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Khallaf. European Journal of Pharmaceutical and Medical Research
www.ejpmr.com
118
BUTTOCK AUGMENTATION WITH FAT TRANSERFERE: EXPERIENCE WITH 200
CASES
Abdel Nasser M. Khallaf, M.D*
Plastic Surgery Dept., Faculty of Medicine, Al Azhar University, Cairo, Egypt.
Article Received on 03/05/2017 Article Revised on 24/05/2017 Article Accepted on 14/06/2017
PATIENTS AND METHODS
We prospectively evaluated all female patients who
voluntarily sought to improve the contour of the trunk
and hips via liposuction from July of 2011 to July of
2015 at Al manar clinic , Kuwait.
Laboratorial analyses were performed preoperatively in
all patients and included determination of hemoglobin,
hematocrit, prothrombin time, partial thromboplastin
time, glucose, urea, creatinine, Patients were advised to
stop oral contraceptive pills for 30 days and acetyl
salicylic acid for 7 days before surgery.
In patients older than 45 years of age or who presented
significant medical history, a complete medical
evaluation, including a resting electrocardiogram, was
performed.
Patients were followed clinically, and data were
collected regarding their preoperative and postoperative
course through photographs, patients’ subjective level of
satisfaction with the procedure, and complications. In all
patients, the results were evaluated with preoperative and
postoperative photographs. The assessment considered
patients’ level of satisfaction regarding their waist and
buttocks using a scale of 1 to 4 (1, poor outcome; 4,
excellent improvement).
Surgical Technique
Markings all patients were performed with the patient in
standing position.
Most of the patients the procedure were done under
general anaesthesia (90%) and the rest under spinal
anaesthesia upon the patient request.
Antibiotic given the patient with induction of
anaesthesia.
Tumescent infiltration of the fat tissue undergoing
liposuction with 0.9% saline solution associated with
adrenaline 1mg/500ml saline.
Liposuction with 3- and 4-mm cannulas of fat in the
flanks, thigh roots, saddlebags, and sub-gluteal region,
through as few ports as possible, in the prone position,
with no need for lateral decubitus.
Decanting for 30 minutes to separate the supernatant fat
from underlying liquid inside a closed system to avoid
exposure to air. There was no kind of preparation of the
fat tissue to be grafted.
Fat grafting with retrograde injection using a 60-cc
syringe and a blunt, 3-mm cannula in previously
demarcated areas of the buttocks, in different planes,
avoiding the grafting of large volumes of fat tissue in a
SJIF Impact Factor 4.161
Research Article
ISSN 2394-3211
EJPMR
EUROPEAN JOURNAL OF PHARMACEUTICAL
AND MEDICAL RESEARCH
www.ejpmr.com
ejpmr, 2017,4(7), 118-124
*Corresponding Author: Abdel Nasser M. Khallaf, M.D
Plastic Surgery Dept., Faculty of Medicine, Al Azhar University, Cairo, Egypt.
ABSTRACT
Background: Anatomical features that make the buttocks attractive include adequate volume, projection, and a
defined infragluteal fold. simple and reproducible surgical technique for gluteal shaping and augmentation with
autologous fat is needed. The female waist-hip ratio of around 0.7 is reachable through liposuction and gluteal fat
grafting. The authors evaluated the reliability of this technique. Methods: Prospective evaluation was performed of
all female patients subjected to gluteoplasty with autologous fat tissue between July of 2011 and July of 2015
without a weight change greater than 10 percent during follow-up. Results were evaluated through photographs.
The degree of satisfaction (patient and surgeon) was assessed on a scale of 1 (poor outcome) to 4 (excellent
improvement), and agreement was measured by Kappa statistics. The technique involved epidural anesthesia,
tumescent infiltration, liposuction around the buttocks, fat decantation, and grafting with retrograde injection in
different planes. Results: A total of 200 patients were included. Patient age ranged between 22 and 60 years (mean,
33 years). The preoperative body mass index was between 19 and 31.6 kg/m2 (mean, 24.8 kg/m2). The volume
grafted to the buttocks ranged between 350 and 1000 cc (mean, 700 cc). There were no medical complications.
