Buttock Lift

DEFINITION

Buttock lift describes excision of lax and/or redundant lower back tissue to improve lift and shape to the buttocks, as well as posterior waist contour. It is the basis for the posterior element to lower body lifting for individuals who have sustained massive weight loss. The procedure may be performed in combination with augmentation of the buttock using fat, autologous flaps, or implants or with lifts of adjacent body regions such as the abdomen or thigh to globally improve the lower body region.

ANATOMY

The 10 gluteal aesthetic units, identified by Mendieta,¹ while not all in the buttock proper, impact the appearance of buttock (FIG 1A):
- Sacrum
- Flank
- Upper buttock
- Lower back
- Outer leg
- Gluteus
- Diamond zone
- Midlateral buttock
- Inferior gluteal/posterior leg junction
- Upper back
Anatomic layers of the lower back/buttock (FIG 1B)
- The skin can demonstrate varying degrees of redundancy, vertical excess, laxity, and collagen strength as manifested by striae. Thin skin may have greater recoil after surgery resulting in exacerbated loosening of the surgical result.
- Subcutaneous fat varies in thickness. A thinner fat layer is more appropriate for buttock lift than a thick one, which might be more suitable for a liposuction contouring procedure or recommendation for weight loss. If subcutaneous fat is limited, an augmentation with autologous flaps, fat, or implant may be considered.
- Scarpa fascia is the pseudofascial plane in the subcutaneous fat that varies in strength and is relied upon for closure and lift and may need more sutures to provide greater tension or better support for weak tissue.
- Subscarpal fat is the layer in which dissection is performed for buttock lift.
- Deep muscular fascia should not be cut during buttock lift. This layer protects the muscles and vital vessels and nerves.
- Muscles of significance in this region include the paired gluteus maximus muscles, which should not be invaded during surgery so all structures deep to the gluteus maximus are not dissected or visualized. Attenuated muscle may account for buttock deflation and may be improved with fat augmentation.
- Circulation of greatest importance is provided by the superior gluteal arterial system and inferior gluteal artery system. Perforators from these arteries should be preserved, particularly when performing autologous gluteal augmentation² (FIG 1C).

PATHOGENESIS

With skin laxity and/or weight loss of varying degrees, individuals can suffer from excess vertical dimension of skin in the lower back with deflation and flatness of the buttock area, an ill-defined infragluteal crease, cellulite, and lack of fullness.
Ptosis may occur in the buttock and lateral thigh. This is associated with an aged look or with difficulty in wearing clothing.
Lower backlift/buttock lifting surgery improves the posterior waist and shape and tautness of the buttock, in conjunction with improving adjacent areas, like the upper posterior thigh, outer thigh, and back.

PATIENT HISTORY AND PHYSICAL FINDINGS

Patient history should be probed for significant weight loss, and if present in the history, the mode and degree of weight loss, as well as nutritional challenges that may exist.
- Weight should be stable at the time of surgery at least 3 months.
- Medical conditions that may impact outcome of backlift surgery should be queried, such as diabetes, peripheral vascular disease, heart disease, sleep apnea, autoimmune and endocrinological disorders, and coagulation disorders and venous thromboembolic history.
Physical findings should note skin quality and degree of excess and redundancy, as well as adiposity.
- Adjacent body regions such as the upper back, abdomen, and thigh anteriorly and posteriorly are examined to see if addressing these regions will improve overall lower body aesthetics.

SURGICAL MANAGEMENT

Preoperative Planning

Preoperative planning depends on patient preference and deformities present.

Limitations in patient state of health or finances may curtail extensive surgical procedure and mandate a staging plan.

FIG 1 • A. The 10 gluteal aesthetic units are shown. The diamond zone includes the inner gluteal/leg injection. B. From superficial to deep, anatomy of the buttocks includes the skin, fat, pseudofascial plane in the fat, muscle fascia, and muscles. The subcutaneous fat layer may vary in thickness and deposition, and fascial layers may have varying degrees of strength. Thickness of each of these layers affects gluteal contour. C. Arterial supply of the gluteal region is primarily provided through the superior and inferior gluteal artery perforators. The autologous flap is primarily supplied by the superior gluteal artery perforator system as it is within the angiosome.

Buttock lift is typically performed in continuity with abdominoplasty and may be performed either at the time of abdominoplasty or at a later stage.

Planning and discussing possible augmentation in conjunction with buttock lifting should take place prior to surgery.³
- Prediction needs to be made by the surgeon to determine whether excision of lower back tissue alone will provide adequate improvement to buttock position and contour or if additional tissue in the form of autologous flap tissue or fat graft should be harvested from the tissue that would otherwise be discarded to help amplify and shape a severely deflated buttock.
- Liposuction of the outer thigh also may be considered if it will improve contour and allow greater tissue resection.

Positioning

Prone positioning is most optimal for buttock lift. It allows a symmetrical, safe, and stable approach.

The patient is laid on two gel rolls laid horizontally across the OR table, one under the upper chest and axillae, and the other under the lumbar area (FIG 2).

Axillae and elbows are positioned at no greater than 90 degrees to limit traction on nerves and vessels.

The neck is in neutral position, and the face should be protected in a prone pillow, avoiding any pressure to the eyes.

FIG 2 • Prone positioning helps provide the best access to the lower back, allowing symmetrical treatment. Safety measures must be followed to avoid blindness, stroke, neurapraxia, and pressure phenomena. A. Face in prone pillow with goggles protecting eyes from pressure and desiccation. B. Arms at 90 degrees and bumps under chest and lumbar region. C. Bump under lumbar region. Patient is warmed with forced warming blanket intraoperatively.

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