INTRODUCTION
Plastic surgeons all over the world are challenged
with a dramatically increased public interest
and demand for aesthetic gluteal contouring surgery.
31
This growing interest may be explained by global
cultural interaction, the evolution of body contouring
techniques, and the physical appearance of
aesthetic and fashion idols. In this work, the authors
introduce a comprehensive yet easy and versatile
method for the assessment of “Gluteal-Related
Aesthetic Subunits”. This method works as a tool
to treat the variety of differences in patients' racial
body morphology, personal preferences, cultural
and ethnic related demands, thus improving the
results of gluteal aesthetic surgery.
Historical backgrounds:
The value of an aesthetically attractive gluteal
region has been dated as early as recorded history.
The ancient Greeks described beautiful women by
the term "callipygian" (derived from calli, i.e.
beautiful, and pyge, i.e. buttocks) [1]. The ancient
Arabs in the medieval ages valued beautiful buttocks
that were harmonious with an attractive back
and a narrow waist when they praised a woman's
beauty. They described beautiful women's waists
and buttocks in the following song lyrics: "Her
buttocks quiver when she walks; her back is like
a willow branch, her waist is slim" [2]. Across
cultures, generations, and ethnicities, a wellprojected
full buttock with a narrow waist (hourglass
figure) symbolized female reproductive potential
and physical health [3]. The well-developed
buttock is a trait exclusive to humans that contributes
to the vertical posture along with the lumbosacral
curve [1].
The earliest attempts of gluteal augmentation
using implants were made in 1969. The surgeons
used breast implants, but the results were frustrating
regarding the complications and aesthetic outcomes,
which led to the need for better techniques [1,4,5].
Currently, plastic surgeons have numerous techniques
for gluteal enhancement that can be broadly
classified into three categories, including the use
of implants (subfacial, submuscular and intramuscular
placements), autologous fat transfer and
autologous flap augmentation combined with circumferential
body lift [6-11].
There is growing advocacy for autologous fat
transfer techniques for gluteal contouring among
surgeons due to its reported safety, flexibility and
long-lasting results. Fat transfer techniques are
modified continuously to enhance safety and aesthetic
results [6,12]. The recent popularity of body
contouring surgeries after massive weight loss led
to the development of techniques for gluteal contouring
using combinations of autologous flaps,
fat transfer or implants along with circumferential
body lift [9,11,13].
Aesthetic analysis of the gluteal region:
Like all body contouring surgeries, gluteal
enhancement requires proper planning.
For appropriate planning, it is essential to carefully
identify the aesthetic characteristics of the
gluteal area and the surrounding related body areas.
A proper scientific method to define the beautiful
gluteal area was not reported until the work of
Cuenca-Guerra and Quezada reported the most
recognizable features of the aesthetically pleasing
gluteal area from the posterior and side views
according to their study [7]. These features included
the following:
• A lumbosacral curve that defines the back from
the buttock.
• Two defined presacral dimples or supragluteal
fossettes.
• Two slight lateral depressions overlying the
greater trochanters of the femur.
• Short infragluteal creases (not extending laterally
beyond the medial half of the posterior thigh).
• A point of maximum projection on the lateral
view that corresponds to the level of the mons
pubis. The ratio of the anterior superior iliac
spine to the greater trochanter and the greater
trochanter to the lateral point of maximum projection
of the buttock should not exceed 1:2.
Centeno stressed the effects of the aesthetic
subunits that surround the gluteal area and their
impact on the aesthetics of the gluteal area itself.
He mentioned the subunits that must be analysed
before the performance of any type of body contouring
surgery to the gluteal area to achieve the
best results (2 symmetrical “flank “units, 1 “sacral
triangle” unit, 2 symmetrical gluteal units, 2 symmetrical
thigh units, and 1 “infragluteal diamond”
unit) [1].
32 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
Mendieta [14] demonstrated the aesthetic value
of the ratio of the intergluteal fold length and the
length of the sacral height (ideally, it is greater
than 0.5 but less than the full sacral height). He
gave a simple classification for buttock shapes
(round, A-shaped, V-shaped, square shaped and
intermediate) and gave a simple classification of
buttock ptosis. Mendieta also defined five zones
that directly surround the buttocks and determine
its aesthetics, namely, the sacrum V-zone, flank,
upper buttock, lower back, and outer thighs [15].
According to the works of Roberts et al., [16],
Heidekrueger et al., [17] and Wong et al., [18], there
are significant variations in ideal aesthetic parameters
among various human ethnic and racial
groups.
