https://orcid.org/0000-0002-7330-4369
Abstract
Gluteal ptosis results in a severe disturbance of gluteal aesthetics. Currently, satisfactory procedures for improving gluteal ptosis are lacking.
To improve gluteal ptosis, the authors propose a novel concept of combined liposuction of the lower gluteal region and fat grafting to the upper gluteal and infragluteal regions, and verify its efficacy and safety.
Patients who underwent liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions between January 2020 and July 2023 were retrospectively reviewed. Postoperative changes in the gluteal ptosis grade, complications, and patient satisfaction were evaluated.
A total of 28 patients were enrolled in this study; 21 (75.0%) patients had gluteal ptosis grade 4 and 7 (25.0%) patients had gluteal ptosis grade 5. The median fat removal volume was 210 mL, and the median fat graft injected volume was 355 mL in the gluteal region and 180 mL in the infragluteal region. All patients showed improvement in gluteal ptosis; 16 (57.1%) patients improved by 1 grade and 12 (42.9%) patients showed a 2-grade improvement. All patients were satisfied with their posttreatment outcomes. Only 1 patient showed lateral translocation of the fat graft. No other complications were observed.
Liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions is effective in improving gluteal ptosis, with a low risk of complications and high patient satisfaction.
The gluteal region is important for body contour, and beautiful buttocks are perceived to contribute to female beauty. Although the vision of beauty is influenced by geographic, ethnic, and cultural backgrounds, a full and highly positioned buttock with a short infragluteal fold is preferred for a youthful appearance, whereas gluteal ptosis results in severe disturbances in gluteal aesthetics.1
Currently, studies on gluteal aesthetic surgery mainly have focused on gluteal augmentation; fewer studies have focused on gluteal ptosis.2 Previous surgical methods for improving gluteal ptosis most often have included implantation, gluteal suspension, and gluteal fold reconstruction. Solid silicone implants have been placed for gluteal lifting; however, implant-related complications, such as implant infection, malposition, visibility, capsular contracture, and wound dehiscence, have been reported.3 Gluteal region suspension with silhouette sutures, polypropylene strips, or other materials has also been reported for buttock lifting; however, postoperative pain is a prominent problem, and its long-term effect is not definitive.4,5 Gluteal fold reconstruction is a conventional method for improving gluteal ptosis, which removes excess skin and fatty tissue through a direct incision at the infragluteal fold.6-8 However, this surgery is difficult for Asian patients to accept because of obvious scars. Therefore, at present, satisfactory procedures for improving gluteal ptosis are lacking.
Previously, we have reported that concomitant fat grafting to the infragluteal/posterior thigh junction region during circumferential liposuction of the thigh is effective in preventing postliposuction gluteal ptosis, and the concomitant fat grafting procedure can partially improve the gluteal ptosis in some cases.9 Based on these results and the reason for gluteal ptosis, we proposed a novel concept of combining liposuction of the lower gluteal region and fat grafting to the upper gluteal and infragluteal regions, aiming to improve gluteal ptosis through soft tissue volume reduction and addition.
METHODS
Surgical Techniques
Liposuction
Surgical markings were identified with patients in the standing position. As shown in Figure 1, the liposuction region included the inferolateral and inferomedial parts of the gluteal region, which are responsible for the corpulent and sagging appearance. The incisions were designed to be hidden in the natural skin folds, including the gluteal cleft and bilateral infragluteal folds, maintaining invisibility whenever possible. Surgery was performed with the patient in the prone position under intravenous sedation and tumescent anesthesia. Tumescent solutions (comprising 1000 mL of normal saline, 400 mg lidocaine, and 1 mg epinephrine) were infiltrated into the subcutaneous fat layer of the surgical area.
Schematic representation of the effect of liposuction and fat grafting (dorsal view). (A) Liposuction is performed at the inferolateral and inferomedial parts of the gluteal region. Fat grafting is performed in the gluteal and infragluteal regions. In the gluteal region, the distribution of the fat graft was mainly in the center area of the upper half buttock and gradually reduced to the outer circumference. In the infragluteal region, the distribution of the fat graft was mainly along the infragluteal fold and the vertical middle line of the thigh. (B) After the operation, the infragluteal fold line was shorter and the sagging appearance of the buttock was improved.
