History

The norms of beauty for the gluteal region have changed over the centuries, and probably more during the past 10 to 15 years. The Rubenesque curves of the Renaissance are no longer acceptable to many women today. Contemporary women search for an athletic look with well-defined curves in the buttock area. Standards of beauty include a well-projected gluteus and a uniform line that on the lateral view makes a natural curve from the waist to the knee.¹

The demand for gluteal augmentation has been growing since the 1960s, even though no surgical technique had been described at that time. The first way to augment the buttocks was with round silicone gel breast implants, but problems related to their use in the buttock region led to the development of implants designed specifically for gluteal augmentation.² Surgical procedures were then developed to improve the aesthetic results. Gonzalez-Ulloa was one of the first surgeons to reconstruct the gluteal region, either by lifting “sagging” buttocks or placing a subcutaneous implant to augment them.³ With his technique, the aponeurotic expansions running from the gluteal aponeurosis to the dermis must be divided. Following that, the skin is loose and displacement of the implant results in poor aesthetic results. The second generation of implants included Dacron patches on the back. The goal was to affix the implant within the pocket. However, these patches were not sufficient to maintain implant position. Since that time, techniques for gluteal augmentation have progressed through three other anatomic planes: submuscular, intramuscular and subfascial (Fig. 70.1).

Fig. 70.1 Schematic representation of anatomic planes for gluteal augmentation: Submuscular, intramuscular and subfascial.

In 1984, Robles described the submuscular approach.⁴ This approach preserved the aponeurotic system that holds the gluteal skin in position. However, it introduced a new anatomical problem with the potential risk of injury to the sciatic nerve. The intramuscular plane was developed by disrupting the gluteal muscle fibers.^5,6 The goal was to leave a 3–4 mm thickness of gluteus maximus muscles attached to the aponeurosis. In fact, it is very difficult to estimate the quantity of muscle on top because undermining was done blindly with no anatomic landmarks to guide the dissection. Moreover, the possibility of injuring the sciatic nerve was not totally eliminated and seroma incidence and complication rate are above 30%. To solve problems encountered with other techniques, we sought to identify a new anatomic plane that could hold gluteal implants securely with little morbidity. Extensive anatomic dissections were performed in which we studied the gluteal aponeurosis. Our subfascial technique is based on these anatomic studies.^7–10

Physical evaluation

Technical steps

Fourteen days before the surgery, patients are advised to suspend any aspirin, vitamin E or other medications that promote bleeding during surgery. Three days before, they are instructed to consume a low-fiber diet. The day before the surgery, the patient is given an enema and started on an antibiotic to avoid infection.

With the patient in the upright position, skin markings are made using a custom-designed template (Fig. 70.2). This template must fit perfectly into the gluteal region leaving 5 cm above the infragluteal sulcus and 2 cm lateral to the external rim of the sacral bone. The sacral triangle must be preserved; it is an important aesthetic landmark of this region. The implant should never be placed on top of the sacral bone. Laterally, the template will extend to the external border of the gluteal region, leaving at least 2 cm from the external line (continuation from the iliotibial line of the thigh) (Figs 70.3 and 70.4).

Fig. 70.2 Templates designed for preoperative evaluation of implant size. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

Fig. 70.3 Skin marking with the template. Markings must follow the anatomical shape of the gluteal region.

Fig. 70.4 Skin marking. The sacral triangle and infragluteal fold are preserved. In red, the aponeurotic expansions are shown.

General or epidural anesthesia is used for the procedure. If epidural anesthesia is used, the catheter may be left in place for pain control after surgery. Elastic compression stockings and sequential compression pumps are used for deep venous thrombosis prophylaxis. The patient is then placed on the operating table in the prone position. Special care must be taken to cushion the face and pressure sites such as the iliac spine and breasts. After the prepping and the draping, a 4 × 4 gauze soaked in poviodone iodine is placed inside the anus and the perianal area covered with adherent sterile drape.

The marking of the incision is then done. Two paramedial incisions are drawn 1 cm lateral to the midline (intergluteal crease), which leaves the crease intact. These incisions start 4 cm above the anus, which corresponds to the level of the distal tip of the coccyx, and extend cephalically for 6–7 cm. The incision, which remains above the presacral fascia, includes skin and subcutaneous tissue (no undermining in performed over the sacral bone) and proceeds laterally until the lateral border of the sacral bone is reached. Then, an 8–10 cm incision is made parallel to the lateral edge of the sacrum in the gluteal aponeurosis and reaching the subfascial space. Care is taken to not cut any of the muscle fibers. Infiltration of Klein’s solution is done under the aponeurosis. This facilitates the identification of the avascular plan deep to the fascia, an area containing a network of septa emerging from the posterior aspect of the gluteal aponeurosis (Fig. 70.5). These aponeurotic expansions are not easily divided, but the tumescent infiltration permits sharp dissection of the septa in the subfascial plan. Accurate division of the expansions in this plan raises an intact fasciocutaneous flap in the area outlined by the template marking.

Fig. 70.5 Aponeurotic expansions traverse the superior layer of the gluteal maximus muscle. Sharp dissection between the aponeurotic expansions is essential for the creation of the implant pocket. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

Sharp dissection, lighted retractors and long instruments are mandatory for safe retraction, cutting and coagulation to ensure that all aponeurotic expansions over the muscle are divided. Bleeding is minimal if undermining and coagulation are done carefully and simultaneously. Perforator vessels from the superior and inferior gluteal arteries are identified and ligated. To facilitate undermining, it is advisable to dissect from medial to lateral and from cephalic to caudal, while maintaining a wide field of exposure without going beyond the skin marking (Fig. 70.6).

