Fat Grafting for Gluteal Augmentation: A Systematic Review of the Literature and Meta-Analysis

Multidisciplinary Experience for Gluteal Fat Grafting

BACKGROUND

Gluteal fat grafting, colloquially known as Brazilian Butt Lift, has experienced a significant rise in popularity in recent years. Despite this increase, potential complications associated with the procedure have also been observed, necessitating a thorough examination of the current practices and outcomes.

METHODS

This study collected experiences of a multidisciplinary group of surgeons through a detailed survey sent in April 2022. This study aimed to shed light on the practices employed by these surgeons, the frequency and types of complications they encounter, and the overall outcomes of their procedures.

RESULTS

Of the 100 surgeons surveyed, 86 responded. The study identified that pulmonary fat embolism (PFE) was the most serious complication, with fatality due to PFE recorded at a rate of 1:23,878. Liposuction site seromas were the most common complications, with an overall rate of 2.45%. Although there were no overall differences in complications between plastic and non-plastic surgeons, plastic surgeons were found to have a sixfold increase in the odds of experiencing a liposuction seroma. The survey also revealed substantial practice variations, particularly regarding fat preparation methods, recipient-site preparation, antibiotic use, and postoperative care protocols.

CONCLUSION

Despite known complications, a strong tendency to continue performing these procedures was observed among surgeons, demonstrating the sustained demand and acceptance of the procedure. This study underscores the need for continued surveillance and research to enhance the safety and effectiveness of gluteal fat grafts. The experiences and data gathered from practicing surgeons provide valuable insights, paving the way for refining techniques, building consensus, and facilitating informed discussions with patients about the risks and benefits of the procedure.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Bibliometric Analysis of the Top 100 Papers on Gluteal Augmentation

Background

Gluteoplasty or gluteal augmentation is a popular cosmetic procedure that is used to improve the volume, shape, and contour of the buttocks.

Objectives

This bibliometric analysis aims to characterize emerging research trends and to assess the methodological quality of the highest impact gluteoplasty research.

Methods

The 100 most-cited publications in gluteoplasty were identified on Web of Science, across all available journal years (from Inception to August 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence Based Medicine level of evidence (LOE) of each study was assessed.

Results

The 100 most-cited publications regarding gluteoplasty were cited by a total of 2375 publications. Citations per publication ranged from 5 to 176 (mean 23.75 ± 25.86), with the highest-cited study being authored by Simonacci, discussing autologous fat grafting (n = 176). Most publications were LOE 5 (n = 55), representative of the large number of case series and reports. The number of publications for LOE 1, 2, 3, and 4 was 1, 9, 13, and 22, respectively. The main content focus was "surgical technique" in 38 publications, followed by "outcomes" (n = 34) and "risk factors/prognosis" (n = 10). Patient-reported outcome measures (PROMs) were used in 20 publications, and 33 publications reported aesthetic outcome measures.

Conclusions

This analysis demonstrates a need for improvement in research methodologies regarding gluteoplasty research. This advancement would be facilitated by robust, high-quality research through randomized control trials and multicenter studies, as well as the further development of validated PROMs for gluteoplasty.

Level of Evidence 2

B-ultrasound-assisted gluteal fat grafting in Asians: A prospective study of quantitative results from three-dimensional imaging and B-ultrasound analysis

BACKGROUND

The increasing number of fatalities caused by gluteal fat grafting is concerning; thus, there is a need to determine ways to obtain the ideal aesthetic effect while ensuring a safe operation. In this study, three-dimensional (3D) measurements combined with B-ultrasound were used to evaluate the effect of gluteal fat augmentation in Asians, whose safety and effectiveness were confirmed using quantitative data.

METHODS

Thirty-five consecutive female patients were evaluated in this prospective clinical study. All patients underwent B-ultrasound-assisted gluteal fat augmentation on the subcutaneous plane alone. 3D imaging and B-ultrasound analysis of the adipose tissue thickness in the gluteal region were performed preoperatively and at 1 week, 3 months and 6 months post-operatively.

RESULTS

The waist circumference of the patients decreased, gluteal circumference and length of the gluteal crease increased and average waist-to-hip ratio improved from 0.78 to 0.74. At 3 months and 6 months post-operatively, the adipose tissue thickness decreased by 5.1% and 15.1%, respectively. The fat retention rates calculated using 3D imaging measurements at 3 months and 6 months post-operatively were 77.9% and 64.7%, respectively. According to the BODY-Q scale scores, patients reported a high level of satisfaction post-operatively.

CONCLUSIONS

B-ultrasound guidance can effectively prevent the occurrence of fatal fat embolism during gluteal fat grafting and maximise the augmentation effect. The quantitative data obtained using 3D measurements and B-ultrasound confirmed the safety and effectiveness of fat injections for gluteal augmentation under B-ultrasound guidance.

Complications From Fat Grafting and Gluteal Augmentation in Outpatient Plastic Surgery: An Analysis of American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, QUAD A) Data

BACKGROUND

Gluteal augmentation with autologous fat grafting, colloquially referred to as Brazilian butt lift (BBL), is an increasingly common procedure with a highly reported complication profile.

OBJECTIVES

In this study we aimed to analyze the prevalence and characteristics of complications that accompanied these surgeries at ambulatory surgery facilities.

METHODS

Adults patients who experienced fat grafting complications from 2019 to 2021 were identified in QUAD A, formerly known as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, Highland Park, IL, USA), database. Patients and complications were analyzed based on sociodemographic, surgery-, and facility-specific variables with descriptive statistics and logistic regression.

RESULTS

Overall, 436 fat grafting procedures with complications were reported to QUAD A, with an overall complication rate of 0.94%. Of these complications, 164 (37.6%) were confirmed to be from gluteal augmentation procedures. Notably, the number of gluteal augmentation with fat grafting complications decreased from the year 2019 (48) to 2020 (36), then nearly doubled from 2020 to 2021 (69). The majority of patients were female (96.7%), with a mean age of 42.0 years and a mean BMI of 28.3 kg/m2. Wound infection was the most commonly documented complication (22.3%). Of the patients who experienced complications, 35.9% presented to a hospital for their complications and 12.6% required reoperation. Four deaths were described. There was no association between sociodemographic or surgical variables and increased odds of readmission or reoperation (P > .05), except for increasing surgeon number and reoperation (P = .02).

CONCLUSIONS

Gluteal augmentation accounts for a large proportion of complications from fat grafting procedures. Increased reporting requirements may aid in future determination of incidences of complications and improve patient safety.

