Recent Advances in Buttock Contouring Tarek A Abulezz

Recent Advances in Buttock Contouring Tarek A Abulezz, M. D. Sohag University

Background • A well-developed buttocks are only found in Human • In women, 2 constant signs of feminity and beauty: the breasts and the buttocks • Buttock contouring is rising in the media and in doctors’ offices

Criteria of Beautiful Buttocks

Beautiful Buttocks • Beautiful buttocks are symmetric and rounded, with the greatest projection in the upper and middle thirds. • After an extensive anthropometric study preliminary criteria of beautiful buttocks were published in 2004 and 2006

Landmarks of Beautiful Buttocks • Lateral depression formed by the greater trochanter • Infragluteal fold junction between buttock and thigh. • Supragluteal fossettes post. Sup. iliac spine and medially by the multifidus muscle. • V-shaped crease two lines from intergluteal crease toward the supragluteal fossettes.

Criteria of Beautiful Buttocks • A = Greater trochanter • B = max projection of the mons veneris • C = max gluteal projection • D = Ant superior iliac spine • AC = 2 AB

Various forms of females’ Buttocks (Frames) Gynacoid Android Square H-shaped Round O-shaped Pear A-shaped Elderly Inverted V-shaped

Waist to Hip Ratio

Breast: Waist : Hip

Waist : Hip Ratio

Most Pleasing Waist : Hip Ratio Post V = 0. 65 Lat V = 0. 7

Male Vs Female WHR

Ethnic Variations • Buttock size, lateral buttock fullness, and lateral thigh fullness are different among various ethnic types. • These ethnic variations have to be kept in mind while evaluating a patient and planning how to manage his problem to preserve his specific ethnic considerations.

Ethnic Ideals of Beautiful Buttocks Ethnic Type Buttock Size Lat. Buttock Fullness Asian Small to moderate No No Full Rounded or hollow No Caucasian Lat. Thigh Fullness Hispanic Very Full Slight Fullness African American Hugely Full Very Full

Gluteal Ptosis • Ageing and massive weight loss are always associated with some degree of gluteal ptosis. • Buttock Ptosis is evaluated by 2 variables: - Extent of infragluteal creae, - The amount of gluteal tissue sagging over in the midline of the thigh posteriorly.

Classification of Gluteal Ptosis Degree zero Degree 1 Degree 2 Pre-ptosis Degree 3 Borderline True Ptosis

Measurement of Gluteal Ptosis The amount of buttock tissue sagging over the thigh is measured with a ruler at the “M” line. The patient will have degree 4 ptosis with a 0. 5 -, 1 -, or 2 -cm ptosis.

Pseudoptosis of the Buttocks When the infragluteal crease is displaced downwards … known as Banana Fold

Factors Affecting in Buttocks’ Harmony • Obesity • Aging process • Massive weight loss … “Postbariatric” • Lack of muscle activity • Gravity and Weight of the buttocks’ mass

• Morbid obesity and bariatric surgeries are on the rise • Two main problems: Skin laxity and tissue redundancy (ptosis) • Buttock lifting and augmentation by autologous tissue transfer is the best options

When Gluteoplasty is Required

Indications for Buttock Contouring • Genetic abnormality: – Genetically absent or hypoplastic buttock – Disproportionately large buttock – Genetic lipodystrophies involving the gluteal region • Acquired abnormalities caused trauma – Motor vehicle accidents – Animal bites – Post-injection deformities caused by post-injection abscess or hematoma – Depression induced by steroid injection

Indications for Buttock Contouring • Acquired degenerative gluteal deformities – Aging and massive weight loss (skin laxity) – Obesity, menopause and skeletal deformities – Loss of substance in longstanding bed-ridden state – Previous radiotherapy • Acquired iatrogenic abnormalities – Iatrogenic deformities after surgeries in the trochanteric or gluteal regions as in tumor resection – Contour irregularities after liposuction

Evaluation of the Buttocks • 3 items must be evaluated: volume, shape, and skin quality. • The buttock is divided into 3 sections – The upper buttock (outer - central) should be round with most of the fat located directly posterior. – The mid-buttock (central – outer) – The lower buttock is the most difficult area to address. (inner – central – outer). – Evaluate the infragluteal crease, the intergluteal fold and the outer thigh skin fold as well.