The authors of this work adopted their own
analytical method and believe that this analytical
method is more comprehensive yet simple. The
method helps body contouring surgeons in planning
for surgical aesthetic procedures on the back of
the trunk, thighs and gluteal area.
PATIENTS AND METHODS
This study took place in the Plastic and Reconstructive
Surgery Department in the University
Hospital where the authors work and in private
practice. The study examined the aesthetic outcomes
of the enhancement of the gluteal area by
liposuction and fat transfer and compared the
results during the following two time periods:
Group (A) in the period between 2007 and 2014
(150 female patients), and Group (B) in the period
between 2015 and 2018 (100 female patients). All
patients underwent liposuction and fat transfer to
the subcutaneous tissues of the gluteal area.
All participants were subjected to a full clinical
history and general clinical examination to confirm
their fitness for surgery i.e., fulfilling the criteria
of the American Society of Anaesthesiologists
(ASA) grades I & II. The exclusion criteria included
patients with the following conditions: Coagulopathies,
uncontrolled hypertension, obligatory antiplatelet
and anticoagulant drug administration,
unrealistic expectations, younger than the legal
age, high Body Mass Index (BMI) (35 or greater),
previous liposuction to the trunk area, history of
aesthetic enhancement of the gluteal area, buttock
ptosis, significant weight loss, musculoskeletal
anomalies and poor compliance to the follow-up
programme. Any patient who showed overt weight
gain or overt weight loss at the time of the final
follow-up visit was excluded.
Egypt, J. Plast. Reconstr. Surg., January 2020 33
Informed consent forms were signed by the
patients of the two studied groups including statements
regarding scientific photography and the
potential use of their data and photographs in
scientific studies and publications. Photographs of
patients from both groups were published using
the same views used by Wong et al., 2016 [18] and
Heidekrueger et al., 2017 [18].
• Group (A): This group was operated during the
time period between 2007 and 2014 before the
era of high definition liposuction. The aesthetic
assessment and surgical planning according to
the criteria suggested by Centeno in 2006 [1].
(See previous content) and liposuction were
performed using the traditional method (liposuction
of the layer of fat that lies deep to the
membranous layer of the superficial fascia). This
group data were used retrospectively as a control
group.
• Group (B): This group was operated during the
time period between 2015 and 2018. The aesthetic
assessment and surgical planning according to
the criteria suggested by the authors of this work
and liposuction were performed according to the
new principles of the liposculpture method (superficial
liposuction-high definition liposuction)
[19,20].
In Group (B), the authors advocated the aesthetic
analysis of the following subunits (areas)
Figs. (1,2):
- Areas 1 and 2, i.e. the back: The entire back (not
only the lower back).
- Areas 3 and 4, i.e. the flanks.
- Area 5, i.e. the sacral triangle: The inverted
triangle with its base superiorly with the line
between the overt sacral dimples.
- Areas 6 and 7, i.e. the buttocks: Include a, b, and
c, as described below:
“a”: Overall fullness and location of the maximum
projection point on the lateral view.
“b”: The length of the intergluteal cleft.
“c”: The infragluteal line.
- Areas 8 and 9, i.e. the trochanteric area.
- Area 10, i.e. the infragluteal diamond.
- Areas 11 and 12, i.e. the lateral thighs.
Fig. (2): Example of the authors adopted plan put into practice.
*G.T. = Greater Trochanter. *S.P. = Symphysis Pubis.
Hispanics & Africans:
* Fill areas 6,7 with 6(a)
& 7(a) above G. T.-S.
P. plane.
* Fill areas 8,9,11,12
Asians:
* Fill areas 6,7 with 6(a)
& 7(a) above G. T.-S.
P. plane.
* Fill areas 8,9.
Caucasians:
* Fill areas 6,7 with 6(a)
& 7(a) at G. T.-S. P.
plane.
* Incomplete filling areas
8,9 keeping slight depression
over insertion
of gluteus maximus
muscle.
Define which gluteal
related areas
that need filling:
Decide according to
patients race, body
characters and/or
personal demands
Check areas of fat
excess:
e.g. areas (1-5),
(10-12), abdomen etc.
Good candidates:
Patients that have
proper volume of fat
are available for transfer
to gluteal areas &
good skin tone.
Fig. (1): (A) Buttocks and buttocks-related aesthetic subunits (areas)
according to the plan adopted by the authors. (B,C) The
aesthetic curves of the female body (C, R, and S) relations
with aesthetic units of the plan adopted by the authors.
