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

418.e4
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.6  Intramuscular plane.
C
FIG. 40.4  Continued
shows on the upper third of the gluteal region. The gluteal
aponeurosis insertions are on the posterior iliac bone, the
sacral bone, and the coccyx bone, and on the lateral limit
inserts on the greater trochanter and extends to the iliotibial
line.
This large aponeurosis covers the entire gluteal region
and at the same time molds the gluteal augmentation; it is
stronger at the insertion sites and softer in the middle,
helping to achieve a natural result (Fig. 40.9A, B).
The aponeurosis expansions are distributed in a trans­
verse direction, along the axis of the muscle fibers through­
out the gluteal region. Because they originate on the deep
part of the gluteal aponeurosis, the attaching fibers convert
the superficial surface of the gluteus maximus into a uniform
space shaped like the muscle. The aponeurotic expansions
to the skin are preserved, and the subaponeurotic space
allows proper positioning of an implant without risking
injury to the deep neurovascular structures (Fig. 40.10A, B).
FIG. 40.5  Submuscular plane.

418.e5
Chapter | 40  Buttock implants
FIG. 40.7  The inferior border of the implant was high, and the lower
part of the gluteal region was empty and loose with the appearance
of a double contour.
A
B
C

418.e6
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.8  Subfascial (subaponeurotic) plane.
FIG. 40.9  This large aponeurosis covers the entire gluteal region and
at the same time molds the gluteal augmentation.
A
B
FIG. 40.10  The aponeurotic expansions to the skin are preserved,
and the subaponeurotic space allows proper positioning of an implant
without risking injury to the deep neurovascular structures.
A
B

419
Chapter | 40  Buttock implants
WHY IS THE SUBFASCIAL
PLANE RECOMMENDED?
The subfascial plane is the most superficial anatomical
space that can hold an implant capable of molding and
shaping the buttocks using the gluteus maximus muscle as
a platform for the implant. This space is limited inferiorly
by the infragluteal fold where the gluteal aponeurosis
attaches to the posterior thigh fascia (Fig. 40.11). In addi­
tion, the likelihood of implant displacement is minimal
because the subfascial space is closed.
The gluteal aponeurosis sends expansions to the skin,
which insert onto the deep portion of the dermis; these
expansions work as a system to maintain the skin and
subcutaneous tissues adherent to the gluteal region in the
same way the skin of the palm of the hand is attached to
the deep tissues. These aponeurotic expansions are distrib­
uted transversely. They originate on the deep part of the
gluteal aponeurosis and cover the superficial part of the
gluteus maximus muscle in a muscle group divided by these
expansions. To maintain this system intact, subcutaneous
undermining should be avoided. We prefer a subaponeu­
rotic space that can be carefully undermined on top of the
gluteus maximus muscle. This undermining allows perfect
positioning for the implants without possible injuries to the
deep neurovascular structures while preserving the aponeu­
rotic expansions to the skin. After the implants are placed,
this space is anatomically contoured by the gluteal
FIG. 40.11  The gluteal aponeurosis sends expansions to the skin.
A
B
C

420
PART | 6  Thigh, buttock and lower extremity contouring
aponeurosis, and it is limited inferiorly by the infragluteal
crease where the gluteal fascia is attached to the posterior
thigh fascia (Fig. 40.11B, C).
Implant Decision
This procedure employs small anatomic implants for gluteal
augmentation, as well as bigger implants for larger patients
who want a better contour of the gluteal region. Gluteal
contour is gained by insetting anatomic implants on top of
the gluteal maximus muscle and under the gluteal aponeu­
rosis. The anatomic decision making system designed for
this operation consists of templates (Fig. 40.12A) for the
preoperative skin markings, sizers for transoperative
measurement (Fig. 40.12B), and gel-filled implants (Fig.
40.12C). Further explanation of decision making for indi­
vidualized implant selection will be elaborated in the tech­
nique portion of this chapter.
FIG 40.2D, E APPEARS ONLINE ONLY
Implant Characteristics
Implants have a textured surface with the maximum soft­
ness available; these implants are highly cohesive gel–filled
FIG. 40.12  Implant decision.
A
B
C
implants with texturized surfaces and/or a polyurethane
cover. It has been demonstrated that polyurethane can
lower the incidence of capsular contracture in breast
augmentation and currently we have an ongoing study to
demonstrate its benefits in gluteal augmentation.
New designs of gluteal implants have been launched
onto the market recently. The design recommended can
vary depending on the desires of the patient and their
anatomy but the most important factor to keep in mind
when deciding on a type of implant is making sure that the
transverse length of the buttocks is not increased, that is
why a narrow base with adequate projection is desired
(Fig. 40.12D, E; De la Peña Design implants on the left
with a polyurethane cover).
Incision
The skin incision has changed over the years. At the begin­
ning a midline incision was used over the sacrum all the
way to the coccyx as described by Robles and colleagues
in 1984. This was followed by de-epithelializing an ellipse
of skin to maintain the skin and fat of the midline and
perform the subcutaneous undermining independently.

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Chapter | 40  Buttock implants
FIG. 40.12  Implant decision.
D
E

421
Chapter | 40  Buttock implants
FIG. 40.13  The paramedial incisions are 4 to 6 cm in length and
2 cm apart.
Despite this modification the incidence of small wound
dehiscence remained high. With the use of two separate
incisions the rate dropped to 4%.
Using two incisions provides a better anatomic preser­
vation of the crease, isolates the pocket if a complication
in the other side should occur and has a lower incidence of
dehiscence and hypertrophic scarring because of lesser
tension in the scar.
The paramedial incisions are 4 to 6 cm in length and
2 cm apart (Fig. 40.13), each beveled in an oblique fashion
from the skin edge down to the gluteal aponeurosis at the
lateral border of the sacrum. The subcutaneous tissue at the
midline is left intact.
PREOPERATIVE PREPARATION
Patients are instructed to consume a low-fiber diet 3 days
in advance of the procedure and to suspend any aspirin,
vitamin E, or other medications that promote bleeding
during surgery. Patients are admitted to the hospital the
night before the operation and skin markings are performed.
Patients are given an enema and started on an antibiotic.
Knowing in advance the exact measurements of the
implant pocket, as well as the patient’s expectations for
augmentation, it is easy to determine the implant size. In the
anatomic system designed for this operation, the implant’s
base diameter becomes larger with very little increase in
projection and volume, making the decision easier.
Markings
With the patient in the upright position, skin markings are
made using a custom-designed template. The template must
fit perfectly into the gluteal region leaving 2 cm above
the infragluteal sulcus and 2 cm lateral to the external
rim of the sacral bone (Fig. 40.14). The sacral triangle
must be preserved; it is an esthetic landmark of this region.
The implant should never be placed on top of the sacral
bone.
Laterally the template will extend to the external border
of the gluteal region, leaving at least 2 cm from the external
line (Fig. 40.16A); this is the line that continues up from
the iliotibial line of the thigh. Liposculpture lines are drawn
at the same time when indicated (Fig. 40.15B).
Some of the same principles used in breast surgery can
be applied to the gluteal region. When evaluating a gluteal
augmentation candidate it is important to take into consid­
eration the following aspects:
1. Skin quality of the lower back, gluteal region and flanks.
2. Length or cephalocaudal distance of the buttocks.
3. Presence and grade of ptosis.
If redundant skin exists in the lower back and gluteal
area due to excess laxity of the skin or important weight
loss, introducing a gluteal implant will improve the volume
of the buttocks but it will not correct any drooping, sagging,
or ptosis of this area. This is the same phenomenon seen
with the breast; it will continue to be a ptotic buttock, only
bigger in volume.
For the correction of this problem, resection of the
excess skin is necessary, reposition of the anatomical struc­
tures and the restoration of the volume and projection
desired.
Proposed Classification for
Gluteal Ptosis (Fig. 40.15C)
No ptosis: The infragluteal fold entails only the middle
third of the posterior aspect of the transition area from
the buttocks to the leg.
2 cm above
gluteal fold
Greater
trochanter
Lateral limit of sacrum
Posterior
superior
iliac spine
Sacrum
FIG. 40.14  Markings.

