Buttock augmentation
Encyclopedia
Gluteoplasty denotes the plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 and the liposculpture procedures for the correction of the congenital, traumatic
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

, and acquired defects and deformities of the buttocks and the gluteal region anatomy; and for the aesthetic enhancement (by augmentation or by reduction) of the contour of the buttocks
Buttocks
The buttocks are two rounded portions of the anatomy, located on the posterior of the pelvic region of apes and humans, and many other bipeds or quadrupeds, and comprise a layer of fat superimposed on the gluteus maximus and gluteus medius muscles. Physiologically, the buttocks enable weight to...

. The corrective procedures for buttock augmentation and repair include the surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 emplacement of a gluteal implant (buttock prosthesis); liposculpture (fat transfer
Fat transfer
Fat transfer is a medical procedure that uses the patient`s own fat tissue to increase the volume of fat in the subcutaneous area of the body. Autologous adipose tissue transplantation has been used for breast augmentation for cosmetic reasons and after breast cancer surgery...

 and liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...

); and body contouring (surgery and liposculpture) to resolve the particular defect or deformity of the gluteal region. Moreover, in the praxis of sexual reassignment surgery, the prosthetic and liposclupture augmentation of the buttocks can be performed on the transsexual
Transsexualism
Transsexualism is an individual's identification with a gender inconsistent or not culturally associated with their biological sex. Simply put, it defines a person whose biological birth sex conflicts with their psychological gender...

 woman and the transgender
Transgender
Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles....

 woman to enhance the anatomic curvature of the gluteal region in order to establish the markedly feminine buttocks and hips that project more (to the rear and to the side) than do masculine hips.

Background

The functional purpose of the buttocks musculature is to establish a stable gait
Gait
Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on speed, terrain, the need to maneuver, and energetic efficiency...

 so that the man or woman possesses a balanced manner of walking; therefore, the restoration of anatomic functionality is the therapeutic consideration that determines which gluteoplasty procedure will effectively correct the damaged muscles of the buttocks. The applicable techniques for surgical
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 and fat-transfer
Fat transfer
Fat transfer is a medical procedure that uses the patient`s own fat tissue to increase the volume of fat in the subcutaneous area of the body. Autologous adipose tissue transplantation has been used for breast augmentation for cosmetic reasons and after breast cancer surgery...

 correction include the surgical emplacement of allopathic
Allopathic medicine
Allopathic medicine refers to the practice of conventional medicine that uses pharmacologically active agents or physical interventions to treat or suppress symptoms or pathophysiologic processes of diseases or conditions. It was coined by Samuel Hahnemann , a homeopath, in 1810...

 gluteal implants; autologous tissue-flaps
Flap (surgery)
Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is similar to but different from a graft, which does not have an intact blood supply and therefore relies on growth...

; the cutting and removal of damaged tissue (excision); lipoinjection augmentation; and liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...

 reduction — to resolve the defect or deformity caused by a traumatic injury (blunt
Blunt trauma
In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

, penetrating
Penetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

, blast
Blast injury
A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

) to the buttocks muscles (gluteus maximus
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

, gluteus medius
Gluteus medius muscle
The gluteus medius , one of the three gluteal muscles, is a broad, thick, radiating muscle, situated on the outer surface of the pelvis....

, gluteus minimus
Gluteus minimus muscle
The gluteus minimus , the smallest of the three gluteal muscles, is situated immediately beneath the gluteus medius.-Origin and insertion:...

), and any deformation of the anatomic contour of the buttocks. Likewise, the corrective techniques apply to resolving the sagging skin of the body, and the muscle and bone deformities presented by the formerly obese
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...

 patient, after a massive weight loss (MWL) bariatric surgery
Bariatric surgery
Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device or through removal of a portion of the stomach or by resecting and re-routing the small intestines...

 procedure; and for resolving congenital defects and congenital deformities of the gluteal region.

Surgical anatomy of the buttocks

Muscular origins and insertions
Anatomically, the mass of each buttock
Buttocks
The buttocks are two rounded portions of the anatomy, located on the posterior of the pelvic region of apes and humans, and many other bipeds or quadrupeds, and comprise a layer of fat superimposed on the gluteus maximus and gluteus medius muscles. Physiologically, the buttocks enable weight to...

 principally comprises two (2) muscles — the gluteus maximus muscle
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

 and the gluteus medius muscle
Gluteus medius muscle
The gluteus medius , one of the three gluteal muscles, is a broad, thick, radiating muscle, situated on the outer surface of the pelvis....