(A) (B) (C)
Operative steps:
Infiltration of the selected areas for liposuction
in patients of both groups was performed according
to the Klien formula [21].
- Group (A) patients: Liposuction of the deep fat
(deep to the membranous layer of the superficial
fascia).
- Group (B) patients: Liposuction of the deep and
superficial fat (in relation to the membranous
superficial fascia) according to the criteria of
high-definition liposuction, i.e. liposuction of
both deep and superficial fat accumulations in
the back with care to create a smooth and gradual
transition area between the buttocks and flanks
and eliminate any back rolls [3].
In both groups: Liposuction was performed
using a 3-mm accelerator cannula. Fat tissue was
left in the containers to be decanted. Fat tissue was
loaded into 20-ml syringes for transfer. The fat
tissue was injected into the subcutaneous tissue of
the buttocks taking extreme care to avoid intramuscular
injection. The authors used 4-mm gauge fat
transfer cannulas of variable lengths (from Delta
Med SurgicalR, Sialkot, Pakistan). The fat tissue
was transferred to the buttocks according to the
assessment (each group according to its assigned
assessment method).
- In Group (A), the fat tissue was transferred and
distributed to increase the volume of the gluteal
unit described by Centeno [1].
- In Group (B), the fat tissue was transferred according
to the authors' assessment criteria, i.e.
in a differential manner to achieve maximum
results in the gluteal unit and its subunits (a, b
and c) as well as the trochanteric and thigh units
according to the patient's demands or ethnic
background. The lateral thigh units were managed
by liposuction or fat transfer according to each
patient's ethnic background and demands Fig.
(2).
The liposuction ports were closed with 5/0
Vicryl RapideR in both groups; however, in Group
(B), the dependent liposuction ports were left
(without stitches) to establish free drainage.
A pressure garment was used by all patients
for three months after surgery.
Photographic documentation was acquired preoperatively
and at the end of the first six postoperative
months (posterior and lateral views). The
photography session during the last follow-up visit
was considered to be the post-operative photograph-
34 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
ic result as long as it was performed six months
or more after surgery.
Subjective assessment of the results for all
patients after at least six months according to the
following scale.
3 points: Excellent results.
2 points: Fair results.
1 point: Poor results.
The pre and post-operative photography (at
least six months post-operative pictures) were
assessed by independent observers (four plastic
surgeons from other university) for objective opinion
depending on the degree of asymmetry, persistence
of deformities and/or irregularities in the
results using the same scale. The collected data of
the degrees of satisfaction of both patient and
objective opinion were used to measure patient/
objective assessment agreement by Kappa statistical
analysis (no agreement K=0, slight agreement K=
less than 0.2, fair agreement K=0.21 to 0.4, moderate
agreement K=0.4 to 0.6, substantial agreement
K=0.6 to 0.8 and perfect agreement K=0.8 to 1)
[22].
RESULTS
A total of 250 female patients participated in
this study and were arranged into two groups Figs.
(3-14):
• Group (A): 150 patients (during the period between
2007 and 2014).
• Group (B): 100 patients (during the period between
2015 and 2018).
The Kappa statistical analysis [22] showed that
the agreement between patients' opinion and objective
assessment was substantial as regard to
results (K=0.751) of Group (A) and was perfect
regarding to Group (B) (0.831).
DISCUSSION
The curvatures of the female back and buttocks
were described by Aristotle as the most attractive
form in the human body [23]. Like the abdomen to
the front of the trunk, due to the central location
of the gluteal area, it affects and is affected by the
surrounding aesthetic subunits. It is logical to state
that the entire back of the trunk, buttocks, and
thighs are aesthetically interactive [1]; thus, there
are cases in practice that result in a very nice
aesthetic enhancement of the buttocks by liposuction
of the surrounding subunits without any fat
transfer Fig. (15) (a demonstrative case that was
excluded from this study).
(A)
(B)
(C)
(D)
(E)
(F)
(A)
(B)
(C)
(D)
(E)
(F)
Egypt, J. Plast. Reconstr. Surg., January 2020 35
Fig. (3): Group (A) patient, aged 27 years, with a good
outcome. (A, B, C) Pre-operative views. (E, F, G)
Post-operative views after liposuction of 5 liters of
fat from the abdomen, back, and flanks. Fat was
transferred to buttocks (1050ml per buttock).
Fig. (4): Group (A) patient, aged 34 years, with a good
outcome. (A, B, C) Pre-operative views. (D, E, F)
Post-operative views after liposuction of 6 liters of
fat from the abdomen, back, and flanks. Fat was
transferred to buttocks (1250ml per buttock).