422
PART | 6  Thigh, buttock and lower extremity contouring
Skin incision
Template sized,
positioned,
and outlined
A
B
C
D
FIG. 40.15  Degrees of ptosis.

423
Chapter | 40  Buttock implants
E
Skin
incisions
Scar position
Dividing half line
F
FIG. 40.15  Continued
Grade I: Evident laxity of the skin with the infragluteal
fold extending more than one third of the posterior
aspect of the transition area from the buttocks to the leg.
Grade II: Lax gluteal tissue at the level of the infraglu­
teal fold.
Grade III: Gluteal tissue beneath the infragluteal fold.
Skin markings in patients with ptosis is different (Fig.
40.15D–F) because there is an excision of skin in the upper
part of the buttock and lower part of the back from where
the surgery is carried out, but the subfascial plane is created
in the same manner when compared with gluteal augmenta­
tion only.1-4
LIPOSCULPTING AND GLUTEAL IMPLANTS
The most frequent procedure done simultaneously with
gluteal implants is liposculpture of the gluteal area includ­
ing the lower back, posterior thighs, and lateral thighs.
By combining these procedures, the results of gluteal aug­
mentation are positively enhanced. Ultrasound-assisted
liposculpture is preferred because it results in fewer hema­
tomas and less ecchymosis and blood loss than with
standard suction-assisted liposuction. During the proce­
dure, care must be taken not to connect the liposuction
area with the implant pocket; this will decrease the possi­
bility of drainage from the liposuction space into the
implant pocket.
Liposuction of the lower back enhances the gentle curve
produced by the implants in the upper part of the buttocks.
In very thin patients, another procedure performed simul­
taneously is insertion of calf implants to improve calf
contour and balance the volume gained in the gluteal region
with the calf.
Anesthesia
General or epidural anesthesia can be used for the proce­
dure. If epidural anesthesia is used, the catheter may be left
in place for pain control after surgery.
After the incisions are made and the subfascial space
has been reached, tumescent infiltration with a modified
Klein solution is performed (Fig. 40.16). This has two
advantages: It produces hydrodissection of the subfascial
plane, making it easier to create the pocket for the implant
and produces vasoconstriction with less bleeding, giving a
better visualization of the anatomical structures.
Patient Positioning
The patient is placed in the prone position. Special care
must be taken to cushion the face and pressure sites such
as the iliac spine and breast. The surgical procedure is done
in this prone position. After the pro­cedure, the patient is
placed in a supine position. There is no need for a prone
position during the postoperative period.
SURGICAL PROCEDURE
The procedure is outlined in Box 40.1.

424
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.16  After the incisions are made and the subfascial space has
been reached, tumescent infiltration with a modified Klein solution is
performed.
BOX 40.1  The Basic Surgical Technique
1. Skin approach in the intergluteal fold.
2. Subcutaneous undermining over the sacral region.
3. Subfascial dissection where the template area is marked.
4. Placement of the implants so that they fit loosely in the
pocket.
5. Closure of the different spaces with care to ensure that
the subfascial space is waterproof.
6. Approximating of the subcutaneous dissection over the
sacral bone.
7. Closing the incision so that the intergluteal fold is
recreated.
B
C
FIG. 40.17  Surgical technique.
Surgical Technique
The surgical incision begins at a point 3 cm above the
anus corresponding to the level of the coccyx and extends
cephalad approximately 6 cm. The incision then proceeds
laterally to the presacral fascia on the subcutaneous tissue
until the external rim of the sacral bone is reached. At this
time an incision is made parallel to the external rim of the
sacral bone on the gluteal aponeurosis and reaching the
subfascial space (Fig. 40.17A). Care is taken not to cut any
of the muscle fibers. Infiltration of Klein’s solution is done
under the aponeurosis; this facilitates identification of the
avascular plane under the fascia. The multiple septae from
the aponeurotic expansions are identified and infiltration is
done between this network (Fig. 40.17B). Because these are
aponeurotic expansions, they are not easily disrupted so
they all need to be cut to ensure hemostasis (Fig. 40.17C).
The goal is to raise a fasciocutaneous flap in the gluteal
region.
FIG 40.17A APPEARS ONLINE ONLY
Sharp dissection continues; lighted retractors and long
instruments for retraction, cutting, and coagulation are
essential to divide all aponeurotic expansions over the
muscle. Bleeding is minimal if undermining proceeds care­
fully, with simultaneous coagulation with dissection. Per­
forator vessels from the superior and inferior gluteal arteries
are identified and legated (Fig. 40.17C). To facilitate under­
mining, it is advisable to maintain the dissection from
medial to lateral and from cephalic to caudal, maintaining
a wide field of exposure extending from the initial subfas­
cial undermining (Fig. 40.18A). It is also important to
remember to restrict the undermining to the level of the skin
marking, thus preventing it from extending beyond the
infragluteal crease.
Once dissection is completed, we use implant sizers to
confirm the size of the implants to be used and to determine
if any further dissection is needed. These sizers are
developed as part of the anatomic system for gluteal
augmentation; they are white smooth-surfaced gel-filled
implants, each with the corresponding size mark and with
the “sizer legend” on top. These are not the definitive
implants; however, they are handled with the same no-touch
technique used for the final implants. It is advisable to

FIG. 40.17  Surgical technique.
A
424.e1
Chapter | 40  Buttock implants

425
Chapter | 40  Buttock implants
FIG. 40.19  These implants have a transverse line on their equator
so that they can be seen through the incision and to ensure perfect
placement and alignment.
A
B
FIG. 40.18  It is advisable to maintain the implant in saline solution
with antibiotic until the end of surgery.
maintain the implant in saline solution with antibiotic until
the end of surgery (Fig. 40.18B).
Once the final implants are selected, closed suction
drains are inserted to help maintain the adhesion of soft
tissues to the implant. The selected implants are placed.
These implants have a transverse line on their equator so
that they can be seen through the incision and to ensure
perfect placement and alignment (Fig. 40.19).
The implant must fit loosely in the pocket, and closure
of the aponeurosis must be without tension. Tissues are rear­
ranged to comfortably drape over the implant. It is advisable
to dissect both pockets before inserting any implant so
that the augmented gluteus does not interfere with the dis­
section of the contralateral pocket (Fig. 40.20A, B).
Once the implants are placed, closure of the pocket
begins by reinserting the aponeurosis under no tension; a
watertight repair is done with absorbable sutures. Superfi­
cial and deep subcutaneous fascia are closed separately on
both sides of the presacral fascia. Finally, the skin is closed
and fixed to the presacral fascia to reconstruct the interglu­
teal crease. Tissue glue can be used to maintain the incision
closed and dry. At this point any adjunctive procedures are
begun.
OPTIMIZING OUTCOMES
See Box 40.2.
ADJUNCTIVE PROCEDURES
The most frequent procedure done simultaneously with
gluteal implants is liposculpture of the gluteal area includ­
ing the lower back, posterior thighs, and lateral thighs. By
combining these procedures, the results of gluteal aug­
mentation are positively enhanced. We prefer ultrasound-
assisted liposculpture because it results in fewer hematomas
and less ecchymosis and blood loss than with standard
suction-assisted liposuction. During the procedure, care
must be taken not to connect the liposuction space with
the implant pocket, thereby diminishing the possibility
that the liposuction space will drain into the implant
pocket.
Liposuction of the lower back enhances the gentle curve
produced by the implants in the upper part of the buttocks.