 — which are covered by a layer of adipose body fat
Adipose tissue
In histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...

. The upper aspects of the buttocks end at the iliac crest
Iliac crest
-External links: - "Superficial muscles of the gluteal region and posterior thigh." - "Anterior Abdominal Wall: Osteology and Surface Anatomy " - "The Back, Posterior View" * *...

 (the upper edges of the wings of the ilium
Ilium (bone)
The ilium is the uppermost and largest bone of the pelvis, and appears in most vertebrates including mammals and birds, but not bony fish. All reptiles have an ilium except snakes, although some snake species have a tiny bone which is considered to be an ilium.The name comes from the Latin ,...

, and the upper lateral margins of the greater pelvis
Greater pelvis
The greater pelvis is a portion of the cavity surrounded by the skeleton of the pelvis, situated above and in front of the pelvic brim...

), and the lower aspects of the buttocks end at the horizontal gluteal crease, where the buttocks anatomy joins the rear, upper portion of the thighs. The gluteus maximus muscle has two (2) points of insertion: (i) the one-third (1/3) superior portion of the (coarse line) linea aspera
Linea aspera
The linea aspera is a ridge of roughened surface on the posterior aspect of the femur, to which are attached muscles and intermuscular septum.Its margins diverge above and below....

 of the thigh bone (femur
Femur
The femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...

), and (ii) the superior portion of the iliotibial tract
Iliotibial tract
The iliotibial tract or iliotibial band is a longitudinal fibrous reinforcement of the fascia lata. It is attached to the anterolateral iliac tubercle portion of the external lip of the iliac crest and to the lateral condyle of the tibia...

 (a long, fibrous reinforcement of the deep fascia lata
Fascia lata
-Thickness:It is an investment for the whole of the thigh, but varies in thickness in different parts.Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers; it...

 of the thigh). The left and the right gluteus maximus muscles (the butt cheeks) are vertically divided by the intergluteal cleft (the butt-crack) which contains the anus
Human anus
The human anus is the external opening of the rectum. Like other animals, its closure is controlled by sphincter muscles...

.

The gluteus maximus muscle
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

 is a large and very thick muscle (6–7 cm) located on the sacrum
Sacrum
In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...

, which is the large, triangular bone located at the base of the vertebral column
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...

, and at the upper- and back-part of the pelvic cavity
Pelvic cavity
-External links:* * *...

, where it is inserted (like a wedge) between the two hip bone
Hip bone
The hip bone, innominate bone or coxal bone is a large, flattened, irregularly shaped bone, constricted in the center and expanded above and below...

s. The upper part of the sacrum is connected to the final lumbar vertebra
Lumbar vertebrae
The lumbar vertebrae are the largest segments of the movable part of the vertebral column, and are characterized by the absence of the foramen transversarium within the transverse process, and by the absence of facets on the sides of the body...

 (L5), and to the bottom of the coccyx
Coccyx
The coccyx , commonly referred to as the tailbone, is the final segment of the vertebral column. Comprising three to five separate or fused vertebrae below the sacrum, it is attached to the sacrum by a fibrocartilaginous joint, the sacrococcygeal symphysis, which permits limited movement between...

 (tailbone). At its origin, the gluteus maximus muscle extends to include parts of the iliac bone
Ilium (bone)
The ilium is the uppermost and largest bone of the pelvis, and appears in most vertebrates including mammals and birds, but not bony fish. All reptiles have an ilium except snakes, although some snake species have a tiny bone which is considered to be an ilium.The name comes from the Latin ,...

, the sacrum, the coccyx, the sacrosciatic ligament, and the tuberosity of the ischium
Tuberosity of the ischium
-External links: - "The Female Perineum: Bones" - "Major Joints of the Lower Extremity: Hip bone "...