36 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
Fig. (5): Group (A) patient, aged 23 years, with residual back
rolls. (A, B, C) Pre-operative views. (D, E, F) Postoperative
views after liposuction of 4 liters of fat
from the abdomen, back, and flanks. Fat was transferred
to buttocks (900ml per buttock).
Fig. (6): Group (A) patient, aged 29 years, with residual back
rolls, residual fullness and modest improvement in
the posterior projection of the buttocks. (A, B, C)
Preoperative views. (D, E, F) Post-operative views
after liposuction of 4.8 liters of fat from the abdomen,
back, and flanks. Fat was transferred to buttocks
(1300ml per buttock).
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(A)
(B)
(C)
(D)
(E)
(F)
Egypt, J. Plast. Reconstr. Surg., January 2020 37
Fig. (7): Group (B) patient, aged 26 years, from a Hispanic
ethnic background (from Puerto Rico). (A, B, C, D) Preoperative
views showing fullness in areas (1, 2, 3, 4, 5) and
emptiness in areas (6, 7, 8, 9). (E, F, G) Post-operative views
after liposuction of 3.6 liters of fat from the abdomen and
areas (1, 2, 3, 4, 5) and 900ml of fat transfer to areas (6, 7,
8, 9). The patient did not want a diamond zone (area 10).
Fig. (8): Group (B) patient, aged 30 years, from an Arabian
Gulf ethnic background. (A, B, C, D) Pre-operative views
showing fullness in areas (1, 2, 3, 4, 5) and emptiness in areas
(6, 7, 8, 9). (E, F, G) Post-operative views after liposuction
of 3.6 litres of fat from the abdomen and areas (3, 4, 5) and
750ml of fat transfer to areas (6, 7, 8, 9). The patient did not
want a diamond zone (area 10). Fullness in the upper part of
area (9) was preferred by the patient to give what she called
a heart-shaped buttock.
(A)
(B) (E)
(C) (F)
(D) (G)
(A)
(B) (E)
(C) (F)
(D) (G)
38 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
Fig. (9): Group (B) patient, aged 36 years, from an African
ethnic background (North Sudan). (A, B, C) Pre-operative
views are showing fullness in areas (1, 2, 3, 4, 5) and emptiness
in areas (8, 9). The patient asked to add more posterior
projection to areas (6, 7). (D, E, F) Post-operative views after
liposuction of 5.2 liters of fat from the abdomen and areas
(1, 2, 3, 4, 5) and 800ml of fat transfer to areas (6, 7, 8, 9.
The patient did not want to have a diamond zone (area 10),
and she was satisfied regarding the shape of areas 11 and 12.
Fig. (10): Group (B) patient, aged 32 years, from a North
African ethnic background (from Morocco). (A, B, C, D) Preoperative
views are showing fullness in areas (1, 2, 3, 4, 5)
and shortness in areas (6b, 7b). The patient asked for more
posterior projection areas (6, 7) and a slight reduction in the
lateral thighs areas (11, 12). (E, F, G) Post-operative views
after liposuction of 3.8 liters of fat from the abdomen and
areas (1, 2, 3, 4, 5, 11, 12) and 1 liters of fat transfer to areas
(6, 7, 8, 9). The patient did not want to have a diamond zone
(area 10).
(A)
(B)
(D)
(C)
(E)
(F)
(A)
(B)
(D)
(C)
(E)
(F)
Egypt, J. Plast. Reconstr. Surg., January 2020 39
Fig. (11): Group (B) patient, aged 35 years, from a European
Mediterranean ethnic background (from Italy). (A, B,
C) Pre-operative views showing fullness in areas (1, 2, 3, 4,
5) and asymmetry between areas (8, 9); The patient asked for
Hispanic-shaped buttocks and waist (she used the media
nickname Spanish waist). (D, E, F) Post-operative views after
liposuction of 3.8 liters of fat from the abdomen and areas
(1, 2, 3, 4, 5) and 900ml of fat transfer to areas (6, 7, 8, 9).
The maximum posterior projection point areas (6c, 7c) were
adjusted above the level of the symphysis pubis-greater
trochanter plane. The patient did not want to have a diamond
zone (area 10).
