Subfascial Technique for Gluteal Augmentation. José Abel de la Peña, MD

Transcription

1 Subfascial Technique for Gluteal Augmentation José Abel de la Peña, MD

2 Subfascial Technique for Gluteal Augmentation The author performs gluteal augmentation by inserting implants into subfascial pockets after using templates and sizers to determine implant size. He reports that this technique yields good projection, is easily reproducible, and provides predictable results.(aesthetic Surg J 2004;24: ) As cultural standards of female beauty shift, the notion of what constitutes a beautiful gluteal shape changes. The Rubenesque curves of the Renaissance are no longer acceptable to many women. Contemporary women prize muscle definition and a svelte, athletic look. Exceptions are the breasts and the buttocks. In these anatomic regions, a round contour is currently in fashion. In comparison with apes, human beings walk fully upright, have larger brains, and also have larger buttocks. Whether buttock size is a prerequisite to or a consequence of our upright posture is a matter of speculation. Apes have a smaller gluteus maximus muscle that attaches to the ischium only to function as a useful tree-climbing hip extensor. Human beings, on the other hand, have a thick, powerful gluteus maximus muscle that attaches higher up on the ilium to provide the leverage required for walking and standing. Over the last 17 years, I have introduced the concept of subfascial gluteal augmentation and the surgical technique to achieve this. 1 I have also developed an anatomic system for gluteal augmentation, including implants for this procedure. 2 5 Although gluteal augmentation is a safe and reproducible operation, it has not yet gained widespread acceptance among plastic surgeons because of poor results in the early 1980s However, pleasing gluteal contour is an important part of the body aesthetic, and demand is rapidly increasing for surgery to achieve this goal. 16,17 Anatomic Factors It is important to understand some key anatomic factors related to gluteal augmentation. I have found that the best results are achieved by developing a subfascial pocket in the gluteal region in which to place anatomic implants resembling the gluteus maximus (Figure 1). Normally the skin of the gluteal region adheres to the aponeurotic expansion that invests the superficial surface of the gluteal muscles (Figure 2). 18 Because of the aponeurotic expansions, subcutaneous gluteal implants cannot produce good results (Figure 3). Cutting the aponeurotic expansions leads to implant displacement superiorly. Additionally, ptosis of the implant and gluteal skin may occur with subcutaneous implant placement. The submuscular space also has been suggested for gluteal implant placement. 19 This anatomic space should not be used because the sciatic nerve emerges at the level of the junction between the medial and lower thirds of the gluteal region, making it impossible to undermine beyond this point. The result of submuscular implant placement is an unpleasant upper gluteal augmentation with an empty lower third, high incidence of double infragluteal crease (resembling the double-bubble appearance of breast implants positioned below the inframammary sulcus), and a gluteus that appears too long. In an attempt to avoid this problem, a small, round implant was designed for submuscular placement so that the implant is less noticeable if a low volume is used. The anatomic system for gluteal augmentation consists of (1) surgical technique using the subfascial approach, (2) templates to help determine implant size, (3) sizers for use during the operation, and (4) solid or gel-filled implants. Preoperative Markings José Abel de la Peña, MD, Mexico City, Mexico, is a member of the Mexican Association of Plastic, Aesthetic and Reconstructive Surgery. As with every surgical intervention, patient selection is A ESTHETIC S URGERY J OURNAL ~ May/June