LEVEL OF EVIDENCE: 3

Enhancing Buttock Contours: A Safer Approach to Gluteal Augmentation with Ultrasonic Liposuction, Submuscular Implants, and Ultrasound-Guided Fat Grafting

Background: The global popularity of gluteal augmentation has risen significantly, driven by the desire for enhanced buttocks size and shape to align with individual patient preferences. This increased demand has prompted extensive research into diverse techniques and their safety. Methods: A retrospective analysis was conducted to evaluate the outcomes of a gluteal augmentation technique involving ultrasound-assisted liposuction, submuscular implants, and ultrasound-guided fat grafting. Our study involved a review of the medical records of 50 consecutive patients who underwent this procedure between February 2020 and July 2023. Results: Data related to patient demographics, the quantity of fat grafts, and any complications were analyzed. Additionally, a brief survey was conducted to evaluate patient satisfaction. The Polytech implants were used in forty-four patients, and Sebbin implants in six. The implant size varied from 285 to 560. Most of the Polytech implants were 390 cc (25/44; 56.8%). Two patients had a minor infection at the incision sites and subsequent wound dehiscence. No revision surgeries were needed. Conclusions: The presented technique incorporates ultrasonic liposuction, submuscular silicone implants, and ultrasound-guided fat grafting to achieve safe and aesthetic gluteal enhancements. This method is especially suitable for patients looking to augment both the central and lateral areas of the buttocks, particularly when they lack adequate fat tissue for augmentation through fat grafting. With the addition of ultrasound guidance, the fat grafting step is significantly safer.

Lower Gluteal Liposuction Combined With Upper Gluteal and Infragluteal Region Fat Grafting: A Novel Concept to Improve Gluteal Ptosis

BACKGROUND

Gluteal ptosis results in a severe disturbance of gluteal aesthetics. Currently, satisfactory procedures for improving gluteal ptosis are lacking.

OBJECTIVES

To improve gluteal ptosis, the authors propose a novel concept of combined liposuction of the lower gluteal region and fat grafting to the upper gluteal and infragluteal regions, and verify its efficacy and safety.

METHODS

Patients who underwent liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions between January 2020 and July 2023 were retrospectively reviewed. Postoperative changes in the gluteal ptosis grade, complications, and patient satisfaction were evaluated.

RESULTS

A total of 28 patients were enrolled in this study; 21 (75.0%) patients had gluteal ptosis grade 4 and 7 (25.0%) patients had gluteal ptosis grade 5. The median fat removal volume was 210 mL, and the median fat graft injected volume was 355 mL in the gluteal region and 180 mL in the infragluteal region. All patients showed improvement in gluteal ptosis; 16 (57.1%) patients improved by 1 grade and 12 (42.9%) patients showed a 2-grade improvement. All patients were satisfied with their posttreatment outcomes. Only 1 patient showed lateral translocation of the fat graft. No other complications were observed.

CONCLUSIONS

Liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions is effective in improving gluteal ptosis, with a low risk of complications and high patient satisfaction.

LEVEL OF EVIDENCE: 3

Danger Zones of the Gluteal Anatomy: Improving the Safety Profile of the Gluteal Fat Grafting

INTRODUCTION

Knowledge of the vascular anatomy is critical to performing safe gluteal surgery. To date, only the course of the main blood vessels within the muscles has been outlined. These findings are based on MRI and CTA images that do not conform to a topographically standardized and normalized probability distribution.

OBJECTIVES

The aim of this study was to develop a three-dimensional mapping of the gluteal zones of high vascular density in relation to anatomical landmarks.

MATERIALS AND METHODS

This single-center retrospective cohort analysis comprised all consecutive patients who underwent cone-beam computed tomography (CBCT) scans between January 2016 and October 2021. The location of blood vessels in the gluteal region was allometrically normalized in relation to anatomical landmarks. Moreover, the caliber and area of the blood vessels were assessed.

RESULTS

CBCT scans of 32 patients with an average age of 64 ± 12 years (range 34-87 years) were included. Fifty-three percent were female. The median [IQR] caliber of the intramuscular gluteal vessels was 1.47 [1.15-1.88] mm, significantly greater than that of the subcutaneous vessels 1.09 [0.72-1.44] mm (p < 0.001). Vascular density was higher intramuscularly, as 4.5% of the area of the muscle was occupied by blood vessels, as opposed to 0.3% in the adipose tissue.

CONCLUSION

The analysis of the CBCT scans showed a higher vascular density and larger vessels intramuscularly. We, therefore, recommend the injection of autologous fat merely to the subcutaneous plane.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Superficial Intramuscular Gluteal Lipograft by Doppler Ultrasound: A Report of 24 Patients

Background

Gluteal fat grafting is a common procedure in liposculpture. This study proposes a Doppler ultrasound-guided intramuscular and subcutaneous gluteal lipotransfer technique that allows for visualization of the location of the gluteal vessels, avoiding approaching them during lipotransfer by having the cannula localized during fat infiltration.

Methods

This new technique was applied to 24 women after obtaining informed consent and providing them with a clear explanation of potential risks and complications. Doppler ultrasound was used to locate the site and depth of blood vessels, and for quadrant scanning of vessels and superficial intramuscular visualization of the cannula's location. Intramuscular lipotransfer was performed with a volume of 400 mL per gluteus (or less), and 12 patients underwent magnetic resonance imaging before and 3 months after surgery.

Results

This technique allowed for visualizing the location of the gluteal vessels, and infiltration could be easily performed in patients. In the 24 glutei reviewed postsurgery, from 12 patients who underwent pre- and postsurgery magnetic resonance imaging, intramuscular fat was found; however, there was no migration outside the gluteus maximus muscle.

Conclusions

No local or systemic complications were observed. The results of our report show that fat filtration did not migrate outside the gluteus maximus muscle. This finding seeks to promote new research to create theoretical/practical precedents for the intervention of plastic surgeons and, from there, promote the standardization of a new and safe technique.

Augmented Safety Profile of Ultrasound-Guided Gluteal Fat Transfer: Retrospective Study With 1815 Patients

BACKGROUND

Gluteal augmentation with autologous fat transfer is one of the fastest growing aesthetic surgical procedures worldwide over the past decade. However, this procedure can be associated with high mortality from fatal pulmonary fat embolism events caused by intramuscular injection of fat. Ultrasound-guided fat grafting allows visualization of the transfer in the subcutaneous space, avoiding intramuscular injection.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of gluteal fat grafting performed with ultrasound-guided cannulation.

METHODS

A retrospective chart review of all patients undergoing ultrasound-guided gluteal fat grafting at the authors' center between 2019 and 2022 was performed. All cases were performed by board-certified and board-eligible plastic surgeons under general anesthesia in ASA Class I or II patients. Fat was only transferred to the subcutaneous plane when over the gluteal muscle. Patients underwent postoperative follow-up from a minimum of 3 months up to 2 years. Results were analyzed with standard statistical tests.

RESULTS

The study encompassed 1815 female patients with a median age of 34 years. Controlled medical comorbidities were present in 14%, with the most frequent being hypothyroidism (0.7%), polycystic ovarian syndrome (0.7%), anxiety (0.6%), and asthma (0.6%). Postoperative complications occurred in 4% of the total cohort, with the most common being seroma (1.2%), local skin ischemia (1.2%), and surgical site infection (0.8%). There were no macroscopic fat emboli complications or mortalities.

CONCLUSIONS

These data suggest that direct visualization of anatomic plane injection through ultrasound guidance is associated with a low rate of complications. Ultrasound guidance is an efficacious adjunct to gluteal fat grafting and is associated with an improved safety profile that should be considered by every surgeon performing this procedure.

