Autologous Gluteal Lipograft

Aesth Plast Surg (2011) 35:216–224 DOI 10.1007/s00266-010-9590-y

ORIGINAL ARTICLE

Beatriz Nicareta • Luiz Haroldo Pereira • Aris Sterodimas • Yves Ge´rard Illouz

Received: 14 January 2010 / Accepted: 15 July 2010 / Published online: 25 September 2010 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010

Abstract In the past 25 years, several different tech- expressed the desire of further gluteal augmentation, 16 had niques of lipoinjection have been developed. The authors one more session of gluteal fat grafting. The remaining five performed a prospective study to evaluate the patient sat- patients did not have enough donor area and instead isfaction and the rate of complications after an autologous received gluteal silicone implants. At 12 months, 70% gluteal lipograft among 351 patients during January 2002 reported that their appearance after gluteal fat augmentation and January 2008. All the patients included in the study was ‘‘very good’’ to ‘‘excellent,’’ and 23% responded that requested gluteal augmentation and were candidates for their appearance was ‘‘good.’’ Only 7% of the patients the procedure. Overall satisfaction with body appearance thought their appearance was less than good. At 24 months, after gluteal fat augmentation was rated on a scale of 1 66% reported that their appearance after gluteal fat aug- (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent). mentation was ‘‘very good’’ (36%) to ‘‘excellent’’ (30%), The evaluation was made at follow-up times of 12 and and 27% responded that their appearance was ‘‘good.’’ 24 months. The total amount of clean adipose tissue However, 7% of the patients continued to think that their transplanted to the buttocks varied from 100 to 900 ml. In appearance was less than good. At this writing, the average nine cases, liponecrosis was treated by aspiration with a follow-up time for this group of patients has been 4.9 years. large-bore needle connected to a 20-ml syringe, performed The key to successful gluteal fat grafting is familiarity with as an outpatient procedure. Infection of the grafted area also the technique, knowledge of the gluteal topography, and occurred for four patients and was treated by incision understanding of the patient’s goals. With experience, the drainage and use of antibiotics. Of the 21 patients who surgeon can predict the amount of volume needing to be grafted to produce the desired result. Although the aim of every surgeon is to produce the desired augmentation of the gluteal region by autologous fat grafting in one stage, the Presented in the 2nd Professor Illouz Association Meeting during the patient should be advised that a secondary procedure may 11th European Societies of Plastic Reconstructive and Aesthetic be needed to accomplish the desired result. Surgery Congress in Rhodes, Greece. Winner of the 1st Illouz Prize and awarded the amount of 5000 US$. Keywords Autologous fat transplantation Á Gluteal B. Nicareta augmentation Á Lipograft Á Liposuction Department of Plastic Surgery, Policlinca Geral, 38 Av Nilo Peçanha, Rio de Janeiro 22020-100, Brazil Fat injection reportedly started in 1893 when German L. H. Pereira (&) Á A. Sterodimas Department of Plastic Surgery, LH Clinic, Rua Xavier da physician Franz Neuber used a small piece of upper arm fat Silveira 45/206, Rio de Janeiro 22061-010, Brazil to build up the face of a patient whose cheek had a large pit e-mail: [email protected] caused by a tubercular inflammation of the bone [1]. In 1926, Dr. Conrad Miller warned that ‘‘the end-results in Y. G. Illouz Department of Plastic Surgery, Saint Louis Hospital, Avenue free fat transplantation depend, aside from various local Claude-Vellefaux, 75010 Paris, France and general factors, on the method and technique’’ [2]. 123 Aesth Plast Surg (2011) 35:216–224 217

