Buttocks

Published on 16/03/2015 by admin

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23 Buttocks

Ada R. Trindade de Almeida, Raúl Alberto Banegas

Summary and Key Features

• The gluteal region is an important component of body beauty

• There is an increasing search for techniques and products to enhance body shape and contours

• Autologous fat is abundant, easily collected, and promotes long-lasting results

• The donor area is chosen to contribute also to the final aspect of the buttocks: while liposuction models its shape, lipotransfer improves its projection

• The best areas to augment firmness and volume are the two upper quarters of the buttocks; the amount of fat tissue used is around 100–200 mL per side

• The hyaluronic acid used for body contouring is a large-particle gel called Macrolane VRF (Volume Restoration Factor)

• Indications include: correction of concave body deformities, trauma scars, and for shaping and augmentation of body areas, like calves, buttocks, chest, and breasts

• Advantages are the known safety record of NASHA™ (non-animal stabilized hyaluronic acid) products, no requirement of donor site, little downtime, reversibility, and performance on an outpatient basis

• The main disadvantage is cost when large amounts of the product are needed

The gluteal region is one of the main components of the body beauty, occupying a preponderant position in the physical ideal. Universally pleasing features include fullness, smooth convex contours, and homogeneous skin tone and texture. In recent years, the search for procedures to improve buttock volume, firmness, and / or shape has been increasing. Traditional treatments (massages, exercises) are still in use, while surgical techniques are being refined and new energy-based (lasers, radiofrequency, infrared) treatments are expanding. No one type of procedure will achieve improvement in all aspects and multiple modalities are necessary to obtain the highest patient satisfaction. This chapter will address volume augmentation through autologous fat grafts and correction of gluteal contour deformities with hyaluronic acid gels.

Aesthetic characteristics of the buttocks

The shape of the buttocks is determined by anatomical structures such as the underlying bone component, gluteus maximus muscle, adipose tissue, and skin. Their combination and interaction give individuals their characteristic buttock shape. According to ethnic ideals, some characteristics of the gluteal region should be preserved, recreated, or corrected in order to enable a harmonious result in relation to the rest of the body. They are described here and summarized in Box 23.1.

Lateral depressions: formed on each buttock at the greater trochanter by the medius gluteus, external vastus, gluteus maximus, and quadratus femoris muscle insertions.

Infragluteal fold: formed superiorly by the inferior border of the gluteus maximus and inferiorly by the insertion of the semitendinosus and biceps femoris muscles in the ischial tuberosity. This fold’s length and shape has a pre-eminent role in gluteal aesthetics: a long fold indicates a ptotic buttock, whereas a short one suggests a young buttock.

Supragluteal fossettes: depressions at each side of the sacral region formed by the confluence of the upper portion of the posterior iliac spine, the lumbosacral aponeurosis, and the gluteus maximus.

Triangle or V-shaped fold: formed superiorly by the supragluteal fossettes and inferiorly by the insertion of the gluteus maximus and coccyx.

Smooth waist-to-lumbar inward curve: with aging, women tend to develop a more centralized fat distribution with accumulation of subcutaneous adipose tissue at the waist, losing the smooth inward sweep of the lumbosacral area and waist, as described by Roberts and colleagues.

Box 23.1

Gluteal aesthetic landmarks

Lateral depressions

Infragluteal fold

Supragluteal fossettes

Sacral triangle

Smooth waist-to-lumbar inward curve

Gluteal augmentation with fat grafting

For gluteal augmentation, the majority of investigators believe that autologous fat can be considered the ideal filler as it is abundant, easily available, of low cost, and easily and repeatedly collected. The donor area is selected to contribute also to the final shape of the buttocks; thus, the alternative sites would be the supragluteal, paralumbar, subgluteal, and trochanteric regions (thigh bulges). In this way, while liposuction models the shape of the buttocks, lipotransfer improves their projection.

Fat may be obtained as a single process associated with regional or circumferential liposculpture, or combined with other procedures such as lipectomies. Table 23.1 describes the tumescent solution used for gluteal augmentation. Fat extraction is performed using 3–4 mm blunt-tipped cannulas to avoid the destruction of the adipocyte, with continuous negative aspiration at 0.5 atmospheres of pressure, collected in a sealed vial. For minor procedures 10, 20, or 60 mL syringes may be used.

Table 23.1 Tumescent solution used for gluteal augmentation

0.9% Saline solution	1000 mL
2% Lidocaine	25 mL
1/1000 Ephinephrine	1 mL
8.4% Sodium bicarbonate	12.5 mL

Fat preparation for injection

There are several methods to process the fat obtained through liposuction. One of the most popular techniques is centrifugation to separate the fat from free lipids and serosanguineous fluid. This technique is performed using different centrifugation parameters; in our clinic, we use centrifugation at 900 rpm for 1 minute. Another procedure consists of washing the fat with 5% glucose or with normal saline solutions for the purpose of obtaining blood-free adipose tissue, or adding other substances to increase survival.

Fat grafting with growth factors

Although there is no support from clinical trials with significant follow-up, an increase in fat graft survival associated with growth factors has been observed, including discrete volume increase and skin improvement with simple infiltration of platelet-rich plasma. This could be justified by the increase in concentration of growth factors, which would cause higher and faster revascularization of the grafted fat and increased multiplication of pluripotent cells (which are abundant in fatty tissue).

Injection

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