Gluteoplasty With Lumbar Gluteal Flap Associated With Liposuction and Fat Grafting: A Safe Technique for Massive Weight Loss Patients

Abstract

Background

Weight loss leads to excessive flaccidity, volume loss, and tissue descent in the gluteal region. Translated autologous flaps during lower body lifting have been utilized in patients; they address sagging tissue and the lack of volume. However, sometimes use of these autologous flaps does not provide adequate gluteal projection, and a second procedure with fat injection may be required.

Objectives

The authors describe their technique of a lower body lift with a lumbosacral flap in association with liposuction and lipofilling for gluteoplasty.

Methods

A prospective series of 23 post–bariatric surgery individuals who underwent a lower body lift with lumbosacral flap gluteal augmentation, liposuction, and lipofilling between January 2021 and September 2022 were described. The satisfaction rate and complications were assessed 6 months postoperatively with a validated questionnaire (BODY-Q scale).

Results

The patients had a mean age of 38.18 (range, 28-56 years) and median body mass index of 26. Four patients with dehiscence were diagnosed and treated conservatively. All wound breakdowns were observed in the paramedian plane of the torsoplasty. No reoperations were performed. The mean satisfaction percentage of the BODY-Q scale transformed score was 97.5.

Conclusions

A technique for a lower body lift with buttock augmentation combined with liposuction and fat grafting was presented. In future studies other techniques to maximize gluteal contouring should be investigated.

Massive weight loss leads to sagging of the skin and loss of volume of the lower back and buttocks. The most common techniques for gluteal augmentation include silicone implants, fat grafting, and local flaps.^1–7 In 1969, Bartels et al were the first to use silicone breast implants to add volume to the buttocks.⁸ However, in addition to volume gain, patients with massive weight loss also require tissue repositioning and removal of excess skin.⁶ A large volume of fat graft can provide fullness but still does not treat the sagging skin.⁷ Fat grafting can lead to seroma, abscess, and transient sacral numbness and asymmetry, depending on the take percentage.⁵ Gluteal flaps have been employed since 2002 as an autologous method for gluteal augmentation associated with torsoplasty in patients with significant weight loss.⁹ A medially based deepithelialized flap is harvested from the flank and positioned over the gluteus maximus. Some of these techniques provide suboptimal positioning of the flap and fail to provide enough soft tissue for adequate volumization.^6,10 Srivastava et al reported no significant difference improvement in satisfaction after dermal/fat transposition compared with no flap transposition, however, patients were happy regardless of the technique performed.¹¹ Schmitt associated the use of flaps with fat grafting to provide additional adequate gluteal projection but only for certain types of patients, which he classified as type III.¹⁰ Autoaugmentation may not improve lateral gluteal deficiency and fat injection may be needed to provide lateral fullness.¹² Many of the previous techniques failed to fill the lateral aspect of the buttocks, resulting in suboptimal results.

We report our approach to massive loss weight patients with lower body lift and lumbosacral flap combined with liposuction and fat grafting to provide fullness of the lateral aspects of the buttocks and the inferior pole.

METHODS

This prospective study included individuals with sagging skin and gluteal ptosis due to weight loss after undergoing bariatric surgery who underwent a lower body lift with lumbosacral flap gluteal augmentation, lipofilling, and liposuction. The procedures were performed at Hospital Salvalus, São Paulo, Brazil, between January 2021 and September 2022. The study followed the tenets of the Declaration of Helsinki and was approved by the Institutional Committee of Ethics of the Notredame Hapvida Group (no. 5.735.229). Included in the study were female patients who had undergone bariatric surgery at least 1 year previously, had weight stability for at least 6 months, and had lower back skin excess. Exclusion criteria included a history of torsoplasty, comorbidities, inability to remain in the prone position postoperatively, and concurrent procedures. Descriptive analyses of the pocket size, hospitalization time, and complications were performed. Additionally, a 5-question BODY-Q scale for satisfaction with the buttocks was completed 6 months postoperatively, which included 5 questions with answer options ranging from 1 (very dissatisfied) to 4 (very satisfied). The questions assessed the size, profile view, shape, smoothness, and skin quality of the buttocks. All statistical analyses were performed with Excel, version 2021 (Microsoft, Redmond, WA).

Flap Demarcation

The first 3 points were marked while the patient was standing. Point A was the beginning of the intergluteal cleft, and point B was the end of the abdominoplasty scar, or if not present the iliac crest. A third point, C, above the beginning of the intergluteal sulcus, was demarcated according to the aesthetic need to position the new intergluteal sulcus. The flap was drawn with the patient in the prone position, as a straight line parallel to the inferior gluteal sulcus starting at point A and curving as it reached point B. This was the inferior margin of the flap. An arcuate line between point B and C representing the superior margin of the flap was created with the pinch test. (Figure 1, Video 1).