426
PART | 6  Thigh, buttock and lower extremity contouring
In very thin patients, another procedure performed simul­
taneously is insertion of calf implants to improve calf
contour and balance the volume gained in the gluteal region
with the calf.
Fat Grafting
Because of the added volume and contour that the
implants provide it is not usually necessary to perform
fat grafting to the buttock area. We recommend this
procedure only for subcutaneous depressions that may
have been present before the procedure and only in small
amounts. Grafting large amounts of fat can lead to fat
necrosis and infection that can compromise the entire
operation.
POSTOPERATIVE CARE
Patients are taken to the recovery room in a supine position,
with a comfortable pillow above and below the buttocks;
they are instructed to start moving their legs and feet
as soon as possible. A compression garment is worn for
1 month after the operation, and sitting will be restricted to
when going to the bathroom.
BOX 40.2  Optimizing Outcomes
For optimal results apply the following steps:
●
Skin approach in the intergluteal fold.
●
Subcutaneous undermining over the sacral region.
●
Subfascial dissection where the template area is
marked.
●
Placement of the implants so that they fit loosely in the
pocket.
●
Closure of the different spaces with care to ensure that
the subfascial space is waterproof.
●
Approximating of the subcutaneous dissection over the
sacral bone.
●
Closing the incision so that the intergluteal fold is
recreated.
On the first day after the procedure, patients are
instructed to stay in bed with the compression garment on
and move their legs and feet. Patients can lie on their side
or in a prone or supine position but ambulation will not be
allowed until the next day. For the next 2 weeks, patients
are able to stand, lie in bed, or crouch on their knees;
however, sitting is restricted to when going to the bathroom.
Drains usually are left in place for 7 to 10 days and removed
once the drainage is less than 30 ml per day. Antibiotic
ointment is applied at the site of entry of the drains. The
wound does not require any special treatment. However,
during the first office visit the surgeon may apply more
tissue glue to help maintain a watertight wound.
Once the surgical incisions are mature and strong
enough the patient can renew sitting for limited amounts of
time (no more than 2 hours at a time), and once 30 days
have passed normal activity can begin.
Recovery
Subfascial implant gluteal augmentation should not be a
painful procedure; if a patient complains of severe pain
careful evaluation of the area should be performed and
especially to check for a hematoma formation, which would
need a surgical drainage procedure.
Normal activity resumes at 2 weeks. Driving and exer­
cise as well as steam baths are to be avoided. A gentle
Jacuzzi bath or shower is preferred for the first 3 weeks.
Exercise can be started again at 2 months to prevent the
wound incision from expanding; it is advisable to take good
care of the scar for the next 3 months.
Patient compliance is one of the most important parts
of this procedure. This is why explaining the recovery
time and process is imperative. If one predicts that the
patient will not adhere to the surgeons instructions it is
better to postpone the procedure for another time or
completely.
OUTCOMES AND RESULTS
Case # 1: 30-year-old female patient wanting improvement
in the size, volume and projection of the gluteal area. Note
that there is no ptotic tissue and skin elasticity is ideal (Fig.
40.21A–C). De la Peña Design implants (250 cm3 gel-
filled) with a polyurethane cover were placed in a subfascial
plane (Fig. 40.22A–C).
Case # 2: 32-year-old female patient seeking improve­
ment in gluteal volume and projection (Fig. 40.23A–C).
Note the lack of projection with scarce gluteal fat. De la
Peña Design gluteal implants (300 cm3 gel-filled) were
placed in a subfascial plane (Fig. 40.24A–C).
FIG 40.25–40.35 APPEARS ONLINE ONLY
FIG. 40.20  It is advisable to dissect both pockets before inserting
any implant so that the augmented gluteus does not interfere with the
dissection of the contralateral pocket.

426.e1
Chapter | 40  Buttock implants
Case # 3: 35-year-old female patient with lower back
lipodystrophy and lack of projection and definition of the
buttock area (Fig. 40.25A–C). De la Peña design implants
(300 cm3 gel-filled) were placed in a subfascial plane (Fig.
40.26A–C).
Case #4: 42-year-old female patient unsatisfied with the
size of her previous implants placed 2 years before (Fig.
40.27A–D). She is seeking to increase the volume of the
implants and better her general contour and shape when
undressed and fully clothed. Two hundred and twenty-five
cm3 implants were removed and 375 cm3 gel-filled, De la
Peña design implants were placed in the same plane as
before (subfascial) (Fig. 40.28A–D).
Case # 5: 19-year-old patient with the desire to augment
her buttock area, gaining projection and contour to the area
(Fig. 40.29A–D). A 225 cm3 gel-filled, De la Peña design
implant was placed in a subfascial plane (Fig. 40.30A–C).
Case # 6: 46-year-old patient with ptotic buttocks and
redundant skin (Fig. 40.31A–D). A gluteal lift was per­
formed with placement of a 330 cm3 gel-filled, De la Peña
design implant in the subfascial plane. Note the rippling on
the excess gluteal skin and upper pole depression bilaterally
(Fig. 40.32A–C).
COMPLICATIONS AND
THEIR MANAGEMENT
A large number of patients have been operated on with this
technique. The incidence of infection for the cosmetic pro­
cedures is 1%, and this required temporary removal of the
implant.
Seromas and hematomas are prevented by using meticu­
lous technique, but if they do occur (Fig. 40.33A–C), they
must be evacuated (Fig. 40.34A–C). Diagnosis is usually
performed with ultrasound. The incidence of hematoma in
our series is 1.3% of cases and seroma in 2% of cases.
Herniation of the implant can result from poor technique
during the aponeurosis closure or from excessive tension.
If herniation of the implant is observed, surgical
re-approximation of the fascia should be performed as soon
as possible.
Sensation to the gluteal region is lost during the first 6
weeks, and recovery of normal sensitivity may take up to
4 months. Patients must be fully informed about this sensory
loss to prevent possible burns or puncture wounds in the
region during this time because with the loss of sensitivity
these may go unnoticed by the patient.
The scar may be noticeable if it is detached from the
presacral fascia or if wound dehiscence occurs during the
healing process. Patient satisfaction is excellent. Patients
have cited the following positive changes: visually improved
appearance in clothing, enhanced self-esteem, and improved
physical appearance beyond expectations.
Many unscrupulous people have tried to enhance the
buttock area with different types of injectable substances
such as motor oil, paraffin, baby oil, methylmethacrylate
etc., causing serious damage to the tissue in this area and
to the overall health of these victims.
Some examples are shown (Fig. 40.35A–C) to illustrate
the damage some of these materials can do.

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PART | 6  Thigh, buttock and lower extremity contouring
C
A
B
FIG. 40.25  Preoperative photographs.

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Chapter | 40  Buttock implants
A
B
C
FIG. 40.26  Postoperative photographs were taken 6 weeks after
surgery.

426.e4
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.27  Preoperative photographs.
A
B
C
D

426.e5
Chapter | 40  Buttock implants
A
B
C
D
FIG. 40.28  Postoperative pictures taken 3 months after surgery.

426.e6
PART | 6  Thigh, buttock and lower extremity contouring
A
B
C
FIG. 40.29  Preoperative photographs
D
E
F

426.e7
Chapter | 40  Buttock implants
FIG. 40.30  Postoperative pictures taken 3 months after surgery.
A
B
C
D
Continued

426.e8
PART | 6  Thigh, buttock and lower extremity contouring
E
FIG. 40.30  Continued

426.e9
Chapter | 40  Buttock implants
FIG. 40.31  Preoperative pictures.
A
B
C

426.e10
PART | 6  Thigh, buttock and lower extremity contouring
A
B
FIG. 40.32  Postoperative pictures taken 2 months after surgery.
C

426.e11
Chapter | 40  Buttock implants
FIG. 40.33  The incidence of hematoma and seroma.
A
B
C

426.e12
PART | 6  Thigh, buttock and lower extremity contouring
A
B
FIG. 40.34  Same patient as in Fig. 40.33 after seroma drainage.
C

426.e13
Chapter | 40  Buttock implants
A
B
FIG. 40.35  Some examples to illustrate the damage some injectable substances such as motor oil, paraffin, baby oil, methylmethacrylate, etc.,
can do.
Continued

426.e14
PART | 6  Thigh, buttock and lower extremity contouring
C
D
E
FIG. 40.35  Continued

427
Chapter | 40  Buttock implants
A
B
C
D
FIG. 40.21  Preoperative photographs.

428
PART | 6  Thigh, buttock and lower extremity contouring
A
B
C
FIG. 40.22  Postoperative photographs 3 months after surgery.

