Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

653
Conclusions
Transition vectors
Due to a larger body circumference at the height of the inferior
compared to the superior incision line, more tissue has to be
moved medially in the lower gluteal area. This fact becomes
more apparent when a fleur-de-lis abdominoplasty is per­
formed in the anterior part with reduction of the superior
circumference. For this reason, we symmetrically mark three
vectors per side, enabling a medial transposition of the lower
gluteal tissue with tissue accumulation at the medial buttock,
which may further accentuate the gluteal projection.9,12
Further, this maneuver may induce a slender waist and
improve the entire gluteal shape. In cases of extensive tissue
surplus in the lateral and anterior thigh region, we recom­
mend shifting the entire skin and soft-tissue envelope medi­
ally, resulting in a skin congestion in the medial thigh and
groin region. This tissue surplus may then be excised during
the second-stage inner thigh lift.
Conclusions
The lower lipo-bodylift presents an extremely effective proce­
dure for body rejuvenation and body contouring. Besides the
advantages and enhancements attainable in the abdominal
region, the overall body and gluteal shape can be significantly
improved. The gluteal auto-augmentaton (transposition-
gluteoplasty) presents an effective and reliable method for
gluteal augmentation in terms of transpositioning of the
subfascial lateral gluteal, lateral thigh, and hip adipose tissue.
It can be integrated into every bodylift procedure, without
any considerable amount of time extension or additional
expenditure.
If clinical routine is ensured, the lower lipo-bodylift can be
safely performed with reduced operating time and conse­
quently fewer complications in total, with high patient
satisfaction and optimized aesthetic outcomes (Fig. 25.3.13).
However, these expectations are dependent on the patients’
preoperative conditions and tissue characteristics.
during the gluteal procedure. The harvested fat tissue may be
prepared and used for additional fat grafting in the gluteal
region.
Scar appearance
We favor performing an arch-shaped scar course that com­
mences at the superior end of the intergluteal cleft and pro­
ceeds to the upper lateral gluteal border. The central back
region is characterized by a strong midline zone of adherence,
which consequently disables any significant skin and soft-
tissue sagging. This has to be taken into account, since a more
superior scar ending in the dorsal midline may result in a
prolonged intergluteal cleft with aesthetic limitations. Further,
the arch-shaped scar course accentuates a round-shaped
buttock and respects the borders of the gluteal aesthetic unit
(Fig. 25.3.12).
Fig. 25.3.12  Comparison of an arch-shaped scar (A) to a straight scar (B) on the
backside, showing the optical elongation of the infragluteal fold when using a
straight back incision.
A
B
1A
1B
1C
1D
Fig. 25.3.13  Results. (1A–D): 34-year-old patient after 66 kg weight loss due to sleeve gastrectomy, before and 3 months after the lower bodylift with fleur-de-lis.
Continued

654
SECTION II
CHAPTER 25.3 • Circumferential approaches to truncal contouring: The lower lipo-bodylift
2A
2B
2C
2D
3A
3B
3C
3D
(2A–D): 31-year-old patient after 46 kg weight loss due to diet and exercise, before and 3 months after the lower bodylift.
(3A–D): 34-year-old patient after 87 kg weight loss due to bypass surgery, before and 3 months after the lower body- and thighlift.
Fig. 25.3.13, cont’d
1. Roberts TL 3rd, Weinfeld AB, Bruner TW, et al. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394.
2. Roberts TL 3rd, de la Pena JA, Cardenas JC, et al. Cosmetic surgery
of the buttocks region. Aesthet Surg J. 2003;23:381–387.
3. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018.
4. Lockwood TE. Lower body lift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112–1122.
5. Lockwood TE. The role of excisional lifting in body contour
surgery. Clin Plast Surg. 1996;23:695–712.
6. Lockwood TE. Maximizing aesthetics in lateral-tension
abdominoplasty and body lifts. Clin Plast Surg. 2004;31:523–537.
7. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation
during lower body lift. Aesthetic Plast Surg. 2005;29:133–137,
discussion 138–140.
8. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for
autoprosthesis buttock augmentation. Plast Reconstr Surg.
2012;129:766–776.
9. Richter DF, Stoff A. Lower body lift. In: Rubin P, Jewell M, Richter
DF, et al., eds. Body Contouring and Liposuction. St. Louis, MO:
Elsevier Saunders; 2012.
10. Stoff A, Richter DF. Abdominoplasty and body contouring. In:
Farhadieh RD, Bulstrode NW, Cugno S, eds. Plastic and
Reconstructive Surgery Approaches and Techniques. Hoboken, NJ:
Wiley; 2015.
Access the complete reference list online at

654.e1
References
References
1. Roberts TL 3rd, Weinfeld AB, Bruner TW, et al. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394.
2. Roberts TL 3rd, de la Pena JA, Cardenas JC, et al. Cosmetic surgery
of the buttocks region. Aesthet Surg J. 2003;23:381–387.
3. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018.
4. Lockwood TE. Lower body lift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112–1122.
5. Lockwood TE. The role of excisional lifting in body contour
surgery. Clin Plast Surg. 1996;23:695–712.
6. Lockwood TE. Maximizing aesthetics in lateral-tension
abdominoplasty and body lifts. Clin Plast Surg. 2004;31:523–537.
7. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation
during lower body lift. Aesthetic Plast Surg. 2005;29:133–137,
discussion 138–140.
8. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for
autoprosthesis buttock augmentation. Plast Reconstr Surg.
2012;129:766–776.
9. Richter DF, Stoff A. Lower body lift. In: Rubin P, Jewell M, Richter
DF, et al., eds. Body Contouring and Liposuction. St. Louis, MO:
Elsevier Saunders; 2012.
10. Stoff A, Richter DF. Abdominoplasty and body contouring. In:
Farhadieh RD, Bulstrode NW, Cugno S, eds. Plastic and
Reconstructive Surgery Approaches and Techniques. Hoboken, NJ:
Wiley; 2015.
11. 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;116:1535–1544.
12. Richter DF, Stoff A, Velasco FJ, et al. Circumferential lower truncal
dermatolipectomy. Clin Plast Surg. 2008;35:53–71.
13. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA:
Saunders Elsevier; 2009.
14. Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content
of abdominal skin after surgical weight loss. Obes Surg.
2010;20:480–486.
15. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale
for tobacco abstention with plastic surgery. Plast Reconstr Surg.
2001;108:1063–1073, discussion 1074–1077.
16. Rubin JP, Nguyen V, Schwentker A. Perioperative management of
the post-gastric-bypass patient presenting for body contour surgery.
Clin Plast Surg. 2004;31:601–610, vi.
17. Richter DF, Stoff A, Ramakrishnan V, et al. A comparison of a new
skin closure device and intradermal sutures in the closure of
full-thickness surgical incisions. Plast Reconstr Surg. 2012;130:
843–850.
18. Richter DF, Stoff A. The Scarpa lift – a novel technique for minimal
invasive medial thigh lifts. Obes Surg. 2011;21:1975–1980.
19. Richter DF, Stoff A. Abdominoplasty procedures. In: Neligan PC,
ed. Plastic Surgery. 3rd ed. St. Louis, MO: Elsevier Saunders; 2012.
20. Aly AS. Body Contouring after Massive Weight Loss. St. Louis, MO:
Quality Medical Publishing; 2006.

SECTION II • General Aesthetic Surgery
25.4 
SYNOPSIS
■ Previous methods of buttock auto-augmentation have employed
rotational flaps that are prone to complications due to poor vascularity.
Purse string gluteoplasty was developed as a unique method of
buttock auto-augmentation that does not require any undermining or
rotation of flaps, thus adding to its simplicity and safety.
■ Key elements of the procedure are buttock lifting combined with
auto-augmentation, no undermining of auto-augmentation tissue, and
use of a purse string suture to enhance projection of auto-
augmentation tissue.
■ Other options in these patients include buttock fat grafting, but this
does not correct skin laxity, and fat is usually not present in sufficient
quantities to harvest from massive weight loss patients. Traditional
buttock lifting is an option, but lack of volume will not be well
corrected. Lastly, buttock auto-augmentation with rotational flaps is
effective, but this requires additional dissection, and flaps may not be
reliable in terms of vascularity.
■ The ideal patient for purse string gluteoplasty has buttock deflation and
ptosis and wishes to improve projection. Patients should be healthy
enough for elective surgery and, as in any body contouring, must be
accepting of the proposed scar.
■ Buttock ptosis and atrophy are very common after weight loss or even
normal aging. Purse string gluteoplasty is a safe and effective
technique to correct both of these problems.
Introduction
Buttock atrophy and ptosis after massive weight loss or as
part of normal aging is a common complaint of many patients.
The purse string gluteoplasty was first described in 20091 as
an alternative to existing methods where rotation flaps had
random vascularity of the tips and were fraught with tip loss.
It is a method of autologous buttock augmentation, which
uses the patient’s own redundant soft tissues to augment the
atrophic buttocks in conjunction with buttock lifting. Autolo­
gous buttock augmentation has been described by several
authors.2–7 Previous methods typically involve undermining,
rotational flaps, or flaps with a narrow base that are based on
named perforator vessels.
The purse string gluteoplasty was developed as a safe and
straightforward method of autologous buttock augmentation.
No undermining or rotation of the augmentation tissue is
required, therefore the safety and simplicity of the procedure
are high. This method provides complete vascular preserva­
tion. In addition, the purse string suture lends shape and
additional projection to the buttocks. The procedure can be
done as an isolated buttock reshaping surgery, or in conjunc­
tion with circumferential abdominoplasty/bodylift.
Body contouring secondary to massive weight loss is
experiencing ever-increasing demand in the US. This is sec­
ondary to increasing obesity and increasing success of weight
loss surgery.8 This patient population has been shown to have
significant psychological distress due to the deformities
of massive weight loss.9 It has also been suggested that
buttock auto-augmentation during buttock lifting leads to
higher patient satisfaction than buttock lift without auto-
augmentation.10 These patients will continue to demand
ever-improving and aesthetically pleasing body contouring
results, as may be provided by offering the purse string
gluteoplasty.
Patient selection
The ideal candidate is a patient with redundant skin and soft
tissues of the lower back and gluteal region. This can be
determined using bimanual pinch and palpation. Many of
these patients have experienced significant weight loss, but
this procedure is not exclusive to the weight loss population.
Patients with buttock atrophy and ptosis also benefit from this
procedure.
Patients should be medically healthy enough for body
contouring surgery and have adequate cardiopulmonary
status to tolerate the prone position during surgery. Since the
procedure involves moderate tension on the skin, smoking
cessation is imperative for at least 6 weeks prior to surgery
Circumferential approaches to truncal
contouring: Autologous buttocks
augmentation with purse string
gluteoplasty
Joseph P. Hunstad and Nicholas A. Flugstad
  Access video lecture content for this chapter online at expertconsult.com

656
SECTION II
CHAPTER 25.4 • Autologous buttocks augmentation with purse string gluteoplasty
and until complete healing has occurred. Caution should be
used in those with diabetes or vascular disease. The surgeon
should also be aware of the patient’s coagulation status and
hemoglobin preoperatively, although blood loss is typically
minimal.
In consultation, patients will often demonstrate their desire
for buttocks augmentation and lifting by pulling up on their
buttocks and thigh tissue, demonstrating their desired result.
Patients may wish to discuss other options such as buttock fat
grafting or buttock implants. In the typical massive weight
loss patient, it is important to remember that skin removal
will almost always be required to achieve satisfactory lifting
of the ptotic and deflated buttock. In addition, patients with
“complete weight loss” will not have adequate fat on their
body to harvest via liposuction for buttock fat grafting.11
Prosthetic buttock implants come in a limited size range and
are not recommended for use in conjunction with buttock
lifting. Autologous tissue is plentiful, natural feeling, and
redundant in virtually all massive weight loss patients.
Surgical technique
The markings are made in a fashion similar to the posterior
component of a circumferential abdominoplasty.12 The posi­
tion of the final scar is marked somewhat more caudal than a
typical buttock lift, so that the central tissue mound will be in
a better location for buttock augmentation. The ideal line of
maximum buttock projection is from the coccyx to the greater
trochanter of the femur.13
During patient marking, the planned scar line is drawn
oriented horizontally, at or just below the level of the gluteal
apex from the greater trochanter to the coccyx (Fig. 25.4.1). An
estimate of the amount of tissue to be incorporated into the
autologous buttocks augmentation is made using strong
bimanual palpation (Fig. 25.4.2). This technique is used to
draw the extent of the resection superior and inferior to the
planned scar position. On each buttock, the tissue intended
for augmentation is marked within the resection pattern
(Fig. 25.4.3). The lateral extent of the augmentation mounds
Fig. 25.4.1  The desired level of the scar is marked at the level of the gluteal apex.
Fig. 25.4.2  Bimanual pinch is used to estimate and mark the extent of skin
resection.
Fig. 25.4.3  The area of intended augmentation is marked within the resection
pattern, and in this case labeled “purse sting gluteoplasty”.
corresponds to the lateral contour of the buttocks. Vertical
realignment marks are placed to facilitate accurate soft-tissue
closure, with the final markings shown in Fig. 25.4.4. As a
safety measure, once the bimanual palpation lines are drawn,
we frequently come in 1 cm from the superior and 1 cm from
the inferior markings to ensure closure without undue tension.
The patient is brought to the operating room and placed in
the prone position under general anesthesia. Appropriate
padding and sequential compression pumps on the lower
extremities are used. Penetrating towel clamps are used to
check that the markings are correct and that closure can be
performed without undue tension (Fig. 25.4.5). The realign­
ment marks are then tattooed with methylene blue using a
tuberculin syringe with a 27-gauge needle, which ensures
they will not be washed off. Dilute lidocaine-containing epi­
nephrine is infiltrated into the incision lines and under the
skin overlying the gluteal mound to facilitate hemostasis. This

657
Surgical technique
is done prior to full prepping and draping to allow the epi­
nephrine to take maximum effect before the procedure begins.
The incisions are made with a No.10 scalpel partially
through the dermis. The augmentation mounds are then de-
epithelialized. Electrocautery is used to complete the incisions
controlling bleeding throughout the procedure and continue
the dissection through the subcutaneous tissue down to the
deep muscular fascia (Fig. 25.4.6). The dissection plane should
be straight and not beveled, such that no undermining of the
gluteoplasty mounds is done. The purse string suture is then
placed around each mound at the level of the superficial fascia
system. Placement at this level is important, as placement too
superficially or at the edge of the de-epithelialized skin will
create undesirable invagination of the soft tissue, as opposed
to increased projection. A No.1 braided polyester suture is
used to perform the purse string component of the procedure
in running fashion around each mound, taking equal but
Fig. 25.4.4  The complete markings are shown, with realignment marks drawn in
blue.
Fig. 25.4.5  In the operating room, towel clamps are used to check the markings
and estimate the amount of tension required.
Fig. 25.4.6  The gluteoplasty mounds are de-epithelialized, and dissection around
the mounds is performed straight down to the deep fascia, taking care not to bevel
or undermine the augmentation mounds.
Fig. 25.4.7  The purse string suture is placed in the superficial fascial system in
running fashion and tightened, narrowing the base of the gluteoplasty mound,
imparting shape and projection to the soft tissue.
substantial bites along the way. When placed, the suture must
glide and never be locked. When the suture is tightened, it
narrows the base and increases the projection of the gluteal
mound (Fig. 25.4.7). The purse string creates a beautiful,
round shape and imparts impressive projection. The dermis
of the augmentation mounds is then sutured to the midline at
the level of the superficial fascia to prevent lateral displace­
ment of the mound (Fig. 25.4.8). Undermining of the buttock
soft tissue inferiorly is performed as needed to allow the
autologous tissue to fit properly and allow adequate tissue
recruitment for closure (Fig. 25.4.9). Suction drains are placed
and coiled laterally for final placement at the end of the pro­
cedure. Towel clamps are used to approximate the closure,
and a temporary V–Y closure with No.1 Prolene is done later­
ally on each side (Fig. 25.4.10); otherwise the incision can end
usually at the anterior axillary line when an isolated buttocks
augmentation and lift is being performed. Incision line closure

658
SECTION II
CHAPTER 25.4 • Autologous buttocks augmentation with purse string gluteoplasty
is performed in three layers. The superficial fascia is closed
with 0 or 1 Vicryl, usually one per centimeter of incision
length. The deep dermis is closed with buried interrupted 2-0
Vicryl, and the final intradermal closure is performed with 4-0
Monocryl (Fig. 25.4.11). After completion of the prone portion,
the patient is turned supine. If the purse string gluteoplasty
is being performed in isolation, the Prolene suture is removed,
followed by lateral dog-ear excision and closure. If the purse
string gluteoplasty is being performed as part of a circumfer­
ential abdominoplasty, the latter portion of the procedure is
then completed. The surgeon must remember that reflexing
the patient during the abdominoplasty increases tension and
pressure on the purse string gluteoplasty. The immediate
result of this procedure is dramatically improved buttock
laxity and soft-tissue projection. A certain amount of relax­
ation will undoubtedly occur, but this technique has been
reliable in achieving and maintaining buttocks volume and
projection (Figs 25.4.12–25.4.14).
Fig. 25.4.8  The gluteoplasty mounds are secured to a central remnant of
superficial fascia tissue to keep the mounds from migrating laterally.
Fig. 25.4.9  Undermining of the buttock soft tissue is done inferiorly to create a
pocket for the gluteoplasty mound to fit in and allow proper soft-tissue recruitment
to facilitate closure.
Fig. 25.4.10  Temporary towel clips are used to align the skin edges during
closure. The superficial fascial system layer is closed with 1 Vicryl. Laterally, a
temporary V–Y closure is done, to be finalized when the patient is turned supine.
Fig. 25.4.11  Final closure in the operating room.
Hints and tips
• Checking your marks with towel clamps will help ensure
that excessive tension or inability to close the skin over the
gluteoplasty mounds does not occur. Avoid over-resection
when performing this procedure by marking 1 cm inside the
lines of the bimanual palpation.
• Tattooing the realignment marks with methylene blue before
prepping ensures they will not be washed off.
• The most tension can often occur laterally. When marking
the lateral aspect, instruct the patient to lean slightly away
from you to avoid over-resecting that area.
• Engaging the superficial fascial system (SFS) with your
deepest layer of sutures allows for the majority of the
tension to be placed on the SFS layer and not the skin.
This allows the skin to heal with minimal tension, improving
the final scar outcome.

