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 IJCS / Year: 2002 / Volume 2 - Number 2 / Original Papers
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Nikolay P. Serdev, MD, PhD
Pages: 1 - 7/


Nikolay P. Serdev, MD, PhD

Medical Centre "Aesthetic Surgery, Aesthetic Medicine", Sofia, BULGARIA


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 sacro-cutaneous fascia, discovered by the author. 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".


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.


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".


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.


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 Serdev sacro-cutaneous fascia 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.


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/

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.


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].


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.


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

The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine

Send for publication: 25 09 2002

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 IJCS / Year: 2002 / Volume 2 - Number 2 / Original Papers
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