FOLLOW-UP

Combined Gluteoplasty: Liposuctionand Gluteal ImplantsLazaro Cardenas-Camarena,

M.D.Juan Carlos Paillet, M.D.

Zapopan, Jalisco, Mexico; andSanta Fe, Argentina

Throughout time, body contouring has beenpart of the feminine standard par excellence,with the breast and buttocks being the most

relevant and important areas. Today, there is aconstant evolution in surgical procedures that seekto improve the areas of sparse volume and harmo-nize areas that exhibit excess tissue. A considerablenumber of alternatives for improving gluteal con-tour have been pointed out in multiple studies.Some authors claim good results using liposuctiontogether with fat infiltration.1–4 Others use liposuc-tion exclusively in adjacent areas, producing bettergluteal projection, volume, and appearance, with-out the necessity of specific manipulation of thearea.5–8 Still other authors demonstrate the efficacyof using gluteal prostheses, and their indicationsand advantages over fat infiltration. Each one dem-onstrates the virtues and advantages with regard tothe placement plane, the surgical technique, andthe type of implants.9–13 This constant evolutionimpels us to seek treatment alternatives for patientswith marked gluteal hypoplasia and fat deposits inadjacent areas that exacerbate gluteal deformityand simply do not improve their aesthetic appear-ance. For this reason, we are presenting our casu-istic on the combination of liposuction and glutealimplant placement to improve the contour of thisarea, a combination that up to now has been de-tailed very little in the medical literature.

PATIENTS AND METHODSA retrospective review was conducted on our

patients who underwent surgery for gluteal area

improvement between October of 1999 andMarch of 2005. The study included and analyzedall those who required gluteal implant placementand liposuction of adjacent areas to achieve inte-gral enhancement of the area. The principal au-thor (L.C-C.) operated on all of the patients,whose ages ranged from 22 to 51 years, with anaverage age of 26 years. Implants of different sizesand models were used, depending on the needsand preferences of each patient. Liposuction wasperformed using the tumescent technique in thelumbar, trochanteric, and subgluteal areas, de-pending on the requirements of each case.

Surgical TechniqueThe patients are marked preoperatively in two

positions: standing and seated. While standing,the liposuction areas are delimited. The lumbar orsupragluteal area, the trochanteric area, and thesubgluteal area are marked. With these areas de-limited, the patient is placed in a seated positionfor marking the lowest line of the gluteal area. Thisline will represent the implant’s inferior limit,which will encompass the upper two-thirds of thegluteal area. The implants will be placed at ap-proximately 4 cm from the medial line of thebuttocks, with a slight upward and inward incline,with the narrowest portion in the upper part. Thearea for implant placement is marked by usingtemplates specially designed for that purpose.With this marking done, it is possible to calculatethe options of available sizes, comparing the mea-surements of the marked area with the table ofsizes. These delimitations and marks are shown inFigure 1. The entire surgical procedure is per-formed in ventral decubitus position, using peri-dural anesthesia. The liposuction is performedusing the tumescent technique described in pre-vious reports,1,5 infiltrating a preparation consist-ing of 1 liter of 0.9% saline solution with an ampuleof adrenaline. Liposuction is achieved through in-cisions in the uppermost portion of the interglu-teal fold and in the lateral supragluteal area for

From the Instituto Jalisciense de Cirugıa Reconstructiva,Jalisco College of Plastic Surgeons.Received for publication July 27, 2005; accepted November30, 2005.Follow-up to Cárdenas-Camarena, L., Lacouture, A. M.,and Tobar-Losada, A. Combined gluteoplasty: Liposuctionand lipoinjection. Plast. Reconstr. Surg. 104: 1524,1999.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000252659.30428.11

