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479
CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 33 (2006) 479–496
Autologous Gluteal Augmentation
With Circumferential Body Lift
in the Massive Weight Loss
and Aesthetic Patient
Robert F. Centeno,
-
-
MD
Platypygia in the massive weight loss
and aesthetic patient
Evolution of techniques
Technique selection
Autologous flap indications
Clinical anatomy
Flap design and markings
The recent increase in the demand for gluteal
augmentation in the United States is likely a result
of changing demographics, improvement in body
contouring techniques, and an evolution of aesthetic preferences and fashion norms. This article
describes techniques that are more appropriate
than gluteal implants for massive weight loss
(MWL) and other lower body lift patients. These
procedures are designed to conform with current
patient preferences, as well as ideal gluteal aesthetics described elsewhere in this volume. MWL
and aesthetic lower body lift patients have major
deformities in the region of the buttocks. The results obtained with autologous tissue in combination with the circumferential body lift (CBL)
cannot match those typical of gluteal augmentation
in patients who are not overweight and have little
skin excess. Nevertheless, the gluteal aesthetics can
be significantly enhanced by using autologous tissue in the massive weight loss and aesthetic patient
undergoing CBL.
-
-
Operative technique
Complications
Perioperative care and safety
considerations
Summary
References
Platypygia in the massive weight loss
and aesthetic patient
As one ages, anatomic changes occur in the gluteal
region that contribute to platypygia. Several
changes may coexist, including accumulation of
subcutaneous adipose tissue around the gluteal region, loss of adipose volume in the buttock, postmenopausal accumulation of intra-abdominal fat
coupled with rectus diastasis, skin laxity and buttock ptosis, increased hip width, and lengthening
of the infragluteal fold [1–3]. All of these natural
changes contribute to decreased buttock projection
and ptosis, and any one of them may prompt aesthetic patients to seek consultation for body contouring procedures. The CBL effectively addresses
many of these concerns and is often recommended.
Unfortunately, significant flattening of the buttocks
can occur if aggressive lifting is performed to improve contour of the thighs and buttocks. Any preexisting platypygia that is worsened by a CBL may
BodyAesthetic Plastic Surgery & Skincare Center, 969 North Mason Road, Suite 170, St Louis, MO 63141, USA
E-mail address: [email protected]
0094-1298/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
doi:10.1016/j.cps.2006.05.006
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erode satisfaction among both aesthetic and MWL
body lift patients (Fig. 1).
MWL patients are another group greatly affected
by platypygia. Weight loss secondary to diet and exercise or gastric bypass surgery often occurs in an
uneven manner. Data suggest that certain areas of
adipose tissue on the body are more resistant to
weight loss than others [4]. The genetic programming of the resistant adipocytes differs from more
responsive areas, which may mean that genetics influence different somatotypes, or body types. Following weight loss, the ‘‘Apple’’ somatotype seems
to have less adipose tissue in the gluteal region,
while the ‘‘Pear’’ tends to retain more tissue in the
gluteal region. Regardless of body type, however,
many MWL patients tend to lose volume in the gluteal region.
Massive weight loss patients also develop skeletal
changes that may contribute to platypygia (Fig. 2).
Morbid obesity is by definition a restrictive lung disease. It also has an obstructive component that is
more pronounced in the supine position. Expiratory flow limitation in the supine position may
lead to pulmonary hyperinflation and intrinsic positive end-expiratory pressure (PEEP). This is
thought to play a role in the positional orthopnea
reported by obese patients [5,6]. Over time, the thoracic skeleton expands in obese patients to accommodate the increased need for functional reserve
capacity and to accommodate hyperinflation. Thoracic kyphosis secondary to thoracic spine compression and anterior inclination of the pelvis also
occur [7]. Inadequately treated post–gastric bypass
hypocalcemia and vitamin D malabsorption, secondary hypoparathyroidism, and independent negative bone remodeling modulated by either sex
hormone alterations or serum telopeptides may
also worsen these weight-related skeletal alterations
[8]. These changes appear to be permanent and
tend to exacerbate any preexisting primary or secondary platypygia caused by loss of adipose tissue
in the gluteal region.
Fig. 1. Gluteal flattening effect of a circumferential body lift. (A, B, C) This 46-year-old woman had typical gluteal deformities following massive weight loss. Her preoperative photos illustrate preexisting platypygia. (D, E, F)
The postoperative views demonstrate how buttocks lifting can exacerbate this platypygia. In addition, the
straight incision makes her buttocks appear shorter, more square, and masculine after her CBL.
AGA and CBL in the MWL and Aesthetic Patient
Fig. 2. Skeletal deformities encountered in MWL patients include a ‘‘barrel chest’’ from long-term expansion of
the rib cage (A), pelvic rotation (B), and kyphosis (C).