Fig. (12): Group (B) patient, aged 28 years, from an East
European ethnic background (from Bosnia). (A, B, C) Preoperative
views showing asymmetry between areas (11, 12),
and fullness in areas (1, 2, 3, 4, 5). The patient asked for a
narrow waist and fuller buttocks with a mild posterior projection
and a diamond zone (area 10). (D, E, F) Post-operative
views after liposuction of 2.4 liters of fat from the abdomen
and areas (1, 2, 3, 4, 5, 10, 11, 12) and 700ml of fat transfer
to areas (6, 7, 8, 9).
(A)
(B)
(C)
(D)
(E)
(F)
(A)
(B)
(C)
(D)
(E)
(F)
40 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
Fig. (13): Group (B) patient, aged 36 years, from a European/
Asian ethnic background (from Turkey). (A, B, C) Preoperative
views showing fullness in areas (1, 2, 3, 4, 5),
emptiness in areas (7, 8) and asymmetry in the intergluteal
cleft (6b, 7b). The patient asked for rounded buttocks with
an enhanced posterior projection. (D, E, F) Post-operative
views after liposuction of 4.4 liters of fat from the abdomen
and areas (1, 2, 3, 4, 5, 10, 11, 12) and 1L of fat transfer to
areas (6, 7, 8, 9). The patient did not want to have a diamond
zone (area 10). There was persistence of her intergluteal cleft
asymmetry after surgery. She is the only patient in this series
with intergluteal cleft asymmetry.
Fig. (14): Group (B) patient, aged 34 years, from a West
Asian ethnic background (from Iran) with residual fullness
in the flanks and back rolls (areas 1, 2, 3, 4). (A, B, C, D)
Pre-operative views showing fullness in areas (1, 2, 3, 4, 5)
and emptiness in areas (6, 7). The patient asked for rounded
buttocks with posterior projection. (E, F, G) Post-operative
views after liposuction of 4.7 liters of fat from the abdomen
and areas (1, 2, 3, 4, 5) and 1.2L of fat transfer to areas (6,
7, 8, 9). The patient did not want to have a diamond zone
(area 10).
(A)
(B)
(D)
(C)
(E)
(F)
(A)
(B)
(C)
(D)
(E)
(F)
(G)
Table (1): Liposuction volume in litres.
Group
A
B
p-value
Maximum
3.7
4.3
Average
2.45
3.3
Minimum
1.2
2.3
Mean
2.9
0.002 3.8
Table (2): Total volume of transferred fat tissue for both
buttocks.
Group
AB
p-value
Maximum
2.6
2.4
Average
2.2
1.8
Minimum
1.8
1.2
Mean
1.9
1.3
0.009
Fig. (15): Overt improvement in the shape of the buttocks using liposuction and only following the authors' adopted algorithm
(this case was excluded from the study as no fat transfer was performed). (A) Pre-operative posteroanterior view. (B) Postoperative
posteroanterior view. (C) Constructed comparative posteroanterior view.
Egypt, J. Plast. Reconstr. Surg., January 2020 41
(A) (B) (C)
Fig. (16): A patient from a North African ethnic background
(from Libya) gave a history of poliomyelitis affecting the
right gluteus maximus. (A, B, C) Pre-operative views. (D, E,
F) Post-operative views after liposuction of 3.2 litres of fat
from the abdomen and areas (1, 2, 3, 4, 5). Fat was transferred
to areas (7, 9) to increase the size of the right buttock in all
dimensions and to minimize asymmetry (600ml fat). The
patient showed partial improvement in her asymmetry, and
she is scheduled for another session of fat transfer. This patient
was excluded from the study due to the severe musculoskeletal
pathology.
(A)
(B)
(D) (C)
(E)
(F)
This work aimed to produce a comprehensive
yet simple analytical tool to assist body contouring
surgeons in planning for surgical aesthetic procedures
of the back, thighs, and gluteal area.
The authors advocated for these subunits (better
known as areas where the junctions between them
are ill-defined and smooth shifts Fig. (1):
- Areas 1 and 2, i.e., the back: The entire back (not
only the lower back) is an integral part that was
not evaluated in the previous works of other
authors. The back with no rolls helps show the
beauty of the “S” curve of the buttocks in the
posterior and lateral views, as described by Hoyos
[24].
- Areas 3 and 4, i.e., the flanks: The empty flanks
enhance the appearance of sizable buttocks and
vice versa. Additionally, the smooth shift between
the buttocks and flanks enhances the “S” curve
of the buttocks and flanks [24] in the posterior
view. This aesthetic “S” curve is valued by several
human cultures, even in ancient history [2,23].
- Area 5, i.e., the sacral triangle: The inverted
triangle with its base superiorly located at the
level of the line between the overt sacral dimples
and the apex inferiorly located at the sacrococcygeal
junction level.
