What is Buttock Lipofilling?

Introduction

The buttocks are an essential element of sexual attraction and a significant component of the concept of beauty in most cultures and ethnic groups. Several factors have led to a dramatic increase in the numbers of patients seeking buttock lipofilling:

1. Media: with our increasing acceptance of cultural diversity, the popularity of Latina star Jennifer Lopez, African American singer “Beyonce,” and tennis star Serena Williams have made their ample derrieres the goal of many young women of all ethnic groups.
2. Clothing styles: Low-cut jeans and bare midriffs call attention to the buttocks. “Thong” style underwear and bathing suits uniquely expose and emphasize the “gluteal aesthetic unit.”
3. The Internet: By simply typing in a phrase such as “buttocks augmentation,” one can instantly obtain a wealth of information (and misinformation) about various types of surgery.
4. The exercise/physical fitness movement (and its tight-fitting attire) called attention to the development and shaping of the buttocks.”
5. The increasing awareness that buttocks augmentation using the patient’s fat is possible, bypassing concerns about foreign implant material.

Preoperative Assessment of Buttock Lipofilling

Detailed medical history for buttock lipofilling should be obtained, including medications, allergies, and tobacco use. Critical are notations in the medical history of diabetes, massive weight loss, earlier surgery, previous lipoaspiration, and a complete detailed list of medications and supple­ments.

Any concerns about a patient’s medical suitability to undergo anesthesia and buttock lipofilling operative procedure should result in a referral for preoperative clearance with either an internist or cardiologist. This typi­cally includes anyone with a significant medical history or patients older than 50.

Massive weight loss patients should undergo the same preoperative evaluation as any excisional-type body contouring procedure. Preoperative laboratory tests for buttock lipofilling should include a complete blood count (white cell count, hemoglobin, platelets), coagulation tests (PT, PTT), renal function (urea, creatinine, potassium, sodium), and liver function (AST, ALT, bilirubin, alkaline phosphatase). Any abnormalities should prompt repeat tests and further investigation before the procedure.

Patient Education on Buttock Lipofilling

Appropriate patient selection and education are critical to buttock lipofilling’s success. The patient should clearly understand what buttock lipofilling can and cannot accomplish.

In the current climate of photograph-altering applications and social media filters, patient education and understanding realistic outcomes for buttock lipofilling are more critical. It is the surgeon’s responsibility to provide honest expectations for typical results of buttock lipofilling.

Contrary to popular opinion, exercise (even when focused on the “gluteals”) will not increase buttock size and can only minimally improve shape. As with breast enlargement, this fact leaves surgery as the only option.

As with breasts, our main objective of buttock lipofilling is an appropriate volume with a beautiful shape. Advances in morphology, psychology, and anatomy have shown that giving shape to the buttock is much more complex than increasing its volume. A large buttock is no better than a well-formed small buttock.

Delivering a beautiful buttock contouring with appropriate projection is not just a matter of adding volume. Still, it requires two contradictory processes, i.e., adding fat and removing fat, to best obtain the ideal buttocks shape.

Let us first define what a perfect buttock looks like or the universal Ideal buttock Characteristics:

• A waist-to-hip ratio of 0.7. Men always have a higher WHR (0.85–1.0).
• A smooth inward sweep of the lumbosacral area and waist resembles a lazy S shape.
• There should be no excess fat either in the lumbosacral or subgluteal region.
• Two well-defined dimples on each side of the medial sacral crest correspond to the posterior-superior iliac spines (PSIS).
• A V-shaped crease (or sacral triangle) arises from the intergluteal crease’s upper end and arch to end at the sacral dimples.
• The sacral space (the area between the L5-sacral junction and the intergluteal crease); should be50%to 100%of the intergluteal crease length.
• The gluteus muscle edges should not be marked and should be seen as a single unit.
• On the lateral view, the buttocks show a C-shaped curve.
• The volume is in the central zone, maximum at the level of the pubic bone. The remainder of the bulk is equally distributed in the upper and lower zones.
• The ideal buttock has equal volumes in four quadrants and should be equally complete.
• A feminine cleavage as the buttocks separates superiorly and inferiorly.
• The infragluteal fold and the inner thigh should create a diamond-shaped space.
• The Infragluteal fold is shot and does not exceed beyond the medial-two thirds of the post-mid-thigh
• No drooping of the buttock below the infragluteal fold
• Two mild lateral thigh depressions correspond to the femur’s greater trochanter.

