thanks to Dr Tarek Zahra who participated mainly in this ppt

2. Contents:
• History
• Gluteal aesthetics
• Reshaping methods hints
• How to deal?
Mahgoub MA 2018

3. History
• The idea of an aesthetically pleasing gluteal region has been
with us since early recorded history.
• The ancient Greeks had nomenclature to describe an
aesthetically pleasant buttock area: callipygian is derived
from calli, meaning beautiful, and pyge, meaning buttocks.
• The well-developed buttock, a trait unique to primates,
appeared with the evolution of vertical posture, a uniquely
human characteristic that contributes to the lumbosacral curve.
Mahgoub MA 2018

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5. • Gluteal augmentation is not just about making the buttock
bigger, but rather accentuating, contouring, and reshaping.
The focus becomes volume redistribution; shifting volume from
an unattractive zone to a more desirable position.
Mahgoub MA 2018

6. • With this perspective, even the full-figured woman
becomes a candidate since, on closer examination, the
large buttock has maldistributed adiposity, with deficient
volume in pertinent aesthetic zones
• The question is no longer who is a candidate, but rather,
what reshaping method is best for each particular patient?
Mahgoub MA 2018

7. There are 3 acceptable methods of buttock
augmentation:
1. Silicone implants ( sub muscular, sub fascial,
intramuscular )
2. Autologous micro fat grafting (MFG).
3. Autologous autoaugmentation flaps.
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8. Ethnic variation
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9. Gluteal aesthetic ideals
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14. • The skin will influence the appearance if there is laxity or ptosis,
as in the case of massive weight loss patients.
• In fact, the attractiveness of the female buttock is primarily
dependent on the thickness and distribution of the fatty layer,
which is usually 50–60% of the volume of the buttock.
Mahgoub MA 2018

15. • Traditional teaching tells us that
the muscle attaches all along the
superior iliac crest,
• But in reality it only follows the
crest for one-third of its initial
distance.
• The superior limit of the gluteus
maximus muscle is the posterior
iliac spine.
• The gluteus maximus inserts into
the iliotibial tract, and to a lesser
degree, the greater trochanter
Mahgoub MA 2018

16. AESTHETIC ANALYSIS
• The ideal buttock also has equal
volumes on both sides of the
midbuttock line.
• the lower quadrants, three and
four are equal, but tend to be
slightly wider than one and two.
Mahgoub MA 2018

17. AESTHETIC ANALYSIS
• there are three other zones that surround the buttock, which become
important in evaluation:
• 1-the upper inner gluteal/sacral junction,
• 2- the lower inner gluteal fold/leg junction,
• 3-mid-lateral gluteal/hip junction.
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19. • The inner gluteal/sacral space should be well defined so that a V-shape is
apparent
As the “V” zone becomes more visible, the buttock has greater aesthetic appeal.
In the ideal buttock, the gluteal muscle edge should be well defined and have a
semicircular upward turn. Mahgoub MA 2018

20. • Lower inner gluteal fold/leg junction
• should create a diamond shape space
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21. • Lateral mid-buttock/hip contour
• This zone is categorized as having; no depression, mild depression,
moderate or severe depression
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22. Lateral view aesthetics
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23. • lazy S shape (from the
back to the bottom of
the gluteus)
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24. Most of the gluteal volume is central and has equal distribution in
the upper and lower gluteal zones, giving a C-shape curve.
The peak of the central mound should be at the level of the pubic
bone
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26. • The overall goal of buttock
augmentation is to achieve a
more youthful appearance
and contour
• to create the ideal waist-to-hip
ratio of 0.7.
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28. Muscle height to
width ratio
At a glance you will notice a
height to width relationship which
will fall into one of three ratios:
1:1 (short muscle),
2:1 (tall muscle),
or 1.5:1 (intermediate). The ideal
buttock is intermediate but leans
more towards a 2:1 relationship
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32. Types of gluteal frames:
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35. IMPLANT AUGMENTATION
• The ideal patients for implant-based augmentation are young,
with an athletic build with little or no ptosis.
• The larger the body frame, the greater the risk of wound
dehiscence and implant exposure
• Any patient with enough fat is not candidate for implant
augmentation
Mahgoub MA 2018

36. • Tall buttock (2:1 height to width ratio) is best augmented with the
anatomic implant.
• Short buttock (1:1 ratio) is best augmented with
the round implant,
• Intermediate buttock (1.5:1 ratio) may require the lateral view to
make the final determination
Mahgoub MA 2018

37. The lateral view
• If the buttocks are fuller inferiorly, a round
implant will look best since the round
implant adds most of its projection in the
upper and central zones.
• If the buttocks have no significant
projection superiorly or inferiorly, we
prefer the oval implant for the
intermediate or tall muscle.
• If the maximum fullness is in the upper
buttock, an anatomic implant (maximum
prominence inferiorly)
Mahgoub MA 2018