- Areas 6 and 7, i.e., the buttocks: These areas
include the following:
“a”: Overall fullness and location and projection
of the maximum projection point in the lateral
view as this element is subjected to racial and
subjective variability.
“b”: The length of the intergluteal cleft compared
to the sacral height (more than half of the
buttock's height but less the full sacral height).
The two buttocks share in the creation of this cleft;
thus, areas 6b and 7b are necessary when the
intergluteal cleft is described. An asymmetrical
intergluteal cleft was present only once in this
series Fig. (13). An intergluteal cleft that is too
short will give the optical sense of small buttocks,
while an intergluteal cleft that is too long will give
the buttocks the appearance of so called “alien
buttocks” [14]. We did not see an intergluteal cleft
that was too long in this series, and it was noted
that short clefts were corrected by fat transfer to
the upper part of areas 6a and 7a. Liposuction of
the flanks gives an optical illusion of reduced sacral
height and thus helps to correct the relative shortness
of the intergluteal cleft Fig. (10).
“c”: The infragluteal line should not cross the
meridian of the posterior thigh in aesthetically
perfect buttocks. This line crosses the posterior
thigh meridian in ptotic buttocks. Patients showing
ptotic buttocks were excluded from this study. The
well-defined infragluteal line with the absence of
a banana fold in the uppermost posterior thigh
gives the aesthetic “R” curve when viewing the
female form from the lateral and posterior-lateral
(oblique) views [24].
- Areas 8 and 9, i.e., the trochanteric area: The
fullness and depression in this area are aesthetically
subjected to great variation according to
cultural, racial and subjective factors and will be
detailed later. A full trochanteric area will enhance
the “C” curve in the posterior view of the female
form [24].
- Area 10, i.e., the infragluteal diamond (diamond
zone): It denotes the absence of thigh obesity
and partially shows the vulva if viewed from
behind. It was noted from our series that patients
with slim thighs and a more athletic form usually
Table (3): Complications of the fat tissue transfer procedures.
6% (9 patients)
3% (3 patients)
Group Seroma
A (150 patients)
B (100 patients)
Liposuction port
complications
15.33% (23 patients)
4% (4 patients)
Table (4): Patient satisfaction data.
74%
(111 patients)
88%
(88 patients)
Group Excellent
A
(150 patients)
B
(100 patients)
Fair
14%
(21 patients)
8%
(8 patients)
Poor
12%
(18 patients)
4%
(4 patients)
Table (5): Main causes of dissatisfaction.
3
*Not satisfied
with buttock
shape
Dissatisfied
patients
Group (A)
18 (12%)
Group (B)
4 (4%)
*Buttocks
smaller
than expected
5
2
*Complication
1. Seroma (2)
2. Liposuction port complications (2)
Seroma (1)
*Residual
back
rolls
6 patients
1 patient
42 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
Egypt, J. Plast. Reconstr. Surg., January 2020 43
ask for an infragluteal diamond (it was sculptured
by liposuction of the medial thigh and lower
medial parts of the buttocks) while those with
plump curvy forms with robust thighs do not ask
for it or even sometimes refuse to have it.
- Areas 11 and 12, i.e. the lateral thighs: The upper
lateral thigh shares in the formation of the “C”
curve with the trochanteric area [24]. The lateral
thigh is another area that is aesthetically subjected
to great variation according to cultural, racial
and subjective factors. The restoration of the
back/flanks related “C”, “S”, and “R” curves by
liposuction alone can be enough to enhance the
gluteal area in some cases (Fig. 15).
According to the works of Roberts et al., [16],
Heidekrueger et al., [17] and Wong et al., [18], there
are great variations in the ideal aesthetic parameters
among ethnic groups. Caucasian Americans prefer
more athletic buttocks with greater definition of
the muscular and bony anatomy, less posterior
projection if compared to other ethnic groups and
with maximum projection at the plane connecting
the symphysis pubis and greater trochanter (the
distance of this point to the greater trochanter is
nearly double the distance between the symphysis
pubis and the greater trochanter in the lateral view).
They favour lateral thigh depression and do not
like fullness of the lateral thigh. The Asian American
culture favours short buttocks with a higher
point of maximum projection (higher than the
symphysis pubis-greater trochanter plane), giving
the illusion of longer lower limbs and thus, giving
better proportion between the trunk and extremities.