Fig. 70.6 The dissection of the pocket is done from medial to lateral and from cephalic to caudal. Long instruments are used for maintaining a good field exposure. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

Once the pocket is completed, an implant sizer is used to confirm the size of the definitive implants and to determine if any further dissection is needed (Fig. 70.7). Even if these are not the definitive implants, they are handled with the same no-touch technique used for the definitive implants. They are soaked in a saline solution with antibiotic until the end of the surgery. It is better to develop both pockets before inserting the implants so the volume of the buttock plus an implant on one side does not interfere with the dissection of the contralateral pocket.

Fig. 70.7 Sizer is used to evaluate the implant pocket. The implant should fit loosely in the space. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

Once the final implants are selected, double-checking for hemostasis is done and closed suction drains are inserted to help maintain the adhesion of soft tissues to the implant. Then a definitive implant is inserted using the no-touch technique, making sure that the implant is perfectly aligned on its long axis. The implant must fit loosely in the pocket, and closure of the aponeurosis must be without any tension. Tissues are rearranged to comfortably drape over the implant. Anatomical implants designed for this operation must be used and are in three presentations with the same sizes and volumes (Fig. 70.8):

Fig. 70.8 Anatomical implants designed for gluteal augmentation. A, High cohesive gel-filled implant texturized surface. B, High cohesive gel-filled implant polyurethane cover surface.

Finally, closure of the pocket begins by reinserting the aponeurosis without tension. An absorbable suture such as 2-0 Monocryl should be used. The closure is done by placing sutures without tying them in order to maintain control over the closure and being sure not to pinch the implant. The superficial and deep subcutaneous fascias are closed separately, with 4-0 Monocryl, on both sides of the presacral fascia. Finally, each skin incision is closed separately and the intergluteal crease is maintained in the midline (Fig. 70.9). Tissue glue is used to maintain the incision closed and dry. A watertight closure is critical at all levels to avoid infection.

Fig. 70.9 Implants in correct position in relation to the sacrum, intergluteal sulcus and lateral limits. The white transverse line on the implant ensures perfect positioning and alignment. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

A long-lasting local anesthetic is used to prevent pain in the immediate postoperative period. It is left in place for 30 minutes before placing the drains on suction, mostly raloxifene 7.5%.

The most frequent procedure done simultaneously with gluteal implants is liposculpture of the gluteal area including the lower back, posterior thighs and lateral thighs. By combining these procedures, the results of gluteal augmentation are positively enhanced. During the procedure, care must be taken to not join the liposuction space with the implant pocket, thereby diminishing the possibility that the liposuction space will drain into the implant pocket. In very thin patients, another procedure that can be done simultaneously is the insertion of calf implants to improve calf contour and balance the volume gained in the gluteal region.

Postoperative care

Immediately after surgery, a compressive garment is used and is kept for 1 month. The urinary catheter is left in place for the next 12 hours. Patients are taken to the recovery room in a supine position with a pillow above and below the buttocks. They start moving their legs and feet as soon as possible. They can lie in the lateral, supine or prone positions. Ambulation is started next morning. Once ambulatory, patients may stand, walk, lie in bed or be upright on their knees, but sitting is restricted to the bathroom only for the first 2 weeks. The constant vacuum drains are left in place for 7–10 days and are removed once the drainage is less then 30 mL per day. The wound does not need any special treatment, but at the subsequent follow-up visit, the patient may require additional Dermabond to maintain the watertight seal of the incision. After 2 weeks, the patient may return to normal activities, except for exercise and prolonged sitting. For the first 3 weeks, patients can only take showers. Exercise is permitted after 2 months, but patients are asked to refrain from activities that would apply pressure to the buttocks or stretch the incision, such as riding a bicycle or horse, which may lead to wound dehiscence. It is advisable to take good care of the scar for the next 3 months.

Complications

The incidence of infection is less than 1%, and treatment requires temporary removal of the implant. Seroma and hematoma are usually prevented with meticulous surgical technique, but if they occur, evacuation is required. The best way to diagnose the problem is with ultrasound. Wound dehiscence and implant extrusion are caused by technical errors in closing the aponeurosis or excessive tension during the closure. Scars may be noticeable if the skin is detached from the presacral fascia or if there is wound dehiscence during the healing process. Sensation in the gluteal region is lost during the first 6 weeks, and full recovery of normal sensation may take 4 months. Patients must be aware of this surgical side effect because an injury to the area, such as a burn or puncture wound, may go unnoticed by the patient and lead to complications.

Pearls & pitfalls

Pearls

• Ideal candidates: thin patients with an athletic build and little or no ptosis; they can obtain spectacular results.

• Overweight patients may also benefit from this technique, but often require a more extensive liposculpture in the same surgery.

• This anatomic approach produces natural, reliable results, providing the best option for a truly cosmetic gluteal augmentation (Figs 70.10, 70.11 and 70.12).

Fig. 70.10 A&B, Preoperative views of a 34-year-old woman. C&D, 1 year after liposculpture and subfascial gluteal augmentation with 385 mL Silimed high-cohesive gel-filled implants. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT. Subfascial technique for gluteal augmentation. Aesthetic Surg J 2004; 24:265–273.

Fig. 70.11 A, Preoperative lateral view of a 28-year-old woman. B, Postoperative view with anatomical gluteal implants (volume 385 mL).

Fig. 70.12 A, Preoperative view of 31-year-old woman. B, Postoperative view 2 years after liposculpture of abdomen and gluteal augmentation with 455 mL cohesive gel-filled implants.

Pitfalls

• There are very few criticisms associated with this technique. Most important is marking exactly as described and staying inside the markings during the dissection of the pockets. If not, the implants will not be in the correct position and the result will be mitigated. Patient comfort is optimal with the use of cohesive-gel implants, but the use of these implants is not permitted in some countries.