Gluteal Ligamentous Anatomy and Its Implication in Safe Buttock Augmentation

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 .

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

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.

Gluteoplasty With Lumbar Gluteal Flap Associated With Liposuction and Fat Grafting: A Safe Technique for Massive Weight Loss Patients

BACKGROUND

Weight loss leads to excessive flaccidity, volume loss, and tissue descent in the gluteal region. Translated autologous flaps during lower body lifting have been utilized in patients; they address sagging tissue and the lack of volume. However, sometimes use of these autologous flaps does not provide adequate gluteal projection, and a second procedure with fat injection may be required.

OBJECTIVES

The authors describe their technique of a lower body lift with a lumbosacral flap in association with liposuction and lipofilling for gluteoplasty.

METHODS

A prospective series of 23 post-bariatric surgery individuals who underwent a lower body lift with lumbosacral flap gluteal augmentation, liposuction, and lipofilling between January 2021 and September 2022 were described. The satisfaction rate and complications were assessed 6 months postoperatively with a validated questionnaire (BODY-Q scale).

RESULTS

The patients had a mean age of 38.18 (range, 28-56 years) and median body mass index of 26. Four patients with dehiscence were diagnosed and treated conservatively. All wound breakdowns were observed in the paramedian plane of the torsoplasty. No reoperations were performed. The mean satisfaction percentage of the BODY-Q scale transformed score was 97.5.

CONCLUSIONS

A technique for a lower body lift with buttock augmentation combined with liposuction and fat grafting was presented. In future studies other techniques to maximize gluteal contouring should be investigated.

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.

Patient Pre-operative Planning of Gluteal Augmentation

Demand for autologous gluteal augmentation with fat transfer continues to rise paralleling the increasingly complex nature of the operation. Improved overall aesthetic outcomes are a result of: (1) donor site fat harvest has evolved to circumferential torso high-definition lipo-sculpting; (2) a shift from indiscriminate buttock augmentation to precise gluteal re-shaping. Discussing complex operations with patients, particularly ones of artistic nature, can be challenging. The senior author has developed a gluteal re-shaping graphic to focus a patient's attention to the four most important areas. It also serves as a foundation for surgeons to create operative plans and track outcomes for professional development.

The S-Curve®: Clinical Importance of the Gluteal Ligaments in Efficacious Fat Transfer

Liposuction cannulas are versatile tools in a plastic surgeon's armamentarium useful for dissection, deep subcutaneous ligamentous release, fat extraction, and lipofilling. Experienced surgeons develop the ability to navigate subcutaneous anatomy through real-time tactile feedback of the cannula's depth, angulation, excursion, and resistance. Peripheral gluteal ligaments acting as anatomic boundaries must be understood and protected. However, central ligaments tether the dermis to deeper structures precluding expansion. Appropriate, targeted ligamentous weakening improves focal capacitance allowing precise gluteal contouring while staying in safe planes. This maneuver is critical during subcutaneous lipofilling of the S-Curve® procedure to create an aesthetically pleasing, convex gluteal silhouette.

Art and Safety of Gluteal Augmentation: Future Directions

Gluteal augmentation is a quickly evolving field that continues to grow in the realms of patient safety, surgical education, and technological advancement. This article discusses innovation in gluteal augmentation and suggests potential new pathways for developing the practice of gluteal augmentation.

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.

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

Gross anatomical study of the subcutaneous structures that create the three-dimensional shape of the buttocks