Hispanic and African American cultures value
buttocks having more projection than either Asian
or Caucasian Americans. A higher point of maximum
posterior projection (higher than the symphysis
pubis-greater trochanter plane), deeper lumbosacral
curve, and fullness rather than lateral
thigh depressions also appear to be favoured by
African Americans.
Wong et al., [18] studied ideal parameters of
the buttocks in the mass population irrespective
of ethnic groups but with consideration of age and
sex. They found greater variability in the ideal
waist-hip ratio. There were a good percentage of
advocates for the ratio values of 0.65, 0.7 and even
0.5. They found no effect on the woman's overall
body size as long as she had an ideal ratio. In the
opinion of the authors, the advocated new analytical
method accommodates these different racial preferences
better than the previous methods. There
are even more detailed studies on the vast variety
of ideal aesthetic parameters in more selective
racial and ethnic subgroups [25,26].
Mendieta and Centeno agreed on nearly the
same five aesthetic zones that surround the buttocks,
but using a different nomenclature. Mendieta agreed
with Centeno and mentioned the work of Centeno
in detail in a recent publication [27]. In our opinion,
the classifications of Mendieta and Centeno are
very similar to one other. In both authors' works,
the buttock itself was considered as a single aesthetic
area and was not subdivided. The division
of the buttock units is important in our opinion.
The racial differences in the shape of the buttocks
depends on the location of the point of maximum
lateral projection (points 7a and 8a in the new
classification) as well as the trochanteric area and
lateral thighs (areas 8, 9, 11 and 12 in the new
classification). The importance of the upper back
was not emphasized in both the Mendieta and
Centeno classifications. The entire back is very
important in our opinion, as it forms the curves
that define the feminine beauty in the eyes of the
beholder. The beholder sees an overall image of
the back, thighs and buttocks and not only a focused
image of the buttocks and its close surroundings.
As previously mentioned, even our ancestors' description
of the beauty of the buttocks was associated
with the admiration of the long curves of the
entire back and thighs. These curves were recently
given names (C, S & R) by Hoyos [24]. We believe
that our new classification is a valuable addition
to the foundation set by the work of authors such
as Mendieta and Centeno.
Regarding this work-related comparative study:
The number of patients fulfilling the inclusion
criteria in Group (A) (150 patients in 8 years)
seems much smaller compared to that of Group
(B) (100 patients in 4 years). This is accounted for
by the recent increase in the number of patients
seeking enhancement of the gluteal area due to
refinements of liposuction techniques and fascination
by media beauty idols.
Liposuction volumes seem to be significantly
higher in Group (B) due to the harvesting of both
superficial and deep fat in relation to the membranous
layer of the superficial fascia. In Group (A),
only the fat deep to the membranous layer of the
superficial fascia was harvested (Table 1).
Regarding the volume of fat transfer for both
buttocks, Group (A) needed significantly higher
volumes to the volumes needed in the Group (B)
cases. This volume difference is explained by the
fact that in Group (A), the authors used to inject
fat tissue to augment the size of the buttocks as a
simple aesthetic subunit following previous authors'
guidelines, but later in Group (B), they started to
44 Vol. 44, No. 1 / The Role of Liposuclpture of the Posterior Trunk & Thighs
do a combination of differential augmentation and
liposuction according to the need of each aesthetic
area (areas 6, 7, 8, 9, 10, 11, and 12 in their newly
adopted method of evaluation). In Group (B), the
authors managed to meet more of the variations in
ethnic and personal demands Fig. (2). Getting a
good aesthetic outcome with a smaller volume is
advantageous, as the rate of transferred fat survival
is much better with smaller fat volumes (Table 2).
Seromas and minor burns of the liposuction
port were the only complications in this work. The
seroma incidence was 6% and 3% in Group (A)
and Group (B), respectively. The frequency of
seroma development was much less in Group (B)
due to the act of leaving dependent liposuction
ports unstitched at the end of the surgery. The
incidence of seromas is higher among high definition
liposuction cases in general and even more in
cases of ultrasound-assisted liposuction compared
to traditional liposuction in the absence of any
drainage form [28]. Hoyos advocated the use of
open drainage, e.g., corrugated silicon drains, over
closed drains of the liposuction areas to avoid
seroma development [29]. The liposuction portrelated
complications (friction burns and bad scars)
were much less in Group (B) as the patients of this
group benefited from the appearance of the port
protectors in practice. The port protectors were not
yet available in practice during the era the authors
were operating on Group (A) cases. No major
complications were encountered in this series such
as major blood loss, skin loss or pulmonary complications
(Table 3).
