utilization of large
implants (greater than 545 cm3) has also been associated
with severe inferior ptosis.
Seroma formation has been found to occur in 2–4% of
intramuscular augmentations. While small seromas may
resolve spontaneously, most will require serial aspiration.
In the rare instance of chronic seroma, the capsule may
be scored, implant replaced and closed-suction drainage
undertaken.
Implant asymmetry or migration are more common
when the intramuscular approach is employed, as this
involves creation of an unnatural tissue plane. It is common
to inadvertently allow dissection to become too superficial
when one works superolaterally. Because the gluteus
maximus muscle forms the base on which an implant sits
in the subfascial location, with the robust muscle fascia
overlying it, implant malposition is less common utilizing
a subfascial technique. Furthermore, the close proximity

416
PART | 6  Thigh, buttock and lower extremity contouring
org/Documents/news-resources/statistics/2010-statisticss/Top-
Level/2010-US-cosmetic-reconstructive-plastic-surgery-minimally-
invasive-statistics2.pdf; 2010 (accessed 17 April 2012).
2. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics
and surgical techniques. Clin Plast Surg 2006;33:321–32.
3. Roberts T, Weinfeld A, Bruner T, et al. “Universal” and ethnic
ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuctions. Clin Plast Surg 2006;33(3):
371–94.
4. Centeno R. Gluteal aesthetic unit classification: a tool to improve
outcomes in body contouring. Aesth Surg J 2006;26:200–8.
5. Mendieta C. Classification system for gluteal evaluation. Clin Plastic
Surg 2006;33:333–46.
6. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg
1976;3(2):193–203.
7. Bartels R, O’Malley J, Douglas W, et al. An unusual use of
Cronin breast prosthesis. Case report. Plast Reconstr Surg 1969;
44:500.
8. Cocke W, Ricketson G. Gluteal augmentation Plast Reconstr Surg
1973;52:93.
9. Gonzalez-Ulloa M. Gluteoplasty: a ten year report. Aesth Plast Surg
1991;5:85–91.
10. Robles J, Tagliapietra J, Grandi M. Gluteoplastia de aumento:
implane submusular. Cir Plast Iberolatinoamericana 1984;10:
365–9.
11. Mendieta C. Intramuscular gluteal augmentation technique. Clin
Plast Surg 2006;33:423–34.
12. De la Pena J. Subfascial technique for gluteal augmentation. Aesth
Surg J 2004;24:265–73.
13. Coleman S. Structural fat grating: more than a permanent filler. Plast
Reconstr Surg 2006;118:108S–20S.
14. Avendano-Valenzuela G, Guerrerosantos J. Contouring the gluteal
region with tumescent liposculpture. Aesth Surg J 2011;31(2):
200–13.
15. Aiache, A. Gluteal recontouring with combination treatments:
implants, liposuction, and fat transfer. Clin Plast Surg 2006;33:
395–403.
16. Cardenas-Camarena L, Arenas-Quintana R, Robles-Cervantes J.
Buttocks fat grafting: 14 years of evolution and experience. Plast
Reconstr Surg 2011;128:545–55.
17. Lockwood T. Superficial fascial system (SFS) of the trunk
and extremities: a new concept. Plast Reconstr Surg 1991;87:
1009–18.
18. Centeno RF, Mendieta CG, Young VL. Gluteal contouring
surgery in the massive weight loss patient. Clin Plast Surg 2008;
35:73–91.
19. Cardenas-Camarena L, Silva-Gavarrete J, Arenas-Quintana R.
Gluteal contour improvement: different surgical alternatives. Aesth
Plast Surg 2011;35(6):1117–25.
20. Bruner T, Roberts T, Nguyen K. Complications of buttocks augmen­
tation: diagnosis, management, and prevention. Clin Plast Surg 2006;
33:449–66.
21. Mendieta C. Intramuscular buttocks implant augmentation. Chicago:
Presented at the Annual Meeting of the American Society of Plastic
Surgery; Sept 27, 2005.
