Prosthetic Gluteal Augmentation – An Overview

Gluteal augmentation for reconstruction was first described by Bartels in 1969.⁷ Cosmetic correction of lateral gluteal depressions was subsequently undertaken by Cocke and Ricketson in 1973 with their utilization of mammary implants.⁸ Specific gluteal implants are now available in various shapes and textures. Numerous options for prosthetic implantation exist in Mexico and South America. Cohesive gel implants with a polyurethane textured surface allow implants to have a natural feel with less capsular contracture and a tendency to maintain their position. Unfortunately, the soft solid elastomer prostheses available in the United States are more rigid, leading to increased palpability and firmness.

Subcutaneous implant placement was originally described by Gonzalez-Ulloa.⁹ This approach has been abandoned secondary to unacceptably high complication rates and utilization of more appropriate tissue planes.

Prosthetic Gluteal Augmentation – Submuscular Approach

In 1984, Robles and colleagues described gluteal augmentation utilizing the submuscular space.¹⁰ This approach successfully addressed the capsular contracture and palpability complications seen with the subcutaneous approach. However, the anatomy of the submuscular space limits the augmentation that may be achieved. Because the sciatic nerve exits on the underside of the piriformis muscle at its inferior border, augmentation is limited to utilization of smaller round implants placed in a more superior location. This results in greater projection in the upper gluteal region with a deficiency in the lower portion (Fig. 39.6). Furthermore, with such superior placement, gluteal ptosis may not be appropriately addressed. Risk of direct injury to the sciatic nerve also accompanies this approach. While this technique may be used today for patients with a well-developed inferior gluteal region requiring upper pole augmentation, it has largely fallen out of favor with the advent of intramuscular and subfascial descriptions.

FIG. 39.6 Submuscular placement of gluteal prosthetics. Because of anatomic limitations, augmentation is limited to the utilization of smaller, round implants placed in a superior position.

IC, iliac crest; PSIS, posterior superior iliac spine; IGF, Inferior gluteal fold.

Prosthetic Gluteal Augmentation – Intramuscular Approach

The intramuscular approach to prosthetic gluteal augmentation provides padding both above and below the gluteal implant. Utilization of this space allows for better inferior placement when compared to the submuscular approach and decreases the risk of injury to the sciatic nerve (Fig. 39.7).

FIG. 39.7 Intragluteal placement of gluteal prosthetics. Dissection is superficial to the sciatic nerve, thus allowing for more inferior placement of the prosthetic. A 5–6 cm incision is made in the midline approximately 2.5cm superior to the anus. The depth of dissection, allowing for 2–3 cm of muscle thickness overlying the implant, is established. A closed suction drain is inserted through a separate stab incision. The implant is then inserted into the pocket and rotated into position. Closure is undertaken without undue tension.

The authors prefer the technique outlined by Mendieta.¹¹ Preoperative Decadron and clindamycin are administered and intermittent pneumatic compression stockings are applied. General anesthesia or epidural placement with IV sedation may be utilized. The patient is placed in the prone jackknife position with the entire gluteal region prepped and draped. A Betadine-soaked gauze is placed over the anus to prevent contamination of the surgical field. While a single midline approach had previously been advocated, two parasacral incisions are now utilized to minimize postoperative wound dehiscence. The midline is marked and two paramedian lines are drawn 1 cm lateral to the midline which curves to follow the upper gluteal curvature superiorly for a total length of 8 cm.

The incision lines, intramuscular and subcutaneous tissues are infiltrated with 1% lidocaine with epinephrine (adrenaline) 1 : 100 000. Incisions are made in the skin and taken down to the gluteal fascia. It is critical to preserve the gluteal fascia at this point to allow for closure and appropriate implant coverage. Approximately 6 cm of subcutaneous dissection is performed and the fascia opened for a length of 6 cm. Blunt dissection is taken perpendicular to the gluteus muscle fibers to a depth of 2–3 cm along the corresponding fascial incision. Pocket dissection with a tissue thickness coverage of 2–3 cm is created, beginning in a superolateral direction. At this point, given the lack of natural tissue plane and areolar tissue, the dissection will no longer be bloodless. Dissection continues in a sweeping counterclockwise motion from this superolateral point with little dissection (3–5 cm below the coccyx) undertaken inferiorly. A breast implant expander may be placed into the pocket at this time and over-inflated to assist in dissection. This is then replaced with a gluteal prosthesis sizer to estimate the volume of permanent implant to be used. A closed-suction drain is placed in the pocket and brought out through a separate stab incision in the infragluteal fold.