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working in the lumbar area. The trochanteric andinfragluteal areas are worked through incisions inthe infragluteal fold and the lateral portion of thetrochanteric area. Only 4- and 3-mm-diameter can-nulas are used for liposuction. After finishing theliposuction, silicon drains are left only in the su-pragluteal area through the superior incision ofthe intergluteal fold. The technique for placingthe implants is similar to that described by Vergaraand Marcos.12 Gluteal implant placement is ap-proached through an intergluteal incision 7 to 8cm in length, after isolating the anal orifice withan antiseptic-impregnated gauze. The incision willstart approximately 1 cm under the liposuctionorifice that was made. It extends to the presacralfascia, and lateral undermining is performed up tothe medial edge corresponding to the preopera-tive marking. This edge is located approximately4 cm from the intergluteal line. At this level, theplane of dissection becomes intermuscular, forwhich a dissection is made in the fibers of themajor gluteal muscle, to facilitate access to thecorrect plane. Using digital dissection and then along blunt dissector, the pocket is completed forimplant placement. At this point, special care mustbe taken to remain on the plane and not go too

deep or too shallow, avoiding undermining in thesubcutaneous plane. Likewise, it must not extendbeyond the delimited lateral plane, to prevent theimplant from moving outside. It is important topoint out that in the superior region and occa-sionally in the lateral portion, the implant mayremain in a partially subcutaneous plane, becausethe muscle does not entirely cover those areas.Once dissection is completed, an implant sizer ofthe volume and characteristics determined pre-operatively is used to check for space and projec-tion. If muscle fibers are limiting the space, theycan be cut under direct vision using an optic lightfiber retractor. Hemostasis is achieved using directlight with the same retractor. Once hemostasis isverified, the implant is placed and the incision isclosed by planes after placing a negative-suctiondrain. Drainage is through a counteropening in theuppermost part of the incision, 0.5 cm under theliposuction drain. This drain will emerge betweenthe liposuction drain and the superior edge of theincision made for placing the implant. We useMonocryl 2-0 (Ethicon, Inc., Somerville, N.J.) forclosing muscle fibers. Then, the edges of the ma-jor gluteal muscle fascia will be brought toward thepresacral fascia with the same type of suture.

Fig. 1. (Left) Posterior view of the surgical design. The horizontal and ver-tical lines that correspond to the inferior and medial limits, respectively, ofthe gluteal implants are marked. Also delimitated are the areas to be lipo-suctioned. (Right) Three-quarters view of the surgical design. This designcorresponds to patient 1. We notice the great hypoplasia that the patient hasin the upper gluteal region.

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Closure of the intergluteal fold has the specialcharacteristic of being performed mostly withnonabsorbable stitches, which overlap the tissues,proceeding toward the presacral fascia to reformthat fold. For this, Prolene 1-0 and 3-0 sutures areused as one advances to the surface. Cutaneousclosing ends with absorbable Monocryl 3-0 intra-dermal sutures, thus avoiding postoperative re-moval. A compress dressing and bandage are ap-plied, keeping the patient in the ventral decubitusposition. The compress dressing is made duringthe first days, with Micropore tape (3M. St. Paul,Minn.) delimiting the gluteal implant area andelastic bandaging. After removal of the drains,around the fifth day, a girdle that is specifically forgluteal implants and liposuction is placed. Medi-cations such as analgesics, antibiotics, and antiin-flammatory drugs are used postoperatively for aperiod of 5 to 7 days. The patient can sit and movearound the next day but must avoid the dorsaldecubitus position for at least 10 days. The patientreceives ultrasound therapy every third day, forapproximately 1 month, starting after removal ofthe drains.

RESULTSOver a 6-year period, surgery was performed

on 44 female patients who required placement ofgluteal implants and liposuction for improvementof the gluteal area. The patients were aged 22 and51 years, with an average age of 26 years. It wasnecessary to perform liposuction of the supraglu-teal area in all of the patients. In 32, liposuctionof the infragluteal area was performed, and lipo-suction of the trochanteric region was performedin 26. The amount of fat liposuctioned fluctuatedbetween 250 and 1300 cc, with an average of 500cc. The implants used were 250, 300, and 350 cc,with five of them being 250 cc, 27 being 300 cc, and12 being 350 cc. Four lumbar seromas developedsecondary to the liposuction and were treated withdirect drainage: one gluteal seroma 2 years aftersurgery, which was treated surgically with drainageand an exchange of implants; one hematoma inthe intergluteal incision area, which disappearedwith conservative treatment; and evidence in onecase of an implant that could be partially felt in themedial and lateral portions of the buttock (thispatient decided to keep the implant). Four pa-tients considered the buttocks to be too large,three decided to keep the implants, and one pre-ferred definitive removal. One patient underwenta second operation to increase the buttock sizebecause it felt smaller than she had expected. Re-

sults of this procedure are shown in Figures 2through 4.