659
Outcomes and complications
healing is progressing as expected, as well as to answer any
questions that may arise. Drains are removed when the drain­
age amount decreases to less than 25 mL per 24-h period.
When complete healing has occurred at approximately 4
weeks, the patient is released from activity restrictions.
Outcomes and complications
Long-term buttock projection with the purse string gluteo­
plasty is excellent. The overlying skin may relax to some
degree over time, but the underlying gluteoplasty mounds are
living tissue – therefore long lasting and natural. The suture
maintains the shape and projection of the autologous aug­
mentation and is quite durable. Adequate preparation and
informed consent of the patient prior to surgery is an essential
component. Patients must be prepared for scars from this
procedure as the trade-off for skin removal and ptosis correc­
tion. Patients must also be prepared for potential widened or
unfavorable scarring. Patient satisfaction with this procedure
is consistently high in our experience.
Postoperative care
Our typical dressing is 1-inch paper tape over the incisions,
with cuts in the tape every 5 cm to allow for swelling. The
tape allows reinforcement of the closure and protection from
shearing for the first 2–3 weeks and should be changed every
5–7 days. Due to difficulty with placement and replacement,
no compression garments are used following this procedure.
In recovery, patients who have isolated purse string gluteo­
plasty may be placed flat and in a lateral decubitus position
while recovering. If concurrent circumferential abdomino­
plasty is performed, the patient will remain supine and in a
beach-chair position. Upon discharge, routine narcotic pain
medication as well as prophylactic antibiotics are taken.
During the healing period, patients are asked to sit very
gently on a pillow or cushion as opposed to a hard surface,
and are asked to limit time sitting if possible. Periodic ambu­
lation ensures pressure relief on the buttocks as well as reduc­
ing the likelihood of deep vein thrombosis (DVT). Frequent
follow-up is performed within a few days to make sure
Fig. 25.4.12  (A,B) A 60-year-old female who has experienced buttock ptosis and deflation with aging. She is not a weight loss patient. (C,D) At 3 months postoperatively
from buttock lift with purse string gluteoplasty.
A
B
C
D

660
SECTION II
CHAPTER 25.4 • Autologous buttocks augmentation with purse string gluteoplasty
Fig. 25.4.13  (A,B) A 47-year-old female with weight loss and complaints of buttock ptosis. (C,D) At 1 year and 3 months after circumferential abdominoplasty with purse
string gluteoplasty. She went on to have a scar revision.
A
B
C
D
Fig. 25.4.14  (A,B) A 34-year-old female with complaints of loose skin and flat buttocks.
A
B

661
Outcomes and complications
The most frequent complications are focal areas of wound
dehiscence and superficial infection. Areas of dehiscence are
treated with wet to dry dressings until healed. Small areas of
incisional opening can often be treated with removal of suture
material that is extruded. Localized infections are treated
with broad-spectrum oral antibiotics such as amoxicillin/
clavulanate or clindamycin, keeping in mind that the incisions
are in close proximity to the anus. We have not experienced
any infection or delayed healing secondary to necrosis of the
gluteoplasty mounds. The gluteoplasty mounds are durable
and reliable in this technique. In addition, as in any dissection
with large potential space, seroma or hematoma is possible
but have been rarely encountered. Hematoma should be
treated with immediate evacuation. Seroma is treated with
serial aspiration until resolution. Finally, in the long term,
inferior migration of the lateral scar onto the upper thigh is
occasionally seen. This has been treated in two patients with
scar revision and release of the lateral thigh zones of adher­
ence inferior to the scar.
Patients who wish to undergo buttock lifting and improve
their buttock shape and projection may choose to undergo
purse string gluteoplasty. It is reflected in the literature that
body contouring produces physical and psychological benefits
for the patient. With careful planning and preparation, fantas­
tic and predictable results are possible.
References
1. Hunstad JP, Repta R. Purse string gluteoplasty. Plast Reconstr Surg.
2009;123:123e–125e.
2. Centeno RF. Autologous gluteal augmentation. Clin Plastic Surg.
2006;33:479–496.
C
D
(C,D) At 18 months following buttock lift with purse string gluteoplasty. Her buttock shape and projection is improved.
Fig. 25.4.14, cont’d
3. Balague N, Combescure C, Huber O. Plastic surgery improves
long-term weight control after bariatric surgery. Plast Reconstr Surg.
2013;132:826–833.
4. van der Beek ES, Geenen R, de Heer F. Quality of life long-term
following bariatric surgery: sustained improvement after 7 years.
Plast Reconstr Surg. 2012;130:1133–1139.
5. Rohde C, Gerut Z. Augmentation buttock-pexy using autologous
tissue following massive weight loss. Aesthetic Surg J. 2005;25:
576–581.
6. Raposo-Amaral CE, Cetrulo CL, de Campos Guidi M. Bilateral
lumbar hip dermal fat rotation flaps: a novel technique for
autologous augmentation gluteoplasty. Plast Reconstr Surg.
2006;117:1781–1788.
7. Sozer SO, Francisco JA, Wolf C. Autoprosthesis buttock
augmentation during lower body lift. Aesth Plast Surg. 2006;29:
133–137.
8. Kitzinger HB, Aayev S, Pittermann A. The prevalence of body
contouring surgery after gastric bypass surgery. Obes Surg.
2012;22:8–12.
9. Azin A, Zhou C, Jackson T, et al. Body contouring surgery after
bariatric surgery: a study of cost as a barrier and impact on
psychological well-being. Plast Reconstr Surg. 2014;133:776e–782e.
10. Srivastava U, Rubin JP, Gusenoff JA. Lower body lift after massive
weight loss: autoaugmentation versus no augmentation. Plast
Reconstr Surg. 2015;135:762–772.
11. Hunstad JP, Aiken ME. Circumferential body contouring. In: Aly A,
ed. Body Contouring after Massive Weight Loss. Boca Raton, FL: CRC
Press; 2006:183–212.
12. Hunstad JP, Deos M, Repta R. Circumferential abdominoplasty. In:
Hunstad JP, Repta R, eds. Atlas of Abdominoplasty. Philadelphia, PA:
Saunders Elsevier; 2009:89–114.
13. Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery
in the massive weight loss patient. Clin Plast Surg. 2008;35:73–91.

SECTION II • General Aesthetic Surgery
25.5 
Circumferential approaches to truncal
contouring: Lower bodylift with autologous
gluteal flaps for augmentation and
preservation of gluteal contour
Robert F. Centeno and Jazmina M. Gonzalez
SYNOPSIS
■ There has been a dramatic rise in popularity of aesthetic gluteal
contouring in both weight loss and non-weight loss patients.
■ While most procedures performed today are autologous fat transfer
and implant procedures, some gluteal deformities including skin
excess or buttock ptosis demand alternative body contouring solutions.
■ Several techniques for autologous gluteal auto-augmentation with
circumferential bodylift and excisional buttock lifts are used.
■ Three categories of autologous flaps are described in this chapter:
island flaps, what the senior author describes as incremental flaps,
and transpositional flaps.
Introduction
The ongoing demand for bariatric surgery procedures and its
effect on massive weight loss (MWL) patients presenting with
severe body contour deformities has unexpectedly driven
demand for gluteal contouring procedures. Changing socio­
cultural gluteal aesthetic norms and exposure in popular
culture media channels has also increased demand for aes­
thetic gluteal contouring procedures across the US.1 While
most procedures performed today are autologous fat transfer
and implant procedures, the MWL patient can present with
unique gluteal deformities demanding alternative body con­
touring solutions. The dramatic rise in popularity of aesthetic
gluteal contouring has also increased the demand for circum­
ferential bodylifts and excisional buttock lifts with auto-
augmentation in weight loss patients and non-weight loss
patients with significant skin laxity or hypoplasia. Several
techniques for autologous gluteal auto-augmentation (AGA)
with circumferential bodylift (CBL) and excisional buttock
lifts (EBL) have been posited as a solution to this problem.
Three general categories of autologous flaps are described in
this chapter: island flaps, what the senior author describes as
incremental flaps, and transpositional flaps. Experience and
knowledge of the variety of techniques will allow expanded
application to the aesthetic patient presenting with gluteal
hypoplasia in addition to the MWL population. Indications,
technical variations, surgical planning, results, complications,
and postoperative management are discussed.
Gluteal hypoplasia in the massive
weight loss and aesthetic patient
As one ages, anatomic changes that occur in the torso and
gluteal region contribute to decreased gluteal projection and
aesthetics. Accumulation of subcutaneous fat in areas sur­
rounding the gluteal region detracts from the aesthetic
appearance of the buttock. The accumulation of intra-
abdominal fat in women that accompanies perimenopausal
changes coupled with rectus diastasis negatively affects the
contour of the torso. Age-related skin laxity and ptosis of the
subcutaneous fat also decreases projection of the gluteal
region. Dramatic loss of adipose volume in the buttock of
weight loss patients uniquely contributes to decreased projec­
tion and ptosis. The average female patient gets wider at the
hips and the infragluteal crease lengthens with age.2–4 Many
of these findings prompt aesthetic patients to seek consulta­
tion for body contouring procedures. The circumferential
bodylift has proven to be a very effective procedure in
addressing many of these concerns and is often recommended.
Unfortunately, significant flattening of the buttock can occur
with aggressive lifting posteriorly (Fig. 25.5.1). Pre-existing
platypygia is also worsened by the procedure and is of concern
to many aesthetic patients.
The massive weight loss patient represents another end of
the spectrum. Weight loss secondary to exercise or bariatric
procedures often occurs in a variable manner. There is data
to suggest that certain areas of adipose tissue on the body
are more resistant to weight loss than others. The genetic
programming of the resistant adipocytes differ from more
responsive areas, suggesting a genetic role of different
somatotypes. Some somatotypes such as “apples” seem to
  Access video lecture content for this chapter online at expertconsult.com

663
Gluteal hypoplasia in the massive weight loss and aesthetic patient
have less adipose tissue in the gluteal region. “Pears” tend to
retain more tissue in the gluteal region. These somatotypes
can also affect the shape of the pelvis and buttock shape.
Final post-weight loss body mass index (BMI) has a significant
impact on these findings, irrespective of body shape. Many
MWL patients tend to lose some volume in the gluteal
region.4,53
Fig. 25.5.1  (A–F) Circumferential bodylift/excisional buttock lift and buttock flattening.
A
B
C
D
E
F
Fig. 25.5.2  (A–C) Skeletal changes after massive weight loss.
A
B
C
The MWL patient also develops skeletal changes that may
contribute to platypygia (Fig. 25.5.2). Morbid obesity is a
restrictive lung disease with an obstructive component that is
more pronounced in the supine position. Expiratory flow
limitation in the supine position may lead to pulmonary
hyperinflation and intrinsic positive end-expiratory pressure
(PEEP). This is thought to play a role in positional orthopnea

664
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
reported by obese patients.5,6 Over time, obese patients are
hypothesized to develop thoracic skeletal expansion to
accommodate this increased need for functional reserve
capacity and to accommodate hyperinflation. Thoracic
kyphosis or scoliosis secondary to thoracic spine compression
and anterior inclination of the pelvis also occurs.7 Inadequately
treated post-bypass hypocalcemia, vitamin D malabsorption,
secondary hypoparathyroidism, and independent negative
bone remodeling modulated by either sex hormones or serum
telopeptides may also worsen these weight-related skeletal
changes.8 These skeletal changes are permanent and worsen
pre-existing primary or secondary platypygia caused by loss
of adipose tissue in the gluteal region. The skeletal findings
also contribute significantly to asymmetry that is resistant to
body contouring.
Development of techniques
As demand for gluteal enhancement and the collective experi­
ence with the various forms of alloplastic and autologous
gluteal augmentation have grown, a consensus has emerged
that limitations in gluteal implant design have limited the
success and widespread acceptance of alloplastic gluteal
augmentation in the US. Nevertheless, these techniques are
still applicable in certain subsets of well-informed patients.
Alloplastic techniques are very successful in enhancing the
gluteal aesthetic but have limited applicability because of
their significant long-term complication rates. The “aesthetic
success” of these alloplastic procedures has inspired the
authors and others to continue to refine several autologous
flap techniques for gluteal augmentation.9–12 Furthermore, the
impact of implant position on buttock projection and aesthet­
ics has significantly influenced autologous augmentation
techniques.
Submuscular implants have the highest point of maximum
projection in comparison to the ideal at the level of the mons
pubis. Intramuscular implants lower the point of maximum
projection, but they are still higher than ideal. Subfascial
implants lower the point of maximum projection closest to the
ideal at the level of the mons pubis (Fig. 25.5.3).
The MWL patient with significant skin excess and buttock
ptosis is not the ideal candidate for either alloplastic aug­
mentation in any of the three accepted planes: subfascial,
intramuscular, submuscular; nor autologous fat transfer.
The combination of an excisional procedure (CBL/EBL)
Fig. 25.5.3  Implant position and gluteal point of maximal projection.
characterized by a higher than average minor complica­
tion rate, with alloplastic augmentation procedures where
infection would be catastrophic, seems imprudent.13,14 De-
epithelialized flaps have been used in gluteal contouring for
some time.15–17 Published references to the use of autologous
tissue in preventing gluteal deformities with CBL were also
reported but lacked significant detail and did not substantiate
their potential for augmentation.18,19 The description of the
superior gluteal artery, inferior gluteal artery, and transverse
lumbosacral back flaps and their vascular supplies also bol­
stered the clinical viability of this approach.20 More recent
anatomic studies have further refined our knowledge of the
vascular anatomy of the gluteal region.21,22
The island AGA flap, one of the earliest techniques,
simulated the round, non-anatomic design of submuscular
gluteal implants. This flap is based on perforators from the
superior gluteal artery, which are preserved by restricting
undermining of the flaps. Hunstad has reported a variation
of the island flap, an imbrication flap, which utilizes a purse
string suture to enhance the projection of the flap. Colwell
described a variation of the island flap based on a superior
gluteal artery perforator (SGAP) flap design (Fig. 25.5.4).
Pascal, Raposa-Amaral, and Kohler all proposed variations
of the SGAP island flap with incremental recruitment of
additional surrounding tissue to enhance outcomes (Fig.
25.5.5). While projection is enhanced significantly with these
incremental flaps, the point of maximum projection remains
high compared to alternative flap designs. Flap dissection
that limits undermining and mobilization of the flap from the
original donor site in order to preserve vascularity is the main
limiting factor. Long-term augmentation results with these
approaches have been disappointing in the author’s experi­
ence. Higher than ideal gluteal projection and lack of inferior
pole projection continue to plague the aesthetic outcomes of
these techniques. These shortcomings led to the development
of the author’s preferred technique, the moustache autolo­
gous gluteal augmentation (AGA) flap (Fig. 25.5.6), which
is one variation of a transpositional flap. The moustache
AGA flap utilizes the back and lateral flank tissue as a partial
island and partial transposition flap based on perforators
from the superior gluteal artery and lumbar perforators.23,24
Inferomedial transposition of the “handle-bar” part of the
moustache AGA flap allows recruitment of additional tissue
for augmentation purposes as well as lowers the point of
maximum projection to the level of the mons pubis, which is
more aesthetically harmonious. Loose imbrication of the flap
with sutures allows for the formation of an “anatomically”
shaped autologous implant reminiscent of the alloplastic
procedures. The central area of the flap tissue is typically
divided to allow for easier closure and turned inferolaterally
to be incorporated into the flap. Rohde also proposed a partial
transposition flap to lower the point of maximum projection of
the autologous flaps to enhance outcomes.25 Sozer, in multiple
reports, proposed a gluteus maximus muscle turnover flap
based on partial dissection of the gluteus maximus muscle to
enhance projection and reach of the flap to the mid to lower
pole of the buttock with pleasing results.26–29 Based on the
published results and a critical assessment of aesthetic out­
comes, the Centeno–moustache transposition flap, or one of
the other iterations as described by Rohde or Sozer et al., likely
represent the procedures of choice where significant, long-
lasting aesthetic augmentation is desired and a lower point

