Deep Subcutaneous Gluteal Fat Compartments: Anatomy and Clinical Implications

Refractory lipoatrophy treated with autologous whole blood injection: A case report

BACKGROUND

Intramuscular corticosteroid injection may cause adverse effects such as dermal and/or subcutaneous atrophy, alopecia, hypopigmentation, and hyperpigmentation. Although cutaneous atrophy can spontaneously resolve, several treatment options have been suggested for this condition.

CASE SUMMARY

In this paper, we report a case of corticosteroid injection induced lipoatrophy treated with autologous whole blood (AWB) injection, as the condition had been unresponsive to fractional laser therapy. A 29-year-old female patient visited the dermatology clinic complaining of skin depression on her right buttock area, which had appeared six months earlier. There had been only subtle improvement at the margins after fractional CO2 laser treatment; therefore, after obtaining informed consent from the patient, AWB treatment was initiated. One month after the first AWB injection, the size and depth of the lesion had noticeably improved, and a slight improvement was also observed in discoloration.

CONCLUSION

Close observation is the initial treatment of choice for steroid induced skin atrophy; however, for patients in need of immediate cosmetic improvement, AWB injection may be a safe and cost-effective alternative.

Clinical Implications of Fat Grafting in the Posterior Calf: A Dynamic Cadaver-based Study

BACKGROUND

Intramuscular fat grafting in extremity muscles, especially the gastrocnemius, has become increasingly popular. However, while safety in truncal muscle fat grafting has been well-studied, research on extremity muscles is lacking.

OBJECTIVES

In this study, we aimed to explore the anatomy of the gastrocnemius muscle and adjacent structures as intramuscular and subcutaneous recipient sites. Additionally, we sought to analyze pressure-volume relationships and fat migration patterns during posterior calf grafting.

METHODS

Eight cadaveric lower extremities were examined. A prosection was performed to better understand the vascular complex around the gastrocnemius. Ultrasound-guided fat injections were then performed into both the subcutaneous and intramuscular layers; dynamic pressures were measured with a manometer. Last, dyed-injectant was injected subcutaneously to better elucidate subcutaneous anatomy.

RESULTS

Anatomic prosection demonstrated the proximity of the gastrocnemius muscle to the popliteal venous system that arborized (>1 mm) intramuscularly. In the 3 specimens that underwent intramuscular fat grafting, the peak intramuscular pressures plateaued at 21 mmHg (19.5-23 mmHg); there was no observed extrafascial migration of the injectant. With subcutaneous injectant in 1 specimen, pressures in the subcutaneous space increased (125 mmHg) with additional injectant (240 mL) while pressures in the intramuscular space remained relatively constant (4 mmHg).

CONCLUSIONS

Intramuscular gastrocnemius fat grafting should be done with caution: its proximity to critical veins and sustained increased intramuscular pressures following grafting increases risks of embolus and thrombosis, respectively. Subcutaneous injection may be safer in that increased pressures are not communicated to deep structures. Last, we present a novel description of posterior calf subcutaneous compartments that may better allow surgeons to direct and predict subcutaneous injectant.

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

BACKGROUND

The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli.

OBJECTIVES

This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures.

METHODS

An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform.

RESULTS

The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality.

CONCLUSIONS

Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

LEVEL OF EVIDENCE: 5

Static Injection, Migration, and Equalization (SIME): A New Paradigm for Safe Ultrasound-Guided Brazilian Butt Lift: Safer, Faster, Better

BACKGROUND

Although the Brazilian butt lift (BBL) is one of the most popular procedures in body contouring, it has been associated with the risk of pulmonary fat embolism when fat graft is injected into the gluteal muscles. The subcutaneous plane has been identified as a safe site for fat graft injection, but deaths from fat embolism continue to occur because there is no mechanism to confirm consistent subcutaneous placement.

OBJECTIVES

The aim of this paper was to determine if real-time intraoperative ultrasound could accurately identify the subcutaneous gluteal anatomic landmarks and permit a single surgeon to consistently target fat graft placement in the subcutaneous space.

