- Email: [email protected]
Gluteal Recontouring With Combination Treatments: Implants, Liposuction, and Fat Transfer
395
CLINICS IN PLASTIC SURGERY Clin Plastic Surg 33 (2006) 395–403
Gluteal Recontouring With Combination Treatments: Implants, Liposuction, and Fat Transfer Adrien E. Aiache, -
MD, FACS
Gluteal augmentation with implants Combination gluteal implants and liposuction techniques
Patients seeking augmentation or recontouring of the gluteal region have three basic options: gluteal implants, liposuction, and augmentation with fat injections. In many cases, all three treatments are used together to achieve attractively shaped buttocks with proper proportions and good projection. The treatment or combination of approaches that is appropriate for each individual patient is discovered through consultation that focuses on understanding a patient’s goals. To determine the treatment(s) required by a patient, his or her unique anatomy must be analyzed to identify gluteal areas that have excesses or deficiencies that can be successfully addressed in gluteal recontouring.
Gluteal augmentation with implants The choice of the most appropriate implant type and position is a cooperative effort between the patient and plastic surgeon. What the patient hopes to achieve and his or her individual anatomy must be carefully evaluated before surgery
-
-
Autologous fat injections for buttocks augmentation References
to prevent postoperative dissatisfaction with the results. As part of the consultation, the advantages and disadvantages of the various types, shapes, and positions of gluteal implants must be thoroughly explained during the informed consent process. The anatomy and shape of the buttock before surgery determine the type of implant that will produce the optimal results. When considering a patient’s anatomy, the width of the pelvis is critical. For example, thin patients with narrow hips have better results with round or high projection oval implants that have a relatively small base diameter. In contrast, patients with broad, wide hips benefit from low projection implants with a wider base even though these implants tend to produce less projection. Some degree of compromise is often required, which must be discussed with patients. Patients who have a marked pelvic curvature must be approached carefully to avoid producing excessive projection of the buttock (as in the Hottentot Venus body type). Implants with low projection are preferred in patients with marked lordosis and a flat lower spinal region for fear of creating
9884 Little Santa Monica Boulevard, Suite 102, Beverly Hills, CA 90212, USA E-mail address: [email protected] 0094-1298/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2006.04.004
396
Aiache
a poorly shaped upper buttock (Fig. 1). The risk of this deformity increases when implants are in a submuscular or intramuscular position because this type of placement creates more projection in the upper buttocks. Implant spacing is another important factor that surgeons and patients must consider when planning gluteal augmentation. The space between gluteal implants should be without tension to minimize the risk of wound breakdown. For patients who desire wider spacing between implants, they may be placed more laterally, as seen in Fig. 2. This positioning can be helpful in filling the posterior trochanteric depression that is objectionable to some patients. In 1984, Jose Robles and his colleagues [1] of Buenos Aires, Argentina, described the submuscular implantation of solid elastomer implants for preventing the problems seen with subcutaneous placement of gluteal implants. His technique became popular in the United States despite the additional technical difficulties that accompany submuscular placement because it helped prevent the capsular contracture seen in subcutaneous
implants. Placement of submuscular implants is technically demanding because dissection of the submuscular space is limited inferiorly by the exit of the sciatic nerve into the lower buttocks (Fig. 3). Placement of implants in a submuscular or intramuscular position is the best option for patients who desire increased volume in the upper pole (Fig. 4). Placing implants beneath or within the gluteal maximus muscle allows for higher positioning, as illustrated in Fig. 5. However, these patients must be closely evaluated because creating too much upper pole fullness may require liposuction to restore a more harmonious contour. Implants placed in the subfascial plane are capable of augmenting the entire buttock because this position accommodates the use of implants that are large and wide, as illustrated in Fig. 2. Ideally, subfascial implants should be soft, textured, or have a polyurethane cover, but this implant model is not available in the United States. The textured surface reduces the risk of displacement and dislocation, which can result in
Fig. 1. This 48-year-old woman with lordosis post spinal surgery underwent gluteal augmentation with implants and lower buttock liposuction. Patients like this require low-profile implants. Preoperative views (A, C) and postoperative views (B, D) are shown.