Although those mentioned above universal ideal buttock characteristics are shared among different ethnic groups however there are some different preferences in what a beautiful buttock means in a particular ethnic group:

1. Asian patients prefer buttocks that are small to moderate in size but shapely; they do not like or request fullness in the lateral buttocks or lateral thighs.
2. Caucasians fall into two subgroups: some prefer a full rounded lateral buttock, while others prefer a flat or hollow lateral buttock, which gives a more “trim” or athletic look.
3. Hispanic patients choose full buttocks, lateral buttocks that are full, and prefer a slight fullness in the lateral thigh.
4. African Americans patients have a solid and consistent cultural ideal of enormous buttocks, and several requests a “shelf” (extreme prominence of the upper buttocks). The lateral buttocks must be complete.

To meet the expectations of many of our patients (Egyptians, Arabs, or Africans) for buttock lipofilling, we must achieve a waist-to-hip ratio of less than 0.7. In addition, we must add volume not only to the medial two-thirds of the buttocks but also to the lateral buttocks and the lateral thighs. Only autologous fat grafting can accomplish these goals:

• Sculpting the waist and lordosis of the lower back is routinely done during buttock lipofilling. Still, I cannot do it at the time of buttocks implants because it would increase the already high risk of complications associated with implants. Only buttock lipofilling can create the universal ideal proportions of the female torso in one operation and meet the specific ethnic ideals of beautiful buttocks.
• No implants can augment the entire lateral buttocks or the lateral thighs, nor is there a feasible anatomic possibility for using implants in these areas.
• Of course, implants are the only choice if a patient has inadequate fat and is unwilling to gain weight despite their inherent limitations. However, implants have several other disadvantages and problems and are laden with complications.
• Although some massive weight loss patients may not need additional volume, they may benefit from moving the volume to another part of the buttocks to produce better gluteal projection at the level of the mons pubis. In these cases, fat transfer provides a good option.
• Gluteal implants are not a good choice for MWL patients because the poor quality of their subcutaneous tissue and skin may increase the risk of complications.
• Filler injections are costly, temporary, and frequently associated with foreign body complications.

Physical Examination and Markings of Buttock Lipofilling

You should learn what the surgeon will examine. And why did he choose his surgical plane? The physical exam for buttock lipofilling is best performed before a full-length mirror, allowing an open dialogue between patient and physician. Buttock lipofilling requires the physician to evaluate that area circumferentially. An excellent example is that the final buttock shape will depend on the area of the back, abdomen, thigh, hips, or flanks. The markings for buttock lipofilling should be based on several factors, including skin laxity, bony anatomy, fat, and muscle fullness.

Buttock  Aesthetic Units

For buttock lipofilling to be successful, your surgeon will divide the treatment area into eight gluteal aesthetic units:  2 symmetric flank units, one sacral triangle unit, two symmetric buttock units, one infragluteal diamond unit, and two symmetric thigh units. All eight gluteal aesthetic units can be augmented, reduced, preserved, or better defined to improve the aesthetic outcome of buttock contouring.

The types of buttock frame

Also, for successful buttock lipofilling to reach its target, your surgeon will define your buttock frame depending on the skin quality, the fat amount and distribution, the bulk of its muscle mass, and even your bone.

Of course, the amount and distribution of fat content play an essential role in achieving ideal gluteal aesthetics for buttock lipofilling, as fat is responsible for the round shape and projection of the buttocks.