Conclusions: This gluteoplasty technique is simple and inexpensive, with minimal morbidity and excellent results.
A good result depends on harmoniously combining fat elimination by liposuction and fat grafting for buttocks
sculpting, with lasting results.
Khallaf. European Journal of Pharmaceutical and Medical Research
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single area to prevent graft necrosis, and re-
accommodating eventual lumps of fat by massaging the
gluteal surface. First, we injected superficially to
improve the shape of the buttocks, from lateral to center.
Later, we injected deeper toward the gluteal muscle to
expand and augment its volume, giving projection but
avoiding overcorrection to obtain the desired contour at
the end of the surgery.
No drains were used.
Having the patient sit and sleep in the supine position in
the recovery room. Patients were also instructed to wear
an elastic compression garment for 2 months
postoperatively and start lymphatic drainage from the
first week after surgery, except in grafted areas. Patients
were instructed to take in about 4 liters of liquid per day
to avoid dehydration.
RESULTS
During the study period, 200 patients met the inclusion
and exclusion criteria and were operated on. All of them
were women. The age ranged between 22 and 60 years
(mean, 33 years). The body mass index at the time of
surgery ranged between 19 and 31.6 kg/m2 (mean, 24.8
kg/m2). The total volume grafted in each gluteal region
ranged between 350 and 1000 ml (mean, 700 ml) .
In the sample of patients evaluated, there were no
medical complications or postoperative complications
within the period evaluated. There were no cases of
infection.
Case 1. A 25-year-old patient preoperatively (above) and 6 months postoperatively (below) who underwent liposuction
(3.5 liters) and fat grafting of
600 cc in each buttock.
Khallaf. European Journal of Pharmaceutical and Medical Research
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Case 2. A 22-year-old patient preoperatively (above) and 1 year postoperatively (below) who underwent liposuction
(3.0 liters) and fat grafting of 700 cc in each buttock.
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Case: 3. A 28 years old patient preoperatively (Above) and 6 months postoperatively
(below) who underwent liposuction (4.o liters) and tummy tuck , with fat grafting of 900cc each buttock.
Case.4. A 35 years old patient preoperatively ( Above) and 6 months postoperatively
( below) who underwent liposuction ( 4.o liters) and fat grafting of 900cc each buttock.
Khallaf. European Journal of Pharmaceutical and Medical Research
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DISCUSSION
Buttock contour surgery includes a wide variety of
procedures performed in various ways. Pitanguy4 and
Regnault et al.[5] improved the gluteal appearance by
resecting tissue from the trochanteric region and gluteal
fold. Gonzalez-Ulloa[6] and Lockwood[7] obtained a
better shape by lifting the whole gluteal region,
achieving substantial improvement but creating large and
visible scars.[4,7]
Power-assisted gluteal augmentation with autologous fat
is an efficient, safe, and reproducible procedure that
produces an aesthetically pleasing gluteal projection and
contour. 36
With the development of implants, several authors have
obtained good results with this technique.[8–10]
Undoubtedly, the use of gluteal implants is an advance
because they provide an adequate volume to the contour
of the region with minimal scars. However, the implants
have the disadvantages of cost, diminished durability
compared with breast implants,[11] and complication
incidence reaching up to 38.1percent in a multicenter
review of experienced gluteal augmentation surgeons.[12]
Many patients have an aversion to the use of foreign
material in their bodies. Moreover, implants do not allow
treating different parts of the buttocks according to each
patient need.
