The Clinical Problem ( Figs. 35.1 and 35.2 )
Gluteal augmentation surgery has grown by 42%/year in Brazil. Patients who look for gluteoplasty augmentation with implants are about 36 years of age. This type of surgery does not have any relationship with occupation and socioeconomic status. The main clinical complaints that lead patients to seek this procedure are related to the following:
A lack of projection in the gluteal area
This may present as a purely cosmetic request to give shape and form to the buttock or, in extreme cases, as a functional request, such as when the trousers cannot be held with a belt.
Anatomic imbalance between the gluteal volume, torso, and hips
Low body self-esteem
Gluteal augmentation with implants is a surgery with a high level of satisfaction to patients, affecting and improving many aspects of their lives. Its outcome should produce a natural look and be hardly noticed by others.
Indications for Buttock Augmentation
Body contour is a concern for most women, and buttock reshaping has been increasing in importance and gaining popularity over the past decade. Buttock reshaping has been improved by the development of prosthetic implants and ancillary procedures. Gluteal augmentation with implants is one of the most popular procedures to contour the gluteal region. It has been used to correct gluteal ptosis, gluteal hypoplasia, or gluteal agenesis, as well as for aesthetic purposes and increased self-esteem. In some cases, it has been used to correct ptosis and enhance hypoplasia.
Surgical Preparation and Technique
There are currently two techniques for gluteal augmentation, as described here.
Liposuction With Autologous Fat Grafting
An autologous fat graft is indicated for patients who may have a surplus of body fat in other areas. In addition to augmenting the buttock, this allows the surgeon to reproportion the adjacent body contours. Autologous fat is transferred into both the subcutaneous layer and gluteus maximus muscle to give an overall increase in bulk to the region. Fat needs to be available from donor sites in sufficient quantity to cover primary and possibly secondary grafting procedures.
These are indicated for patients who do not have body fat excess or have it in an insufficient amount to increase the gluteal region. Surgical techniques for buttock implants insertion have evolved over time to correct anatomic deficiencies and fulfill patients’ requests. The procedure for aesthetic purposes has gained strength since the 1970s, after the description of the use of implants in the gluteus by Cocke and Ricketson, the dissemination of technical enhancements by González-Ulloa, and the development of a specific range of gluteal implants. Several techniques have evolved, including procedures for the dissection plane, such as for the subcutaneous plane by González-Ulloa, the subfascial plane by de la Peña et al., the submuscular plane by Robles et al., and the intramuscular plane by Vergara and Marcos ( Fig. 35.3 ).
Subcutaneous placement of a gluteal implant has serious disadvantages. Because the system that maintains the skin attachment to the gluteal region is composed of aponeurotic expansions from the gluteal aponeurosis to the dermis, the creation of a subcutaneous pocket will damage these expansions, leaving the skin without fixation. This could possibly result in implant displacement. Furthermore, in this plane, the implants are palpable and highly visible, there is an increased chance of rupture of the implant shell, the skin envelope can become ptotic, and severe capsular contracture can occur.
The subfascial plane technique described by de la Peña et al. is based on gluteal layers. The pocket that is created under the gluteal fascia is very extensive and covers the entire gluteus maximus muscle. It has the same problems as subcutaneous implants—visible margins, palpable, rupture, displacement, and capsular contracture are the most common complications.
The submuscular approach preserves the aponeurotic system that holds gluteal skin in position and has the advantage of reducing the incidence of capsular contracture, displacement, rupture, and palpation. However, it introduced a new anatomic issue— the potential risk of injury to the sciatic nerve. Another disadvantage of the submuscular position relies on its small size and therefore limits the use of larger implants.
To prevent subcutaneous, subfascial, and submuscular complications, and at the same time gain the benefits of the muscular cover, the intramuscular plane is the most used technique. The pocket is created by splitting the muscular fibers of the gluteus maximus. The goal is to have 2 to 3 cm of muscle over the pocket and the same 2- to 3-cm thickness of gluteus maximus deep to the pocket to protect the sciatic nerve, allowing the surgeon to place the implant in the best position for each type of buttock.
Selection of Implants
Over the years, different types of implants have been used for gluteal augmentation, having either a round ( Fig. 35.4 ) or oval ( Fig. 35.5 ) base and with higher and lower profiles. Buttock implants are firmer in consistency than breast implants and have stronger, smooth, elastomer shell covers. Indications vary according to the buttock dimensions and the capacity to expand the soft tissues. Virtually all implants in my practice are inserted within an intragluteus maximus pocket.