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Buttocks Fat Grafting: 14 Years of Evolution and Experience
Abstract
Fat infiltration for gluteal contour improvement is a procedure that is gaining more advocates. This has caused the application technique and the amount of fat infiltrated to change over time. The authors present their buttocks fat grafting technique evolution that occurred over a 14-year period.
From April of 1995 to March of 2009, 789 patients underwent liposuction and buttocks fat grafting. Patients were divided into three stages according to chronologic evolution and amount of fat infiltrated.
During the first period (April of 1995 to January of 2004), 120 to 320 cc of fat was infiltrated in the upper gluteal area. During the second period (February of 2004 to February of 2006), 210 to 460 cc of fat was infiltrated in the upper and lower gluteal area. In the third period (March of 2006 to March of 2009), 220 to 1160 cc of fat was infiltrated in the aforementioned areas and in the trochanteric and subgluteal areas. Complications such as fat necrosis, gluteal erythema, infection, and fat embolism syndrome were more frequent and serious in the first stage, despite the authors having infiltrated smaller volumes.
Increasing the volume of fat infiltration in the buttocks has resulted in better contour results in the whole area, and distribution of that larger volume in more extensive areas and in different layers has decreased the index and number of complications. Therefore, to obtain better aesthetic results, it is necessary to keep in mind that these larger amounts must be distributed in larger areas and layers to decrease postsurgical morbidity.
Therapeutic, III.
... throughout the superior buttock, lateral gluteal depression, trochanter, ischium, lateral and posterior thighs. 3,4,[6][7][8][9] Some respondents from a population analysis favor a shift from the traditional waist-to-hip ratio of 0.7 to 0.6 with an emphasis on the greatest point of projection lying at the midpoint of the buttocks. 10 Patient satisfaction after this procedure is reported to be 86.3% to 97.1% with their buttocks [11][12][13] and 100% with their waistline contouring. ...
... 24 Complications may be either regional or systemic, and include infection, contour deformity, oil cyst formation, hematoma, acute blood loss anemia, hypovolemia, deep venous thrombosis (DVT), pulmonary embolism (PE), fat embolism, and death. 3,6,22,25,26 It is also reported by Cardenas-Camarena from their series of 789 patients, that with increased experience the complication rate decreased despite increasing volumes of fat injected. 6 To satisfy the growing demand by patients for the procedure and for higher grafting volumes per patient, 6,13 we have devised a technique that allows for safe, efficient buttock augmentation for use across the spectrum of patients' goals. ...
... 3,6,22,25,26 It is also reported by Cardenas-Camarena from their series of 789 patients, that with increased experience the complication rate decreased despite increasing volumes of fat injected. 6 To satisfy the growing demand by patients for the procedure and for higher grafting volumes per patient, 6,13 we have devised a technique that allows for safe, efficient buttock augmentation for use across the spectrum of patients' goals. ...
Background
Autologous buttock augmentation with fat grafting has emerged as one of the preeminent modalities for body contouring employed by plastic surgeons today. Since 2009, we have used the roller pump injection technique.
Objectives
This procedure can be performed safely without specialized equipment and eliminates the tasks of manual graft preparation and injection. We describe our technique and standard safety measures. The anatomy of and complications associated with liposuction and fat grafting were recorded and reviewed.
Methods
Retrospective chart review of 916 patients who underwent autologous buttock augmentation by this method from February 2009 to November 2016 was performed. All procedures were performed under general anesthesia at the same surgical center. Liposuction was performed and using a roller pump, the fat layer was propelled through an open-ended cannula into the recipient site.
Results
Mean volume of fat removed and fat grafted in each patient was 3156 mL and 1807 mL per patient, respectively. There were complications in 13 patients for a rate of 1.4% with 10 (1.1%) related to fat grafting. Fourteen patients (1.5%) had subsequent procedures for volume and four patients (0.44%) for asymmetry. There were no venous thrombolic events, fat embolic events, or deaths.
Conclusions
The roller pump injection technique for buttock augmentation with fat grafting is safe and efficient. This technique minimizes preparatory effort and does not require additional equipment. We were unable to identify variables associated with complication risk due to the power of this study and the low percentage of complications.
Level of Evidence: 4
... The outer thighs were treated in 6 patients. Many patients prefer lateral gluteal (trochanteric) fullness to accentuate the hourglass shape, 2,8 and this area was routinely treated with the rest of the buttock during lipoinjection. Patients were marked in a standing position before surgery. ...
... Drains may be needed. 2,8,17 Painful paresthesias of the flanks and gluteal regions are sometimes encountered. 16,19 Contour irregularities may occur, especially in thin women. ...
... This video is available in the "Related Videos" section of the Full-Text article on PRSGlobalOpen.com or available at http:// links.lww.com/PRSGO/A198.) 8,14 Although several studies provide clinical data and subjective evaluation of buttock fat transfer, 2,8,[14][15][16][17][18] objective measurements are lacking. Murillo 17 used magnetic resonance imaging to document a qualitative increase in buttock fullness in 6 patients undergoing intramuscular buttock fat injection. ...
Background:
Buttock fat transfer is now the preferred method for gluteal augmentation. However, its efficacy has not been well-documented using measurements.
Methods:
Twenty-five consecutive patients underwent buttock fat transfer performed by the author. Twenty-one patients returned for measurements ≥3 months after surgery (inclusion rate, 84%). A separate group of 25 patients undergoing cosmetic surgery without buttock fat transfer served as controls. All patients underwent superwet liposuction using total intravenous anesthesia and no prone positioning. A closed filtration system was used to collect the fat. Subcutaneous fat thickness was assessed using ultrasound imaging. Measurements were made on standardized photographs. The data were controlled for change in body mass index. Clinical data were also evaluated.
Results:
The mean fat volume injected per buttock was 287 mL (range, 70–550 mL). Ultrasound measurements detected a significant increase in the subcutaneous fat thickness (P ≤ 0.001), with mean increments of 0.66 cm for the right buttock and 0.86 cm for the left buttock and no significant change for control patients. The mean calculated fat retention, based on the measured surface area injected, was 66%. Photographic measurements of buttock projection revealed a significant increase in treated patients (P < 0.01) and no significant change in control patients. There were no clinical complications at either recipient or donor sites and no evidence of oily cysts on ultrasound examinations.
Conclusions:
Photographic and ultrasound measurements, and clinical findings, confirm that buttock fat transfer effectively and safely increases buttock projection.
... Buttock augmentation surgery has been widely on demand in the recent years owing to more focus on body sculpting and the widespread media access to global figures [1]. The ideal waist-to-hip ratio of 0.7 that had been previously regarded as the gold standard may even see a shift in the coming years towards a lower ratio and a curvier figure [2]. ...
... The main methods used to achieve buttock augmentation are the introduction of prostheses, autologous fat sculpting, or a mixture of both techniques [4]. The advancement of lipoinjection 497 techniques in the modern times has allowed larger infiltrations in multiple areas [1]. The fat is placed in the gluteal region within the superficial intramuscular or subcutaneous plane with the goal of augmenting fat survival [5]. ...
... The technique we selected in this trial requires lipoaspiration, which has been used for decades in plastic surgery with a very low incidence of major complications [44]. The absence of procedure-related death and major adverse events allowed us to confirm the safety of both the lipoaspiration and the injection of the autologous micro-fragmented adipose tissue in the amputation stump. ...
... Several factors were taken into account when planning the trial with micro-fragmented adipose tissue: the harvesting is safe and simple [44], the mechanical fragmentation avoids laboratory manipulation of the product (e.g., enzymatic treatment), the use of minimally manipulated autologous adipose tissue complies with ethics laws, the immunological rejection could be avoided without heterologous and/or allogeneic material, and injecting the graft at the stump level avoids possible complications related to the endovascular delivery [13]. The results lead us to confirm the abovementioned positive features, in particular, the intra/perilesional injection was safe and feasible in a wide range of stumps (DA/ TMA). ...
Background:
The diabetic foot ulcer (DFU) is one of the most prevalent complications of diabetes mellitus and often develops severe effects that can lead to amputation. A non-healing "minor" amputation often precedes a major amputation resulting in a negative impact on the function and quality of life of the patients. Stem cell-based therapies have emerged as a promising option to improve healing, and the adipose tissue is an abundant and easy to access source. The injection of autologous micro-fragmented adipose tissue at the amputation stump of a diabetic population undergoing a lower limb minor amputation was evaluated and compared with the standard care.
Methods:
In this randomized controlled trial with two arms (parallel assignment) and no masking, 114 patients undergoing a lower limb minor amputation were randomized to standard of care or to micro-fragmented adipose tissue injection prepared using a minimal manipulation technique (Lipogems®) in a closed system. Clinical outcomes were determined monthly up to 6 months. Primary endpoint of the study was the evaluation of the healing rate and time after the minor amputation. Secondary endpoints included the assessment of safety, feasibility, technical success, relapse rate, skin tropism, and intensity of pain.
Results:
At 6 months, 80% of the micro-fragmented adipose tissue-treated feet healed and 20% failed as compared with the control group where 46% healed and 54% failed (p = 0.0064). No treatment-related adverse events nor relapses were documented, and technical success was achieved in all cases. The skin tropism was improved in the treatment group, and the pain scale did not differ between the two groups.
Conclusion:
The results of this randomized controlled trial suggest that the local injection of autologous micro-fragmented adipose tissue is a safe and valid therapeutic option able to improve healing rate following minor amputations of irreversible DFU. The technique overcomes several stem cell therapy-related criticisms and its potential in wound care should be better evaluated and the therapeutic indications could be expanded.
