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BUTTOCK
LIFTS. PART I: AMBULATORY BUTTOCK LIFT USING A SUTURE WITHOUT INCISION
SCARS
Nikolay
P. Serdev, MD, PhD
Medical
Centre "Aesthetic Surgery, Aesthetic Medicine", Sofia, BULGARIA
SUMMARY
BACKGROUND:
This article presents the author's experience in the treatment of the
flaccid "unhappy buttock" form with his surgical procedure of
buttock lift by suture, without incision scars. The author at the 3rd
International Congress of the South-American Academy of Cosmetic Surgery
at Buenos Aires, October 19-21, 2001 first presented this new operation
technique [2], and after that over the world [3, 4]. The result is a visual
change in the buttock position to a higher one, which elongates the lower
limbs and changes the proportions between lower and upper half of the
body. OBJECTIVE: The aim of this study is to describe a new procedure
of beautification of the buttock form without scars by creating a lifting
effect on the buttock's subcutaneous tissue, using a suture that takes
the inferiorly positioned deep fibrose tissue and fixes it upwards to
the fascia of m. gluteus maximus. Aesthetic and technical considerations
required sculpting properly the buttocks to a higher position and nicely
rounded form are demonstrated. Preoperative shape is discussed and patient
evaluations, operative techniques, postoperative management, and results
after 4 years of experience are emphasized. METHODS: From September
1998 to September 2002, 23 female patients, aged 18-34 years, with ptosis
and cellulite on the buttocks were treated on an outpatient basis by the
"Serdev's suture technique without visible scars". Important
instrumentarium is a long, straight, elastic needle and Polycon - elastic
Bulgarian antimicrob polyamide silk surgery fibres, produced in PK "Tonzos",
Jambol. This operation has been performed either alone or after ultrasonic
assisted liposculpture (UAL) that reduces the fat amount and heaviness.
RESULTS: All patients reported a high degree of satisfaction. A
stable improvement in the buttock position and form was observed for the
period described. In the postoperative period the complication rate was
minimal and solved in the first 4-5 days post op. The skin contact in
the perianal zone makes antibiotic prophylaxis obligate as well as a strict
follow up for the first 7 days. Some pain in lower sitting position (driving
or sitting in a car) was observed for at least 5 to 10 days, but all other
social and professional duties and activities were possible. CONCLUSIONS:
This outpatient procedure is effective in the correction of buttock laxity
and ptosis and creates a new form, universally accepted as "happy
buttocks".
INTRODUCTION
As more people
seek body contour surgery, we should use our growing, developing knowledge
and surgical experience to create new non-scaring surgical procedures
for beautification in areas where former results of body contour surgery
have been less satisfying, like the buttocks. A very small number of techniques
are available for correction of the form and the aesthetics of the buttocks,
especially for lax and ptotic buttocks. Non-scarring and sparing methods
are preferred and asked for by patients. So far, the most used minimally
invasive technique for the fatty tissue was exclusively liposuction, but
in our hands the ultrasonic assisted liposculpture (U.A.L.). Unfortunately,
liposuction alone cannot lift or tighten up the buttocks and is mostly
followed by excision of the tissue, or other surgical methods. To improve
the gluteal region in those patients whose problem is skin flabbiness
rather than excessive fat, combination techniques are performed: liposuction,
lipoinjections, implants for augmentation, and lipectomy.
The aim of our paper is to present a new outpatient buttock lift surgical
procedure by suture that can meet the patients requirements for beautification
of the buttock form and position without scars, and has an easy and fast
recovering post operative period, and is long lasting.
ANATOMY
The well
accepted gluteal position is the position of the m gluteus maximus. The
musculo-sceletal framework is normally nice formed (Fig 1). Unfortunately,
women structure includes mostly an inferiorly positioned fatty tissue
deposit, elongating ladies buttocks in lower aspect. Those long hanging
buttocks are visible from the frontal view as well (Fig. 2) and shorten
the lengths of female lower limbs from the back view. The hanging soft
tissue is well known as "unhappy buttocks", different from the
high gluteal position, called "happy buttocks".
A/ B/
Fig
1. A, B. Gluteal muscle structure is high placed and rounded.
Its position corresponds to the Venera triangle in the front.
A /
B/
Fig
2. A. Sagging loose buttock soft tissue, dropping between
the thighs, often depresses ladies and they ask for buttock lift. B.