Gluteal Recontouring With Combination Treatments
Fig. 2. Subfascial implants with a relatively wide base (postoperative views B, D) were selected to help fill in the trochanteric depressions the patient objected to (preoperative PA views A, C). Autologous fat transplantation was also used to even out the gluteal contour.
extrusion or deformity. Because subfascial positioning is the most superficial of the implantation planes, the buttock shape directly depends on the shape of the implant itself. There is less tissue coverage of the implant in this position so even minor asymmetries are more likely to be visible. The gluteal fascia is poorly developed and consists essentially of fascial bands penetrating vertically into the gluteus maximus muscle. Because of this anatomy, subfascial implants can be placed partially or totally in the subcutaneous plane. They therefore produce results similar to those reported in the early days of gluteal augmentation when implants were placed in the deep subcutaneous plane. In Mexico and South America, implants designed specifically for subfascial plane placement consist of cohesive silicone gel with a polyurethane textured surface. Such
implants stay in position, have a natural feel, and are less likely to produce capsular contracture. The soft solid elastomer implants available in the United States for subfascial placement eventually develop a capsule that contracts and may sometimes secrete fluid forming seromas that are difficult to correct. This complication may require multiple aspirations and at times removal of the implants. Gluteal implants have come a long way since the early days when breast implants were used for buttock augmentation. Because implants filled with cohesive gel and a polyurethane cover are not available in the United States, the latest generation of devices that may be used consist of soft silicone elastomer with either a smooth or textured surface. The author uses these implants with good results when they are placed in the
397
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Aiache
submuscular plane. Outcomes are less successful when these soft solid implants are used in the subcutaneous or subfascial planes.
Combination gluteal implants and liposuction techniques
Fig. 3. Anatomy and landmarks for placement of submuscular gluteal implants. Note the lower landmark consisting of the piriformis muscle, below which the sciatic nerve exits.
Liposuction is often needed to enhance the results of gluteal augmentation with implants. The areas that benefit from contouring liposuction are the flanks, the presacral area, the hips, the inner and outer thighs, and the infragluteal ‘‘banana roll’’ area. Liposuction may be done conservatively at the time of gluteal implant placement or as a secondary procedure at a later time. In both scenarios, liposuction adds definition to the gluteal aesthetic unit and refines the overall shape of the buttocks following gluteal implantation. In the example seen in Fig. 6, the patient received a unilateral implant and liposuction was a useful adjunct for improving the overall buttock contour. If liposuction is performed in the central cleft area, some presacral fat Fig. 4. (A–D) This 36-year-old woman received submuscular implants and liposuction to even out the ‘‘banana roll’’ area beneath the buttocks. She also received autologous fat injections in this zone. The postoperative lateral view (D) is a good example of how submuscular placement creates fullness in the upper gluteal region.
Gluteal Recontouring With Combination Treatments
Fig. 5. Schematic view of submuscular implant (in green) placement shows why this position produces most of the projection in the upper buttock.
should be conserved to prevent wound dehiscence postoperatively. The combination of gluteal augmentation with implants and liposuction is especially beneficial for patients who are overweight or obese and desire increased volume for gluteal projection to counteract the flattening that is often associated with weight gain and weight loss. For these patients, treatment often consists of augmentation with implants plus liposuction of the abdomen, flanks, waist, and/or infragluteal area. Massive weight loss patients who have undergone lower body lift may not need liposuction with their gluteal augmentation. Instead, autologous fat injections may be required to fill depressions and smooth the overall buttock contour (Fig. 7). A common complaint of patients seeking improved gluteal contour is the bulge or fat excess in the infragluteal area, commonly called a ‘‘banana roll.’’ A naturally occurring banana roll,
Fig. 6. Preoperative (A, C) and postoperative (B, D) views of a 24-year-old woman with poliomyelitis sequelae of left buttock underdevelopment. She received a unilateral implant on the left as well as contouring liposuction of the gluteal region, saddlebags, and lower thighs. Unilateral implantation is relatively rare but beneficial for correcting some deformities.