665
Aesthetic analysis
of maximum projection is critical for a harmonious outcome
(see Fig. 25.5.6).
Aesthetic analysis
Selection of a technique for gluteal contouring in the MWL or
aesthetic patient begins with a careful aesthetic analysis of the
nature and causes of the gluteal deformity. The status of the
subcutaneous adipose tissue in the gluteal region as well as
the surrounding gluteal aesthetic units of the torso and lower
extremities is the first step of the analysis (Fig. 25.5.7).30
Volume excess or paucity is precise enough for technique
selection purposes. The buttock shape as described by Mend­
ieta is then determined (Fig. 25.5.8). V-shaped buttocks are the
most difficult to correct and require the largest volume of
A
B
C
D
E
F
Fig. 25.5.4  Island gluteal flaps: (A–D) Centeno–island flap; (E,F) Hunstad–purse string flap; (G–J) Colwell–Borud–SGAP (superior gluteal artery perforator) flap.
Continued

666
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
G
H
I
J
Fig. 25.5.4, cont’d
tissue in the lower pole and lateral aspect of the buttocks.
Muscle and bony skeletal height and width is then identified
to determine if the buttock needs apparent shortening or
lengthening and the final location of the point of maximum
projection determined (Fig. 25.5.9).31 This analysis is important
to incision height placement as it relates to flap selection and
final incision location. High-riding CBL/EBL incisions can
enhance waist definition while lengthening the buttocks
favorably in shorter-buttock patients and unfavorably in
longer-buttock patients (Fig. 25.5.10). Shorter buttocks char­
acterized by short gluteus maximus muscle and pelvic height
can be favorably treated more efficiently with shorter flaps
such as the island or incremental flaps. Buttocks characterized
by longer muscle, bony, and visual length, as well as V-shaped
buttocks, are more appropriately treated with a transposition
flap. The transposition flaps recruit additional tissue to fill the
lower third of the buttock, the lower lateral aspect of V-shaped
buttock, and lower the point of maximum projection closer to
the ideal. Finally, the quality and laxity of the skin of the
abdomen, flanks, hip, back, buttock, anterior thigh, lateral
thigh, and posterior thigh are noted. The results of this analy­
sis are then used to guide the surgeon through a “gluteal
contouring algorithm” for body contouring (Fig. 25.5.11).
Once the decision is made that gluteal augmentation is desir­
able and that an excisional procedure is indicated due to
posterior skin laxity, then CBL or EBL is considered. If CBL or
EBL are indicated, then autologous augmentation with a
vascularized gluteal flap becomes the procedure of choice in
patients with BMI under 30. The gluteal augmentation algo­
rithm in indicates preferred choices for gluteal augmentation
under various conditions. Over time, the use of autologous
tissues either as a flap or in fat transfer have become the
procedures of choice in the author’s practice. The moustache
flap and other transpositional flaps have made supplemental
procedures such as staged fat transfer or alloplastic implants
less necessary due to the significant augmentation achieved.
The high complication rates experienced with the various
forms of implant augmentation have also relegated these
procedures to last-resort procedures in only the most well-
informed and compliant patients.
BMI and procedural indications
Obese patients with a BMI over 30 have been shown to be at
higher risk for perioperative complications in aesthetic and
MWL body contouring. Wound healing dehiscence, delayed
healing, seromas, infection, and deep venous thrombosis are
some of the common complications observed in obese patients.
These patients are far from the generally agreed upon ideal

667
BMI and procedural indications
can benefit from AGA with CBL/EBL. Which procedures are
combined and how they are staged is determined by combin­
ing aesthetic judgment, preoperative medical status, age, BMI,
physical findings, and patient desires.
Low-range BMI patients (BMI <25) with skin laxity, gluteal
hypoplasia, and no other viable long-term options for gluteal
augmentation likely represent the ideal group for AGA with
CBL/EBL. They typically do not have enough fat for autolo­
gous fat transfer and prosthetic implants alone would pose an
aesthetic goals and should be managed more conservatively.
Less risky approaches such as staged liposuction and exci­
sional procedures and limited dissection can reduce morbidity
in this group. AGA with CBL/EBL is not recommended in this
group.
Mid-range BMI patients (BMI 25–30) also benefit from
excisional procedures, adjunctive liposuction, and the addi­
tion of autologous fat transfer for further shaping. Younger
patients without comorbidities in the lower part of this range
B
C
A
1
2
Fig. 25.5.5  Incremental gluteal flaps: (A) Pascal; (B) Raposa–Amaral; (C) Koller.

668
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
A
B
C
D
E
F
G
Fig. 25.5.6  Transpositional gluteal flaps: (A–E) Centeno–moustache flap; (F) Sozer–Split gluteal turnover
flap; (G,H) Rohde.
H

669
Gluteal flap selection
unjustifiable risk in the MWL population. This group benefits
the most aesthetically from AGA with CBL/EBL procedure
and typically has fewer complications with all other factors
being equal (Table 25.5.1).
Gluteal flap selection
Once the patient has been determined to be a good candidate
for AGA with CBL/EBL, the selection of the appropriate flap
design to meet the aesthetic goals is paramount (Fig. 25.5.11).
The island AGA flap, with or without imbrication, and its
variations are the procedures with the smallest volume of
tissue and consequently the least augmentation. The position
of these flaps usually sits on the upper third or mid two-thirds
of the gluteus maximus muscle, making them appropriate
for shorter buttocks. They are only indicated for preven­
tion of the flattening effect of the CBL/EBL. Preoperative
buttock projection should either be “normal” or as close to
what is desired by the patient. The island AGA flaps’ point
Fig. 25.5.7  Centeno – gluteal aesthetic unit classification.
1
2
3
4
5
6
7
8
Fig. 25.5.8  Mendieta – buttock shape classification.
V-Shape going
towards square
A-Shape going
towards square
A-Shape buttock
V-Shape buttock
Short square buttock
Round buttock
A
A
A
A
C
C
B
B
B
B
C
C
Fig. 25.5.9  (A,B) Mendieta – gluteus maximus and pelvic height evaluation.
Bone
Fat
Gluteal
muscle
Overall buttock shape
A
Gluteal muscle
(gluteal shape)
Frame
Bone
Fat
B

670
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
of maximum projection usually lies at, or slightly above, the
transposed level of the mons pubis. As such, they may be
more aesthetically applicable in African-American and Asian
women as well as male patients. A desire for a higher point of
maximum projection or a shorter vertical height of the pelvis
may contribute to these aesthetic preferences. These aesthetic
findings are thought to be more desirable in these subsets of
patients.32 Finally, use of the island flap design is discouraged
in the “V-shaped” buttock as inferomedial and lateral volume
restoration is critical to a good aesthetic outcome. They may
Fig. 25.5.10  (A–H) Incision placement and buttock lengthening/shortening. (E–H) Gluteal flattening effects of circumferential body lift.
A
B
C
D
E
F
G
H
Table 25.5.1  Body mass index (BMI) and gluteal contouring
procedure selection
BMI
Gluteal contouring procedures
BMI <25
CBL/EBL with AGA ± fat transfer ± adjunctive
excisional procedures
BMI 25–30
Fat transfer, ± adjunctive excisional procedures
± CBL with AGA
BMI >30
CBL/EBL, liposuction ± fat transfer ± adjunctive
excisional procedures
CBL, circumferential bodylift; excisional buttock lift; AGA, autologous gluteal
auto-augmentation.
be effective in the appropriate “A-shaped”, “square”, and
“round” buttocks.
Incremental AGA flap designs that incorporate additional
non-undermined tissue inferior or lateral to an island flap
design are thought to represent the next level of AGA. They are
indicated in patients who have mild preoperative platypygia
and desire modest augmentation. This was accomplished by
designing a larger flap with significantly more volume inferi­
orly and laterally. These flap designs are effective in “padding”
the gluteal region slightly more effectively than the island
flaps. Because the point of maximum projection remains sig­
nificantly higher than the transposed level of the mons pubis,
the inferior pole of the buttock is not addressed. This approach
can work in a patient with significant buttock ptosis and
“A-shaped”, “round” or “square” buttocks. The incremental
flaps can be particularly helpful in improving lateral buttock
deficiency in patients of the aforementioned buttock shapes.
Transpositional AGA flap designs are the flap designs of
choice when definitive augmentation is desired. These flaps
have the greatest volume and the versatility to restore volume
in all regions of the buttock including the upper, mid, and
lower thirds of the buttock. The final desired volume can
be easily adjusted to suit the patient’s aesthetic wishes by
varying both the height and width of the flap. By recruiting
lateral trunk tissue inferomedially or superior gluteal tissue

671
Clinical anatomy
injury during the posterior portion of a CBL/EBL. The iliohy­
pogastric and ilioinguinal nerves are both branches of the L1
nerve root and originate in the sacral plexus. These nerves
travel inferomedially between the transversus abdominis and
internal oblique muscles. The iliohypogastric nerve divides
into lateral and anterior cutaneous branches to supply skin
overlying the lateral gluteal region and above the pubis.
Circumferential bodylift incisions made at or below the ingui­
nal crease can put these nerves at risk. The lateral cutaneous
branch of the iliohypogastric and the intercostal nerves also
can be entrapped laterally during surgery. This can occur if
aggressive lateral plication of the external oblique muscle is
performed to enhance waist definition or if three-point sutures
or quilting sutures are used laterally to close “dead space”.
Sensation to the gluteal region and lateral trunk has several
sources: the dorsal rami of sacral nerve roots 3 and 4, the
cutaneous branches of the iliohypogastric nerve arising from
the L1 root, and the superior cluneal nerves originating from
the L1, L2, and L3 roots and then passing over the iliac crest.
The protective cutaneous sensation transmitted by these
nerves is temporarily disrupted during the CBL and AGA
with CBL. Patients should be counseled about frequent posi­
tional changes and avoidance of heating pads and blankets to
avoid pressure necrosis and burns.
Perfusion to the skin overlying the gluteal region is sup­
plied by perforating branches of the superior and inferior
inferiorly, their final point of transposed maximum projection
is at the level of the mons pubis and characterizes the most
generally accepted gluteal aesthetic. The inferior pole and
lateral aspect of the buttock and lateral hip can be augmented
significantly to enhance the gluteal aesthetic in a “square” or
“V-shaped” buttock, making it the flap design of choice. The
transpositional AGA flaps are the procedure of choice because
of their wide applicability, good long-term aesthetic outcome,
and ease of “down-staging” as the clinical situation demands.
Irrespective of the final flap design chosen, the volume of
the flap can be adjusted as required by the clinical situation
and patient wishes. The primary limitation to larger flap
volume is the upper limit of the skin marking pattern used
for the CBL/EBL. Smaller flaps can also be used for an
increased safety margin in terms of tissue perfusion, or to
avoid excessive tension on the posterior CBL/EBL flaps. All
flaps can be “down-staged” or completely resected for patient
safety if there is any concern about tissue perfusion, excessive
tension on the CBL closure, or inability to close the flaps over
the autologous implant.
Clinical anatomy
The integrity of superficial anatomic structures of the lateral
trunk, posterior trunk, and gluteal region are most at risk of
Fig. 25.5.11  Gluteal contouring algorithm.
Paucity of gluteal volume
Gluteal volume excess
Skin laxity
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Abdomen only
Abdominoplasty
Fat Transfer
Implants
Medial thigh lift
Extended thighplasty
≥2L volume excess in
surrounding aesthetic units?
Short, anthropometric pelvis, conservative
augmentation desired, A,S,R, shaped Butt, male?
Island or Incremental flaps ss proposed by Cartel,
Raposa-Amaral, Hixistad, or Kohler
Long, gynecoid pelvis, significant
augmentation desired, A,S,R,V, shaped Butt, female?
Circumferential bodylift
/excisional buttocks lift
Gluteal augmentation
(implant, fat transfer)
Transposition flaps or variations as proposed by
Centeno, Rohde, or Sozer.
Posterior thigh lift
Lower buttocks lift
Medial thigh
STOP
Posterior thigh
Infragluteal fold ptosis
Flanks, back, and buttocks
Liposuction of lateral / medial thighs,
buttocks or lumbosacrum
Gluteal hypoplasia

672
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
desired, and the upper limits of the CBL or buttock–flank lift
markings. The flaps are centered from medial to lateral over
each gluteal region. When utilizing a transpositional flap, the
lateral “handle-bars” or superior gluteal turnover tissues of
the desired width and length are then drawn. A towel or tape
measure is used to determine adequate inferior rotation of the
turnover flap or inferomedial transposition of the “handle-
bars” of the moustache transpositional flap. The limiting point
to the “arc of rotation” is 12 cm from the midline for the
moustache transpositional flap and the inferior border of
the gluteus maximus muscle for the turnover flap. Once in the
prone position on the operating table, the central (sacral)
superior and inferior markings for the posterior portion of the
CBL/EBL can then be adjusted inferiorly 1–3 cm to accom­
modate the superior displacement of lax tissues, to ensure the
safety of the central resection, to preserve the gluteal aesthet­
ics, and to shorten a long intergluteal sulcus. Traditional
descriptions of the posterior CBL/EBL markings result in a
final incision that is either aesthetically too high, violates the
gluteal aesthetic units, or gives the buttock an elongated or
square appearance.34–36 The final placement of the posterior
CBL/EBL with AGA markings represents somewhat of a
compromise. In order to develop a flap that allows for aug­
mentation of the middle and lower pole of the buttock and is
between gluteal aesthetic units, the markings have to be lower
than traditional descriptions. The permanent placement of
the incision at the junction between gluteal aesthetic units
improves the appearance of the buttock in the posteroanterior
(PA) view at the potential cost of harming waist definition by
widening it. This problem can be overcome by performing
adjunctive liposuction in patients with excess flank fat. In
contrast, a traditionally high posterior CBL/EBL incision
improves lumbar lordosis and apparent gluteal projection in
the lateral view and waist definition in the PA view but at the
expense of a permanently elongated buttock on PA view. The
traditional high incision may also be visible above normal
underwear or clothing.
Operative technique
The procedures all begin with de-epithelialization of the AGA
flap design of choice. The island and incremental flaps are
both dissected in a beveled fashion with electrocautery down
through the superficial fascial system (SFS), gluteal fascia, and
lumbosacral fascia. The sacral fascia is left intact. The sur­
rounding tissue is resected as planned to complete the CBL/
EBL leaving a layer of fat above the muscular fascia. The
gluteal pockets centered over the gluteal region are symmetri­
cally dissected below the SFS but above the gluteal fascia
down to, but not beyond, the infragluteal crease. A lateral
tissue bridge is left in place as a border to the pocket to
prevent lateral malposition of the AGA flap. When using the
island AGA flap, the flap may be imbricated from the 9 o’clock
to the 3 o’clock position or imbricated with a purse string
suture from the dermis to the SFS to improve projection. If a
transpositional flap is used, the “handle-bar” extensions of the
moustache AGA flap are then dissected from the posterior
thoracic fascia up until 12 cm from the midline to preserve the
superior gluteal artery perforators. The extent of the gluteus
maximus muscle limits the inferior dissection of the split
gluteal turnover flap. The dermis of the distal “handle-bar”
gluteal arteries, both of which branch from the internal iliac
artery. The lumbosacral region is also supplied by lumbar
perforators. Some of these perforators must be sacrificed
during the posterior portion of the CBL/EBL, or AGA with
CBL/EBL, but the abundant supply provides robust perfu­
sion to surrounding tissue flaps.
The fascial anatomy of the gluteal region has significant
clinical implications for the aesthetic of the aging buttock.
Relaxation of the fascial “apron” is implicated in gluteal ptosis
in conjunction with volume loss and skin laxity. Resection and
tightening of this superficial fascial “apron” not only improves
gluteal ptosis, but can play a significant role in the CBL/EBL
procedure and AGA with CBL/EBL. This fascial apron is
analogous to the superficial facial system. The deep gluteal
fascia plays a significant role in AGA with CBL as a fixation
point, but also as a strong retaining fascia in the subfascial
approach to alloplastic gluteal augmentation. The superficial
apron and the deep gluteal fascia fuse and become tightly
adherent to form the infragluteal fold, a structure that should
not be violated as it is exceedingly difficult to recreate.33
Operative markings
Marking a patient for AGA with CBL/EBL begins with
marking the patient for a modified version of the traditional
CBL/EBL. The posterior CBL/EBL markings are placed lower
than usual to allow for augmentation of the mid or lower pole
of the buttock and to conform to gluteal aesthetic units. The
lowering of the posterior markings also serves to visually
“shorten” the gluteal region to enhance aesthetics. The point
of maximum gluteal projection is first projected from the level
of the mons pubis to the back and marked. This projected
point is used to help determine the level of maximum projec­
tion for the augmentation component. The position of the
superior markings of the CBL/EBL is then chosen based on a
number of factors. These factors include the transposed point
of maximum projection, the desire to visually shorten or
lengthen the buttock, and how much lower pole augmenta­
tion is needed. A useful anatomical landmark described by
Mendieta is the sacral promontory that corresponds to the
origination site of the gluteal maximus muscle or the “buttock
proper”.31 A “gull-wing” shaped superior incision is used for
two purposes: (1) to place the incision between the sacral and
gluteal aesthetic units, thereby enhancing aesthetics, and (2)
to prevent or improve unfavorable intergluteal fold lengthen­
ing associated with buttock lifting. The iliac crest is too high
an anatomic landmark for the superior markings and will
excessively lengthen the buttock, limit inferior augmentation
of the gluteal region, and unfavorably lengthen the interglu­
teal sulcus. The inferior markings of the CBL/EBL are then
marked by pulling and pinching the ptotic, lax gluteal skin
up to meet the superior markings. This amount of skin resec­
tion is sufficient to correct gluteal laxity while safely accom­
modating the newly placed AGA flaps without undue tension.
Two symmetrical gluteal pockets are then measured and
marked below the inferior CBL/EBL markings starting 2–3 cm
above the infragluteal fold.
The desired island or incremental flap designs are then
marked beginning at the most inferior resection mark in the
gluteal region. The size of the flap is determined by the pre-
existing gluteal dimension, the amount of augmentation