Three-Dimensional Buttocks Contouring This can be achieved through several procedures: • • • Liposuction to the perigluteal areas. Autolonous Fat grafts. Gluteal implant. Buttock lifting Autologous tissue augmentation Minimally-invasive procedures

Options of interference Patient characteristics Appropriate intervention Lipodystrophy; sufficient fat volume for grafting Liposuction + fat grafting Lipodystrophy; insufficient fat volume for gluteal grafting Liposuction + implant Lipodystrophy; hip hypoplasia; Liposuction + implant + insufficient fat volume for gluteal grafting fat grafting Lipodystrophy; insufficient fat volume for gluteal grafting; ptosis Liposuction + implant + buttock lift Lipodystrophy; insufficient fat volume for Liposuction + implant + gluteal grafting; hip hypoplasia; Ptosis buttock lift + fat grafting

Procedures of Buttock Contouring Invasive § Liposuction § Lipofilling § Silicone implants Less Invasive § Silhouette Suture lift § Fillers Gluteoplasty (Silicone, Macrolane) § Endopeel gluteopexy § Dermofat flaps

Liposuction +/- Lipofilling Liposuction of excess fat from perigluteal areas, processing then lipoaugmentation Liposuction Lipofilling Liposuction

Liposuction +/- Lipofilling • Tumescent liposuction is the most commonly used method to improve the buttock contour • Ultrasonic or laser-assisted liposuction can be beneficial in large volume of lipodystrophy • Superficial liposuction with 2 mm cannula for fine irregularities or cellulites

• Started in 1969 by Bartels and colleagues who inserted a mammary implant to correct a unilat. Buttock deformity • Gonzalez-Ulloa placed almond-shaped implants subcutaneously via infragluteal crease incisions

Gluteal Implant Augmentation

Gluteal Implant Augmentation Gluteal implants can improve the upper and midbuttock contour, but they will not correct the lower buttock deformities

Dermofat Flap Augmentation Dermofat flap is dissected from the supragluteal lumbosacral region and transposed downward to augment the buttock as an autologous implant. Very useful in post-bariatric patients undergoing belt abdominoplasty.

Dermofat Flap Augmentation

Banana Fold Correcting gluteal ptosis and banana fold by dermotuberal anchorage.

Thread Lift with Silhouette Sutures Minimally invasive technique, using 2 -0 Prolene sutures with 10 Polylactic cones in the distal sections to improve the projection of the gluteal region.

Thread Lift with Silhouette Sutures Ø 2 surgical steps. Ø First step, the sutures are inserted without any proximal fixation. Ø 3 months later, the sutures are tightened to obtain the gluteopexy

Macrolane Gluteoplasty • Stabilized hyaluronic acid (HA) gel (Macrolane) is composed primarily of water (98 %) and HA (2 %). • It is biocompatible and biodegradable • The gel was FDA-approved for temporary aesthetic augmentation of the buttocks

Endopeel Gluteopexy • Oily carbolic acid is injected through 25 -gauge flexible needles in the subcutaneous plane • It is claimed to induce muscular contracture that provide immediate enhancement of the appearance of the buttock that lasts for about 6 months • However, the word “endopeel” is not found in the Pub. Med

Complications Gluteoplasty is a major surgical procedure with the potential major complications including: • • • Serious infections Wound dehiscence Pulmonary complications Hematologic and electrolyte disturbances Implant and Fillers complications Unaccepted wide scars after lifting surgeries

Implant Complications • Infection, wound dehiscence and implant exposure, reoperation, rupture of the implant, seroma, capsular contracture, asymmetry, implant displacement (subcutaneous and subfacial plane), overcorrection, sciatic nerve injury (submuscular plane), and paresthesia • Limited subcutaneous undermining, and gentle tissue handling are the keystones to reduce wound complications.

Future Prospect • The rapidly advancing technology of autologous fat transfer and the possible incorporation of stem cells is very promising. • Continuous refinement and improvement of buttock implants will make it more accepted with less rate of complications.