With the advent of liposuction in the 1980s, it became possible to aspirate and reinject fat, allowing transplantation of small volumes for soft tissue augmentation to correct contour irregularities [3]. Initially, it was performed by using microcannulas and small 5- and 10-ml syringes. In the past 25 years, several different techniques of lipoinjection have been developed to correct various prob- lems such as those involving the buttocks (augmentation and reshaping), trochanteric depressions, breast augmentation, scar depressions, thighs and legs (calf and ankle augmentation), small wrinkles and depressions of the face (Romberg’s disease), the nasolabial fold, the upper outer breast quadrant, and liposuction sequelae [4–8]. In 1989, the senior author (LHP) started introducing autologous fat to different anatomic areas such as the buttocks, the trochanteric regions, and the inner aspect of Fig. 1 Marking of the areas to be liposuctioned and lipoinjected the thighs [9]. The authors performed a prospective study to evaluate patient satisfaction and the rate of complica- intravenous sedation. The patient is placed in the prone tions after autologous gluteal lipografting. position. Intraoperative intravenous (IV) cefazolin is administered. 3. After injection of the normal saline wetting solution Patients and Methods containing 1:500,000 of adrenaline by a small-bore cannula and a wait of 15 min, a 60-ml syringe attached A total of 351 consecutive women underwent surgery from to a 4-mm blunt cannula is inserted through small January 2002 to January 2008. The women ranged in age incisions in the intergluteal fold as well as two from 19 to 72 years (mean, 31.3 years). The preoperative incisions in the iliac crest and two additional incisions body mass index (BMI) of the patients ranged from 17.1 to in the gluteal fold. Each incision is less than 1 cm 25.6 kg/m2 (mean, 21.6 kg/m2), obtained at the first office long. visit. Of the 351 patients, 73 were smokers, who were 4. Fat is aspirated using the syringe method. The donor asked to refrain from smoking for 1 month before and after sites include flanks, thighs, and knee fat. Each the surgical procedure. All the patients included in the individual area to be aspirated is treated separately study requested gluteal augmentation and were candidates (Fig. 2a). for the procedure. No other surgical procedures were 5. The fatty tissue aspirated is treated in the following performed. manner. With the syringe held vertically, open end The overall satisfaction with body appearance after down, the fat and fluid are separated. Isotonic saline is gluteal fat augmentation was rated on a scale of 1 (poor), 2 added to the syringe. The fat and saline are separated (fair), 3 (good), 4 (very good), and 5 (excellent). The and the exudate discarded. The procedure is repeated patient satisfaction scale has been used already in pub- until the fat becomes yellow in color and free of blood lished papers and peer reviewed [10–12]. All the patients and other contaminants (Fig. 2b). underwent surgery by the same team of surgeons com- 6. At completion of the liposuction procedure, access to prising Luiz Haroldo Pereira, Aris Sterodimas, and Beatriz the buttock region is gained through the same incisions Nicaretta. The evaluation was made at follow-up office in the intergluteal fold. consultations at 12 and 24 months. 7. Initially, a deep plane to the gluteal muscles is created by the 4-mm cannula. Then other planes are created Surgical Technique of Fat Grafting using the same cannula in different trajectories, always from the deeper aspect to the gluteal surface. The fat is 1. Marking of the areas to be liposuctioned and fat inserted into these tunnels, beginning at the deep layer grafted are made while the patient is in the standing and working up into the intermediate fat compart- position (Fig. 1). The areas to be lipoaspirated are ments. The fat is injected as the cannula is withdrawn. parallel-line marked, and the areas to be fat grafted are Care should be taken to avoid injection of more fat in only hollow marked. the superficial fat compartment. Separate incisions, if 2. Preoperative sedation is administered in the surgical necessary, can be used to treat the whole gluteal region suite. Anesthesia consists of an epidural block and (Fig. 3). 123 218 Aesth Plast Surg (2011) 35:216–224

Fig. 2 a Liposuction using the syringe technique. b The ‘‘treated’’ fat ready to be inserted using 60-ml syringes

Fig. 3 a–d Insertion of lipograft in the gluteal area

8. Immediate postoperative dressing is performed in the position when lying down, even when large amounts area that was lipoaspirated, avoiding any pressure in of fat are injected. Return to mild physical activities the gluteal area. is allowed after the third postoperative week, and 9. The patient remains hospitalized for 24 h. Analgesics lying down supine is permitted after 2 weeks. A and antiinﬂammatory medications are prescribed nonzippered pull-over female body vest is placed on during the following 7 postoperative days. The the second postoperative day and kept in place for patient is instructed to remain in the supine body 1 month.