The most dangerous complication of fat transfer
to the buttocks is pulmonary fat embolism, which
occurs mainly due to intramuscular injection of
fat [30]. The incidence of mortality is 3% according
to Mofid et al., [30] and in one of each 3000 procedures
according to the Multi-Society Task Force
for Safety in Gluteal Fat Grafting (ASAPS, ASPS,
ISAPS, IFATS, ISPRES), which recently issued a
global online warning [30]. According to this warning,
it is possible to avoid this tragic complication
by injection with larger bore cannulas (larger than
4mm), injection strictly in the subcutaneous tissues
and withdrawal before injection, and injection
while withdrawing the cannula [30,31]. The subject
of fat embolization with fat transfer to the buttocks
is not the main subject of this work.
The satisfaction rates were high in both groups,
but they were better in Group (B) compared to
Group (A). In our opinion, this difference is due
to the greater flexibility in meeting the variable
ethnic, racial and personal aesthetic demands of
patients, giving more harmony and balance between
the buttocks and buttock-related subunits,
e.g., back and lateral thigh, a low complication
rate (Table 4). It was noted that a good percentage
of the dissatisfied patients in Group (A), who
asked mainly for buttock enhancement, were not
happy because of residual back rolls after surgery
(Table 5).
Pre-operative and post-operative photography
were assessed by four senior plastic surgeons from
other university. They shared as independent assessors
to give an objective opinion regarding
results of the patients. The Kappa statistical analysis
[22] showed that the agreement between patients'
opinion and objective assessment was substantial
as regard to results (K=0.751) of Group (A) and
was perfect regarding to Group (B) (0.831).
Conclusion:
The authors of this work believe that this new
analytical tool is a valuable step forward to help
achieve results that are more satisfying to patients.
The benefits of this tool are as follows:
- It was shown to be versatile enough to meet the
demands of patients with different racial body
characteristics and even subjective demands.
- It helps the surgeons assess what and where the
aesthetic defect is that needs correction by liposuction
versus fat transfer, thus helping to remove
fat from the undesired areas and shifting it to the
areas where increasing fat volume is demanded.
A good aesthetic outcome can be achieved, even
with relatively smaller volumes of fat tissue.
- It can help surgeons to recognize asymmetry and
the appropriate plane for treatment e.g. Fig. (16).
- It helps surgeons to assess their work results and
to recognize the poor results in a more objective
way e.g. Fig. (14).
- It is better for the greater expectations of the
patients nowadays.
- It allows a relatively larger volume of fat tissue
for transfer yet lesser volumes needed to obtain
good aesthetic outcomes; thus, a better result can
be achieved in the case of patients with relatively
small fat stores and sparing fat for transfer to
other areas if needed, e.g., breasts.
- It is a simple and reproducible method, i.e., taking
tissue from identified areas of tissue excess to
be added to the identified areas that lack tissue.
It allows for liposuction and fat tissue transfer
to be combined together, which allows for appropriate
management for most patients.
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Egypt, J. Plast. Reconstr. Surg., January 2020 45
Despite all the merits of this new analytical
tool and the advantages of the innovations in liposuction,
some limitations remain. Fat transfer alone
will not treat and even may worsen ptosis. Liposuction
and fat injections are not an ideal treatment
for very thin females with low subcutaneous fat
amounts. Additionally, patients with significant
weight loss will not benefit from these techniques.
The authors of this work are not claiming their
analytical algorithm to be perfect, but they believe
it to be a valuable step in the aesthetics of the
backside of the female body.
Acknowledgement:
The authors like to acknowledge the efforts of
professor Dr. Mohammed Elhaddi-Plastic and Reconstructive
Surgery Department, Al-Mansoura
University, Egypt and the Department Plastic Surgeons
for giving their valuable objective opinion
in the assessment of the results of this work.
Conflicts of interest:
The authors have no conflicts of interest to
disclose.
Ethical approval:
All the procedures performed in this study that
involved human participants were in accordance
with the institutional and national research committees
and with the 1964 Declaration of Helsinki
and later amendments or comparable ethical standards.
Worth confirming that there was no discrimination
between the patients in both groups. Each
of the studied groups of patients were managed by
the up to date techniques in each group time era.
Group (A) data were used in a retrospective manner
as a control group for comparison. The authors of
this work believe that this approach was the best
way to avoid unethical discrimination between
patients. All the patients signed an informed consent
that included sharing their data in all kinds of
scientific studies and scientific publications provided
that their human rights are respected. No
studies are allowed in the authors' department
unless approved by the Department Ethical Committee.
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