Clinical Implications of Fat Grafting in the Posterior Calf: A Dynamic Cadaver-based Study.

BACKGROUND: Intramuscular fat grafting in extremity muscles, especially the gastrocnemius, has become increasingly popular. However, while safety in truncal muscle fat grafting has been well-studied, research on extremity muscles is lacking. OBJECTIVES: This study aims to explore the anatomy of the gastrocnemius muscle and adjacent structures concerning intramuscular and subcutaneous recipient sites. Additionally, it seeks to analyze pressure/volume relationships and fat migration patterns during posterior calf grafting. METHODS: Eight cadaveric lower extremities were examined. A prosection was performed to better understand the vascular complex as it exists about the gastrocnemius. Ultrasound-guided fat injections were then performed into both the subcutaneous and intramuscular layers; dynamic pressures were measured with a manometer. Lastly, dyed-injectate was injected subcutaneously to better elucidate subcutaneous anatomy. RESULTS: Anatomic prosection demonstrated the proximity of the gastrocnemius muscle to the popliteal venous system which arborized (>1mm) intramuscularly. In the three specimens that underwent intramuscular fat grafting, the peak intramuscular pressures plateaued at 21mmHg (19.5-23mmHg); there was no observed extra-fascial migration of the injectate. With subcutaneous injectate into one specimen, pressures in the subcutaneous space increased (125mmHg) with additional injectate (240cc) while pressures in the intramuscular space remained relatively constant (4mmHg). CONCLUSIONS: Intramuscular gastrocnemius fat grafting should be done with caution: its proximity to critical veins and sustained increased intramuscular pressures following grafting increases risk of embolus and thrombosis, respectively. Subcutaneous injection may be safer in that increased pressures are not communicated to deep structures. Lastly, we present a novel description of posterior calf subcutaneous compartments that may better allow surgeons to direct and predict subcutaneous injectate.

Static Injection, Migration, and Equalization (SIME): A New Paradigm for Safe Ultrasound-Guided Brazilian Butt Lift: Safer, Faster, Better.

BACKGROUND: Although the Brazilian butt lift (BBL) is one of the most popular procedures in body contouring, it has been associated with the risk of pulmonary fat embolism when fat graft is injected into the gluteal muscles. The subcutaneous plane has been identified as a safe site for fat graft injection, but deaths from fat embolism continue to occur because there is no mechanism to confirm consistent subcutaneous placement. OBJECTIVES: The aim of this paper was to determine if real-time intraoperative ultrasound could accurately identify the subcutaneous gluteal anatomic landmarks and permit a single surgeon to consistently target fat graft placement in the subcutaneous space. METHODS: In total, 4150 BBLs were performed with real-time intraoperative ultrasound being used to confirm the subcutaneous position of a static cannula during fat graft injection. Serial deposits of fat graft were performed in each buttock. Ultrasound confirmed that fat graft consistently remained above the deep gluteal fascia and migrated through the deep subcutaneous space. These fat graft deposits were then equalized with a moving cannula to correct any contour deformities. Operative times were recorded and compared with BBL performed by expansion vibration lipofilling without ultrasound. RESULTS: Real-time intraoperative ultrasound allowed for the visual confirmation of consistent subcutaneous fat graft deposition and the targeting of fat graft into specific gluteal subcutaneous compartments. CONCLUSIONS: Real-time intraoperative ultrasound allows the surgeon to confirm a subcutaneous-only fat graft injection, target specific gluteal subcutaneous compartments, and take advantage of the unique architecture of the deep subcutaneous space to create gluteal projection and correct contour deformities.

Nanotechnology and Artificial Intelligence: An Emerging Paradigm for Postoperative Patient Care.