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Results their appearance was less than good (‘‘fair’’ 6% and ‘‘poor’’ 1%) (Fig. 5). In this study, the total amount of clean adipose tissue At 24 months, 66% of the patients reported that their transplanted to the buttocks varied from 100 to 900 ml appearance after gluteal fat augmentation was ‘‘very good’’ (mean, 692 ml) (Fig. 4). Nine cases of liponecrosis small (36%) to ‘‘excellent’’ (30%), and 27% responded that their in volume (2.5%) developed in the grafted gluteal area. appearance was ‘‘good,’’ whereas 7% continued to think Liponecrotic lumps were palpated at postoperative evalu- that their appearance was less than good (‘‘fair’’ 6% and ation and after ultrasound confirmation. Aspiration with a ‘‘poor’’ 1%) (Fig. 6). At this writing, the average follow-up large-bore needle connected to a 20-ml syringe was per- time for this group of patients has been 4.9 years. formed as an outpatient procedure. A correlation seemed to exist between the amount of lipograft injected and the liponecrosis complication rate. Patient 1 The total gluteal fat injected was 401 to 600 ml for six patients, 601 to 800 ml for two patients, and 801 to 900 ml A 24-year-old woman presented reporting that she had ‘‘not for one patient. Infection of the grafted area also occurred enough buttocks,’’ which made her ‘‘unattractive’’ (Fig. 7a, for four patients (1%), which was treated by incision c). Liposuction of the back, flanks, and abdomen together drainage and use of oral cephalexin for 7 days. Prompt with autologous gluteal lipografting was performed. The recognition of the infection signs led to immediate treat- total gluteal fat transfer was 530 ml. Photos were taken ment that did not alter the final aesthetic result. However, 3 years after the procedure (Fig. 7b, d). The woman’s one case needed further fat grafting of 20 ml, which was performed as an outpatient procedure. There were no cases of cellulitis in donor and grafted areas, no deep vein thrombosis, and no pulmonary embo- lism. The postoperative body mass index (BMI) of the patients ranged from 17.4 to 25.2 kg/m2 (mean of 21.5 kg/ m2), obtained at the 24-month office visit. Of the 21 patients (6%) who expressed the desire for further gluteal augmentation, 16 had one more session of gluteal fat grafting. No complications were reported for the patients who underwent an additional fat-grafting session. The remaining five patients did not have enough donor area and instead received gluteal silicone implants. At 12 months, 70% of the patients reported that their appearance after gluteal fat augmentation was ‘‘very good’’ (38%) to ‘‘excellent’’ (32%), and 23% responded that their Fig. 5 Schematic representation of the degree of satisfaction appearance was ‘‘good.’’ Only 7% of the patients thought 12 months after autologous gluteal lipografting

Fig. 4 Diagram of the total amount of clean adipose tissue Fig. 6 Schematic representation of the degree of satisfaction transplanted to the buttocks for the 351 patients 24 months after autologous gluteal lipografting 123 220 Aesth Plast Surg (2011) 35:216–224

Fig. 7 a,c Preoperative view of 24-year-old woman complaining of unattractive ‘‘buttocks.’’ b,d Postoperative view of 24-year-old woman 3 years after a 530-ml autologous gluteal lipograft. Her satisfaction 12 and 24 months postoperatively was rated as excellent

satisfaction 12 and 24 months postoperatively was rated as Patient 3 excellent. A 39-year-old woman complained about her buttocks Patient 2 (Fig. 10a, c). Liposuction of the back, ﬂanks, and abdomen together with autologous gluteal lipografting was per- A 30-year-old woman presented for liposuction and mod- formed. The total gluteal fat transfer was 390 ml. Photos erate buttock enhancement (Fig. 8a, c). Liposuction of the were taken 4 years after the procedure (Fig. 10b, d). The back, ﬂanks, and abdomen as part of the composite body woman’s satisfaction 12 and 24 months postoperatively contouring procedure was done. Autologous gluteal lipo- was rated as good. grafting was performed. The total gluteal fat transfer was 460 ml. Photos were taken 4 years after the procedure (Fig. 8b, d). The woman’s satisfaction 12 and 24 months Discussion postoperatively was rated as very good. Computer tomography (CT) imaging of the gluteal area preoperatively and As in every surgical procedure, the success of gluteal fat 24 months postoperatively is shown in Fig. 9. Arrows are grafting is dependent on many factors: the techniques and incorporated in the postoperative CT scan showing the instruments used to harvest the fat tissue, the fat process- transplanted fat. ing, the volumes of fat implantation, the sites to be