The implant pocket is then irrigated and the implant rolled and placed within the pocket. The muscle and subcutaneous layers are closed with absorbable braided suture in a layered fashion. It is critical that this closure be without undue tension to avoid dehiscence and implant exposure. The final skin closure is performed after augmentation of the contralateral buttock to ensure symmetry.

Prosthetic Gluteal Augmentation – Subfascial Approach

While rewarding and successful, the intramuscular approach may be frustrating to some surgeons, owing to its lack of a natural tissue plane. De la Pena describes his approach to subfascial gluteal augmentation, which exploits the natural subaponeurotic space to allow for implant placement.¹² This space utilizes the gluteus maximus as a base for the implant to rest and is limited inferiorly by its fusion with the infragluteal fold, thus limiting implant migration.

The authors prefer the description of this technique detailed by De la Pena.¹³ With the patient in a standing position, markings are made based on templates designed to estimate the volume implant to be placed. This template is centered over the gluteal region with a minimum of 2 cm separating the inferior margin from the infragluteal fold and 2 cm separating the medial margin from the lateral border of the sacrum (Fig. 39.8). Preoperative antibiotics are administered and sequential compression devices applied to the calves. General anesthesia or epidural placement with IV sedation may be administered. The patient is placed in the prone position with the gluteal region prepped and draped in a sterile fashion. A Betadine-soaked gauze is placed in the anus and covers the perineal area.

FIG. 39.8 Subfascial placement of gluteal prosthetics. Dissection is superficial to the sciatic nerve, thus allowing for more inferior placement of the prosthetic. A minimum of 2 cm separates the inferior margin from the infragluteal fold. A 5–6 cm incision is made in the midline approximately 2.5 cm superior to the anus. Dissection is carried down through the gluteal fascia and a pocket created. A closed suction drain is inserted through a separate stab incision. The implant is then inserted into the pocket and rotated into position. Closure is undertaken without undue tension.

Two paramedian skin incisions are made as described by Mendieta and beveled toward the gluteal aponeurosis at the lateral border of the sacrum. Dissection is carried down through the subcutaneous tissue to the presacral fascia until the lateral aspect of the sacrum is encountered. There, an 8–10 cm incision is made in the gluteal fascia parallel to the lateral edge of the sacrum. Dissection is then carried out in a subfascial plane; instillation of tumescent solution facilitates identification and dissection in this plane. This avascular plane with aponeurotic extensions is sharply defined with the assistance of long instruments and lighted retractors. Dissection continues in a superomedial to inferolateral direction to create a pocket defined by the preoperative skin markings. Once completed, a sizer is placed in the pocket to estimate the volume of permanent prosthesis to be used. Hemostasis is ensured and a closed-suction drain is placed in the pocket.

The permanent implants are then soaked in antibiotic solution and inserted into the pocket. The gluteal fascia is reapproximated with absorbable monofilament suture in a tension-free fashion. The deep and superficial subcutaneous tissues are closed separately, followed by final skin closure and adhesive.

Prosthetic Gluteal Augmentation – Optimizing Outcomes

When performing prosthetic gluteal augmentation, utilization of the intramuscular or subfascial plane produces the most reliable long-term results with lower rates of morbidity (Table 39.1). The submuscular approach may be appropriate for those patients only requiring augmentation of the upper gluteal region. Paramedian skin incisions are preferred over midline incisions, which are associated with higher complication rates. Maintenance of a cuff of fascia (or gluteus muscle if using the submuscular or intramuscular approach) is necessary to allow for a deep closure with little tension. Utilization of long instruments and lighted retractors assists greatly in visualization and dissection of the implant pocket. Careful handling of the prosthesis must be ensured to minimize infectious complications. Finally, meticulous, tension-free, multilayered closure is paramount in reducing the risk of wound dehiscence and possible implant exposure (see Video Attachment 1).

TABLE 39.1 Prosthetic Gluteal Augmentation – Planes of Dissection

Liposculpture – An Overview

Autologous fat transfer was initially described by Neuber in 1893; more recently this technique has been refined by the work of Coleman.¹³ Success has been attributed to deposition of small aliquots of centrifuged fat in a layered fashion into a well-vascularized bed. When applied to gluteal augmentation, this may be a powerful and long-lasting technique.¹⁴ When combined with liposuction of targeted regions of localized lipodystrophy, one may rejuvenate the buttock.