BACKGROUND: An increasing number of aesthetic surgery procedures are being performed in an ambulatory fashion in office-based settings. Postoperative monitoring of these patients has historically required paid private-duty nurses measuring vital signs, encouraging ambulation, and monitoring overall comfort level. Recently, advancements in nanotechnology have permitted high-acuity data acquisition of multiple clinical parameters that can be transmitted to the surgeon's mobile device in a continuous fashion. OBJECTIVE: The aim of this study was to describe the authors' early experience with this emerging artificial intelligence technology in the postoperative setting. METHODS: Twenty-three consecutive patients underwent radiofrequency-assisted liposuction and Brazilian butt lift surgery, and were placed in a monitoring garment, SimpleSense (Nanowear Technologies, Brooklyn, NY) postoperatively. The primary outcome was device usability, reflected by compliance with wearing the device and completeness of data collection. RESULTS: During the first 48 hours, 91% of patients wore the device for more than 12 hours per day. Only 39% were compliant with postoperative positioning. No postoperative events were detected. CONCLUSIONS: The quality of data collected enables detection of clinical derangements and can alert the surgeon in real time, prompting interventions such as drug administration, position changes, or presentation to the emergency room.

Deep Subcutaneous Gluteal Fat Compartments: Anatomy and Clinical Implications.

BACKGROUND: Advances in gluteal fat grafting have resulted in diminished risks through improved understanding of regional anatomy and technical nuances. No anatomic studies identifying the presence or absence of buttock fat compartments have yet been reported. OBJECTIVES: The aim of this cadaveric study was to identify and characterize the deep subcutaneous gluteal fat compartments to further understand the nuanced differences between deep and superficial subcutaneous fat layers. METHODS: A cadaveric study was performed to identify the fat compartments. Latex injection into the iliac artery and vein was used to prepare 4 fresh (N = 8 hemibuttocks) hydrated cadavers for dissection. Preliminary work identified the likely position of deep gluteal fat compartments. The cannula was positioned under ultrasound guidance in between the superficial and deep gluteal layers. Cadaveric buttocks were infiltrated by the static technique with dyed human fat, dyed applesauce, and dyed saline in an attempt to identify the gluteal deep subcutaneous fat compartments. RESULTS: Dissection identified and characterized 7 discrete deep gluteal fat compartments. These comprise 3 medial fat compartments (superior, middle, and inferior); a central fat compartment; and 3 lateral (superior, middle, and inferior) deep fat compartments. CONCLUSIONS: Seven deep gluteal fat compartments have been identified that have distinct boundaries and maintain injected contents separate from each other above the gluteal muscle fascia. These compartments can be selectively expanded for buttock augmentation. Knowledge of these compartments enables surgeons to perform gluteal augmentation by static infiltration, injecting autologous fat under ultrasound guidance in the deep subcutaneous fat layer, while optimizing aesthetic considerations.

Practice Advisory on Gluteal Fat Grafting.

On January 31, 2018, The Multi-Society Task Force for Safety in Gluteal Fat Grafting released a practice advisory regarding gluteal fat grafting. The task force was assembled in the wake of several highly publicized patient deaths involving Brazilian Butt Lift (BBL) and produced a second practice advisory in August 2019. In 2021, The Aesthetic Surgery President commissioned a Working Group on BBL Patient Safety, charging the group to address new guidelines affecting safety and welfare of BBL patients. The "Practice Advisory on Gluteal Fat Grafting" is the first advisory developed since the working group was formed. In addition to surgical technique as a major cause of fatal complications of BBL, the working group focused on micro-economic trends of operative time and regional BBL pricing and considered fatigue and distraction in formulating the current guidelines. In Florida, the majority of BBL deaths occur at the end of the week. Such a non-normalized distribution most likely represents the result of fatigue and/or distraction, which has been linked to surgical mortality in multiple published communications. In addition, mortality is likely due to uncertainty or lack of documentation as to the correct plane of fat injection. Therefore, the newest and most compelling recommendations from these guidelines include the utilization of ultrasound-guided documentation of cannula placement prior to and during fat injection, and the limitation of 3 BBL cases as a maximum amount of total operative cases per day. The authors thank members of the task force for the insights they brought to this process.

Simultaneous Separation and Tumescence: A New Paradigm for Liposuction Donor Site Preparation.