The fat content of the buttocks is usually more significant in women vs. men, infants vs. adults, and some ethnic groups. Men tend to accumulate weight in the flank areas above the pelvis bone, unlike women, who accumulate fat on the hips and lateral thighs. The most significant differences in young vs. older adults are noticed at the waist and mid-thigh levels.

The amount and fat distribution among the buttock varied in 3 zones: lateral hip, lateral thigh, and lateral mid-buttock

• The most protruding point in the upper lateral hip is marked point A
• The most protruding point in the lateral thigh is marked point B
• The lateral mid buttock is point C.

The connection of points A and B on each side (left and right) of the body will make your surgeon quickly identify your buttock frame. There are four basic frame types: A-shaped, V-shaped, square, and round. Remember, no one is perfect, and the buttock frame may have a vital asymmetry.

The most frequent irregularity is scoliosis or a difference in hip height owing to the shortness of one leg. It is vital to highlight asymmetries and to point them out to the patient, planning the procedures to reduce these asymmetries. Your surgeon will also evaluate the four quadrants of the buttock and determine whether the volume of each is sufficient or deficient.

Let us discuss the four basic frames that your surgeon will identify and choose the best surgical plan that meets your needs and desires about buttock lipofilling.

Square Shape

The square buttock is the most common in about 40% of patients. Equal volumes at points A and B characterize the square-shaped buttock. The square shape is the most malleable of the four types because any variations at points A, B, or C can turn it into a different shape. Point C can have varying degrees of fat deficiency.

Round Shape

The round buttock is seen in about 15% of patients. The round shape is characterized by having excess fat at point C. A gentle C-shaped curve becomes apparent when all 3 points (A, B, and C) are connected.

Patients with round-shaped buttocks tend to be heavier than those with a square shape. The round shape has most often had a narrow base. This shape also may deform excess fat or skin in the lower-inner gluteal fold area.

A-Shaped (Pear-shaped)

The A-shaped buttock is present in about 30% of patients. When points A and B are connected, an A shape is apparent. This shape is characterized by having more fat in the lateral upper thigh (point B) and less in the lateral upper hip area (point A).

The A-shaped buttock is usually improved with liposuction of point B and occasionally of point A or lateral thigh. Ideally, point A should protrude more than other hip areas. Point C can be severely deficient, but in most cases, the depression is mild to moderate. Point C may require fat transfers, depending on the degree of depression.

V-Shaped (Apple-shaped)

The V-shaped buttock is seen in about 15% of patients. When points A and B are connected, a shape can be appreciated, along with gluteal base width. Most fat is in the upper lateral hip area (point A) and very little in point B. Deficiency around point C is rarely a problem.

The intergluteal crease line also appears to be short and low-lying. This shape is unique because patients tend to have a tall pelvis, skinny legs, and a tendency toward central obesity. The clinical significance of the V-shaped buttock is that this shape is the hardest to re-contour.

The last step of the buttock evaluation is determining if any buttock ptosis exists. The lateral view categorizes buttock ptosis into no-ptosis and ptosis groups, with three classes or subcategories. This categorization is essential for choosing the best buttock reshaping procedure to perform.

If ptosis exists, is it grade I, II, or III? Examining the quality of the skin at unique points will help your surgeon to assess the presence of ptosis or even wrinkling often seen in patients with massive weight loss. This information will help the surgeon inform patients if they need either an upper buttock lift (helpful for grades II and III) or later excision of the inferior intergluteal crease in addition to buttock lipofilling.

If no ptosis is present, determine whether the buttock is class A, B, or C. This information will help identify whether fat transfers or liposuction is needed to achieve the best results in buttock lipofilling.

At the end of the examination, your surgeon will decide if any other accessory or adjunctive procedures will be needed in addition to buttock lipofilling. If so, which is most beneficial: buttock lift, lower gluteal cleavage crease excision, or infragluteal fold excess excision?