Cuenca-Guerra and Lugo-Beltran have analyzed the distribution of gluteal fat in elucidating how to better achieve the gluteal esthetic.² They state the following: (1) The ratio of the anterior superior iliac spine to the greater trochanter and the greater trochanter to the lateral point of maximum projection of the buttock should not exceed 1 : 2 on lateral view; (2) A visible lumbosacral depression should aid in distinguishing the back from the buttocks; (3) Excess fat should be removed from the lumbosacral, subgluteal, flank, “love handle”, “saddle-bag,” and “banana roll” regions; (4) The point of maximum gluteal projection should correspond to the level of the mons pubis. It should be noted that one must not aggressively remove fat from the region just inferior to the infragluteal fold (“banana roll”), as this may exacerbate buttock ptosis.

These points are reflected in Mendieta’s frame classification system. As referenced above, patients with a square shape buttock find improvement with liposuction at the A and B points with lipoinjection at the C point. Patients with an A-shape (pear) buttock find improvement with liposuction at the B point with lipoinjection into the C point depression. Finally, patients with a V-shape (apple) buttock require liposuction at the A point and flank regions with lipoinjection into the upper inner gluteal region.

When one understands the classification systems devised to characterize the various buttock morphologies, a systematic operative plan may be devised. More broadly, the regions which benefit most from liposuction are the flanks, presacral region, hips, inner thighs, outer thighs and “banana roll” areas.¹⁵ Lipoinjection may then be utilized to fill depressions, fill the trochanteric region and augment projection at the level of the mons pubis.

Liposculpture – Liposuction with Lipoinjection

Countless descriptions for the handling of harvest fat may be found in the literature. For the sake of this text, the authors will outline the technique described by Cardenas-Camarena in his 2011 publication examining 14 years of gluteal fat grafting.¹⁶ With the patient standing, markings are made over areas to be liposuctioned and lipoinjected. Preoperative antibiotics are administered. The patient is placed in the prone position and epidural block or general anesthesia is delivered. Liposuction is undertaken first, utilizing a tumescent technique (1 mg epinephrine in 1000 ml normal saline without the use of an anesthetic). Access incisions are made in the intergluteal fold, the superior portion of the posterior iliac crest and the subgluteal fold. The infiltration to aspiration ratio is approximately 1.5 : 1 and performed with 3–4 mm cannulae. Targeted liposuction is performed; when employed in the lumbosacral region, two 2 mm diameter silicone drains are placed and removed on postoperative day 4.

The lipoaspirate is collected in sterile bottles and 300 mg of clindamycin is added. The fat is then left to decant and is subsequently placed in 60 ml syringes. If cannulae larger than 3 mm are used for harvesting, the resulting lipoaspirate will contain a significant amount of fibrous tissue. If not removed from the aspirate with an instrument, this will lead to syringe and injection cannula clogging. A 3 mm, three opening lipoinjection cannula is attached and lipoinjection is commenced utilizing the liposuction access sites. The authors advocate instilling injected fat into all layers of the subcutaneous plane as well as the superficial intramuscular region. Fat is injected in a linear retrograde fashion with careful avoidance of deposition of large aliquots. Approximately 20–30 cm³ of fat is deposited with each retrograde pass. The fat is then reaccommodated using manual gluteal massage. Overcorrection is not performed; a combination of palpation and visualization determine the endpoint for lipoinjection.

Liposculpture – Optimizing Outcomes

A clear surgical plan must be in place with targeted liposuction and lipoinjection based on the preoperative patient classification schema. Liposuction is targeted to the flanks, presacral region, hips, inner thighs, outer thighs and “banana roll” areas. One must be careful not to be over-aggressive with liposuction in the “banana roll” region, as this may potentiate gluteal ptosis. Fat may be isolated utilizing an array of techniques. Lipoinjection must be performed in a multilayered fashion utilizing small aliquots in a retrograde passing motion. High volume lipoinjection may be performed safely with good long-term outcomes if a wide area is injected in a multiple layer fashion.

Autologous Tissue Flaps – An Overview

Patients presenting with excess truncal, gluteal and lateral thigh skin are often candidates for excisional procedures which utilize autologous tissue flaps to augment the gluteal region. Often, these are patients with significant weight loss following bariatric surgery or lifestyle changes. It is Lockwood’s popularization of the lower body lift, along with his description of the superficial fascial system (SFS) which form the cornerstone of today’s autologous gluteal augmentation procedures.¹⁷ His original description involved a correction of the lateral thighs and buttocks with anterior incision lines merging into the groin crease (Type I). Lockwood’s modification to include an abdominoplasty with this lift, creating a continuous circumferential incision has been termed a Type II lift. With the correction of posterior tissue excess, one may augment the gluteal region utilizing local tissue rotation flaps.