Evolution of techniques
As the author’s clinical experience with the various
forms of alloplastic and autologous gluteal augmentation grew, it became apparent that gluteal implant
designs have limitations, especially in the context of
MWL patients and cosmetic treatment of pronounced platypygia. In addition, whether gluteal
augmentation with implants will be widely accepted
in the United States remains in doubt because the
types of implants available here are limited to silicone elastomer, and complications are not uncommon. Despite this fact, augmentation with
implants is still applicable in certain subsets of carefully selected and well-informed patients. Implant
augmentation can be very successful in enhancing
gluteal aesthetics, but the complication rates limit
their widespread adoption and reduce patient satisfaction. Consistent problems with implant augmentation procedures inspired my interest in and
development of autologous techniques for gluteal
augmentation.
The severe nature of skeletal deformities, skin laxity, and platypygia encountered in the MWL patient
was the natural place to start. MWL patients, with
their significant skin excess and buttock ptosis, are
not ideal candidates for alloplastic augmentation
in any of the three accepted planes: subfascial, intramuscular, or submuscular. Combining excision
with the complications associated with augmentation procedures, especially infection, could be catastrophic [9–13]. Similarly, autologous fat transfer is
not an ideal option for these patients. They must be
repositioned several times during and after surgery,
including the supine position. Lying on transferred
fat may decrease the overall survival of the transfer,
although no data definitively address this issue.
Furthermore, the wisdom of combining extensive
liposuction with excisional procedures in this nutritionally compromised population is debatable.
Excisional procedures (such as CBL) are often characterized by a higher than average rate of minor
complications such as delayed wound healing
[14–23].
The fact that gluteal implantation in conjunction
with posterior excisional procedures seemed imprudent—along with growing experience with the wellvascularized tissue encountered in the posterior portion of a CBL—led to a review of the literature. Deepithelialized flaps have been used in gluteal contouring for some time [24–26]. Published references
to the use of autologous tissue in preventing gluteal
deformities with CBL were also reported, although
they lacked significant detail and did not substantiate their potential for augmentation [27,28]. Descriptions of the superior gluteal artery, inferior
gluteal artery, and transverse lumbosacral back flaps
and their vascular supplies also bolstered the clinical
viability of using autologous tissue flaps for enhancing gluteal volume [29].
The natural evolution of what was learned in the
literature review combined with experience in alloplastic augmentation led to the concept of using
available, well-vascularized autologous tissue in
the buttock region. Instead of discarding this existing tissue, it could be molded into the shape of an
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implant and inset beneath the skin flaps of a CBL.
Three autologous flap designs emerged over time.
The first flap design, called an Island AGA Flap, simulated the round, non-anatomic design of submuscular gluteal implants (Fig. 3). This flap produces
good results (Figs. 4 and 5), but long-term augmentation was modest with the Island flap.
Some drawbacks of the Island flap led to the evolution of a second flap design, the Propeller AGA
Flap (Fig. 6). Other reasons for developing this design included the need to address the postsacral
pain reported by MWL patients owing to a paucity
of sacral tissue while also recruiting additional tissue
for augmentation purposes as suggested by Pascal
and Le Louarn [27]. However, the Propeller flap
had its own disappointments: the amount of volume that could be added with this flap was minimal
and the gluteal projection it did produce was located
in a higher than ideal location, as shown in Fig. 7.
Although neither the Island nor the Propeller flaps
could be considered complete failures, the aesthetic
results were less than optimal and the amount of volume they delivered was insufficient to overcome the
gluteal flatness produced by a CBL in MWL patients.
However, experience with these two early flap designs was valuable because it led to development
of the author’s preferred technique, the Moustache
AGA Flap (Fig. 8). The Moustache flap uses the
back and lateral flank tissue as a partial island and
partial transposition flap based on perforators
from the superior gluteal artery and lumbar perforators [30]. Superio-medial transposition of the ‘‘handle-bar’’ portions of the Moustache flap allows
recruitment of additional tissue for augmentation
purposes to produce greater projection and also
lower the point of maximum buttock projection to
the level of the mons pubis, which is considered
the aesthetic ideal. In addition, imbrication of the
flap with sutures permits formation of a more anatomically shaped tissue mound that is reminiscent
of anatomic gluteal implants. Because resection of
tissue from the central area of the flap to allow easier
insetting would likely decrease projection, the tissue
volume in the central area of the flap is included
to decrease symptoms and prevent lateral flap
displacement. This final evolution of flap design,
the Moustache flap, is currently my procedure of
choice when significant, long-lasting aesthetic augmentation is desired (Figs. 9 and 10).
Technique selection
Selection of a technique for gluteal contouring in
the MWL or aesthetic patient begins by determining
the status of the subcutaneous adipose tissue in the
gluteal region and the surrounding areas of the
Fig. 3. Island flap design.
(A, B) The Island flap is outlined and de-epithelialized.
(C) The flap dissection is
beveled down through the
dermis, SFS, the lumbosacral and gluteal fascia, and
surrounding excess tissue
is removed down to the
level of the lumbosacral
fascia. This creates the two
dermal ‘‘islands’’ of tissue.
(D) The superior half of
each island is imbricated
(dermis to SFS), and the inferior aspects of the islands
are anchored to the gluteal
fascia at the desired level.