Now your surgeon will inform you what lipoaspiration part of buttock lipofilling will help to achieve the perfect results of buttock lipofilling. Lipoaspiration of the body reduces subcutaneous fat and can result in conservative skin retraction, so it is a procedure that does not apply to patients with marked overhanging skin or a substantial proportion of intra-body lipoaspiration visceral fat.

Therefore, patients seeking buttock lipofilling may not be candidates for liposuction alone and require excisional techniques to get the best contour. It is helpful to explain that efforts to remove all fat in your body to be used in buttock lipofilling are likely to result in poor results, such as skin irregularities or laxity, and increase the risk of complications such as hematomas, seromas, and asymmetry.

Lipoaspiration part of buttock lipofilling is contra­indicated in pregnant patients or poor general medical health. Patients with morbid obesity, cardiopulmo­nary disease, body image belief issues, unrealistic expectations, wound healing difficulties, or patients with exten­sive or poorly located scars should be excluded from consid­eration buttock lipofilling.

The ideal candidate for buttock lipofilling has an average body mass index (BMI), good skin tone, protuberant areas of exercise- and diet-resistant fat, no comorbid disease, is a non-smoker, and has realistic expectations. Thin patients with lower body fat are generally poor for buttock lipofilling and are instructed to gain weight with a diet that increases lipoaspirate yield.

The back, flanks, and thigh are the most critical elements that surround and participate in the aesthetics of the buttock. By judicious liposuction alone of the abdomen, anterior thigh, medial thigh, lateral thigh, post thigh, hips, flanks, and the lower back, we can remove “love handles,” “saddle bags,” and “banana roll” and define better the lumbosacral depression, the sacral triangle, the subgluteal area, and infragluteal folds we can achieve excellent results in buttock lipofilling and shaping.

For body lipoaspiration part of buttock lipofilling, six key elements are Notified and documented:

• Fatty tissue deposits and deformities
• Skin tone and quality
• Asymmetries
• Stretch marks
• Hernia’ orifices
• Superficial fat layers.

Marking for Lipoaspiration Part of Buttock Lipofilling

During the initial and follow-up visits, calculating body mass index (BMI) is paramount to patient safety. It is well known that morbid obesity (BMI > 35) imparts a threefold to fourfold risk from anesthesia.

The design is created with the patient standing with their back facing the physician. The midline is marked, and then two lines extend from the posterior axillary fold to the upper inner buttocks line on both sides. This line delimits the lateral areas to which lipoaspiration can be extended.

We then draw a horizontal line that joins both elbows and generally corresponds with the 12th rib. This line indicates the area to be improved with lipoaspiration, that is, the waist, taking care not to leave a step at the level of the iliac spines; doing so converts the body frame into an A-frame.

The iliac crest should be marked because it is a transition zone serving the low liposuction point. Laterally, the distance from the lowest rib will determine the potential for waste definition in the flanks. The posterior iliac spines are also marked. A vertical line is added, dividing the buttock right in the middle that goes up until it meets the axillary lines and the rib union.

I should mark incision sites for lipoaspiration and fat placement parts of buttock lipofilling. These sites should allow your surgeon to easily access all areas to be contoured while placing them in discrete sites.

Your surgeon will explain where he will put the fat in the second part of buttock lipofilling.

Augmentation gluteoplasty can be performed through various techniques, including autologous fat grafting, prostheses, fillers, and local dermal fat flaps. However, buttock lipofilling n requires surgical finesse and comprehensive knowledge of the gluteal anatomy.

Patients with previous gluteal augmentation with permanent agents, including silicone, hydrogel, and unknown or illicit agents, may not be ideal candidates for buttock lipofilling.

To optimize the safety of the second part of buttock lipofilling, i.e., injection, I should identify the danger zone on each buttock of fat injection. It is a triangle, the apex at the posterior superior iliac spine, and the lateral and medial points are at the greater trochanter and ischial tuberosity, respectively. It is imperative to avoid deep medial infiltration to avoid the gluteal vessels and macroscopic fat embolization in the second part of buttock lipofilling.