. Like every pelvic-area muscle, the gluteus maximus muscle originates from the pelvis; nonetheless, it is the sole pelvic muscle not inserted to the trochanter (head of the femur), and is approximately aligned to the femur
Femur
The femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...

 and the fascia lata
Fascia lata
-Thickness:It is an investment for the whole of the thigh, but varies in thickness in different parts.Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers; it...

 (the deep fascia
Deep fascia
Deep fascia is a layer of fascia which can surround individual muscles, and divide groups of muscles into compartments....

 of the thigh); its tissues cover only the rear lateral face of the trochanter, and there form a bursa (purse) that faces the interior of the thigh
Thigh
In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...

.

Innervation
The motor innervation of the gluteus maximus muscle is performed by the inferior gluteal nerve
Inferior gluteal nerve
The inferior gluteal nerve is a nerve in the pelvis that innervates the gluteus maximus muscle.-Structure:The inferior gluteal nerve originates in the sacral plexus...

 (a branch nerve of the sacral plexus
Sacral plexus
-External links:*...

) and extends from the pelvis to the gluteal region, then traverses the greater sciatic foramen
Greater sciatic foramen
-Boundaries:It is bounded as follows:* anterolaterally by the greater sciatic notch of the illium* posteromedially by the sacrotuberous ligament* inferiorly by the sacrospinous ligament and the ischial spine* superiorly by the anterior sacroilliac ligament...

 (opening) from behind and to the middle to then join the sciatic nerve
Sciatic nerve
The sciatic nerve is a large nerve fiber in humans and other animals. It begins in the lower back and runs through the buttock and down the lower limb...

. The inferior gluteal nerve divides into three (3) collateral branches: (i) the gluteus branch, (ii) the perineal branch, and (iii) the femoral branch. The first ramification — the gluteus branch — is a branch nerve that is very close to the emergence of the inferior gluteal nerve to the area, next to the inferior border of the pyramidalis muscle
Pyramidalis muscle
The pyramidalis is a small and triangular muscle, anterior to the Rectus abdominis, and contained in the rectus sheath.-Attachments and actions:...

. As it arises, the inferior gluteal nerve then divides into four (4) or more fillets (bands of nerve fibres) that travel (in a crow’s-foot configuration) between the gluteus maximus muscle and its (front) anterior fascia; the thickest nerve-bands are the superior-most and the inferior-most fillets. The superior-most fillet runs almost vertically, near the sacrum, and innervates the superior portion of the gluteus muscle; the inferior-most fillet, which has the greatest calibre, travels very close and parallel to the sacrotuberous ligament
Sacrotuberous ligament
The sacrotuberous ligament is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends....

; the inferior-most fillet provides fine-gauge branch-nerve ramifications that innervate the gluteus muscle through its anterior (front) face.
  • In surgical and body contouring praxis, the the plastic surgeon creates the implant-pocket — either for the gluteal prosthesis or for the injections of autologous fat
    Fat transfer
    Fat transfer is a medical procedure that uses the patient`s own fat tissue to increase the volume of fat in the subcutaneous area of the body. Autologous adipose tissue transplantation has been used for breast augmentation for cosmetic reasons and after breast cancer surgery...

     — by undermining the gluteus maximus muscle with a dissection technique that avoids the sacrum
    Sacrum
    In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...

    , the sacrotuberous ligament
    Sacrotuberous ligament
    The sacrotuberous ligament is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends....

    , and the tuberosity of the ischium
    Tuberosity of the ischium
    -External links: - "The Female Perineum: Bones" - "Major Joints of the Lower Extremity: Hip bone "...

    ; which, if accidentally cut, might isolate the posterior (back) portion of the muscle and lead to denervation, the loss of nerve function and of innervation.


Vascularization
The superior gluteal artery
Superior gluteal artery
The superior gluteal artery is the largest branch of the internal iliac artery, and appears to be the continuation of the posterior division of that vessel....

, the inferior gluteal artery
Inferior gluteal artery
The inferior gluteal artery , the larger of the two terminal branches of the anterior trunk of the internal iliac artery, is distributed chiefly to the buttock and back of the thigh....

, the superior gluteal veins
Superior gluteal veins
The Superior Gluteal Veins are venæ comitantes of the superior gluteal artery; they receive tributaries from the buttock corresponding with the branches of the artery, and enter the pelvis through the greater sciatic foramen, above the Piriformis, and frequently unite before ending in the...