METHODS

In total, 4150 BBLs were performed with real-time intraoperative ultrasound being used to confirm the subcutaneous position of a static cannula during fat graft injection. Serial deposits of fat graft were performed in each buttock. Ultrasound confirmed that fat graft consistently remained above the deep gluteal fascia and migrated through the deep subcutaneous space. These fat graft deposits were then equalized with a moving cannula to correct any contour deformities. Operative times were recorded and compared with BBL performed by expansion vibration lipofilling without ultrasound.

RESULTS

Real-time intraoperative ultrasound allowed for the visual confirmation of consistent subcutaneous fat graft deposition and the targeting of fat graft into specific gluteal subcutaneous compartments.

CONCLUSIONS

Real-time intraoperative ultrasound allows the surgeon to confirm a subcutaneous-only fat graft injection, target specific gluteal subcutaneous compartments, and take advantage of the unique architecture of the deep subcutaneous space to create gluteal projection and correct contour deformities.

Combining Gluteal Shaping with High-Definition Liposuction: New Concepts and Techniques

Gluteal contouring has been subject to numerous publications in aesthetic plastic surgery. Not only the female but also the male features that govern such procedures have been thoroughly described by different authors. In this article, we will provide the reader with an updated account of how gluteal contouring blends with High Definition Liposculpture (HDL). We discuss the most current techniques for buttocks reshaping through a holistic approach of new anatomical and artistic concepts. We will dive into new techniques to perform multiplanar and 4-dimensional Fat Grafting and equalization of the buttocks and surrounding areas, which we believe might help plastic surgeons to improve the quality of their patient outcomes. In effect, a proper understanding of the anatomical structures and its variations among different gender and ethnicities, will both help the surgeon to individualize the procedure based on patient preferences.

Buttock and Full Body Contouring Harmony

The concept of the gluteal framework has significantly enhanced our understanding of the gluteal anatomy. The buttock does not constitute a bulging area in the human body. To be attractive, it must harmonize with all elements of the human body around it. Nevertheless, the changes in patient desires and demands, in addition to innovations in surgical technique open a field of opportunity to achieve more beautiful and natural results. In this work, the main updates in the management of body contouring are condensed, including new safe and aesthetic fat infilration techniques.

Ultrasound-Guided Gluteal Fat Grafting: A to Z

Low-cost, high-resolution ultrasound systems allow surgeons to visualize and manipulate the subcutaneous space and inject fat graft with millimeter accuracy.

The Hybrid Technique for Autologous Gluteal Augmentation

This article accompanying these videos will describe the technique created and innovated by the senior author for gluteal augmentation with autologous fat transfer. While the principles of gluteal fat grafting originated with Pitanguy, Regnault, Gonazalez, and Spina, the nuances vary greatly from surgeon to surgeon. Although there is much controversy regarding gluteal fat grafting, the major principle of avoiding intramuscular injection is the central pillar of safe and effective augmentation today. The senior author fine-tuned his method to optimize patient outcomes over the past 14 years and demonstrated lasting, aesthetic results while maximizing patient safety with his technique. More recently, the senior surgeon has developed the Hybrid Technique, involving manual injection of fat through a syringe and a power-assisted cannula to maximize aesthetic outcomes while adhering to safety principles. This method follows the deep and moderate depth subcutaneous injection principle while respecting the muscular, neurovascular, and ligamentous anatomy of the buttock.

Level of Evidence 4

Experimental study on clinical and morphological determination of the optimal cannula diameter for lipoaspirate harvest from rabbit inguinal fat pad

Determining the most appropriate cannula diameter for lipoaspirate harvesting is important, both in terms of the quality and composition of the material obtained, and the ease of practical use of the cannula. The size of the cannula is one of the main factors affecting the qualitative characteristics of the obtained lipoaspirate sample for further use of adipose tissue. The purpose of the investigation was to clinically and histomorphometrically determine the optimal cannula diameter for lipoaspirate samples collection from rabbit inguinal fat pad in an experimental study. The methods of Animal models, Surgical procedures, Macroscopic examination, Histological examination, and Morphometric study were applied. There is a direct correlation between the percentage of connective tissue fibres in the lipoaspirate and the diameter of the cannula. The lack of clear criteria for selecting a lipoaspiration cannula is one of the limitations to obtaining generally accepted lipoaspiration protocols with subsequent use of adipose tissue. In this study, the animal experiment determined the most ideal cannula diameter suitable for collecting the largest amount of lipoaspirate for subsequent use.