Trial registration:
ClinicalTrials.gov number: NCT03276312. Date of registration: September 8, 2017 (retrospectively registered).
... In all cases, liposuction was also performed in other areas. 17 The infiltrated fat varied from 120 to 280 mL per gluteus muscle, with a mean of 210 mL. Follow-up ranged from 3 months to 3 years and 5 months, with an average of 17 months. ...
... Cárdenas-Camarenas et al. 17 have studied the cases of 789 patients who underwent gluteal liposuction and lipograft. They were injected with different volumes of fat, varying from 120 to 1,160 mL. ...
Buttocks augmentation with pmma Polymethylmethacrylate .
... Liposuction and lipoinjection were combined. In all cases, liposuction was also performed in other areas [17]. The infiltrated fat varied from 120 to 280 mL per glutaeus muscle, with a mean of 210 mL Follow-up ranged from 3 months to 3 years and 5 months, with an average of 17 months. ...
... C ardenas-Camarenas et al. [17] have studied the cases of 789 patients who underwent glutaeal liposuction and lipograft. They were injected with different volumes of fat, varying from 120 to 1160 mL. ...
Silicone prostheses are an alternative to shape the buttock but further studies are still needed to support the effectiveness of its use. A patient sought medical attention for being dissatisfied with the glutaeal silicone prostheses inserted using subcutaneous technique four years before. The treatment adopted was prosthesis removal surgery, and subsequent filling with PMMA.
... Over the past decades, the demand for a better definition of the body and the buttock area has been increasing [1]. Augmenting the buttocks by placement of implants represents a commonly used technique. ...
... After increase of the grafted volume, complications like liponecrosis, infection and lack off buttock projection increased significantly [20]. Several cases of the potentially life-threatening fat embolism syndrome were reported [1,20]. In a study of Nicareta et al., a high patient satisfaction is reported within the first months after surgery and after several years [4]. ...
Background: Buttock augmentation is gaining increasing popularity in aesthetic surgery . The relativ ely high incidence of complications af ter silicone implant placement lead to the increased use of lipofilling techniques, y ielding v ariable results with respect to graf t take rate and long-term stability . Platelet-rich plasma (PRP) has been shown to hav e benef icial ef f ects on wound healing and angiogenesis in the past.
Theref ore, we aimed at inv estigating the long-term results and patient satisf action af ter PRP-enriched lipof illing f or buttock augmentation. Methods: Twenty -f our bilateral gluteal augmentations with PRP-enriched autologous f at were perf ormed. Additionally , contour shaping was achiev ed by liposuction of the adjacent zones. Post-operative results and complications were recorded, and satisfaction with buttock shape was estimated by a patient questionnaire.
Results: Mean follow-up time was 44 months, and mean amount of
transf erred f at was 481 cc f or both sides. No seroma or hematoma
f ormation, inf ection or liponecrosis were reported during the post-operativ e
f ollow-up. Subjectiv e patient satisf action in general increased f rom preoperativ ely to 3 months postoperativ ely and declined only slightly in the long-term course. Satisf action lev els in general were specif ic f or each patient. Patient recovery was quick, and the majority of patients returned to work within 10 day s af ter surgery .
Conclusion: PRP-enhanced lipof illing of the buttocks prov ed to be a saf e procedure including a low complication rate and consistent results.
Howev er, subjectiv e patient expectations hav e to be taken into account when choosing the indication. Further large volume studies are needed to elucidate the potential and benefit of PRP in this context.
Lev el of Ev idence: Lev el V.
... In the case of implant removal with mastopexy, the transferred fat volume is elevated, and the appropriate distribution of adipose tissue is crucial for achieving a high retention rate. Several authors consider the muscular plane to be the ideal recipient area for fat grafting due to its strong neoangiogenetic potential [14][15][16]. In order to reduce the risk of adipose cell reabsorption, we perform a multiplane infiltration as advised by Auclair and Yoshimura [3,16,17]. ...
Background
Due to its unpredictable retention rate, using autologous fat alone for the enhancement of breast volume is often unsatisfactory. To overcome this limitation, fat transfer has been proposed as an immediate adjuvant procedure to aesthetic breast surgery, creating the concept of hybrid mammoplasty.Fat transfer has already been shown to correct minor defects with good clinical outcome, but the amount of fat that can be safely transferred has not yet been identified. Our hypothesis is that contour improvement with small-volume fat transfer as a primary adjuvant treatment can lead to a better patient outcome.MethodsA retrospective single-centre uncontrolled case series study was conducted on 70 patients who underwent hybrid mammoplasties for aesthetic purposes only. Primary and secondary cases were included and divided into corresponding groups. An ad-hoc outcome scale based on clinical parameters was created to standardise results; results were analysed after a follow-up period of at least 12 months.ResultsThe overall results were reported as good in 48.7% of cases, moderate in 32.8%, and sufficient in 18.5%. Primary cases with small deformities showed a better outcome on our scale compared to revisional ones (57.4% good compared to 29%; p = 0.038). A transferred volume of fat up to 100 ml was associated with a higher retention rate (OR = 2.3; p = 0.032).Conclusions
Small breast contour deformities or prosthesis coverage can be easily corrected with fat transfer. Based on our score system, this technique is indicated for volume enhancement up to 100 ml; beyond that the outcome quality decreases, and further corrections would be needed.Level of evidence: Level IV, Therapeutic.
... In addition, the gluteus muscles are an important element of female sexual attraction and a major component of the concept of beauty in most cultures and ethnic groups [16]. The demand for a better definition of the body and the buttock area has been increasing, [17] and women focus more on the hip muscles and lower body than men with respect to exercise behaviors and motivations [18]. The musculoskeletal conditions involved in the hip muscles are associated with specific challenges to sex, such as decreased ability to provide sexual stimulation to one's partner or to comfortably position oneself during sexual intercourse [11]. ...
Introduction:
The pelvic floor muscle (PFM) could affect female sexual functions. The hip muscles are morphologically and functionally linked to PFM and are important elements of female sexual attraction.
Aim:
To determine the relationship between female sexual function and hip muscle strength and PFM functions in women with stress urinary incontinence (SUI).
Methods:
A total of 42 women with SUI were recruited in this study. Female sexual function was measured using the pelvic organ prolapse urinary incontinence sexual function questionnaire (PISQ). PFM functions were measured using a perineometer. Hip muscle strength was measured using a Smart KEMA tension sensor. The relationship between female sexual function and PFM function and hip muscle strength was assessed using Pearson correlation coefficients and multiple regression analyses with forward selection.
Main outcome measures:
PISQ score, PFM functions (strength and endurance), and strength of hip extensor, abductor, and adductor were the main outcome measures.
Results:
For the behavioral/emotive domain in the PISQ, hip extensor strength (r = 0.452), PFM strength (r = 0.441), PFM endurance (r = 0.362), and hip adductor strength (r = 0.324) were significantly correlated and hip extensor strength emerged in multiple regression. For the physical domain in the PISQ, hip abductor strength (r = 0.417), PFM endurance (r = 0.356), hip adductor strength (r = 0.332), and PFM strength (r = 0.322) were significantly correlated and hip abductor strength entered in multiple regression. For partner-related domain in the PISQ, hip adductor (r = 0.386) and abductor strength (r = 0.314) were significantly correlated and hip adductor strength appeared in multiple regression. For the PISQ total score, hip extensor strength (r = 0.484), PFM endurance (r = 0.470), hip adductor strength (r = 0.424), hip abductor strength (r = 0.393), and PFM strength (r = 0.387) were significantly correlated and hip extensor strength and PFM endurance emerged in multiple regression.
Conclusion:
The female sexual function could be related to not only PFM functions but also hip muscle strength in women with SUI. Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Relationship Between Sexual Function and Pelvic Floor and Hip Muscle Strength in Women With Stress Urinary Incontinence. Sex Med 2021;XX:100317.
... Gluteal fat transfer, popularly called the "Brazilian butt lift," is an application of liposuction in which large volumes of fat are transferred from an undesirable area, such as the abdomen or inner thighs, to the buttocks. 20 Fat is first removed by liposuction (the volume of which varies extensively and remains largely based upon the patient's preoperative anatomy) and is then used to augment the contour of the buttocks commensurate with the patient's desires and anatomic deficiencies. 21,22 High-volume fat transfer, defined as a volume greater than 1,000 mL per buttock, has historically been associated with a higher risk of infection at the graft site and seroma formation at the harvested site. ...
Liposuction is the second most commonly performed cosmetic surgery in the United States and the most common surgical procedure in patients between the ages of 35 and 64; practitioners of medicine and surgery will undoubtedly encounter these patients in their practice. This brief review discusses the role of liposuction and fat transfer in aesthetic and reconstructive surgery, as well as key considerations, indications, and safety concerns.
... FT collection is carried out from undesirable zones, which allows to combine buttocks' augmentation with the correction of the overall contour of the body. If there is a sufficient amount of donor material, FT transplantation for buttocks' augmentation can replace implantation (Cárdenas-Camarena et al., 2011). ...
– The role of noninvasive and minimally invasive procedures in cosmetic medicine and surgery is constantly increasing. Fatty tissue transplantation is a minimally invasive reconstructive cosmetic procedure used in patients with the loss of tissue volume or disruption of body contours resulting from diseases, trauma, birth defects or normal aging. Characteristics of fatty tissue make it possible to use it as universal filler. Main techniques for fatty tissue sampling are vacuum aspiration, syringe aspiration, and surgical excision. The process of transplantation is accompanied by a complex of biological processes. The paper discusses in detail the possibilities of fat cells’transplantation for facial rejuvenation, hands’ rejuvenation, rhinoplasty, breast and buttocks’ correction, as well as potential complications of these procedures.