, and the inferior gluteal veins
Inferior gluteal veins
The Inferior Gluteal Veins , or venæ comitantes of the inferior gluteal artery, begin on the upper part of the back of the thigh, where they anastomose with the medial femoral circumflex and first perforating veins....

 irrigate the gluteus maximus muscle with arterial
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...

 and venous
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...

 blood. The vascularization, the entrance of the blood vessels to the muscle tissues, occurs at the anterior (front) face of the muscle, very close to the sacrum
Sacrum
In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...

. As the arteries and the veins enter the mass of the gluteal muscle, they divide into narrower blood-vessel ramifications (configured like the horizontal branches of a tree), most of which travel parallel to the muscle fibres.
  • In surgical and body contouring praxis, the plastic surgeon effects the implant-pocket undermining of the gluteus maximus muscle by carefully separating the muscle fibres to avoid severing the pertinent blood vessels, which would interfere with the blood irrigation of the muscle tissue. Therefore, to create an implant-pocket, either for a gluteal prosthesis or for lipoinjection
    Fat transfer
    Fat transfer is a medical procedure that uses the patient`s own fat tissue to increase the volume of fat in the subcutaneous area of the body. Autologous adipose tissue transplantation has been used for breast augmentation for cosmetic reasons and after breast cancer surgery...

    , a low-angle muscle-dissection is performed in order to avoid the risk of severing any major branch — superior
    Superior gluteal artery
    The superior gluteal artery is the largest branch of the internal iliac artery, and appears to be the continuation of the posterior division of that vessel....

     or inferior
    Inferior gluteal artery
    The inferior gluteal artery , the larger of the two terminal branches of the anterior trunk of the internal iliac artery, is distributed chiefly to the buttock and back of the thigh....

     — of the gluteal artery, which travels very close to the sacrum
    Sacrum
    In vertebrate anatomy the sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...

     and to the sacrotuberous ligament
    Sacrotuberous ligament
    The sacrotuberous ligament is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends....

    .

Surgical procedures

Medical therapy
The resolution of the defects and deformities of the muscles of the gluteal region (the buttocks and the thighs) of the human body cannot be realized with medical therapy; thus, for example, a treatment with cellulite-diminishing cream is ineffective for correcting the corresponding physical faults respectively presented by the man and by the woman patient.

Surgical therapy
The resolution of the defects and deformities of the gluteal region can be realized surgically; yet, the assessment of the degree of severity of the injury organizes treatment therapies into three types: (i) buttocks augmentation, (ii) buttocks reduction, and (ii) contour irregularity treatments that combine surgery and liposculpture (fat-removal and fat-injection).

I. — Buttocks augmentation treatments
Gluteal implants
The augmentation of the buttocks is realized with a gluteal implant, which is emplaced under each gluteus maximus muscle
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

; the insertion of the buttock prosthesis is through a midline incision (5–8-cm-wide) over the tailbone (coccyx
Coccyx
The coccyx , commonly referred to as the tailbone, is the final segment of the vertebral column. Comprising three to five separate or fused vertebrae below the sacrum, it is attached to the sacrum by a fibrocartilaginous joint, the sacrococcygeal symphysis, which permits limited movement between...

). Augmentation with a gluteal implant is the method most effective for enlarging the buttocks of the man or of the woman whose body possesses few stores of excess adipose fat in the lower portion of the trunk, the buttocks
Buttocks
The buttocks are two rounded portions of the anatomy, located on the posterior of the pelvic region of apes and humans, and many other bipeds or quadrupeds, and comprise a layer of fat superimposed on the gluteus maximus and gluteus medius muscles. Physiologically, the buttocks enable weight to...

 and thighs
Thigh
In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...

, the anatomic regions where the human body usually stores excess body fat. Post-operatively, because of the cutting (incising) into the flesh of the tailbone muscles, the full healing of the augmented tissues can be approximately 6–8 months, in the course of which the gluteal-muscle tissues relax, and the settled buttocks prostheses are integrated to the gluteal region. The implantation procedure can be performed upon a patient who is either sedated
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...

 or anaesthetized, either under general anaesthesia
General anaesthesia
General anaesthesia is a state of unconsciousness and loss of protective reflexes resulting from the administration of one or more general anaesthetic agents...

 or under local anaesthesia. The usual operating-room time for a buttocks augmentation procedure is approximately 2.0 hrs; and the medical procedure can be managed either as an overnight in-patient treatment, or as a hospital outpatient treatment. Given the nature of the surgical incisions to the gluteus maximus muscles, the therapeutic management of post-surgical pain (at the surgical-wound sites) and normal tissue-healing usually require a 4-6-week convalescence, after which, the patient resumes his or her normal-life activities.

