maximizing aesthetic results of buttock augmentation in

Egypt, J. Plast. Reconstr. Surg., Vol. 43, No. 3, October: 503-508, 2019

Maximizing Aesthetic Results of Buttock Augmentation inPost-Bariatric Patients-Dual Approach

ABDEL RAHMAN MOHAMED, M.D.; NIVEEN F. AL-MAHMOUDY, M.D. and EMAN N. MOHAMED, M.D.

The Department of Plastic & Reconstructive Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt

ABSTRACT

Background: Post-bariatric patients suffer from laxity ofskin and redundancy in different parts of the body, withresultant unaesthetic appearance. Concerning the lower body,different surgeons have introduced lower body lift and buttockaugmentation and have discussed different approaches andtechniques. In this study, we compare between buttock auto-augmentation with fat injection and buttock auto-augmentationwith gluteal implant application as regards the maximumaesthetic outcome in post-bariatric patients.

Patients and Methods: 26 post-bariatric patients withredundancy of the skin of the abdomen and buttocks. Allpatients had belt lipectomy/abdominoplasty and buttockaugmentation (auto-augmentation) in addition to fat injection(Group A, 15 cases), or application of intramuscular glutealimplants (Group B, 11 cases).

Results: All patients had follow-up for one year with nomajor complications. The p-value was calculated for bothgroups and was found that there is a highly significant statisticaldifference in the post-operative measurements in Group A(fat injection).

Conclusion: Dual autoaugmentation for post bariatricptotic buttocks give more appealing results for patients, eitherobjectively by measurements or subjectively by high satisfac-tion scores with a higher preference for fat injection.

Keywords: Buttock augmentation – Post-bariatric – Fatinjection in buttocks.

INTRODUCTION

In 1966, bariatric surgery evolved and offereda great degree of weight loss in a short time in themorbidly obese candidates, and since then, post-bariatric plastic surgery has officially arrived inthe world [1].

Contouring procedures after bariatric surgeryhave grown in frequency as announced by theAmerican Society of Plastic Surgeons. Accordingto the statistics, there were 52,000 body-contouringprocedures performed in post-bariatric weight losspatients in 2003 and raised by 36% in 2004 [2].

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After 50% weight loss, patients will have loose,ptotic skin envelopes, and protruding bulges, andcreases will be present instead of the previouslylarge amount of adipose tissue, and smooth con-tours. These deformities commonly have bad aes-thetic and psychological impacts on the patients[3].

Changes in gluteal anatomy after massiveweight loss is observed as excess skin and fat inthe area between the iliac crest and the perceivedsuperior gluteal margin defined by the superiorextent of the origin of the gluteal muscles and alsoin the region between the L5 dimple and centralcrease. Also, there is drooping of the central creaseand inferior gluteal crease. In addition, the excessof skin and fat is more prominent in the lateralcompared with medial quadrants of the buttocks[4].

The belt-lipectomy removes only sagged skinand tissues of the abdomen as well as lower backand gluteal region; however, this procedure alonefails to satisfy the patient as the deficient projectionand buttock definition will be missed. Previousstudies reported that belt-lipectomy when combinedwith autologous augmentation alone; give subop-timal results [5].

In the current study, we aim to assess the aes-thetic results of buttock augmentation by dualmethod; auto-augmentation with fat injection incomparison to buttock auto-augmentation withgluteal implant application as regards the maximumaesthetic outcome in post-bariatric patients, bothsubjectively and objectively.

PATIENTS AND METHODS

Twenty-six patients requiring lower body-contouring procedures after massive weight losshad increased skin laxity, decreased adiposity were

divided in two groups; (Group A) 15 patientsunderwent buttock auto-augmentation combinedwith fat injection & belt-lipectomy/abdominoplasty,(Group B) 11 patients underwent buttock auto-augmentation combined with prosthetic siliconeimplant application, also with belt-lipectomy/abdominoplasty. The study was conducted in thePlastic Surgery Department, Ain Shams UniversityHospitals in the period between February 2016and February 2019. The study was controlled bythe following selection criteria: Age (18-40 yearsold), sex (female), body mass index followingbariatric surgery (25-35kg/m2); and all patientshad a constant weight over the prior 6 months, anyco-morbid conditions were recorded as diabetes,hypertension, and/or smoking.

Pre-operative istance between the iliac crestand apparent superior gluteal margin and distancebetween the L5 dimple and the central crease weremeasured, recorded and compared with 6 monthspost-operative distance.