... As a result of this high risk, authors have begun to describe techniques and anatomic safe zones in an attempt to improve patient safety and reduce mortality. [9][10][11]15,17,19,20 The Villanueva et al 15 article, "Staying Safe During Gluteal Fat Transplantation," describes 4 key principles aimed to reduce PFE: use of a large-bore cannula (≥4 mm) to minimize the risk of deep muscle penetration and venous injury, continuous cannula motion to promote layered dispersal of fat and prevent inadvertent continuous injection into underlying vessels, staying subcutaneous to likewise avoid injury to the deeper veins, and avoiding overfilling in order to decrease the chance of creating a pressure gradient. 15 The Ramos-Gallardo et al 17 cadaveric study shed light on safe cannula angle to avoid insertion into the gluteal vessels. ...
Objective: The increase in demand for gluteal fat grafting seen in recent years in the United States has not been met with an equal gain in knowledge of the perils of this anatomic territory. The purpose of this study was to identify anatomic landmarks that can be readily used by surgeons to identify the takeoff of the superior and inferior gluteal veins. Method: Six fresh cadaveric gluteal specimens were dissected at the University of Louisville anatomy laboratory. A question mark incision was made for exposure, followed by identification of the sciatic nerve in the proximal thigh. This was traced retrograde to the sciatic forearm. The piriformis muscle was identified dividing the foreman into superior and inferior portions, which corresponded to the takeoff of the superior and inferior gluteal vessels, respectively. The distance of the gluteal vessels from the one-third point of a line from the mid-sacrum to the greater trochanter was measured. Result: Our cadaveric dissection series demonstrated that the superior and inferior gluteal veins were on average 3.28 cm (2-5.9 cm) and 1.25 cm (0-3.5 cm) away from the point one third the distance from the mid-sacral border to the greater trochanter. Conclusion: The mid-sacrum and the trochanter of the femur are the anatomic landmarks used to identify the large gluteal vein trunks. Understanding the location and trajectory of these deep gluteal structures with use of readily identifiable landmarks may assist surgeons in avoiding inadvertent injection of fat to these veins during fat grafting.
... [2] Fat is in fact an ideal soft tissue filler as it is completely biocompatible, abundantly available, and easily harvested and processed, and therefore, it is widely used for treating cosmetic, traumatic, and reconstructive deficits in the face, abdomen, trunk, and thigh. [3][4][5][6] Despite the appeal of fat and its widespread adoption, many shadows remain around fat stability and graft survival: The amount of fat retention is far to be predictable and reliable considering that as much as 40-60% of fat graft could be lost. [7][8][9][10][11][12] In 1993, Carpaneda and Ribeiro [13] reported a necrosis rate of 60% in 3.5 mm diameter cylindric fat grafts when observed 2 months after transplantation. ...
Context
Breast lipofilling usually involves three different stages (harvesting, processing, and placement), and in each of these phases, adipocyte cells can be damaged. Our technique of fat placement is quite different from the others as we focus our attention on the last stage of fat graft procedure, which could explain the better results in graft survival.
Aims
Our method is focused on eliminating any unnecessary manipulation of the graft so as to optimize graft retention and clinical outcomes: Controlled movement and slow rate of fat injection are the cornerstone of our technique and guarantee a nontraumatic fat transfer and a greater survival rate of adipocytes.
Settings and Design
This was a retrospective cohort study.
Materials and Methods
Of 120 patients (average age 41,5 years) affected by breast soft tissue defects, 60 were managed with the lipofilling procedure using fat graft injected by “Gentle technique.” To establish the effects of the injection’s procedure, we compared the results obtained in fat graft maintenance with a control group made up of 60 patients, treated with fat graft injection according to Coleman procedure.
Statistical Analysis Used
Values are expressed as mean plus standard error and analyzed using Student’s t test.
Results
In patients treated with Gentle technique, we observed a 60.5% + 12.5% maintenance of contour restoring and three-dimensional volume after 1 year (P < 0.0001 vs. control group); we compared the results obtained with only 39% + 4.4% of the control group treated with fat graft injected according to Coleman.
Conclusions
Controlled 26 movement and slow rate of fat injection are the cornerstone of our technique and guarantee a nontraumatic fat transfer and a greater 27 survival rate of adipocytes.
... Murillo et al 20 adopted intramuscular fat injection for buttock augmentation for 162 patients over a 7-year period, with subcutaneous fat injection to correct superficial irregularities, and achieved favorable aesthetic outcomes. Cardenas-Camarena et al, 21 who have 14 years of experience in buttock surgeries, recommend fat grafting to both subcutaneous and muscular layers. And Yoshimura suggested that the optimal recipient site for lipoaugmentaiton of breast includes the periglandular and muscular layers. ...
Background
Fat grafting has become a popular procedure in aesthetic and reconstructive surgeries due to its safety, minimal invasiveness, and favorable visual outcomes, although the volume retention rate is unpredictable.
Objectives
A prospective clinical study on lipoaugmentation of the breast was conducted to compare fat retention rates in the pectoralis muscle and the periglandular area.
Methods
This prospective study included 20 breasts from 11 patients who underwent primary lipoaugmentation. Volume retention rate and percentage augmentation among different recipient layers, as well as complications and patient satisfaction, were evaluated. Magnetic resonance imaging was performed preoperatively and at 1 day and 3 months postoperatively. Complications were recorded, and patient satisfaction was appraised through the use of the Breast-Q questionnaire.
Results
Breasts were injected with 207 ± 29 mL of fat, achieving overall volume retention rates of 56.63% ± 16.40%. The overall augmentation was 21.53% ± 10.27%. Volume retention rate was significantly higher (59.00% ± 13.84%) in the periglandular area than in the pectoralis muscle (47.21% ± 22.41%) (P = 0.04). Augmentation was significantly higher (32.13% ± 12.96%) in the periglandular area than in the pectoralis muscle (4.95% ± 4.23%) (P = 0.00). Pain and numbness were the only reported complications. The Breast-Q score increased significantly for the measures “satisfaction with breasts,” “psychosocial well-being,” and “sexual well-being.”
Conclusions
Fat transfer is a safe and acceptable method for aesthetic and reconstructive breast surgery. The periglandular area was a better recipient site than muscle for transferred fat.
Level of Evidence: 4
... (A, B) These diagrams show injection at the middle of the buttock at the level of the posterior superior iliac crest with a −30° angle with red dye toward the trochanter (in the lateral direction only). (C, D) The peritrochanteric access at the level of the femur head at a 10° angle with green dye, and (E, F) at a 0° angle with blue dye.GA is the application of the synthetic graft within the subcutaneous adipose tissue and the superficial gluteal muscle, which achieves better aesthetic results and graft survival and diminishes the risk of fat embolism.3,[6][7][8][9][10][11][12][13][14][15] In 2016, when Condé-Green et al 3 described a meta-analysis of fat graft application, they found that in 4105 patients, the fat graft was applied within the subcutaneous and intramuscular planes in 46.7% patients, within the intramuscular plane in only 26.7% of patients, and within the subcutaneous plane in only 20% of patients. ...
Background
Fat grafting for gluteal augmentation (GA) is one of the most popular aesthetic surgery procedures. It has an associated mortality to fat embolism of 0.2%.
Objectives
This study described which technique for synthetic graft application was least likely to cause a fat embolism.
Methods
Ten fresh bodies were obtained and four groups arranged with five buttocks each randomly assigned. Group 1 was infiltrated through the upper medial intergluteal sulcus (upper medial intergluteal sulcus) with an angulation of -30º, -10º, and 0º. Group 2 was infiltrated through the middle lower gluteal sulcus (MLGS) with an angulation of -30º, 0º, and +15º. Group 3 was infiltrated through a peritrochanteric (PT) access at the level of the femur head at 0º, and +10º, and in the middle of the buttock (MB) at the level of the iliac crest at -30º directed to the trochanter (lateral direction). Group 4 was infiltrated in the same manner as Group 1 without -30º. A complication occurred when the graft was in contact with the vascular or nervous bundle, within the gluteus medius muscle, or both.
Results
Group 1 had three buttocks with a complication (UMIGS −30º). Group 2 had complications in all of the injection techniques. Group 3 had five buttocks with a complication (PT at 0º). Group 4 had no complications.
Conclusion
The injection of the fat graft through the UMIGS at 0º and -10º angles, and through the MB at a -30º angle, reaches the surface needed for GA. The Group 2 techniques should be avoided because of they have a high risk of a complication.
... It represents 5,9% of all nonsurgical aesthetic procedures [1]. For the gluteal injection site, the complication rates can be up to 5,89%, making them very rare, with incidents including fat necrosis, gluteal erythema, infection, and fat embolism [2]. ...
Lipofilling is a popular cosmetic procedure, meaning to enhance the volume in certain body segments (such as breasts and buttocks) and slim down others (as fat is usually harvested from the abdomen, flanks, and thighs). It represents 5,9% of all nonsurgical aesthetic procedures. Gluteal as a site of fat injection has a complication rate of up to 5,89%, with incidents including fat necrosis, gluteal erythema, infection, and fat embolism. We will present the case of a 34 years old female, who developed extensive necrotizing fasciitis of the back and thigh after undergoing a lipofilling procedure, complicated with meningoencephalitis and an accentuated deterioration of neurological functions.