Lipoinjection

The augmentation and contouring of the buttocks with autologous-fat transfer
Fat transfer
Fat transfer is a medical procedure that uses the patient`s own fat tissue to increase the volume of fat in the subcutaneous area of the body. Autologous adipose tissue transplantation has been used for breast augmentation for cosmetic reasons and after breast cancer surgery...

 (lipoinjection) therapy is realized with the excess adipose-fat tissue harvested from the abdomen
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...

, flanks, and thigh
Thigh
In humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...

s of the patient. The gentle liposuction applied to harvest the autologous fat minimally disturbs the local tissues, especially the connective-tissue layer
Connective tissue
"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...

 between the skin and the immediate subcutaneous muscle tissues. Then, the harvested fat is injected to the pertinent body area of the gluteal region, through a fine-gauge cannula inserted through a small incision, which produces a short and narrow scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

. Lipoinjection contouring and augmentation with the patient’s own body fat avoids the possibility of tissue rejection, and is physically less invasive than buttocks-implant surgery. Therefore, depending upon the health of the patient, the convalescence period allows him or her to resume daily, normal-life activities at 2-days post-operative, and the full spectrum of physical activity at 2-weeks post-operative. Furthermore, the liposuction harvesting of the patient’s excess body fat improves the aesthetic appearance of the body fat donor-sites. Nonetheless, physiologically
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...

, the human body’s normal, health-management chemistry does resorb (break down and eliminate) some of the injected adipose-fat tissue, and so might diminish the augmentation. According to the degree of diminishment of the volume and contour caused by the fat-resorption, the patient might require additional sessions of fat-transfer therapy to achieve the desired size, shape, and contour of the buttocks.

Body contouring
The augmentation of the buttocks, by rearranging and enhancing the pertinent muscle and fat tissues of the gluteal region, is realized with a combined gluteoplasty procedure of surgery (subcutaneous dermal-fat flaps
Flap (surgery)
Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is similar to but different from a graft, which does not have an intact blood supply and therefore relies on growth...

) and liposculpture (fat-suction, fat-injection). Therapeutically, such a combined correction-and-enhancement procedure is a realistic and feasible lower-body-lift treatment for the man and for the woman patient who has undergone massive weight loss (MWL) in the course of resolving obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...

 with bariatric surgery
Bariatric surgery
Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device or through removal of a portion of the stomach or by resecting and re-routing the small intestines...

. In the case of the man or woman who presents under-projected, flat buttocks (gluteal hypoplasia
Hypoplasia
Hypoplasia is underdevelopment or incomplete development of a tissue or organ. Although the term is not always used precisely, it properly refers to an inadequate or below-normal number of cells. Hypoplasia is similar to aplasia, but less severe. It is technically not the opposite of hyperplasia...

), and a degree of gluteal-muscle ptosis (prolapsation, falling forward), wherein neither gluteal-implant surgery nor lipoinjection would be adequate to restoring the natural anatomic contour of the gluteal region, the application of a combined treatment of autologous dermal-fat flap surgery and lipoinjection can achieve the required functional correction and aesthetic contour.

II. — Buttocks reduction treatments
The methods for reducing the size of the buttocks include the varieties of liposuction
Liposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...

, such as lipectomy (with and without ultrasonic
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...

 enhancement) to reduce excess body fat, and superficial liposculpture, to reshape, refine, and re-establish the natural contour of the body. The usual buttocks-reduction treatment is lipectomy with applied tumescence
Tumescence
Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues, marking sexual excitation and possible readiness for sexual activity...

 and anaesthesia, wherein the body fat is harvested by aspiration (suction) through a small-gauge cannula (2-4 mm) that is inserted through a small incision, either to the intergluteal sulcus (the butt-crack), or to the upper area of the gluteus maximus muscle
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

 proper.