Suction-assisted liposuction was performed with 3 to 3.5-mm blunt-tip cannulas. Liposuction should be moderate, with the principle of reducing the excessive volume in the lower half of the buttock, mainly removing the superficial fat, which is more redundant and likely to contribute to the sagging appearance. Furthermore, because the critical neurovascular structures are relatively superficial in this area, liposuction in the superficial layer is necessary from a safety perspective. Importantly, overaggressive liposuction should not be performed in this area because it might cause flabbiness of the buttocks and aggravation of ptosis. The infragluteal fold is an area prone to adhesion, where liposuction should be avoided to prevent infragluteal fold deformities. In this study, the volume of fat removed refers to the volume of fat after settling.
Fat Grafting
Fat grafting was performed with the patient in the prone position upon completion of the liposuction procedure. Aspiration was collected in a sterile container, and the connective tissue was manually eliminated. Fat grafts were harvested and prepared by centrifugation (700 × g for 3 minutes). Fat was injected into the subcutaneous fat layer with the spiral syringe as the cannula was withdrawn through the same incision utilized for liposuction. Fat grafting regions are shown in Figure 1. In the gluteal region, fat was mainly injected in the deep fat layer, then proceeding superficially. The distribution of the fat graft was mainly in the center area of the upper half of the buttock and was gradually reduced to the outer circumference to make the most prominent portion at the upper-mid height of the buttocks and to achieve a satisfactory convexity. In the infragluteal region, fat infiltration was concentrated at the surface of the deep fascia and was gradually dispersed into the superficial layer, distributed mainly along the infragluteal fold and vertical midline of the thigh. Sufficient volume addition was required in this area to produce sufficient support to the buttocks. The surgical process is shown in the Video. The effects of integrated gluteal liposculpture are shown in Figure 1 and Figure 2.
Schematic representation of the effect of liposuction and fat grafting (lateral view). (A) Before the operation, the buttock shows a sagging appearance. Ptotic tissue can be seen at the infragluteal fold. (B) After the operation, the most prominent portion position was elevated from the lower half to the upper half of the gluteal area, and the supporting effect of the infragluteal region to the gluteal area was enhanced, achieving significant improvement of gluteal ptosis and a gluteal lifting effect.
Patients
Data of patients who underwent gluteal liposculpture performed by the authors between January 2020 and July 2023 were retrospectively reviewed. Demographic data and medical history, including age, body mass index (BMI), preoperative and postoperative degrees of gluteal ptosis, volume of liposuction and fat grafting, and postoperative complications, were collected and analyzed. The degree of gluteal ptosis was classified from grade 0 (no ptosis) to grade 6 (severe ptosis) according to the length of the infragluteal fold line and the ptotic fold angle, described by Rau et al (Figure 3).9-11 Patients with grade 0 to 3 (no ptosis to borderline pre-ptosis) and grade 6 (severe ptosis) were excluded because they were not eligible for this integrated gluteal liposculpture operation. Preoperative and postoperative photographs were obtained for all patients. All procedures were performed in accordance with the ethical standards of the institutional committee and the 1964 Declaration of Helsinki with its later amendments, or comparable ethical standards. Informed consent was obtained from all participants.