429
Chapter | 40  Buttock implants
A
B
C
FIG. 40.23  Preoperative photographs.

430
PART | 6  Thigh, buttock and lower extremity contouring
A
B
C
FIG.
40.24  Postoperative photos taken 6 weeks after the
procedure.
REFERENCES
1. González-Ulloa M. Gluteoplasty: A ten-year report. Aesth Plast Surg
1991;15:85–91.
2. Baroudi R. Body sculpturing. Clin Plast Surg 1984;11:419–43.
3. Roberts TL, de la Peña JA, Cardenas JC, et al. Cosmetic surgery of
the buttocks region. Aesth Surg J 2003;23:381–7.
4. de la Peña JA. Subfascial technique for gluteal augmentation. Aesth
Surg J 2004;24:265–73.
FURTHER READING
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.
Buchuck L. Complication with gluteal prosthesis. Plast Reconstr Surg
1986;77:1012.
Cocke WM, Ricketson G. Gluteal augmentation. Plast Reconstr Surg
1973;52:93.

431
Chapter | 40  Buttock implants
de la Peña JA. Advances in gluteal augmentation. Presented at the Twelfth
Congress of the Ibero-Latin American Federation of Plastic Surgery
(FILACP). Santo Domingo, Dominican Republic, October 1998.
de la Peña JA. Gluteal augmentation. Presented at the Thirteenth Biennial
Congress of the International Society of Aesthetic Plastic Surgery,
New York, September 1995.
de la Peña JA. Gluteal augmentation: An operation for plastic surgeons.
Presented at the Annual Meeting of the American Society of Plastic
Surgery and ASPSEF Hot Topics in Plastic Surgery, San Antonio,
2002.
de la Peña JA. Gluteal, leg and calf contour with implants. Presented at
the Moscow National Russian Congress in Plastic and Reconstructive
Surgery, Moscow, Russia, February 2002.
de la Peña JA. Subfascial gluteal augmentation. Presented at the Four­
teenth Congress of the International Society of Aesthetic Plastic
Surgery, São Paolo, Brazil, June 1997.
de la Peña JA. Subfascial gluteal augmentation. Presented at the Sixteenth
National Venezuelan Congress of Plastic and Reconstructive Surgery,
Caracas, Venezuela, March 2000.
de la Peña JA, Lopez MH, Gamboa LF. Augmentation gluteoplasty: Ana­
tomical and clinical considerations. Key issues. Plast Cosmetic Surg
2000;17:1–12.
Ford RD, Simpson WD. Massive extravasation of traumatically ruptured
buttock silicone prosthesis. Ann Plast Surg 1992;29:186–8.
Hsiao CW. Buttock augmentation with silicone prosthesis: A case report.
Changgeng Yi Xue Za Zhi 1994;17:90–3.
González-Ulloa M. A review of the present status of the correction for sad
buttocks. Presented at the Fourth Congress of the International Society
of Aesthetic Plastic Surgery, Mexico City, Mexico, 1977.
International Advances in Aesthetic Surgery. Congress of the American
Society of Aesthetic Surgery, Las Vegas, April 2002.
Lewis JR. Body contouring. South Med J 1980;73:1006–11.
Robles JM, Tagliapietra JC, Grandi MA. Gluteoplastia de aumento:
implante submuscular. Cirplast Ibero Latinoam 1984;10:365–9.
Warwick R, Williams P, editors. Gray’s Anatomy. 35th ed. London:
Churchill-Livingstone; 1973.
B.  INTRAMUSCULAR BUTTOCKS
IMPLANTS: THE “XYZ” METHOD
Raul Gonzalez
Key Points
●
Intramuscular implant techniques are described.
●
Gluteal augmentation is a good method to achieve
buttocks remodeling.
●
The technique of buttocks implants is described.
●
Complications and postoperative care are described.
Gluteal implants are a good way to achieve buttocks remod­
eling. The implant enhances the volume and achieves the
desired round shape through a concentrated projection
that no other methods are capable of providing. However,
complications can be frequent when not using proper
methods. The main problems to avoid in gluteal implant
surgery are seroma, dehiscence, extrusion, and a visible or
palpable implant. Perceptible breast implants are accept­
able, but perceptible buttocks implants are very embarrass­
ing to patients.
Nevertheless, it is important to remark that complica­
tions occur in a different fashion and at very different rates
on each anatomical plane: subfascial, subcutaneous, sub­
muscular and intramuscular.
THE PROBLEMS OF SUPERFICIAL PLANES:
SUBCUTANEOUS AND SUBFASCIAL
Superficial planes such as the subcutaneous and subfascial
may lead to perceptible implants even if the technique is
well performed. Implant visibility with those planes can be
immediate or appear after 2 or 3 years, due to loosening of
the fascia and subcutaneous tissue at the implant site. In
some cases the implant is not visible when the patient is
resting, but when the patient contracts the gluteal muscle
the implant becomes visible because the muscular motion
is not followed by the implant. Moreover, seromas, extru­
sion displacement and asymmetry are more frequent in
superficial planes.
THE ADVANTAGES OF THE
INTRAMUSCULAR PLANE
Compared with the other planes in performing gluteal
implants, the intramuscular one has many advantages, but
the most important is that it is less likely to present percep­
tible implant problems and complications of any kind. The
muscle cover provided at this plane is enough to hide the
implant, when well performed.
At the submuscular plane, between the gluteus maximus
and medium, because of the local anatomy’s relationship
with the sciatic nerve, the caudal undermining should not
go beyond the lower edge of the pyramidal muscle, which
restricts the implant pocket at the upper part of the buttocks,
giving an impression of double buttocks, especially in
patients who have long buttocks.
However, the intramuscular plane must satisfy certain
principles to prevent asymmetry, muscle damage or a
visible implant.
SURGICAL TECHNIQUE
Skin Marks: The Line A and the Heart
Inverted Mark
We make just one skin mark with the patient standing, a
line (line “A”) that shows the top of the intergluteal crease
and which prevents the incision from becoming visible
(Fig. 40.36). Any other skin mark to indicate the implant

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Chapter | 40  Buttock implants
PRINCIPLES FOR INTRAMUSCULAR
UNDERMINING
The Muscle Bipartition
The gluteus maximus muscle (GM) can be partially bisected
to accommodate an implant without having its function
altered. However, in order to preserve muscular function
and to obtain good esthetic results, the undermining must
split the muscle in half, leaving the same amount of muscle
in front of and behind the implant.
Undermining too deeply, too superficially, or deeply at
one point and superficially at another, may lead to muscle
damage where the muscle is left thinner. If the muscle is
too thin it may become atrophied and the implant may be
visible and palpable. If the detachment is superficial or if it
partially externalizes the implant, the implant may be
visible and palpable.
Too much deep dissection can pass through the anterior
muscle fascia and reach the gluteus medium muscle.
This muscle is not multi-innervated like the GM. It is com­
posed of three separate parts and each one has its own
nerve, which enters on the muscle posteriorly. An eventual
bipartition of this muscle can definitively damage the
anterior part of the dissected muscle because of lack of
innervation.
As stated above, it is tremendously important to divide
the muscle into two equal parts in order to maintain mus­
cular function, avoid muscle atrophy and implant visibility;
this is something that can occur some months after the
surgery.
The Sandwich Plane: The Ideal
Intramuscular Plane
I have been calling the intramuscular plane (which splits
the muscle in two equal parts, and is made following the
principles above) the “ideal plane”, or the “sandwich
plane”, because it involves the implant as if in a sandwich.
When performed properly the results are natural, with no
visible or perceptible implants.
However, while one is detaching there is no way of
assessing the depth because the dissection is done blindly,
and there is no anatomical undermining plane to be
followed.
All those drawbacks may be overcome when the surgeon
is able to intraoperatively identify the muscle’s limits and
the exact midpoint of its width in order to bisect it. This is
the major feature of the XYZ technique: to provide key-
points to enable muscle bisection at the ideal “sandwich”
plane.