Patients should be able to prioritize the areas for which they would like more projection and fullness. The ability to prioritize areas of importance is vital in buttock lipofilling, especially in those patient populations who lack a good amount of fat.

In the second part of buttock lipofilling, I must identify which area is best to project and concentrate the fat there at the level of the pubic bone. I should mark the infrabuttock fold if it extends beyond the mid-post thigh line. Areas of dimpling and areas of adherence should be marked for pre-tunneling or expansion as these areas have limited capacities for fat grafting.

Preoperative Instructions for Buttock Lipofilling

• If you have any doubt about the buttock lipofilling, do not have it done
• If you have had problems with drug or alcohol abuse at any time, notify the surgeon before scheduling buttock lipofilling
• Absolutely no smoking for at least two weeks before and two weeks after buttock lipofilling
• Report to the physician any history of excessive bleeding or bruising
• Report all prior mental disorders or psychological problems to your surgeon
• If anticoagulants (blood-thinning) medication is being taken, I must stop this at least five days before buttock lipofilling, and I must take blood tests before buttock lipofilling
• I should take no aspirin or products holding aspirin (salicylic acid) for at least two weeks.
• Do not take a non-steroidal anti-inflammatory such as brufen, Voltaren
• Do not take any vitamins, especially vitamins C and E, for two weeks before surgery and for one week after surgery
• Discontinue all estrogens (check with your physician first) 4 weeks before surgery and two weeks after surgery
• Discontinue all benzodiazepines, such as Xanax, etc.
• Try not to schedule buttock lipofilling on a day close to your menstrual period. It is preferable not to do surgery during the first five days of menstrual bleeding.
• Take a shower daily with Betadine for three days before surgery

The preoperative consultation of buttock lipofilling should stress the risks of fat graft survival. Finally, a prescription for antibiotics and analgesia is given to the patient, with instructions to take the first dose of antibiotics the night before.

Perioperative Notes of Buttock lipofilling

It is up to the surgeon to determine the optimal surgical setting for each patient undergoing lipoaspiration. Factors influencing this decision are the amount of expected lipoaspi­rate, length and extent of the procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall patient health.

Patient Core Temperature

The patient is placed in a warming blanket 30–60 min before the procedure. The wetting solutions should be warmed at 38C and not administered cold.

Patient Positioning

Patient positioning depends on the area or areas that need to be treated, other procedures the patient will be undergoing, the patient’s body habitus/BMI, and surgeon preference. It is better to have excellent and efficient positioning allowing better contouring of the areas from several access points and directions to achieve the most significant aesthetic.

With that said, we believe that the prone and supine positioning offers the best opportunity to achieve symmetry by simultaneously evaluating the left and right sides of all body areas and reducing the need for revision.

A urine catheter is placed for expected lipoaspiration volume greater than 4 liters. We are keeping the patient well-padded at all pressure points. The knees are placed on a pillow to encourage flexion, and anti-embolism support stockings and sequential compression devices are started before anesthesia.

The appropriate dose of preoperative antibiotics is given before the start of the case and dosed every 4 hours as the surgical duration permits. 

Small-volume body lipoaspiration cases can be performed with local anesthesia, with or without mild seda­tion. Complex, large-volume body lipoaspiration and combined cases should be performed under general anesthesia.

Infiltration of local anesthetic solution is injected through the preoperatively appointed assess sites through the tubing with a motor-driven pump at a slow infusion rate (<50 mL/min)—infiltration into the superficial subcutaneous fat.

The composition of the infiltration fluid depends on the amount of lipoaspiration anticipated. Later deep infiltration using the blunt cannula is easily tolerated, even in challenging fibrous areas. After withdrawing the cannula, a band-aid is placed to stem the flow of fluid from the incision site to prevent a reduction in pressure in the fat compartment.

If large-volume infiltration is used, it is safer to inject by sections, even procedure’s duration due is prolonged. This way, a specific area is injected and extracted, and the next area is treated. Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety. The authors consider lipoaspiration to be “large” when over 5,000 mL.