Ultrasonic lipectomy
Ultrasonically-assisted liposuction can quickly remove a large volume of body fat for the correction of a notable occurrence of lipodystrophy
Lipodystrophy
Lipodystrophy is a medical condition characterized by abnormal or degenerative conditions of the body's adipose tissue. A more specific term, lipoatrophy is used when describing the loss of fat from one area...

, a deposit of adipose fat to the buttocks and related anatomic areas. The ultrasonic
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...

 liposuction machine liquefies the excess fat tissue, and so more readily facilitates its removal with conventional suction-lipectomy. The quick fat-harvesting allowed by the ultrasonic lipectomy technique has eliminated the larger (long and wide) surgical incisions that once were required for removing a large volume of adipose tissue. Nonetheless, because of the sensitivity of the gluteal-region tissues, the skin of the pertinent donor-site is cooled in order to prevent ultrasonic heat damage caused by the liquefying and removal of the excess adipose fat.

Superficial liposculpture
Reshaping the buttocks with liposculpture is performed with a small cannula (2 mm) specifically for contouring superficial body fat, the configuration of which (number of open ports) is determined by the type and the degree of gluteal correction to be realized. To sculpt rounded contours to square-shaped buttocks muscles, superficial liposculpture allows the plastic surgeon to control the injection-rate of the fat-volume. Moreover, superficial liposuction can be combined with other treatment methods for contouring the gluteal region to achieve the required functional, anatomic correction, and the aesthetic enhancement sought by the patient, such as reshaping the lateral area of the buttocks into an athletic form. The study Contouring the Gluteal Region with Tumescent Liposculpture (2011) indicated that effective, gluteal-region contouring is best achieved by tailoring the liposuction-reduction and the lipoinjection-augmentation techniques to the anatomic topography of the body areas to be corrected. Furthermore, the study Contouring of the Gluteal Region in Women: Enhancement and Augmentation (2011) indicated that natural contours of the buttocks and the thighs are effectively achieved with a combined gluteoplasty of selective liposuction and lipoinjection, which reduces the need for aggressive surgical procedures, decreases the risk of medical complications, abbreviates wound-recovery-time, and lessens post-operative scarring. Combined with any buttocks-correction method, superficial liposculpture facilitates the treatment of contour irregularities, the surgical revision of scars, and the correction of gluteal-region contour depressions.

Surgical technique

Surgical contouring of the gluteal region
Pre-operative matters
To meet the functional requirements and the aesthetic expectations (body image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...

) of the patient, the plastic surgeon establishes a realistic and feasible surgery plan by which to correct the anatomic contour deficiencies of the gluteal region. The surgeon and the patient determine the location of the surgical-wound scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

s, and determine the best operative position, to allow the proper exposure of the pertinent anatomy to be corrected. Because the surgical procedure requires the tumescence
Tumescence
Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues, marking sexual excitation and possible readiness for sexual activity...

 and anaesthesia of the gluteal-region area to be corrected, the physician and the anaesthesiologist determine the volumes of the anaesthetic and tumescent fluids to be administered to the patient during the procedure, and so avoid the risks of drugs overdose and toxicity.

Intra-operative matters
Once the patient is atop the operating table, the surgeon positions him or her to best expose the pertinent gluteal-region area that is to be corrected or contoured, or both; the usual operative position is the prone (face down) position, but the patient can also be positioned laterally (on his or her side). The surgical correction plan can be delineated and marked to the patient’s body when he or she is awake (before sedation or anaesthesia) or it can be delineated when the patient is on the operating table (already sedated
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...

 or anaesthetized). In operative praxis, the second option allows the plastic surgeon greater freedom to properly manipulate the patient into the position best suited for performing the body-contouring surgery.

Operative matters
Once the patient is in the operative position, the surgeon begins the liposuction correction by making incisions to the marks of the surgical-correction plan, and then infiltrates (injects) a solution of anaesthesia- and tumescence-inducing drugs, usually a combination of lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...

 and epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...

. The volume of the anaesthetic-tumescent solution is gradually infiltrated to the pertinent gluteal area, in order to avoid the nerves and the deeper anatomic structures of the gluteus maximus muscle. The particular anatomic features to be contoured determine the types of cannula (gauge, size, grade) used to effect and control the harvesting of excess adipose fat from the patient’s body.