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PART | 6  Thigh, buttock and lower extremity contouring
position is absolutely useless because when lying on the
OR table all marks change position.
With the patient in the OR, in prone position, starting
at line “A”, a spindle-shaped 7 or 8 cm long double line is
demarcated on the intergluteal crease, measuring 3 or
4 mm at its broadest dimension. Following this sketch, a
strip of skin is obtained, preserving on its base the sacro­
cutaneous ligament, which I described in 1992,1 an ana­
tomic structure which forms the intergluteal crease and
will serve to close the incision. At each side of this skin
strip, a 7 cm long hemiellipse shape is drawn, in the direc­
tion of the muscle fibers. This sketch, shaped like an
inverted heart, will guide the suprafascial detachment to
expose the muscle (Fig. 40.37). The subcutaneous tissue
under it is infiltrated with an epinephrine solution to
provide hemostatic effect.
The incision follows the outline of the small skin strip.
After cutting the skin, the subcutaneous is dissected at 45°
until the muscle and fascia are found, and the dissection
advances over the fascia through the whole inverted heart
mark. Muscle and fascia are opened with the knife, along
the muscle fibers from the sacrum border up to the bottom
of the detached area, the incision measuring about 6 cm
(Fig. 40.38). Through this incision, a cleft is created by the
index finger. Once the muscle is opened, it is time to define
its half-width at this site in order to bisect the muscle pursu­
ant to the principles above. For this purpose we will be
guided by a line at two points.
Dissecting the Sandwich Plane Guided by
the A Line and Three Points
As the dissection has to be entirely inside the GM muscle
an intraoperative skin mark to indicate the limit of the
muscle has to be marked; it is a line called “line G”.
FIG. 40.36  The top of the intergluteal crease is marked with a line
(line “A”) with the patient standing to ensure that the incision is made
totally within the intergluteal cleft.
FIG. 40.37  With the patient lying down we make the marks that will
guide the muscle approach. Starting at line “A”, a 3–4 mm wide and
7 cm long spindle-shaped strip is drawn over the intergluteal cleft to guide
the skin incision, preserving the sacrocutaneous ligament. From this line
we draw an “inverted heart”, whose ends are 7 cm away from the crease,
to guide the detachment for muscle exposure. The fascial–muscular inci­
sion is made within this detachment area, following the direction of the
muscle fibers.
FIG. 40.38  The incision follows the outline of the small skin strip
shown on Fig. 40.36. After cutting the skin, the subcutaneous is dissected
at 45° until the muscle and fascia are found, and the dissection advances
over the fascia through the whole inverted heart mark. The fascia is cut
from the bottom of the detached area up to quite close to the sacrum, the
knife goes deep half the length of the blade.

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Chapter | 40  Buttock implants
FIG. 40.39  Line G, which shows the lateral limit of the muscle, is
drawn from a point on the iliac crest, at 4 cm of the upper-posterior
iliac spine up to the lateral-posterior aspect of the trochanter. This line
should be marked in the OR, having the patient in the prone position and
ready for surgery.
GM Lateral Limits, Line G
To find the lateral limit at the cephalic portion of the muscle
we palpate the superior-posterior iliac spine and we
mark a point at a 4 cm distance on the iliac crest. As the
trochanter’s anterolateral aspect indicates the lateral limit
on the caudal portion, we may draw a line to identify the
muscle’s lateral limit, joining the point at the iliac crest and
the trochanter; I call this line G (Fig. 40.39).
The “X” And “Y” Points and Intraoperative
Identification of the GM Muscle’s Thickness
To bisect the muscle on the sandwich plane one must iden­
tify, intraoperatively, the midpoint of the muscle thickness
on at least two points; with these two points the surgeon is
able to make a line inside the muscle, and with this line
make a plane. The two points must be located over the
sandwich plane. To be more practical, the first point is
medial, inside the muscular incision (called point ”X”) and
the other is lateral (called point “Y’), near the iliac crest
and the lateral limit of the muscle. Furthermore, an addi­
tional line, indicating the lateral limit of the muscle, is also
part of this method.
Point X – the Medial Point
Close to the sacrum the muscle thickness varies between
4 and 7 cm. To check the thickness, all one has to do is
introduce the index finger in a caudal direction through
the muscle cleft made as above, pressing deeply until
one feels the sacral tuberous ligament, easily identified
because it feels like a human finger on touch. Since this
ligament is the anterior limit of the muscle, the distance
between the muscle’s posterior surface and the ligament
indicates the muscle thickness at this spot (Fig. 40.40).
To calculate the midpoint of the thickness (location of
point X) the thickness found is divided by two, but in prac­
tice the smallest thickness to be left as muscle cover is
2.5 cm.
Point “Y” – the Lateral Point
On the lateral part of the GM muscle the area close to the
iliac crest is a good place to identify the muscular mid
thickness because we can use the crest as a guide. At this
spot the GM is about 2 cm thick; half of the muscle
adheres to the iliac crest and the other half to the iliac
bone. The point where the crest joins the bone is the mid­
point of muscle thickness. The iliac crest in this area is
more or less 1 cm thick, and coincidentally the muscle is
2 cm thick, so the mid thickness of the muscle is 1 cm,
the same as the crest. If the tip of the indicator finger
touches an exposed sandwich plane it will be parallel to
the iliac crest, and at the same time touching the lower
surface of the crest (Fig. 40.41A). In practice, to find the
point Y, that is, the muscular mid thickness, the iliac crest
is first palpated over line “G”, and then the finger slid
downwards pressing the muscle until it is felt that the
finger is parallel to the iliac crest, and the tip of the finger
is 1 cm below the crest surface. At this time, the fingertip
will be very close to the point where the iliac crest joins
the iliac bone, that is, the midpoint thickness of the muscle
FIG. 40.40  With the tip of the index finger, a 2.5 to 3 cm deep cleft
is made, depending on the muscle thickness. Pressing the finger cau­
dally, the sacro-tuberal ligament can be palpated, indicating the
muscle thickness. Point “X” should be placed at the midpoint of the
muscle thickness found, and always at least 2.5 cm deep.

434
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.41  A diagram showing the sandwich plane close to line “G”,
where the posterior mid half of the muscle was removed with subcu­
taneous and skin. The finger is touching the plane’s surface (A). (B) The
finger is now trying to touch the plane through the skin and subcutaneous,
pressing both strongly; the finger is parallel to the the lower surface of the
crest, as on (A).
(Fig. 40.41B). To illustrate this maneuver diagram shows
the finger indicating point Y.
The Muscular Bisection Maneuver
The first step is done with a detacher that is a 35 × 2 cm
straight steel blade, which runs cephalad from point “X” to
point “Y”. The bisection is a bimanual procedure, using
one hand to drive the underminer and the fingers of the
other indicating point “Y” to guide the way. The first
centimeters, before introducing the detacher, are detached
by the index finger. The detacher must be pushed firmly
towards point “Y”, progressing in very short thrusts
forward and backwards, breaking the septa that divide the
muscle in fascicles. Each thrust needs to be strong and firm
because the septa are quite hard and resistant. Circular-tip
instruments or large spatulas are inadequate to break the
septa. The detacher is kept slanted against the sacral
bone, which provides a better guide to this movement
(Fig. 40.42).
Creating A Triangular Plane
In the second step, after the initial bisection of the muscle,
propping up the detacher on the muscle incision fibers we
rotate it, as a lever, towards the trochanter. The muscle
fibers guide the detacher, always at the mid-thickness of the
muscle, and offer little resistance as it passes towards the
trochanter (Fig. 40.43). The last stop of the rotation, close
to the trochanter, is called point “Z”, the third point on the
ideal bisection plane, after which the technique is called
“XYZ”. This rotation produces a primary triangular detach­
ment, points “X, Y and Z” being on the triangle’s vertices.
Before withdrawing the detacher, a long, slightly curved
12 or 13 cm retractor is placed in the detached area and
directed towards point “Y” and a smaller one is directed
more caudally to provide a view of the detachment. Muscle
septa and remaining fibers close to the sacrum which were
not torn by the rotation maneuver must be broken with the
index finger first and after wards with a larger detacher.
Adjusting the Pocket According to the
Implant Size and Shape
Always following in the direction of the fibers of the
bisected muscle, the detachment is enlarged at its caudal
and lateral portions with an instrument which I devised and
called “duck bill” or Gonzalez detacher (ASSI Instruments,
FIG. 40.42  The step between points “X” (identified in Fig. 40.40),
and “Y” (identified in Fig. 40.41), bisects the muscle at the middle of
its thickness. The maneuver should be done with both hands: one guiding
the detacher (a straight 30 × 2 cm steel blade), the other indicating point
“Y” with the fingertips firmly pressing on line “G”. The detacher pro­
gresses, first against the sacral and then the iliac bone. The detacher
advances into the muscle thickness, beginning at point “X” and always
guided by the fingertips that indicate point “Y”.