3 Figure 3. Undesirable gluteal appearance, with capsule contracture, after insertion of round gluteal implants in the subcutaneous space. Figure 1. Demonstrates the shape and projection of the gluteus maximus muscle that must be achieved to obtain an anatomical gluteal contour. Figure 2. A cadaver dissection demonstrates the aponeurotic expansions that maintain the skin in place in the gluteal region. These expansions run from the dermis and perforate the gluteal fascia into the muscle. the most important issue. The best candidate for gluteal augmentation is a thin patient with a short intergluteal fold. However, as with breast augmentation, this procedure can be performed in a wide range of patients. I admit the patient the night before surgery for skin markings, the administration of antibiotics, and an enema. I mark the patient while he or she is in an upright position, using the templates designed for the operation (Figure 4). The lower limit is 2 cm above the infragluteal fold, the medial limit is the lateral rim of the sacral bone (the implant will always be lateral to the sacrum), and the lateral limit is the projection of the line from the iliotibial line. (Projected on the gluteal region, the iliotibial line represents the external insertion of the gluteal aponeurosis.) The superior limit is marked with the template oriented vertically, toward the posterosuperior iliac spine (Figure 5). The implant is always placed on top of the gluteus maximus muscle and under the gluteal fascia that covers the entire gluteal region, including the gluteal maximus muscle and part of the gluteus medius muscle. During marking, it is important to center the template on the gluteal region, vertically oriented from the infragluteal crease up. The implant must be placed at the level of the infragluteal sulcus, just as in breast augmentation. Undermining will not go beyond the infragluteal fold, so 266 Aesthetic Surgery Journal ~ May/June 2004 Volume 24, Number 3

4 Illustrations by William M. Winn, Atlanta, GA. Figure 4. Markings must follow the anatomic shape of the gluteal region, maintaining the augmented area lateral to the sacral bone and low enough to ensure that the implants are positioned 2 cm above the infragluteal fold. Figure 5. Markings are completed; undermining must exceed 2 cm at the periphery. Subfascial Technique for Gluteal Augmentation A ESTHETIC S URGERY J OURNAL ~ May/June

5 Figure 6. On the left gluteal region, markings are shown for the muscle-fiber orientation for the gluteus maximus muscle. On the upper area, markings are shown for the gluteus medius muscle. An implant sizer is placed on top on the right gluteal region. it is important to place the template 2 cm above the fold (Figure 6). Choice of implant size is based on patient expectations and anatomic evaluation of the gluteal area. Implants must be chosen with the use of the templates so that the implant s transverse diameter will not exceed that of the gluteal region. If a smaller implant is used, the template will be centered on the gluteal region. During the operation, sizers are used to ensure that implant size is correct. Surgical Technique Perform the surgery with the patient under general or epidural anesthesia (with the epidural catheter left in place for postoperative analgesia when regional anesthesia is used). Place the patient in a prone position. While preparing the patient for surgery, leave a 4 4 gauze pad with povidone inside the anus and then place a sterile drape in this area. Begin surgery with a 6- to 8-cm midline intergluteal incision that ends 3 cm above the anus, at the level of the coccyx. This incision, which remains above the presacral fascia, includes skin and subcutaneous tissue (only gluteal aponeurosis undermining is performed over the sacral bone) (Figure 7). Then make a 6- to 8- cm incision on the gluteal aponeurosis, parallel to the external border of the sacral bone. Take care not to cut Figure 7. The gluteal augmentation plan is as follows: midline intergluteal skin incision, gluteal fascia incision, subfascial pocket for implant placement, with the gluteus maximus muscle used as a platform for the implant. Figure 8. Cadaver dissection demonstrates the fasciocutaneous flap that has been raised in keeping with the principles of this operation. Note that a large incision has been used for demonstration purposes; the normal approach is a 6- to 7-cm midline incision exactly in the intergluteal fold. 268 Aesthetic Surgery Journal ~ May/June 2004 Volume 24, Number 3

6 Figure 9. Once the pocket is completed, place a sizer, evaluate the pocket, and assess implant size. The implant should fit loosely in the space. Figure 10. Implant insertion and position. Make sure the implant is perfectly aligned on its long axis. Figure 11. Implants in place. Posterior view shows the relation of the sacral bone, infragluteal sulcus and lateral limits. any fibers of the gluteus maximus muscle; the goal is to raise a fasciocutaneous flap. Once the incision in the fascia has been made, infiltrate Klein s solution under the fascia. On a vascular plane that is interrupted by several septae, you will find the same aponeurotic expansions that continue from the skin into the gluteus maximus muscle. Continue sharp dissection with lighted retractors. Lighted retractors and long instruments for retraction, cutting, and coagulation (to cut all aponeurotic expansions over the muscle) are essential. Bleeding is not a problem if undermining is performed carefully and coagulation is performed simultaneously with dissection. Clearly visualize and ligate perforator vessels of the superior and inferior gluteal arteries. To facilitate subfascial dissection, it is important, from the very beginning of dissection, to continue undermining evenly from medial to lateral, maintaining a wide field to work in (Figure 8). Subfascial Technique for Gluteal Augmentation A ESTHETIC S URGERY J OURNAL ~ May/June