LEVEL OF EVIDENCE: 3

Effectiveness and Role of Using Hyaluronic Acid Injections for Gluteal Augmentation: A Comprehensive Systematic Review of Techniques and Outcomes

INTRODUCTION

There has been a rapid increase in the number of patients undergoing non-surgical gluteal augmentation in recent years, leading to an increase in the number of articles in the literature regarding the use of hyaluronic acid (HA) for gluteal augmentation. No systematic review has been published on the effectiveness of HA for gluteal augmentation. This study aimed to provide a comprehensive review regarding the effectiveness and role of using HA for gluteal augmentation.

METHODS

This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. We conducted a search across MEDLINE, EMBASE, Cochrane, and Google Scholar, using the following search keywords: gluteus, buttocks, gluteoplasty, gluteal augmentation, hyaluronic acid, and filler.

RESULTS

Ten articles published between 2013 and 2022 that included 168 patients. The estimated duration of product effectiveness is 16.16 months. Most studies showed statistically significant improvements in patients' satisfaction. Mean volume of HA injected for optimal gluteal fat augmentation was 206.71 ml. Of included studies, two reported major complications, five patients experienced bruising and erythema as minor complications, five patients experienced effusion and inflammation at the injection site, three patients experienced gel dislocation, and one patient experienced irregular contours.

CONCLUSIONS

Based on our findings, HA is a predictable method for gluteal augmentation. Patients were satisfied with their outcomes. Despite gluteal augmentation with HA having a modest complication rate, it can still involve serious complications such as diffuse alveolar hemorrhage and death. There is a need for further research in a randomized control trial.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Subfascial/Intramuscular Dual-Plane Gluteal Implantation and Supplemental Fat Grafting: A Novel Technique for Buttock Augmentation

BACKGROUND

Much debate exists within the current literature as to which plane is safest and most effective for gluteal implant buttock augmentation. A novel subfascial/intramuscular (SF/IM) dual-plane technique appears to combine the benefits of each plane.

OBJECTIVES

The aim of this study was to describe our experience with SF/IM plane gluteal implantation, and to discuss its indications, efficacy, and safety, and offer recommendations on its proper use.

METHODS

A retrospective chart review was conducted of 175 consecutive cases of gluteal augmentation with solid silicone implants in the SF/IM pocket, with and without supplemental autologous fat transfer. Outcomes from all patients were analyzed to determine the rate of complication and need for surgical revision.

RESULTS

In 175 cases of bilateral buttock augmentation with gluteal implantation using the SF/IM pocket, the most common complication was infection. This complication was seen in 13 cases (7.43%), 7 (4%) of which were superficial and did not require surgical intervention. Other complications included dehiscence, seroma, capsular contracture, and implant migration.

CONCLUSIONS

The SF/IM gluteal implantation, in combination with liposculpture and autologous fat transfer into the overlaying subcutaneous space, allows for a durable cosmetic augmentation of the buttocks in patients lacking sufficient volume for augmentation with fat transfer alone. This technique was found to have complication rates similar to those of other established augmentation techniques, as well the cosmetic advantages of a large, stable pocket with thick, soft tissue coverage of the inferior pole.

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.

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.

Comparing the safety profiles of implants and autologous fat grafting in gluteal augmentation: A systematic review

Gluteal augmentation has become a popular esthetic procedure since its inception. The main methods are augmentation using implants or autologous fat grafting, which is the harvesting and grafting of patients' own fat tissue. The last review comparing the safety of these methods was written 7 years ago, which warrants the writing of a new one. PubMed, Cochrane, and Medline were searched for studies focusing on the methods of gluteal augmentation listed previously. Five search terms were used and 15 studies fulfilled the criteria. The data were cataloged according to the method described and outcomes compared. Seven articles focused on gluteal implants and another seven assessed autologous fat grafting, whereas one detailed both. The most common complications in 524 implant procedures were wound dehiscence (9.16%), excessive implant palpability (5.92%), and seroma (3.82%), with an overall complication rate of 25%. The most common complications in 1788 gluteal fat augmentation procedures were seroma (6.9%), infection (3.0%), and transient sciatic paresthesia (1.0%), with an overall complication rate of 13%. Several articles listed satisfaction figures, but these were not assessed because this article was not powered to assess this outcome. Overall, gluteal augmentation using autologous fat grafting leads to fewer postoperative complications than implants and allows greater contouring of the buttocks and the surrounding areas. However, it can also be a far more dangerous procedure if certain recommendations are not followed.

Three-dimensional Quantitative Standards for Assessing Outcomes of Facial Lipotransfer: A Review

BACKGROUND

Reliable quantitative data are required to address the unpredictability of facial autologous fat grafting (AFG). Facial evaluation by 3D scanning technology is getting popular. However, this process lacks unified standards and the reliability assessments. This study aimed to summarize a set of standards to improve the 3D quantified reliability of AFG outcomes.

METHODS

A systematic review was used to collect the differences in and limitations of 3D assessments and analyze the effect of the quantification process on the AFG outcomes. Healthy subjects undergoing only one facial structural AFG and 3D assessments were included. The revealed specific issues guided the subsequent narrative review that involves 3D measurement and fat volume retention rate (FVRR) analysis. Criteria were formulated based on the narrative review.

RESULTS

The systematic review revealed the quantitative process to be operator-dependent. The intra-group FVRR in the postoperative 11+ month group varied significantly (P=.03). The review identified a set of 3D measurement standards, including two optimal software products, two necessary steps for preprocessing, and four testing criteria. We proposed a new calculation formula and parameter and recommended a segmental area analysis for assessing the outcomes of full-face fat grafting.

CONCLUSIONS

As far as the 3D evaluation of AFG outcomes is concerned, this is the first study to comprehensively analyze the process and set quantitative criteria. These standards would not only guide future research more reliably, but also provide fresh insight into the review of the past research. 3D measurement standards also apply to all face-related studies requiring 3D registration.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Adipose Tissue Transfer in Dynamic Definition Liposculpture PART III. The Arms: Biceps, Triceps, and Deltoids

Arm contouring usually represents a challenge for the surgeon due to zones with high risk of irregularities/asymmetries, the variable degree of skin laxity, and the differences between patient/gender preferences. In men, the bigger and muscular the arms the better, while women tend to prefer a slim and soft silhouette.

Methods

We performed arm cadaveric dissections and also searched our records for patients who underwent fat grafting of the arm in addition to HD2, from January 2016 to May 2022 at a single center in Bogotá, Colombia.

Results

Two hundred eighty-nine consecutive patients (275 men and 14 women) underwent high-definition lipoplasty/HD2 plus fat grafting of the biceps (72 muscles), the triceps (46 muscles), the deltoids (426 muscles), or a combination of them. Mean age was 39 and 36 years for men and women, respectively. Range of the fat graft volume was 30-150 ml. No major complications were reported. Follow-up period ranged from 2 to 24 months. Most patients were satisfied with the results.

Conclusions

Men usually seek an overall well-toned and muscular extremity, while women tend to prefer a slim but also athletic contour. Such outcomes can be achieved through intramuscular fat grafting of the biceps, triceps, and deltoids. The proper recognition of the pedicles and a precise surgical technique will ensure both its safety and the reproducibility of the results.