DISCUSSIONOne of the principal reasons for consultation

in aesthetic surgery is improvement of the bodycontour. A certain percentage of these consulta-tions have to do with the desire for a better buttockprofile, increasing its size or improving the defi-nition of the area. Until a few years ago, this pro-jection of the gluteal area was considered an ex-clusive characteristic of Latin women. However,this concept has changed because of the popular-ity of different artists who base their publicity onan excellent body shape, with emphasis on theirbuttocks. This has caused the entire gluteal regionto acquire a preponderant place in the daily con-sultations of any plastic surgeon, regardless of thecountry in which he or she practices. Because ofthe infrequency of this surgical procedure, thereis little bibliography about it, whether in specialtytextbooks or in accredited scientific publications.9–13

For the same reason, the training of many pro-fessionals in this specific area, and especially in thecorrect placement of gluteal implants, and in theproper evaluation of the patient preoperatively is,in many cases, deficient. For this reason, in thegreat majority of cases, the results are not what thepatients really expected. Nevertheless, there is alot of information referring to improvement of thebody contour with liposuction.1–8 When liposuc-tion is performed instead of using gluteal im-plants, achieving good results in areas with abun-dant fat deposits is more feasible for the plasticsurgeon and for the patient.

In some patients, combined liposuction andfat injection can improve the gluteal area, withvery good results.1–4 However, there are patientsfor whom the placement of gluteal implants incombination with liposuction in adjacent areas isthe indicated surgical procedure. In the currentliterature, we do not find publications that dem-onstrate the correct manipulation of the glutealarea with the combination of two different surgicaltechniques, such as liposuction and the placementof gluteal implants. The combination of thesetechniques is reported only in a letter to the editorthat documents the use of a calf implant and li-posuction for improvement of the gluteal area.14

Despite its being one of our most frequenttechniques,1 we have observed that not every pa-tient is an ideal candidate for gluteal lipoinjection.This is true principally for patients with significantgluteal hypoplasia and little fat in the surroundingarea. The combination of significant gluteal hypo-

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plasia and reduced fat in the adjacent area makesan unsatisfactory final result for the surgeon andfor the patient. Therefore, we recommend a cor-rect diagnosis, especially in thin patients withmarked hypoplasia and little or no buttock pro-jection. For these patients, only the correct use ofprosthetic materials will give the desired result forthe surgeon and the patient. In these patients,there is the added impossibility of improving thelack of buttock projection using only liposuction

in areas adjacent to the gluteal region. This en-tails, in turn, obtaining a very small amount of fatto then infiltrate into the thick part of the but-tocks. In contrast, for those patients who have agreater volume of fat in the periphery of thegluteal area but a sparse projection, we cangreatly improve this deficiency by proper ma-nipulation of the fat excess with liposuction and,later, lipoinjection.1 Therefore, slim patients, withmarked gluteal hypoplasia but with excess fat,

Fig. 2. Photographs of patient 1, aged 32 years, obtained 1 year after surgery with 300-cc glutealimplants. Liposuctionwasperformed onthelumbar, subgluteal, andtrochantericareas. (Above, left)Presurgical lateral view of patient 1. (Above, right) Postsurgical lateral view. (Below, left) Presurgicalthree-quarters view. (Below, right) Postsurgical three-quarters view.

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principally in the supragluteal area, are the idealpatients for use of the combination of liposuctionand gluteal implants. Liposuction will accuratelydelimit the gluteal area and, to a certain degree,will allow a dissembling of the lack of projection,which will be completed with placement of the glu-teal implant. In these slim patients, with markedgluteal hypoplasia and little fat excess, our currenttreatment option is combined gluteoplasty: lipo-suction plus gluteal implant.