435
Chapter | 40  Buttock implants
USA).2,3 Its rhombic blades (shaped like a duck’s bill) open
when the grip is pressed. With rapid and repeated push-
and-open movements the pocket is enlarged (Fig 40.44).
Remaining septa must be broken with a flat 4 × 30 cm
detacher, similar to the one formerly used on the line “X-
Y”, but wider. The pocket must be enlarged according to
the size and shape of the chosen implant and should enable
FIG. 40.43  Once the detacher has reached point “Y”, the surgeon
makes a circular motion with the detacher, leaning it on the muscle
fibers of the incision and rotating until it gets close to the trochanter.
This last point reached by the rotation is called point “Z”, the third
point of the triangle formed by the detacher’s path.
comfortable placement of the implant, but never be too
large (Fig. 40.45).
IMPLANT CHOICE
Gluteal implants may be either round or oval, and may be
filled with highly cohesive silicone (Silimed, Brasil; Sebbin,
France) or made of soft silicone blocks, very smooth to the
touch (several producers in the USA).
Round implants should be left for patients who are not
tall and have short buttocks, since in those with long but­
tocks their projection may be too concentrated at the upper
and medial poles without proper filling of the lower part of
the buttocks (Fig. 40.46).
Oval implants, also called anatomic, should be used in
the vertical position, very close to the sacrum, with the
larger part at the top in order to fill the upper pole more
adequately. The “Quartzo” model oval implant (Silimed)
has proven to be an excellent choice due to its multiple
indications. Elastomere implants available in the USA can
be a little bit harder than the gel-filled implants, but some
FIG. 40.44  The Gonzalez detacher, shaped like a duck’s bill with
curved branches, is used to complete the first triangular detachment
(in yellow) to suit the implant’s size and model; it works like an old
hair cutting machine: opening and closing as it advances forward,
detaching becomes relatively easy.
FIG. 40.45  With the duck- bill underminer we complete the pocket
caudally, according to the size and shape of the implant to be used.
During the detachment several interfascicular septa can disturb the
procedure; they have to be broken with a strong blade in order to
obtain proper pocket undermining.

435.e1
Chapter | 40  Buttock implants
The most common late ones are muscular atrophy, when
the undermining is not well guided and leaves a thin mus­
cular covering, and implant rotation due to late pocket
enlargement, and both may lead to visible implants. No late
seroma or capsular contracture was observed when using
smooth or microtextured “Quartzo” implants (textured
implants have high incidence of late seroma).
In 1127 cases performed between 1986 and 2010 the
dehiscence rates dropped from 14% in the general rate to
less than 10% in the last 500 cases, most of them minor
problems and none of those last cases required a new pro­
cedure to close the incision, except those which progressed
to infection. Of the 11 cases of infection (1.051%), eight
resolved just by cleaning the site and removing debris,
under general anesthesia, and resterilizing the implant or
changing it for a new one; after careful resuture of all planes
an aspirative drain is left in the intramuscular pocket for 72
hours, providing antibiogram-guided antibiotic therapy.
We found no changes of muscle function or measurable
muscle atrophy in many patients controlled with MRI and
CT scan; neither did we see any sign of muscle cell necrosis
in the muscle biopsies we performed in eight reoperated
cases, either to change or to reposition the implant.
Nevertheless, in the several secondary surgeries to
correct visible implants for patients operated elsewhere, we
noticed muscular atrophy of the posterior muscle layer
(four proven by muscle biopsy), which shows the impor­
tance of splitting the muscle in two equal layers.
Avoiding Complications
When I started to perform gluteal implants 23 years ago, I
had a quite high complication rate. The rate dropped as I
found solutions and knacks to tackle each problem. The
technique presented here, which I had described previ­
ously2,3 is the result of all the solutions found. Each detail
shown can help avoid astonishing complication rates that
vary between 30 and 80%, as reported in articles on the
topic,4 leading to acceptable levels, similar to most esthetic
surgeries.
Many of the details pertaining to this technique can
explain the drop in complication rates, as follows:
Seroma
Seromas and everted edges causing micronecrosis are the
major causes of wound dehiscence. A seroma may come
either from the dissected intramuscular pocket or from
suprafascial detachment performed to expose the muscle
before opening it, at the inverted heart area (sometimes
from liposuction on neighboring areas). If the suprafascial
area is healing well, it is unlikely that the seroma coming
from the intramuscular pocket will reach the skin incision,
Drainage
Drainage tubes placed inside the muscle pocket from a
point adjacent to the lower part of the incision are left for
48 hours.
Closing the Incisions
A large needle thread such as Nylon 2-0 is used to close the
muscular incision edges. The inverted heart detachment
surfaces, including that close to the flap left to preserve the
sacral-cutaneous ligament, are brought together with 2-0
Vicryl quilt sutures (Baroudi sutures), avoiding dead spaces
at all costs. The epidermis on this ligament is stripped and
sutures are made taking the ligament and subcutaneous and
deep derma of both sides of the incision, at 1 centimeter
intervals, providing adequate closure. A few 4-0 Vicryl
sutures close the deep dermal plane, ending with a continu­
ous 6-0 suture. The final sutures must not evert the surgical
wound’s edges, since this leads to micro-necrosis of the
edges and dehiscence.
POSTOPERATIVE CARE
It is essential to maintain the epidural analgesia catheter,
because the major inconvenience of this surgery is no doubt
the severe pain that may appear on the first few postopera­
tive days. Pain-pumps have been tried, but did not achieve
a good result. On the first postoperative day the patient
should lie in the prone position supported by special hex­
agonal, 10-cm high, very firm pillows, placed in Fowler’s
position (the ventral decubitus position is avoided, in order
to prevent fluids from the detached area flowing by gravity
to the sciatic nerve area and causing pain). When using the
special pillow, the buttocks must not touch the mattress,
remaining free of any pressure. If a pillow with these fea­
tures is not available the lateral decubitus position is
advised. The patient starts deambulating and sitting as soon
as possible and from the second day onward the lateral
decubitus position is encouraged, avoiding long periods
in the prone or ventral position. Neither girdles nor adhe­
sive tape dressings are necessary. Driving is allowed after
10 days.
COMPLICATIONS
If all the principles described herein are followed, the com­
plication rate should be low and comparable to that of any
other esthetic surgery.
The most frequent complications can be divided in two
groups: immediate – that is, those that come up within the
first 30 days postop, and the late ones.
The most common immediate complications, in order
of frequency, are: pain, dehiscence, seroma, and infection.