Autologous Tissue Flaps – Lower Body Lift with Autologous Gluteal Augmentation

Here, the authors prefer the technique described by Rubin.¹⁸ It should be noted that the surgical details below refer strictly to the gluteal augmentation portion of the larger lower body lift (Lockwood Type II) procedure.

Prior to embarking on markings for the procedure, the surgeon must understand that specific anatomic landmarks are of little value. Rather, one will note that a more superior resection will emphasize the waistline by directly excising overhanging flank rolls. This approach will elongate the buttocks, limit flap placement so maximum projection is more superior than ideal, violate the sacral triangle, and create a scar which may be visible in some clothing.¹⁸ At the same time, a more inferior incision (preferred by the author) allows for improved correction of the lateral thigh and buttocks. However, this incision placement will diminish waist definition.

It should be noted that in patients who have experienced massive weight loss after a prolonged history of obesity, satisfactory waist definition is very difficult to achieve secondary to the “barrel chest” deformity resultant from years of rib cage expansion.¹⁸

As previously discussed, the eight gluteal esthetic units and their subsequent derangement following massive weight loss must be understood and addressed. While patients who benefit from autologous tissue flaps for gluteal augmentation generally suffer volume loss, localized regions of relative volume excess, gluteal hypoplasia and skin integrity must be evaluated. Centeno has devised a massive weight loss gluteal contouring algorithm which assists greatly with this portion of the surgical planning stage (Fig. 39.9).¹⁸

FIG. 39.9 Gluteal contouring algorithm for the massive weight loss patient.

The markings begin with the patient in the supine position. With upward tension on the abdominal tissue, a midline mark 6 cm above the anterior vulvar commissure is made. This should rise above the pubic symphysis; if not, it should be moved superiorly until it lies above the symphysis. The patient then stands and faces away from the surgeon. Here, the superior anchor line (superior line of incision) is drawn as low as possible to allow for reshaping of the buttocks. This line is extended from the midline to the mid-axillary line bilaterally. Vertical reference lines are then drawn at 6 cm intervals. A pinch test is then performed by rolling the inferior tissues underneath the superior anchor line to estimate the inferior margin of resection. To assist in the estimation of the lateral tissues, the patient is asked to stand with legs slightly abducted. The inferior line is drawn in, as well as the lateral margin of resection at the mid-axillary line, which connects the superior and inferior incision lines. The regions of adipose tissues which will be used for gluteal augmentation are marked and symmetry is checked. At this point, the patient turns to face the surgeon and markings continue for the abdominoplasty portion of the operation.

Preoperative antibiotics are administered within 1 hour of incision and can be redosed if the procedure exceeds 2 hours or if there is excessive blood loss. The patient is kept under forced air warming blankets in the preanesthesia area; these are also utilized intraoperatively in order to prevent hypothermia during the case. After general anesthesia is induced, a Foley catheter is placed and the patient is positioned in the prone position on the operating room table. Two arm boards are placed at the lower portion of the table so the legs may be abducted during the procedure. The buttocks and legs are prepped and draped in a circumferential fashion. Sterile drapes are wrapped around the legs from knees down to allow for intraoperative manipulation. A 1 : 100 000 epinephrine solution without anesthetic is infiltrated into the dermis to aid in hemostasis. The region of gluteal tissue marked for autoaugmentation is de-epithelialized, then circumscribed down to the fascial level. The lateral margin of resection is incised with excision of the marked tissues around the dermal pedicle at the level of the fascia. The circumscribed paddle is then undermined laterally at the level of the muscle fascia to allow for subsequent downrotation. A subcutaneous pocket is then undermined at the level of the muscle fascia, inferior to the lower incision line marking. The dermal-fat flaps are then rotated into this pocket and secured with permanent braided nylon suture. The surgeon may then elect to plicate the dermal surface of these flaps to enhance gluteal projection (Fig. 39.10).

FIG. 39.10 The region for autologous gluteal augmentation is circumscribed, de-epithelizalized and dissected laterally at the fascial level. The flaps may be partially incised or plicated to assist in obtaining projection. A subcutaneous pocket is created over the muscle fascia inferiorly (dotted line) and the flap is downrotated. The flaps are secured with braided permanent suture and closure undertaken in a layered fashion.