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Fig. 8 a,c Preoperative view of 30-year-old woman requesting ‘‘buttock’’ enhancement. b,d Postoperative view of 30-year- old woman 4 years after a 460- ml autologous gluteal lipograft. Her satisfaction 12 and 24 months postoperatively was rated as very good

Fig. 9 a Preoperative computer tomography (CT) imaging of a 30-year-old woman’s glutealarea. b Postoperative CT imaging of 30-year-old woman 24 months after an autologous gluteal lipograft. Arrows indicate the fat graft

implanted, the levels of placement, and even the individual of processing the fat to ensure maximal take and viability patient. Because of this variability and perhaps other fac- of the graft [13]. tors not yet understood, the results of fat grafting with some However, certain proven points should be taken into techniques, in some patients, and in some areas can be account when gluteal augmentation is performed. No sta- unpredictable. A standard procedure has not been adopted tistical differences in adipocyte viability have been dem- by all practitioners. No agreement exists as to the best way onstrated among abdominal fat, thigh fat, ﬂank fat, and

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Fig. 10 a,c Preoperative view of 39-year-old woman complaining about her buttocks. b,d Postoperative view of 39- year-old woman 4 years after an autologous gluteal lipograft. The total gluteal fat transfer was 390 ml. Her satisfaction 12 and 24 months postoperatively was rated as good

knee fat donor sites [14, 15]. A recent paper has reported a tissue architecture of fat will result in eventual necrosis of significant difference in adipose cell concentrations the injected fat. obtained at the different harvest sites. In the lower abdo- Guerrerosantos [17] has performed numerous successful men, the adipose cell concentration was greater than in autologous fat transfers and advocates injection into the other areas, but no significant difference was found in muscle as well as deep into the fat. The transplanted fat relation to the inner thigh [16]. A mixture of fat obtained must have access to a blood supply [18]. The creation of from the abdomen, thigh, flank, and knee areas was used multiple tunnels ensures an adequate blood supply for the for the majority of the patients in this study because the grafted fat. amount of required fat graft could not be obtained by Grafting of the superficial gluteal fat compartment must choosing only a single harvest area. not exceed 20 ml per tunnel due to low vascularity and Recent reports have shown that mechanical centrifuga- excessive compression of the area that can result in li- tion does not appear to enhance immediate fat tissue via- ponecrosis [9]. Intramuscular fat grafting should be done in bility before implantation [15]. An important consideration tunnels also, and retrograde injection should be performed, for harvesting and refinement in preparation for grafting is to avoid intravascular fat injection. Pressure should not be to respect and maintain the tissue architecture of living fat. applied in the grafted gluteal area [19]. Excess fat should Any mechanical or chemical insult that damages the fragile not be injected at one spot.