After the introduction of liposuction, a new
alternative[13,14] became available for the treatment of
body contours. Illouz himself, the creator of
liposuction,15 used fat as a graft to correct liposuction
deformities in a patient in 1984.[16] The first report of
successful fat grafting to the buttocks was in 1986 by
Gonzalez and Spina,[17] along with the development of
the first sterile device to accumulate the fat to be grafted.
The authors stressed the importance of injecting the fat in
different levels, avoiding large collections and using
cannulas between 1 and 3 mm. Since then, this procedure
has gained popularity around the globe,[18,19] with several
authors publishing classifications and treatment
strategies,[2,20,21] corroborated by the evidence of fat
survival in long-term monitoring studies.[22–26]
Therefore, this procedure has been used to improve the
contour of the buttocks, and when needed, the projection
of the buttocks has been achieved without implants.
Considering the wishes of our patients and using the
principle of fat removal where it is in excess and
injection where it is needed, we decided to improve the
contour of the buttocks by a combination of two surgical
procedures that have given excellent results in plastic
surgery: lipoinjection and liposuction. Liposuction has
been considered the best choice for body
contouring.[15,27,28]
We obtained favorable results in patients using a
combination of both techniques. More than 90 percent of
our patients felt satisfied and showed improvement in
photographs, as determined by postoperative evaluation
by surgeons and patients. Two patients complained of
excess volume in lateral hips and underwent revision
surgery. Given this complaint, we have since started to
draw a line laterally, dividing anterior and posterior hip
and avoiding the injection of fat anterior to this line,
which has led to no more complaints about it. Notably,
we had no complaints regarding waist results.
The excess fat in the lumbosacral region is one of the
basic factors that must be corrected to achieve a proper
gluteal shape. For this reason, it was necessary to
perform liposuction in this area in all patients.
Liposuction of the subgluteal and saddlebag regions was
necessary in most patients, but not all of them. About 10
percent of the patients were thin (body mass index <20.0
kg/m2) and improved with a graft of less than 240 ml in
each buttock, later becoming satisfied, probably because
of a more realistic expectation built during preoperative
consultation. There was no relationship between the
volume injected and the satisfaction of patients or
surgical team. Of note, patients gave lower scores to
preoperative photographs than surgeons but higher
scores in the postoperative evaluation. Perhaps this
observation was attributable to a more objective analysis
by the surgeons, who showed a nearly perfect
postoperative agreement (K = 0.896/0.896), because they
are devoid of the emotional issues involved in patients’
assessments. Despite this difference, the Kappa analysis
showed that the postoperative agreement between
patients and surgeons was higher with regard to buttocks.
Regarding the prevention of complications, the amount
of fat and where it is infiltrated are two of the variables
to be considered to prevent local reaction and fat
necrosis.
According to Carpaneda’s principle,[29] in which the fat
graft survives up to 1.5 mm in radius, we used only 3-
mm or thinner cannulas to inject. Fat embolism
syndrome did not occur in any of our cases, but it is an
entity that deserves special attention because its
occurrence is not explained solely by fat grafting and has
been reported even after liposuction of smaller volumes
in sole surgical procedures.30–32 The relationship of
multiple factors in the occurrence of this syndrome
warrants additional studies aimed to clarify its causes
during liposuction.
There are important aspects about the surgical technique
that are essential for good results. Liposuction with the
tumescent technique allows the surgeon to suction the fat
needed to achieve a good body contouring despite the
aspirated volume, which represents a limiting factor.[33–
35] Likewise, the tumescent technique allows the
aspiration of very clean fat. We had no need for
additional procedures to clean the fat tissue, as other
authors have described.[23–25] Letting the fat rest for a
while allows us to get clean fat for infiltration.
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Infiltration is always made at the top of the gluteus
medius in an oval or circular pattern, depending on each
patient. The infiltration of the upper region works by
elevating the buttocks. The grafting of fat in different
planes and in various directions ensures symmetrical
results. Furthermore, using a continuous movement of
the syringe during the infiltration of fat and in different
planes prevents fat necrosis and accumulation of large
amounts of fat in one area. By applying these principles,
our complications have decreased, and the results have
improved considerably over time.