Pre-operative markings:The patients were marked pre-operative in both

the standing and supine positions. The patients'backs were marked on the lateral side by drawinga vertical line through the middle of the armpit;next a vertical spinal line was drawn dorsally, theL5 dimple was identified (point A) and a point B5cm inferior to the dimple was marked serving asthe low point of the V in the upper transverseincision, the Posterior Superior Iliac Spine (PSIS)was marked (point C), the incision courses frompoint B just one finger breadth above point C andcontinues laterally approximately one finger breadthabove the upper margin of the gluteus maximustill reach mid axillary line. The lower incision wasdetermined by pinching the skin after 30 degreesof trunk flexion Fig. (1).

504 Vol. 43, No. 3 / Maximizing Aesthetic Results of Buttock Augmentation

Operative technique:

Surgery was performed under general anesthe-sia. Antibiotic prophylaxis of 2gm ceftriaxone aday before surgery was administered, with a further2gm given later during surgery. All patients tooka shower using betadine shampoo one hour beforesurgery. Two wide bore intravenous cannulas wereinserted in the arms.

The procedure started after full anesthesia ofthe patient then sterilization and toweling tookplace with insertion of the urinary catheter, infil-tration with an adrenaline solution in saline(1:500000) of planned lipodystrophy areas wasdone to reduce bleeding during surgery and tofacilitate liposuction.

In all cases, the procedure started with thepatient in the prone position. Liposuction of theback performed primarily; all fat was removedbetween the dermis and the muscular fascia usinga 4-mm-diameter cannula. The fat harvested wasused for buttock augmentation in (Group A). Skinexcisions were checked peri-operatively by pinch-ing. Next, the incision was done and de-epithelialization was performed.

In (Group A), dermofat flap was created afterde-epithelialization of the marked flap, then; thelower edge of the flap was incised and dissectedto raise the redundant lower flap. After closure ofthe fascia and subcutaneous tissue, assessment ofthe projection of the buttock and overall shapewere done to determine the areas that need fatinjection. Fat injection was done in multiple layersin subcutaneous tissue never perpendicular orintramuscular to avoid fat embolism. The woundclosure was done in a tension-free manner overthe created flap.

In (Group B), dermofat flap was created asbefore after de-epithelialization, but with exposureof gluteal maximus and its fascia, then incision infascia and muscle fiber was done in the samedirection of the muscle fibers and intramuscularplane was created for gluteal biconvex shape sili-cone implant (400-450cc) application. After that,wound closure was done in a tension-free mannerover the flap and prosthesis.

Closure is done using absorbable vicryl (0) forthe fascia and subcutaneous tissue, Monocryl 2/0stitches was used for skin closure, then reassess-ment of the projection of the buttock and overallshape were done.

Fig. (1): Pre-operative marking where point A represents L5dimple, point B represents 5cm inferior to the dimple,point C represents PSIS

Egypt, J. Plast. Reconstr. Surg., October 2019 505

After that, the patient turned to the supineposition in order to perform abdominoplasty andre-sterilization of the patient was done. Whereasin cases of belt lipectomy in combination withbuttock augmentation in either group, we startedin the supine position and ended with the proneposition. Finally, sterile dressings were applied forall patients' wounds and they wore pressure gar-ments over the dressings.

Post-operative care:All patients wore compression stockings to

prevent phlebitis, low-molecular weight heparin(Clexane 20 units) was given to all patients post-surgery. Broad spectrum antibiotics (Ceftriaxone1gm for 12 hours), with systemic analgesia usingPatient Controlled Analgesia as well as antiemeticsand antigastric medications were taken. Dressingswere changed every other day. Patients were giveninstructions of early ambulation on the day of thesurgery and the urinary catheter was removed thenext day.

RESULTS

Twenty-sex post-bariatric surgery female pa-tients, age from (23-44 years) underwent beltlipectomy/abdominoplasty after massive weightloss; There was a decrease in the distance betweenthe iliac crest and perceived superior glutealmargin, a decrease in the distance between theL5 dimple and the central crease, with lifting ofthe central crease, and a relative increase in thebuttock projection compared with pre-operativedistance in both groups Figs. (2,3). All measure-ments were taken and statistically analyzed. Thep-value was calculated for both groups and wasfound that there is a highly significant statisticaldifference in the post-operative measurements inGroup A.

All patients had been followed-up for one yearwith no major complications (i.e., hematoma,thromboembolism, bleeding and skin necrosis).The aesthetic results were considered satisfactoryin all cases with variable scores, of all 26 patients,8 cases experienced at least one complication.