The idea is to lift the hanging buttocks that optically elongates the
legs and is more aesthetic.
The gluteal fatty tissue includes fibrotic fibres, fascial layers and
trabecular system attaching the skin to the gluteus maximus fascia. The
fascial tissue represents a flexible support for the "soft framework
of the human body" [1]. It forms a stable network for subdermal and
deep fat layers, as well as cases for muscles, and sheaths for blood vessels
and nerves. We use this stable fascial structure to fix higher the buttock
soft tissue.
PATIENTS AND METHOD
The primary
indication for buttock lift surgery by suture is the moderate to severe
soft-tissue laxity in the lower trunk with minimal or mild residual fat
deposits. We initially treat patients with significant fat deposits with
UAL to reduce the volume and heaviness of the buttock fat tissue [2].
This new procedure was created for aesthetic purposes with the intention
of creating a higher and more rounded attractive buttocks, at the same
time creating a visible elongation of the legs and a change of the correlation
body to lower limbs length. True buttock sculpting demands a three-dimensional
artistic understanding of the anatomic and surgical adipose layers of
the central trunk. This is essential in preventing complications from
the buttock lifting where the higher fibrous fixation has to be done without
damaging neurovascular structures or major tendons or penetrating a joint.
A/ B/
C/
Fig.
3. A, B, C. Three steps minimum are necessary for a complete
fixation of the buttock superficial fascial system. It realizes a stable
fixation of the lower buttock soft tissue to the upper area of the stable
gluteus fascia.
Our surgical
technique contains a fixation of the complete superficial fascial system
and dermal suspensions through a special long needle (Fig 3) and a suture
technique including 3 steps:
The first step for fixation of the subdermal fascial tissue begins on
the lateral aspect of the buttock (mostly using the same penetration point,
like in liposuction, UAL or using an old one) and ends medial 2-3 cm higher
and lateral from the anus, while the second begins on the second penetration
point and ends on the upper aspect of the inter-gluteal fold. The third
fixation with the same suture starts from there, passes convex through
the hard fibrous tissue and the gluteus maximus fascia and ends passing
trough the first penetration laterally, fulfilling the circular character
of the suture. Elastic tightening of this suture assures a higher fixation
of the gluteal fibrosis layers of the lower part of the buttock to the
upper part of the gluteus fascia in the upper part near the sacrococcygeal
area. This elastic tightened suture provides a stable support of the loose
hanging lower buttock soft tissue, lifting it in a higher position and
fixed to a stable fibrotic tissue. At the same time it corrects the trabecular
system of the skin in a superficially convex "bucket". This
superficial roundness is moved superiorly to its previous position. The
fixation of the suture to the stable inelastic deep gluteus fascia, maximally
guaranties the longevity of the aesthetic effect. The elastic quality
of the antimicrob polycaproamide surgery fibres Polycon, a product of
PK "Tonzos, Jambol, Bulgaria, that we use, reduces the possibility
of decubiti of the fibrotic tissue and it reduces complications such as
infection, slow healing wounds etc.
The buttock lift by suture requires 10 to 15 min of operating time per
side, no blood transfusions, no stay at the clinic, no nursing care, and
not more than a day or two off work.
Twenty-three cases of laxity and ptosis in the gluteal area during the
years May 1998-May 2002 were treated by the author's operative technique
to lift the buttocks for purely aesthetic reasons. The patients ranged
in age from 18 to 34 years. In the same session, eleven of the patients
had moderate lower trunk and lower limb cellulite that required additional
ultrasonic liposculpture of the lower body. The patients were followed
up from 3 month to 4 years.
Combined
methods
Eighteen patients have had buttock lifts in combination with ultrasonic
assisted liposculpture. In all cases, UAL was performed to reduce the
volume and to sculpture the buttocks and in other areas for total leg
or body beautification. Its additional positive qualities are skin tightening
and weight loss. When using the UAL for buttock sculpturing, our goal
is to minimize the fat deposits and their weight and to obtain a nice
rounded and higher positioned buttocks over the m. gluteus maximus. Secondary
skin tightening occurs in all patients but its result is better in younger
patients. In cases where we cannot expect a good skin and tissue tightening,
we first remove the fat deposits and after that we use the same puncture
entry points to lift the buttock soft tissue with the suture procedure.