Adipose Tissue Transfer in Dynamic Definition Liposculpture Part II. The Lower Limb: Gastrocnemius, Vastus Medialis, Vastus Lateralis, and Rectus Femoris Muscles

One big challenge of body contouring surgery is the liposculpture of the lower limbs, probably because of the imperative symmetry and the risk of contour irregularities. We are reporting our experience in fat grafting of the thighs and calves for men and women undergoing dynamic definition liposculpture.

Methods

We did cadaveric dissections of the vastus lateralis, vastus medialis, rectus femoris, and gastrocnemius muscles and identified each of their primary pedicles. We also performed fat grafting of these muscles in the contralateral virgin cadaveric specimen. We searched our records for patients who underwent fat grafting of the lower extremity in addition to dynamic definition liposculpture, from January 2016 to May 2022 at a single center in Bogotá, Colombia.

Results

Seventy-three consecutive patients met the inclusion criteria (26 men and 47 women). We grafted 102 gastrocnemius muscles, 86 vastus medialis muscles, 98 vastus lateralis muscles, and 22 rectus femoris muscles. Mean age was 34 and 41 years for men and women, respectively. Range of the fat graft volume was 50-200 mL. No complications were recorded related to fat grafting. Almost all patients were satisfied with the procedure (89%). Follow-up period ranged from 2 to 36 months.

Conclusions

Fat grafting of the lower limb muscles should be considered an alternative operative technique to enhance volume and athletic appearance of this body segment. Based on cadaveric dissections and clinical evidence, our technique is considered reliable and reproducible with remarkable outcomes and a very low complication rate.

The British Association of Aesthetic Plastic Surgeons (BAAPS) Gluteal Fat Grafting Safety Review -and Recommendations

Superficial gluteal lipofilling (SGL) is a fat grafting procedure that is performed to correct a trochanteric depression and buttock deflation. Brazilian Butt Lift (BBL) is gluteal lipofilling procedure traditionally associated with exaggerated appearance and intramuscular fat transfer. The risk of mortality from fat embolism in Brazilian Butt Lift (BBL) was previously reported as being 1:2500. The actual risk was later estimated to be nearer 1:15,000, which is similar to the mortality risk in abdominoplasty. There is increasing evidence regarding the safety of subcutaneous gluteal lipofilling. This has principally been related to new technologies, surgical techniques and training being developed to avoid intramuscular injection of fat. The efficacy and benefits of using intraoperative ultrasound scan has been demonstrated in guiding the subcutaneous placement of fat and avoiding inadvertent deep lipofilling. Other serious risks and complications must be considered in addition to mortality. These include hypothermia, sepsis, skin necrosis, and poor aesthetic results, as well as the much-publicised risk of fat embolism. Complications are better controlled and managed in strictly regulated healthcare settings. Patients seeking surgery at unregulated facilities or via medical tourism are deemed to be at higher risk of being exposed to these serious complications and/or inadequate subsequent management.

Current Knowledge and Future Perspectives of Buttock Augmentation: A Bibliometric Analysis from 1999 to 2021

Background

The number of patients undergoing buttock augmentation surgery has increased rapidly with time, changes in people’s aesthetic perceptions, and the increased concern for their shape. The number of publications regarding buttock augmentation has also continued to increase. However, no bibliometric analysis concerning buttock augmentation has been published. This study aimed to provide a qualitative and quantitative evaluation of buttock augmentation-related publications using bibliometric analysis and information on research hotspots and trends in this field.

Methods

The buttock augmentation-related publications published between 1999 and 2021 were extracted from the Web of Science Core Collection (WOSCC) database for analysis. The data were analysed and presented using VOSviewer and Microsoft Excel.

Results

There were 492 articles in the (WOSCC) database, including 442 (89.84%) original research articles, with the number of publications increasing each year. The USA (208 publications, 42.28%) is the leading contributor in this field and has a high academic reputation. The most productive and co-cited journal on this subject is “Plastic and Reconstructive Surgery” (66 publications, 13.41%, 2200 citations). Cardenas-Camarena (9 publications, 1.83%, 158 citations) was the most published and co-cited author. Research hotspots include the following three topics: experience and technology of buttock augmentation, autologous fat buttock augmentation and its safety, and buttock aesthetics study. There will be more publications in the future, and research trends will focus on silicone implants, safety, satisfaction, and autologous fat grafting.

Conclusion

Buttock augmentation research is rapidly evolving, and this study provides a perspective view of buttock augmentation research in Plastic and Reconstructive Surgery.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Circumferential Liposuction of the Thigh with Concomitant Fat Transplantation to the Infragluteal Region: A Promising Option for Preventing Postliposuction Gluteal Ptosis

BACKGROUND

Gluteal ptosis is a common complication of circumferential liposuction of the thigh. The authors propose a novel concept of combining circumferential liposuction of the thigh with concomitant fat transplantation to the infragluteal/posterior thigh junction region to prevent postliposuction gluteal ptosis.

METHODS

Patients underwent circumferential liposuction of the thigh with or without concomitant fat transplantation from 2015 to 2020 and were retrospectively reviewed. The postoperative changes in the grade of gluteal ptosis, length of hospitalization, time to recovery, postoperative complications, and patient satisfaction were evaluated.

RESULTS

A total of 109 patients were enrolled in this study, including 46 patients in the liposuction-only group and 63 patients in the liposuction plus fat transplantation group. There was no significant difference in fat removal volume between the liposuction-only group and the liposuction plus fat transplantation group ( p = 0.152). Aggravation of gluteal ptosis occurred in 43 patients (93.5 percent) in the liposuction-only group and four patients (6.3 percent) in the liposuction plus fat transplantation group ( p < 0.001). The length of hospitalization and time to recovery was not significantly different between the two groups ( p = 0.402 and p = 0.423, respectively). Complications were rare in both groups. With a minimum evaluation time of 6 months, patients in the liposuction plus fat transplantation group showed significantly higher satisfaction ( p < 0.001).

CONCLUSION

Concomitant fat transplantation to the infragluteal/posterior thigh junction region during circumferential liposuction of the thigh is effective in preventing postliposuction gluteal ptosis and improving patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The General Registry of Autologous Fat Transfer: Concept, Design, and Analysis of Fat Grafting Complications

BACKGROUND

The American Society of Plastic Surgeons and The Plastic Surgery Foundation launched GRAFT, the General Registry of Autologous Fat Transfer, in October of 2015. This web-accessible registry addresses the need for prospective and systematic data collection, to determine the rates of unfavorable outcomes (complications) of fat grafting. Understanding and avoiding the factors that lead to complications can help establish safe practices for fat grafting.

METHODS

Data collected between October of 2015 and November of 2019 were summarized for age, sex, indications, processing techniques, and fat graft volume. Rates of complications for fat grafting to various anatomical areas were calculated.