Regardless of the technique used, the infiltration should be allowed at least 30 min before extraction. The waiting period will allow the local anesthetic solution to reach its maximum effect and helps with fatty tissue homogenization.

Lipoaspiration, or fat extraction Part of Buttock Lipofilling

The author uses high-oscillation, power-assisted ng 4- and 5-mm Mercedes tip cannulas for tunneling and the release of fascial adhesion before performing Lipofilling. Tunneling without aspiration will allow adequate fat removal, mobilization, even distribution of remaining fat, and redraping of the tissues postoperatively. Furthermore, pre-tunneling is used judiciously to release dimpling and zone of adherence. Massaging and rolling of the soft tissue for the final contour can be performed to the surgeon’s specifications and preferences.

A blunt three or mm multi holes blunt tip cannula attached to 10-20- or -50-ml syringes are used for fat extractions. Multiple access incisions are placed at various points to allow a cross-hatched pattern of the cannula to pass at various depths to avoid contour irregularities.

The operating hand moves forwards and backward radially like the spokes of a wheel while the other hand stabilizes the skin over the tip of the cannula. As extraction continues, the pinch test is performed intermittently to assess symmetry and reduction in thickness of the fat layer. The surgeon must use a syringe reduction technique to create a smooth transition between contours.

The fat layers are approached from superficial to deep, and slower strokes are used throughout the deeper layers and faster strokes in the superficial layers to avoid dimpling and injury to the skin.

Superficial body lipoaspiration is frequently applied to excess fat and lax skin patients. Smaller cannulas may be used for more precise lipoaspiration of superficial fat deposits in thinner patients. The cannula tip should always be 1 cm deep to the dermis.

Fat removal is done in areas that improve the gluteal region’s definition. Lipoaspiration should begin in the midline sacral region and proceed laterally to the flanks, including the soft tissue superior to the iliac crest and inferior to the 12^th rib. Liposuction should continue to the lower flanks and end over the lower lateral thigh. Lipoaspiration in this area accentuates depth, decreases the waist-to-hip ratio, and can enhance the S-curve silhouette.

The lower lateral body /thigh interface requires a careful, “less is more” approach to lipoaspiration.

The sacral area is vital because the removal of fatty tissue in this region creates an apparent increase in lower back lordosis and enhances the projection of the upper pole of the buttock. However, I must take caution not to be overaggressive as the destruction of lymphatics in this area can lead to increased seromas and deep skin rhytids.

The endpoint is reached when the desired amount of debulking and improvement in body contour has been achieved based on the pinch test and careful inspection from different vantage points in the operating room.

Measured volume aspirated is a good indicator for bilateral procedures to judge symmetry and contour, comparing each side to the opposite. Other indicators such as treatment time, blood in aspirate, and amount of aspiration are essential factors to consider.

The shape of the buttocks is defined by a final suctioning. Sometimes the buttock will not expand into a rounded shape, rising as a block or platform. The margins of the buttock are slowly and carefully suctioned down to create the ideal shape, curving smoothly into the new inward sweep of the low back and waist. Any flank fluid is also suctioned off to avoid overwhelming the drains.

The Second Part of Buttock Lipofilling: Fat Placement or Injection

Fat is highly susceptible to injury or death during the harvest and transfer. The surgeon must optimize fat graft survival while placing the fat correctly and avoiding complications. The fat graft survival depends on various aspects of trauma, nutritional depletion, and excessive pressure in the recipient area.

Fat Preparation

There are multiple approaches to processing lipoaspirate. The principle remains to separate the viable fat from the aqueous component sterilely.

The author prefers the spontaneous separation of the fatty content from the aqueous component of the lipoaspirate. Direct removal removes the aqueous component, and the remaining fatty tissue is cleared from fibrous tissue. For some patients with BMI less than 25 or those with poor fat yield, we use a commercial filter to remove residual aqueous components and obtain a viable fat ratio of 30 to 50% of the aspirate volume ready for injection. Otherwise, we routinely centrifuge the fat before placing the fat.