7 Figure 12. Lateral projection and relation of the highest projection point in accordance with natural shape: This point is at the level of the pubic bone. Also note the gluteal fascia covering the implant and the gluteal muscle used as a platform for the implant. Once the pocket is completed, place a sizer, evaluate the pocket, and assess implant size (Figure 9). The sizers are gel-filled smooth silicone implants; the size is indicated on top. Introduce the sizer into the pocket with the same no touch technique used for the permanent implants; use saline solution with an antibiotic (garamycin 80 mg in 200 ml) to wet the implants. After double-checking the pocket and implant size, insert a closed drain to help maintain perfect adhesion of the soft tissues to the implant. Then introduce a solid or cohesive gel-filled implant, making sure that the implant is perfectly aligned on its long axis. The implant should fit loosely in the space; the tissues must be rearranged to fit comfortably with it (Figure 10). I prefer to create both pockets (left and right) before inserting the implants so that the volume of the gluteus does not interfere with dissection of the contralateral pocket. Once the implants have been inserted, begin closure by reattaching the gluteal aponeurosis at the same level where it was cut, placing no tension on the suture. Make a watertight closure with absorbable suture material; I use 2-0 Monocryl (Ethicon, Inc., Somerville, NJ). Next, suture the superficial and deep subcutaneous fascia separately on both sides of the presacral fascia. Finally, fix the skin to the presacral fascia to reconstruct the intergluteal fold, using a running suture of absorbable 4-0 Monocryl on the skin. To maintain a watertight closure, I use Dermabond (Ethicon) on top of the suture (Figure 11). Apply pressure garments and leave in a urinary catheter for the next 12 hours. Send the patient to the recovery room in a supine position. For patient comfort, place pillows above and below the buttocks. Instruct the patient to move her feet and legs as soon as possible and to assume a sitting position only when using the bathroom. Ambulation is started the next morning. Patients may return to their normal activities except for exercise, in 2 weeks and may resume exercise in 2 months. I ask the patient to refrain from bicycle or horseback riding for 3 months. It is important to remember that aesthetic improvement of the gluteal region includes not only volume 270 Aesthetic Surgery Journal ~ May/June 2004 Volume 24, Number 3

8 A B C D E F G H I Figure 13. A, C, E, Preoperative views of a 34-year-old woman. B, D, F, Postoperative views 1 year after liposculpture and subfascial gluteal augmentation with 385-cc Silimed cohesive gel-filled implants. G, H, I, The patient in motion, flexing and extending the hips, 1 year after surgery. Subfascial Technique for Gluteal Augmentation A ESTHETIC S URGERY J OURNAL ~ May/June

9 A B Figure 14. A, Preoperative view of a 31-year-old woman. B, Postoperative view 2 years after subfascial gluteal augmentation with cohesive 445- cc gel-filled implants and liposculpture of the abdominal region. Figure 15. Anatomic textured, cohesive gel-filled gluteal implant, showing the transverse line used as a marker for perfect positioning during the operation. gain but also volume distribution. The maximal projection in the gluteal region must correspond to the level of the pubis when seen in the lateral view (Figures 12 14). If this rule is not followed, we will keep seeing patients with high-projecting, unnatural-looking implants, a long gluteus, and absence of volume in the lower third. This technique provides improvement to the gluteal region and resistance to ptosis when the inferior attachments of the gluteal fascia at the level of the infragluteal sulcus are preserved. To date, I have not observed implant ptosis. A perfect closure and loose-fitting implant are key factors in preventing herniation of the implant through the gluteal fascia. Over the years, many surgeons worldwide have used my technique. It is important to have a precise knowledge of the anatomy and to follow the principles I have delineated. Otherwise, if the implant is placed in the subfascial space but not low enough, the final result will be disappointing. 272 Aesthetic Surgery Journal ~ May/June 2004 Volume 24, Number 3