22. Talbot S, Parrett B, Yaremchuck M. Sepsis after autologous fat graft­
ing. Plast Reconstr Surg 2010;126(4):162e–164e.
contouring procedures. Wound dehiscence and seroma are
generally the most common complications encountered uti­
lizing this technique. These complications tend to be minor.
Wound dehiscence is generally best managed with local
wound care. After appropriate debridement, large wounds
may be successfully managed with negative pressure wound
dressings. Wounds which are grossly infected or associated
with significant undermining require operative debridement
and formal closure.
Shermak and colleagues have described the manage­
ment of seromas in the massive weight loss population in
outstanding detail.24 The majority of seromas encountered
resolve utilizing serial aspiration. Those recalcitrant to this
line of therapy may resolve with placement of an indwell­
ing catheter or sclerotherapy (500 mg of doxycycline in
50 ml of normal saline). Failure of sclerotherapy requires
operative excision of the established seroma cavity.
Other complications, including infection, skin and fat
necrosis, scarring and venous thromboembolism have been
described but are far less common than wound dehiscence
and seroma formation. For patients undergoing autologous
gluteal augmentation, Colwell et al have demonstrated that
patients with an operative BMI of 30 kg/m2 or greater are at
significantly increased risk of wound, seroma and fat necro­
sis complications.25 Patient selection remains paramount in
minimizing the risk of postoperative complications.26
CONCLUSION
The buttocks have long been considered a symbol of beauty.
Recontouring and augmenting the gluteal region has
become an increasingly popular intervention demanding a
thorough understanding of the relevant regional anatomy
and surgical options available to the plastic surgeon.
Knowledge of the esthetic gluteal subunits, their interplay
and classification scheme is critical as the surgeon devises
a viable surgical plan. Execution of that plan with gluteal
prostheses, fat injection, autologous tissue transfers or
combinations thereof is simplified when one is familiar
with the anatomy. Assurance of satisfactory long-term
results may be achieved with meticulous postoperative
attention. Complications, although relatively uncommon,
may be managed successfully in the vast majority of cases.
Regardless of the technique employed, satisfactory long-
term results may be achieved when the surgeon has a thor­
ough understanding of the principles of gluteal contouring
and augmentation.
REFERENCES
1. American Society of Plastic Surgeons. Report of the Plastic Surgery
Statistics.
Online. Available
from

417
Chapter | 39  Gluteal contouring and rejuvenation
25. Colwell A, Borud L. Autologous gluteal augmentation after massive
weight loss: aesthetic analysis and role of the superior gluteal artery
perforator flap. Plast Reconstr Surg 2007;119:345.
26. Michaels V, Coon D, Rubin JP. Complications in postbariatric body
contouring: postoperative management and treatment. Plast Reconstr
Surg 2011;127:1693.
23. Sherman J, Fanzio P, White H, et al. Blindness and necrotizing
fasciitis after liposuction and fat transfer. Plast Reconstr Surg 2010;
126(4):1358–62.
24. Shermak MA, Rotellini-Coltvet L, Chang D. Seroma development
following body contouring surgery for massive weight loss: Patient
risk factors and treatment strategies. Plast Reconstr Surg 2008;122:
280–8.

Part 6  Thigh, buttock and lower extremity contouring
418
© 2013 Elsevier Inc
Chapter 40 
Buttock implants
INTRODUCTION
The esthetic standards of beauty for the gluteal region have
changed over the past few decades. The “Rubenesque”
curves of the Renaissance are no longer considered attrac­
tive; today, women seek an athletic look with well-defined
curves for the breast and buttock area. Standards of beauty
include a well-projected gluteal area and a uniform line that
on the frontal view makes a natural curve from the waist to
the knee. Our current ideal of the female buttocks implies
a small waist so the gluteal area has appealing posterior
projection but without disproportionate width in the side-
to-side dimension.