Illustration of gluteal ptosis grades. (A) Grade 0 (no ptosis). No infragluteal fold, or the infragluteal fold is limited to the T line. No ptotic tissue on the lateral view. (B) Grade 1 (minimal pre-ptosis). The infragluteal fold passes the T line but fails to reach the M line. No ptotic tissue on the lateral view. (C) Grade 2 (moderate pre-ptosis). The infragluteal fold reaches the M line. No ptotic tissue on the lateral view. (D) Grade 3 (borderline pre-ptosis). The infragluteal fold extends beyond the M line. No ptotic tissue on the lateral view. E) Grade 4 (mild ptosis). Ptotic gluteal tissue passes over the infragluteal fold at the M line. The angle of the ptotic fold at the infragluteal fold is less than 10° on the lateral view. (F) Grade 5 (moderate ptosis). Ptotic gluteal tissue passes over the infragluteal fold at the M line. The angle of the ptotic fold at the infragluteal fold is between 10° and 30° on the lateral view. (G) Grade 6 (severe ptosis). Ptotic gluteal tissue passes over the infragluteal fold at the M line. The angle of the ptotic fold at the infragluteal fold is more than 30° on the lateral view. M line, the virtual line that passes vertically through the middle of the thigh; T line, the virtual line that passes vertically through the ischial tuberosity.
Evaluation of Surgical Results
Surgical evaluation was performed at a median follow-up time of 10 (7 to 11) months. The efficacy of surgery was evaluated with ptosis grade and patient satisfaction scales. General satisfaction with body appearance after surgery was rated by the patients on a scale of 1 to 5 (1 = poor, 2 = fair, 3 = good, 4 = very good, and 5 = excellent), which has been reported extensively in previous publications.12-15 Surgical safety was evaluated based on the presence of complications. Adverse events observed by the investigators or reported by the patients during the follow-up period were recorded.
Statistical Analysis
Statistical analyses were performed with IBM SPSS Statistics (version 22.0; IBM Corp., Armonk, NY). Continuous variables were expressed as median (interquartile range) and compared with the Mann–Whitney U test. P values less than .05 (2-sided) were considered statistically significant.
RESULTS
A total of 28 patients were enrolled in the study. All patients were female, with a median age of 29 (24.3 to 32.0) years and a BMI of 20.9 (19.5 to 24.5) kg/m2. Twenty-one (75.0%) patients had gluteal ptosis grade 4 and 7 (25.0%) patients were grade 5. The median fat removal volume was 210 (180 to 385) mL. The median fat graft injected volume was 355 (200 to 458) mL in the gluteal region and 180 (133 to 240) mL in the infragluteal region. After the procedure, 8 (28.6%) patients were gluteal ptosis grade 2, 17 (60.7%) were grade 3, and 3 (10.7%) were grade 4. All 28 patients showed an improvement in gluteal ptosis; 16 (57.1%) patients improved by 1 grade, and 12 (42.9%) showed a 2-grade improvement. The evolution of the gluteal ptosis grade is shown in the Table and Figure 4. A significant difference was observed between the preoperative and postoperative gluteal ptosis grades (P < .001). The infragluteal fold line was shortened, and the sagging appearance of the buttocks was improved after the procedure (Figures 5–7). All patients were satisfied with their posttreatment outcomes; patient satisfaction was rated as good (3.6%), very good (10.7%), or excellent (85.7%). Overall, 1 patient showed lateral translocation of the fat graft (Figure 6C). No other complications were observed.
The improvement in gluteal ptosis grade of the 28 patients after the operation.
(A, C) Preoperative views of a 26-year-old female with grade 5 gluteal ptosis who underwent liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions. (B, D) Postoperative views 6 months after surgery. The total volume of fat removed was 140 mL, and the volume of fat grafting was 400 mL in the gluteal region and 200 mL in the infragluteal region. The grade of gluteal ptosis was improved by 2 grades after surgery (from grade 5 to grade 3).
(A, C) Preoperative views of a 27-year-old female with grade 4 gluteal ptosis who underwent liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions. (B, D) Postoperative views 10 months after surgery. The total volume of fat removed was 170 mL, and the volume of fat grafting was 150 mL in the gluteal region and 210 mL in the infragluteal region. The grade of gluteal ptosis was improved by 1 grade after surgery (from grade 4 to grade 3). The arrow shows lateral translocation of the fat graft.