As the inferior CBL skin
flap is elevated and advanced over the AGA flap,
the overlying CBL and underlying AGA flaps are attached together with #1
Vicryl Plus quilting sutures
to reduce dead space.
AGA and CBL in the MWL and Aesthetic Patient
Fig. 4. Island flap results. (A, B, C) Preoperative views of a weight loss patient who wanted a CBL with an Island
flap. (D, E, F) Although these postoperative views show that her scar has not completely settled and is widened
in some areas, the patient is apparently able to hide them beneath a small bikini.
torso and lower extremities. A lack or an excess of
subcutaneous volume serves as the starting point
for technique selection. Next, the quality and laxity
of the skin of the abdomen, flanks, hips, back, and
buttocks, as well as the anterior, lateral, and posterior thighs are noted. The results of this physical examination are then used as a guide through the
‘‘Lower Trunk Algorithm’’ for body contouring presented in Fig. 11. If, based on the algorithm, a circumferential body lift is indicated and gluteal
augmentation is also desirable, then an AGA flap
is included as part of the CBL.
The Gluteal Augmentation Algorithm shown in
Fig. 12 illustrates the preferred choices for gluteal
augmentation under various conditions. In our
practice, the safest results are obtained with the use
of autologous tissues, either as a flap or as transferred
fat. However, the Moustache flap has made supplemental procedures such as staged fat transfers or
alloplastic implants almost irrelevant because of
the significant augmentation achieved with this
flap. The high complication rates experienced with
various forms of implant augmentation have relegated these procedures to the last resort for our patients—and only for those who are well informed
and compliant [31].
Autologous flap indications
Once AGA with CBL is chosen, selection of the appropriate flap design is the next step (Table 1). The
Island AGA Flap design produces the smallest volume of tissue and consequently the least amount
of augmentation. However, it is indicated for minimizing the gluteal flattening effects of a CBL in patients who have sufficient preoperative buttock
projection or do not desire increased gluteal volume. This flap should be used only for patients
with adequate tissue overlying the sacrum. Inadequate postsacral tissue typically elicits complaints
of pain in the coccyx or sacral area when sitting, especially from MWL patients. The Island flap’s point
of maximum projection usually lies slightly above
the transposed level of the mons pubis, a location
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Fig. 5. Island flap results in a patient who lost a significant amount of weight and was left with major skin wrinkling and tissue laxity.
that is often preferred by African American and
Asian women as well as male patients [31]. See
the article by Roberts and colleagues elsewhere in
this issue for further exploration of this topic.
The Propeller flap was originally designed for patients who had mild preoperative platypygia, those
who desired modest augmentation, and those with
a symptomatic paucity of postsacral tissue. The Propeller flap produces more volume than the Island
flap, as well as a central bridge of tissue that can
be used for ‘‘padding’’ the postsacral area to decrease symptoms. However, this flap’s design places
the point of maximum projection significantly
higher than the transposed level of the mons pubis,
and the inferior pole of the buttocks looks ‘‘empty.’’
This flap design quickly fell out of favor in the
Fig. 6. Design of the Propeller flap.
author’s practice and has since been abandoned. For
this reason, it is not shown as an option in Table 1.
The Moustache AGA Flap is the design of choice
when definitive augmentation is desired. It yields
the greatest amount of volume, produces superior
aesthetic results, and the augmentation achieved
seems to be long lasting. The flap is quite flexible
in that both its height and width can be adjusted
to produce the amount of volume desired by the patient. Thus, the flap can be easily ‘‘down-staged’’ during surgery as the clinical situation demands. It
potentially addresses the symptoms of postsacral tissue deficiency by maintaining a central bridge of tissue, which also serves the purpose of maintaining
appropriate flap position and reducing the risk of delayed wound healing in the central ‘‘water-shed’’ area
of the posterior CBL incision. Because it recruits lateral trunk tissue inferio-medially, the final point of
transposed maximum projection is at the level of
the mons pubis, which is the most generally accepted gluteal ideal. Patients with a post–weight
loss body mass index (BMI) below 25, skin laxity,
buttocks ptosis, and platypygia are ideal candidates
for a Moustache flap. Higher BMI patients also benefit from the Moustache flap, but the results are less
aesthetically pleasing.