For a lipoinjection augmentation, the surgeon first dissects and prepares the augmentation-pocket to which will be injected the autologous fat-tissue. The surgical creation (muscle dissection) of the augmentation-pocket avoids the gluteal innervation (superior gluteal nerve and inferior gluteal nerve
Inferior gluteal nerve
The inferior gluteal nerve is a nerve in the pelvis that innervates the gluteus maximus muscle.-Structure:The inferior gluteal nerve originates in the sacral plexus...

) and the vascular system (venous
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...

 and arterial
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...

) of the gluteus maximus muscle
Gluteus maximus muscle
The gluteus maximus is the largest and most superficial of the three gluteal muscles...

. Afterwards, the surgeon sutures the dissection-incision and secures it with adhesive tape to ensure that the augmentation-pocket remains open, as dissected, ready to receive the injections of adipose fat. For the revision of scars, with surgery and injections of autologous fat, or with allopathic synthetic fillers, the surgeon applies subcuticular closures to the incision wounds, which then are bandaged.

Post-operative matters
After completing the surgical corrections and the lipoinjection contouring of the pertinent area(s) of the gluteal region, the surgeon thoroughly examines the patient to ensure his or her general recovery from the operation; and examines each surgical incision to ascertain that it is correctly sutured and taped, in order to facilitate the uneventful healing of the gluteus-muscle tissues, without medical complications. The patient is advised to avoid exercise and strenuous physical activity until 3-weeks post-operative; how to properly care for surgical-incision wounds; and how to wear a compression garment that will keep in place the surgically corrected tissues, and so ensure their healing as a whole anatomic unit of the gluteal region.

Follow-up and convalescence
The physician advises the patient who has undergone a surgical contouring of the buttocks with gluteal implants, that, although immediate results can be observed, the final, corrected body contour usually is observed at 6-months post-operative, and at 1-year post-operative, depending upon the tissue-healing capabilities of the patient’s body. The liposculpture patient usually requires approximately 6 months, and occasionally 1 year before producing the final, corrected body contour. For both procedures, at approximately 1-month post-operative, marked aesthetic improvement is noticeable in the corrected body areas, as is the elimination of the initial, post-operative weight gain caused by the body’s retention of the infiltrated, anaesthetic and tumescent
Tumescence
Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues, marking sexual excitation and possible readiness for sexual activity...

, fluids. The patient is advised to wear a compression garment to contain swelling and to immobilize the corrected tissues, so that they heal as one anatomic unit of the gluteal region. Moreover, throughout the convalescence, to facilitate shrinking the skin to the new, corrected body contour, and to resolve unevenness, wrinkles to the skin, and localized swelling, the continual application of massage and (occasional) ultrasound treatments can facilitate the diminishment of the post-operative conditions.

Complications
The surgical and liposculpture contouring of the human body presents possible medical complications such as: the psychological — unmet body image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...

 expectations of aesthetic improvement; the physical — uneven contour, local and general; the physiologic — toxic reactions to the anaesthesic and the tumescent
Tumescence
Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues, marking sexual excitation and possible readiness for sexual activity...

 drugs; and the nervous — paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...

, localized areas of perduring numbness in the corrected portion(s) of the gluteal region. The medical complications possible to a surgical buttocks augmentation procedure, the submuscular emplacement of a gluteal implant, include infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

, surgical-wound dehiscence
Wound dehiscence
Wound dehiscence is a surgical complication in which a wound breaks open along surgical suture. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.-Symptoms:...

 that exposes the implant, revision surgery, rupture of the implant, seroma
Seroma
A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....

 (a pocket of clear serous fluid), capsular contracture
Capsular contracture
Capsular contracture is an abnormal response of the immune system to foreign materials in the human body. Medically, it occurs mostly in context of the complications from breast implants and artificial joint prosthetics....

, asymmetry of the corrected area, shifting of the implant, surgical over-correction, injury to the sciatic nerve
Sciatic nerve
The sciatic nerve is a large nerve fiber in humans and other animals. It begins in the lower back and runs through the buttock and down the lower limb...