... Free fat grafting 4 has become prevalent in gluteal augmentation due to the success seen in breast grafting, [5][6][7][8] and though questions exist about technique and safety, the procedure is increasing in popularity. 9,10 Recently, the efforts of many surgeons in the arena of fat grafting have contributed to a surge in the number of patients undergoing lipogluteoplasty, and to the clinical understanding of successful aesthetic outcomes. [11][12][13][14][15][16][17] However, while many studies have looked at goals and results in gluteal augmentation, 18,19 there is no literature that discusses the role of the thigh contour in overall buttock aesthetic. ...
Background
As the popularity of aesthetic gluteoplasty continues to grow, there is renewed focus on defining the ideal buttocks. However, the literature lacks studies characterizing an ideal thigh, despite the impact of thigh contour on overall gluteal aesthetic.
Objectives
The authors performed the first population analysis of the characteristics of perception of attractive thighs, to identify a role for fat grafting of the thigh in gluteoplasty.
Methods
Survey images were digitally modified to create thighs of varying widths and angles relative to fixed buttocks. Thigh-to-buttock ratios and the buttock-thigh junction were studied. Data were stratified and analyzed according to age, gender, and ethnicity of the respondents. Amazon Mechanical Turk was used as a novel crowdsourcing platform for surveying aesthetic preferences.
Results
A total of 1034 responses were included of whom 54.4% were male, and 45.6% were female. All age groups and ethnicities were represented. Overall, 43.8% of respondents preferred the widest buttock-thick junction angle on posterior view. There was no clear preference between larger or smaller thigh-to-hip ratios on lateral view.
Conclusions
Characteristics of the ideal thigh include wider thighs with greater horizontal projection, creating a more natural contour from the augmented buttock. These findings represent a paradigm shift from the traditionally assumed preference for slender thighs. Plastic surgeons should carefully consider thigh anatomy in their gluteal augmentation patients, as simultaneous thigh augmentation may lead to a more aesthetically pleasing outcome. Further research is needed into best practices and techniques to attain ideal thigh proportions.
... 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][23][24][25][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. ...
Buttock augmentation using fat transfer is it effective and simple procedure than others
... 52 Adequate hydration is indicated as a factor that protects against the appearance of FES. 53 There are multiple theories associated with FES, with the hypovolemia theory being the most accepted with respect to the liposuction procedure because it predisposes the patient to circulatory stasis and to the formation of microaggregates. 4 The exterior of fat microembolisms offers a surface to which these microaggregates and activated platelets can adhere, causing a macroscopic (> 3 cm) embolism that can produce a mechanical obstruction. ...
Background:. Liposuction has become one of the most common cosmetic surgical procedures, and severe complications secondary to this procedure have also increased significantly. That is why we carry out a research work to know the most frequent severe complications reported in the scientific literature to indicate criteria for prevention.
Methods:. English-language scientific publications about liposuction and its complications were analyzed using the PubMed.gov, from the beginning of PubMed's history through June 10, 2017. Five terms were used to define liposuction and its complications: "liposuction," "liposuction AND complications," liposuction AND major complications," "liposuction AND complications AND death," and "liposuction AND death." The quantities of results for the 5 phrases were analyzed, along with their contents.
Results:. One thousand sixty-three results were obtained from 1973 through June 10, 2017 for the phrase "Liposuction and Complications" in humans; for "Liposuction and Major Complications," 153 articles were found; for "Liposuction and Deaths," 89 articles were found; and 42 articles were obtained with the terms "Liposuction and Major Complications and Deaths." After final depuration, all those that were not specific to severe liposuction complications were eliminated, leaving a total of 39 articles that were included in our study. Five problems proved to be the most serious complications when performing liposuction: Thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion.
Conclusions:. The 5 most important complications that can cause death in liposuction are easily preventable using simple measures and proper safety protocols that are described in this work.
... Indeed, fat grafting involves the harvesting of fat from unwanted areas, and this allows associating gluteal augmentation with body contouring surgery. Fat grafting will play an important role in gluteal augmentation and may replace implant-based gluteal augmentation if the patient has a great enough amount of fat as a donor material (133,137,138). ...
Objective
To systematically review the procedure, applications, and outcomes of autologous fat grafting, a promising technique with various clinical applications.
Patients and methods
Literature review of publications concerning autologous fat grafting.
Results
Since its introduction, lipofilling has become increasingly popular; however, its results are variable and unpredictable. Several modifications have been made to the procedures of fat harvesting, processing, and injecting. Surgical excision and low negative-pressure aspiration with large-bore cannulas minimize adipocyte damage during fat harvesting. The “wet” method of fat harvesting involves fluid injection at the donor site and facilitates lipoaspiration while minimizing pain and ecchymosis. For fat processing, centrifugation at a low speed is preferable to high-speed centrifugation, gravity separation or filtration. Fat injection at the recipient site should be performed using small-gauge cannulas in a fanning out pattern over multiple sessions, rather than a single session. Fat grafts exhibit not only dermal filler properties but also regenerative potential owing to the presence of stem cells in fat tissue. Thus, the clinical applications of autologous fat grafting include correction of secondary contour defects after breast reconstruction, release of painful scar contractures, and treatment of burn scars and radiodermatitis. Lipofilling is also used in aesthetic surgery, such as facial and hand rejuvenation, augmentation rhinoplasty, and breast and gluteal augmentation. The complications of lipofilling are minimal and include bruising, swelling, pain, infection, necrosis, and calcification.
Conclusions
Lipofilling is a low-risk procedure that can be used to correct soft-tissue defects in the face, trunk, and extremities, with minimal discomfort for patients.
... Centrifugation was the first successful attempt to improve fat graft survival by removing oil, fluid and dead cells from the harvested fat tissue. This method also inspired clinical trials to assess volumetric augmentation of the breast and buttocks (Cardenas-Camarena et al., 2011;Khouri et al., 2012). ...
Lipofilling or lipografting is a novel and promising treatment method for reduction or prevention of dermal scars after injury. Ample anecdotal evidence from case reports supports the scar-reducing properties of adipose tissue grafts. However, only a few properly controlled and designed clinical trials have been conducted thus far on this topic. Also, the underlying mechanism by which lipofilling improves scar aspect and reduces neuropathic scar pain remains largely undiscovered. Adipose-derived stromal or stem cells (ADSC) are often described to be responsible for this therapeutic effect of lipofilling. We review the recent literature and discuss anticipated mechanisms that govern anti-scarring capacity of adipose tissue and its ADSC. Both clinical and animal studies clearly demonstrated that lipofilling and ADSC influence processes associated with wound healing, including extracellular matrix remodelling, angiogenesis and modulation of inflammation in dermal scars. However, randomized clinical trials, providing sufficient level of evidence for lipofilling and/or ADSC as an anti-scarring treatment, are lacking yet warranted in the near future.
... Procedures to fulfill these goals are described in the literature and include gluteal fat injections [2,3], gluteal implants [4,5], gluteal lifting [6,7], and autologous flaps [8,9]. ...
The gluteal region is an important aesthetic symbol of the body and represents a major component of sexual attraction. Buttocks descent and atrophy are common presenting complaints for patients seeking elective improvement of their body. Gluteal surgery has a recent history of technique evolution, with various reported methods and refinements, including autologous tissue and alloplastic materials. It has been gaining popularity, and an exponential growth in buttocks procedures has been recorded in the recent years. Modern comprehensive gluteal rejuvenation must address both gluteal atrophy and ptosis. Gluteal implants can give a rounded and enhanced appearance to the buttocks while lifting in the form of excisional techniques can address the ptosis. These techniques may be applied together in one surgical procedure or performed in a staged sequence. This report describes the combination of lifting and enhancement techniques to achieve improvement in the gluteal region. An algorithm, to assist with decision making, based on the gluteal deformity encountered, is also proposed. Two separate clinical examples are described, a patient with gluteal implants with synchronous buttocks lift and a patient with pursestring gluteoplasty followed by gluteal implants at a later time.
Level of Evidence: Level V, therapeutic study.