38. Implant size selection
• Since each patient’s anatomy is different and implant
exposure rates rise as tension increases, implant size
cannot be determined prior to surgery.
• Sizers are used intraoperatively to identify the largest
implant the buttock will accommodate, without creating
excessive muscle tension at closure.
Mahgoub MA 2018

39. Planes of implant
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40. Subcutaneous plane (of historical interest)
• Resulting in implant
migration .
• The implants are highly
visible; the skin envelope
can become ptotic, and
severe capsular contracture
giving the shape of a large
mushroom
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42. SUBFASCIAL
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43. Submuscular plane
•This approach preserves the aponeurotic
system that holds gluteal skin in position and
has the advantage of reducing the formation
of capsular contracture.
• However, it introduced a new anatomic
problem with the potential risk of injury to the
sciatic nerve.
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45. Intramuscular plane
• The goal is to have 2–3 cm of muscle over the pocket and to
leave 3 cm thickness of gluteus maximus deep to the pocket to
protect the sciatic nerve.
• A common problem is to break out of this plane during superior
dissection, perforating into the subcutaneous tissue.
• Then when the patient sits, the implant shifts upwards, causing
pain at the iliac crest.
Mahgoub MA 2018

46. • In the intramuscular procedure; no plane exists, and you must
create a pocket curved like the surface of a globe.
• It is mandatory to have a variety of sizers and implants
available in the operating room to help assess what is the
largest implant that can be placed with minimal tension.
Mahgoub MA 2018

47. Incision design/selection
• Bilateral parasacral incisions.
• These incisions avoid the
sacral midline with its poor
blood supply, thereby
decreasing dehiscence rates
to <10%.
• UPWORD 4-5 CM APART
• LOWER ART 1-2 CM APART
Mahgoub MA 2018

48. • The template must be
centered over the gluteal
region leaving at least 2 cm
between the template and the
infragluteal fold and 2 cm
from the border of the sacrum
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50. Micro fat grafting surgical technique
• Sculpt the flanks, lumbar area
and lumbosacral area to
create an inward sweep,
which will synergistically
emphasize the new fullness
of the buttocks after fat
grafting.
• This includes performing
liposuction to create a deep
sacral
“V”
Mahgoub MA 2018

51. • The vast majority of buttock augmentation procedures
range from grafting 600–1000 cc per buttock or 1200–
2000 cc of graftable fat.
• Up to one-third of the fat that is harvested may become
damaged during the harvesting process, meaning
1800–3000 cc must be available for the body
Mahgoub MA 2018

52. • Once harvested, the fat is then quickly processed.
• This begins with instilling 10 cc of an antibiotic solution
(3 g ampicillin/sulbactam and 80 mg Gentamicin plus 1
g Cefazolin in 1000 cc of saline) into each canister
(200–300 cc asp.rate).
• The fat is placed into 60 cc syringes and centrifuged at
2000 rpm for 3 min.
Mahgoub MA 2018

53. • Fat is grafted to layers in the subcutaneous
plane Starting from deep to superficial
• It is essential to maintain an awareness of the
course of the sciatic nerve and avoid
compression or trauma to it.
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56. Post operative care for lipofilling
• Encourage movment from the evening of surgery
• 1st 2 weeks No sitting allowed except for bowel movment
• Strict prone postion during sleeping for 4 weeks
• Minimal sitting for 15-20 min allowed after 2 weeks
• Regular activity after 6 weeks
• Unrestricted activity after 12 weeks
• Pressure garment for 12 weeks
• Daily inspection for areas of redness or tenderness
Mahgoub MA 2018

57. Post operative care for implant
• The same
• No driving for 4 weeks
• If no liposuction is performed only abdominal binder for 4 weeks
to apply pressure over the implant
Mahgoub MA 2018

58. Complications
• Infection
• Seromas
• Dehiscence
• Implant rotation
• Implant malposition
• pigmentation
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69. So , How to deal ???
Mahgoub MA 2018

70. 1. Is liposuction needed ?? >> the flank, sacral area (V-zone), upper
buttock (point A), lateral thigh (point B), infragluteal fold, or lower
lateral gluteal-thigh junction?
2. Are fat transfers needed?? >> point C; lower lateral gluteal-thigh
junction; midlateral gluteal-hip junction; upper inner gluteal-sacral
junction; or lower, central, or lower gluteal zone?
3. Is buttock augmentation needed with fat transfer or with implants?
a) If fat transfer, what volume, to which tissue plane, and to augment
which portion of the frame or gluteal aesthetic units?
b) If implants, what shape and size, and what tissue plane
(intramuscular, submuscular, or subfascial)?
4. Are any accessory or adjunctive procedures needed for contouring >>
which is most beneficial: buttock lift, lower gluteal cleavage crease
excision, or infragluteal fold excess excision?
Mahgoub MA 2018

71. The procedure to perform is up to
each individual plastic surgeon’s
comfort level and sense of
aesthetics.
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