Fat Placement, Fat Injection, Lipoinjection, or Buttock Lipofilling

The essential principle to ensure successful fat transfer is to inject fat in small aliquots with each stroke in multiple planes. The transferred fat must be within an average radius of 1.5 mm to surrounding well-vascularized tissue. We use a 3.7-mm cannula attached to 10ml syringes to inject in both anterograde and retrograde fashion. We do not inject more than 5 to 10 mL of fat per pass.

Multiple passes should be performed in multiple directions and planes to ensure a homogeneous fat distribution. The fat is injected into only the superficial, intermediate, and deeper subcutaneous planes, starting deep and walkthrough to the superficial fatty layer. Avoiding the deep fat injection is critical to avoid intravascular or sciatic nerve injury, especially If release and expansion of the medial lower pole region (lower portion of the danger zone) are done.

The injection plane is constantly changed, and tactile feedback of tissue resistance is assessed throughout lipoinjection. There should always be a moderate to light degree of tissue feedback resistance during lipoinjection.

The buttock soft tissue’s preoperative volume determines the recipient site’s fat graft capacity. Overcorrection is not recommended because excessive injection overloads the graft capacity of the recipient site and may reduce fat graft survival overall. Furthermore, fat grafts may progress to areas of fat necrosis or liquefaction that can create a sizeable cystic cavity of saponified sterile fat cells.

Massaging is performed throughout the fat injection to avoid the coalescence of fat lobules into clumps.

Systematization in gluteal fat infiltration is recommended from the bottom to the upper part of the buttock and from deep to superficial. This approach will generate the shape of the buttock and will lift the tissues.

Performing the infiltration of this area helps create a broader base from which the buttock will rest and push it upward by a purely mechanical effect. Additionally, it will allow the gluteal crease to be shortened and oriented more vertically.

The definition of the point of most excellent projection is essential because it will provide the curvature of the gluteal frame and the basis for changing the shape from a V or square to an A shape.

Treating the transition between the gluteal frame and the gluteal volume will help us to achieve a smoother appearance and allows the curves to unite into a single, natural curve.

The lateral gluteal depression is better injected may be injected from an intergluteal cleft incision or a lower lumbar/ upper mid-buttock access point. Avoiding excessive fat transfer to the mid-lateral and inferior lateral areas is crucial because they are notorious for having decreased fat graft survival.

Postoperative Notes of Buttock Lipofilling

At the end of the operation, we use a specially made roller to gently milk out the remaining tumescent solution and break down fat cells from the entry points. Sutures are not applied to liposuction access points for easy fluid dripping, allowing for easy drainage during the postoperative period.

A gauze triangle, shaped like an old wide bicycle seat, is placed in the midline over the sacrum to help the skin adhere to the sacrum and maintain the critical superior gluteal cleavage. A compressive garment is then applied. Without this, the presacral skin will tent up, fluid will accumulate, and later fibrosis will develop, and I will lose cleavage.

The authors encourage the use of garments that are looser or open over the buttocks for approximately 6 to 8 weeks.

We monitor patients carefully in the recovery room (O2 saturation EKG, blood pressure, and urine output), and they must meet standard criteria before discharge. Patients are encouraged to ambulate immediately after surgery.

Patients are given antibiotics for five days postoperatively. Patients should be educated on meticulous hygiene and are instructed to increase caloric intake for the first to the third week after surgery to ensure nutrition and fat retention and avoid thromboembolic complications.

The patient should be drinking a gallon of sports electrolyte fluid per day. If intake or output is poor, or there are orthostatic symptoms, we administer 2 to 3 L of IV fluid. Hemoglobin and metabolic profile are rechecked on days 4 to 5 and managed appropriately.

Patients are instructed to avoid lying or sitting on their buttocks for the first two weeks and up to 8 weeks. We recommend that patients sit on special pillows that place pressure only on the posterior thigh as the buttock is floated.