435.e2
PART | 6  Thigh, buttock and lower extremity contouring
but rather will be contained at the pocket without causing
any harm. However, a seroma at the suprafascial detach­
ment area can easily reach the skin and muscular incision
and cause them to break open. The extension and the
manner by which such detachment is made, as well as its
closure, are important to avoid a seroma and the subsequent
dehiscence of the wound. The inverted heart-shaped detach­
ment keeps the muscle exposure limited to that strictly
necessary; larger and unnecessary detachments can lead to
seroma formation and subsequent dehiscence. Quilt Baroudi
sutures that bring together the surfaces of the inverted heart
detachment also reduce the risk of seroma. Late seromas
are always caused by textured implants and they have to be
avoided.
Dehiscence
The de-epidermized strip of skin that preserves the sacro­
cutaneous ligament for incision closure very much improves
healing, reducing not only the incidence of dehiscence but
also the severity thereof. Any dehiscence, when this strip
of skin is used, usually opens at only one of the detached
sides and has a favorable evolution; conversely, without
the strip, both the detached sides break open and a large
dehiscence is easily formed and difficult to heal. In a large
dehiscence, the sacrocutaneous ligament prevents wide
separation of the borders and serves as a base to anchor the
two sides of the dehiscence if a new suture is required. It
is not advisable to make two incisions close to the interglu­
teal cleft in an attempt to reduce the incidence of dehiscence
because they leave visible scars of poor quality instead of
a single one, hidden in the intergluteal cleft, which leaves
a high quality scar and has extremely low rates of dehis­
cence that would require a new intervention.
Pain
Drainage has two important advantages: avoiding seroma
formation in the muscular pocket in the short term, and
better pain control. The fluids that remain in the pocket, if
not properly drained, may descend by the force of gravity
to the compartment before the GM muscle and reach the
sciatic nerve causing sciatic pain or, by remaining in the
pocket, evolve to a seroma. Avoiding the ventral decubitus
position also helps to prevent pain for the same reason.
Visible Implants
Using the intramuscular plane and having landmarks to
guide the muscular bisection in the ideal sandwich plane is
the best way to avoid visible implants. On the lateral portion
of the GM muscle there are two palpable bone references:
the trochanter and the iliac crest. Many surgeons have been
using the trochanter as guide, but the crest has many
advantages:
The “point X – trochanter” route is inadequate because
the lateral part of the muscle is hidden at the lateral aspect
of the trochanter and thus not reached by the detacher,
leading the surgeon to detach superficially or out of the
plane; also the muscle mass is convex at this path, which
makes it difficult to achieve the correct bisection.
The “point X – point Y” route bisects the muscle at the
optimal plane. The course between the two points is on the
only flat area of the buttocks (the others are convex), and
also the only course on which the whole muscle surface can
be covered. In addition, the iliac crest is the only anatomical
structure that is a good indicator of the muscle’s mid-
thickness at the lateral part of the GM; this can not be done
relying on the trochanter.
Therefore, the bisection achieved by using this path
provides both correct muscle cover for the implant and
symmetry, preventing the implant from becoming visible.

436
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.46  Woman complaining of lack of buttocks projection. (A and C) Preoperative views, (B & D) postoperative views of the same patient
18 months after surgery for buttocks reshaping using the XYZ method for intramuscular gluteal implants together with back and love-handle liposuction
and fat grafting on the ischiatic depression. A pair of elastomer semisolid soft 250 cm3 Silimed-Sientra implants of moderate projection was used.
A
B
C
D

437
Chapter | 40  Buttock implants
of the implants available are soft enough to obtain the same
good results as when using gel-filled implants.
The choice of size depends on the size of the pelvis
and the desired augmentation. Sizes range from 200 to
500 ml. When using round implants, one should opt for
smaller sizes, from 220 to 240 ml for small women and 270
to 300 ml for a medium height woman with medium sized
hips; if choosing the “Quartzo” type for medium hips, the
size could be 350 or 400 ml because they have less lateral
projection (Fig. 40.44). To use sizes bigger than these can
lead to muscular compression and consequent atrophy that
leave the implant visible. The pocket should house the
implant comfortably and allow for easy muscle closure.
We prefer to perform surgery under epidural anesthesia
using a catheter, because the catheter may be left in for 48
hours, to provide adequate analgesia with 20 ml ropiva­
caine doses at 0.2% every 6 or 8 hours. As pain might be
strong, when using general anesthesia it is advisable to
introduce the epidural catheter as soon as the surgery is
over. After the antisepsis procedure a dressing should be
sutured over the anal area to avoid contamination.
REFERENCES
1. Gonzalez R, Tornieux A. Prótese para a região glútea. In: Atualização
em Cir Plást. São Paulo; 1992; Ed. Robe Editorial: 555–70.
2. Gonzalez R. Augmentation gluteoplasty: “The XYZ method”. Aesth
Plast Surg 2004;28(6):417–25.
3. Gonzalez R. The XYZ intramuscular method. In: Buttocks Reshaping
and the Posterior Body Contour. Indexa Ed., Rio de Janeiro; 2006.
p. 109–60.
4. Bruner TW, Roberts III TL, Nguyen K. Complications of buttocks
augmentation: diagnosis, management and prevention. Clin Plast Surg
2006;33(3):449–66.
C.  GLUTEAL IMPLANTS
José H. Aboudib and Fernando G. Serra
been placed to augment the gluteal region. Bartels et al,
in 1969, were the first authors to describe gluteal recon­
struction with breast implants. During the seventies the
procedure gained increased acceptance after Cocke and
Ricketson described the placement of a silastic pancake
prosthesis for an esthetic operation and González-Ulloa
popularized and refined the technique as a cosmetic proce­
dure with a subcutaneous pocket using implants developed
specifically for the gluteal area.1–6 Since then, several tech­
niques for gluteal implantation have been proposed, differ­
ing mainly with respect to implant location. González-Ulloa4,7
described augmentation under the subcutaneous layer. De
la Peña7,8 employed a subfascial approach, Vergara and
Marcos7,9 an intramuscular approach, and Robles et al7,10 a
submuscular placement (Fig. 40.47).
Nevertheless, many plastic surgeons are reluctant to
perform gluteal augmentation with implants because of the
risk of problems and complications such as sciatic nerve
injury. To resolve these difficulties, we propose a surgical
technique based on fixed anatomic reference points that
simplifies the operation and provides predictable and highly
reproducible results while avoiding the most common
complications.
ANATOMY
The gluteus maximus muscle is the thickest muscle in the
human body, ranging from 4 to 7 cm. It originates in
the iliac crest, ileum, sacrum, coccyx, and sacrum tuberal
Key Points
●
Intramuscular pocket
●
Anatomic reference marking
●
Texturized quartz implant prothesis
●
Suture of the pockets
●
Postoperative – prone position for seven days
Subfascial
(De La Peña)
Submuscular
(Robles)
Intramuscular
(Vergara)
Subcutaneous
(Gonzalez-Ulloa)
FIG. 40.47  Different layers for implant positioning: subcutaneous
(Gonzalez-Ulloa), subfascial (De la Peña), intramuscular (Vergara),
and submuscular (Robles).
INTRODUCTION
Historically, standards of beauty have changed over time,
but the gluteal region and the breast have always been
considered as symbols of femininity. Various implants have