The improvement that can be achieved with the
combined technique of liposuction and fat grafting
depends on the amount of fat that can be removed from
adjacent areas of the buttocks and the amount of volume
that is needed in the gluteal region. When more fat is
aspirated, the result is more evident. For this reason, the
best results are obtained when the required increase is
less than 460 cc. We avoid grafting large volumes (>600
cc) because they give the buttocks an unnatural
appearance, with a ―balloon‖ shape, which leads fading
of the cosmetically nice curves related to it.[2,21]
Although we cannot objectively and precisely measure
the survival of injected fat, this technique is simple and
low cost, with minimal morbidity and an excellent result.
The gluteal shape obtained after prolonged follow-up is
satisfactory and demonstrates a significant survival of the
fat tissue over a long period of time. Good results depend
not on a large increase of the buttocks but on the
combination of two procedures used in a harmonious
manner to give the patient an ideal body contour by
removing fat deposits with liposuction and the
application of fat where it is needed.
CONCLUSIONS
This buttock augmentation technique is simple and
inexpensive, with minimal morbidity and excellent long-
term patient satisfaction. It is important to note that a
good result depends not on a lot of fat infiltration but on
the harmonious combining of the two surgical
procedures—the elimination of fat by liposuction and fat
grafting for buttock sculpting—for lasting results.
REFERENCES
1. Singh D. Universal allure of the hourglass figure:
An evolutionary theory of female physical
attractiveness. Clin Plast Surg, 2006; 33: 359–370.
2. Roberts TL III, Weinfeld AB, Bruner TW, Nguyen
K. ―Universal‖ and ethnic ideals of beautiful
buttocks are best obtained by autologous micro fat
grafting and liposuction. Clin Plast Surg, 2006; 33:
371–394
3. Viera AJ, Garrett JM. Understanding interobserver
agreement: The kappa statistic. Fam Med., 2005; 37:
360–363
4. Pitanguy I. Trochanteric lipodystrophy. Plast
Reconstr Surg, 1964; 34: 280–286.
5. Regnault P, Baroudi R, de Silveira Carvalho CG..
Correction of lower limb lipodystrophy. Aesthetic
Plast Surg, 1979; 3: 233–249.
6. Gonzalez-Ulloa M.. Gluteoplasty: A ten-year report.
Aesthetic Plast Surg, 1991; 15: 85–91.
7. Lockwood TE. Transverse flank-thigh-buttock lift
with superficial fascial suspension. Plast Reconstr
Surg, 1991; 87: 1019–1027.
8. Novack BH. Alloplastic implants for men. Clin Plast
Surg, 1991; 18: 829–855.
9. Vergara R, Amezcua H. Intramuscular gluteal
implants: 15 years’ experience. Aesthetic Surg J,
2003; 23: 86–91.
10. Gonzalez R. Augmentation gluteoplasty: The XYZ
method. Aesthetic Plast Surg, 2004; 28: 417–425.
11. Daniel MJB, Maluf I, Jr. What is the durability of
gluteal prostheses? Rev Bras Cir Plast, 2012; 27:
93–96.
12. Mofid MM, Gonzalez R, de la Pena JA, Mendieta
CG, Senderoff DM, Jorjani S. Buttock augmentation
with silicone implants: A multicenter survey review
of 2226 patients. Plast Reconstr Surg, 2013; 131:
897–901.
13. Schrudde J. Lipexeresis as a means of eliminating
local adiposity. Aesthetic Plast Surg, 1980; 4: 215–
226.
14. Kesselring UK. Regional fat aspiration for body
contouring. Plast Reconstr Surg, 1983; 72: 610–619.
15. Illouz YG. Body contouring by lipolysis: A 5-year
experience with over 3000 cases. Plast Reconstr
Surg, 1983; 72: 591–597.