We recommend specific actions to avoid sero-mas, our most frequent complication. Drainage inthe lumbar area is indispensable, as is adequatecompression in that area. Primary attention mustbe given to this compression, because with an or-dinary garment, it is not possible to achieve it,because of a marked lumbar concavity plus theincreased gluteal projection. Therefore, specificcompression should be placed in this area. Wesuggest to our patients that they increase com-

Fig. 3. Photographs of a 21-year-old patient obtained 8 months after surgery with 300-cc glutealimplants. Liposuction was performed only on the lumbar region. (Above, left) Presurgical posteriorview. (Above, right) Postsurgical posterior view. (Below, left) Presurgical three-quarters view. (Below,right) Postsurgical three-quarters view.

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pression in the lumbar region with tufts of cottonunder the liposuction girdle, which in turn willhelp them remain dry and comfortable for alonger time. Both factors (drainage plus compres-sion), which together reduce the seromas, arepoints of vital importance to bear in mind duringsurgery and in the immediate postoperative phase.During surgery, we know that this complicationand others, such as hematoma, can be avoided orreduced with constant drainage. That is why we

have always placed separate drains in each area butwith the precaution of never making a commonexit site for both the liposuction and the implantdrains. Doing so can lead to contamination of thelatter and the formation of seromas in the glutealarea because of the great volume that drains fromthe posterior lumbar area with tumescent liposuc-tion. For the same reason, we do not performliposuction through the same implant incision.We suggest using drainage by gravity in the li-

Fig. 4. Photographs of a 29-year-old patient obtained 6 months after surgery with 350-cc glutealimplants. Liposuction was performed only on the lumbar region. (Above, left) Presurgical lateralview. (Above, right) Postsurgical lateral view. (Below, left) Presurgical three-quarters view. (Below,right) Postsurgical three-quarters view.

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poaspirated area and continuous vacuum drain-age in the implant area.

With this in mind, our markings of the area tobe lipoaspirated and the area for placing the im-plant must be well delimited and differentiatedpreoperatively. The respective measurements andmarkings are obtained with the patient standingand seated. These measurements tell us the vol-ume of the implant to be used, which we definebased both on the patient’s desire and availablecommercial options, remembering not to movedownward beyond the support point that the is-chium represents when the patient sits down. Thisallows the patient to sit on the day after surgerywithout any discomfort and without any risk to herimplants. The measurements obtained on the areawhere the implants are to be placed are the mostimportant factors that determine the implant’ssize. Comparing the length and the width of themarked area of the patient with the commercialoptions is the best way to decide the size of theimplants. However, we need to bear in mind thatadding liposuction will produce a larger projec-tion than gluteal implants placed without liposuc-tion. For this reason, some patients have felt thatthe implant was larger than they expected, andthis has to be considered when deciding on size.

We do not perform an extensive dissection ofour pocket, especially laterally, because it couldlead to an unaesthetic displacement of the im-plant. Because our plane of placement is intra-muscular, it is extremely important to keep inmind the surgical anatomy of the area and achievea superior flap or covering of the implant at least3 cm thick.13 This provides a better covering andprotection of the implant and a more harmoniousand anatomical appearance with the augmenta-tion that has been obtained. Achieving a similarthickness in the entire flap allows us to obtain amore natural appearance and helps avoid sinkinginto the dissection plane, which can involve nervedamage. We must avoid a superficial or subcuta-neous dissection, which will create a thinner su-perior or covering flap, with the subsequent dis-agreeable appearance of an implant that is poorlyhidden and palpable. Also, we must not forget thewell-known consequences that implants in this lo-cation can have over the long term, such as pros-thetic ptosis, with a consequent unaesthetic ap-pearance and a greater incidence of capsularcontracture.

The good results and scarcity of local and sys-temic complications have made this procedure animportant alternative for obtaining body and glu-teal contour improvement. This, in turn, has al-

lowed us to combine it with other operations foraesthetic purposes, providing patients with theknown benefits that these procedures offer foroverall results and recovery time. A common fac-tor in our patients was their desire to improve thegluteal area with a harmonious body contour,without requesting an excessive or obvious in-crease, as sometimes occurs with breast implants.We always base the size of the implant on ourdetailed preoperative measurements, the differ-ent commercial sizes, and our patients’ desires. Itis important to point out that we do not suggestthis technique as the only treatment alternative forimproving the gluteal contour; rather, we believeit forms a part of the treatment alternatives, likeliposuction, with or without fat infiltration, andgluteal implants alone. Nevertheless, for cases withmarked gluteal hypoplasia and a lack of abundantfatty tissue in the gluteal periphery, we recom-mend dual gluteoplasty as a treatment option,combining liposuction plus gluteal implants.