Pocket Demarcation

The pocket was composed of an upper minor triangle that defined the pocket entrance, and a lower major rectangle where the flap would be accommodated in the lateral and central buttocks.

The right triangle had a hypotenuse, represented by the inferior border of the flap, and its base was defined by 2 points: D, 2 cm lateral to the intergluteal cleft, and E, between 9 and 10 cm from D. Point E was 2 to 3 cm lateral to the most lateral part of the flap pedicle for easy rotation to the pocket. The height of the triangle was 4 to 5 cm above point E and was defined as point F (Figure 1).

The upper limit of the rectangle was the base of the right triangle, which extended laterally. Its lateral border was 6 to 7 cm in height and was defined by superior point G and inferior point H. This height varied according to the distance between the greater trochanter and the iliac crest. The inferior border of the rectangle was the connection between points H and I, located 2 cm medial to the intergluteal sulcus. The line connecting points D and I represented the medial border of the rectangle (Video 1).

Liposuction areas in the trochanteric portion and flank are marked in pink, and lipofilling areas are represented in green, as shown in Figure 1.

Surgical Technique

The patient was placed in a prone position under general anesthesia. The tumescent solution composed of 400 mg lidocaine (0.04) and 1 mL epinephrine (1:500) per liter of normal saline was infused into the subcutaneous space. Deep subcutaneous suction-assisted liposuction of the lumbar, sacral, and lateral thigh roots was carried out. The fat was decanted in an open system for 30 minutes to separate the supernatant from the underlying liquid before grafting (Video 2).

First, the flap was deepithelialized and then raised in the lateral to medial direction, straight down to the underlying lumbodorsal fascia. The pedicle area, located 8 cm from the midline, was left attached. The flap was rotated to the pocket, and its distal part was sutured to the most lateral limit of the pocket to address the trochanteric depression. If the medial part of the flap created unusual fullness in the sacrum, debulking was performed. Four-layer closure was performed in the deep and superficial subcutaneous tissues to reduce the tension on the final skin closure (Video 2).

Ultrasound-assisted fat grafting of the lower and lateral portion of the buttocks was performed with a 60-cc syringe in a deep and superficial subcutaneous plane with a blunt cannula 2.5 mm in diameter.¹³ Two closed-suction drains were placed on both sides of the pockets and left in place for 7 to 10 days. The drains were removed when the output decreased to <20 mL in 24 hours for 2 consecutive days. We recommended that patients sleep in the prone position and restrict bending over for 14 days. An elastic compression garment and lymphatic drainage were prescribed for 3 days after surgery. Preventive pharmacological chemoprophylaxis, analgesics, and an antibiotic (cefadroxil) were prescribed for 7 days.

RESULTS

We enrolled 23 female patients (mean age, 38.18 years; range, 28-56) with a mean BMI of 26 (range, 22-29) (Supplemental Table 1, available at www.aestheticsurgeryjournal.com). The mean values for pocket inlet width, pocket inlet length, pocket width, pocket extension, and fat graft volume for these patients were 9.3 +/− 0.76 cm, 4.1 +/− 0.88 cm, 15.3 +/− 1.92 cm, 8.3 +/− 1.55 cm, and 300 (range, 100 to 600 cc) respectively. Mean time of hospitalization was 1.4 +/− 0.65 days and follow-up was done after 2 months, 6 months, or 1 year. Only minor complications were reported, with a total rate of 21.7%. The 4 patients with dehiscence were treated conservatively. One patient complained of a fat necrosis nodule in the inferior portion of the gluteus with no other associated symptoms. All wound breakdowns were observed in the paramedian plane of the torsoplasty. No seromas or wound infections were reported. No reoperations or blood transfusions were performed. The total operative time was 3 to 3.5 hours. All patient satisfaction results were evaluated at 6 months postoperatively (Figures 2-4). The mean BODY-Q scale transformed score was 97.5% +/− 0.97%. The mean satisfaction scores for size, profile view, shape, smoothness, and skin quality of the buttocks were 100%, 98.9% +/− 0.2%, 96.7% +/− %0.45, 93.4% +/− 0.61% and 98.9% +/− 0.2%, respectively.

