CHAPTER 38 Subfascial Male Buttock Augmentation

10.1055/b-0040-178178

CHAPTER 38 Subfascial Male Buttock Augmentation

J. Abel de la Peña and Guillermo J. Gallardo

Summary

Subfascial buttock augmentation provides an aesthetic ideal plane for implant placement in practically every candidate, but certain key points should be considered for the male patient given the differences in anatomical architecture between the genders. The male buttock is narrower and shorter and therefore rounder than that of the female because of differences in pelvic frame, muscle height and width, and femoral bone angulation. These differences make implant selection and pocket dissection more focused on obtaining a masculine aesthetic result. The templates Dr. Abel de la Peña developed are particularly helpful for implant selection and to plan pocket dissection. Several other key surgical instruments like a long fiberoptic retractor and blunt round double-ended dissectors are of great importance to simplify the procedure. It is vital during the procedure to keep in mind the limits of pocket dissection (i.e., 5 cm above the infragluteal fold and 2 cm lateral to the sacroiliac joint). Once the pocket has been dissected in a caudal and lateral manner, a sizer is inserted into the pocket to confirm dissection and implant volume selection. Once the implant has been placed, wound closure is carried out in at least four suture planes. Still, the most important part of gluteal augmentation remains preoperative education and postoperative care to prevent any complication.

Introduction

In a world where aesthetics take a greater importance in our everyday life, design, fashion, and marketing industries have placed the human figure in the centerspot of their inspiration. Curves, youthfulness, and fitness preoccupy the minds of both men and women. As such, it is no surprise that gluteal shaping is currently placed as the 10th most frequent worldwide surgical procedure performed by plastic surgeons. There is no doubt that male plastic surgery has had a dramatic increase over the last 10 years, and buttock augmentation is clearly one of the main concerns, even if only 5% of all buttock surgeries are done in males. ¹

In 1969, Bartels and colleagues2 published a unilateral gluteal augmentation with a Croninstyle breast implant to correct a left gluteal muscle atrophy with a satisfactory aesthetic result. In 1973, Cocke and Ricketson3 described the subcutaneous plane for implant placement, but in 1977, Gonzalez-Ulloa4 designed a special implant taking into account gluteal anatomy. The submuscular pocket was described by Robles and colleagues in 1984, ⁵ and Vergara and Marcos, ⁶ in 1996, placed gluteal implants in an intramuscular space through an incision in the intergluteal crease. ⁷ ^, ⁸ To overcome the complications arising from these techniques, the primary author has described gluteal augmentation with silicone implant placement in a subfascial plane through a double paramedian incision. He has also developed a system for gluteal augmentation that includes templates ( Fig. 38.1 ), sizers, and an anatomically shaped implant designed specifically for subfascial placement, which will be described later in this chapter.

**Fig. 38.1** The set of templates used for preoperative evaluation of implant size.

Physical Evaluation

Ideal candidates desire an improved gluteal shape but lack gluteal projection; they are thin with an athletic build and have little or no ptosis.
Overweight patients also benefit from this technique but often require a more thorough liposculpture during the same procedure.
Fat deposits around the gluteal area may be corrected with liposculpture of the neighboring areas, and should be considered beforehand to achieve the best result.
Male anatomy should be kept by analyzing the patient’s buttock dimensions and considering his expectations.
The most appropriate implant size should be selected before surgery using templates and measuring in advance the subfascial space. The male buttock has a shorter vertical distance and is therefore rounder than the female buttock.
The most important factor to guide implant selection is its base’s vertical and horizontal dimensions, which should fit the buttock leaving at least 5 cm between the pocket dissection limit and the infragluteal fold and 2 cm lateral to the sacrum.
The final result should be to attain a waist-to-hip ratio (WHR) close to 0.9.