, and paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...

 (tingling skin). The medical complications possible to a liposclupture buttocks augmentation include the bodily resorption of some of the injected adipose fat, asymmetric contour of the corrected body area, an irregular contour to the body, seroma, abscess
Abscess
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...

 (pus enclosed by inflamed tissue), cellulitis
Cellulitis
Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters,...

 (subcutaneous connective-tissue inflammation), and paresthesia.
  • Unmet expectations

In the surgical praxis of body contouring therapy, the patient’s body-image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...

 expectations can be different from the contoured body that is the outcome of the performed surgical operation. Such unmet aesthetic expectations can be avoided at the pre-operative consultation stage, whereby, with informed consent, the physician and the patient jointly establish a realistic and feasible surgery plan to achieve a mutually satisfactory corrective outcome (functional and aesthetic) of the operation to the gluteal region, the buttock- and thigh-areas.
  • Contour problems

Contour problems of the corrected gluteal region can be prevented with the operational use of small-gauge cannulas (ca. 2.0 mm) specifically for superficial liposuction; and with the application of cross-pattern harvesting of the excess body fat, to avoid removing too much adipose fat tissue, which might disfigure the contour of the patient’s fat-donor area. The possible contour problems that might arise from ultrasonic liposuction are skin burns and hypertrophic scarring, which might occur if the fat-donor area skin is not cooled and protected during the fat harvest. To that end, the infusion of a tumescence-inducing solution to the fat-donor area(s) assists in cooling the patient’s skin during the ultrasonic lipo-harvesting; likewise, the application of moist towels, a skin protector, and the constant cooling-fluid infiltration of the cannula in an integrated sheath.
  • Drug complications (anaesthetic and tumescent)

The infiltration of a solution of anaesthesia- and tumescence
Tumescence
Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues, marking sexual excitation and possible readiness for sexual activity...

-inducing drugs can present medical complications such as a fluid overload of the tissues, the inadequate replacement of the infiltrated solution, and the partitioning (separation) of a single infiltration into several pools, which then are removed by suction lipectomy. Moreover, during anaesthesia, maintaining the patient’s stable blood pressure can be difficult, which increases the possibility of bleeding, and the possibility that anaesthetic toxicity can occur if excessive doses are administered by infiltration; the symptoms are manifested as central nervous system
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...

 (CNS) occurrences of drug-induced anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

, apprehension, restlessness, nervousness, disorientation, confusion, dizziness, blurred vision, tremors, nausea, vomiting, shivering, and seizures; likewise, as manifestations of drowsiness, unconsciousness, respiratory depression, and respiratory arrest. Furthermore, the toxicity symptoms of a tumescence-inducing drug (e.g. epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...

) might cause such CNS symptoms, for which reason the operative application of a tumescent drug is limited throughout the operation.
  • Numbness (paresthesia)

Post-operatively, local areas of numbness (paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...

) might occur in the contoured portion(s) of the gluteal region, and might perdure for a long time after the surgery. Hence, the patient is advised to facilitate the re-sensitizing of the numb area(s) with applications of gentle massage, to prevent the development of a neuroma
Neuroma
A neuroma is a growth or tumor of nerve tissue. Just as the Latin word for swelling is now restricted to neoplasias, the equivalent Greek suffix -oma has shared in that fate. Thus, the typical modern usage of neuroma is for nerve tumors...

 complication, and to alleviate pain. Nonetheless, depending upon the tissue-healing capabilities of the patient, he or she can recover in full at 2-years post-operative.

Outcome
The outcome of a buttocks-contouring procedure depends upon the specific defect or deformity that can be effectively corrected with liposculpture, ultrasonic
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...

 or not. Nonetheless, depressed scars and deep morphological
Morphology (biology)
In biology, morphology is a branch of bioscience dealing with the study of the form and structure of organisms and their specific structural features....

defects are difficult to correct because of the curvature of the buttocks as an anatomic unit, and because of the scar-contracting elements of the tissues across the gluteal curvature. In such a case, although the injection of (autologous or artificial) tissue fillers to correct the defect or the deformity might be impermanent — it usually will remedy the functional and aesthetic shortcoming(s) required by the patient, which is the therapeutic purpose of gluteoplasty.
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