399
400
Aiache
Fig. 7. Preoperative (A, C) and postoperative (B, D) views of a 28-year-old woman who received submuscular buttock implants after massive weight loss following bariatric surgery and a prior lower body lift. Fat was transferred to fill in depressions. Flattening of the buttocks is common after a lower body lift.
which is a concentration of subcutaneous fat, becomes more noticeable after submuscular augmentation. Submuscular implants are primarily effective for augmenting the upper pole of the buttocks and are better suited for women deficient in that area and for men. Because these implants must be placed superior to the sciatic nerve exit, they are not suited to fill the whole buttock surface. A banana roll also may be a sequela of liposuction or submuscular gluteal implant placement. In the latter case, the banana roll takes on the appearance of a second mound, or double bubble, below the implants (Figs. 4 and 8). To minimize the banana roll, liposuction of the infragluteal area is usually necessary when placing submuscular implants. Liposuction of the ‘‘saddlebag’’ area, or outer thighs, also enhances the gluteal contour when performing implant augmentation (Fig. 9). In addition to areas that have excess volume, others sometimes require augmentation for increased volume. Such areas are diverse and depend on the patient’s wishes and anatomy. Three regions are most likely to need augmentation. First, the medial area, including that area just above the anal opening, is frequently deficient in volume. In these cases, the buttocks have a flattened appearance. A second deficient area is the
retrotrochanteric depression. This normal groove situated immediately posterior to the trochanter often contains little fat, lacks gluteal musculature, and therefore appears flat (Fig. 2). Immediately below this depression, the buttock has more fatty tissue and the gluteus maximus muscle runs obliquely toward the trochanter. The third area that may have deficient volume is the zone immediately below the waist. When this area is deficient, there is a loss of contrast between the buttock and waist. Augmentation of the upper third of the buttock, liposuction of the waist, or a combination of the two enhances the definition between the two areas and improves the gluteal aesthetics (Fig. 8).
Autologous fat injections for buttocks augmentation The author uses a combination of different procedures in about 50% of gluteal implant cases. A patient may need implants plus liposuction, implants plus fat transfer, or implants plus liposuction and fat transfer. The best options for an individual are determined during the preoperative planning in consultation with the patient. For
Gluteal Recontouring With Combination Treatments
Fig. 8. Preoperative (A, C) and postoperative (B, D) PA and lateral views of 30-year-old woman who had contour liposuction for abdomen and back lipodystrophy and buttock implants. A double-bubble effect beneath the implants is visible on the postoperative lateral view (D).
those who have liposuction as part of their gluteal recontouring, it may be a good idea to harvest some of the fat removed during liposuction in case contour refinements are needed during the surgery or as a secondary procedure. Harvested fat can be stored in a freezer for up to 3 months for subsequent fat grafting. Longer periods of freezing (5 to 6 months) are discouraged owing to the lack of knowledge about the viability of the fat beyond 3 months and the potential for either viral or bacterial infection. Within the first 3 months following augmentation, contour irregularities or areas with deficient volume may become apparent. The fat harvested and frozen during the initial procedure can be reimplanted up to 3 months later. The zones of autologous fat injections vary according to each case. Medial injections increase posterior projection (Fig. 7), while lateral injections increase buttock width and improve lateral shaping. A
patient’s particular anatomy and desires determine the location and extent of the fat grafting. One common area that benefits from fat grafting is the retrotrochanteric depression. Although this depression is a natural anatomic entity, some patients object to it and want it filled. Lateral positioning of gluteal implants can often help disguise the retrotrochanteric depression, but correction also can be achieved by injecting autologous fat harvested at the time of surgery into the area lateral to gluteal implants (Fig. 2). Fat injections are ideal for correcting isolated defects and volume deficiencies, as seen in the example shown in Fig. 10. This patient had gluteal underdevelopment, especially on the right side, where an odd depression was effectively treated with a combination of subfascial augmentation and fat injection. The two techniques used together achieved much better definition of the gluteal area.