Patient interest in gluteal augmentation has consistently increased in recent years; 24,099 American patients underwent this procedure in 2018, which was 19% more than that in 2017 (American Society of Plastic Surgeons, 2018). However, the mortality of this procedure is still high (Mofid et al. Aesthet Surg J 37:796–806, 2017).Recent publications have associated mortality with the intramuscular application of fat, which can rupture the gluteal veins and consequently introduce macroscopic fat embolism, causing pulmonary thromboembolism (Cardenas-Camarena Plast Reconstr Surg 136:58–66, 2015). Several authors agree that grafting should be performed with only subcutaneous fat, and they recommend using a systematic technique for liposuction for fat grafting, with the objective of reducing the mortality risk (Del Vecchio Plast Reconstr Surg 142:286–8, 2018, Villanueva et al. Plast Reconstr Surg 141:79–86, 2018, Turer and Rubin Aesthet Surg J 39:185–6, 2019).Antigravitational liposculpture is a systematic technique based on preoperative marking while the patient is in the prone position; this technique considers the anatomy of the body surface and divides the body into five aesthetic units (A, B, C, D, and E) that cover the trunk, hips, gluteal area, and proximal third of the thigh.Each aesthetic unit is divided into aesthetic subunits to facilitate their evaluation and the surgical plan.The abdominal area is not described in this marking, but it is treated to collect fat that will be used in the procedure.The objective of marking is to establish a plan that schematizes the zones to treat before liposculpture in a tridimensional way. Outlining or marking is focused on highlighting the relation between the waist and hips, with the objective of a 1:7 (Singh J Pers Soc Psychol 65:293–307, 1993) or smaller (Freese and Meland J Sex Res 39:133–8, 2002) ratio, as well as to beautify the body contour in an aesthetic and harmonious way. This is performed in a selective and systematic way and is therefore safe during liposuction and ensures that fat grafts in the gluteal area are applied in the safe zone exclusively (Del Vecchio and Rohrich Plast Reconstr Surg 145:281–3, 2020).KeywordsAntigravitational liposculptureButtocks augmentationNajar markingSystematic liposculptureSafe zoneFat grafting
Currently there is a high demand of patients to make gluteal plastic surgery procedures that meet or are within the current standards of beauty where the large volumes in the gluteal region stand out. All surgical procedures carry a risk that if not calculated and minimized with appropriate measures can cause unwanted results in patients and even death. There are several complications derived from buttock surgery, mainly local manifestations, however, the most feared complication is fat embolism. The main objective is to know the causes of the complications, as well as the strategies to reduce them or otherwise identify them in a timely manner.KeywordsButtock surgeryComplicationsFat graftingImplantsGluteal
Fat infiltration in the buttocks has become one of the main surgeries to improve buttocks contour; however, the secondary complications to its realization have been established as the most serious in the field of esthetic plastic surgery. These serious complications can be divided into five types: fat necrosis, infections, sciatic nerve injury, micro fat embolism (MIFE), and macro fat embolism (MAFE). The first three can leave very important esthetic or functional sequelae, while the last two are very serious, with the MAFE having a mortality rate close to 100%. Fortunately, all these pathologies have a very precise identification of their physiopathology so that their prevention can be carried out in a very adequate way following certain basic premises when performing the surgery. Not injecting large amounts of fat in very limited areas, having strict protocols in the sterilization process of our fat infiltration cannulas, and above all, avoiding the injection of fat on an intramuscular plane will allow us to reduce the incidence of these complications in a high percentage.KeywordsGluteal lipoinjectionComplications following gluteal lipoinjectionGluteal fat necrosisMycobacterial infection in the buttocksSciatic nerve injury by gluteal lipoinjectionMicro fat embolism (MIFE)Macro fat embolism (MAFE)
The gluteal region has been historically associated with healthiness and couple mating while considered one of the most appealing features of the human body for both men and women.
Background: Treatment of diabetic wounds is a major challenge in clinical practice. Extracellular vesicles (EVs) from adipose-derived stem cells have shown effectiveness in diabetic wound models. However, obtaining ADSC-EVs requires culturing vast numbers of cells, which is hampered by the need for expensive equipment and reagents, extended time cost, and complicated procedures before commercialization. Therefore, methods to extract EVs from discarded tissue need to be developed, for immediate application during surgery. For this reason, mechanical, collagenase-digestive, and constant in-vitro -collective methods were designed and compared for preparing therapy-grade EVs directly from adipose tissue.
Methods: Characteristics and quantities of EVs were detected by transmission electron microscopy, nanoparticle tracking analysis, and Western blotting firstly. To investigate the biological effects of EVs on diabetic wound healing, angiogenesis, proliferation, migration, and inflammation-regulation assays were then evaluated in vitro , along with a diabetic wound healing mouse model in vivo . To further explore the potential therapeutic mechanism of EVs, miRNA expression profile of EVs were also identified and analyzed.
Results: The adipose tissue derived EVs (AT-EVs) were showed to qualify ISEV identification by nanoparticle tracking analysis and Western blotting and the AT-EVs yield from three methods was equal. EVs also showed promoting effects on biological processes related to diabetic wound healing, which depend on fibroblasts, keratinocytes, endothelial cells, and macrophages both in vitro and in vivo . We also observed enrichment of overlapping or unique miRNAs originate from different types of AT-EVs associated with diabetic wound healing for further investigation.
Conclusion: After comparative analyses, a mechanical method was proposed for preparing immediate clinical applicable EVs from adipose tissue that would result in reduced preparation time and lower cost, which could have promising application potential in treating diabetic wounds.
Background
Duration and take of gluteal lipografting are unpredictable. More importantly, unsafety of intramuscular lipofilling has been recently proven. Stromal Enriched Lipograft (SEL) is likely to enhance survival of injected fat. The purpose of this study is to describe the use of SEL for gluteal augmentation through injection into the subcutaneous layer.MethodsA retrospective study was performed to assess outcomes and patient satisfaction with subcutaneous gluteal augmentation through SEL in 194 patients between 2015 and 2017. A control group (non-SEL) in which fat injection was performed through a traditional Coleman’s technique between 2010 and 2013 was compared with the SEL group.Demographics and the amount of injected tissue were sought in patients’ charts. Complications and aesthetic outcomes were taken into account. The mean surgical gain of hip circumference was determined. Comprehensive improvement after gluteal fat augmentation was rated on a scale of 1 to 5, in which 1 is “worse,” 2 is “no change,” 3 is “improved,” 4 is “much improved,” and 5 is “very much improved.” The evaluation was made at 12 months by an independent assessor.ResultsAt 12 months postoperatively, the mean gain in terms of hip circumference was 3.3 cm in the SEL group and 0.9 in the non-SEL group and this outcome was statistically significant. No cases of infection or liponecrosis of the grafted area occurred. At 12 months, 75% of cases were rated as much improved or more and 16% were classified as improved.Conclusions
More research is needed, but when SEL is utilized, the increased and prolonged duration of the grafted fat is such that repeat procedures are rare, which allows to target the subcutaneous layer as the recipient site, instead of the muscular plane, with increased safety.Level of evidence: Level IV, Therapeutic study.
Autologous fat transfer is a common method to correct soft‐tissue defects. It has been used in various conditions with subcutaneous atrophy induced by trauma or inflammation. Recently, the use has become popular for cosmetic purposes such as facial rejuvenation andbody contouring. In this article, we review the science and method behind its practice and describe other possible indications for autologous fat transfer.
Buttock fat transfer is now the preferred method for gluteal augmentation. However, its efficacy has not been well-documented using measurements. Objectivity is needed as part of evidence-based medicine. To evaluate gluteal fat augmentation, the author evaluated 21 patients who underwent buttock fat transfer and compared them with 25 controls. Subcutaneous fat thickness was measured using depth measurements on ultrasound images. Measurements were also made on standardized before-and-after photographs. The mean fat volume injected per buttock was 287 ml (range, 70–550 ml). Ultrasound measurements detected a significant increase in the thickness of the subcutaneous fat (p ≤ 0.001), with mean increments of 0.66 cm for the right buttock and 0.86 cm for the left buttock, and no significant change for control patients. The mean calculated fat retention, based on the measured surface area injected, was 66%. Photographic measurements of buttock projection revealed a significant increase in treated patients (p < 0.01) and no significant change in control patients. There were no clinical complications at either recipient or donor sites and no evidence of oily cysts on ultrasound examinations. Photographic and ultrasound measurements are effective tools to evaluate changes in gluteal volume. The findings confirm that fat transfer effectively and safely increases buttock projection. This method may be used to compare buttock fat transfer techniques in future studies.
With the surge of new surgical procedures, there have also been complications caused by these procedures that were not common before. In the case of body contouring, gluteal lipoinjection has become a common procedure for improvement of the gluteal contour; however, the number of complications has also increased. While performing gluteal lipoinjection, fat can be introduced into the bloodstream in a microscopic or macroscopic form, which can produce two totally different clinical pictures. When fat is introduced in a microscopic manner, it can produce a microscopic fat embolism (MIFE), and when it enters macroscopically it produces a macroscopic fat embolism (MAFE). The entry of fat in a microscopic manner produces the so-called fat embolism syndrome, due to biochemical alterations secondary to irritation produced by free fatty acids, which usually appears 24–48 hours after the surgery. However, when fat enters in a macroscopic manner, it produces a picture similar to pulmonary thromboembolism, with an acute mechanical obstruction of large vessels and cardiac cavities by fat, resulting in high morbidity and mortality. The knowledge of the characteristics and particularities of each one of these pathologies is essential for all plastic surgeons who perform gluteal lipoinjection.
Adipose tissue transplantation is one of the minimally invasive reconstructive cosmetic procedures used in patients with tissue loss or impaired body contours following diseases, injuries, congenital defects or aging. Transplantation is associated with a complex of biological processes including neoangiogenesis for maintaining of vital activity of fat cells. This review is devoted to the problem of fat cells in plastic surgery, description of their role and capabilities for solving the problems of aesthetic medicine. Autologous transplantation of fat cells to rejuvenate the face, hands, for rhinoplasty, breast and buttocks correction is discussed in the article. Possible complications associated with transplantation of adipocytes are under special attention.
Background:
Mortality after gluteal augmentation with fat transfer techniques is extremely high. Placement of fat subcutaneously versus in the gluteal musculature, or both, are considerably debated. The purpose of this study was to radiographically show the anatomical difference in live subjects in different procedural positions: the flexed or "Jack-knife" versus prone positions.
Methods:
A total of ten females underwent Computerized Tomography (CT) scanning of the pelvis with venous phase run-off in both the "Jack-knife" and prone positions. A CT specialized radiologist then reviewed images and measured distances from the inferior and superior gluteal veins (IGV and SGV, respectively) to the skin and muscle. Three-dimensional (3D) imaging and analysis were also performed.