FIG 40.1–40.10 APPEARS ONLINE ONLY
INDICATIONS
Patient selection is very important for this procedure. The
ideal patients for gluteal augmentation with implants placed
with a subfascial technique are:
● Young patients with an athletic build with little or no
ptosis.
● Morbidly obese patients are not candidates for this
surgery unless they lose weight, after which the laxity
of tissues converts them into good candidates if they
undergo excisional procedures to correct the back and
gluteal regions.
● Those patients who lack projection of the gluteal region
and desire to improve the shape of the gluteus.
● Unilateral implant placement is occasionally needed to
correct an asymmetry or reconstruct subcutaneous tissue
lost through infection trauma, or neurological problems
that result in muscle atrophy.
● Subfascial augmentation with anatomically shaped
implants can correct minor degrees of gluteal ptosis.
But, as with breast surgery, implants are not the solution
to severe ptosis.
● The implants used today minimize the risk of displace­
ment, having a textured surface, or a polyurethane
foam cover that minimizes the occurrence of capsular
contracture.
● Patients must be informed preoperatively about restric­
tions for sitting in the postoperative period, in which
they will be limited to sitting only when going to the
bathroom for the first month postop. If these instructions
are not followed, the chance of wound dehiscence and
other complications is elevated. If you predict that the
patient will not comply with the instructions, you should
not proceed with the surgery because serious complica­
tions may occur.
For additional online content visit

A.  GLUTEAL IMPLANT
AUGMENTATION
José Abel de la Peña Salcedo,
José Fernando López-Salguero
and Miguel A. Soto-Miranda
Key Points
●
Ideal candidates are thin patients with an athletic build
and little or no ptosis.
●
Determine the patient’s expectations and evaluate the
size of the proposed implant with templates.
●
The day before the surgery the patient should be given
an enema and begin antibiotics.
●
Mark the patient in a standing position.
●
Make two incisions, one for each implant, leaving 2
centimeters between them.
●
Subcutaneous undermining in the sacral area is
minimal and the skin and underlying tissue at the
midline remain untouched.
●
Subfascial undermining and flap elevation begins at
the lateral border of the sacrum.
●
Create both pockets before placing any implants.
●
No sitting is allowed for the first month after surgery.
●
If infection of the pocket is determined, treatment
requires temporary removal of the implant.
●
Infection of the wound is locally treated. Prophylactic
antibiotic is used.

418.e1
Chapter | 40  Buttock implants
In response to this esthetic norm, which favors more
athletic, defined buttocks, the demand for gluteal augmen­
tation has been growing since the 1960s. At that time no
surgical technique had been described for gluteal augmen­
tation, and silicone implants were designed only for breast
augmentation. This demand launched a new search for a
surgical solution and was the impetus for the development
of a new procedure that includes regional shaping by lipo­
sculpture with placement of special implants designed for
gluteal augmentation.
The authors have been focused on developing a natural
and esthetic gluteal augmentation technique over the past
19 years. During these years they have progressively
improved the surgical technique and developed an anatomic
system for gluteal augmentation that includes the ideal
implant design. The goal has been to identify the best tech­
nique: one that is safe, effective, and reproducible by all
plastic surgeons, with excellent, natural results.
EVOLUTION OF TECHNIQUE
Gluteal augmentation as a surgical procedure was intro­
duced to clinical practice in 1969 by Bartels and col­
leagues; using a Cronin-style round mammary implant a
unilateral deformity was corrected; the procedure was pri­
marily reconstructive. It was not until 4 years later that
the procedure was first performed as a cosmetic operation.
Since then, a few reports have appeared in the medical
literature describing the technique, reporting long-term
follow up, and outlining the possible complications of this
procedure.
In 1973, Dr. William Cocke and G. Ricketson described
the use of mammary implants for correction of lateral
gluteal depressions. The implants used had Dacron patches
on the underside for better fixation, although other types of
breast implants were also used. This was the first description
of the placement of gluteal implants in the subcutaneous
plane. However, the use of mammary implants in a subcu­
taneous plane produced less than optimal esthetic results
(Fig. 40.1). The implants are noticeable through the skin
and do not give a natural appearance.