401
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Aiache
Fig. 9. (A–D) Preoperative PA view shows the outline of the pockets where submuscular implants will be placed in a thin 28-year-old woman. The ‘‘saddlebag’’ area to receive liposuction is also outlined.
The author’s preference for harvesting fat is to use 60-cc syringes with the Tulip instrumentation (Tulip Medical, San Diego, CA). The 60-cc syringe Tulip system is first connected to a 3-mm cannula and then a 4-mm cannula. Injection of the harvested fat is performed with the same cannulae and may often be injected through the same skin incisions used for liposuction. Syringe aspiration with such a system allows the immediate reinjection of fat to deficient areas or storage for later use. At the beginning of the aspiration process using the tumescent technique, the fat is so pure that cleaning it before reinjection is often unnecessary. Because the tumescent fluid in the aspirate quickly separates from the fat, it can
be discarded and the fat injected into the recipient site. As the aspirate becomes bloodier, the syringes are set vertically to allow the fat that will be used for recipient site injection to concentrate at the top of the syringe. The blood is then discarded. Centrifugation of the aspirate may be performed, but this necessitates more manipulation of the aspirate and presumably more loss of the sensitive fat cells that may not survive if they are subjected to too much manipulation or exposure. Any buttock area that seems to be lacking in volume at the time of gluteal implantation can be supplemented with fat injections. As examples, fat transfer to the areas medial to implants will
Gluteal Recontouring With Combination Treatments
Fig. 10. (A–D) This 32-year-old woman received subfascial implants to treat buttock underdevelopment. Fat injections were used to fill in the right buttock depression visible in the preoperative views (A, C).
increase projection, and liposuction of the banana roll can be complemented with autologous fat injection to obtain a smooth transition between the implants and the lower and outer portions of the buttocks.
Reference [1] Robles JM, Tagliapertra JC, Grandi MA. Gluteoplastia de aumento: Implante submuscular. Cir Plast Iberolatinoamer 1984;10(4):365–9.
403
CLINICS IN PLASTIC SURGERY Clin Plastic Surg 33 (2006) 395–403
Gluteal Recontouring With Combination Treatments: Implants, Liposuction, and Fat Transfer Adrien E. Aiache, -
MD, FACS
Gluteal augmentation with implants Combination gluteal implants and liposuction techniques
Patients seeking augmentation or recontouring of the gluteal region have three basic options: gluteal implants, liposuction, and augmentation with fat injections. In many cases, all three treatments are used together to achieve attractively shaped buttocks with proper proportions and good projection. The treatment or combination of approaches that is appropriate for each individual patient is discovered through consultation that focuses on understanding a patient’s goals. To determine the treatment(s) required by a patient, his or her unique anatomy must be analyzed to identify gluteal areas that have excesses or deficiencies that can be successfully addressed in gluteal recontouring.