Minor complications included wound dehis-cence (2 cases in Group A, 3 cases in Group B)treated by frequent dressing and healing withsecondary intention. Only 2 patients recurred toperform scar revision operation for aesthetic pur-poses (one case in each group). One patient sufferedfrom fat resorption in Group A after 3 months needfor reinjection. Patients' data are illustrated in(Table 1) (Group A) and (Table 2) (Group B).

In (Group A) patients, the overall shape of thegluteal augmentation was more natural in appear-ance with a very good projection, compared topatients of (group B), Those patients with siliconeaugmentation have good augmentation and projec-tion but they had aberrant overall shape and unnat-ural appearance as prosthesis boundaries are some-times visible with an unnatural appearance.

Fig. (2): Pre-and post-operative (after 6 months) for a patientin Group A.

Fig. (3): (Upper) lateral view (Lower) front view pre-operativeand post-operative (after 6 months) for a patient inGroup B.


Table (1): Patients data for (Group A): Patients underwent belt-lipectomy/abdominoplasty procedure with auto-augmentationcombined with fat injection of the buttock.

No

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Ageyear

23

44

35

26

39

25

42

44

36

40

27

24

35

38

41

BMIkg/m2

30

29

33

26

28

32

31

30

32

33

30

29

28

28

30

Co-morbidconditions

–

–

DM

–

DM

HTN

DM

–

Smoker

–

Smoker

–

HTN

–

–

420

380

400

390

350

390

350

320

320

350

320

330

320

350

320

Operativetime

minutes

6 monthspost-operative

Pre-operative

Measurement (distance)

Iliac creast- superior

gluteal margin

11

10.6

10.5

11.3

11.5

11

11.6

11.3

11.6

11

10.9

10.8

11.5

11

11.5

L5 dimple- centralcrease

6.7

6.9

7

7.2

6.9

7.4

7.3

7

7.7

6.9

7

7.8

7

7.3

7.4


gluteal margin

7

7.2

6.9

7.1

6.8

6,8

7

7.2

7.4

7.1

7.5

6.9

7.1

7.2

7


5.2

5

5.1

5.4

5.2

5.1

5.5

5.3

5

5

5.2

5

5.1

5.2

5.5

Amountof fat

injected (cc)

600

800

400

400

500

660

440

400

500

600

500

400

700

400

500

Complications

–

–

–

–

Scar revision

–

Wound dehiscence,

fat resorption

–

Wound dehiscence

–

–

–

Table (2): Patients data for (Group B): Patients underwent belt-lipectomy/abdominoplasty with auto-augmentation combinedwith prosthetic silicone implant.

No

1

2

3

4

5

6

7

8

9

10

11

Ageyear

40

35

38

41

34

33

23

44

35

26

39

BMIkg/m2

30

28

28

30

29

33

26

28

32

31

30

Co-morbidconditions

–

HTN

–

–

–

DM

–

DM

HTN

DM

–

400

320

350

320

380

400

390

350

390

350

320

Operativetime

minutes

6 monthspost-operative

Pre-operative

Measurement (distance)


gluteal margin

11

10.9

10.8

11.5

11

11.5

11

10.7

11.7

11.5

11.4


7

7.8

7

7.3

7

7.8

7

7.3

7.4

7.3

7


gluteal margin

6.8

7

7.2

7.4

7.1

7.5

6.9

7.1

7.2

6.8

7


5.1

5.5

5.3

5

5

5.2

5

5.1

5.2

5.1

5.3

Sizeof the

implant(cc)

450

450

450

400

400

400

450

450

400

400

450

Complications

–

Wound dehiscence

–

Scar revision

–

Wound dehiscence

–

Wound dehiscence

–

–

Egypt, J. Plast. Reconstr. Surg., October 2019 507

The overall patient satisfaction score 6 in GroupA was 11 patients (excellent), 2 patients (good), 1patient (satisfactory) and 1 patient (poor). Whereas,overall patient satisfaction score in Group B was8 patients (excellent), 2 patients (good), and 1patient (satisfactory).

In current study, we thought that the mostpractical means of augmenting the gluteal regionis to use tissue that would otherwise be discarded.

Large-volume fat injections are used as a meanof autoaugmentation, collect autologous fat fromareas of excess are collected and redistributed inthe area with a relative deficiency [11]. However,Complications as seroma and abscess may occur,and moreover there are published reports aboutfatal and non-fatal pulmonary fat embolism result-ing from this procedure. So, fat injection into deepmuscle and pointing downwards during intramus-cular fat injection should be avoided to avoidpulmonary fat embolism [12].

Murillo reported excellent take of large-volumefat injections for buttock augmentation, with only20 percent loss in patients followed for one year[13], however further long-term studies are neededto confirm fat resorption rates.