Results:
Measurements were significantly shorter with respect to distance from skin to muscle, skin to vessel, and vessel to muscle observed from IGV and SGV in the "Jack-knife" versus the prone positions. 3D modeling showed a significant reduction in the volume and SGV and IGV diameters when in the "Jack-knife" position.
Conclusions:
When placed in the "Jack-knife" position for gluteal augmentation with fat transfer, extreme caution should be taken with the injecting cannula as the underlying muscle is only 2-3 centimeters deep. 3D analysis showed narrowed and reduced volume of gluteal vasculature when in the "Jack-knife" position; a possible indication of torsion or stretch on the vessel around the pelvic rim that could cause vein avulsion injury from the pressurized fat within the piriform space.
This is a comprehensive overview of the epidemiology of each type of soft tissue defects and the current successful applications of regenerative medicine and methods of advancing the regeneration of these tissues. The authors discuss the epidemiology of soft tissue defects, successful application of regenerative treatments, challenges associated with regeneration, surgical techniques, scaffold-based treatments, drug-based therapy, cell-based therapy, and other treatments. There are unsolved questions discussed, such as vascularization in the process of regeneration, functional tissue regeneration, immune system problems, and problems with biomaterials, regulations and ethics. An outlook is given on necessary future developments for successful translation of advanced concepts of regenerative medicine to day-to-day routine in plastic surgery.
New insights in facial aging made it apparent that not only sagging/ptosis but also facial volume loss is a major factor of this process. Classic facial rejuvenating procedures that only lift or reposition tissue in a vertical vector did not correct for facial volume loss. Since the (re-)introduction of lipofilling it appeared that this procedure is a well-tolerated natural alternative to correct for volume loss due to facial aging. The success and extent of the effect of lipofilling, however, is plagued by a vast number of variables, like the technique of harvesting, the fat processing and injection of the lipograft; factors that all influence the lipograft viability and the ASC. Platelet Rich Plasma (PRP) has been suggested to increase the lipograft viability and retention Moreover, PRP could also increase wound healing resulting in a faster recovery.
With our studies we have attempted to investigate and clarify the role of lipofilling and lipofilling with the additional use of PRP in facial rejuvenation with regard to the aesthetic outcome, possible regenerative skin effects and recovery time. Also, we have tried to unravel the effects of PRP on the ASC itself.
This thesis concludes that lipofilling is a valuable additive to lifting procedures in order to maximize rejuvenating effect. PRP proves a powerful additive when looking at patient recovery, but its effect on rejuvenation remains uncertain. Mixed clinical results of PRP addition to lipofilling could be explained by its concentration depended effect on ASC fenotype, proliferation and secrotome as demonstrated in vitro. Future lipofilling/ASC/SVF based therapies have the potential of regenerating damaged tissue.
This article presents an overview of intramuscular gluteal augmentation involving primary and secondary augmentation with implants. Although gluteal augmentation is a well-studied procedure, few reports have described the intramuscular technique or this technique in association with lipofilling. This article presents experience with a combined technique; this recent innovation combines placement of an anatomic silicone gel implant underneath the gluteus maximus and immediate fat grafting. Primary and secondary gluteal augmentations using implants resulted in satisfactory outcomes. A majority of complications were minor, predictable, and did not affect aesthetic outcome or normal postoperative recovery. Success depends on patient selection and careful intraoperative and postoperative management.
Dr. Constantino Mendieta demonstrates and details his personal technique for gluteal augmentation. The video demonstration is divided into three parts: Part I, Aesthetic Analysis and Preoperative Marking; Part II, Creating the Female Silhouette with Circumferential Lipoplasty; and Part III, Autogenous Gluteal Augmentation. Artistic concepts for gluteal augmentation and contouring the female silhouette and technical considerations for patient safety are emphasized. This Master Series Video article is the first in a planned series of video vignettes.
Buttock appearance is undeniably important to human attraction. A low (0.70) waist-to-hip ratio in women is regarded as ideal. Today, the Brazilian Butt Lift is one of the most requested cosmetic surgical procedures, even though it is a misnomer.
Background:
Liposuction and gluteal lipoinjection are two of the most frequent surgical procedures in body contouring surgery, and two of the most important complications are microscopic fat embolism (MIFE) commonly called fat embolism syndrome (FES), and macroscopic fat embolism (MAFE). Despite having a high index of morbidity and mortality, few reports exist about these complications, and although they have the same causal agent, their etiopathogenesis, clinical evolution, treatment, prognosis and prevention are totally different. Therefore, we performed a comprehensive review of the literature to exhaustively analyze both pathologies, and we present the differences between each condition.
Material and methods:
A detailed search was carried out in PUBMED of studies on humans from 1946 to March 2017 in any language and including the keywords MIFE and MAFE with either liposuction or gluteal lipoinjection. The articles found were selected according to the search criteria and were analyzed to provide the final data and recommendations RESULTS:: Of the 1245 and 26 articles that were found on complications related to liposuction and gluteal lipoinjection, respectively, only 41 on liposuction and MIFE and 7 on gluteal lipoinjection and MIFE met the specific criteria for inclusion in the final analysis. Only two articles on liposuction and two on gluteal lipoinjection referred to MAFE as a complication.
Conclusions:
Although MIFE and MAFE are pathologies with high morbidity and mortality rates in association with liposuction and gluteal lipoinjection, few reports about them exist; therefore, we made recommendations based on this study for their diagnosis, prevention and treatment.
A 30-year-old female presented with a three-month history of a multilocular cystic lesion over the lumbosacral spine. Fine-needle aspiration biopsy (FNA) of the lesion was performed at an outside institution, and a cytologic diagnosis, suspicious for chordoma, was rendered. The patient presented for surgical consultation at our institution. Repeat FNA demonstrated an unusual fat-like material. Upon further inquiry, the patient provided a recent history of gluteal contour improvement with fibroadipose tissue implants. A diagnosis of myospherulosis was made with a concurrent surgical pathology correlation. No evidence of chordoma was identified. To date, this is the first reported case of acquired myospherulosis in the context of gluteal contour enhancement and represents an important diagnostic pitfall to consider on cytology preparations.
Mycobacterium chelonae is a nontuberculous mycobacterium, classified as a Runyon type IV mycobacterium. In relation to humans, it is most commonly associated with tissue trauma or pulmonary infections. The majority of medical reports describe finding M. chelonae in the surgical setting, attributing infection to inadequate sterilization of surgical equipment. Symptoms are often nonspecific and include pain, erythema, and draining subcutaneous nodules and skin lesions. Therefore, the diagnosis of M. chelonae is often difficult to establish without prior suspicion of the disease, but can be confirmed with culture. We will describe the case of a 40-year-old female who contracted M. chelonae infection of the buttocks after abdominal liposuction and gluteal fat injection. We will describe her symptomatology, diagnosis, and successful treatment with surgical excision and antibiotics. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Introduction:
Liposuction is a popular surgical procedure. As in any surgery, there are risks and complications, especially when combined with fat injection. Case reports of fat embolism have described a possible explanation as the puncture and tear of gluteal vessels during the procedure, especially when a deep injection is planned.
Methods:
A total of 10 dissections were performed in five fresh cadavers. Each buttocks was divided into four quadrants. We focused on the location where the gluteal vessels enter the muscle and the diameter of the vessels. Colorant at two different angles was injected (30° and 45°). We evaluated the relation of the colorant with the main vessels.
Results:
We found two perforators per quadrant. The thickness of the gluteal muscle was 2.84 ± 1.54 cm. The area under the muscle where the superior gluteal vessels traverse the muscle was located 6.4 ± 1.54 cm from the intergluteal crease and 5.8 ± 1.13 cm from the superior border of the muscle. The inferior gluteal vessels were located 8.3 ± 1.39 cm from the intergluteal crease and 10 ± 2.24 cm from the superior border of the muscle. When we compared the fat injected at a 30° angle, the colorant stayed in the muscle. Using a 45° angle, the colorant was in contact with the superior gluteal artery and the sciatic nerve. No puncture or tear was observed in the vessels or the nerve.
Conclusions:
The location where the vessels come in contact with the muscle, which can be considered for fat injection, were located in quadrants 1 and 3. A 30° angle allows for an injection into the muscle without passing into deeper structures, unlike a 45° injection angle.
The use of autologous fat grafting for a wide variety of clinical applications has increased dramatically over the past few decades. The article provides an overview of the technique, a historic background, and briefly explores some of the current ways in which fat grafting is being used in plastic surgery.
Circumferential bodylift is a powerful procedure for achieving dramatic and natural body contouring changes in the massive weight loss patient. The care of these patients has raised our awareness of several important issues including safety, nutritional status, skin quality, recurrent laxity, surgical steps, and postoperative scars. Integration of this knowledge with various technical modifications over the last 15 years has improved our care for this cohort. We have not only seen a rise in the number of surgeries performed, but also the development of principles, techniques, and details that the authors feel necessary to share to achieve improved contour and more predictable outcomes.Level of Evidence 4
Therapeutic
One goal of lipoplasty is to create a round and projected buttock contour. Despite multiple papers evaluating lipoinjection, controversies still remain.
This report describes a series of patients who underwent liposuction, gluteal lipoinjection, and evaluation with magnetic resonance imaging (MRI). From January 2003 to January 2004, the patients scheduled for contour surgery by the investigators were evaluated using MRI, photographic records, and gluteal circumference measurement 1 week before surgery, then 2 weeks and 3 months after the procedure. A statistical analysis was performed for 10 patients who received, on the average, a 350-ml injection of fat obtained during liposuction.