Gluteal augmentation with implants The choice of the most appropriate implant type and position is a cooperative effort between the patient and plastic surgeon. What the patient hopes to achieve and his or her individual anatomy must be carefully evaluated before surgery
-
-
Autologous fat injections for buttocks augmentation References
to prevent postoperative dissatisfaction with the results. As part of the consultation, the advantages and disadvantages of the various types, shapes, and positions of gluteal implants must be thoroughly explained during the informed consent process. The anatomy and shape of the buttock before surgery determine the type of implant that will produce the optimal results. When considering a patient’s anatomy, the width of the pelvis is critical. For example, thin patients with narrow hips have better results with round or high projection oval implants that have a relatively small base diameter. In contrast, patients with broad, wide hips benefit from low projection implants with a wider base even though these implants tend to produce less projection. Some degree of compromise is often required, which must be discussed with patients. Patients who have a marked pelvic curvature must be approached carefully to avoid producing excessive projection of the buttock (as in the Hottentot Venus body type). Implants with low projection are preferred in patients with marked lordosis and a flat lower spinal region for fear of creating
9884 Little Santa Monica Boulevard, Suite 102, Beverly Hills, CA 90212, USA E-mail address: [email protected] 0094-1298/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2006.04.004
396
Aiache
a poorly shaped upper buttock (Fig. 1). The risk of this deformity increases when implants are in a submuscular or intramuscular position because this type of placement creates more projection in the upper buttocks. Implant spacing is another important factor that surgeons and patients must consider when planning gluteal augmentation. The space between gluteal implants should be without tension to minimize the risk of wound breakdown. For patients who desire wider spacing between implants, they may be placed more laterally, as seen in Fig. 2. This positioning can be helpful in filling the posterior trochanteric depression that is objectionable to some patients. In 1984, Jose Robles and his colleagues [1] of Buenos Aires, Argentina, described the submuscular implantation of solid elastomer implants for preventing the problems seen with subcutaneous placement of gluteal implants. His technique became popular in the United States despite the additional technical difficulties that accompany submuscular placement because it helped prevent the capsular contracture seen in subcutaneous
implants. Placement of submuscular implants is technically demanding because dissection of the submuscular space is limited inferiorly by the exit of the sciatic nerve into the lower buttocks (Fig. 3). Placement of implants in a submuscular or intramuscular position is the best option for patients who desire increased volume in the upper pole (Fig. 4). Placing implants beneath or within the gluteal maximus muscle allows for higher positioning, as illustrated in Fig. 5. However, these patients must be closely evaluated because creating too much upper pole fullness may require liposuction to restore a more harmonious contour. Implants placed in the subfascial plane are capable of augmenting the entire buttock because this position accommodates the use of implants that are large and wide, as illustrated in Fig. 2. Ideally, subfascial implants should be soft, textured, or have a polyurethane cover, but this implant model is not available in the United States. The textured surface reduces the risk of displacement and dislocation, which can result in
Fig. 1. This 48-year-old woman with lordosis post spinal surgery underwent gluteal augmentation with implants and lower buttock liposuction. Patients like this require low-profile implants. Preoperative views (A, C) and postoperative views (B, D) are shown.
Gluteal Recontouring With Combination Treatments
Fig. 2. Subfascial implants with a relatively wide base (postoperative views B, D) were selected to help fill in the trochanteric depressions the patient objected to (preoperative PA views A, C). Autologous fat transplantation was also used to even out the gluteal contour.
extrusion or deformity. Because subfascial positioning is the most superficial of the implantation planes, the buttock shape directly depends on the shape of the implant itself. There is less tissue coverage of the implant in this position so even minor asymmetries are more likely to be visible. The gluteal fascia is poorly developed and consists essentially of fascial bands penetrating vertically into the gluteus maximus muscle. Because of this anatomy, subfascial implants can be placed partially or totally in the subcutaneous plane. They therefore produce results similar to those reported in the early days of gluteal augmentation when implants were placed in the deep subcutaneous plane. In Mexico and South America, implants designed specifically for subfascial plane placement consist of cohesive silicone gel with a polyurethane textured surface. Such
implants stay in position, have a natural feel, and are less likely to produce capsular contracture. The soft solid elastomer implants available in the United States for subfascial placement eventually develop a capsule that contracts and may sometimes secrete fluid forming seromas that are difficult to correct. This complication may require multiple aspirations and at times removal of the implants. Gluteal implants have come a long way since the early days when breast implants were used for buttock augmentation. Because implants filled with cohesive gel and a polyurethane cover are not available in the United States, the latest generation of devices that may be used consist of soft silicone elastomer with either a smooth or textured surface. The author uses these implants with good results when they are placed in the
397
398
Aiache
submuscular plane. Outcomes are less successful when these soft solid implants are used in the subcutaneous or subfascial planes.
Combination gluteal implants and liposuction techniques
Fig. 3. Anatomy and landmarks for placement of submuscular gluteal implants. Note the lower landmark consisting of the piriformis muscle, below which the sciatic nerve exits.