(A, C) Preoperative views of a 21-year-old female with grade 5 gluteal ptosis who underwent liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions. (B, D) Postoperative views 30 months after surgery. The total volume of fat removed was 150 mL, and the volume of the transplanted fat was 220 mL in the gluteal region and 140 mL in the infragluteal region. The grade of gluteal ptosis was improved by 2 grades after surgery (from grade 5 to grade 3).
Evolution of Gluteal Ptosis Grades
| Grade 2post | Grade 3post | Grade 4post | Grade 5post | Total | |
|---|---|---|---|---|---|
| Grade 4pre | 8 (28.6%) | 13 (46.4%) | — | — | 21 (75.0%) |
| Grade 5pre | — | 4 (14.3%) | 3 (10.7%) | — | 7 (25.0%) |
| Total | 8 (28.6%) | 17 (60.7%) | 3 (10.7%) | — | 28 (100.0%) |
| Grade 2post | Grade 3post | Grade 4post | Grade 5post | Total | |
|---|---|---|---|---|---|
| Grade 4pre | 8 (28.6%) | 13 (46.4%) | — | — | 21 (75.0%) |
| Grade 5pre | — | 4 (14.3%) | 3 (10.7%) | — | 7 (25.0%) |
| Total | 8 (28.6%) | 17 (60.7%) | 3 (10.7%) | — | 28 (100.0%) |
postpostoperative grade of gluteal ptosis; prepreoperative grade of gluteal ptosis.
Evolution of Gluteal Ptosis Grades
| Grade 2post | Grade 3post | Grade 4post | Grade 5post | Total | |
|---|---|---|---|---|---|
| Grade 4pre | 8 (28.6%) | 13 (46.4%) | — | — | 21 (75.0%) |
| Grade 5pre | — | 4 (14.3%) | 3 (10.7%) | — | 7 (25.0%) |
| Total | 8 (28.6%) | 17 (60.7%) | 3 (10.7%) | — | 28 (100.0%) |
| Grade 2post | Grade 3post | Grade 4post | Grade 5post | Total | |
|---|---|---|---|---|---|
| Grade 4pre | 8 (28.6%) | 13 (46.4%) | — | — | 21 (75.0%) |
| Grade 5pre | — | 4 (14.3%) | 3 (10.7%) | — | 7 (25.0%) |
| Total | 8 (28.6%) | 17 (60.7%) | 3 (10.7%) | — | 28 (100.0%) |
postpostoperative grade of gluteal ptosis; prepreoperative grade of gluteal ptosis.
DISCUSSION
The appearance of gluteal ptosis is a complex process. The infragluteal fold is anatomically important in defining the inferior border of the gluteal region. In the infragluteal fold area, deep fat is absent and superficial fascial tissues firmly adhere to the deep fascia of the underlying muscles, which is an important part of the gluteal suspension system.16,17 When the soft tissue or skin of the gluteal region is excessive, such as during weight gain and massive weight loss, or anything causing weakness of the gluteal suspension system, such as trauma or iatrogenic damage, the gluteal tissue begins to move downward. The presence of the adhesive region keeps the gluteal fold in place, and the downward movement of the gluteal tissue causes ptotic deformity. Previously reported methods for gluteal lifting, such as implants and gluteal suspensions, do not target both the tissue excess of the gluteal region and the weakness of the gluteal suspension system, and the improvement of ptosis is limited.