673
Perioperative care and safety
postoperative semi-Fowler’s position, and the extent of central
resection is limited. Careful preoperative planning to avoid
posterior over-resection and conservative flap size initially is
helpful in avoiding serious wound healing problems, skin
necrosis, and dehiscence. Proper selection of lower BMI
patients who are at lower risk of wound healing problems is
also helpful. While these restrictions may limit the quality of
your initial results, significantly better results can be achieved
once more experience is gained.
Large, clinically significant seromas due to dead space can
be reduced by putting drains in the most dependent portion
of the gluteal pocket. Doxycycline sclerosis is used in postop­
erative seroma or excessive drain output management in CBL
patients in the author’s practice. Tissue sealants are not cur­
rently used due to cost considerations and the absence of
convincing data in this application. Quilting sutures are not
routinely used due to the inefficiency and tethering effect that
these sutures may cause.
In addition to the aforementioned precautions, the impor­
tance of proper patient selection cannot be overstated when
contemplating AGA with CBL/EBL. Utilizing the appropriate
procedure for the proper BMI group and matching physical
characteristics will significantly reduce the complication rates.
Higher BMI patients over 30 are at risk for wound healing
complications from virtually all body contouring procedures
and do not represent ideal candidates for these procedures.
Less risky approaches are recommended.
Perioperative care and safety
On average, AGA with CBL patients prefer 1–2 days of hos­
pitalization. AGA with EBL patients typically tolerate the
procedure well as an outpatient. Multi-procedure MWL cases
are physically demanding on the patient and require attentive
or of the “split turnover flap” is anchored to the gluteal fascia
in the most inferomedial aspect of the gluteal pocket. The
medial portion of the moustache flap is divided centrally and
rotated inferolaterally and sutured to the dermis of the flap.
The moustache transpositional AGA flap is loosely imbricated
with suture to refine projection, shape, and symmetry (see Fig.
25.5.6A–F). The flaps are further anchored to the medial aspect
of the gluteal pocket with absorbable sutures to enhance final
shape and prevent lateral displacement. Drains are placed
bilaterally in the inferior most aspect of the dissection pocket.
The CBL incision is temporarily closed with towel clips. Once
symmetry is confirmed, the SFS is closed with the preferred
suture. The deep and superficial dermis are closed in the usual
fashion. The incision is dressed with the preferred dressing
but care is taken to avoid shearing forces caused by restrictive
dressings.
Complications
Complications directly related to the AGA do not seem to be
significantly elevated when compared to historical standards
for CBL/EBL. The reported rates of delayed wound healing,
epidermolysis, or skin necrosis is in the range of 0–77%, and
the overall complication rates in the range of 10–80%.34–38 The
robust vascularization of the flaps seen in MWL patients and
limitation of flap dissection to no more than two contiguous
angiosomes seem to provide good flap perfusion and viability.
Only one series of AGA with CBL reported a significantly
higher wound healing complication rate when compared to
the CBL-only cohort of MWL patients.39 By the authors’ own
admission, the patients in the AGA cohort had a higher weight
on average, even though BMIs were comparable, and the
markings for the AGA with CBL procedure were quite aggres­
sive. These findings suggest potential confounding variables
such as flap design, obesity-associated risk, and patient selec­
tion issues that could affect the conclusions. In the author’s
series, one case of minor flap necrosis was likely a result of
an excessively long “handle-bar” lateral extension of the
moustache flap into the “posterior-intercostal” angiosome as
described by Taylor’s unit.21,22 Because this lateral extension
is undermined to allow inferomedial transposition in the
moustache variation of the transpositional AGA flap, the “two
adjacent angiosomes” limitation of perforator flap perfusion
may have been exceeded.
Aggregate, retrospective comparison of delayed wound
healing rates and complications for CBL patients and for AGA
with CBL in the does not suggest a significantly increased
complication rate (Fig. 25.5.12). The delayed wound healing
rates noted in these two series are comparable to the delayed
wound healing rates for CBL and body contouring in MWL
or obese patients in the aforementioned published series.
MWL patients, which compromised the majority of the
patients in the series, likely represent more “at risk” patients
when compared to normal, healthy aesthetic patients. None­
theless, the undermining of the inferior flap and tension on
the closure may be more significant when AGA is added to
the CBL. This can lead to wound healing problems, especially
in the central aspect of the incision in the “water-shed” region
of tissue perfusion. To help reduce this problem, the patient
is marked for the central resection in the bent-over posture to
simulate the tension placed on the incision when in the
Fig. 25.5.12  Aggregate retrospective circumferential bodylift (CBL) vs. CBL/
autologous gluteal auto-augmentation (AGA) complication rates.
0
CBL series
AGA series
Complications CBL vs. CBL-AGA
Number of patients
AGA - Centeno, Rubin, Sozer, Hunstad, Rohde, Koller, Raposo-Amaral,
Derunz, Colwell
439 patients, 110 complications, 25% compl. rate
CBL - Van Huizum, Aly, Rohric, Lockwood, Strauch, Rubin, Hurwitz, Capella
581 patients, 226 complications, 38% compl. rate
Number of complications
Percentage of complications
100
200
300
400
500
600
700

674
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
to performing sclerosis, local anesthesia can be achieved by
infusing a weight-appropriate dose of 0.5% Marcaine into the
seroma cavity. Post-procedure pain can be experienced for
8–24 h after sclerosis, and oral narcotics are recommended.
This procedure may need to be repeated several times before
a significant reduction in drainage output is observed. This
doxycycline concentration is higher than the recommended
intravenous dosage because of its inflammatory properties. It
is an “off-label” use of the medication, and patients should be
informed of this status. Alternatively, if a seroma occurs after
drain removal, the seroma cavity may be injected with the
solution followed by aspiration. Special precautions should be
taken to ensure that the solution is not injected into the subcu­
taneous tissue, as fat and skin necrosis may ensue. Office-based
ultrasound guidance during aspiration or injection has been a
useful tool in the author’s practice. Pain is usually indicative
of subcutaneous infusion, and the procedure should immedi­
ately be aborted. In uncommon situations, seroma cavity
excision or imbrication can be performed.52
Summary
Autologous gluteal augmentation with CBL/EBL in the MWL
or aesthetic patient is a useful adjunct in body contouring
surgery. The aforementioned techniques represent an alter­
native to alloplastic augmentation and other less applicable
autologous techniques for improving gluteal contour in both
the MWL and aesthetic patient for whom an excisional
procedure is indicated. AGA with CBL/EBL seems to achieve
long-lasting correction of platypygia with an acceptable
safety profile. Further refinement of these techniques and
improved patient selection have led to fewer complications
and improved aesthetic outcomes. For more examples of
results, see Figures 25.5.13 and 25.5.14
.
Figs 25.5.13 & 25.5.14 appear online only.
postoperative management. Blood loss, temperature, electro­
lyte, fluid, and deep vein thrombosis/pulmonary embolism
(DVT/PE) prophylaxis issues are routinely monitored. The
patient is placed in the prone position on an operative bed
covered with a full-length gel mattress and gel rolls under the
torso. Adequate padding of the face, eyes, axilla, breasts,
genitals, elbows, knees, and feet are confirmed to prevent
injury.40,41 Hemodynamic and ventilatory stability is confirmed
once the patient is in the final operative position.42,43 Intra­
operative inspired oxygen fraction (FIO2) is increased to 80%
and a “non-rebreather” mask may be utilized in the post-
anesthesia care unit for 2 h postoperatively because of the
evidence that this intervention reduces the incidence of post­
operative infection and nausea.44,45
Routine postoperative laboratory studies include a com­
plete blood count and basic metabolic panel, serum calcium,
magnesium, and phosphate when combined cases are per­
formed. Other studies such as glucose monitoring, total
protein, albumin, and coagulation studies are performed as
indicated.46 Protein supplementation and nutritional optimi­
zation plays a key role in recovery in the MWL and aesthetic
patient.47,48 Foley catheter placement for monitoring urine
output is also routine. Prophylactic antibiotics are used for
24 h. Sequential compression devices and early ambulation
are routinely used for DVT prophylaxis. Postoperative inject­
able or oral anticoagulants are used synergistically with
compression devices if the patient is at moderate to high risk
for DVT/PE or has a history of previous DVT/PE.49–51 The
dosing of these medications is based on lean body weight and
should be adjusted in the obese patient. Postoperative hema­
tomas, while possible, are not common if a delayed anticoagu­
lant start protocol is utilized. A low index of suspicion should
be maintained and appropriate diagnostic studies ordered
when postoperative anticoagulation is utilized.
Compression garments are not routinely used postopera­
tively. Concerns about skin perfusion and pressure necrosis
over drains relegates their use to the late postoperative period.
Traditional dressings have been replaced by tissue glues to
allow monitoring of skin perfusion and to reduce blistering
caused by shear forces and postoperative edema. Drains are
removed once the output is below 50 cc in 24 h. If drainage is
excessive or prolonged, sclerosis can be performed with a high
concentration doxycycline solution (500 mg in 50 cc 0.9%
normal saline solution) by infusing it through the drain,
clamping for 15–30 min, and then returning to suction. Prior
Bonus images for this chapter can be found online at

Fig. 25.5.13 (A–L) Circumferential bodylift/autologous gluteal auto-
augmentation island flap results.
Fig. 25.5.14 (A–L) Circumferential bodylift/autologous gluteal auto-
augmentation moustache flap results.
2. Da Rocha RP. Surgical anatomy of the gluteal region’s subcutaneous
screen and its use in plastic surgery. Aesth Plast Surg. 2001;25:
140–144.
15. Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty
combined with buttocks pexy. Aesthetic Plast Surg. 1997;21:245–253.
17. Pitanguy I. Surgical reduction of the abdomen, thighs and buttocks.
Surg Clin N Am. 1971;51:479–489.
21. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome)
and clinical territories of cutaneous perforating arteries:
development of the concept and designing safe flaps. Plast Reconstr
Surg. 2011;127:1447–1459.
22. Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast
Reconstr Surg. 2009;123:236–249.
23. Centeno RF. Autologous gluteal augmentation with circumferential
body lift in the masssive weight loss and aesthetic patient. Clin
Plast Surg. 2006;33:479–496.
25. Rohde C, Gerut ZE. Augmentation buttock pexy using autologous
tissue following massive weight loss. Aesthet Surg J. 2005;25:
576–581.
29. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for
autoprosthesis buttock augmentation. Plast Reconstr Surg.
2012;129:766–776.
30. Centeno RF. Gluteal aesthetic unit classification: a tool to improve
outcomes in body contouring. Aesthetic Surg J. 2006;26:200–208.
33. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal
contouring surgery. Clin Plast Surg. 2006;33:347–358.
Access the complete reference list online at

674.e1
Summary
A
B
C
D
E
F
G
H
I
Fig. 25.5.13  (A–L) Circumferential bodylift/autologous gluteal auto-augmentation island flap results.
Continued

674.e2
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
J
K
L
Fig. 25.5.13, cont’d
A
B
C
D
E
F
Fig. 25.5.14  (A–L) Circumferential bodylift/autologous gluteal auto-augmentation moustache flap results.

674.e3
Summary
G
H
I
J
K
L
Fig. 25.5.14, cont’d

674.e4
SECTION II
CHAPTER 25.5 • Circumferential approaches to truncal contouring
References
1. The American Society for Aesthetic Plastic Surgery. 2016 Cosmetic
Surgery National Data Bank Statistics. Available online at: http://