Regardless of the flap design chosen, the volume
of the flaps described can be adjusted as required
by the clinical situation and the patient’s wishes. Although larger flaps produce more augmentation,
smaller ones are sometimes desired, especially if it
becomes apparent that an increased margin of safety
AGA and CBL in the MWL and Aesthetic Patient
Fig. 7. (A, B, C) A massive weight loss patient who still had subcutaneous fat but not the skin and tissue wrinkling
evident in the patient seen in Fig. 5. (D, E, F) After undergoing a CBL with a Propeller flap, it is evident that the
point of maximum gluteal projection is much higher than ideal, the amount of augmentation is minimal, and
the inferior buttocks look ‘‘empty.’’ These photos were taken approximately 1 month after surgery and areas of
delayed wound healing are present. This may be because she was a smoker. Her incision eventually healed well.
is needed to guarantee tissue perfusion, or if a larger
flap places excessive tension on the posterior CBL
flaps. The only limitation to larger flap volume is
the upper border of the skin marking pattern used
for a CBL. All three types of flaps can be ‘‘downstaged’’ intraoperatively or resected if an AGA flap
cannot be positioned appropriately or accommodated when the upper and lower buttock lift flaps
are brought together. If there is any concern about
tissue perfusion, excessive tension on the CBL closure, or inability to close the flaps over the autologous tissue mound, the autoaugmentation should
be abandoned so as not to compromise the safety
of the lift procedure.
Clinical anatomy
The integrity of superficial anatomic structures of
the lateral trunk, posterior trunk, and gluteal region
are most at risk of injury during the posterior
portion of a CBL or buttock-flank lift. (See the article on gluteal anatomy earlier in this volume.) The
iliohypogastric and ilioinguinal nerves are both
branches of the L1 nerve root and originate in the
sacral plexus. These nerves travel inferio-medially
between the transversus abdominis and internal
oblique muscles. The iliohypogastric nerve divides
into lateral and anterior cutaneous branches to supply the skin above the pubis and overlying the lateral gluteal region. Circumferential body lift
incisions made at or below the inguinal crease can
put these nerves at risk.
The lateral cutaneous branches of the iliohypogastric and the intercostal nerves also can be entrapped
laterally during a CBL. This can occur if aggressive
lateral plication of the external oblique muscle is
performed to enhance waist definition or if ‘‘3point’’ or quilting sutures are used laterally to close
‘‘dead space.’’ Sensation to the gluteal region and lateral trunk has several sources: the dorsal rami of
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Fig. 8. (A) Outline of the Moustache flap design shows placement of the central bridge of tissue and lateral flap
extensions, or handle-bars. (B) The flap is de-epithelialized and the moustache handle-bars are elevated from
the fascia. (C) The handle-bars are rotated medially, any excess lateral tissue is trimmed off, and the flap is imbricated to itself laterally to prevent trochanteric fullness. (D) The rotated flaps are fixed centrally to the gluteal
fascia with #1 Vicryl Plus and imbricated to create an anatomic mound of tissue. (E) Closure of the Moustache
flap (as described in the text) and sparse stapling.
sacral nerve roots 3 and 4, the cutaneous branches of
the iliohypogastric nerve arising from the L1 root,
and the superior cluneal nerves originating from
the L1, L2, and L3 roots and then passing over the iliac crest. The protective cutaneous sensation transmitted by these nerves is temporarily disrupted
during a CBL, with or without autoaugmentation.
Patients should be counseled about the need for frequent positional changes and avoidance of heating
pads and electric blankets to prevent pressure necrosis or burns.
Perfusion to the skin overlying the gluteal region
is supplied by perforating branches of the superior
and inferior gluteal arteries, both of which branch
from the internal iliac artery. The lumbosacral region is also supplied by lumbar perforators.
Some of these perforators must be sacrificed during the posterior portion of a CBL, an AGA with
CBL, or a buttock-flankplasty; however, the abundant vascular supply of the gluteal region provides
robust perfusion to surrounding tissue flaps
[29,30,32].
The fascial anatomy of the gluteal region greatly
affects the aesthetics of the aging buttock. In addition to volume loss and skin laxity, relaxation of
the fascial ‘‘apron’’ contributes to gluteal ptosis. Resection and tightening of this superficial fascial
‘‘apron’’ not only improves gluteal ptosis, but also
plays a significant role in the CBL procedure and
AGA with CBL. This fascial apron is analogous to
the superficial fascial system (SFS). Similar to the
role played by the deep gluteal fascia as a strong retaining fascia in the subfascial approach to augmentation with implants, it also serves as a fixation point
in AGA with CBL. The superficial apron and the
deep gluteal fascia fuse and become tightly adherent
to form the infragluteal fold, a structure that should
not be violated because it is exceedingly difficult to
re-create [2].
Flap design and markings
Preparing a patient for an AGA with CBL begins
with the CBL markings. However, the posterior
markings are placed lower than usual to allow for
autologous augmentation in the lower pole of the
buttock and to conform to the gluteal aesthetic
units illustrated in Fig. 13 [33]. The patient should
be standing for the initial flap markings. Autologous gluteal augmentation may be performed independent of a CBL but requires, at a minimum, the
markings for a buttock-flank lift. The point of maximum gluteal projection is transposed from the
level of the mons pubis onto the buttocks, with
AGA and CBL in the MWL and Aesthetic Patient
Fig. 9. Before (A, B, C) and after (D, E, F) photos illustrate results of the Moustache flap combined with a CBL in a
MWL patient who requested gluteal augmentation. The patient is less than 1-month postop, but her wound is
healing well, and her gluteal volume is greatly enhanced.
this point used to identify the center of the augmentation flap for each buttock.