Liposuction is often needed to enhance the results of gluteal augmentation with implants. The areas that benefit from contouring liposuction are the flanks, the presacral area, the hips, the inner and outer thighs, and the infragluteal ‘‘banana roll’’ area. Liposuction may be done conservatively at the time of gluteal implant placement or as a secondary procedure at a later time. In both scenarios, liposuction adds definition to the gluteal aesthetic unit and refines the overall shape of the buttocks following gluteal implantation. In the example seen in Fig. 6, the patient received a unilateral implant and liposuction was a useful adjunct for improving the overall buttock contour. If liposuction is performed in the central cleft area, some presacral fat Fig. 4. (A–D) This 36-year-old woman received submuscular implants and liposuction to even out the ‘‘banana roll’’ area beneath the buttocks. She also received autologous fat injections in this zone. The postoperative lateral view (D) is a good example of how submuscular placement creates fullness in the upper gluteal region.
Gluteal Recontouring With Combination Treatments
Fig. 5. Schematic view of submuscular implant (in green) placement shows why this position produces most of the projection in the upper buttock.
should be conserved to prevent wound dehiscence postoperatively. The combination of gluteal augmentation with implants and liposuction is especially beneficial for patients who are overweight or obese and desire increased volume for gluteal projection to counteract the flattening that is often associated with weight gain and weight loss. For these patients, treatment often consists of augmentation with implants plus liposuction of the abdomen, flanks, waist, and/or infragluteal area. Massive weight loss patients who have undergone lower body lift may not need liposuction with their gluteal augmentation. Instead, autologous fat injections may be required to fill depressions and smooth the overall buttock contour (Fig. 7). A common complaint of patients seeking improved gluteal contour is the bulge or fat excess in the infragluteal area, commonly called a ‘‘banana roll.’’ A naturally occurring banana roll,
Fig. 6. Preoperative (A, C) and postoperative (B, D) views of a 24-year-old woman with poliomyelitis sequelae of left buttock underdevelopment. She received a unilateral implant on the left as well as contouring liposuction of the gluteal region, saddlebags, and lower thighs. Unilateral implantation is relatively rare but beneficial for correcting some deformities.
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Aiache
Fig. 7. Preoperative (A, C) and postoperative (B, D) views of a 28-year-old woman who received submuscular buttock implants after massive weight loss following bariatric surgery and a prior lower body lift. Fat was transferred to fill in depressions. Flattening of the buttocks is common after a lower body lift.
which is a concentration of subcutaneous fat, becomes more noticeable after submuscular augmentation. Submuscular implants are primarily effective for augmenting the upper pole of the buttocks and are better suited for women deficient in that area and for men. Because these implants must be placed superior to the sciatic nerve exit, they are not suited to fill the whole buttock surface. A banana roll also may be a sequela of liposuction or submuscular gluteal implant placement. In the latter case, the banana roll takes on the appearance of a second mound, or double bubble, below the implants (Figs. 4 and 8). To minimize the banana roll, liposuction of the infragluteal area is usually necessary when placing submuscular implants. Liposuction of the ‘‘saddlebag’’ area, or outer thighs, also enhances the gluteal contour when performing implant augmentation (Fig. 9). In addition to areas that have excess volume, others sometimes require augmentation for increased volume. Such areas are diverse and depend on the patient’s wishes and anatomy. Three regions are most likely to need augmentation. First, the medial area, including that area just above the anal opening, is frequently deficient in volume. In these cases, the buttocks have a flattened appearance. A second deficient area is the
retrotrochanteric depression. This normal groove situated immediately posterior to the trochanter often contains little fat, lacks gluteal musculature, and therefore appears flat (Fig. 2). Immediately below this depression, the buttock has more fatty tissue and the gluteus maximus muscle runs obliquely toward the trochanter. The third area that may have deficient volume is the zone immediately below the waist. When this area is deficient, there is a loss of contrast between the buttock and waist. Augmentation of the upper third of the buttock, liposuction of the waist, or a combination of the two enhances the definition between the two areas and improves the gluteal aesthetics (Fig. 8).