RESULTS

The General Registry of Autologous Fat Transfer collected data on 7052 fat grafting procedures from 247 plastic surgery practices. The mean age of the patients in the registry was 51 years (range, 1 to 89 years), 94 percent were female, and 64 percent of the procedures were for aesthetic indications. Whereas the overall complication rate was low (5.01 percent), the complication rates for fat grafting to the breast and buttocks (7.29 percent and 4.19 percent, respectively) were higher than those for face and other areas (1.94 percent and 2.86 percent, respectively). Oil cysts (2.68 percent) and infections (1.64 percent) were the most common complications of breast fat grafting, whereas seroma (1.84 percent) and palpable mass (1.33 percent) were most common for fat grafting to buttocks. Palpable mass (0.54 percent) and infections (0.54 percent) were most common for fat grafting to face.

CONCLUSIONS

The General Registry of Autologous Fat Transfer provides a valuable tool for prospective tracking of fat grafting techniques and complications. Data collected in the registry show low rates of complications for all recipient areas treated with fat grafting.

CLINICAL RELEVANCE STATEMENT

GRAFT collects real world data on complications of autologous fat grafting procedures. The data collected over 4 years shows low rates of complications for fat grafting. The benchmarking tools available in GRAFT can help enhance techniques and safety of fat grafting.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Safety of Fat Grafting: An Institutional Retrospective Review

BACKGROUND

Autologous fat grafting is a popular technique for volume replacement in the breast and face. The efficacy, safety, and complication rate of this technique at the division of plastic surgery at the University of Alabama at Birmingham will be described in this review.

METHODS

An institutional review board-approved retrospective review of patients undergoing fat grafting procedures from January 2015 to July 2018 was performed. Records were reviewed for fat graft recipient site, donor site, amount grafted, and complications. Continuous variables were compared using either a t test or one-way analysis of variance test. Categorical data were compared using χ2 test. A P value of 0.05 or less was considered statistically significant for all comparisons.

RESULTS

A total of 396 patients who underwent fat grafting procedures of the face and body from January 2015 through July 2018 met inclusion criteria. Average amount of fat grafted for all grafts was 124.4 +/- 6.74 grams. Two hundred fifty of the grafts (62.7%) involved the bilateral breasts with an average of 140.6 +/- 93.97 g used, 70 per side. Of the 396 patients, 110 (27.8%) experienced complications. Forty three of the complications (10.9%) were considered to be major, which included hematomas/seromas, fat necrosis, dermatitis/cellulitis, and infection. No statistical differences were seen among recipient site complication rate. Types of minor complications were statistically significant per recipient sites with bilateral breasts more likely to experience asymmetry than the other recipient sites (20% for bilateral breasts vs 16% overall, P < 0.05). Fifty nine of the 110 patients (53.6%) had the complications reported to be resolved.

CONCLUSIONS

Fat grafting is a reliable method for volumization of the breasts and face. Minor complications were not infrequent in this case series; however, no life-threatening complications were observed. Continued work needs to be done to use fat grafting beyond traditional measures.

Distant migration of gluteal augmentation fat presenting as a soft tissue knee mass

Gluteal augmentation with autologous fat grafting is an increasingly popular procedure. While complication rates are low, the clinical and imaging evaluation of the various complications can be challenging. We report a case of distal migration of a failed gluteal fat graft in a young female patient presenting as a soft tissue mass in the knee, mimicking a soft tissue sarcoma. Surgical resection of the migrated fat graft confirmed the diagnosis. The diagnosis was challenging as the patient was initially reluctant to disclose her surgical history due to perceived negative social stigmas related to cosmetic contouring procedures. This case highlights the imaging findings of a rare complication following autologous fat grafting for gluteal augmentation and the importance of obtaining a thorough medical history.

Two Cases Surviving Macro Fat Emboli Complications Following Gluteal Fat Grafting

Media attention has in recent years created an increased patient demand for gluteal contouring and augmentation. Gluteal augmentation and contouring with autologous fat transfer, colloquially referred to as the “Brazilian butt lift” (BBL), can be performed safely and effectively, with an overall complication rate ranging from 1.5% to 6.8%. However, there have been an alarming number of lethal events from intravenous passage of injected fat and fatal pulmonary embolism due to macro-fat emboli (MAFE). MAFE (fat emboli &gt;1 cm in diameter), distinct from micro-fat emboli, can quickly result in catastrophic cardiopulmonary compromise and death. Accurate mortality estimates are limited by difficulties in determining accurate values for the total number of BBL procedures performed because most of these cases are performed at budget clinics. Accurate morbidity estimates are limited by a lack of published outcomes and a low level of evidence in published studies. The first case of survival of MAFE secondary to BBL was reported in 2019 by Peña et al. Few highly morbid complications secondary to MAFE have been reported because such events are almost universally lethal. We present 2 recent cases of survival after MAFE in the setting of gluteal fat transfer following expedient transfer to a tertiary care setting, allowing for timely and successful intervention. We illustrate examples of how MAFE is a highly lethal complication of gluteal fat grafting. Early recognition and immediate aggressive vital support to stabilize the patient are key for survival.

Level of Evidence: 5

Fragmented Fat Transfer for Massive Weight Loss Gluteal Contouring

SUMMARY

A recently introduced novel fragmentation technique has made it possible to convert fat tissue from apronectomy into large-scale viable lipograft, providing a glimpse of an alternative to traditional liposuction and its harvesting limitations. The purpose of this study was to assess the initial clinical evidence on fragmented fat transfer to restore volume and enhance deflated gluteal contours in a sample of massive weight loss patients. The authors retrospectively reviewed medical records of 20 women who received autologous buttock fat grafts that were harvested and fragmented following belt lipectomies and/or fleur-de-lis abdominoplasties. The average total volume subcutaneously grafted into the buttocks was 720 ml (bilateral), ranging from 500 ml to 960 ml. No local gluteal complications, such as seroma, infection, fat necrosis, or subcutaneous nodulations, were reported. Photographic observation of postoperative results over a 6- to 14-month follow-up period showed clear enhancement of body contouring in all patients, especially in those in whom fat transfer was combined with circumferential lifts. Fat fragmentation has proved useful and effective in providing great amounts of viable fat graft in a safe, simple, and reproducible technique without noticeable complications. The method eliminates the organic response to the insult of liposuction while using the entirety of formerly discarded apronectomy tissue to provide fine, transferable, autologous fat without increasing operative time. Although preliminary, the authors' clinical findings with this new technique support further studies of fragmented fat as an alternative to liposuction in gluteal fat grafting. Additional potential applications, including in wound healing and regenerative medicine, are worth exploring. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Perception of Risk Among Aesthetic Plastic Surgeons

BACKGROUND

With continuous innovation in plastic surgery, new procedures are constantly being introduced. A number of these procedures are generally safe but have the potential for rare yet serious complications. Many surgeons steer clear of these procedures due to safety concerns.

OBJECTIVES

The aim of this paper was to survey the membership of The Aesthetic Society to elicit perception of risk of several novel or less mainstream procedures.

METHODS

A 24-item survey was sent out to members of The Aesthetic Society. The survey focused on surgeon experience and attitude towards 3 procedures: filler rhinoplasty, gluteal augmentation with fat grafting, and submandibular gland excision.