González-Ulloa, in Mexico, was one of the first sur­
geons to reconstruct the gluteal region, either by lifting
“sagging” buttocks or placing an implant to augment them.
He reported his 10 year experience with gluteal augmenta­
tion and lifting in 1991.
Techniques for gluteal augmentation have progressed
through four anatomic planes: subcutaneous, submuscular,
intramuscular, and subaponeurotic.
Subcutaneous Plane
First attempts at gluteal augmentation placed implants in
the subcutaneous space (Fig. 40.2); breast implants were
FIG. 40.1  Use of mammary implant in a subcutaneous plane pro­
duced less than optimal esthetic results.
FIG. 40.2  First attempts at gluteal augmentation placed implants in
the subcutaneous space.
used until the first implant designed by González-Ulloa
specifically for gluteal augmentation was released by Dow
Corning. However, this subcutaneous space had numerous
anatomic restrictions, making it unsuitable for this opera­
tion. Results were unnatural, and the visibility of the implant
restricts the usefulness of this space for gluteal augmenta­
tion (Fig. 40.3A, B, C).

418.e2
PART | 6  Thigh, buttock and lower extremity contouring
A
B
C
FIG. 40.3  Results were unnatural, and the visibility of the implant
restricts the usefulness of this space for gluteal augmentation.
Complications with this subcutaneous approach con­
sisted of extrusion, infection, and inferior displacement of
the implants. The second generation of implants included
Dacron patches on the back, with the goal of affixing the
implant to the pocket; however, these patches were not
sufficient to maintain implant position. The next genera­
tion design had an area on the implant that could be
sutured to the deep tissues. Results with this approach
were still unnatural, with implant visibility an ongoing
problem.
Correction of these cases implies having to change the
dissection plane to either intramuscular or subfascial and
closing the subcutaneous space permanently. In Fig. 40.4A,
B, and C the correction of the patient shown in Fig. 40.3
has been performed, placing a polyurethane covered gluteal
implant in a subfascial plane (photos were taken 6 weeks
postoperatively).
Submuscular Plane
In 1984, Dr. Robles from Argentina described a new tech­
nique for gluteal augmentation that used a submuscular
approach. This approach preserved the aponeurotic system
that holds gluteal skin in position; however, it introduced a
new anatomic problem with the potential risk of injury to
the sciatic nerve. This nerve emerges from the submuscular
space, at the level of the proximal lower third of the gluteal
region and at the inferior border of the piriform muscle. To
avoid injury to this nerve, an implant could not be placed
below this level (Fig. 40.5). Furthermore, implants had to
be small in diameter and could not be placed close to the
infragluteal fold.
This technique was used for many years. In patients who
had good volume in the lower third of the gluteus, small
implants could be placed in a relatively snug pocket.
However, in slender patients the esthetic results were not
good and patients were often left with a double bubble
deformity, similar to the phenomenon sometimes seen
when mammary implants are placed below the inframam­
mary fold.
Tailoring the pocket for the gluteal implant through the
submuscular approach preserved the aponeurotic expansion
system uninjured, but the implant was positioned high in
the gluteal region. Therefore projection was higher than
normally expected, and the lower third of the gluteal region
was empty, with the loose skin hanging over the upper
thigh. This space, which was named the “subgluteal cellular
space” by Dr. Robles, is developed deep on the depression
of the osseous pelvic bones, and projection of the implant
is lost. This technique was probably the most well known
for gluteal implants, until the subaponeurotic technique was
developed.
The system that maintains the skin attachment to the
gluteal region is composed of aponeurotic expansions
running from the gluteal aponeurosis to the dermis; when
a gluteal implant pocket is developed in this space, these
aponeurotic expansions are divided, skin will be loose, and
the implant will not have the correct anatomic position.
Thus a very obvious implant will result.