Gluteus muscle volume increased, reaching a higher level 2 weeks after the injection than the level 3 months afterward (p < 0.001). The gluteal circumference, modified 2 weeks after surgery by about 1 to 3 cm, came back to previous values 3 months after the procedure (p < 0.05), a phenomena interpreted as reabsorption and resolution of the postoperative edema. There is no correlation between the gluteus muscle volume obtained by MRI and the gluteal circumference (p > 0.05).
The findings led to the conclusion that enhancement of the gluteal contour after fat injection results from survival of the injected tissue 3 months after the surgery, which was objectively evaluated by MRI as having a calculated reabsorption rate of 24% to 36%.
Mittels autologem Fetttransfer ist es mglich, subkutan gelegene Volumendefekte aufzufllen. Das Verfahren wird berwiegend bei der altersbedingten Lipoatrophie eingesetzt. Weitere Indikationen sind eingezogene Narben, Lipodystrophien und die Sclerodermia circumscripta en coup de sabre. Die Injektion des mittels Liposuktion gewonnenen Fettes kann unmittelbar nach der Aufbereitung erfolgen; das Material kann aber auch bei minus 28C ber 2Jahre gelagert werden. Zur Erzielung eines weitgehend dauerhaften Ergebnisses sind mehrere Injektionen in etwa vierteljhrlichem Abstand ntig. Die weltweit angewandte Methode ist sehr wirksam und relativ risikoarm.Autologous fat grafting is a standard method for soft tissue augmentation. The method is commonly used for volume restoration of the ageing face. Furthermore, atrophic scars, lipodystrophy and scleroderma en coup de sabre can be treated. Following liposuction, the harvested fat can be reinjected immediately or stored at minus 28C for at least 2 years. In most cases, several injections at 3 to 4 months intervals are needed for good long-term effects. The procedure is used world-wide with good results and a minimum of side effects.
Aesthetic surgery of the thoracoabdominal region is one of the most frequently performed surgical procedures in plastic surgery. The combination of circumferential liposuction, autologous fat grafting of the buttocks and/or lower limbs, and the modified transverse abdominoplasty as an adjuvant procedure all done in a single surgical procedure is not very common. The authors present a prospective study of the surgical technique of composite body contouring, emphasizing the low rate of complications and the high overall patient satisfaction.
A total of 64 consecutive female patients were operated on between January 2004 and January 2007. All the patients who were included in the study were candidates for a classical abdominoplasty. Posterior and lateral syringe-assisted liposuction combined with fat insertion into the buttocks and/or lower limbs was performed. Autologous fat grafting was done in the gluteal area for buttocks enhancement and in the lower limbs to correct contour deformities. Anterolateral liposuction with modified transverse abdominoplasty was done as an adjuvant procedure. Overall satisfaction with body appearance after composite body contouring was rated on a scale of 1-5.
From 1,500 to 4,600 ml of fat was obtained with liposuction (mean = 2,478 ml). Forty-five patients had fat grafting only to the buttocks area. Six patients had fat insertion into the lower limbs and 13 had fat injection into the buttocks and lower limbs. The amount of fat transplanted to the buttocks varied from 165 to 625 ml (mean = 346 ml) and to the lower limbs it varied from 75 to 270 ml (mean = 195 ml). Three patients (5%) suffered from early complications, including infection (3%) and hematoma formation (2%). Nine patients (14%) had late complications, including hypertophic scars (7.5%), dog ears (4.5%), and localized fat excess (2%). Nine patients (14%) underwent revision surgery. Sixty-three percent reported that their appearance after composite body contouring was "very good" (42%) or "excellent" (21%) and 27% responded that their appearance was "good." Only 10% thought their appearance was less than good, (7% "fair" and 3% "poor").The average follow-up time has been 3.2 years (range = 2-5 years).
Composite body contouring combines circumferential liposuction, fat grafting of the buttocks and lower limbs, and modified transverse abdominoplasty to accomplish very good aesthetic results in a single surgical procedure with a low rate of complications and high patient satisfaction.
The author performs gluteal contouring by removing fat from areas of excess and injecting into areas that will benefit aesthetically. Assuming the patient has adequate fat for harvest, the author contends that fat grafting yields more precise augmentation, quicker recovery, and tremendous patient satisfaction compared with gluteal implants. He believes that about 80% to 85% of injected fat survives at 2 years and, even if fat is lost, there remains a lifelong change in gluteal shape.
The buttocks region has been associated with allure and sex appeal for centuries. Although gluteoplasty employing silicone implants has been practiced for more than 30 years, little has been written on how to evaluate and reshape the area or how to select and place the various implants that are available.
In this article, the clinical anatomy of the buttocks area is reviewed, the properties of silicone elastomer gluteal implants are summarized, and an approach to evaluation and augmentation of the gluteal area involving solid silicone elastomer implants is presented.
The buttocks were augmented through a single intergluteal incision with the use of implants placed in the intramuscular position. Lipoplasty and fat transfers were also performed in most patients to further contour the gluteal region.
Between February 2002 and May 2003, 73 gluteal augmentations were performed, with a high rate of patient satisfaction. Although wound dehiscence remained an issue (30%), implant removal and implant infection rates were low (2%).
An understanding of implant shapes, sizes, and firmness will aid the surgeon in the selection of the most appropriate implant on the basis of the individual patient's gluteal anatomy. Intramuscular implant placement will result in a more natural shape, help prevent implant migration, and, most important, help reduce implant removal rates. (Aesthetic Surg J 2003;23:441-455.).
Although placement of silicone implants remains the standard technique for gluteal augmentation, lipoinjection of autologous fat obtained from lipoplasty is emerging as an alternative procedure.
We report the results of large-volume lipoinjection of the gluteal region in a series of 96 patients.
Lipoplasty was performed by using the wet-technique conventional method with previous infiltration of approximately 0.5 mL of solution for each mL of fat extracted. Autologous fat was injected through incisions from 5 to 8 mm long in the intergluteal fold and infragluteal groove of each side. Lipoinjection continued until the desired aesthetic contour was achieved or until the tension of the soft tissues became evident. Most patients received between 300 and 500 mL of autologous fat.
A durable increase of the gluteal regions was achieved in all patients; all but 2 patients were satisfied with the results. Complications included paresthesias, small irregularities or asymmetries that did not require special treatment or cause patient dissatisfaction, and 1 case of septic shock as a result of gluteal cellulitis.
Large-volume lipoinjection is an alternative to silicone implants for augmentation of the gluteal area that can provide greater volume increase while eliminating the risk of implant rupture and the need for follow-up surgery. (Aesthetic Surg J 2002;22:33-38.).
Background:
Requests for buttock augmentation are increasing in the United States because of changes in lifestyle and fashion that emphasize the "gluteal aesthetic unit."
Objectives:
We review the use of micro fat grafting for enhancing the buttocks in a series of 566 patients.
Methods:
Tumescent solution (1 mg epinephrine per 1000 mL saline solution) was infiltrated; for small cases the volume used was less than half the amount of expected fat to be harvested. Harvesting was accomplished either manually with a syringe or with a liposuction pump that allowed precise control of the vacuum. The fat was injected both intramuscularly and subcutaneously into all levels of the desired area for augmentation of the buttocks. The typical augmentation averaged 300 to 400 mL per side but ranged from 175 mL to about 800 mL, depending on the patient's desires and the amount of donor fat available.
Results:
Patient and physician satisfaction with the results was high. Approximately 50% to 75% of the fat grafted remains in the long term. Complications included cellulitis (1.9% of cases), which responded promptly to treatment with cephalosporin, and infrequent seromas and hematomas (0.8% of cases).
Conclusions:
Buttock augmentation by micro fat grafting is a safe, simple procedure. Compared with implant placement, the advantages of micro fat grafting include greater flexibility in the size and placement of augmentations, less pain and faster recovery for the patient, and less risk of complications. The technique is limited only by the amount of donor fat available. (Aesthetic Surg J 2001;21:311-319.).
The "banana fold," or the infragluteal fold, is a fat deposit on the posterior thigh near the gluteal crease and parallel to it. The "sensuous triangle" is found at the junction of the lateral buttocks, the lateral thigh, and the posterior thigh. The iatrogenic forms of banana fold and sensuous triangle deformity are produced by excessive liposuction. The authors' experience using autologous fat transplantation to treat tissue defects led them to use this technique for correcting iatrogenic forms of banana fold and sensuous triangle deformity. The simplicity of the procedure, the low incidence of complications, and the high satisfaction rate makes autologous fat transplantation an attractive option for correcting iatrogenic complications of liposuction.
In the past, the traditional method of contouring the iliac crest and lateral femoral areas has been liposuction or the surgical removal of the bulges. Unfortunately, this method fails to correct the deep gluteal depression juxtaposed at these two sites. Since we use autologous fat grafts to correct contouring deficiencies elsewhere, it seems logical to investigate whether this technique is applicable to correcting this deformity. We have performed autologous fat grafting to the gluteal depression on 12 patients who underwent lipoplasty of the iliac crest and lateral femoral sites. The longest followup was one year. We have found that this method corrects the deep gluteal depression and yields an improved aesthetic contour. This article describes the technique, addresses the problems encountered, and shows postoperative results.