BACKGROUND: An ever-increasing demand for liposuction and fat transplantation procedures in the United States reflects their continued safety and clinical effectiveness. Technical breakthroughs, such as the utilization of tumescent infiltration and fat separation techniques, have been instrumental in optimizing outcomes but add time to the surgical procedure. Simultaneous separation and tumescence (SST) is a new technique combining these innovations to further improve safety and efficiency in liposuction. OBJECTIVES: The authors describe their technique for utilizing SST on more than 1200 patients spanning a 6-year period. A split abdomen study was designed to compare the vasoconstrictive effectiveness of SST with traditional Klein infiltration techniques. METHODS: A quantification perfusion analysis utilizing indocyanine green angiography was performed on 4 patients to illustrate the vasoconstrictive effectiveness of SST over traditional Klein infiltration techniques. A mean relative vasoconstriction score was calculated relative to the umbilicus for each technique. RESULTS: Compared with traditional Klein tumescence techniques, SST has a similar complication rate, utilizes similar infiltrative volumes, and increases vasoconstriction (mean 89.6% SST hemiabdomen vs 48.1% Klein hemiabdomen at 2 minutes, P < 0.0001). CONCLUSIONS: SST represents a novel, long-overdue departure from Klein tumescence, which has been a valuable mainstay for donor site preparation for over 3 decades. SST will pave the way for more efficient operative times and potentially higher volumes of fat being safely extracted.

Soft Tissue Contraction in Body Contouring With Radiofrequency-Assisted Liposuction: A Treatment Gap Solution.

Radiofrequency-assisted liposuction is a relatively new concept in energy-assisted body contouring techniques and has received instrument approval. This supplemental article reviews the clinical application of electromagnetic energy via the BodyTite (InMode Corporation, Toronto, Canada) device on soft tissues during suction lipectomy, its effect on soft tissue contraction, and its use in aesthetic body contouring in various clinical scenarios.

Safety in Gluteal Augmentation.

Gluteal fat grafting is the fastest growing surgery in body contouring because of the powerful results that no other procedure can achieve. Efforts made to improve the safety of this procedure are reviewed.

Static Injection, Migration, and Equalization: A New Paradigm for Safe Ultrasound-Guided BBL: Safer, Faster, Better.

Static injection, migration, and equalization allows for always subcutaneous-targeted fat grafting to either the deep or the superficial subcutaneous spaces.

The Dual-Plane Gluteal Augmentation: An Anatomical Demonstration of a New Pocket Design.

BACKGROUND: Fat grafting is the favored option for buttock augmentation by most surgeons, and buttock implants are mostly regarded as second choices. Accepted options for buttock implant pocket dissection are subfascial, intramuscular, and submuscular. To overcome the limitations of both intramuscular and submuscular pockets, and combine the benefits of both, the authors present a novel dual-plane pocket dissection. The dual-plane pocket involves a submuscular plane in the cranial half of the pocket and switching to an intramuscular plane in the caudal half. With this study, the authors describe their experience with this technique and analyze the dissection of the pocket on human cadavers. METHODS: The authors reviewed 82 consecutive composite gluteal augmentation cases from March of 2019 to November of 2019. In all cases, the implant was placed in the "dual plane." The clinical study was supplemented by 10 hemigluteal dissections in five cadavers following the surgical technique, with assessment of the anatomical components of the implant pocket created. RESULTS: Patients who underwent this technique showed excellent soft-tissue coverage over the implants. The main complications observed were seroma formation in five of 82 patients and temporary sciatic pain in four of the patients. The anatomical study confirmed double muscle coverage of both gluteus maximus and partial medius in the upper pocket pole and intramuscular gluteus maximus implant position in the lower pole. CONCLUSION: The authors present the dual-plane dissection technique as a valuable innovation to improve soft-tissue cover for the upper implant pole in buttock implant surgery.

Body Feminization Combining Large-Volume Fat Grafting and Gluteal Implants.

BACKGROUND: With the increase in popularity of fat transfer to the buttocks in body contouring surgery, new patient subsets are emerging. The gender confirmation patient has specific characteristics that must be addressed to achieve the best outcomes. METHODS: The authors performed an observational prospective study including 36 consecutive patients who underwent body feminization as a gender affirming operation using large-volume fat transplantation with or without gluteal implants. RESULTS: Thirty-six consecutive male-to-female transgender patients have undergone large-volume fat transplantation to the buttocks performed by the authors, between July of 2016 and January of 2019. In 12 of these 36 cases, large-volume fat grafting was supplemented by intramuscular placement of silicone implants. The mean waist-to-hip ratio before surgery was 1.11, and this improved to 0.81 after surgery (fat transfer-only group, 0.88; fat transfer plus implants group, 0.75). CONCLUSIONS: The transgender patient is a unique patient requiring a specific set of surgeon's skills and intraoperative strategies to achieve good outcomes. Composite solutions with both implants and lipofilling lead to better outcomes in terms of waist-to-hip ratio in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safety Comparison of Abdominoplasty and Brazilian Butt Lift: What the Literature Tells Us.