Based on the cause of gluteal ptosis, we proposed the concept of combining lower gluteal liposuction and upper gluteal and infragluteal region fat grafting to reduce the excessive gluteal volume while enhancing the supporting effect to the gluteal region, effectively improving gluteal ptosis. The lower half was the most significant excessive volume area of the gluteal region; there, liposuction was performed. The importance of liposuction should be moderated and the infragluteal fold should be kept intact to avoid a flat appearance of the gluteal region and infragluteal fold deformities. Nevertheless, simply reducing the volume of the lower gluteus through liposuction will present an effect similar to massive weight loss, which instead causes aggravation of gluteal ptosis. To address this issue, it is necessary to maintain and increase the supportive gluteal volume. Therefore, liposuction is only performed at the inferolateral and inferomedial areas, and the volume of the central area is maintained. In addition, fat is transplanted into the upper gluteal region to move the most prominent portion from the lower to the upper half of the gluteal region (lateral view), achieving a gluteal lifting effect. Moreover, the volume of the infragluteal region is increased by fat grafting to enhance its support of the gluteal region. In summary, the principle of this surgical method is to remove the excessive volume of the lower gluteal region, elevate the prominent portion of the gluteal region, and enhance the support to the gluteal region through soft tissue volume reduction and addition, with the goal of effectively improving gluteal ptosis. This study confirmed the effectiveness of this surgery. After surgery, all 28 patients showed improvement in gluteal ptosis: 16 (57.1%) improved by 1 grade, and 12 (42.9%) showed a 2-grade improvement.
In general, the reported incidence of complications of gluteal augmentation with fat grafting ranges from 7% to 10.5%, of which 95.5% are minor complications.18,19 The major complication of gluteal augmentation is fat embolism, which is related to intramuscular injection.20,21 We injected the fat graft into the subcutaneous fat layer, and even though relatively large-volume fat grafting was performed (median of 355 mL in the gluteal region and 180 mL in the infragluteal region), complications were rare and minor. No seroma, sciatica, or fat embolism was observed; however, 1 patient showed lateral translocation of the fat graft. In our opinion, fat repositioning is the most concerning problem. We recommend concentrating the fat graft on the surface of the deep fascia and gradually dispersing it into the superficial layer of the subcutaneous fat during surgery. Moreover, avoiding local pressure on the fat-transplanted region after the operation is important for preventing fat repositioning.
Our study had several limitations. First, the effect of this soft tissue volume adjustment method by liposuction and fat grafting for improving gluteal ptosis is finite and only applicable to patients with grade 4 or 5 (mild or moderate) ptosis. Grade 6 (severe) gluteal ptosis is always accompanied by significant skin laxity and excess. In this case, the effect of excess skin is significantly greater than that of soft tissue, and adjusting soft tissue volume alone is insufficient for effectively improving gluteal ptosis. To the best of our knowledge, surgical resection of excessive skin and infragluteal fold reconstruction are recommended for patients with severe ptosis. Second, similar to other aesthetic operations, liposuction and fat grafting vary individually, according to the €ntegrated gluteal contour, a”d are highly dependent on the surgeon's experience. Therefore, it is difficult to identify specific criteria for the volume and endpoints of liposuction and fat grafting. In our experience, the significantly shortened and shallower infragluteal fold line can be considered a reference for fat grafting to achieve sufficient gluteal supporting effect. Third, the amount of liposuction from the lower gluteal region is insufficient for the fat grafting. Therefore, it is necessary to extract enough fat grafts from other parts of the body such as the abdomen, thighs, and arms. Finally, the median follow-up time for this study was 10 months. Although the gluteal contour is generally relatively stable 3 to 6 months after surgery, further long-term observation is needed to better evaluate the effectiveness and safety of this surgery.
CONCLUSIONS
Liposuction of the lower gluteal region combined with fat grafting to the upper gluteal and infragluteal regions is effective in improving gluteal ptosis, with a low risk of complications and high patient satisfaction. Based on solid data, this gluteal liposculpture surgery is recommended for patients with mild to moderate gluteal ptosis.
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
This work was supported by the Chinese Academy of Medical Sciences Medical and Health Technology Innovation Project 2020 Clinical and Translational Medicine Research Fund (no. 2020-I2M-C&T-B-077), National Multi-disciplinary Collaborative Diagnosis and Treatment Capacity Building project for Critical Diseases (no. 19038), and General Program of National Natural Science Foundation of China (no. 82372547).
REFERENCES
Author notes
Drs Yang, Li, Dong, Lv, Qi, and Gu are plastic surgeons and Dr Han is a professor, Body Contouring and Fat Grafting Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan District, Beijing, China.
Drs Qi and Ma are professors, Comprehensive Ward, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan District, Beijing, China.