Free fat graft autotransplantation for soft-tissue replacement has been a neglected subject in recent years. In a review of the literature, investigations of the various uses of free fat autotransplantation in animals and humans provide an understanding of the problems associated with the use of fat as a free graft. Results of free fat autotransplantation were found to be quite unpredictable, with wide variations in the resulting bulk of the graft. Microscopic studies of this behavior led to controversy as to whether the graft ultimately was made of surviving graft adipocytes (cell survival theory) or host adipocytes (host replacement theory). Studies revealed a "fibroblast-like" mesenchymal cell within adipose tissue that was believed to be an immature adipocyte precursor or preadipocyte. Further characterization of the preadipocyte and its complete differentiation was accomplished using tissue-culture techniques. These investigations provide evidence of the dynamic nature of adipose tissue that strongly supports the cell survival theory and gives explanation to the unpredictable behavior of free fat autografts. Many conditions treated by plastic surgeons require soft-tissue augmentation. Autogenous adipose tissue is the most appropriate and natural replacement material. With new culturing techniques, preadipocytes in a single cell suspension may provide an injectable soft-tissue replacement. This subject appears ripe for investigation.
The concept of modifying the body contour with liposuction by developing numerous subcutaneous "tunnels" with subsequent homogeneous contractions of the overlying skin will add a new dimension to the plastic surgeon's armamentarium. Successful correction of these deformities can be obtained without a large amount of surgical undermining and skin resection and with minimal scar formation (Figs. 4 through 11).
In trying to achieve symmetry and better contour of the back torso and middle third of the body, the combination of liposuction and lipoinjection is rapidly becoming the procedure of choice. Its versatility makes it suitable for most body contour deformities. The indications and operative and postoperative techniques are detailed in this article. Fat graft long-term survival is presented. This procedure has been used by the author during the past 12 years.
Autologous fat grafting is a standard method for soft tissue augmentation. The method is commonly used for volume restoration of the ageing face. Furthermore, atrophic scars, lipodystrophy and scleroderma en coup de sabre can be treated. Following liposuction, the harvested fat can be reinjected immediately or stored at minus 28 degrees C for at least 2 years. In most cases, several injections at 3 to 4 months intervals are needed for good long-term effects. The procedure is used world-wide with good results and a minimum of side effects.
This article examines the injection of megavolumes of autologous fat cells as a means of buttock augmentation in 162 patients over a 7-year period. The author documents the use of magnetic resonance imaging in six patients to visualize the intramuscular location, integration, and duration of the injected fat. With the patient under epidural or general anesthesia, fat cells were harvested with a 5-mm blunt cannula and then stored in an empty sterile intravenous bag or bottle trap. Decantation was the only process used to separate the fat cells from the saline and serosanguineous components. Up to 1260 cc of fat cells were been injected into each buttock, the largest amount of fat grafting ever reported. Clinical assessment estimated a 20 percent loss of augmentation effect during the first 4 months. Patients were generally pleased with the final shape and volume of the buttock contour. In follow-up evaluation, magnetic resonance imaging supported the clinical indicators that the injection of large quantities of fat cells appears to be a safe and effective method for buttock enhancement. This process has inherent advantages; nevertheless, further research is required to clarify our understanding of the predictability and longevity of this technique.
Gluteal implants offer a good way not only to correct hypoplasias, but also to remodel and give rounded shape to buttocks, achieving beauty and sensuality. However, until recently, only a few surgeons have used this procedure. An intramuscular introduction of the implants may be a good means of reaching this goal, but because the undermining is performed without direct view, difficulties may occur in obtaining a symmetric and safe plane, and this can lead to unpleasant results. This report presents an intramuscular method based on geometry, in which three points (X, Y, and Z) and a line (G) in the pelvis define the plane in which the dissection must be performed, allowing more precise and safe undermining. From 1986 to 2003, 746 patients underwent surgery using this technique, achieving good results. This technique has proved to be a safe and reproducible way of performing augmentation gluteoplasty.
No reports can be found in medical literature describing the anatomic details that make the buttocks beautiful, nor the defects in this region that can help the surgeon decide whether gluteal prostheses are necessary or not, and, if so, which type, design, and volume of prostheses should be used, in which plane they should be placed, and so forth.
The authors studied 1,320 photographs of nude women and measured 132 female patients ages 16 to 62 years. They found that four characteristics determine attractive buttocks. They also found the balanced anatomic dimension of the maximal gluteal projection.
On the basis of the information obtained, the defects of the gluteal region were classified into five types, resulting in surgical recommendations intended to achieve buttocks as close as possible to the standard of beauty, with the right volume and projection.
The authors concluded that surgery for correction of the buttocks involves more than projection and volume. The surgeon must be familiar with the "signs" of beauty so an attempt can be made to recreate them. Most importantly, the surgeon should achieve buttocks with projection and volume. However, these must be in a balanced proportion with the rest of the body.
In the last 20 years, several different techniques of lipoinjection have been developed. Nevertheless, a standard procedure has not been adopted by all practitioners. There is no agreement as to the best way of processing the fat to ensure maximal take and viability of the graft. Other controversial issues include the ideal cannula for harvesting and reinjection, the presence of blood in the transplanted fat, trauma, air exposure, contamination of the graft, durability, and fat cell survival. Newly emerging approaches to fat tissue engineering with the use of cultured autologous preadipocytes may improve the technique of fat injection and transplant.
Over the past several years, there has been a tremendous growth and interest in buttocks augmentation in the United States. Surgical techniques have evolved over time to correct anatomical deficiencies and fulfill patient requests, including silicone implant placement (subcutaneous, intramuscular, submuscular, and subfascial) and autologous micro fat grafting. Unfortunately, these techniques have presented great challenges with regard to the incidence, diagnosis, management, and prevention of various postsurgical complications. Extensive collaboration and transparency in discussing complications has resulted in refinement of both surgical technique and medical management,resulting in improved outcomes for patients undergoing buttocks augmentation.
Patients seeking augmentation or re-contouring of the gluteal region have three basic options: gluteal implants, liposuction, and augmentation with fat injections. In many cases, all three treatments are used together to achieve attractively shaped buttocks with proper proportions and good projection. The treatment or combination of approaches that is appropriate for each individual patient is discovered through consultation that focuses on understanding a patient's goals. To determine the treatment(s) required by a patient, his or her unique anatomy must be analyzed to identify gluteal areas that have excesses or deficiencies that can be successfully addressed in gluteal re-contouring.
Recently there has been a dramatic increase in the number of patients seeking buttocks enhancement and in the degree of augmentation requested. To fulfill these requests,aesthetic plastic surgeons must understand the patient's personal requests and ethnic identity, as well as any universal ideal of proportions and contours that create the impression of beautiful buttocks. "Universally" perceived ideal buttocks are 1.4 times the circumference of the waist, which is consistent cross-culturally and throughout history. Beyond this are important ethnic differences in the image of perfect buttocks shape. The combination of autologous micro fat grafting and liposuction is the best and possibly only way to obtain various ideal shapes, and offers a lower incidence of complications compared with buttock implants.
Grafted fat has many attributes of an ideal filler, but the results, like those of any procedure, are technique dependent. Fat grafting remains shrouded in the stigma of variable results experienced by most plastic surgeons when they first graft fat. However, many who originally reported failure eventually report success after altering their methods of harvesting, refinement, and placement. Many surgeons have refined their techniques to obtain long-term survival and volume replacement with grafted fat. They have observed that transplanted fat not only adjusts facial and body proportion but also improves surrounding tissues into which the fat is placed. They have noted not only the improvement in the quality of aging skin and scars but also a remarkable improvement in conditions such as radiation damage, chronic ulceration, breast capsular contracture, and damaged vocal cords. The mechanism of fat graft survival is not clear, and the role of adipose-derived stem cells and preadipocytes in fat survival remains to be determined. Early research has indicated the possible involvement of more undifferentiated cells in some of the observed effects of fat grafting on surrounding tissues. Of particular interest is the research that has pointed to the use of stem cells to repair and even to become bone, cartilage, muscle, blood vessels, nerves, and skin. Further studies are essential to understand grafted fat tissue.
Transplantation of autologous fat as pedicle or transposition flaps has been a classical method in plastic surgery for tissue reconstruction. The injection of fat for soft tissue reconstruction is also an old innovation. This approach has some significant drawbacks such as resorption of the fat transplant. To regenerate additional and self-regenerating adipose tissue for reconstructive purposes, a thorough understanding of adipose tissue (mesodermal stem cells, adipoblasts, pre-adipocytes, mature, lipid-synthesizing, and lipid-storing white or brown adipocytes) on cellular and molecular levels is required. Several transcription factors that play a central role in the control of adipogenesis have been identified. Among these are the CCAAT/enhancer binding protein gene family and peroxisome proliferator-activated receptor-gamma. Hormones and growth factors, such as insulin and insulin-like growth factor (IGF), transfer external signals to differentiating adipocytes. In an attempt to improve the quality of tissue-engineered fat by culture-expanded adipocytes, various pre-adipocyte and stem cell culture conditions and expansion methods have been developed. In the presence of fetal calf serum, spontaneous differentiation of pre-adipocytes into fat cell clusters occurs to some degree. This in vitro differentiation can be enhanced by addition of inducing agents such as dexamethasone, isobutylmethylxantine, and insulin into the culture medium. Recent work has shown the multipotency of pre-adipocytes, which are fibroblast-like precursors of adipocytes. With use of specific culture conditions, human adipose tissue-derived stem cells can be induced to express markers of adipocyte, osteoblast, and myocyte cell lineages. The multipotent characteristics of adipose tissue-derived stem cells, as well as their abundance and accessibility in the human body, make them a potential cell source for tissue engineering applications.