Anatomy

Body shape is largely defined by skeletal frame, muscle, and fat distribution. Males tend to store less fat than females and have more bone and muscle mass on average. The pelvic bone is no exception, which results in a buttock anatomy that differs between genders. Females are said to have a gynecoid pelvis (rounded shape), while males are associated with an android pelvis (heart-shaped). In general, the structure of the male pelvis is significantly heavier and thicker than that of the female. The male pelvic bones are also adapted to fit a more massive and sturdy body architecture. Men have a narrower pelvic bone than women, which causes the femur or thigh bones to be positioned closer together. The sacrum is longer, narrower, and more angled in the male than in the female. Males have a less rounded pelvic frame, narrower sciatic notches, a deeper greater pelvis, a narrower lesser pelvis and smaller pelvic inlet and outlet, and a rounder obturator foramen. The result is a narrower-shaped and shorter buttock associated with masculinity. ⁹ ^, ¹⁰

The gluteal aponeurosis (GA) covers the gluteus maximus muscle, the largest and most superficial regional muscle responsible for projection of the gluteal area, and the upper two-thirds of the gluteus medius muscle, which provides volume to the superior third of the buttocks. The GA has its origin on the posterior iliac, sacral, and coccygeal bones; laterally, it inserts on the greater trochanter and along the iliotibial line ¹¹ ( Fig. 38.2 ). Because the aponeurosis is stronger at its origin and insertion sites and more compliant in the middle, an implant in this plane can achieve a natural-looking result. When an implant is placed in this space, an anatomical contour is created naturally ⁸ ( Fig. 38.3 ).

The GA sends expansions to the skin, which insert into the deep dermis. They work as a system to adhere the skin and subcutaneous tissues in the gluteal region. Aponeurotic expansions are distributed in a transverse direction, along the axis of the muscle fibers throughout the gluteal region ¹² ( Fig. 38.4 ). This system of fascial attachments should be maintained in any gluteal implant surgery.

The amount and distribution of subcutaneous fat content also accounts for the round shape and projection of the buttocks. Sexual dimorphism in pelvic morphology is most apparent in body fat distribution as measured by WHR. ⁹ Men tend to have straighter hips and a higher WHR compared to most women. Subcutaneous fat content in the gluteal region is usually smaller in men than in women. Singh9 investigated the role of WHR in the male body attractiveness as viewed by females. The results showed that a WHR of 0.9 is ranked as the most attractive.9 Wong et al.10 found that from the lateral view, the most attractive female buttocks have the most prominent portion positioned at the midpoint of the buttocks, that is, a 50:50 vertical ratio. This proportion is deemed ideal even in male patients.

**Fig. 38.2** The aponeurotic expansions run from the gluteal aponeurosis to the dermis in the direction of the red lines. (Reproduced with permission from JA de la Peña. Subfascial technique for gluteal augmentation. Aesthet Surg J. 2004;24(3):265–273.)

**Fig. 38.3** Cadaver dissection demonstrates the fasciocutaneous flap that has been raised in keeping with the principles of this operation. A large incision has been made only for demonstration purposes.

**Fig. 38.4** Bilateral paramedian presacral incisions are used, and a beveled dissection is carried out up to the border of the sacrum, the gluteal fascia in incised, and a subfascial pocket is created over the gluteus maximus muscle leaving the aponeurotic expansions attached to the skin intact.

Steps for Subfascial Technique for Gluteal Augmentation

Patient preparation commences at the time of the first consultation. Postoperative care recommendations are carefully explained to patients so they know beforehand what to expect. The patient is also instructed to stop taking any aspirin, vitamin E, omega fatty acid, and homeopathic supplements (except for arnica montana) at least 2 weeks before surgery because of increased bleeding risk during surgery. Hospital admittance occurs the night before surgery, and an enema is administered.