RESULTS
The cosmetic
results were evaluated with preoperative and postoperative photographs.
(Fig. 4, 5, 6). No patient was dissatisfied with the results, and all
of them considered their results good or excellent.
A/
B/ C/
Fig.
4. A. The patient before total UAL of body and lower extremities.
UAL was performed two months before the buttock lift by suture for total
body and leg beautification as well as to reduce the heaviness of the
hanging buttock soft tissue. Back view of the same patient before UAL
of body and extremities; B. Buttock lift by suture:
result on day first after surgery (back view): Buttocks are softly lifted,
the subgluteal is raised and shortened; C. Buttock
lift by suture: result on day first after surgery (profile view). "Happier"
buttock form and elongation of the legs is visible. The closeness of the
wounds to the anus area makes antibiotic prophylaxis and strict hygiene
obligatory.
A/ B/
C/
Fig.
5. Result after a buttock lift by suture only; A.
Back view: before and after; B. Halfprofile:
before and after; C. Profile view: before and after.
Higher rounded buttock form is achieved. No incision scars persist. The
only visible puncture scar 1-2 mm in diameter could be visible in the
lateral area of the buttock.
A/ B/
C/ D/
Fig.
6. a, c. A patient that was treated previously by excision
lipoplasty of the inner, lateral thigh and buttocks (visible scars, irregularities
and deformities). Fig. 6. b, d. Result one day
after buttock lift by suture and additional simultaneous UAL of flanks
and abdomen. The buttocks are visible lifted and a better-rounded form
obtained. The use of UAL assured a body form beautification and at the
same time a correction of irregularities and deformities.
In our observations,
suction alone has never been sufficient to remove the ptosis of the buttocks
and the rate of reoccurrence in such patients seeking our help has been
found to be nearly 100%. In our patients with UAL treatment of the lower
limbs and buttocks, skin retraction has failed in only 1% due to reasonable
selection. In large and heavy buttock with hanging and loose skin and
tissue, we recommend UAL followed by the author's technique for buttock
lift suture.
DISCUSSION
There is
an increasing demand for surgical correction of the body contour in the
modern society. There are a limited number of operations, which aim is
correction of non-aesthetic buttocks form as a part of the total body
look and proportions. The hips, thighs, and the lower back frame the buttock
contours. Buttock proportions are balanced by the anterior projection
of the breasts. Ethnic differences in the shape and proportions of the
buttocks create a variety of aesthetic variations in size and shape.
Flat and sagging buttocks without fat deposits are a common clinical condition,
but there are no proven aesthetic and effective therapeutic options.
Subcision is a surgical technique that is used in treating advanced degree
cellulite [5]. To treat excesses of fat and skin tissue in that area,
liposuction [6-8] and/or dermolipectomy [9, 10] are mostly used. Liposuction
is performed through small skin incisions, which results in minimal scar
formation and is associated with minimal complication rates. The indication
for liposuction is restricted to the conditions in which the overlying
skin is capable to retract and adapt itself to the new contour. Otherwise,
if excess skin is the cause of the deformity, a dermolipectomy is mostly
performed. In these cases, the incisions are chosen in a way that the
resulting scar may be hidden as well as possible.
Superficial liposuction was introduced to the thin superficial layer of
fat in patients with different types of skin. It has been concluded that
the controlled scar retraction of the thin cutaneous adipose flap allows
for good results even in flaccid and aged skin [8]. Other authors support
this same conclusion [11]. Currently, the most common indications for
surgical removal of excess fat concern mostly the abdomen, hips, thighs
and arms. Liposuction of the buttock area is less mentioned in the literature
and for some authors it is a forbidden zone [12]. Two additional approaches
in suction lipectomy of the buttock region are described: liposuction
of the "banana" and liposuction of the "sensuous triangle"
[7]. The banana is the highest part of the posterior thigh just below
the buttock crease. It appears only in certain individuals and appears
as a bulge. A common complication of liposuction of this area is ptosis
of the buttock crease. The sensuous triangle is at the junction of the
lateral buttock, lateral thigh, and posterior thigh. The result of suctioning
this area is a more athletic-appearing buttock region.
The use of ultrasound to improve the liposuction possibilities in gluteoplasty
is a new and potentially exciting area of clinical and research interest.
[3, 4]. It has resulted in important changes in our practice of suction
lipoplasty in that body area.