The legs are then abducted on armboards and the Lockwood discontinuous undermining device (Byron Medical, USA) is passed through the subcutaneous tissues along the lateral thighs to the level of the knee. Two closed-suction drains are placed in the wound. The wound edges are subsequently reapproximated along the vertical hashmarks. It is critical to maintain thigh abduction at this point to allow for decreased tension of closure at the lateral aspect of the wound. Absorbable braided sutures are placed in the SFS and the dermis is closed in two layers with interrupted absorbable monofilament suture and a running barbed suture. Retention sutures using permanent monofilament sutures may be placed in the sacral region, or other areas of high tension. Cyanoacrylate adhesive and a layered gauze with occlusive plastic dressing is then applied over the incision lines and the lateral dog-ears are stapled shut prior to placing the patient in the supine position and continuing with the abdominoplasty portion of the lower body lift.

Autologous Tissue Flaps – Optimizing Outcomes

The markings made are critical for operative success; one must understand that fixed anatomic landmarks should not be used as immutable guides for surgical planning. The bony and muscular landmarks differ from patient to patient and have an impact on gluteal esthetics. Recognition of how an individual patient’s anatomy differs from the ideal can guide the surgeon in planning for a more esthetically pleasing outcome while using autologous flaps. Oftentimes, these findings lead to a variable alteration of the superior anchor line. Additionally, the origin of the superior gluteal muscle from the sacral promontory can also serve as a palpable guide to looking at muscle height and adjusting the augmentation to either shorten or lengthen muscle height visually with augmentation. Higher superior anchor lines will accentuate the waistline, whereas lower superior anchor lines will allow for greater lateral thigh and gluteal correction. Abduction of the legs during lateral resection margin estimation and closure is critical to decreasing the risk of over-resection and tension of closure. Careful attention must be paid to meticulous closure of the SFS to insure strength of closure.

Prosthetic Gluteal Augmentation

Protocols for postoperative care contain little variation regardless of the technique employed. Ambulation may begin the following morning. Most surgeons recommend sitting be limited to going to the bathroom and sleeping in a position other than supine for 2–3 weeks postoperatively. At that time, clearance for sitting and the initiation of stretching exercises is undertaken. In the event that the incision lines have marginal healing, sitting is deferred for another 2 weeks after interval evaluation. Drainage tubes are left in place until drainage is less than 30 ml/day. When the drainage tubes are discontinued, topical antibiotic ointment may be used until wound closure is complete. Slowly introduced resumption of exercise is generally permitted 6–8 weeks after surgery. It is generally recommended that compression garments be utilized if liposuction is performed. If no liposuction has been performed, we recommend an abdominal binder be placed to apply pressure on the upper portion of the buttocks for 2–3 weeks.

Liposculpture

When liposuction is performed in the sacral region, a silicone drain is left in place and removed 4–5 days postoperatively. Patients are placed in a panty girdle compression garment which is worn for 6 weeks. Therapeutic ultrasound massage is initiated at that time and continued every third day for a total 1 month course.¹⁹ If deemed necessary, 15–20 Endermologie sessions may follow this course of ultrasonic massage. Normal activities may be resumed at 2 weeks after surgery and gradual initiation of exercise may begin at 4 weeks postoperatively.

Autologous Tissue Flaps

During the immediate postoperative period, the patient is maintained in the semi-Fowler’s (beach chair) position, flexed at the waist. Egg crate foam pads are placed at the base of bed flexion to minimize pressure on the gluteal region. The patient is instructed to ambulate with assistance the night of or morning following the procedure. Sequential compression devices are maintained on the lower extremities while the patient is in bed and low-molecular weight heparin is administered twice daily, commencing the night of surgery. When performed as a portion of the lower body lift, patients undergoing autologous gluteal augmentation typically spend 2 nights in the hospital. Drains are maintained until their output is less than 30 ml/day for 2 consecutive days. If retention sutures had been placed, they may be removed 1–2 weeks after surgery. Patients are advised that while their posture will be hunched for the first week or so postoperatively, they will soon thereafter walk upright without undue discomfort. It is generally advised that patients may resume their preoperative level of activity at approximately the 6–8th postoperative week.