The purpose of this study was to clarify the subcutaneous structures involved in the morphology of the gluteal region for clinical application. Thirty-seven formalin-fixed cadavers and one soft-fixed cadaver were used in this study. Gluteal tissue was removed from five formalin-fixed cadavers. A horizontal section and sections parallel to the long axis of the body were made from the excised tissue, and the subcutaneous fat was removed to observe the fibrous structure within the subcutaneous fat. Two formalin-fixed cadavers and one soft-fixed cadaver were used to perform conventional gross anatomical dissection and histological examination. On 30 formalin-fixed cadavers, the thickness of the subcutaneous fat was measured in various areas of the buttocks. The thickness of subcutaneous fat was thicker in the center of the buttocks and thinner on the lateral buttocks. Superficial fascia (SF) was found only in the upper buttock, being indistinct in the lower buttock. In the sacral and coccygeal areas, the dermis was tightly adhered to the bone as a single mass. Fibers arose from around the iliac crest to the SF. On the medial side of the gluteal fold, a strong fiber arose from the sciatic tubercle and inserted into the gluteus maximus and dermis. By identifying the characteristic subcutaneous structures of the gluteal region, we were able to identify the anatomical structures that shape the three-dimensional morphology of the buttocks. These findings may be useful in surgical treatments such as improving the buttock shape.

Deep Subcutaneous Gluteal Fat Compartments: Anatomy and Clinical Implications

BACKGROUND

Advances in gluteal fat grafting have resulted in diminished risks through improved understanding of regional anatomy and technical nuances. No anatomic studies identifying the presence or absence of buttock fat compartments have yet been reported.

OBJECTIVES

The aim of this cadaveric study was to identify and characterize the deep subcutaneous gluteal fat compartments to further understand the nuanced differences between deep and superficial subcutaneous fat layers.

METHODS

A cadaveric study was performed to identify the fat compartments. Latex injection into the iliac artery and vein was used to prepare 4 fresh (N = 8 hemibuttocks) hydrated cadavers for dissection. Preliminary work identified the likely position of deep gluteal fat compartments. The cannula was positioned under ultrasound guidance in between the superficial and deep gluteal layers. Cadaveric buttocks were infiltrated by the static technique with dyed human fat, dyed applesauce, and dyed saline in an attempt to identify the gluteal deep subcutaneous fat compartments.

RESULTS

Dissection identified and characterized 7 discrete deep gluteal fat compartments. These comprise 3 medial fat compartments (superior, middle, and inferior); a central fat compartment; and 3 lateral (superior, middle, and inferior) deep fat compartments.

CONCLUSIONS

Seven deep gluteal fat compartments have been identified that have distinct boundaries and maintain injected contents separate from each other above the gluteal muscle fascia. These compartments can be selectively expanded for buttock augmentation. Knowledge of these compartments enables surgeons to perform gluteal augmentation by static infiltration, injecting autologous fat under ultrasound guidance in the deep subcutaneous fat layer, while optimizing aesthetic considerations.

RESUMEN

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.

Submuscular Gluteal Augmentation and Lipoplasty for Buttock Beautification

The number of gluteal augmentation procedures with implants has increased in the last years. However, due to high complication rates related to the placement of the implants, surgeons have started to avoid using implants. The objective of the present study was to describe the details of the submuscular gluteal augmentation technique together with lipoplasty techniques and to increase the prevalence of its use.

METHODS

All methods are complementary to each other rather than being superior to each other. That is why the author has used submuscular gluteal augmentation with implant technique and lipoplasty together during the surgeries. The complication rates are lower with this easy-to-learn technique described in this article. Eighty-six patients aged 20-46 underwent surgery. The follow-up period was 6-24 months. The implants used consisted of round cohesive silicone, with the most commonly used size being 330 cm3. The average volume of infiltrated fat was 514 cm3.

RESULTS

The sciatic nerve is well protected by the surrounding anatomical structures, indicating that submuscular technique can be used safely. Partial wound dehiscence was noted in 1 patient, implant malposition in 5 patients, and seroma in 2 patients. All patients reported that they are highly satisfied with the results of the procedure.

CONCLUSIONS

The author advocates that the combination of lipoplasty with the submuscular technique described is safe, easy to perform, has a short operative time and low complication rates. It can be preferred in buttock beautification as a simple and safe technique.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting

BACKGROUND

Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins.

OBJECTIVES

The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging.

METHODS

Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes.

RESULTS

The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus.

CONCLUSIONS

The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

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.