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For predictable results, the surgeon should refine the fat the surgeon can predict the amount of volume needing to into relatively pure living tissue using sterile conditions be grafted to produce the desired result [9, 28, 29]. and avoiding external contact, thus preventing contamina- Regenerative cell-based strategies such as those encom- tion. Transplanting a high percentage of nonviable com- passing the use of stem cells hold tremendous promise for ponents such as blood and local factors reduces the augmentation of the soft tissue space. Preclinical studies potential for accurate volume estimation. and early clinical series show that adipose-derived stem In contrast to the facial region, in which graft absorption cells offer the possibility of finally fulfilling the key prin- is notoriously high, the rate of volume loss in the gluteal ciple of replacing like with like as an aesthetic filler area and lower limbs is known to be much lower [9]. The without the drawbacks of current technology [30]. average tissue loss because of reabsorption after lipoin- In cell-assisted lipotransfer (CAL), autologous adipose- jection in the buttock varies between 24% and 36%, and derived stem cells (ADSCs) are used in combination with stabilization after the procedure can take up to 1 year [5, lipoinjection. A stromal vascular fraction (SVF) containing 20]. That is the reason why the evaluation was made at a ADSCs is freshly isolated from half of the aspirated fat and minimal follow-up time of 12 months and repeated at recombined with the other half. This process converts 24 months postoperatively. No significant difference in relatively ADSC-poor aspirated fat to ADSC-rich fat. The patient satisfaction was found when the 12- and 24-month preliminary results suggest that CAL is effective and safe results were compared (Figs. 5 and 6). for soft tissue augmentation [31, 32]. There seems to be a relative correlation of the injected Another study has confirmed that the CAL fat can sur- volume and patient satisfaction. The patients who rated vive better (35% better on the average) than non-CAL fat their result as excellent at 24 months had 270 to 740 ml and that the microvasculature can be detected more (mean, 575 ml) injected in their gluteal area. On the other prominently in CAL fat, especially in the outer layers of hand, the patients who rated their result as poor or less than the fat transfer [33].Well-designed studies with long-term poor at 24 months had 130 to 290 ml (mean, 190 ml) results are needed to compare autologous fat transplanta- injected in their gluteal area. There was no correlation tion and the stem-cell-enriched fat tissue [34]. between the cases in which complications occurred and low patient satisfaction. All the patients who had complications from the procedure rated their satisfaction as 3 Conclusion (good) or 4 (very good) (mean, 3.4). The patients who rated their satisfaction as 2 (less than good) or 1 (poor) were The key to successful fat grafting is familiarity with the those who did not achieve their desired gluteal augmenta- technique, knowledge of the gluteal topography, and tion. Comparison of the mean pre- and postoperative BMIs understanding of the patient’s goals. Although the aim of showed that the autologous gluteal lipograft is a method of every surgeon is to produce the desired augmentation of the repositioning the fat from the waist and hips to the but- gluteal region by autologous fat grafting in one stage, the tocks. Pre- and postoperative CT scans were performed for patient should be advised that a secondary procedure may the patients who decided to undergo this procedure and be needed to accomplish the desired result. cover the extra cost for it. Of 351 patients, only 65 agreed to do so, and that is why this parameter was not included in Conflict of interest The authors declare that they have no conflict the evaluation. of interest of disclose. Surgeons have come to realize that transplanted fat can create not only satisfying changes in contour but also long- lasting results [21]. In 2000, a 7-year experience of grafting References aspirated fat in the gluteal region for 233 patients was 1. Neuber F (1893) Fettransplantation. Chir Kongr Verhandl Dtsch presented. In 90% of the cases, the results were considered Ges Chir 22:66 satisfactory [22]. A recent report has shown long-lasting 2. Miller JJ, Popp JC (2002) Fat hypertrophy after autologous fat results of gluteal fat grafting [23]. transfer. Ophthal Plast Reconstr Surg 18:228–231 The current study confirms the senior author’s clinical 3. Illouz YG (1986) The fat cell ‘‘graft’’: a new technique to fill depressions. Plast Reconstr Surg 78:122–123 observation over more than 18 years, with autologous 4. Matsudo PK, Toledo LS (1988) Experience of injected fat gluteal lipograft producing high patient satisfaction and a grafting. Aesthetic Plast Surg 12:35–38 low rate of complications. 5. Illouz YG, Sterodimas A (2009) Autologous fat transplantation to The limitations of fat transplantation are well known, the breast: a personal technique with 25 years of experience. Aesthetic Plast Surg. Epub ahead of print 4 June particularly the long-term unpredictability of volume 6. Ca´rdenas-Camarena L, Lacouture AM, Tobar-Losada A (1999) maintenance [24–26]. The amount of donor fat available Combined gluteoplasty: liposuction and lipoinjection. Plast also is an important limiting factor [27]. With experience, Reconstr Surg 104:1524–1531; discussion 1532–1533 123 224 Aesth Plast Surg (2011) 35:216–224

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