Prosthetic Gluteal Augmentation

The evolution of prosthetic-based gluteal reconstruction discussed above has allowed for a decrease in postoperative complications. As mentioned, the subcutaneous plane has been fraught with complications and has since been abandoned. Wound dehiscence had previously been reported to occur in approximately 30% of cases. This rate has declined with the increased popularity of using paramedian instead of midline incisions. This is felt to be secondary to a number of factors: (1) The intergluteal crease has an intrinsically poor blood supply and is considered a “watershed” area; (2) Prolonged retraction may crush and traumatize the local tissues; and (3) Inadequate or high tension muscle or fascial closure.²⁰ Should a wound dehiscence occur without implant exposure, these wounds will typically heal secondarily without long-term sequelae. Implant exposure is an indication for explant. The rate of exposure is quoted at 2–5% but is significantly higher in patients who are overweight or receiving implants larger than 350 cm³. Utilization of large implants (greater than 545 cm³) has also been associated with severe inferior ptosis.

Seroma formation has been found to occur in 2–4% of intramuscular augmentations. While small seromas may resolve spontaneously, most will require serial aspiration. In the rare instance of chronic seroma, the capsule may be scored, implant replaced and closed-suction drainage undertaken.

Implant asymmetry or migration are more common when the intramuscular approach is employed, as this involves creation of an unnatural tissue plane. It is common to inadvertently allow dissection to become too superficial when one works superolaterally. Because the gluteus maximus muscle forms the base on which an implant sits in the subfascial location, with the robust muscle fascia overlying it, implant malposition is less common utilizing a subfascial technique. Furthermore, the close proximity of the sciatic nerve during intramuscular dissection may limit the amount of inferior dissection required for optimal implant placement. However, permanent injury to the sciatic nerve using this approach is exceedingly rare. Mendieta has noted transient sciatic parasthesias in approximately 20% of patients undergoing intramuscular augmentation, which respond to gabapentin and resolve within 3 weeks.²¹

Liposculpture

Cardenas-Camarena and colleagues present an excellent review of the evolution of their gluteal fat grafting technique over a 14-year timeframe.¹⁶ The authors found that complications such as fat necrosis, gluteal erythema, infection, and fat embolism syndrome were more common when fat infiltration volumes were small and localized. The injection of large volumes of fat into single small areas in one layer place the patient at increased risk of local complications and fat necrosis. By increasing the area to be infiltrated and utilizing multiple layers of deposition, these complications may be minimized.

Infection rates of 14% have previously been reported by some groups. This rate has decreased to approximately 4% by administering systemic antibiotics, clipping (not shaving) hair in the region, prepping circumferentially with povidone/iodine solution, placing a gauze pad soaked in povidone/iodine in the gluteal cleft, decreasing the handling of fat, coating the grafting cannula with povidone/iodine and administration of triple antibiotic to each canister of fat immediately upon harvesting.

Seroma formation at the site of fat harvesting has been described. This tends to be seen in the lumbosacral region, a common site of fat harvest given its integral role in creating an esthetically-pleasing gluteal region. Most surgeons advocate placing a small silicone drain in this region and reinforcing with compression garments.

The volume of fat grafted has been a disputable risk factor for major and minor postoperative complications. Some authors have described increased complications with fat injection volumes over 1000 cm³ per buttock, while others have noted a decrease in complications with increasing volumes infiltrated. This may be secondary to the area over which the fat has been deposited, with large volume deposition in small spaces predisposing to complications.

More rare, and feared, complications have been described. These include transient blindness, necrotizing fasciitis and sepsis.^22,23

Autologous Tissue Flaps

Complication rates following procedures utilizing autologous tissue flaps tend to parallel those of other major body contouring procedures. Wound dehiscence and seroma are generally the most common complications encountered utilizing this technique. These complications tend to be minor. Wound dehiscence is generally best managed with local wound care. After appropriate debridement, large wounds may be successfully managed with negative pressure wound dressings. Wounds which are grossly infected or associated with significant undermining require operative debridement and formal closure.

Shermak and colleagues have described the management of seromas in the massive weight loss population in outstanding detail.²⁴ The majority of seromas encountered resolve utilizing serial aspiration. Those recalcitrant to this line of therapy may resolve with placement of an indwelling catheter or sclerotherapy (500 mg of doxycycline in 50 ml of normal saline). Failure of sclerotherapy requires operative excision of the established seroma cavity.

Other complications, including infection, skin and fat necrosis, scarring and venous thromboembolism have been described but are far less common than wound dehiscence and seroma formation. For patients undergoing autologous gluteal augmentation, Colwell et al have demonstrated that patients with an operative BMI of 30 kg/m² or greater are at significantly increased risk of wound, seroma and fat necrosis complications.²⁵ Patient selection remains paramount in minimizing the risk of postoperative complications.²⁶