To improve buttock roundness and higher position, fat transplantation
and different implants, including mammary ones, were introduced [13-15].
An augmentation to sagging or hypertrophic buttocks similar to that of
the breasts can be done [16].
Free fat graft has been used with success in cosmetic surgery to avoid
the most common complications of doing a buttock augmentation with silicone
prostheses and to find a better surgical procedure that is simpler, complementary
with liposuction, and better able to deal with subtle body irregularities.
In trying to achieve symmetry and better contour of the back torso and
middle third of the body, the combination of liposuction and lipoinjection
is rapidly becoming the procedure of choice for most of authors. Fat grafting
is done in multiple tunnels in a deep plane [17], results are considered
uniformly satisfactory. Liposuction is done with a tumescent technique
in the lumbosacral, trochanteric, and subgluteal region to improve gluteal
shape using additional lipofilling. The quantity of fat infiltrated varies
from 120 to 280 cc per gluteus, with a mean of 210 cc [14]. Contour defects
treated with autologus intramuscular fat graft injections need overcorrection
by approximately 50 percent more volume. It is not an easy goal because
of the high reabsortion of fatty tissue [18]. Delicate tissue handling
and small total amount of fat transplanted by careful distribution in
the recipient tissues are probably the factors responsible for the long-lasting
improvement in these patients [19]. Complications are minimal with enhanced
satisfaction of both patients and surgeons.
In obese patients the functional benefits of a combination excision-suction
lipectomy outweigh the disadvantages of the scarring [20]. If there is
considerable excess of skin and tissue, excision procedures are performed
to remove excess tissue by surgical resection via appropriately large
incisions. Resulting scars are visible [21] (Fig. 6. a, c). Lipectomy
with suction of the lower extremities has been of greater interest in
recent years. Due to some authors the number of patients seeking dermolipectomy
of the trunk and thighs is increasing. The so-called "lower body
lift" combines the transverse flank/thigh/buttock lift and the fascial
anchoring medial thigh lift in one operation [22]. Secondary high-buttock
corrections pose difficult problems because of the poor vascularization
of certain areas, the limited mobilization of the soft tissue, and the
tendency toward poor scar formation. These factors limit the surgical
techniques available. The tendency for the deformity to recur may necessitate
several corrective procedures [23]. The deep planed torso-abdominoplasty
is beneficial for treating gestation sequelae of the torso-abdominal wall,
ptosis of the abdomen, vertical and horizontal enlargements of the musculoaponeurotic
system, lipodystrophy, stretch marks, rhytidosis of the inguinal region,
and ptosis of the external quadrant of the gluteus and the external trochanter
area in one surgical procedure [24]. It creates pexy of the external quadrant
of the gluteus region. Muscle strength is the limiting factor in repetitive
squat lifting. Fatigue may be one of the determinants for changes in kinematics
and choice of technique in lifting tasks. Lower body lift with superficial
fascial system suspension is introduced to treat laxity of the entire
lower trunk and thigh regions in one stage in selected patients This procedure
needs 3 weeks off work and is expected to result in a tightening of the
flank, buttocks, and total thighs. Minor complications are significantly
higher than with the component procedures alone and occur in nearly 50
percent of patients [22]. Another surgical procedure, a circumferential
torso excision was designed and utilized for minimal number of patients.
This technique dramatically reduces the lateral flank and posterior tissue
rolls to improve the operative results. Contour improvement of the buttocks
and lateral thighs is produced as well [25]. A buried dermal-fat flap
technique is particularly applicable to patients with asymmetry of the
buttocks and thighs as well as those with ptosis of the buttocks. An advantage
is that it creates a new gluteal fold at a predetermined higher level
[10]. Belt lipectomy includes the traditional abdominoplasty or panniculectomy
with excision extended laterally around the entire trunk. This technique
yields a lateral thigh and buttock lift, and when combined with liposuction
is used to improve contour of the thighs [26].
Correction of sequelae of primary hip-buttock-thigh plasty has become
a common challenge in aesthetic plastic surgery. Due to some authors,
suggested techniques for dealing with this problem include denuding the
skin at the depressed area, pulling flaps upward and outward, using dermal
buried flaps, and utilizing liposuction. Liposuction can be used successfully
in combination with classic hip-buttock-thigh plasty to enhance the aesthetic
result as well as to facilitate the surgical technique [21].