438
PART | 6  Thigh, buttock and lower extremity contouring
ligament, with insertions in the rough line and gluteal tuber­
osity of the femur and the iliotibial tract of the fascia lata.11–
16 The muscle acts as a powerful extensor of the thigh and
stabilizes the pelvis during movements where strength is
required, such as sitting up and running.5,12 It is vascular­
ized by two major pedicles (type III, according to Mathes
and Nahai), the upper and lower gluteus arteries (Fig.
40.48).13,14 The piriform muscle originates from the sacrum
and sacrotuberal ligament and inserts on the top edge of the
greater trochanter of the femur.12,14,15 It is highly important
because it splits the higher sciatic foramen, with the sciatic
nerve passing inferiorly (Fig. 40.49).12,15,16
Sciatic Nerve
The sciatic nerve is the largest nerve of the human body,
comprising the tibial and fibular nerve, exiting the pelvis
below the piriform muscle (Fig. 40.50). Anatomic varia­
tions are found in about 30% of cases, as when the nerve
is located above or through the piriform muscle or passage
of the fibular and tibial nerves goes separately above and
below the muscle. However, with the intramuscular tech­
nique, the nerve will always be protected by a muscular
layer, even in cases of anatomic variations.12,14,15
FIG. 40.48  Gluteus maximus muscle.
cial branch
Superfic
ranch
Deep b
or gluteal
Superio
artery
or gluteal
Superio
artery
r trochanter
Greater
ons
insertio
FIG. 40.49  Deep plane anatomy.
Anatomic Reference Point Marking
Through dissection of seven fresh and formalinized cadav­
ers (Fig. 40.50) and a review of previously published
work,4,5,7–10,13,17,18 we developed the following based on
bone reference points that could be fixed and were easily
identifiable: sacrum, coccyx, posterior inferior iliac spine,
iliac crest, and greater femoral trochanter. We have observed
that the lateral limit of the gluteus maximus can be identi­
fied by a line linking the medial third of the iliac crest and
femoral great trochanter. It can be palpated during volun­
tary contraction (Fig. 40.51). The middle third of the dis­
tance between the posterior superior iliac spine and the
coccyx corresponds to the upper and lower limits of the
piriform muscle (insertion in the femoral great trochanter).
The sciatic nerve emerges right below this muscle, at
the midline of the thigh at the coccyx level (Figs 40.51
and 40.52).
Implants
Over the years, different types of implants have been
utilized for gluteal augmentation, with either a round or
anatomic base and a smooth or textured surface, such as the
implants proposed by Hidalgo, Vergara, and De la Peña.5
We have used cohesive gel gluteal implants with either a
spherical or anatomic base (quartz model/Silimed®, Rio de

439
Chapter | 40  Buttock implants
A
B
C
D
FIG. 40.50  Cadaver dissection. (A) Subcutaneous dissection. (B) Intramuscular pocket. (C) Sciatic nerve cover. (D) Sciatic nerve dissection.
FIG. 40.51  Reference points. PSIS, posterior superior iliac spine.
Janeiro, Brazil) and with a smooth surface because of the
low risk of capsular contracture with intramuscular place­
ment (Fig. 40.53). We employed photographic analysis to
determine the implant size and type that would obtain the
best buttocks projection for each case.7,19,20
SURGICAL TECHNIQUE
The subcutaneous layer was infiltrated with 1 : 200 000 epi­
nephrine solution. A 6 cm skin incision was made, posi­
tioned within the 5 mm wide zone in the intergluteal groove.
Subcutaneous dissection was performed at 45 degrees, thus
preserving the sacral ligament and extending to the gluteus
maximum muscle aponeurosis. Above this plane, the dis­
section proceeded along muscle fibers, measuring 5 cm in
length and 2 cm wide. Through blunt dissection, an intra­
muscular placement site was opened at a depth of 2 to 3 cm
and 2 cm wider than the base of the implant, to ensure that
the implant would be fully covered by the gluteal maximus
muscle, thus avoiding injury to the sciatic nerve that is
below and protected by the muscle.
The depth of the intramuscular pocket is a critical issue
because of the risk of implant herniation and sciatic nerve
injury if the dissection is too superficial or too deep, respec­
tively. This dissection was begun cranially to avoid inad­
vertent rupture of the muscle and subsequent herniation of
the implant (Fig. 40.54).
After introducing the implant in the position most suit­
able for each individual case, such that the implant was

440
PART | 6  Thigh, buttock and lower extremity contouring
A
B
FIG. 40.52  Superimposed anatomical figures. (A) Gluteus maximus
muscle. (B) Piriform muscle and sciatic nerve.
FIG. 40.53  Gluteal implants.
A
B
C
FIG. 40.54  Surgical technique. (A) Incision. (B) Subcutaneous detach­
ment. (C) Intramuscular pocket.
covered by the gluteus maximus muscle surface (Fig.
40.55), muscle closure was performed with mononylon 2-0,
fascia included. A surgical suture was placed in the subcu­
taneous detachment, linking it to the fascia of the gluteus
maximus muscle so as to avoid seroma. The intergluteal
groove was reconstituted with a 3-0 mononylon suture
attaching the deep subcutaneous cellular layer to the sacral
ligament, followed by a subdermal suture (including the
decorticated dermis) and finally suture of the skin with 5-0
mononylon (Fig. 40.56).
POSTOPERATIVE CARE
Patients are advised to rest in the prone position for 7 days
postoperatively just because it is more comfortable;
however, they are allowed to sit and take the supine position
after the first postoperative day. The dressing is changed
daily and a girdle is kept in place for 1 month just in case
of liposuction of the flanks.

441
Chapter | 40  Buttock implants
FIG. 40.55  Tc scan showing the implants inside the muscle.
A
B
C
D
FIG. 40.56  Implant insertion and closure of the wound. (A, B) Implant insertion; (C, D) closure.
Results
Since July 2006 we have used Tc scans to document muscle
changes and implant positions. The patients were 90%
female and 10% male; ages ranged from 22 to 67 years.
During this period, no implant changed position, probably
because the intramuscular pocket provided good stability
(Figs 40.57–40.60). The scar was hidden in the intergluteal
fold in all cases. Even in those cases where limited dehis­
cence occurred, the scar was difficult to see without spread­
ing the buttocks. Before learning to close the dead space,
we treated 55 patients and encountered five cases (9.09%)
of seroma and three cases (5.45%) of partial dehiscence.
After beginning to close the undermined area, we treated
more than 100 patients, encountering 2.66% seroma and
2.0% dehiscence. Wound dehiscence secondary to seromas
was conservatively treated without sequelae and with good
esthetic results. Bruising on the side of the thigh was
encountered in four cases (3.8%). There were no postopera­
tive hematomas.

442
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.57  Case studies. (A, B, C) Preopera­
tive views. (D, E, F) Postoperative, gluteal
implants quartz model 350 cm3 low profile and
flanks liposuction.
A
B
C
D
E
F

443
Chapter | 40  Buttock implants
FIG. 40.58  Case studies. (A, B, C) Preoperative views. (D, E, F) Postoperative, gluteal implants quartz model 350 cm3 low profile and flanks
liposuction.
A
B
C
D
E
F

444
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 40.59  Case studies. (A, B, C) Preoperative views. (D, E, F) Postoperative, gluteal implants quartz model 350 cm3 low profile
A
B
C
D
E
F
DISCUSSION
Although implant gluteoplasty is now a frequently per­
formed procedure, it still meets some resistance from sur­
geons and patients because of poor results in the past, such
as an unnatural appearance and ptosis. With the intramus­
cular technique, we were able to achieve a natural
appearance and pleasing esthetic results.9,17,18,21 This tech­
nique has replaced submuscular placement10 in our own
practice. With submuscular placement, the implants should
not exceed the lower limit of the piriform muscle,6,10,22,23 but
with the intramuscular technique, it is possible to exceed
this limit because the sciatic nerve is well protected by a
thick layer of gluteal muscle. We can thereby achieve a
better contour to the buttocks.24
The gluteal fascia is a thin structure, especially at the
center of the muscle surface, as was quite noticeable in our
dissection. Despite our lack of experience with the subfas­
cial technique, we believe that if this technique is employed,
a palpable or visible implant could result, as could ptosis,
especially in the long term.19,22,25,26 We do not employ sub­
cutaneous placement because laxity resulting from the
superficial fascia system incision leads to ptosis, visible
margins, and displacement of the implant.6,22,27,28,29,30
Some authors associate wound dehiscence with place­
ment of larger implants.22 In our series, this complication
always occurred after development of seromas.29 We con­
sider the preservation of the sacral ligament as described
previously18 to be a major advance, in that it isolates each
operated side and hides the scar. Some authors also employ

A
B
C
D
FIG. 40.60  (A, B, C) Preoperative views. (D, E, F) Postoperative, gluteal implants quartz model 400 cm3 low profile.
E
F