Autologous fat injections for buttocks augmentation The author uses a combination of different procedures in about 50% of gluteal implant cases. A patient may need implants plus liposuction, implants plus fat transfer, or implants plus liposuction and fat transfer. The best options for an individual are determined during the preoperative planning in consultation with the patient. For
Gluteal Recontouring With Combination Treatments
Fig. 8. Preoperative (A, C) and postoperative (B, D) PA and lateral views of 30-year-old woman who had contour liposuction for abdomen and back lipodystrophy and buttock implants. A double-bubble effect beneath the implants is visible on the postoperative lateral view (D).
those who have liposuction as part of their gluteal recontouring, it may be a good idea to harvest some of the fat removed during liposuction in case contour refinements are needed during the surgery or as a secondary procedure. Harvested fat can be stored in a freezer for up to 3 months for subsequent fat grafting. Longer periods of freezing (5 to 6 months) are discouraged owing to the lack of knowledge about the viability of the fat beyond 3 months and the potential for either viral or bacterial infection. Within the first 3 months following augmentation, contour irregularities or areas with deficient volume may become apparent. The fat harvested and frozen during the initial procedure can be reimplanted up to 3 months later. The zones of autologous fat injections vary according to each case. Medial injections increase posterior projection (Fig. 7), while lateral injections increase buttock width and improve lateral shaping. A
patient’s particular anatomy and desires determine the location and extent of the fat grafting. One common area that benefits from fat grafting is the retrotrochanteric depression. Although this depression is a natural anatomic entity, some patients object to it and want it filled. Lateral positioning of gluteal implants can often help disguise the retrotrochanteric depression, but correction also can be achieved by injecting autologous fat harvested at the time of surgery into the area lateral to gluteal implants (Fig. 2). Fat injections are ideal for correcting isolated defects and volume deficiencies, as seen in the example shown in Fig. 10. This patient had gluteal underdevelopment, especially on the right side, where an odd depression was effectively treated with a combination of subfascial augmentation and fat injection. The two techniques used together achieved much better definition of the gluteal area.
401
402
Aiache
Fig. 9. (A–D) Preoperative PA view shows the outline of the pockets where submuscular implants will be placed in a thin 28-year-old woman. The ‘‘saddlebag’’ area to receive liposuction is also outlined.
The author’s preference for harvesting fat is to use 60-cc syringes with the Tulip instrumentation (Tulip Medical, San Diego, CA). The 60-cc syringe Tulip system is first connected to a 3-mm cannula and then a 4-mm cannula. Injection of the harvested fat is performed with the same cannulae and may often be injected through the same skin incisions used for liposuction. Syringe aspiration with such a system allows the immediate reinjection of fat to deficient areas or storage for later use. At the beginning of the aspiration process using the tumescent technique, the fat is so pure that cleaning it before reinjection is often unnecessary. Because the tumescent fluid in the aspirate quickly separates from the fat, it can
be discarded and the fat injected into the recipient site. As the aspirate becomes bloodier, the syringes are set vertically to allow the fat that will be used for recipient site injection to concentrate at the top of the syringe. The blood is then discarded. Centrifugation of the aspirate may be performed, but this necessitates more manipulation of the aspirate and presumably more loss of the sensitive fat cells that may not survive if they are subjected to too much manipulation or exposure. Any buttock area that seems to be lacking in volume at the time of gluteal implantation can be supplemented with fat injections. As examples, fat transfer to the areas medial to implants will
Gluteal Recontouring With Combination Treatments
Fig. 10. (A–D) This 32-year-old woman received subfascial implants to treat buttock underdevelopment. Fat injections were used to fill in the right buttock depression visible in the preoperative views (A, C).
increase projection, and liposuction of the banana roll can be complemented with autologous fat injection to obtain a smooth transition between the implants and the lower and outer portions of the buttocks.
Reference [1] Robles JM, Tagliapertra JC, Grandi MA. Gluteoplastia de aumento: Implante submuscular. Cir Plast Iberolatinoamer 1984;10(4):365–9.
403