Patients can apply pressure to their buttocks for only 20 to 30 minutes at a time for necessary tasks of daily living, such as restroom use and eating. Patients should sleep in a prone position or with lateral decubitus.

After 7 to 10 days, the foam pads are removed. Patients are allowed to engage in light exercise 4 weeks after the operation. The authors recommend that patients focus on exercises that will build and tone muscle (yoga, Pilates, weight training, and so forth) rather than strenuous fat-burning exercises and excessive cardio-centric programs in the first six months.

Complications of Buttock Lipofilling

The complication of buttock Lipofilling can be classified as follows:

• Immediate complications (0–3 days) bleeding, fulminant fat embolism, or visceral perforation.
• Delayed complications(3–21 days) bleeding, fat embolism syndrome, deep venous thrombosis, pulmonary thromboembolism, infection, edema, seromas, and fat necrosis.
• Late complications (21 days onward) include irregularities, asymmetry, loss of sensation, seroma, and fat necrosis.

Fat Embolism and Fat Embolism Syndrome

Fat embolism syndrome is a systemic inflammatory response that often does not have significant sequelae. Fat embolism results from mechanical blockage by fat in a medium to a large vessel. The consequences of fat embolism can range from permanent blindness to pulmonary embolism to death. If there is suspicion of fat embolization, the patient should be supported with fluids and oxygen and promptly transferred to a hospital for evaluation and treatment.

Poor Fat Survival

One of the most common complaints of gluteal fat transfer is poor fat survival. We believe losing 25 to 40% of transplanted fat is normal over 3 to 12 months.

Asymmetry and Contour Abnormalities

Contour abnormality and asymmetries are related to many factors, including different fat graft take, inherent donor site characteristics, and preoperative native bony and tissue asymmetry. Although the surgical goal is to improve asymmetry, it is impossible to achieve complete asymmetry, as in all bilateral plastic surgery.

The most crucial first step is to wait at least 4 to 6 months before determining the final graft. Still, waiting until at least one year after the initial operation is preferable. Revising buttock asymmetry with liposuction is not recommended and commonly results in buttock ptosis and significant contour irregularities. In revision augmentation, augmenting only the anatomical zones indicated and not the entire buttock is preferable.

Fat Necrosis and Cysts

Avoidance of fat necrosis and cyst can be accomplished with meticulous fat injection technique and accurate assessment of the regional ability of the buttocks to expand where desired.

As with oil cysts, areas of fat necrosis are treated depending on size. Small fat necrosis areas, less than 2 cm in diameter, may resolve with time and should be observed. Large areas of fat necrosis may require surgical excision.

Infection

Perioperative intravenous, intraoperative, and postoperative oral antibiotics minimize buttock wound infections. Preoperatively, patients are instructed to perform a chlorhexidine shower and maintain good postoperative hygiene. 

If the patient develops localized erythema, surgeons should treat it with antibiotics and drain it. Treatment is typically initiated with a fluoroquinolone for 7 to 10 days. If an abscess develops, it is promptly drained, and cultures are obtained to guide appropriate antibiotic coverage.

Seroma

Seroma can occur in the donor area and should be treated by needle aspiration and compression garments. Seromas clinically relevant in the recipient site or sites are rare and can be treated with simple aspiration. Repeated drainage may be necessary.

Concluding Thoughts of Buttock Lipofilling

Gluteal augmentation with autologous fat grafting has become increasingly popular over the last decade. Fat harvesting with liposuction and augmentation with lipoinjection allows global and comprehensive contouring of the entire torso and buttock region.

Close attention to proper perioperative protocols and meticulous technique enables the procedure to be performed safely with robust and consistent results. When performed carefully, gluteal fat transfer has an extremely low complication.

The procedure’s success is dictated not only by the final aesthetic outcome but also by maintaining patient safety throughout the perioperative journey.

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Brazilian Buttocks Results (before & after)

Buttocks In Shape Surgery Results (before and after)