The desired flap design markings begin at the
most inferior resection mark in the gluteal region.
This is achieved by outlining a circle that measures
11 to 15 cm so the inferior edge of the circle sits at
the line denoting the most inferior extent of tissue
to be resected (Fig. 3). This circle is centered from
medial to lateral over each buttock. The size of
the circle is determined by the preoperative gluteal
dimensions, the amount of augmentation desired,
and the limits of the CBL or buttock-flank lift markings. If indicated, as in the Moustache flap, a central
bridge of tissue over the postsacral region is drawn
to connect the two circles. The lateral portions of
the flap, or ‘‘handle-bars’’ of the Moustache, are
then drawn according to the desired width and
length of the flap (Fig. 8). Starting at the lateral aspect of the circle outline, use a towel or string to determine adequate superio-medial transposition of
the ‘‘handle-bars’’ of the Moustache flap pattern.
The marked point of maximum gluteal projection
serves as a guide for final tissue flap positioning.
The patient is marked for the central portion of
the resection while bending forward to simulate
the tension placed on the incision when the patient
is placed postoperatively in the semi-Fowler’s position [17]. This bending maneuver is important in
the author’s opinion because the central fascial attachments at the spinal column are fixed and do
not allow much cranio-caudad movement of the
skin flaps.
When the patient is placed on the operating room
table in the prone position (with adequate padding
of the face, trunk, and extremities), the superior and
inferior markings for the posterior portion of the
CBL can then be adjusted to accommodate the autologous tissue flaps, to ensure the safety and adequacy
of the resection, and to conform to gluteal aesthetics
as much as possible. Once the patient is in the prone
position, the markings for the superior incision in
the lumbosacral area usually need to be moved
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Fig. 10. Before (A, B, C) and after (D, E, F) photos of a patient who lost a significant amount of weight and
needed multiple body contouring procedures. Her incision is still healing. The less than ideal contour of the right
buttock may improve over time as the flap settles.
inferiorly by 2 to 3 cm so the incision will form an
‘‘inverted-dart’’ shape that ends just above the intergluteal crease (Fig. 14A). This ‘‘V’’ shaped incision
will preserve the important ‘‘sacral triangle’’ gluteal
aesthetic unit (Fig. 14B). If preferred, this central
portion of the superior marking may be left unmarked until the patient is brought into the operating room and placed in the prone position.
This ‘‘inverted dart’’ adaptation was developed
because traditional descriptions of posterior CBL
markings produce an incision—and scar—that is either aesthetically too high, violates the gluteal aesthetic units, or gives the buttock an elongated or
square appearance [14,15,17–19,21,34–36]. The final placement of markings for the posterior portion
of a CBL with AGA represents somewhat of a compromise. To develop a flap that adds volume in the
middle and lower pole of the buttocks and does not
violate the gluteal aesthetic units, the markings
must be lower than traditional descriptions.
In addition to this inverted dart design, we have
recently made another modification to the posterior CBL incision that creates a ‘‘sacral triangle plateau.’’ This modification was added because there
is a possibility that the inverted dart might diminish
skin perfusion. To prevent this, a well-vascularized,
Fig. 11. Lower Trunk MWL Algorithm.
Loss of volume
Yes
No
Gluteal hypoplasia
Yes
No
Gluteal aug.
(auto or implant)
Stop
Volume excess
No
No
Yes
Skin Laxity
Yes
Abdomen only
Liposuction of
lateral thighs
or buttocks
Flanks & back
Abdominoplasty
Circ. Body Lift
AGA and CBL in the MWL and Aesthetic Patient
Fig. 12. Gluteal Augmentation Algorithm.
Gluteal hypoplasia
Stop
No
Yes
Skin laxity
No
Yes
Circumferential body lift
Surrounding lipodystrophy
Yes
+ Auto-Aug
+ Auto-Aug
& staged
fat transfer
+ Auto-Aug
and implant
No
Trunk & lower
extremity SAL
+ autologous
fat transfer
Gluteal aug.
with implants
de-epithelialized bed of tissue is now preserved centrally in all AGA flap designs and CBL procedures to
reduce dead space in the medial area and provide
perfusion to the overlying skin to enhance wound
healing (Fig. 15; also see Fig. 4 in the article on gluteal anatomy earlier in this volume). Preserving this
central plateau of tissue has the added benefit of increasing the soft tissue padding over the sacrum and
coccyx, a lack of which can be painful for MWL patients. The sacral triangle plateau plays another role
in CBL and AGA procedures by greatly enhancing
aesthetic unit #3 in the posterior-anterior view
and possibly the lumbosacral curvature in the lateral view for patients with soft tissue paucity in
the sacral/buttock region. Results of this sacral triangle plateau modification are illustrated in Fig. 16.