DISCUSSION

Since Agris et al described the use of a buried dermal-fat flap to treat gluteal ptosis for the first time, many techniques have been published.^{6,7,9,10,12,14–20} Many of these authors started to utilize the lumbosacral gluteal flap because of its versatility for rotation to the pocket, its ability to recruit excess skin from the lateral flank, and its ability to volumize the buttocks.^7,15,19,20 These flaps are based on medial perforators of the superior gluteal artery and are positioned in the central area of the buttocks.⁷ Rohde et al in 2004 described a series of 62 cases of lumbar rotation flaps for gluteal augmentation, which were inset at the central buttock area with good volumization.¹⁹ One patient with symptomatic fat necrosis underwent reoperation to remove the mass. Sozer et al in 2005 described 20 cases of gluteal augmentation with caudal rotation of 180° of the dermal fat flap toward the central area of the buttocks.⁷ In 2 patients fat necrosis resolved without any intervention. Raposo et al in 2006, and later Colwell et al, attested to the safety of lumbosacral rotation flaps based on the perforators of the superior gluteal region, positioning them in the medial half of the buttock.^6,20 The latter study reported major fat necrosis of the flap in a series of 18 patients who were successfully treated conservatively. In our series, there was no flap loss, and 1 patient had fat necrosis, with no necessary treatments. Although all flaps had good distal perfusion before insertion, local edema in the early postoperative period could have caused distal vascularization impairment and fat necrosis. Therefore, patients were instructed not to lie in the supine position to avoid compression of the buried flap. Lumbar rotation flaps provide a good arch of rotation, which allows positioning of the flap where the surgeon believes that there is a greater volume deficit. Most of the authors position their flaps at the central buttock pole, leading to a lack of volume in the inferior and lateral gluteal areas.^{6,7,9,10,12,14–20} Lockwood et al in 1991 were the first to draw attention to supratrochanteric depression and suggested the use of a superior or inferior decorticated flap to volumize the lateral aspect of the gluteus.²¹ We prefer to position the distal part of the flap laterally to provide lateral fullness, because the body of the flap ensures good anteroposterior projection. The lower portion of the pocket reaches and releases the insertions of the ischial cutaneous ligament attachment, which helps recruit skin from this sagging area.²² The tissue medial to the perforators can be discarded to avoid fullness in the sacrum and improve the gluteal contour. We also debulk the sacral area when it is voluminous, usually with a liposuction procedure, to provide a better transition between the lower back and the buttocks. In previous studies the authors usually slid the inferior gluteal skin over the lumbosacral flaps to create a superior incision.^6,7,10,12 In this technique, a band at the lateral superior part of the gluteus was attached to provide a good transition between the lumbosacral region and the beginning of the gluteus, and to add reliability to pocket detachment, because it may preserve perforators. Skin necrosis of the sliding flap was not observed.

Colwell et al reported 87% aesthetic satisfaction in an anonymous survey regarding buttock appearance, contour, and volume.⁶ We had similar aesthetic satisfaction rates, and 2 patients downgraded the contour question because of the absorption of the fat graft at the lower portion of the buttock. Usually, this area is filled with the maximum volume to avoid such a result; nonetheless, future lipofilling procedures may be required. Additionally, the fifth question in this questionnaire referred to the quality of the skin in the gluteal region, with 22 patients reporting that they were very satisfied, and only 1 patient reporting that they were somewhat satisfied. Because of the repositioning of loose skin, most of the cellulite and laxity of the buttocks were treated.

Sozer et al associated liposuction with the use of a gluteal dermal fat flap during a lower body lift to maximize their results.¹⁸ In our opinion, liposuction provides a pleasant transition between the lower back and buttocks and between the posterior thigh and lower pole of the buttocks. Fat grafting complements the volume in areas that the flap does not fill, such as the lower and lateral poles of the buttocks. Liposuction and lipofilling combined with the lumbosacral flap maximize the aesthetic outcome of the buttocks.

In the literature we found 16%, 10%, and 8% of wound dehiscence; in our study 4 patients had wound dehiscence, representing 17%.^6,7,19 All these cases were reported at the beginning of our study, when only 1 line of sutures was placed in the subcutaneous layer. Subsequently, we placed 2 suture lines in the subcutaneous layer, and had no additional cases of wound dehiscence. We did not encounter any cases of seroma, most likely because we left the long-term drain in place for up to 2 weeks.

Because the lower pole is lipofilled to provide better transition to the medial pole, an insufficient take of the fat graft will result in settling of lower pole. In these patients, further fat grafting may be required. Another shortcoming of this technique is the inability to address significant saddlebags, especially when the main component is an excess of skin.²³ The main limitation of this study design was the lack of a comparison group and the limited sample size. In future studies, patient satisfaction surveys, as well as physician rating surveys, should be performed before and after the surgery to assess significant differences between the groups.

CONCLUSIONS

This study reports on a lumbosacral flap for augmentation and contouring of the buttocks after significant weight loss in post–bariatric surgery patients. The combination of this technique with liposuction and fat grafting is important for maximizing aesthetic results and achieving better satisfaction with gluteal contouring. Further studies are necessary to investigate the role of this standardization of the lower body lift in patients with significant weight loss.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

References

Author notes