BACKGROUND: Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS: Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS: Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS: Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Breast reconstruction for breast asymmetry using recipient site pre-expansion and autologous fat grafting: a case report.

A single case is reported utilizing, recipient site pre-expansion with BRAVA (Brava, Inc, Miami, FL) followed by autologous fat grafting to the breast in a patient with severe breast asymmetry. Recipient site pre-expansion, used 2 to 3 weeks before fat grafting and 2 weeks after fat grafting may have both practical and theoretical benefits in optimizing the volume and enhancing the survival of grafted adipocytes, the mechanism of which is discussed. Recipient site pre-expansion and fat grafting may have early clinical adoption in cases of severe asymmetry, tuberous breasts, and other deformities that are difficult to treat with current reconstructive techniques, but studies are needed to clearly delineate its safety and its role.

Composite Buttock Augmentation: The Next Frontier in Gluteal Aesthetic Surgery.

BACKGROUND: Despite rapid growth, gluteal fat transplantation has a dismal safety record and often results in inadequate domal projection. Implants alone for gluteal augmentation have also been reported to be less than ideal, with significant complication rates. The idea of combining both implants and fat, as has been described in the breast, was therefore applied to surgery of the buttocks. METHODS: One hundred forty-seven consecutive cases of buttock augmentation were reviewed. Average follow-up was 18 months. The technique of composite buttock augmentation used progressive instrument dissection to precisely define the correct intramuscular plane of the implant pocket with a minimum amount of pocket access dissection. RESULTS: Operating times averaged 1 hour 55 minutes. The average volume of fat inserted was 380 cc. The average implant volume was 300 cc. Complications included implant displacements and implant pocket infections requiring surgical intervention. There were no cases of pulmonary thromboembolism, fat embolism, or death. CONCLUSIONS: Taking a lesson from composite breast augmentation, composite buttock augmentation is a new method for gluteal reshaping that seeks to use the best of both worlds: the reliable core projection of an implant combined with the natural appearance and feel of fat. Progressive instrument dissection seeks to minimize unnecessary dissection and to accurately and safely define the intramuscular pocket. The intramuscular placement of implants instead of fat should eliminate the risk of fatal fat pulmonary embolism in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Expansion Vibration Lipofilling: A New Technique in Large-Volume Fat Transplantation.

BACKGROUND: Despite rapid growth, gluteal fat transplantation is an operation in search of science and a teachable technique. Long operating times, tedious syringe transfers, inability to shape the recipient site, and the risk of fat embolism all headline as impediments to clinical adoption of the procedure. Expansion vibration lipofilling is a syringe-free surgical strategy that is a logical extension of Separation, Aspiration, and Fat Equalization (SAFELipo). In expansion vibration lipofilling, there is simultaneous disruption of recipient-site connective tissue, internal expansion using exploded-tip cannulas, and backfilling of these spaces with roller pump-propelled fat. METHODS: Two thousand four hundred nineteen consecutive cases of expansion vibration lipofilling fat transplantation to the buttocks were reviewed. Average follow-up was 12 months. The technique of expansion vibration lipofilling is dependent on the use of larger caliber cannulas attached to a roller pump and to an oscillatory power-assisted liposuction device, which is less labor-intensive, potentially allowing for better knowledge of cannula-tip location at all times during the procedure. RESULTS: Operating times averaged 1 hour 40 minutes. The average volume of fat inserted was 1003 cc. Complications included donor-site seroma, infection, and one pulmonary embolism treated with anticoagulation. There were no cases of fat embolism or death. CONCLUSIONS: Expansion vibration lipofilling is a new method for large-volume fat transplantation. Avoidance of fatal fat emboli demands a surgeon's complete knowledge of cannula tip location at all times during the procedure. Syringe-free, larger caliber, and less flexible cannulas, combined with techniques requiring less operator upper extremity effort resulting in less fatigue, may contribute to avoidance of this dreadful complication. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

"Brazilian Butt Lift" under Local Anesthesia: A Novel Technique Addressing Safety Concerns.