Placing the inverted dart incision at the junction
between several gluteal aesthetic units improves the
appearance of the buttocks in the PA view, but the
waist appears to be widened (Fig. 17). This problem can be overcome by performing adjunctive liposuction and avoiding aggressive plication of the
rectus muscles during the abdominal component
of a CBL. In contrast, a high posterior CBL incision
can enhance lumbar lordosis, raise the point of
maximum gluteal projection, and better define the
waist in the PA view. However, this comes at the expense of a permanently elongated buttock on the
PA view and an incision that may be visible above
normal underwear or clothing (Fig. 18).
Operative technique
Table 1: Indications for flap designs
in AGA with CBL
AGA Island
flap
Prevention of
CBL flattening
Normal/mild
platypygia
Upper pole
projection
desired
African
American,
Asian, and
male patients
Normal
postsacral
tissue without
symptoms
AGA
Moustache
flap
Sacral
triangle
plateau
Prevention of
CBL flattening
Moderate/
severe
platypygia
Mons pubis
level
projection
desired
All ethnic
groups and
both sexes
Presacral pain
Postsacral
tissue deficit
with
symptoms
Postsacral
tissue deficit
with symptoms
Normal/mild
platypygia
Absent
lumbosacral
curve???
All ethnic
groups
Abbreviations: AGA, autologous gluteal augmentation;
CBL, circumferential body list.
Creation of an AGA flap begins with de-epithelialization of the flap design that has been marked.
The sacral triangle plateau is also de-epithelialized
and the dermis is incised. Both the Island and
Moustache flaps are dissected in a beveled fashion
with electrocautery down through the dermis, SFS,
gluteal fascia, and lumbosacral fascia. The sacral
fascia is left intact. Next, the surrounding tissue is
resected as planned to complete the CBL or buttock
lift, with the lateral extent of the incision resected in
a ‘‘V shape.’’
The portion of the inferior CBL flaps that will be
centered over the buttocks are symmetrically dissected below the SFS but above the gluteal fascia
down to, but not beyond, the infragluteal fold.
These areas centered over the buttocks will form
two pockets to hold the tissue mounds created in
the AGA. At the lateral aspect of each pocket, a tissue
bridge is left in place to prevent lateral displacement
and postoperative malposition of the AGA flap.
Drains are then placed bilaterally in the inferiormost aspect of the dissection pocket, coiled, and
temporarily buried in the lateral aspects of the
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Fig. 13. Ideal gluteal aesthetics include eight aesthetic units that should be incorporated into the planning of
a CBL, especially with autologous augmentation. The eight units are two symmetrical ‘‘flank’’ units (1 and 2),
one ‘‘sacral triangle’’ unit (3), two symmetrical buttock units (4 and 5), one infragluteal ‘‘diamond’’ unit (6),
and two symmetrical thigh units (7 and 8).
wound. The lateral ‘‘V-shaped’’ extent of the incision
is temporarily closed with staples bilaterally.
A Moustache flap essentially incorporates an Island flap with the ‘‘handle-bars’’ wrapped around
it. To create the island portion of a Moustache
flap or an Island flap alone, the superior portion
of each flap is imbricated from the 9:00 to the
3:00 positions with #1 Vicryl Plus suture from the
dermis to the SFS to form a rounded mound of tissue that will improve buttock projection. If a Moustache flap is being performed, the ‘‘handle-bar’’
extensions of the Moustache are dissected from
the posterior thoracic fascia until superior-medial
rotation reaches the medial extent of each half of
the flap. The dermis of the ‘‘handle-bar’’ is anchored
to the dermis of the medial extent of the flap and to
the gluteal fascia superio-medially. Next, the Moustache flap is imbricated from the dermis to the SFS
from the 4:00 position to the 1:00 position. The
central oblique line that results from the superiomedial rotation of the ‘‘handle-bar’’ is then imbricated to itself from dermis to dermis to form
a well-shaped anatomical autologous tissue mound
that will increase projection and add fullness to the
lower pole of the buttock.
Both AGA flaps are anchored inferio-medially to
the most caudal aspect of the pocket from the dermis
to the intact gluteal fascia with 1 to 3 #1 Vicryl Plus
sutures. As the inferior CBL skin flap is advanced
over the AGA flap, the overlying CBL and underlying
Fig. 14. (A) Illustration of the low ‘‘inverted-dart’’ incision modification of the posterior circumferential body lift.
(B) Postoperative view of a CBL patient with a well-placed inverted dart and lowered CBL incision.
AGA and CBL in the MWL and Aesthetic Patient
Complications
Fig. 15. Design of the ‘‘sacral triangle plateau’’ in association with a CBL that incorporates an inverted dart
incision.
AGA flaps are attached together with #1 Vicryl Plus
quilting sutures to reduce dead space. The CBL or
buttock lift incision is temporarily closed with towel
clips. Once symmetry is confirmed, the SFS is closed
with #1 Vicryl Plus. The deep and superficial dermis
are closed with 3-0 PDS Monocryl interrupted sutures and subcuticular sutures, respectively. The incision is dressed with Dermabond and allowed to dry.
The posterior CBL incision is reinforced with a sparse
row of temporary staples, which are removed in 3 to
5 days.