2. Da Rocha RP. Surgical anatomy of the gluteal region’s subcutaneous
screen and its use in plastic surgery. Aesth Plast Surg.
2001;25:140–144.
3. Toth MJ, Tchernof A, Sites CK, et al. Menopause-related changes in
body fat distribution. Ann NY Acad Sci. 2000;904:502–506.
4. Kopelman PG. The effects of weight loss treatments on upper and
lower body fat. Int J Obes. 1997;21:619–625.
5. Ferretti A, Giampiccolo P, Cavalli A, et al. Expiratory flow
limitation and orthopnea in massively obese subjects. Chest.
2001;119:1401–1408.
6. Watson RA, Pride NB. Postural changes in lung volumes and
respiratory resistance in subjects with obesity. J Appl Physiol.
2005;98:512–517.
7. De Souza SAF, Faintuch J, Valezi AC, et al. Postural changes in
morbidly obese patients. Obes Surg. 2005;15:1013–1016.
8. Giusti V, Gasteyger C, Suter M, et al. Gastric banding induces
negative remodeling in the absence of secondary
hyperparathyroidism: potential role of serum C telopeptides for
follow-up. Int J Obes Relat Metab Disord. 2005;29:1429–1435.
9. Vergara R. Intramuscular gluteal implants: fifteen years’ experience.
Aesth Surg J. 2003;23:86–91.
10. de la Peña JA. Subfascial technique for gluteal augmentation. Aesth
Surg J. 2004;24:265–273.
11. Gonzalez-Ulloa M. Gluteoplasty: a ten-year report. Aesthetic Plast
Surg. 1991;15:85–91.
12. Mendieta CG. Gluteoplasty. Aesthet Surg J. 2003;23:441–455.
13. Sinno S, Chang JB, Brownstone ND, et al. Determining the safety
and efficacy of gluteal augmentation: a systematic review of
outcomes and complications. Plast Reconstr Surg. 2016;137:
1151–1156.
14. Mofid MM, Gonzalez R, de la Peña JA, et al. Buttock augmentation
with silicone implants: a multicenter survey review of 2226 patients.
Plast Reconstr Surg. 2013;131:897–901.
15. Gonzalez M, Guerrerosantos J. Deep planed torso-abdominoplasty
combined with buttocks pexy. Aesthetic Plast Surg. 1997;21:245–253.
16. Guerrero-Santos J. Secondary hip-buttock-thigh plasty. Clin Plast
Surg. 1984;11:491–503.
17. Pitanguy I. Surgical reduction of the abdomen, thighs and buttocks.
Surg Clin N Am. 1971;51:479–489.
18. Pascal JF, le Louarn C. Remodeling bodylift with high lateral
tension. Aesthetic Plast Surg. 2002;26:223–230.
19. Regnault P, Daniel R. Secondary thigh-buttock deformities after
classical techniques: prevention and treatment. Clin Plast Surg.
1984;11:505–516.
20. Strauch B, Vasconez LO, Hall-Findlay EJ. Grabb’s Encyclopedia of
Flaps. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1988.
21. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome)
and clinical territories of cutaneous perforating arteries:
development of the concept and designing safe flaps. Plast Reconstr
Surg. 2011;127:1447–1459.
22. Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast
Reconstr Surg. 2009;123:236–249.
23. Centeno RF. Autologous gluteal augmentation with circumferential
body lift in the masssive weight loss and aesthetic patient. Clin
Plast Surg. 2006;33:479–496.
24. Young VL, Centeno RF. Large volume liposuction and adjunctive
procedures. In: Matarasso A, Rubin J, eds. Aesthetic Surgery of the
Massive Weight Loss Patient. Philadelphia, PA: Elsevier, Churchill
Livingstone; 2006.
25. Rohde C, Gerut ZE. Augmentation buttock pexy using autologous
tissue following massive weight loss. Aesthet Surg J. 2005;25:
576–581.
26. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation
during lower body lift. Aesthetic Plast Surg. 2005;29:133–137.
27. Sozer SO, Agullo FJ, Palladino H. Bilateral lumbar hip dermal fat
rotation flaps: a novel technique for autologous augmentation
gluteoplasty. Plast Reconstr Surg. 2007;119:1126–1127.
28. Sozer SO, Agullo FJ, Palladino H. Autologous augmentation
gluteoplasty with a dermal fat flap. Aesthet Surg J. 2008;28:70–76.
29. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for
autoprosthesis buttock augmentation. Plast Reconstr Surg.
2012;129:766–776.
30. Centeno RF. Gluteal aesthetic unit classification: a tool to improve
outcomes in body contouring. Aesthetic Surg J. 2006;26:200–208.
31. Mendieta CG. The Art of Gluteal Sculpting. St. Louis, MO: Quality
Medical Publishing; 2011.
32. Lee EI, Roberts TL, Bruner TW. Ethnic considerations in buttock
aesthetics. Semin Plast Surg. 2009;23:232–243.
33. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal
contouring surgery. Clin Plast Surg. 2006;33:347–358.
34. Gonzalez-Ulloa M. Belt lipectomy. Br J Plast Surg. 1960;13:179–186.
35. Lockwood TE. Lower-body lift. Aesthetic Surg J. 2001;21:355–370.
36. Lockwood TE. Maximizing aesthetics in lateral-tension
abdominoplasty and body lifts. Clin Plast Surg. 2004;31:523–537.
37. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: the University of Iowa experience. Plast Reconstr
Surg. 2003;111:398–413.
38. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200
consecutive cases in the massive weight loss patient. Plast Reconstr
Surg. 2006;117:414–430.
39. Srivastava U, Rubin J, Gusenoff JA. Lower body lift after massive
weight loss: auto-augmentation versus no augmentation. Plast
Reconstr Surg. 2015;135:762–772.
40. Cheney FW, Domino KB, Caplan RA, et al. Nerve injury associated
with anesthesia: a closed claims analysis. Anesthesiology.
1999;90:1062–1069.
41. Kroll DA, Caplan RA, Posner K, et al. Nerve injury associated with
anesthesia. Anesthesiology. 1990;73:202–207.
42. Brodsky J. Positioning the morbidly obese patient for anesthesia.
Obes Surg. 2002;12:751–758.
43. Lincoln JR, Sawyer HP. Complications related to body positions
during surgical procedures. Anesthesiology. 1961;22:800–809.
44. Greif R, Laciny S, Rapf B, et al. Supplemental oxygen reduces the
incidence of postoperative nausea and vomiting. Anesthesiology.
1999;91:1246–1252.
45. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for
prevention of surgical site infection. Infection Control Hosp Epidemiol.
1999;20:247–280.
46. Rubin JP, Nguyen V, Schwentker A. Perioperative management of
the post-gastric-bypass patient presenting for body contour surgery.
Clin Plastic Surg. 2004;31:601–610.
47. Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of
post-bariatric surgery body contouring patients: what every plastic
surgeon should know. Plast Reconstr Surg. 2008;122:604–613.
48. Austin RE, Lista F, Khan A, et al. The impact of protein nutritional
supplementation for massive weight loss patients undergoing
abdominoplasty. Aesthet Surg J. 2016;36:204–210.
49. Young VL, Watson ME. The need for venous thromboembolism
(VTE) prophylaxis in plastic surgery. Aesthet Surg J. 2006;26:157–175.
50. Venturi ML, Davison SP, Caprini JA. Prevention of venous
thromboembolism in the plastic surgery patient: current guidelines
and recommendations. Aesthet Surg J. 2009;29:421–428.
51. Jeong HS, Miller TJ, Davis K, et al. Application of the Caprini risk
assessment model in evaluation of non–venous thromboembolism
complications in plastic and reconstructive surgery patients. Aesthet
Surg J. 2014;34:87–95.
52. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development
following body contouring surgery for massive weight loss: patient
risk factors and treatment strategies. Plast Reconstr Surg.
2008;122:280–288.
53. Bauccu O, Gozil R, Ozmen S, et al. Gluteal region morphology: the
effect of the weight gain and aging. Aesth Plast Surg. 2002;26:
10–133.

SECTION II • General Aesthetic Surgery
26.1 
Buttock augmentation: Introduction
J. Peter Rubin
The following two chapters are absolutely essential for an
understanding of achieving desired results in aesthetic buttock
augmentation. These chapters are led by experts Constantino
Mendieta, Jose Abel De La Peña Salcedo, and Thomas Roberts
III, with the first chapter covering prosthetic implants, and the
second chapter focused on fat grafting and liposuction to
achieve an improved buttock shape. Both chapters will give the
reader a keen understanding of principles of buttock aesthetics
and allow the reader to make decisions about which technique
is most suitable for a specific patient. The aesthetic body con­
touring surgeon should be familiar with both techniques for
buttock augmentation and be able to apply principles of patient
selection to plan the most favorable operation safely and with
the greatest probability of addressing the patient’s goals.
One key point that the reader should take away from these
chapters is that adding volume to the buttock, whether with
autologous fat grafting for prosthetic implants, is only part of
a well-designed strategy to enhance the aesthetic contour of
the buttock region. The “subtractive” aspect of removing
adipose tissue with liposuction from the flanks and hips, or
in some cases excision (as is seen in lower bodylifts with the
weight loss patient), is extremely important and will both
accentuate and magnify the impact of the volume augmenta­
tion. Understanding the fundamentals of buttock aesthetics
and how to best use the subtractive and additive components
will enable the body contouring surgeon to successfully meet
the goals of his or her patients.

SECTION II • General Aesthetic Surgery
26.2 
Buttock augmentation: Buttock
augmentation with implants
Jose Abel De la Peña Salcedo, Jocelyn Celeste Ledezma Rodriguez and David Gonzalez Sosa
SYNOPSIS
■ Buttock augmentation is major surgery, with the potential for significant
complications.
■ The overall goal of buttock augmentation is to achieve a more youthful
appearance and contour and to create the ideal waist-to-hip ratio of
0.7.
■ There are three acceptable methods of buttock augmentation: (1)
silicone implants placed in the subfascial plane; (2) silicone implants
placed in the intramuscular plane; and (3) autologous micro fat
grafting (MFG).
■ Each method of buttock augmentation carries its own set
of complications, risks, surgical equipment needs, and
complications.
■ Preoperative planning and the surgical technique used should
be patient-specific with regard to individual anatomy and patient
desires.
■ Preoperative markings are crucial in guiding the surgical procedure and
should be performed with the patient in a standing position.
Gluteal aesthetic ideals
The attractiveness of the buttocks is not judged in isolation,
but in proportion to the waist. According to Singh,1 there is
one female body shape that men universally find most attrac­
tive (full buttocks, narrow waist). These ideal female propor­
tions are summarized as a waist-to-hip ratio of 0.7 (measuring
the waist at its narrowest and the buttock at the level of
maximum circumference). In addition to this overall propor­
tional relationship, there are various characteristics associated
with attractive youthful buttocks. These include: (1) a smooth
inward sweep of the lumbosacral area and waist; (2) a very
feminine cleavage as the buttocks separate superiorly and
inferiorly; (3) maximum prominence on the vertical axis at the
level of the mid- to upper buttock, and on the transverse axis
at the junction of the medial and central thirds of the buttocks;
(4) minimal infragluteal crease; and (5) no ptosis.2
Cuenca-Guerra and Lugo-Beltran identified four defining
features that stood out as consistent features of beauty: (1)
lateral depression formed by the lateral border of the gluteus
maximus, the quadratus femoris, and the insertions of the
gluteus medius and vastus lateralis to the greater trochanter;
(2) infragluteal fold created by the ischial tuberosity, the inser­
tions of the semitendinous muscle and long belly of the biceps
femoris, and the lower border of the gluteus maximus; (3)
supragluteal fossettes (one on either side), over the posterior
superior iliac spine, created by the multifidus muscle, the
lumbodorsal aponeurosis, and the insertion of the gluteus
maximus; and (4) V-shaped crease, arising in the proximal
portion of the gluteal crease.3
Topographical anatomy
A thorough grounding in anatomy and aesthetics is essential
when dealing with the gluteal aesthetic unit.4,5
The gluteus maximus muscle originates primarily along
the lateral margin of the sacrum and, to a lesser extent, from
coccyx and sacrotuberous ligament. The origin continues in
an upward curvilinear fashion to the posterior iliac spine
(identified as bilateral dimples in the parasacral zone); it only
follows the crest for one-third of its initial distance. The
superior limit of the gluteus maximus muscle is the posterior
iliac spine. The gluteus maximus inserts into the iliotibial
tract, and to a lesser degree, the greater trochanter (Fig. 26.2.1).
Knowledge of the superior aspect of the gluteus maximus
origin is essential in describing the ideal buttock. However,
buttocks aesthetics are not solely dependent on the gluteus
muscles; the overall buttock shape is also influenced by bony
pelvic anatomy, fat distribution, and to a lesser degree, the
tightness of skin. The skin will influence the appearance if
there is laxity or ptosis, as is the case in massive weight loss
patients. In fact, the attractiveness of the female buttock is
primarily dependent on the thickness and distribution of the
fatty layer, which is usually 50–60% of the volume of the
buttock.
  Access video content for this chapter online at expertconsult.com

677
Aesthetic analysis
quadrant individually, then the lower quadrants, three and
four, are equal but tend to be slightly wider than one and two.
In determining the best procedure for a particular patient, all
four quadrants are evaluated as either sufficient or deficient.
Once volume has been assessed, there are three other zones
that surround the buttock, which become important in our
evaluation: the upper inner gluteal/sacral junction, the lower
inner gluteal fold/leg junction, and mid-lateral gluteal/hip
junction.
Upper inner gluteal/sacral junction: ideal
presacral space shape
The inner gluteal/sacral space should be well defined so that
a V-shape is apparent; this lower presacral space is appropri­
ately called the “V” zone (Fig. 26.2.3). As the “V” zone becomes
more visible, the buttock has greater aesthetic appeal. In the
ideal buttock, the gluteal muscle edge should be well defined
and have a semicircular upward turn. If this space is not well
defined, the buttock becomes blunt and appears flat, espe­
cially on the lateral view.
Lower inner gluteal fold/leg junction
To describe this relationship, the intergluteal crease will be
referred to as the midline. The upper aspect of the crease is
easily identified; however, the inferior aspect is defined at the
point where the buttock begins to separate from this midline.
In the ideal buttock, this occurs at about the bottom two-thirds
to three-quarters of the muscle. The separation widens until
it meets the inner leg junction. At this point, the lower gluteal
fold has a 45° take-off from the center intergluteal crease line
and the inner gluteal fold/leg junction should create a
diamond-shape space (Fig. 26.2.4). This is a key point in
gluteal aesthetics.
As the lower inner gluteal fold and inner leg become fuller,
it changes the 45° sloping line to a more horizontal position,
which causes the diamond-shape space to turn into a straight
line, losing its aesthetic appeal (see Fig. 26.2.4). As the fullness
increases, it develops an inverse relationship creating an
upward slope (negative angle) (see Fig. 26.2.4). Improvement
of this zone will depend on the severity of the fullness.
Aesthetic analysis
To evaluate the buttock, it is helpful to divide it into quadrants
by drawing an imaginary line down the center of the buttock.
The ideal buttock has equal volumes on either side of this line
and has the shape of a football.
To further assess volume distribution, a horizontal mid-
buttock line is added to divided the buttocks into four quad­
rants (Fig. 26.2.2). The ideal buttock also has equal volume
above and below this horizontal line. If we evaluate each
Fig. 26.2.1  Anatomy of the gluteus maximus muscle.
Bone
Fat
Gluteal
muscle
Fig. 26.2.2  Ideal gluteal aesthetics based on quadrant analysis.
1
2
3
4
Fig. 26.2.3  The “V” zone. Visible muscle fullness versus loss of definition from
excess fat and back of muscle volume.

678
SECTION II
CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
Fig. 26.2.4  Red lines indicate how the fullness increases at the lower inner gluteal
fold and the diamond zone turns from a 45° into a straight line. (A) Downward
slope; (B) horizontal line; (C) upward slope.
A
B
C
Lateral mid-buttock/hip contour
In the aesthetic buttock, the lateral mid-buttock is an area
without any depression. This zone is categorized as having
no depression, mild depression, and moderate or severe
depression (Fig. 26.2.5).
Lateral view aesthetics
On lateral view, the presacral area should have a sweeping
curve that has a lazy “S” shape (from the back to the bottom
of the gluteus; Fig. 26.2.6). Most of the gluteal volume is
Fig. 26.2.5  Variation in lateral mid-buttock depression. (A) None to mild;
(B) moderate; (C) severe.
A
B
C
central and has equal distribution in the upper and lower
gluteal zones, giving a C-shape curve. It has been suggested
that the peak of the central mound should be at the level of
the pubic bone (Fig. 26.2.7).
Determining where most of the volume lies (upper, central,
or lower buttock) will be important in deciding what proce­
dure is best used to augment the buttock (Fig. 26.2.8).