BACKGROUND: The gluteal lift ("Brazilian butt lift") has improved significantly in technique and in outcomes. Some postulate that fat embolism occurs because of damage to veins superficial to the gluteus muscles and that fat must be injected intramuscularly to achieve satisfactory aesthetic results. The purpose of this article is to present data where gluteal lift is performed under local anesthesia, address safety concerns, and clarify these speculations. METHODS: All patients underwent gluteal lift under local anesthesia using oral medications and tumescent infiltration. Fat was harvested by closed-system liposuction, separated by gravity, injected using a peristaltic pump and reticulating basket cannulas. RESULTS: Thirty-two female patients with an average age of 38.6 years and a body mass index of 24.8 kg/m underwent 47 gluteal lift operations under local anesthesia over 52 months. The average volume of injected fat was 359 ml per buttock. There were no deaths or complications. CONCLUSIONS: Recent concerns regarding buttock injections have been raised due to death from fat embolism. Despite numerous theories on the mechanism of entry, the fact that venous injury occurs with the introduction of boluses of fat in enough quantities to cause mechanical disruption of the cardiopulmonary circuit is not in dispute. The authors believe this cannot occur in the awake patient without the surgeon being acutely aware of a misguided cannula. These data suggest that buttock fat grafting under local anesthesia is a safe and effective procedure with an excellent safety profile and durable results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Clinical Implications of Gluteal Fat Graft Migration: A Dynamic Anatomical Study.

BACKGROUND: The intraoperative mortality and overall complication rate for gluteal augmentation with fat transplantation is unacceptably high. The current controversy among experts regarding safety is whether fat should be placed within the gluteus muscle or limited to only the subcutaneous space. The purpose of the present study was to test the hypothesis that under certain pressures, fat injected within the gluteal muscle can actually migrate out of the muscle and into a deeper plane containing critical neurovascular structures, by means of the process of deep intramuscular migration. METHODS: A total of eight human cadaver dissections were performed. Four hemibuttocks were selected for intramuscular fat injection. The patterns of subfascial fat migration were evaluated in three of these hemibuttocks by direct visual inspection and in one hemibuttock by endoscopic evaluation. Four other hemibuttocks were selected for subcutaneous or suprafascial fat injection. RESULTS: Proxy fat was found to migrate through the muscle and into the deep submuscular space with each intramuscular injection. With subcutaneous injection, no proxy fat was found during dissection in the intramuscular septae or submuscular space. CONCLUSIONS: The intramuscular insertion of fat, which up to this point has been considered reasonable to perform in the superficial muscle and even recommended in the literature, is now deemed to be an inexact and risky surgical technique. This technique, because of the migratory nature of injected fat, should be avoided from further use in fat transplantation to the gluteal region.

Staying Safe during Gluteal Fat Transplantation.

Gluteal augmentation with fat transplantation is increasing in demand but has been associated with a concerning number of fatality reports. Despite these reports, various surgeons have safely performed gluteal fat transplantation on a large number of patients with no reported mortality. The important aspects of safely performing gluteal fat transplantation are reviewed. Proper patient selection, favorable instrumentation, patient positioning, proper technique, and knowledge of anatomy are critical to improving the safety of this procedure. Adherence to these key principles should allow a reduction in mortality from this procedure, which would safely allow its continued offering in the setting of increasingly high demand.

MBN 2016 Aesthetic Breast Meeting BIA-ALCL Consensus Conference Report.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon neoplasia occurring in women with either cosmetic or reconstructive breast implants. The actual knowledge about BIA-ALCL deriving from the literature presents several limits, and it remains difficult to make inferences about BIA-ALCL epidemiology, cause, and pathogenesis. This is the reason why the authors decided to organize an evidence-based consensus conference during the Maurizio Bruno Nava (MBN 2016) Aesthetic Breast Meeting held in Milan in December of 2016. Twenty key opinion leaders in the field of plastic surgery from all over the world have been invited to express and discuss their opinion about some key questions on BIA-ALCL, trying to reach a consensus about BIA-ALCL cause, pathogenesis, diagnosis, and treatment in light of the actual best evidence.