Complications directly related to autologous gluteal augmentation in our 21 patients who have
had the procedure in association with CBL are
shown in Table 2. None were major complications.
The incidences do not seem to be significantly different from (and may be lower than) complications
reported for CBL alone. For circumferential body
lifts, the reported rates of delayed wound healing,
epidermolysis or skin necrosis widely range between 0% and 77%, with overall complication rates
in the range of 10% to 80% [14–23].
The robust vascularization of an AGA flap and
limitation of flap dissection to no more than two
contiguous angiosomes seem to provide good flap
perfusion and viability. One case of minor fat necrosis among our patients likely resulted from an
excessively long ‘‘handle-bar’’ lateral extension of
the Moustache flap into the ‘‘posterior-intercostal’’
angiosome as described by Taylor [30]. Because
this lateral extension is undermined to allow superio-medial transposition of both halves of the
Moustache flap, the ‘‘two adjacent angiosomes’’
limitation of perforator flap perfusion may have
been exceeded.
Delayed wound healing is among the most common complications following CBL, and minor delayed wound healing occurred in 24% of our 21
Fig. 16. The sacral triangle plateau incorporated into a CBL was very helpful for reducing postsacral discomfort
and improving the upper buttock contour.
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Centeno
Fig. 17. (A, B, C, D) Low incision
placement with an inverted
dart enhances buttock appearance by shortening the apparent
gluteal length in the PA view at
the expense of diminishing waist
definition.
CBL with AGA patients. However, this frequency is
similar when patients receiving CBL alone are compared with those receiving AGA with CBL. The majority of patients undergoing AGA are MWL
patients, who are likely to be at greater risk for surgical complications than typical, healthy aesthetic
patients. Nonetheless, the undermining of the inferior CBL flap and tension on the closure is greater
when AGA is added to the CBL. This can lead to
wound-healing problems especially in the central
aspect of the incision, which is the ‘‘watershed’’ region of tissue perfusion.
Careful preoperative planning to avoid over-resection and beginning with conservatively sized flaps
are helpful in preventing serious wound-healing
problems, skin necrosis, and dehiscence. While
this may limit the quality and aesthetics of a surgeon’s early results, significantly better outcomes
can be achieved after more experience is gained.
Large, clinically significant seromas because of
dead space can be reduced by putting drains in
the most dependent portion of the gluteal pockets.
Quilting sutures are now routinely used to further
reduce dead space. Doxycycline sclerosis is the procedure of choice for managing postoperative seroma or excessive drain output in CBL patients.
Tissue sealants are not currently used owing to
cost considerations and the absence of convincing
data regarding their effectiveness. As the collective
experience with sealant products continues to accumulate, they may play a future role in the management of seromas in patients undergoing CBL with
or without AGA.
Ano-rectal hypersensitivy or maceration due to
overexposure of the anus has occurred in two of
our patients. In both cases the problem was self-limited as the expected skin laxity relapse and skin creep
occurred. Until this problem resolves, it can be
AGA and CBL in the MWL and Aesthetic Patient
Fig. 18. (A, B, C, D) High incision
placement enhances waist definition and lateral projection at
the expense of elongating the
buttocks.
managed with topical anesthetics such as Anusol,
skin protectants, ‘‘donut’’ cushions for sitting, frequent positional changes, a high-fiber diet, sitz
baths, and ‘‘baby wipes’’ for cleansing the area. Patient reassurance about the temporary nature of
the problem is imperative.
Perioperative care and safety considerations
MWL patients who undergo multiple body contouring procedures are subjected to a great deal of
physiological stress and require attentive postoperative management. On average, AGA with CBL patients prefer 2 to 3 days of hospitalization. Blood
loss, temperature, electrolytes, fluids, and deep
vein thrombosis/pulmonary embolism (DVT/PE)
prophylaxis issues are routinely monitored from
the perioperative period to discharge.
Thirty minutes before anesthesia is to be administered, patients are pre-warmed with a forced-air
warming blanket, intravenous prophylactic antibiotics are administered, and intermittent pneumatic
compression devices are started. Every effort is
made to maintain normothermia [37,38]: the operating room temperature is raised to a maximum of
73ºF, core temperature is carefully monitored and
maintained at least to 36ºC, exposed areas of the
patient are minimized, intravenous and tumescent
fluids (if used) are warmed to between 37º and
43ºC, and body temperature is managed with ‘‘on
table’’ as well as upper and lower body forced air
warming blankets. This minimizes the impact of
hypothermia on the coagulation systems while
also reducing the risks of postoperative wound infections [39–42].
The patient is placed in the prone position on an
operative bed covered with a full-length gel mattress.
Adequate padding of the face, eyes, and peripheral
nerve pressure points is confirmed to prevent injury
[43,44]. Hemodynamic and ventilatory stability are
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confirmed once the patient is in the final operative
position [45,46]. Intraoperative FiO2 is increased
to 80% and continued with a ‘‘non-rebreather’’
mask in the PACU for 2 hours postoperatively because evidence indicates that both interventions reduce the incidence of postoperative infection and
nausea [41,47–49].
