Liposuction With Autologous Fat Grafting

An autologous fat graft is indicated for patients who may have a surplus of body fat in other areas. In addition to augmenting the buttock, this allows the surgeon to reproportion the adjacent body contours. Autologous fat is transferred into both the subcutaneous layer and gluteus maximus muscle to give an overall increase in bulk to the region. Fat needs to be available from donor sites in sufficient quantity to cover primary and possibly secondary grafting procedures.

Gluteal Implants

These are indicated for patients who do not have body fat excess or have it in an insufficient amount to increase the gluteal region. Surgical techniques for buttock implants insertion have evolved over time to correct anatomic deficiencies and fulfill patients’ requests. The procedure for aesthetic purposes has gained strength since the 1970s, after the description of the use of implants in the gluteus by Cocke and Ricketson, the dissemination of technical enhancements by González-Ulloa, and the development of a specific range of gluteal implants. Several techniques have evolved, including procedures for the dissection plane, such as for the subcutaneous plane by González-Ulloa, the subfascial plane by de la Peña et al., the submuscular plane by Robles et al., and the intramuscular plane by Vergara and Marcos ( Fig. 35.3 ).

Evolution of techniques over time. Implant positions—subcutaneous (Gonzalez-Ulloa), subfascial (De la Pena), intramuscular (Vergara), and submuscular (Robles).

(From Serra, F., Aboudib, J.H., Cedrola, J.P., de Castro, C.C., 2010. Gluteoplasty: anatomic basis and technique. Aesthet. Surg. J. 30, 579–592. © The American Society for Plastic Surgery, with permission.)

Subcutaneous placement of a gluteal implant has serious disadvantages. Because the system that maintains the skin attachment to the gluteal region is composed of aponeurotic expansions from the gluteal aponeurosis to the dermis, the creation of a subcutaneous pocket will damage these expansions, leaving the skin without fixation. This could possibly result in implant displacement. Furthermore, in this plane, the implants are palpable and highly visible, there is an increased chance of rupture of the implant shell, the skin envelope can become ptotic, and severe capsular contracture can occur.

The subfascial plane technique described by de la Peña et al. is based on gluteal layers. The pocket that is created under the gluteal fascia is very extensive and covers the entire gluteus maximus muscle. It has the same problems as subcutaneous implants—visible margins, palpable, rupture, displacement, and capsular contracture are the most common complications.

The submuscular approach preserves the aponeurotic system that holds gluteal skin in position and has the advantage of reducing the incidence of capsular contracture, displacement, rupture, and palpation. However, it introduced a new anatomic issue— the potential risk of injury to the sciatic nerve. Another disadvantage of the submuscular position relies on its small size and therefore limits the use of larger implants.

To prevent subcutaneous, subfascial, and submuscular complications, and at the same time gain the benefits of the muscular cover, the intramuscular plane is the most used technique. The pocket is created by splitting the muscular fibers of the gluteus maximus. The goal is to have 2 to 3 cm of muscle over the pocket and the same 2- to 3-cm thickness of gluteus maximus deep to the pocket to protect the sciatic nerve, allowing the surgeon to place the implant in the best position for each type of buttock.