RESULTS

In total, 189 completed surveys were returned. Of the responders, 50%, 49%, and 89% of surgeons said they do not perform filler rhinoplasty, gluteal augmentation with fat grafting, or submandibular gland excision in their practices, respectively. The majority of those who do not perform the procedures selected "danger to the patient" as the primary concern for each of the 3 procedures. Surgeons overwhelmingly reported not learning these procedures in training. Additionally, surgeons perceive the risks of more common procedures such as abdominoplasty and breast augmentation-mastopexy to be significantly lower and more acceptable than those of the studied procedures.

CONCLUSIONS

When comparing the perceived complication rates with data published in the literature, particularly when looking at rates of serious or life-threatening complications, plastic surgeons overestimate the risks of procedures with which they are less familiar. This perception of risk, accompanied by the lack of exposure to novel techniques in training, may contribute to surgeons avoiding these procedures.

Quality and Quantity-Cultured Human Mononuclear Cells Improve Human Fat Graft Vascularization and Survival in an In Vivo Murine Experimental Model

BACKGROUND

Fat graft ischemia impedes us from having satisfying long-term results. The quality and quantity culture is a 1-week cell culture that increases the vasculogenic potential of peripheral blood mononuclear cells (PBMNC). This in vivo murine model investigates whether enrichment with quality and quantity-cultured human mononuclear cells (MNC-QQ) improves the vascularization in the human fat graft and whether this decreases the tissue loss.

METHODS

Human adipose tissue, PBMNC, MNC-QQ, and stromal vascular fraction were prepared. First, PBMNC, MNC-QQ, and stromal vascular fraction were compared in vitro for vasculogenic potential by endothelial progenitor cell colony-forming and culture assays. Second, 0.25-g fat grafts were created with 1 × 106 PBMNC (n = 16), 1 × 106 MNC-QQ (n = 16), 1 × 106 stromal vascular fraction (n = 16), or phosphate-buffered saline as control (n = 16) before grafting in BALB/c nude mice. Grafts were analyzed for weight persistence, vessel formation by CD31 immunohistochemistry, and angiogenic markers by quantitative polymerase chain reaction.

RESULTS

MNC-QQ develop more definitive endothelial progenitor cell colonies and more functional endothelial progenitor cells compared to PBMNC and stromal vascular fraction. Weight persistence after 7 weeks was significantly higher in grafts with MNC-QQ (89.8 ± 3.5 percent) or stromal vascular fraction (90.1 ± 4.2 percent) compared with control (70.4 ± 6.3 percent; p < 0.05). MNC-QQ-enriched grafts had the highest vessel density (96.6 ± 6.5 vessels/mm2; control, 70.4 ± 5.6 vessels/mm2; p < 0.05). MNC-QQ exerted a direct vasculogenic effect through vascular integration and a potential paracrine vascular endothelial growth factor-mediated effect.

CONCLUSION

Quality and quantity-cultured human mononuclear cells containing endothelial progenitor cells stimulate fat graft vascularization and enhance graft survival in a rodent recipient.

Safety Considerations of Fat Grafting in Buttock Augmentation

Autologous fat grafting for buttock augmentation is one of the fastest growing plastic surgery procedures, but has also received significant publicity for the relatively high mortality rate secondary to fat emboli. The literature has grown exponentially in the past 5 years on this subject, helping to clarify our knowledge and providing recommendations to minimize risks, including avoiding intramuscular injections, placing the patient in the jackknife position, and utilizing larger-bore cannulas. Since the application of these recommendations, the rate of pulmonary fat embolism has decreased from 0.097% to 0.04%, with a current mortality of 1 in 14,921, making it statistically safer than abdominoplasty. Despite the evolution in our knowledge, techniques, and outcomes, it remains of utmost importance to properly select and educate patients about the safety of fat grafting for buttock augmentation. Level of Evidence: 4.

Improving the Female Silhouette and Gluteal Projection: An Anatomy-Based, Safe, and Harmonious Approach Through Liposuction, Suspension Loops, and Moderate Lipofilling

BACKGROUND

Liposuction is the main technique to improve body contour, emphasize appealing curves, and highlight one's muscular definition. The number of procedures in which the harvested fat is utilized for gluteal augmentation has greatly increased.

OBJECTIVES

The authors aim to demonstrate their technique in order to obtain a sculpted harmonious body through a safe procedure, as well as review their 101 consecutive cases between 2014 and 2018.

METHODS

Anatomical guidelines and preoperative markings were provided to guide the 3-step procedure: zones of maximal and mild liposuction, barbed wire suspension, and moderate fat grafting. Novel concepts are introduced as the anterior body diagonal, posterior body diagonal as well as other specific axes the pubic unit, and a vertical ratio for the buttock, which are the basic foundations for sculpting the female body into a pleasing hourglass shape with a well projected buttock. Recommendations for location of sacral diamond, sacral dimples, and the maximally projected point of the buttock are given. The authors explain their philosophy through 4 principles: knowledge of anatomy, the relationship between specific body areas and surrounding zones, a balanced gluteal augmentation is not achieved through large volume fat grafting alone, and grafting in the subcutaneous layer.

RESULTS

A total of 101 patients were treated following the described technique and examples are shown. The complication rate was low. No serious adverse effects were recorded apart from 1 ruptured suspension loop.

CONCLUSIONS

The described anatomy-based approach, including liposuction, suspension loops, and fat grafting, is a novel and safe technique leading to a desirable, long-lasting outcome.

LEVEL OF EVIDENCE: 4

A Multimetric Health Literacy Analysis of Online Information for Gluteal Augmentation With Fat Grafting

BACKGROUND AND OBJECTIVES

According to the American Society of Plastic Surgeons the number of gluteal augmentations with fat grafting, colloquially known as the "Brazilian buttock lift" (BBL), doubled from 2014 to 2018. Recent studies have demonstrated that gluteal augmentation with fat grafting has a higher mortality rate when compared with other esthetic surgeries. We hypothesize that online patient-directed information for gluteal augmentation are overly complex, written at an elevated reading grade level, with incomplete or no information regarding associated surgical risks.

OBJECTIVE

To perform an objective appraisal of the most popular online patient education materials for gluteal augmentation surgery and explore potential interventions for improving material quality.

METHODS

An online Google search using the term "Brazilian butt lift" was performed and the top 10 websites providing relevant information were identified. Readability for each website was determined using Readability Studio. Understandability, actionability and cultural sensitivity was assessed with validated tools by 2 independent raters.

RESULTS

The top 10 websites were written at a mean reading grade level of 13.0, appropriate for a high school graduate. No website was written at the American Medical Association and the National Institutes of Health recommended 6th to 8th grade reading level. Mean understandability and actionability scores of 51% and 18.9%, respectively, suggest significant room for improvement. The average cultural sensitivity assessment tool score was 2.30, below the recommended threshold for acceptability of 2.5. Ninety percent of all websites did not meet the threshold for cultural acceptability.

CONCLUSIONS

Online patient education materials for gluteal augmentation with fat grafting were written at an inappropriately elevated reading grade level and were overly complex, did not promote reader action, and were not sensitive to the needs of the target demographic.

Objectifying the Risk of Vascular Complications in Gluteal Augmentation With Fat Grafting: A Latex Casted Cadaveric Study

BACKGROUND

Fat transfer is the most popular means of gluteal augmentation. However, this procedure may be complicated by pulmonary fat embolisms (PFEs). Of 135 PFEs out of 198,857 cases reported by the Aesthetic Surgery Education and Research Foundation task force, 32 were fatal, contributing to the mortality risk of this procedure being as high as 1:2351.