679
Ethnic considerations
Gluteal augmentation is not just about making the buttock
bigger, but rather accentuating, contouring, and reshaping.
Liposuction is for sculpting, while fat transfers and/or
implants are used for volume expansion.
Ethnic considerations
Ethnic ideals need to be taken into consideration regarding
patient desires (Table 26.2.1).2
Caucasian
These patients generally want buttocks that are full but not
extremely large. Fullness of the lateral thigh is an undesirable
characteristic, but in regard to the lateral buttocks, Caucasians
fall into two categories: some prefer more feminine, full,
rounded buttocks, whereas others prefer flat or hollow lateral
buttocks, which give a more athletic look. Neither of these two
types of patients desire fullness in the lateral thigh.
Hispanic
These patients prefer buttocks and lateral buttocks that are
very full and prefer a slight fullness in the lateral thigh.
Compared with the much fuller lateral thighs requested by
African Americans, Hispanic patients desire slight to moder­
ate lateral thigh fullness. Usually Mexican patients show a
lack of lumbar lordosis and need to add liposuction of this
area to recreate it. Colombian patients show a defined lumbar
lordosis with a thicker subcutaneous tissue.
African American
These women have a strong and consistent ideal of very large
buttocks. In addition, lumbar hyperlordosis is a desirable
feature in addition to fullness of the upper buttocks. A full,
prominent trochanteric area of the lateral thighs is desired and
is still seen as a sign of fertility or fecundity. This lateral tro­
chanteric area is uniquely called “the hip” among African
Americans but most other cultures call the iliac crest “the
hip”. African-American patients have large framed, and very
full lateral thigh (hips), and usually request a significant
Diagnosis/patient presentation
Patients present with a desire to improve their body contour/
proportions, due to aging or general soft-tissue deficiency.
Specific patient desires can be affected by ethnic background
and social relationships. There are six zones where augmenta­
tion is requested: upper medial buttocks, mid medial buttocks,
lower medial buttocks, lateral hollow/trochanteric depres­
sion, lateral thigh, and various localized depressions.
Fig. 26.2.6  Aesthetics of the gluteal region – lateral view.
Fig. 26.2.7  Variation in volume distribution on lateral view.
A
B
C

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CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
fat volume, and appropriate skin elasticity. The first two of
these can be partially supplemented with physical activities
such as stretching and yoga. However, the latter two compo­
nents cannot be altered without surgical interventions. In this
regard, the goal of gluteal augmentation was to restore aes­
thetic back curvature, provide sufficient hip volume (projec­
tion), and reposition the point of maximal gluteal projection
to be higher than the pubic hair.6
These patients prefer small to moderate-size buttocks, and
fullness in the lateral buttocks or lateral thigh is almost never
desired. Moreover, the shape of the buttocks and its relative
proportion to the overall body frame is very important to this
ethnic group. They are usually shorter and smaller than other
ethnic groups, so even small changes in size or shape of the
buttocks can have dramatic results.6
Patient selection
The ideal patients for implants are young, 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.
Aesthetic goals
Singh has documented the importance of an ideal waist-to-
hip ratio of 0.7.1 There is a tremendous synergistic effect of
enlargement of every area of the buttocks with as small a
waist as possible. Another common request that is uniquely
African-American is to create an extreme prominence of the
upper buttocks (“shelf”; Fig. 26.2.9).
Asian
As Park, et al. in the Asian culture is defined by an aggregate
of the following four components: S-shaped curvature from
lower back to buttocks, sufficient muscle volume, sufficient
Table 26.2.1  Ethnic ideals of beautiful buttocks
Buttocks size
Lateral buttocks fullness
Lateral thigh fullness
Asian
Small to moderate, but shapely
No
No
Caucasian
Full, but not extremely large
Rounded (voluptuous) or hollow (athletic)
No
Hispanic
Very full
Very full
Slight fullness
African American
As full as possible
Very full
Very full
Fig. 26.2.8  Ideal gluteal aesthetics. One can see that the upper aesthetic unit of
the gluteus follows its origin; it begins at the midsacral line, continues as a
semicircular line that connects to the posterior iliac spine (identified as bilateral
dimples in the parasacral zone), and peaks at 2–3 cm above this point. In a
well-developed buttock with very little lower presacral fat, a visible “V” zone is
apparent, which further accentuates the upper inner muscle anatomy; the muscle
has a football shape with nearly equal volumes in all four quadrants (quadrants
three and four tend to be slightly wider than quadrants one and two). The gluteal
unit is marked superiorly by its attachment to the iliac ridge (easily palpated) and
inferiorly by the inferior gluteal crease. Without a doubt, the most important
contributor to gluteal aesthetics is the volume of distribution in all four quadrants.
When this volume is adequate, all other aesthetic points can be overlooked and still
render an attractive buttock. Inferior gluteal aesthetics are defined by a diamond
shape at the intergluteal/leg junction; the medial buttock cheeks have a 45° take-off
from the intergluteal line and flows into the inferior gluteal crease, which terminates
at or just beyond the mid-buttock line. On lateral view there is an S-shaped curve
from the lower back as it comes into contact with the buttock and most of the
gluteal volume is located in the central zone.
Fig. 26.2.9  A 36-year-old African-American female (A) before and (B) after
buttocks augmentation with 890 cc of fat grafted per side.
A
B

681
Anatomic planes of dissection for implant placement
Intramuscular plane
Intramuscular implant placement is useful in patients with
thin subcutaneous tissue where palpability is a concern.7
This plane disrupts the muscular fibers of the gluteus
maximus. The goal is to have 2–3 cm of muscle over the
pocket and to leave 3 cm thickness of gluteus maximus deep
to the pocket to protect the sciatic nerve. Because the implant
is placed within the muscle, there are no anatomical land­
marks. Once at the right depth, the surgeon must remember
that this plane is curved like the surface of a globe, so
the dissection must be curved downward as it is carried
superiorly, laterally, and inferiorly. A common problem is to
break out of this plane during superior dissection, perforating
into the subcutaneous tissues. Then when the patient sits, the
implant shifts upwards, causing pain at the iliac crest. Another
technical difficulty is the lack of a natural tissue plane within
the gluteus maximus, which means that the dissection pro­
duces disruption of the muscle fibers, promoting a higher
incidence of seroma and hematoma.
The intramuscular placement has been shown that by
keeping all poles of the implant inside the muscle, sciatic
symptoms are quite rare. Since the gluteus maximus extends
almost to the infragluteal crease, this has facilitated the devel­
opment of elliptical implants, which convey maximal fullness
at the mid-buttock level. A double bubble deformity can also
occur, especially if the implant is not low enough to add
volume to the lower pole.
Subfascial plane
This is an excellent technique developed by the author and
requires textured gel implants.9 This technique is based on
extensive anatomical analysis of the gluteal layers. The gluteal
fascia is very strong (Figs. 26.2.10 & 26.2.11). It covers the
entire gluteus maximus muscle, from origin to insertion.
Subfascial implant placement may provide better augmen­
tation of the lower pole of the buttock, especially in patients
with a long buttock.7
liposuction of the lower back, waist, and flanks in conjunction
with buttock augmentation to achieve this ideal waist-to-hip
ratio. This is clearly evidenced by the fact that fuller, more
shapely buttocks appear more attractive when the waist is
slender rather than fuller.
In attractive female buttocks, there is beautiful cleavage as
the buttocks separate superiorly. Furthermore, there is an
inward sweep of the lower back, lumbar, and sacral area,
which accentuates this cleavage. It is also important to make
the buttocks shorter vertically. A short, full buttock is attrac­
tive. A vertically long buttock simply appears big.
Buttock implants (Video 26.2.1 )
The enhancement of buttock volume with silicone gluteal
implants has rapidly gained in popularity over the past
decade. For many leaner patients, gluteal augmentation with
autologous fat grafting is not an option secondary to the lack
of donor tissue. In those patients, gluteal augmentation with
silicone implants is the only remaining option to increase
buttock volume. According to the of Plastic Society of Plastic
Surgeons, 1149 buttock augmentation with implants were per­
formed in 2011 by member surgeons, up from 542 procedures
performed in 2005, the first year with recorded data for this
procedure.7
Implant placement and selection
There are three main issues that need to be decided when
selecting implants: implant location, shape, and size.
The implant content can be a solid silicone elastomer or
silicone cohesive gel. In a multicenter survey, Mofid et al.
showed that the majority of surgeons (63.2%) used textured
implants.7
Anatomic planes of dissection for
implant placement
Submuscular plane
In 1984, Robles described the submuscular approach.8 This
approach preserves the aponeurotic system that holds gluteal
skin in position and has the advantage of reducing the forma­
tion of capsular contracture. However, it introduced a new
anatomic problem with the potential risk of injury to the
sciatic nerve. This is the largest peripheral nerve in the body,
emerging from the pelvis via the greater sciatic foramen,
entering the surgical plane below the bottom edge superiorly
and laterally around the ischial tuberosity. As the dissection
of the submuscular plane is carried inferiorly, the sciatic nerve
can be injured. Even if the nerve is not injured during dissec­
tion, if the lower edge of the implant extends below the
mid-buttock, it will be resting on the nerve and may cause
symptoms. The submuscular position also has the disadvan­
tage of being a small space and therefore limits the use of large
implants. Consequently, implants should rarely be placed in
this submuscular plane.
Fig. 26.2.10  Cadaver dissection showing the raising of a fasciocutaneous flap.
Subfascial undermining starts at the site of the fascial incision.

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CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
Implant shape selection
Choice of implant shape for the intramuscular plane requires
evaluating two aspects:
1. The muscle height-to-width relationship in the
posteroanterior (PA) view
2. The volume of distribution in the lateral view.
Muscle height-to-width ratio
To find this relationship, identify the superior and inferior
points of the gluteus muscle as well as the most medial and
lateral points. At a glance you will notice a height-to-width
relationship that will fall into one of three ratios:
■ 1 : 1 (short muscle)
■ 2 : 1 (tall muscle)
■ 1.5 : 1 (intermediate).
The ideal buttock is intermediate but leans more towards a
2 : 1 relationship (Fig. 26.2.12).
Implant selection
In the intramuscular implant augmentation, the size is deter­
mined intraoperatively with the aid of sizers so as not to
create muscle tension at closure. Implant shape selection is
based on the muscle height-to-width ratio; the tall buttock
(2 : 1 height-to-width ratio) is best augmented with the ana­
tomic implant. The short buttock (1 : 1 ratio) is best augmented
with the round implant, while the intermediate buttock (1.5 : 1
ratio) may require the lateral view to make the final determi­
nation (Fig. 26.2.13).
The lateral view
The lateral view will evaluate where most of the bulk of the
gluteal volume is located; lower, central (mid-buttock), or
upper buttock.
If the buttocks are fuller inferiorly, a round implant will look
best since the round implant adds most of its projection in the
upper and central zones, equalizing the volumes throughout
the buttock. If the buttocks have no significant projection
superiorly or inferiorly, we prefer the oval implant for the
intermediate or tall muscle. If the maximum fullness is in the
Fig. 26.2.11  Cadaver dissection showing the gluteal aponeurosis as a viable
dissection plane for gluteal augmentation.
A
B
Fig. 26.2.12  Variations in height-to-width ratios in buttock anatomy. (A) Short,
1 : 1; (B) intermediate, 1.5 : 1; (C) tall, 2 : 1.
C
upper buttock, an anatomic implant (maximum prominence
inferiorly) will have the best result since the anatomic design
adds most of its volume inferiorly. If a round implant is used
in these cases, it will accentuate the lower gluteal deficiency
making the buttock look very disproportionate.

683
Intramuscular implant surgical technique
Implant size selection
Selecting implant size involves the fine balance of trying to
obtain the size the patient desires, yet preventing the compli­
cations of implant exposure and wound dehiscence. Often
these are in conflict, as the tissues will not allow as large
an augmentation as the patient desires. In these cases, fat
transfers can be combined to further increase volume. Use of
implants that are 375 cc or less in volume can diminish the
incidence of wound dehiscence by reducing wound tension.7
Since each patient’s anatomy is different and implant expo­
sure rates rise as tension increases, implant size cannot be
determined prior to surgery. Sizers are used intraoperatively to
identify the largest implant the buttock will accommodate,
without creating excessive muscle tension at closure. If the
patient desires a larger augmentation, the implants can be
exchanged with larger implants at 3–6 months, or fat transfers
can be performed. Fat transfers have also been performed at
the same time as the implant augmentation, taking great care
to avoid grafting fat particles in the implant pocket, which
greatly increases the risk of infection. Cannula trauma to the
implant pocket (liposuction or grafting) can increase the risk of
seroma and creates the potential for fracture of the implant.
Intramuscular implant surgical
technique
Markings
The areas to have liposuction or fat transfers are marked in
the preoperative area with the patient in the standing posi­
tion. The intraoperative markings are minimal, identifying
only the tip of the coccyx and infragluteal crease.
Preparation
Preoperative medications include Decadron 10 mg intrave­
nous (IV) and Cleocin 600 mg IV. The pneumatic stocking
compressions are placed and functioning prior to induction.
Anesthesia/positioning
The procedure can be performed under general or spinal
anesthesia. The gluteal area is prepped from the knees to the
upper back and as far lateral as possible. Draping should leave
the entire gluteal zone and lower back exposed; a Betadine-
soaked gauze is placed over the anus and secured with 2-0
Fig. 26.2.13  Standard buttock implant shapes.
Anatomic
Oval
Round
Fig. 26.2.14  Bilateral parasacral incisional markings for implant placement.
A
B
silk so as to avoid contamination. A sterile towel is placed
over the gauze to cover the anus and the inner gluteal zone.
Incision design/ selection
A vertical intergluteal midline incision has been supplanted
by bilateral parasacral incisions. These incisions avoid the
sacral midline with its poor blood supply, thereby decreasing
dehiscence rates to less 10%.
These incisions are designed as follows: with the patient in
the prone position, the tip of the coccyx is palpated and
marked; staying exactly in the sacral midline the central
intergluteal crease is drawn from the tip of the coccyx 8 cm
cephalad. The future incisions are marked 1 cm on either side
of this midline, so that both incisions are 2 cm apart in the
inferior and middle portions. If these lower distances are not
respected, central skin necrosis may occur. As the incision
reaches the upper buttock, it follows the upper gluteal curva­
ture (this occurs at about the 6 cm mark from the coccyx),
becoming 4–5 cm apart (Fig. 26.2.14).
Skin flap dissection
The incision sites are infiltrated with 10 cc of 1% lidocaine
with epinephrine 1 : 100, 000. Tumescent fluid is injected into
the intramuscular and subcutaneous tissues, as well as the

684
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CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
Subfascial implant surgical technique
Markings
With the patient in a standing position, the markings are made
using custom-designed templates. The template must be cen­
tered over the gluteal region leaving at least 2 cm between the
template and the infragluteal fold and 2 cm from the border of
areas to be suctioned. The incision is made down to the gluteal
fascia. Using hooked retractors, the tissues are placed under
upward traction. The dissection is performed, making sure to
preserve the fascia on the muscle. The dissection can be done
with a gauze pad wrapped around the thumb, digitally elevat­
ing the subcutaneous tissues with an upward sweeping
motion. The goal of the initial subcutaneous dissection will be
to expose just enough of the muscle and fascia to allow
implant placement. This usually means a subcutaneous tunnel
8 cm wide and about 6 cm long.
Muscle dissection
Using the midsacral level as the reference point, the fascia is
opened following the dissection of the muscle fibers for a
length of 5 cm.
The intramuscular dissection is started by using a long
curved hemostat (tonsil or Kuettner), perforating the muscle
for a depth of 1 cm and spreading widely so that a ring forceps
can be inserted with the other hand. This is then pushed 1 cm
into the muscle, spread, and the tonsil clamp is inserted, alter­
natively spreading the muscle to a total depth of 2.5–3 cm. This
dissection creates only a small muscular opening, which must
be enlarged. With the use of the cautery, the muscle incision is
opened medially and laterally to its full fascial incision length.
Once the correct depth of dissection is achieved, the Deaver
retractors are introduced on both sides of the muscle and
spread. This is an intramuscular procedure; no plane exists, and
you must create a pocket curved like the surface of a globe. The
closed-ring forceps is used to bluntly push and create the
muscle pocket; the muscle pocket should be kept at 3 cm thick­
ness throughout. It is best to start the pocket dissection in the
superior lateral direction. The pocket is further defined with
the Aiache gluteal muscle dissector (serrated instrument).
Dry, long, narrow lap pads are packed in the wound for
1–2 min. This wait is rewarded by a remarkably dry field.
Sizers/implant size
Once the surgeon is satisfied with the dissection, a sizer is
inserted to determine the appropriate implant that can be
used. When the implant is in place, the edges of the muscle
incision should be in close proximity with very little tension
at closure.
Drains
Once the implant size has been determined, a Jackson Pratt
drain is introduced in the pocket and brought out through a
separate stab incision in the infragluteal crease. The use of a
drain has decreased the incidence of seroma formation. The
majority of surgeons use drains for 4 or more days (63.2%).
Implant placement/closure
The implant pocket is irrigated, the surgical field is reprepped
and redraped, and the implant is introduced with the use of
a sterile sleeve to avoid implant contact with the skin. The
muscle is closed with 2-0 monofilament absorbable suture.
The subcutaneous wound is closed in layers with a final
running 3-0 Vycril. The opposite side is then completed in a
similar fashion. The wounds are further reinforced with
Dermabond to seal the incision and prevent contamination.
Fig. 26.2.15  Illustration showing the correct placement of the implant. Markings
must follow the anatomic shape of the gluteal region and ensure that the implants will
be lateral to the sacrum and positioned at least 2 cm above the infragluteal fold.
2 cm above
gluteal fold
Greater
trochanter
Lateral limit
of sacrum
Posterior
superior
iliac spine
Sacrum
Fig. 26.2.16  The planning for surgery should entail the incision, which at the
present time has been replaced from a single midline incision to two incisions in
the intergluteal crease, therefore isolating completely one pocket from the other;
then, the fascial incision and creation of the subfascial pocket using the gluteus
maximus muscle as a platform for the implant. The horizontal line across each
buttock will be matched to a comparable line on the permanent implant to help
guarantee correct implant alignment.
Incision through
gluteal aponeurosis
Template sized,
positioned,
and outlined
Skin incision