CONCLUSIONSGluteoplasty combining liposuction and glu-

teal implants is a treatment option in the aestheticmanagement of the buttocks and their periphery.It does not invalidate or replace liposuction alone,or liposuction plus lipoinfiltration; rather, it com-plements current treatment options. It is an ef-fective and safe procedure for improvement of thegluteal profile, but it requires keeping certain pre-mises in mind before, during, and after surgery, toavoid possible predictable complications and toproduce widely satisfactory results over the short,middle, and long terms. It is a technique that canbe combined with other procedures effectivelyand safely.

Lazaro Cardenas-Camarena, M.D.Centro Medico Puerta de Hierro

Boulevard Puerta De Hierro 5150Edificio C Int. 403

Zapopan, Jalisco 44800, Mexicoplassurg@mail.udg.mx

DISCLOSURENone of the authors has a financial interest in any of

the products, devices, or drugs mentioned in this article.

REFERENCES1. Cardenas-Camarena, L., Lacouture, A. M., and Tobar-

Losada, A. Combined gluteoplasty: Liposuction and lipoin-jection. Plast. Reconstr. Surg. 104: 1524, 1999.

2. Peren, P. A., Gomez, J. B., Guerrerosantos, J., and Salazar, C.A. Gluteus augmentation with fat grafting. Aesthetic Plast.Surg. 24: 412, 2000.

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3. Cardenas Restrepo, J. C., and Munoz Ahmed, J. A. Large-volume lipoinjection for gluteal augmentation. Aesthetic Surg.J. 22: 33, 2002.

4. Murillo, W. L. Buttock augmentation: Case studies of fatinjection monitored by magnetic resonance imaging. Plast.Reconstr. Surg. 114: 1606, 2004.

5. Cardenas-Camarena, L., Tobar-Losada, A., and Lacouture, A.M. Large-volume circumferential liposuction with tumescenttechnique: A sure and viable procedure. Plast. Reconstr. Surg.104: 1887, 1999.

6. Cardenas-Camarena, L., and Gonzalez, L. E. Large-volumeliposuction and extensive abdominoplasty: A feasible alter-native for improving body shape. Plast. Reconstr. Surg. 102:1698, 1998.

7. Rohrich, R. J., Smith, P. D., Marcantonio, D. R., and Kenkel,J. M. The zones of adherence: Role in minimizing and pre-venting contour deformities in liposuction. Plast. Reconstr.Surg. 107: 1562, 2001.

8. Rohrich, R. J., Broughton, G., Horton, B., Lipschitz, A., Ken-kel, J., and Brown, S. A. The key to long-term success inliposuction: A guide for plastic surgeons and patients. Plast.Reconstr. Surg. 114: 1945, 2004.

9. De la Pena, J. A. Subfascial technique for gluteal augmen-tation. Aesthetic Surg. J. 24: 265, 2004.

10. Gonzalez, R. Augmentation gluteoplasty: The XYZ method.Aesthetic Plast. Surg. 28: 417, 2004.

11. Robles, J. M., Tagliiapietra, J. C., and Grandi, M. A. Gluteo-plastia de aumento: Implante submuscular. Cirugıa PlasticaIbero Latinoamericana 10: 12, 1984.

12. Vergara, R., and Marcos, M. Intramuscular gluteal implants.Aesthetic Plast. Surg. 20: 259, 1996.

13. Vergara, R., and Amescua, H. Intramuscular gluteal im-plants: 15 years’ experience. Aesthetic Surg. J. 23: 86, 2003.

14. Barutcu, A., and Top, H. Use of calf implants to reconstructcontour deformities of the buttock and thigh (Letter). Ann.Plast. Surg. 47: 100, 2001.

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