OBJECTIVES

The aim of this study was to generate an anatomic map of the 3-dimensional location and variability in size of the gluteal region vessels.

METHODS

Twenty cadaveric gluteal regions were dissected. The aorta, venae cavae, popliteal, and saphenous veins were cannulated and injected with colored latex. Dissection was performed subcutaneously, in the gluteus maximus (GM), and submuscularly to evaluate the number and vascular distribution of all the vessels. Vessels were mapped on an XYZ axis.

RESULTS

The subcutaneous plane, containing 25 vessels on average, had the smallest vessel diameters (artery, 0.9 [0.3] mm; vein, 1.05 [0.22] mm). The GM vein diameter was 1.3 [0.3] mm. Branches of the inferior gluteal vessels had arterial and venous calibers of 2.2 [0.04] mm and 3.5 [0.99] mm, respectively. Superior gluteal artery and vein branches were 1.8 [0.2] mm and 3.85 [1.9] mm in diameter, respectively. Superior and inferior gluteal vein diameters were 7.61 [2.24] mm and 13.65 [6.55] mm, respectively.

CONCLUSIONS

The deeper and more medial planes of the gluteal region house larger, more prominent vessels. This research objectifies and is consistent with recommendations made by various recent task force reports to limit fat transfer to the subcutaneous plane.

The Role of Fat Grafting in Buttock Augmentation

Autologous fat grafting is now considered the gold standard for buttock augmentation. Although a variety of techniques are currently being used by surgeons around the world, methods of fat grafting to the buttocks remain unsystematized, poorly understood, and controversial in terms of their safety and efficacy. Nonetheless, buttock augmentation by fat grafting has a satisfaction rate of 97.1%, and its mean complication rate has been estimated to be around 7 to 10%, with serious complications occurring in less than 1% of cases. Fat emboli are one such serious complication, with several reports in the literature discussing morbidity and mortality, specifically with intramuscular injection. With the increasing popularity of fat grafting for buttock augmentation, it is more important than ever to continue researching and learning to safeguard the satisfaction and safety of our patients.

The Potential Role of Corticosteroid Prophylaxis for the Prevention of Microscopic Fat Embolism Syndrome in Gluteal Augmentations

BACKGROUND

Microscopic fat embolism syndrome (micro-FES) has been recently identified as a potentially fatal complication following gluteal augmentation utilizing autologous fat grafts; safety recommendations advocating for subcutaneous lipo-injections may be insufficient for its prevention.

OBJECTIVES

The authors of this systematic review evaluated the potential role of corticosteroid prophylaxis for the prevention of micro-FES in gluteal augmentation procedures.

METHODS

The authors performed a systematic search employing the National Library of Medicine (PubMed), Medline, and Embase databases. Search terms were those pertaining to studies reporting the efficacy of prophylactic corticosteroid administration on micro-FES incidence in a high-risk surrogate population.

RESULTS

Thirteen articles met the inclusion criteria for review, comprising 2 studies reporting on the efficacy of a single intravenous (IV) corticosteroid dose for the prophylaxis of micro-FES, 9 studies reporting on multiple prophylactic IV doses, and 2 additional studies reporting on the efficacy of inhaled corticosteroids in this context. All studies were identified from the orthopedic literature given that none were available directly from within plastic surgery. The prophylactic efficacy of multiple IV doses of methylprednisolone, or a single larger dose, was established, whereas the efficacy of inhaled corticosteroids remains elusive.

CONCLUSIONS

A single perioperative IV dose of methylprednisolone may be most appropriate for utilization by plastic surgeons; the safety and implication of this therapy on wound healing and fat graft survival are discussed. Further studies directly evaluating the efficacy of corticosteroid prophylaxis in the gluteal augmentation population are indicated. Finally, recommendations pertaining to the prevention, timely recognition, and effective management of micro-FES are discussed.

Autogenous Fat Grafting to the Breast and Gluteal Regions: Safety Profile Including Risks and Complications

Given the widespread utility and therapeutic potential of autogenous fat grafting, plastic surgeons should be familiar with its safety profile and associated adverse events. This article provides a critical review of the literature and delineates risk factors associated with various complications when grafting to the breast and gluteal regions. The majority of adverse events are related to fat necrosis and require minimal diagnostic or therapeutic intervention. Larger graft volumes, as in cosmetic augmentation, are associated with higher incidences of fatty necrosis. The oncologic safety of fat grafting is supported by multiple clinical studies with thousands of breast cancer patients, albeit predominantly retrospective in nature. Although less frequent, serious complications include fat emboli during gluteal augmentation. Identification of associated risk factors and implementation of proper surgical techniques may minimize the occurrence of life-threatening complications.

A systematic review of the effectiveness and complications of fat grafting in the facial region

INTRODUCTION

The objective of this study was to evaluate the safety and efficacy of fat grafting to the facial region for the reconstruction and aesthetic enhancement of facial contour.

METHODS

A systematic literature review of the National Library of Medicine (PubMed), MEDLINE and Cochrane databases was performed. Studies involving the outcomes of autologous fat grafting to correct or enhance contour defects of the face were included. Extracted data included patient demographics, harvest and injection sites, graft harvesting and injection technique, mean injected volume, retained volume percentage and complications.

RESULTS

Forty-three articles met the inclusion criteria, resulting in 4577 patients with various facial contour defects treated with autologous fat grafting. Injection sites were categorized by anatomic facial regions as upper (32.5%), middle (53%) and lower face (14.5%). The mean volume of injected fat was 16.9 ml. The mean weighted volume retention of non-enriched grafts was 41.63% at the time of follow up (mean 13.9 months). A total of 104 (2.27%) complications were reported including asymmetry (74), skin irregularities (14), prolonged edema (4), graft hypertrophy (4), fat necrosis (3), infection (2), erythema (1), telangiectasia (1), and activation of acne (1).

CONCLUSION

The present study represents the first systematic review of fat grafting in the facial region, a widely-performed procedure within plastic surgery practice. Importantly, it presents pooled important data such as retained grafting volume and complication rates in this anatomical region, providing clinicians with more accurate information with which to guide their decision-making and patient education.

Gluteal Augmentation With Fat: Retrospective Safety Study and Literature Review

BACKGROUND

Use of gluteal augmentation with fat increased by 3267% from 2002 to 2015, and the rate of death is highest compared with other aesthetic procedures: 1 in 3448 patients dies, compared with 1 in 55,000.

OBJECTIVES

To retrospectively investigate patients who underwent this procedure at Oslo Plastic Surgery Clinic, to review international data to determine factors causing mortality, and to provide guidelines for safety.

METHODS

Patient data were searched for reason for the procedure, assessment of patients, techniques performed, and safety measures used. In 60 cases, a vibration machine was used for fat harvesting. Review of the international literature, with special emphasis on fatal complications, was performed on Medline, Google Scholar, and PubMed.