Skin markings are drawn using customdesigned templates with the patient in a standing position. The template must be centered over the gluteal region leaving at least 5 cm between the template and the infragluteal fold and 2 cm lateral to the sacrum ¹¹ ( Fig. 38.5 ). The template equator should be at the level of the pubic crest. Bilateral presacral paramedian skin incisions of 6 cm are marked 5 cm above the anus and at least 1 cm lateral to the midline ( Fig. 38.6 ). Skin incision markings can be elevated along the gluteal sacral margin in cases where it might be desirable (e.g., in patients presenting with adjuvant disease), as it decreases both wound tension and infection rate in patients with already compromised tissues. ¹³ ^, ¹⁴

The most appropriate implant size can be selected before surgery and confirmed with sizers during surgery. Determining implant size is simplified knowing the exact measurements of the template that best accommodates the buttock and patient expectations. Anatomically designed implants with varying projections are now available to accommodate different volumes for a given base size. Because the male buttocks have smaller height or vertical distance than female buttocks, and are therefore rounder in shape, implant size is generally smaller than those chosen for female buttock augmentation.

**Fig. 38.5** The template is centered over the gluteal region leaving 5 cm between the template and the infragluteal fold and 2 cm lateral to the sacroiliac joint.

**Fig. 38.6** Surgical instruments typically used for subfascial gluteal augmentation implant placement.

The skin incision markings are injected with a mixture of 2% lidocaine with epinephrine and 7.5% ropivacaine in a 1:0.25 ratio, dissection is carried up to the muscular aponeurosis at the lateral border of the sacrum, an 8- to 10-cm incision into the aponeurosis is made parallel to the sacral border entering the subfascial dissecting plane. An epinephrine solution of 100 to 150 cc is instilled with a cannula to enable identification of the avascular plane deep to the fascia and facilitates sharp dissection of the septa in the subfascial plane, permitting the elevation of an intact fasciocutaneous flap. The septa parallel the direction of the muscle fibers and, therefore, radiate out in a fan-like pattern. ¹² ^, ¹³ ^, ¹⁴

Double-ended blunt round dissectors are used initially to separate the avascular plane and preserve the septa and the aponeurosis. Visibility during undermining is facilitated if dissection is carried out from medial to lateral and from cephalic to caudal using a fiberoptic retractor. A long cautery tip as well as a pair of long cauterizing scissors are used to dissect the septa ( Fig. 38.7 ). Branches of the superior and inferior gluteal arteries and a few vessels that run through the GA septa are cauterized. It is important to maintain a wide field of exposure without going beyond the skin markings. Once the pocket is dissected, a sizer is used to evaluate the volume and shape of the pocket and confirm the correct implant size for the patient ¹⁴ ( Fig. 38.8 ). Both pockets should be dissected before placement of any implant to facilitate dissection of the contralateral pocket.

We used to place drains exiting high and laterally on the buttocks when we employed textured implants. Because implants became microtextured, we no longer place them routinely. The implant is then inserted, making sure that it is perfectly aligned on its axis and fitting loosely inside the pocket. We insist that all gluteal implants must have a white line through their horizontal axis to facilitate and ensure proper vertical alignment inside the pocket ¹⁴ ( Fig. 38.9 ). Also, the implant’s greatest projection point should be below the equator and closer to its inferior pole. Implants should never be placed in an oblique manner, as this causes a double bubble contour irregularity inferolaterally.

**Fig. 38.7** Bilateral presacral paramedian skin incisions of 6 cm are marked 5 cm above the anus and at least 1 cm lateral to the midline.

Once the implants have been inserted, closure is performed in at least five distinct layers. The GA is closed first with both separate and running sutures ensuring a watertight closure, making sure that no tension is placed along the suture line. Then, the deep and superficial subcutaneous layers are closed separately over the sacrum. The dermis is then closed up using a watertight suture, and a 4–0 running nonabsorbable monofilament suture is placed on the skin and reinforced with a topical skin adhesive.

In gluteal pexy candidate patients, who either present with gluteal ptosis, excess skin laxity of the buttocks, and in weight loss patients, a gluteal implant is always advised. Gluteal pexy surgery causes buttock flattening unless a gluteal augmentation procedure is carried out during the same operation. For this reason, we advise all of these patients to undergo a subfascial gluteal augmentation with implants. Skin resection in patients requiring skin excisions should always be done superiorly on the cephalic part of the buttocks. The incision and resection should be planned in such a way that dissection of the subfascial plane is carried out through it.