10 Implant Design We have designed 3 styles of implants: (1) high-profile, cohesive gel filled, textured-surface implants; (2) high-profile, cohesive gel filled, polyurethane-covered implants, and (3) soft solid-silicone, textured-surface gluteal implants. Implants designed in anatomic shapes and with low projection for the gluteal region, are available in each style with the same volumes and dimensions (Figure 15). References 1. de La Peña JA, Lopez MH, Gamboa LF. Augmentation gluteoplasty: anatomical and clinical considerations. Key Issues Plastic Cosmetic Surg 2000;17/ de la Peña JA. Gluteal augmentation. New York, NY: XIII Biennial Congress of the International Society of Aesthetic Plastic Surgery; de la Peña JA. Subfascial gluteal augmentation. São Paulo, Brazil: XIV Congress of the International Society of Aesthetic Plastic Surgery; June de la Peña JA. Advances in gluteal augmentation. Santo Domingo, Dominican Republic: XII Congress, Ibero-latin American Federation of Plastic Surgery; October de la Peña JA. Subfascial gluteal augmentation. Caracas, Venezuela: XVI National Venezuelan Congress of Plastic and Reconstructive Surgery; March de la Peña JA. Gluteal, leg and calf contour with implants. Moscow, Russia: Moscow National Russian Congress in Plastic and Reconstructive Surgery; February de la Peña JA. Advances in gluteal augmentation: state of the art. Las Vegas, NV: International Advances in Aesthetic Surgery Congress of the American Society for Aesthetic Plastic Surgery; April de la Peña JA. Gluteal augmentation: an operation for plastic surgeons. San Antonio, TX: Annual Meeting of American Society of Plastic Surgeons, Hot Topics In Plastic Surgery; Bartels RJ, O Malley JE, Douglas WM, et al. An unusual use of the Cronin breast prosthesis: case report. Plast Reconstr Surg 1969:44: Gonzalez-Ulloa M. A review of the present status of the correction for sad buttocks. Mexico City, Mexico: Fourth Congress of the International Society of Aesthetic Plastic Surgery; Gonzalez-Ulloa M. Gluteoplasty: a ten year report. Aesthetic Plast Surg 1991;15: Buchuck L. Complication with gluteal prosthesis. Plast Reconstr Surg 1986;77: Ford RD, Simpson WD. Massive extravasations of traumatically rupture buttock silicone prosthesis. Ann Plast Surg 1992;29: Hsiao CW. Buttock augmentation with silicone prosthesis: a case report. Changgeng Yi Xue Za Zhi 1994:17: Cocke WM, Ricketson G. Gluteal augmentation. Plast Reconstr Surg 1973;52: Baroudi R. Body sculpturing. Clin Plast Surg 1984:11: Lewis JR. Body contouring. South Med J 1980;73: Warwick R, Williams P. Myology. In: Gray s Anatomy, 35th ed. Philadelphia., PA: W. B. Saunders; 1973: Robles JM, Tagliapietra JC, Grandi MA. Gluteoplastia de aumento: implante submuscular. Cirplast Ibero Latinoam 1984;10: Reprint requests: Dr. José Abel de la Peña, Hospital Angeles de las Lomas, Vialidad de la Barranca S/NO Consultorio 490, Col. Valle de las Palmas, Huizquilucan, Edo de C.P , Mexico; joseabel@avantel.net. Copyright 2004 by The American Society for Aesthetic Plastic Surgery, Inc X/$30.00 doi: /j.asj Subfascial Technique for Gluteal Augmentation A ESTHETIC S URGERY J OURNAL ~ May/June