RESULTS

Mean patient age was 32 years. Mean amount of grafted fat was 422 mL (range, 210-850 mL). Sedation, local and tumescent anesthesia were used in all patients, with mobilization directly after surgery. Mean operation time was 89 minutes. Eighteen patients required a second surgery. Minor complications occurred in 8 patients. Average follow-up was 8 months. Ninety percent of patients were satisfied. Review of international literature showed that the main reason for death in 2015 was fat lung embolism related to muscular and submuscular grafting.

CONCLUSIONS

Gluteal augmentation with fat is one of the most popular procedures, with an internationally high mortality rate. Patient safety is a priority, and preventive measures should improve safety because appropriate patient selection, avoiding muscular and submuscular grafting, avoiding infragluteal incision, moderate grafted volume, and direct postoperative mobilization are essential.

LEVEL OF EVIDENCE: 4

Safe Gluteal Fat Graft Avoiding a Vascular or Nervous Injury: An Anatomical Study in Cadavers

Background

Fat grafting for gluteal augmentation is one of the most popular aesthetic surgery procedures. It has an associated mortality to fat embolism of 0.2%.

Objectives

The authors of this study sought to describe which technique for synthetic graft application was least likely to cause a fat embolism.

Methods

Ten fresh bodies were obtained and 4 groups arranged with 5 buttocks each randomly assigned. Group 1 was infiltrated through the upper medial intergluteal sulcus (upper medial intergluteal sulcus) with an angulation of -30°, -10°, and 0°. Group 2 was infiltrated through the middle lower gluteal sulcus with an angulation of -30°, 0°, and +15°. Group 3 was infiltrated through a peritrochanteric (PT) access at the level of the femur head at 0° and +10° and in the middle of the buttock at the level of the posterior superior iliac crest at -30° toward the trochanter (lateral direction). Group 4 was infiltrated in the same manner as group 1 without -30°. A complication occurred when the graft was in contact with the vascular or nervous bundle, within the gluteus medius muscle, or both.

Results

Group 1 had 3 buttocks with a complication (UMIGS -30°). Group 2 had complications in all the injection techniques. Group 3 had 5 buttocks with a complication (PT at 0°). Group 4 had no complications.

Conclusions

The injection of the fat graft through the UMIGS at 0° and 10° angles, and through the middle of the buttock at the level of posterior superior iliac crest a -30° angle, reaches the surface needed for gluteal augmentation. The group 2 techniques should be avoided because they have a high risk of complication.

Real-Time Ultrasound-Assisted Gluteal Fat Grafting

BACKGROUND

The number of gluteal fat augmentation procedures has increased recently and so has the number of complications. Because of the increased risk of morbidity and mortality when fat is injected intramuscularly, not knowing where fat is injected is concerning. We sought to identify the planes in which fat is injected during the procedure.

METHODS

We selected 15 consecutive female patients who desired gluteal fat augmentation. All patients had epidural anesthesia and the gluteal region was infiltrated with a vasoconstrictive solution. With the patient in prone position, an ultrasound probe placed on the buttocks was used to identify the fascial layers. While decanted fat was being injected with a blunt cannula, the images were projected wirelessly to a screen, so that the surgeon and assistant could follow the planes in which the cannula was being introduced and the fat injected.

RESULTS

The mean volume of harvested fat was 3533 ml and the mean volume of fat injected per gluteal region was 528 ml. The evaluation of the depth and location of the cannula was performed in real time with the ultrasound, accurately and reliably identifying the planes of fat injection. All injections were subcutaneous. The downsides of this technique were the purchase cost of the ultrasound device, increased surgical time, the need for an assistant to follow the cannula and the probe constantly, and the learning curve.

CONCLUSION

Real-time ultrasound-assisted gluteal fat grafting is reliable and may avoid injuring the deep vessels, further decreasing the risks of major complications.

Expansion Vibration Lipofilling: A New Technique in Large-Volume Fat Transplantation

BACKGROUND

Despite rapid growth, gluteal fat transplantation is an operation in search of science and a teachable technique. Long operating times, tedious syringe transfers, inability to shape the recipient site, and the risk of fat embolism all headline as impediments to clinical adoption of the procedure. Expansion vibration lipofilling is a syringe-free surgical strategy that is a logical extension of Separation, Aspiration, and Fat Equalization (SAFELipo). In expansion vibration lipofilling, there is simultaneous disruption of recipient-site connective tissue, internal expansion using exploded-tip cannulas, and backfilling of these spaces with roller pump-propelled fat.

METHODS

Two thousand four hundred nineteen consecutive cases of expansion vibration lipofilling fat transplantation to the buttocks were reviewed. Average follow-up was 12 months. The technique of expansion vibration lipofilling is dependent on the use of larger caliber cannulas attached to a roller pump and to an oscillatory power-assisted liposuction device, which is less labor-intensive, potentially allowing for better knowledge of cannula-tip location at all times during the procedure.

RESULTS

Operating times averaged 1 hour 40 minutes. The average volume of fat inserted was 1003 cc. Complications included donor-site seroma, infection, and one pulmonary embolism treated with anticoagulation. There were no cases of fat embolism or death.

CONCLUSIONS

Expansion vibration lipofilling is a new method for large-volume fat transplantation. Avoidance of fatal fat emboli demands a surgeon's complete knowledge of cannula tip location at all times during the procedure. Syringe-free, larger caliber, and less flexible cannulas, combined with techniques requiring less operator upper extremity effort resulting in less fatigue, may contribute to avoidance of this dreadful complication.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Gluteal Augmentation and Contouring with Autologous Fat Transfer: Part I

Gluteal augmentation with autologous fat transfer is an increasingly popular procedure that has the ability to transform a patient's entire body silhouette and gluteal appearance. Proper patient selection, preoperative evaluation, and planning are critical to the success of the procedure. Using the preoperative planning, surgical technique, and postoperative care described, the procedure can be performed safely with powerful and consistent results and avoidance of complications associated with gluteal fat transfer.

Gluteal Ligamentous Anatomy and Its Implication in Safe Buttock Augmentation

BACKGROUND

The number of buttock augmentations with fat transfer is steadily increasing, but a number of fatalities caused as a direct result of gluteal fat grafting have been reported. The technical details relating to cannula size, injection angle or trajectory, and plane of injection are critical for avoiding morbidity and mortality. However, the ligamentous anatomy has not been thoroughly explored, particularly how the ligaments are encountered in the clinical setting of fat transfer by means of cannulas.

METHODS

The gluteal regions of five fresh cadavers were dissected, for a total of 10 hemidissections. All pertinent cutaneous ligaments in the region were identified. In addition, cannulas were used to simulate typical variations in injection planes.

RESULTS

The osseocutaneous and fasciocutaneous ligaments of the buttocks were identified.

CONCLUSIONS

The authors describe important ligamentous structures consistently found in the region in cadaveric dissections and discuss the implications while safely performing gluteal augmentation. The anatomical features, boundaries, and soft-tissue attachment points may play a role in cannula-directed fat injection misguidance. The ligaments, when not released, can lead to undesired deep injection and therefore fat lobule migration into the venous system. The density, danger zones, and soft-tissue attachments must be clarified further as we continue to offer our patients improved buttock contour with a higher safety profile.