Excision body lifts are surgical procedures that are infrequently performed
because the length of operating time increases the risk to the patient
as well as the likelihood of surgeon fatigue. The other drawback of body
lifts is the long incision line. However, these incisions are well accepted
if they are well placed and if the results of body change are significant.
Meticulous haemostasis, limited undermining, and the closure of dead space
are factors that produce a more reliable procedure, both in terms of postoperative
problems and the final results [27].
The transgluteal approach could be responsible, according to some authors
for bad clinical results, due to injury of the nervus gluteus superius.
Many anatomical variations are found concerning the point of the nerve's
division into 2 branches, nearer or farther from the foramen ischiadicum
[28].
RISKS AND COMPLICATIONS
All surgical
procedures are associated with risks. They may be divided into undesired
sequelae, which are normal and expected, and complications, which are
not normal or expected. The undesired sequelae of suction lipectomy are
contour irregularities, hypaesthesia, oedema, ecchymosis, and pigmentary
deposits. The potential complications are blood loss, haematoma, seroma,
infection, greater saphenous vein thrombosis, fat emboli, and skin slough
[14, 23]. In excision procedures additional complications are spreading
scars as a result of tension, and occasional delayed healing of tense
wounds. Excision buttock lifts has not gained widespread acceptance because
of problems such as large trauma and blood loss, prolonged post op period,
early inferior scar migration, and recurrence of ptosis. The most frequent
complaint is unacceptable scarring and hypaesthesia [29, 30]. Lipoinjection
complications are gluteal temporal hyperaemia and erythema, corresponding
to fat necrosis [31-33].
Acceptance of bodily proportions in races different from those of Caucasians
has to be foreseen. Furthermore, black people and Japanese tend to hypertrophic
scarring [34].
In our patients we observed one case with a painful hardness around one
of the entry points and another case with a local infection in one of
the wounds. The cause for the first complication was the rigid nylon suture
we have used in our first patient, causing a tissue decubitus in the point
of tension on the soft tissue. After this complication occurred we changed
the suture and now we use the elastic Bulgarian antimicrobial one. In
the second case the Streptococcus local infection was easily treated.
CONCLUSION
Redundant
tissue in sagging buttocks can be corrected by excision lifts. However,
these are seldom used procedures because of postoperative problems such
as unaccepted inferiorly displaced and wide scars, and early recurrence
of ptosis, large trauma and blood loss, prolonged post op period.
In order to limit these complications in flat and sagging buttocks without
remarkable fat deposits, we developed a surgical technique using a circumferential
suture of the soft tissue to the gluteus fascia. A group of 12 of our
23 patients underwent a buttock lift, using this technique only, and were
followed for at least 3 months to 4 years after surgery. The fascio-fascial
suspension gives strong vertical support with minimal tension on the skin,
and reduces the complications traditionally associated with such procedures.
The results of our operations are aesthetically compatible with non-scarring
techniques such as UAL and liposuction in young patient having strong
and elastic skin and tissue, described in our presentations as well [3,
35]. The author's operation offers fewer complications than any other
described.
In the other 11 patients, whose problem was excessive fat in conjunction
with skin flabbiness, UAL of the buttocks, combined with the buttock lift
suture method, completed the main goals of the procedure in one or more
different stages. The combination of UAL and buttock lift by our suture
technique is a minimally invasive correction that can be used to reduce
and lift the buttocks at the same time.
It is an efficient and safe procedure to correct or enhance buttock contour.
It has virtually eliminated blood transfusions and the major complications
of liposuction and dermolipectomies under general anaesthesia.
The author's surgical procedure using a suture is simple and low in cost,
with minimal morbidity and very good results. It is important to note
that a good result does not depend on a great surgery but rather on a
more simple, acceptable procedures for the patients, resulting in harmonious
structuring and positioning of the form, lifting of the lower portion
of the buttocks, augmentation in the upper gluteus and better projection.
Complications are few, and patient satisfaction is high.
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Address correspondence:
Nikolay
P. Serdev, MD, PhD
Medical Center "Aesthetic Surgery and Aesthetic Medicine"
11, "20th April" St., 1606 Sofia, Bulgaria
Phone (mobile) +359 88 802004
Fax +359 2 9515668
E-mail nserdev@infocom.bg
http://www.drserdev.com
President
The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine
Send for
publication: 25 09 2002
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