16. Illouz YG. L’avenir de la réutilisation de la graisse
après liposuccion. La Revue de Chirurgie Esthétique
de Langue Française, 1984; 36: 13—14.
17. Gonzalez R, Spina L. Grafting of fat obtained by
liposuction: Technique and instruments. Rev Bras
Cir, 1986; 76: 243–250.
18. Pereira LH, Radwanski HN. Fat grafting of the
buttocks and lower limbs. Aesthetic Plast Surg.,
1996; 20: 409–416.
19. Cardenas-Camarena L, Arenas-Quintana R, Robles-
Cervantes JA. Buttocks fat grafting: 14 years of
evolution and experience. Plast Reconstr Surg, 2011;
128: 545–555.
20. Mendieta CG.. Classification system for gluteal
evaluation. Clin Plast Surg, 2006; 33: 333–346.
21. Cuenca-Guerra R, Quezada J. What makes buttocks
beautiful? A review and classification of the
determinants of gluteal beauty and the surgical
techniques to achieve them. Aesthetic Plast Surg,
2004; 28: 340–347.
22. Guerrerosantos J, Gonzalez-Mendoza A, Masmela
Y, Gonzalez MA, Deos M, Diaz P. Long-term
survival of free fat grafts in muscle: An
experimental study in rats. Aesthetic Plast Surg,
1996; 20: 403–408.
23. Coleman SR. Facial recontouring with lipostructure.
Clin Plast Surg, 1997; 24: 347–367.
24. Coleman SR. Long-term survival of fat transplants:
Controlled demonstrations. Aesthetic Plast Surg,
1995; 19: 421–425.
25. Chajchir A.. Fat injection: Long-term follow-Up.
Khallaf. European Journal of Pharmaceutical and Medical Research
www.ejpmr.com
124
Aesthetic Plast Surg, 1996; 20: 291–296.
26. Niechajev I, Sevcuk O. Long-term results of fat
transplantation: Clinical and histologic studies. Plast
Reconstr Surg, 1994; 94: 496–506.
27. Baroudi R.. Body sculpturing. Clin Plast Surg, 1984;
11: 419–443.
28. Gasparotti M.. Superficial liposuction: A new
application of the technique for aged and flaccid
skin. Aesthetic Plast Surg, 1992; 16: 141–153.
29. Carpaneda CA, Ribeiro MT. Study of the histologic
alterations and viability of the adipose graft in
humans. Aesthetic Plast Surg, 1993; 17: 43–47.
30. Ross RM, Johnson GW. Fat embolism after
liposuction. Chest, 1988; 93: 1294–1295.
31. Laub DR Jr, Laub DR. Fat embolism syndrome after
liposuction: A case report and review of the
literature. Ann Plast Surg, 1990; 25: 48–52.
32. Boezaart AP, Clinton CW, Braun S, Oettle C, Lee
NP. Fulminant adult respiratory distress syndrome
after suction lipectomy: A case report. S Afr Med J.
1990; 78: 693–695.
33. Cardenas-Camarena L, Tobar-Losada A, Lacouture
AM.. Large-volume circumferential liposuction with
tumescent technique: A sure and viable procedure.
Plast Reconstr Surg, 1999; 104: 1887–1899.
34. Klein JA. Tumescent technique for local anesthesia
improves safety in large-volume liposuction. Plast
Reconstr Surg, 1993; 92: 1085–1098. discussion
1099–1100.
35. Samdal F, Amland PF, Bugge JF. Blood loss during
suction-assisted lipectomy with large volumes of
dilute adrenaline. Scand J Plast Reconstr Surg Hand
Surg, 1995;29:161–165
36. Abboud MH, Dibo SA, Abboud NM , Power-
assisted gluteal augmentation: a new technique for
sculpting, harvesting, and transferring fat. Aesthet
Surg J. Nov, 2015; 35(8): 987-94.