In this study, fat injection was used for auto-augmentation with autologous de-epithelializedflap in Group A, (400-800cc) of fat was usedharvested from back and area of excess, injectedin multiple layers to increase buttock projection.None of patient had seroma or abscess formationwith one case showed fat resorption after 3 monthsand fat was injected again after 2 months.

Gonzalez described intramuscular placementof gluteal implants [14]. Although implant insertionin any plane increases volume and projection, italso introduces a foreign body into the buttocks,and a technical learning curve exists for properplacement.

In our study, intramuscular silicone implantwas used together with the de-epithelialized flapfor more buttock shape definition. None of thepatients had any complication related to implant,rather than wound dehiscence in 3 cases due topoor healing of the patients.

A study was made to determine the satisfactionbetween autoaugmented buttock and non-augmented one and it showed no statistical signif-icance between the two groups [15]. So in thecurrent study, the dual method of augmentationwas proposed for more definition and projectionof buttocks, and the patients were satisfied in bothgroups with higher preference (satisfaction score)in Group A.

Conclusion:Dual autoaugmentation for post bariatric ptotic

buttocks give more appealing results for patients,

Fig. (4): Patient satisfaction score in Groups A and B.

Group A Group B12

10

8

6

4

2

0Excellent Good Satisfactory Poor

Chart Title

DISCUSSION

The goal of plastic surgical management aftermassive weight loss is to optimize the functionaloutcomes that are possible by means of surgicalremoval of redundant skin folds, which may neg-atively impact both the quality of life and physicalfunction [7,8].

Attractive buttocks should include adequatevolume, projection, and a defined infra-glutealfold. The gluteal region in patients with massiveweight loss is characterized by excessive skin andexaggerated fat loss. Lower body lift proceduresremove excess skin and lift sagging buttock tissue,but they typically result in further gluteal flattening[4].

Gluteal augmentation techniques fall into threemain categories: Autologous flaps, large-volumefat injections and implants. Autoaugmentationprocedures using autologous skin and fat from theregion of the lower body lift have previously beendescribed for gluteal augmentation. Pascal et al.,described a technique where tissue flaps weredesigned within the lower body lift incisions butnot mobilized; rather, the inferior gluteal tissue ismobilized and brought over the stationary flaps[9]. Young and Centeno used a similar techniquebut with release of the muscle fascia superior andlateral to the flap to allow more downward mobility[10]. Others use superior gluteal artery perforatorflap as a mean of autoaugmentation [4].

either objectively by measurements or subjectivelyby high satisfaction scores with a higher preferencefor fat injection.

REFERENCES

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2- Song A.Y., Rubin J.P., Thomas V., Dudas J.R., Marra K.G.and Fernstrom M.H.: Body Image and Quality of Life inPost Massive Weight Loss Body Contouring Patients, 14:1626-36, 2006.

3- Giordano S., Victorzon M., Koskivuo I. and SuominenE.: Physical discomfort due to redundant skin in post-bariatric surgery patients. J. Journal of Plastic, Recon-structive Aesthetic Surgery, 66: 950-5, 2013.

4- Amy S.C. and Loren J.B.: Autologous Gluteal Augmen-tation after Massive Weight Loss: Aesthetic Analysis andRole of the Superior Gluteal Artery Perforator Flap, Plast.Reconstr. Surg., 119: 345-56, 2007.

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9- Pascal J.F. and Le Louarn C.: Remodeling body lift withhigh lateral tension. Aesthetic Plast. Surg., 26: 223, 2002.

10- Young V.L. and Centeno R.F.: Marking and operativetechnique. Plast. Reconstr. Surg., 117 (1 Suppl.): 50S,2006.

11- Baran C.N., Celebioglu S., Sensoz O., Ulusoy G., CivelekB. and Ortak T.: The behavior of fat graft in recipientareas with enhanced vascularity. Plast. Reconstr. Surg.,109: 1646, 2002.

12- M. Mark Mofid, Daniel Suissa, Denis C. and ConstantinoMandieta: Report on mortality from gluteal fat grafting,recommendation from the ASERF Task Force. In: Aestheticsurgery Journal, 37 (7): 796-806, 2017.

13- Murillo W.L.: Buttock augmentation: Case studies of fatinjection monitored by magnetic resonance imaging. Plast.Reconstr. Surg., 114: 1606, 2004.

14- Gonzalez R.: Augmentation gluteoplasty: The XYZ meth-od. Aesthetic Plast. Surg., 28: 417, 2004.

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maximizing aesthetic results of buttock augmentation in

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