685
Subfascial implant surgical technique
To facilitate visibility while undermining, it is advisable to
dissect from medial to lateral and from cephalic to caudal.
Maintain a wide field to exposure without going beyond the
skin markings.
Create both pockets before introducing any implants so the
volume of the buttock plus an implant on one side does not
interfere with dissection of the contralateral pocket. Once the
pockets are dissected, a sizer is used to evaluate the volume
and shape of the pocket and confirm the correct implant size
for the patient.
Drains
Drains are placed exiting the infragluteal fold. The solid elas­
tomer or cohesive gel implant is then inserted, making sure
that the implant is perfectly aligned on its axis (Fig. 26.2.19) and
fitting loosely inside the pocket (Figs. 26.2.20 & 26.2.21).
the sacrum (Figs. 26.2.15 & 26.2.16). Positioning and incisional
markings are the same as the intramuscular technique.
Technique
The initial incision and dissection is as for the intramuscular
technique. When reaching the muscular aponeurosis at the
lateral border of the sacrum, an 8–10 cm incision into the
aponeurosis is made parallel to the sacrum border entering
the subfascial dissecting plane. Tumescent solution, 100–150 cc,
is instilled with a tumescent cannula. This enables the identi­
fication of the avascular plane deep to the fascia and facilitates
sharp dissection of the septa in the subfascial plane, permit­
ting the elevation of an intact fasciocutaneous flap.
The septae parallel the direction of the muscle fibers and,
therefore, radiate out in a fan-like pattern (Figs. 26.2.17 &
26.2.18).
Fig. 26.2.17  Fascial incision and elevation of the gluteal aponeurosis to create the
implant pocket.
Fig. 26.2.18  Aponeurotic expansions traverse the superior layer of the gluteal
maximus muscle. Dissection between the aponeurotic expansions is essential for
creation of the implant pocket. This view gives a sense of the uniformity of the
space that is shaped like the gluteus maximus muscle below.
Fig. 26.2.19  Anatomically shaped, highly cohesive silicone-filled gel gluteal
implant. The transverse line ensures perfect positioning and alignment inside the
pocket.
Fig. 26.2.20  Undermining of the subfascial plane of dissection must extend 2 cm
beyond the periphery of the implant.
Extent of
undermined
area
Fibers of
gluteus
maximus m.
Cut edge of
gluteal aponeurosis

686
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CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
Drains
While drains are in place, the patient is kept on prophylactic
antibiotics. Antibiotic ointment should be applied to the drain
sites daily. The drains are removed when the output is less than
30 cc/day. They are usually not kept for more than 7–10 days.
Postoperative pain management
Most of the discomfort occurs between days 3 and 10. The
discomfort is greatest in the early mornings. In order to help
with the postoperative discomfort, Medrol dose packs and
Neurontin 100 mg PO bid are helpful. Muscle relaxants are
also prescribed, as well as anxiolytic medications.
Complications
Wound dehiscence
The most common complication reported was wound dehis­
cence. By changing the surgical incision from midsacral to
separate bilateral parasacral incisions, the resultant improved
blood supply has decreased wound dehiscence from 30%
to 5–7.9%.7,8 Should wound dehiscence occur, management
includes meticulous local wound care and serial dressing
changes. The result is wound closure via secondary intention.
Any scar revision can be performed 3–6 months after the
wound is healed (Fig. 26.2.22).
Implant exposure
If no tension is placed during muscle closure, the incidence of
exposure is approximately 2%. If excessively large implants are
placed or the patient has extremely tight muscle fibers with very
little stretch, the incidence can be as high as 30%.8 If implant
exposure occurs, surgery is necessary to irrigate the wound and
exchange the implant. Patients are told that these are implant
salvage techniques and implant removal may be required.
Infection
This is rare with an incidence of approximately 1%. If an
infection develops, treatment usually requires temporary
removal of the implant. Infections most commonly occur
around the 10th to the 14th day postoperatively, but can occur
as late as 3 months.
Minor infection not requiring implant removal presents in
3.6% of the cases.7 However, implants have been salvaged
with implants exchange using a closed antibiotic irrigation
system. The pocket is irrigated for several days. Ultimately,
implant removal may be required in 38% of the patients for
major infection. The infection rate may be higher for surgeons
who do not perform buttock augmentation routinely or have
limited experience with this procedure.7
Seroma
Another common complication of buttock augmentation with
an implant is seroma formation. Both ultrasound and magnetic
resonance imaging can be helpful with diagnosis of peri-
implant seroma. If a seroma occurs, it must be evacuated. The
use of drains has decreased the incidence of seroma in the
immediate postoperative period. Late seroma has an incidence
Closure
Once the implants have been inserted, begin the closure by
reattaching the gluteal aponeurosis at the same level where
it was cut, making sure that no tension is placed in the
suture line. Then separately close the deep and superficial
subcutaneous layers over the sacrum. Finally, each incision
is closed using a running 4-0 monofilament and sealed with
Dermabond.
Postoperative care
Activity
Since most wound dehiscences occur between days 12 and 16,
patients are instructed to minimize activities that cause wound
pressure or friction. They are asked to sleep prone for 3 weeks.
They allowed to sit only when going to the bathroom. After
2 weeks, the patient may return to normal activities, except
for exercise and prolonged sitting. For the first 4 weeks,
driving is nor permitted.
Patients usually return to work after 3 weeks. Patients
can resume physical exercise after 6–8 weeks. If wound
dehiscence occurs, an additional 6 weeks of restricted activ­
ity may be required. The patient may resume unrestricted
activity at 12 weeks postoperatively. The implants will ini­
tially feel very firm, and it will take 3 months for them to
soften.
Garments
If liposuction was performed, patients wear compressive gar­
ments for 6 weeks. If no liposuction was performed, an
abdominal binder is used for 2–3 weeks to place pressure in
the upper part of the buttock. This theoretically helps decrease
tension on the incision.
Fig. 26.2.21  Once the pocket is created, insert a sizer, evaluate the pocket, and
assess implant size and positioning. The implant should fit loosely in the pocket.
Implant inserted
and positioned

687
Complications
incidence. If this occurs, capsulorrhaphy sutures will help
close the pocket (Figs. 26.2.23 & 26.2.24). Excessive implant
palpability is present in 3.4% of the patients.
Hyperpigmentation/skin discoloration
Skin discoloration can occur, especially in the medial quad­
rants. The etiology is unknown but may be associated with
subclinical hematoma. This may be followed by wound
dehiscence, drainage, and exposure and require reoperation
and implant removal. If the discoloration persists and the
wound remains intact without issues, topical skin lighteners
may help.
of 3–3.7% and is usually seen at around 3–6 months postop­
eratively. It has mainly been seen with the use of textured
implants. Resolution requires implant exchange (substituting
for smooth implants), partial capsulectomy, and drainage.
If left untreated, seroma formation may lead to implant
displacement and asymmetry or even infection. Larger
seromas that do not respond to aspiration should be drained
to allow the peri-prosthetic space to shrink around the implant
and reduce the likelihood of implant migration. Seroma for­
mation may be minimized by reduction of activity in the early
postoperative period and by wearing compression garments
for several weeks postoperatively.
Capsular contracture
Capsular contracture has a 1% incidence; it is improved with
implant exchange and partial capsulectomy.
Neuropraxia
Hesitation by surgeons with this technique revolves around
concerns for sciatic nerve injury. Understanding the anatomy
is crucial; however, one must realize that these structures are
deeper than our intended 3 cm muscle thickness dissection.
Patients will complain of sciatic type discomfort and decreased
sensation in the first 4–6 weeks following surgery due to swell­
ing. This acute prolonged pain is present in 4.2% of the cases.7
In these patients, symptoms are improved with physical
therapy, oral non-steroidal anti-inflammatory drugs, and Neu­
rontin. Most of these symptoms will improve and eventually
resolve over the next 2–4 months. Until full recovery occurs, the
patient must be cognizant of the decreased sensation, as any
trauma or ischemia may go unnoticed by the patient.
Implant rotation
This is not an issue with the round implants; however, there
is a small, less than 1%, incidence of implant rotation with the
anatomic implants.
Implant malposition
Over time, the pocket and capsule may widen, thereby dis­
placing the implant (Fig. 26.2.23). This has about a 1–2%
Fig. 26.2.23  Patient with subfascial round implants with subsequent inferior
malpositions.
Fig. 26.2.22  Intramuscular implant
augmentation with dehiscence of the
intergluteal incision 10 days
postoperatively.
A
B

688
SECTION II
CHAPTER 26.2 • Buttock augmentation: Buttock augmentation with implants
Chronic pain
Chronic pain is rare. Possible causes include: myositis, fasci­
itis, capsular contracture, or nerve impingement. On some
occasions, the implant may be too large and results in pain on
sitting as the implant shifts superiorly against the muscle
attachments to the posterior iliac crest. In these cases, decreas­
ing implant size or exchanging from an anatomic to a round
implant may help.
Secondary procedures
Secondary revisions may be necessary in order to achieve the
desired result for our patients. Some secondary procedures
are technique dependent, while others apply to buttock aug­
mentation patients as a whole, regardless of the primary
procedure that was performed.
Scar revision
Following initial buttock augmentation surgery, the final
appearance of the scars required for the surgical procedure
may be suboptimal. This would include the midline or para­
median sacral incisions for buttock implants.
Other complications include the need for implant revi­
sion in 5% of the patients. Implant removal is necessary
in 3.8% of patients for reasons including major infection,
chronic pain, and chronic seromas. An in-depth analysis of
the diagnosis, management and prevention of complications
associated with buttock augmentation has been previously
described.
Conclusion
Gluteal augmentation with silicone implants is a safe and
effective procedure with high patient satisfaction in compari­
son to other implant procedures of the face and body, includ­
ing breast augmentation.
Fig. 26.2.24  Preoperative view of a 38-year-old patient with gluteal hypoplasia.
The patient was subjected to a gluteal augmentation 2 years before using a small
intramuscular implant. Note the high-sitting implant and double contour of the
buttock profile.
Skin ulceration
This is rare but seen more in subcutaneous and subfascial
placements. This will require the removal of implants and a
wait of 3–6 months for correction.
1. Singh D. Universal allure of the hourglass figure: an evolutionary
theory of female physical attractiveness. Clin Plast Surg. 2006;33:
359–370.
2. Roberts TL 3rd, Weinfeld AB, Bruner TW, et al. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394.
The largest series of augmentation by fat grafting with the technique well
illustrated. The authors report for the first time the importance of ethnic
variations in the perception of ideal shape and how to obtain these ideals.
Also documented for the first time is the importance of the ideal 0.7
waist-to-hip ratio and a fascinating appendix summarizing Singh’s theory
of why it is truly universally acknowledged as the ideal female shape.
3. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics
and surgical techniques. Clin Plast Surg. 2006;33:321–332.
4. De la Peña JA, Rubio OV, Cano JP, et al. History of gluteal
augmentation. Clin Plast Surg. 2006;33:307–319.
5. Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body
contouring surgery. Clin Plast Surg. 2006;33:347–358. An outstanding
and well-illustrated description of the anatomic relationships that must be
understood to safely perform the various techniques of buttocks
augmentation.
6. Park TH, Whang KW. Buttock resharping with intramuscular gluteal
augmentation in an Asian Ethnic group: A six-yearexperience with
130 patients. Ann of Plast Surg. 2016;77(3):272–279.
7. Mofid MM, Gonzalez R, De la Peña JA, et al. Buttock augmentation
with silicone implants: a multicenter survey review of 2226 patients.
Plast Reconstr Surg. 2013;131:897–901.
8. Mendieta CG. Gluteoplasty. Aesthet Surg J. 2003;23:441–455.
9. De la Peña JA, Rubio OV, Cano JP, et al. Subfascial gluteal
augmentation. Clin Plast Surg. 2006;33:405–422. The most
comprehensive paper on this technique by its developer. These excellent
results depend on the use of the author’s silicone gel implant, which is not
available in the United States; the available elastomer complications
preclude this technique.
Access the complete reference list online at

688.e1
Further reading
Further reading
De la Peña JA. Subfascial technique for gluteal augmentation. Aesthet
Surg J. 2004;24:265–273.
Flores-Lima G, Eppley BL, Dimas JR, et al. Surgical pocket localization
for gluteal implants: a systematic review. Aesthetic Plast Surg.
2013;37:240–245.
Mendieta CG. Classification system for gluteal evaluation. Clin Plast
Surg. 2006;33:333–346.
Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast
Surg. 2006;33:423–434.
Roberts TL, Toledo LS, Badin AZ. Augmentation of the buttocks by
micro fat grafting. Aesthet Surg J. 2001;21:311–319.

SECTION II • General Aesthetic Surgery
26.3 
Buttock augmentation: Buttock shaping
with fat grafting and liposuction
Constantino G. Mendieta, Thomas L. Roberts III, and Terrence W. Bruner
SYNOPSIS
■ Ideal candidates for augmentation by autologous fat grafting
have sufficient liposuction donor sites to provide adequate fat
for grafting.
■ Buttock augmentation by autologous fat grafting is extremely
technique-dependent and requires meticulous attention to sterility and
even distribution of grafted fat over hundreds of passes, from
mid-muscle to skin.
■ The synergistic effect of augmentation combined with concomitant
liposuction is the optimal method to achieve ideal proportions.
■ Preoperative markings are crucial in guiding the surgical procedure
and should be performed with the patient in the standing
position.
■ Sitting is allowed postoperatively by using a pillow that is placed in the
posterior thigh; this will raise the buttock, keeping pressure off it. The
pillow is used for 6 weeks.
Access the Historical Perspective section online at

Introduction
Autologous fat grafting (AFG) is a powerful technique for
buttock enhancement. Successful treatment starts with a
careful analysis of the patient’s anatomic features and surgical
planning based on aesthetic goals. Importantly, optimal
buttock shaping often results from a combination of adding
fat to deficient regions and subtracting fat tissue from regions
where too much is present.
Gluteal aesthetic ideals
Gluteal aesthetic ideals are presented in a comprehensive
manner in Chapter 26.2, and the reader is referred to that
section for an overview of the anatomy, aesthetic analysis, and
ethnic considerations in planning a surgical approach.
Diagnosis/patient presentation
Patients present with a desire to improve their body contour/
proportions due to aging or general soft-tissue deficiency.
Specific patient desires can be affected by ethnic background
and social relationships. There are six zones where augmenta­
tion is requested: upper medial buttocks, mid medial buttocks,
lower medial buttocks, lateral hollow/trochanteric depres­
sion, lateral thigh, and various localized depressions.
While many surgeons and patients think about gluteal
augmentation as a procedure to make the buttocks bigger, that
is only part of the process in achieving aesthetic improvement
in the buttock shape. The real focus becomes volume redistribu­
tion – shifting volume from an unattractive zone to a more
desirable position. With this perspective, even the full-figured
woman becomes a candidate since, on closer examination,
the large buttock has maldistributed adiposity, with deficient
volume in pertinent aesthetic zones (Fig. 26.3.1). Liposuction is
for sculpting, while fat transfer is used for volume expansion.
Patient selection
Who is a good candidate for autologous fat
grafting of the buttocks?
Every patient has different aesthetic goals and volume prefer­
ences; therefore, the patient has to have enough fat to deliver
the desired shape and size of buttock. This will vary in every
patient, but the goal is to graft between 500 and 1500 cc per
buttock (in some cases more), depending on patient frame and
goals. There is no foolproof way of assessing how much fat is
available other than surgeon experience and the pinch test.
Using body mass index (BMI) has not been helpful since some
patients are skinny-fat (thin with a thick layer of fat on pinch
  Access video lecture content for this chapter online at expertconsult.com

689.e1
Historical perspective
Historical perspective
Buttock augmentation advanced with the advent of autolo­
gous fat grafting, first reported by Chajchir and colleagues in
1990.1 Since then, there has been an increase in the literature
documenting that there is one female body shape that is
universally found to be most attractive, with the buttocks as
one of the two most important determinants of beauty of the
female torso. This attractiveness is directly related to the
proportion of the waist to the buttocks, or the waist-to-hip
ratio.2,3
Patient and physician interest gradually escalated during
the late 1990s and through to today.4–6 Over that time, there
has been an evolution in gluteal augmentation, with modifica­
tions in the approach, understanding of the various anatomi­
cal planes for implant insertion, and improvement of the
surgical technique for implant-based augmentation.7–12 We
have learnt that AFG is a versatile technique for buttock
shaping and augmentation, and there has been refinement
of the autologous fat grafting technique to improve fat sur­
vival, minimize complications, and optimize outcomes for
patients.13–16

690
SECTION II
CHAPTER 26.3 • Buttock augmentation: Buttock shaping with fat grafting and liposuction
Aesthetic goals
Research by Singh, as well as other authors, has documented
the importance of an ideal waist-to-hip ratio of 0.7.2 I have found
that in some cultures a 0.6 can be extremely desirable. There is
a tremendous synergistic effect of liposuction of the lower back,
test), while others may have a large BMI but the fat is mostly
visceral. In cases where you may be in doubt if enough fat is
available, the patient can gain 10–20 lb. Chapter 26.2 discusses
buttock augmentation with implants. For a detailed summary
of the advantages and disadvantages of the various techniques
for buttock augmentation, see Table 26.3.1.
Fig. 26.3.1  Improvement of the gluteal
region with overall volume redistribution.
A
B
Table 26.3.1  Advantages and disadvantages of various techniques of buttocks augmentationa
Autologous fat grafting:
current technique (excluding
>1000 cc/buttock) (n = 74)
Intramuscular or
submuscular implants
Subfascial implants
(semisolid, textured)
Possible to consistently obtain ideal
proportions (WHR = 0.7) in one
operation?
Yes
No
No
Can this technique meet all ethnic shape
requests?
Yes
No
No
Area of buttock that can be augmented
Any and all areas
Upper and mid-buttock only
Lower and mid-
buttock only
Augment lateral buttock?
Yes
No
Minimally
Augment lateral thigh?
Yes
No
No
Possible to lipo sacral area at same time?
Yes
No
No
Shifting of implant possible?
No
Yes
Yes
Can this technique consistently deliver as
large a size as the patient desires?
Yesb
No
Often, but not always
Edge of implant visible?
No
Occasionally “double bubble”
Occasionally
Implant palpable (firm)?
0%
10%
100%
Foreign body concerns for patient?
No
Yes
Yes
Future silicone litigation possible?
No
Yes
Yes
Wound dehiscence
0% (but 4% have <2 cc sterile
drainage/day for 1–6 weeks)
About 30%
About 30%
Seroma around implant
0%
2–4%
19%
Length of operation
5–6 h
2–4 h
4 h
Infection
2.7%
1.4%
7%
Total major complications
2.7%
15–25%
35%
aSee also Bruner TW, Roberts TL 3rd, Nguyen K. Complications of buttocks augmentation: diagnosis, management, and prevention. Clin Plast Surg. 2006;33:449–466.
bUnless patient requests large augmentation >1000 cc.
WHR, waist-to-hip ratio.