Routine postoperative laboratory studies include
a complete blood count and basic metabolic panel,
serum calcium, magnesium, and phosphate. Other
studies such as glucose monitoring, total protein,
albumin, and coagulation studies are performed
as indicated [50]. Foley catheter placement for
monitoring urine output is also routine. Prophylactic antibiotics are used for 24 hours unless grafts are
in place, in which case antibiotics are continued for
5 to 7 days.
DVT/PE prophylaxis includes the use of intermittent pneumatic compression devices until discharge, with their removal for and reapplication
after ambulation. Ambulation begins the morning
after surgery and its necessity is stressed throughout
the postoperative period. Postoperative low molecular weight heparin (such as Lovenox) or fondaparinux (Arixtra), and possibly warfarin, are used
synergistically with compression devices and ambulation for patients at high risk for DVT/PE or with
a history of previous DVT/PE. Most MWL patients
are in a high-risk category so DVT/PE prevention
must be taken seriously [51]. The dosing of these
medications often needs to be adjusted for obese
patients [52]. Patients are routinely typed and
cross-matched if chemoprophylaxis is anticipated
because transfusion rates anecdotally appear to be
slightly elevated. Postoperative hematomas, while
Table 2: Complications occurring in 21
patients
Complications
AGA with
CBL, n (%)
Seroma requiring drainage
Superficial wound dehiscence
Major wound dehiscence
Minor delayed wound healing
AGA flap malposition
Infection
Palpability
Minor fat necrosis
Major fat necrosis
Skin necrosis
Pressure sores
Temporary anal overexposure
DVT/PE
1
3
0
5
1
1
1
1
0
0
0
2
0
(5)
(14)
(24)
(5)
(5)
(5)
(5)
(10)
Abbreviations: AGA, autologous gluteal augmentation;
CBL, circumferential body list; DVT/PE, deep vein thrombosis/pulmonary embolism.
possible, are not common. A low index of suspicion
should be maintained and appropriate diagnostic
studies ordered when postoperative anticoagulation is used.
Gastric bypass surgery patients can be placed on
a low concentrated sweets ‘‘bariatric’’ liquid diet
once alert. Consultation with a dietician is ordered
to plan a postoperative diet that will meet the needs
of bariatric patients and ensure adequate protein intake to support wound healing. Attention to protein
intake in a suitable form and avoidance of concentrated sweets also reduces postoperative gastrointestinal symptoms associated with an inappropriate
diet. Communication with the bariatric surgeon
facilitates consultation if a gastrointestinal issue
becomes apparent.
Compression garments are not routinely used
postoperatively. Concerns about skin perfusion
and pressure necrosis over drains relegates their
use to the late postoperative period. Traditional
dressings have been replaced by tissue glues, such
as Dermabond, to allow monitoring of skin perfusion and to reduce blistering caused by shear forces
and postoperative edema. Sparse placement of reinforcing skin staples on the posterior aspect of the
CBL incision seems to reduce the incidence of superficial wound dehiscence caused by excess tension because of flexed posture and postoperative
edema. The staples are removed as early as the first
postoperative visit, as skin tension allows, to prevent scarring.
Drains are removed once the output is less than
50 cc in 24 hours. If drainage is excessive or prolonged, sclerosis can be performed with a high-concentration doxycycline solution (500 mg in 50 cc
0.9% normal saline solution) by infusing it through
the drain, clamping for 15 to 30 minutes, and then
returning to suction. Before performing sclerosis,
local anesthesia may be given by infusing
a weight-appropriate dose of 0.5% Marcaine into
the seroma cavity. Because post-procedure pain
may last for 8 to 24 hours after sclerosis, oral narcotics are recommended. This procedure may
need to be repeated several times before a significant
reduction in drainage output is observed. The inflammatory properties of doxycycline make this
concentration higher than the recommended intravenous dosage; thus, this sclerosis procedure is an
‘‘off-label’’ use of the medication, and patients
must be informed of this status. If a seroma occurs
after drain removal, the seroma cavity may be injected with doxycycline. Special precautions should
be taken to ensure that the solution is not injected
into the subcutaneous tissue because fat and skin
necrosis may develop. Pain is usually indicative of
subcutaneous infusion; if it occurs, the procedure
should immediately be stopped.
AGA and CBL in the MWL and Aesthetic Patient
Summary
Autologous gluteal augmentation with CBL or buttock-flank lift in the MWL or aesthetic patient is
a useful adjunct in body contouring surgery. The
techniques described represent an alternative to alloplastic augmentation and other less applicable
autologous techniques (such as fat transfer) for improving gluteal contour in both the MWL and the
aesthetic patient for whom an excisional procedure
is indicated. AGA with CBL seems to achieve longlasting correction of platypygia with an acceptable
safety profile. Further refinement of these techniques, adjunctive procedures, and improved
patient selection will likely lead to fewer complications and improved aesthetic outcomes.
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