691
Fat grafting surgical technique
Harvesting and preparing fat is a multiple-step process. A
4 or 5 mm harvesting cannula is used with the power-assisted
liposuction (PAL) device (MicroAire). Since incorporating the
use of the PAL hand-held device, the authors feel there has
been a reduction in the time required to harvest the appropri­
ate amount of fat without compromising fat survival. It is
essential that the vacuum used to provide negative suction be
maintained at <24 inches of mercury, otherwise “gassing-out”
of oxygen and nitrogen can disrupt cell membranes and
markedly decrease fat survival.
The collection and reinjection technique has changed as the
procedure has evolved. Many different systems are available
to collect and reinject, and the surgeon can use what he or she
is most comfortable with. The current preparation system
used by the author for fat involves a decanting method. This
preserves the smaller fat cells but at the expense of having
more liquid in the injected fat. This is a drawback of this
system, but hopefully, as technology advances, we will have
a better preparation system.
In the past, syringes were used to inject fat, but due to
technical advancements, a reinfusion pump with a closed
system is used. This facilitates injections tremendously and
makes the procedure extremely efficient. Therefore, two
systems are involved in the reinjection process: The first is the
cannula system to inject the fat; this is a power-assisted recip­
rocating 4–5 mm vibrating basket cannulas system (Micro­
Aire). If you do not have a power-assisted vibrating system,
then a regular liposuction cannula system can be used. The
reciprocating power-assisted vibrating cannula will expand
tissues, pre-tunnel the area allowing for release of tight dermal
attachments, and create space for the fat to be injected. The
second equipment used is a reinfusion pump, this pump
system will reinject the fat directly from the canister; this way
the fat is not manipulated or exposed to air. Several systems
are available. The system described is the Wells Johnson High
Volume Precision Auto-Graft System (HVP).
The fat is collected in a large 2–3 L canister that has a bottom
port with a Y connector that allows removal of the liquid
through one of the tubes. The extraction end of the tubing can
then be clamped and the reinjection tubing used to reinject
through the pump. The reinjection cannula used is the 5-mm
basket attached to the reciprocating PAL. Prior to transferring
the fat, 10 cc of an antibiotic solution (3 g ampicillin/sulbactam
and 80 mg gentamicin plus 1 g cefazolin in 1000 cc of saline) are
injected into the canister at every 500 cc mark of fat collected.
Any grafting to the anterolateral areas is performed at this
time with the patient in the supine position. The patient is
then placed in the lateral decubitus position to complete the
liposuction of the flanks, lower thoracic, and lumbosacral
areas. Injections will also occur in the lateral decubitus posi­
tion to work on the lateral buttock zones, prior to placing the
patient in the prone position to finalize the suction. The prone
gluteal fat injections will be performed in all anatomic layers
from the mid gluteal muscle up into the subcutaneous tissues.
(Avoid deep injections into the muscle to prevent injury to the
gluteal vessels as they exit the piriformis). You can assure
mid-muscle placement by placing the injection cannula paral­
lel to the posterior leg (no downward angling of the cannula).
It is essential to maintain an awareness of the course of the
sciatic nerve and avoid compression or trauma to it. Subcuta­
neous injections are for reshaping the buttock, and muscle
injections are for volume.
waist, and flanks in conjunction with buttock augmentation to
achieve this ideal waist-to-hip ratio. This is clearly evidenced by
the fact that fuller, more shapely buttocks appear more attrac­
tive when the waist is slender rather than fuller.
A specific goal is achieving a cleavage of the buttocks
superiorly, along with lordotic curve. Buttock height should
be short, as this is more of an aesthetic shape than a vertically
long buttock.
Fat grafting surgical technique
Pre-surgical markings
There are two essential points regarding appropriate marking
for buttock augmentation by autologous fat grafting. The first
is to thoroughly sculpt the flanks, lumbar area, and lumbosa­
cral area to create an inward sweep, which will synergistically
emphasize the new fullness of the buttocks after fat grafting.
This includes performing liposuction to create a deep sacral
“V”, which will enhance the superior gluteal cleavage. This is
further accentuated by grafting the upper medial buttocks,
immediately adjacent to the sacrum. Second, it is important
to have adequate donor sites. Clinically, we have discerned
no difference of fat survival from the various areas that are
used for donor fat. The vast majority of buttock augmentation
procedures range from grafting 500 cc (small-framed petite
patients) to 1500 cc (larger-framed patients) per buttock. Up
to one-third of the fat that is harvested may become damaged
during the harvesting process, meaning that 3000–4000 cc
must be available for the body.
The areas of maximum prominence should be at the junc­
tion of the middle and central thirds transversely and the mid
and upper poles of the buttocks. The patient is asked to bring
a favorite bathing suit and markings are made outlining the
borders of the swimwear and, during the surgical procedure,
every effort is made to place liposuction incisions within the
boundaries of these markings.
Surgical technique
This is a three-dimensional procedure; therefore, liposuction
as well as the fat injections will be performed by placing the
patient in the supine, lateral decubitus, and prone positions.
In preparation, the patient will have a warming blanket placed
on the surgical table, which is covered by a sterile sheet;
pneumatic stocking compressions are placed prior to induc­
tion and a Foley catheter inserted once under general anes­
thesia. Therefore, after marking, the patient undergoes a
standing circumferential povidone–iodine prep; if allergic,
then Hibiclens. Antibiotic prophylaxis is clindamycin 600 mg
intravenous (IV) (30 min prior to procedure), and cefazolin
(Ancef) 1 g at the end of the procedure. A sterile towel is
placed in the small of the back to help facilitate turning. Since
constant turning is being performed, there are no drapes on
the patient except for the anesthesia end. The procedure takes
about 1 h 30 min to 2 h.
Maximum effort is made to maintain sterility and prevent
infection. With the patient in the supine position, tumescent
solution is infused to all of the fat donor sites and is warmed
up to 110–115°F just prior to infusion. This is an excellent
method of maintaining the patient at appropriate body tem­
perature during the surgical procedure.

692
SECTION II
CHAPTER 26.3 • Buttock augmentation: Buttock shaping with fat grafting and liposuction
Interestingly, BMI does not appear to correlate with the overall
incidence of both major and minor complications, which
include the following:
Infection
There are certain predisposing factors associated with fat
grafting that make infection a significant concern. These
include potential contamination of the fat during the harvest­
ing, preparation, and grafting process; the presence of the anus
within the operative field and in close proximity to the opera­
tive incisions; and the generally poor vascularity of the recipi­
ent site (the buttock being primarily comprised of fat) for
placement of non-vascularized fat grafts into a warm, moist
environment. The most common cultured bacteria associated
with infections are Gram-negative bacteria and skin flora.
Management of an infection includes culture-specific antibiot­
ics. Localized abscess formation can occur and usually requires
drainage and local wound care. Mycobacterial infections are
known to occur; these manifest at 1–3 months post-surgery.
Seromas
Because extensive liposuction of the flanks, lower lumbar, and
sacral area is performed to achieve gluteal cleavage and an
inward sweep of the lower back, this area is prone to accumu­
lation of fluid postoperatively. Seroma formation in the
postoperative period generally requires serial aspiration and
optimization of compression. Percutaneous placement of a
pigtail drain may be needed for larger, recurrent seromas.
Neuropraxia
There is a small but significant risk of patients developing
neuropraxic injury or sciatic nerve compression. Management
includes both medical and surgical options. The administra­
tion of Neurontin and steroids, as well as non-steroidal anti-
inflammatory drugs, will markedly improve the symptoms
that the patients are experiencing. Should more severe sciatic
compression be of concern, surgical management consists of
liposuction of any fat grafted around the sciatic nerve.
Hematologic and metabolic disturbances
Symptomatic hypovolemia may present during the first
couple of days postoperatively and is best managed with PO
fluid intake, and in more severe cases, administration of IV
fluid. To prevent any metabolic and electrolyte disturbances,
patients are encouraged to drink a gallon of sport electrolyte
drink on a daily basis.
Anemia may occur requiring blood transfusion. The hemo­
globin can be typically falsely low due to fluid shifting. On
occasions, it can be seen to be in the mid 7 to low 8 g/dL
range. If the patient is not symptomatic, an observation period
is suggested with iron supplementation.
Secondary procedures
Additional augmentation
There may be limitations regarding the amount of fat avail­
able from donor sites or the quantity of fat grafted in a single
setting. A second episode of fat grafting can be performed.
Final contouring is performed by judicious liposuction to
achieve the desired contour. Virtually all areas that are
dimpled or flat and resist distension are tethered down by a
fascial band to the muscle. Even if you can hydraulically
pump these areas up, they will reappear postoperatively
unless the tethering bands are selectively released. This is
performed with a J-shaped dissector and should only be done
after fat has been forcefully grafted into the area. The
J-dissector may need to be passed extensively, but only in a
radial fashion; a sweeping motion can accomplish complete
subscission and must be avoided, as this can result in a bulge.
A compressive garment is applied. A 3-inch-thick gauze tri­
angle made from Kerlix rolls is applied to the lower lumbar/
sacral area to help facilitate skin adherence to the sacrum and
maintain the superior gluteal cleavage and inward sweep of
the lumbosacral area. The sacral incision is left open to allow
for drainage as well as both groin access incisions.
Postoperative care
Buttock augmentation by autologous fat grafting is performed
on an outpatient basis. The patient must meet standard criteria
for appropriate discharge, as outlined by accrediting organi­
zations. It is essential that each patient have a competent
caregiver for the first 3–4 days postoperatively. A Foley cath­
eter is left for the first 24 h, since there are no drains and no
postoperative antibiotics are used.
Activity and follow-up
The patient is allowed to sit by placing a pillow in the poste­
rior leg. This will elevate the buttock, keeping pressure off the
grafted gluteal areas. The patient must sleep in the prone
position and is encouraged to ambulate as much as possible
starting the evening of surgery. A buttock examination is
performed by the patient on a daily basis to check for any
areas of redness or tenderness. The compression garment is
worn for 4 weeks. Patients can resume regular exercise at 6
weeks. The patient may resume unrestricted activity at 8
weeks postoperatively.
Outcomes, prognosis, and
complications
Buttock augmentation by autologous fat grafting can restore
a more youthful appearance to the female buttocks and better
approximate the aesthetic ideal waist-to-hip ratio of 0.7.
Outcomes are patient specific and dependent upon how well
the surgical procedure achieves the patient’s desires. This
requires taking into consideration the ethnic identity of the
patient and incorporating this into the surgical procedure.
Overall, patients are extremely satisfied with the surgical
results and often comment about their improved self-image.
In general, autologous fat grafting provides greater flexibility
in obtaining the desired degree of augmentation, as well as
achieving the various ethnic ideals, as previously described.
Complications of grafting
The complications associated with buttock augmentation by
fat grafting are diverse and vary in acuity and severity.

693
Secondary procedures
1. Chajchir A, Benzaquen I, Wexler E, et al. Fat injection. Aesthetic Plast
Surg. 1990;14:127–136.
2. Singh D. Body shape and women’s attractiveness: the critical role of
waist-to-hip ratio. Hum Nat. 1993;4:297–321.
3. Singh D. Universal allure of the hourglass figure: an evolutionary
theory of female physical attractiveness. Clin Plast Surg. 2006;33:
359–370.
4. Roberts TL, Toledo LS, Badin AZ. Augmentation of the buttocks by
micro fat grafting. Aesthet Surg J. 2001;21:311–319.
9. Mendieta CG. Classification system for gluteal evaluation. Clin Plast
Surg. 2006;33:333–346.
13. Roberts TL 3rd, Weinfeld AB, Bruner TW, et al. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394.
The largest series of augmentation by fat grafting with the technique well
illustrated. The authors report for the first time the importance of ethnic
variations in the perception of ideal shape and how to obtain these ideals.
Also documented for the first time is the importance of the ideal 0.7
waist-to-hip ratio and a fascinating appendix summarizing Singh’s theory
of why it is truly universally acknowledged as the ideal female shape.
14. Guerrerosantos J. Autologous fat grafting for body contouring. Clin
Plast Surg. 1996;23:619–631.
15. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation
with fat grafting. Aesthetic Plast Surg. 2000;24:412–417.
16. Toledo L. Syringe liposculpture: a two-year experience. Aesthetic
Plast Surg. 1991;15:321–326.
Access the complete reference list online at

693.e1
References
References
1. Chajchir A, Benzaquen I, Wexler E, et al. Fat injection. Aesthetic Plast
Surg. 1990;14:127–136.
2. Singh D. Body shape and women’s attractiveness: the critical role of
waist-to-hip ratio. Hum Nat. 1993;4:297–321.
3. Singh D. Universal allure of the hourglass figure: an evolutionary
theory of female physical attractiveness. Clin Plast Surg. 2006;33:
359–370.
4. Roberts TL, Toledo LS, Badin AZ. Augmentation of the buttocks by
micro fat grafting. Aesthet Surg J. 2001;21:311–319.
5. Gonzalez R. Augmentation gluteoplasty: the XYZ method. Aesthetic
Plast Surg. 2004;28:417–425.
6. González-Ulloa M. Gluteoplasty: a ten-year report. Aesthetic Plast
Surg. 1991;15:85–91.
7. Mendieta CG. Intramuscular gluteal augmentation technique. Clin
Plast Surg. 2006;33:423–434.
8. De La Peña JA, Rubio OV, Cano JP, et al. Subfascial gluteal
augmentation. Clin Plast Surg. 2006;33:405–422.
9. Mendieta CG. Classification system for gluteal evaluation. Clin Plast
Surg. 2006;33:333–346.
10. Robles JM, Tagliapertra JC, Grandi MA. Gluteoplastia de aumento:
implante submuscular. Cir Plast Iberolatinoamer. 1984;10:365–375.
11. Vergara R, Amezcua H. Intramuscular gluteal implants: 15 years’
experience. Aesthet Surg J. 2003;23:86–91.
12. Vergara R, Marcos M. Intramuscular gluteal implants. Aesthetic Plast
Surg. 1996;20:259–262.
13. Roberts TL 3rd, Weinfeld AB, Bruner TW, et al. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394.
The largest series of augmentation by fat grafting with the technique well
illustrated. The authors report for the first time the importance of ethnic
variations in the perception of ideal shape and how to obtain these ideals.
Also documented for the first time is the importance of the ideal 0.7
waist-to-hip ratio and a fascinating appendix summarizing Singh’s
theory of why it is truly universally acknowledged as the ideal female
shape.
14. Guerrerosantos J. Autologous fat grafting for body contouring. Clin
Plast Surg. 1996;23:619–631.
15. Peren PA, Gomez JB, Guerrerosantos J, et al. Gluteus augmentation
with fat grafting. Aesthetic Plast Surg. 2000;24:412–417.
16. Toledo L. Syringe liposculpture: a two-year experience. Aesthetic
Plast Surg. 1991;15:321–326.