The Tumescent Technique By Jeffrey A. Klein MD
Liposuction of the buttocks using large cannulas causes unpredictable asymmetry and irregularities. The designation of “Bermuda Triangle of the buttocks” recognizes the potential hazards of traditional liposuction techniques applied to the derriere.
Using careful microcannular tumescent liposuction techniques, surgeons can treat the entire buttocks and routinely produce excellent, symmetric, and smooth results. The youthful buttocks consist of large, smooth, dome-shaped, proximomedial mounds. Reestablishing this geometric form is one of the goals in remodeling the buttocks with microcannulas and tumescent liposuction.
Persons in early middle age begin to manifest a gibbosity (bulging) of the inferolateral buttock. Almost impossible to eliminate by liposuction without risking the appearance of a wrinkled depression, the inferior gibbosity can often be improved by about 50% with a careful conservative approach.
The buttocks consist of deep gluteal muscle and superficial fat. Traditionally, gross anatomists have focused on the deep-seated structures of muscle and bone. Liposuction surgeons, however, are interested in the broader and more superficial structures.
Gross Anatomy of Subcutaneous Fat
Fat of the buttock is relatively homogeneous. Gluteal fat is largely devoid of any significant vascular or neurologic structures. No focal areas within the buttock fat have an excessive degree of fibrosis. Because muscle is not anesthetized by subcutaneous tumescent local anesthesia, if the cannula should contact muscle, the conscious patient will inform the surgeon immediately.
Buttock fat is not bottomless. Liposuction of the buttock must be done carefully to avoid muscle injury. Because the sciatic nerve courses approximately 2 cm deep within the gluteus muscle, however, there is little risk that a cannula will penetrate far enough to cause nerve injury.
Coursing deep within the fat are numerous fibrous septa and bands that support the buttock similar to the way the suspensory ligaments of Cooper support the female breast. These buttock ligaments, known as the suspensory ligaments of Jacque, are easily traversed by a microcannula. With age these ligaments lose a degree of elasticity. The visible manifestation of this ligamentous laxity is a drooping of the inferolateral quadrant of the buttock (Figure 36-1).
The study and geographic analysis of the surface anatomy of the female gluteal region is a popular pursuit. Detailed examinations of caudal topography from every perspective have been done throughout history.
The horizontal infragluteal crease is the visible superficial manifestation of the condensation of fibrous connective tissue. This partition is formed by a confluence of intermeshing fibrous strands originating from the fascia distal to the gluteus muscles. These strands insert diffusely into the deep dermis of the inferior horizontal gluteal crease, a distal boundary of the buttocks. The condensation of fibrous sheets and strands responsible for the infragluteal crease is known as the ligaments of Luschka.
The concept of the proximal posterior thigh as a pillar of support for the buttock only partly explains the surface anatomy of buttock fat. The banana-form fold provides minimal support to the buttock. The position of the buttock is more importantly determined by the suspensory ligaments of Jacque; it is suspended from the lumbar and gluteal muscle fascia by means of these ligaments.
Medially the buttocks are separated by the intergluteal crease. Laterally the buttocks blend into the landscape of the hip and lateral thigh. Some patients have a genetically determined lumbosacral fat pad proximal to the intergluteal crease. From an aesthetic perspective the lumbosacral pad is regarded as a component of the buttock, and the areas are usually treated concomitantly (Figure 36-2).
With increasing degrees of obesity the buttocks may develop random bumps, or moguls. These secondary pads are the superficial manifestations of overstuffed fat sections within the subcutaneous fat compartment. With careful use of the smallest microcannulas, moguls can be flattened.
The superficial buttocks consist of expansive volumes of subcutaneous fat having functional and aesthetic importance. Functionally the buttock is a soft, resilient cushion that provides protection and comfort. Aesthetically a callipygian buttock is shapely and pleasing to behold (Figure 36-3).
When well proportioned, buttocks fit into clothing more comfortably. When misshapen or disproportionate, buttocks may be a source of dissatisfaction, inconvenience, and embarrassment.
The word pygal, meaning a relationship to the buttocks, is derived from the Greek stem words pygo- and pyg- (pyge, buttocks). These stems are often combined with other words to describe various aspects of the buttocks with scientific precision. Other words derived from Greek roots might prove helpful when documenting a preoperative examination of the buttock before liposuction.
Steatopygia (steatopygous; steato-, fat) describes the condition of possessing a very large or excessively fat buttock. Leptopygian (leptopygous; leptos, narrow) denotes slender, skinny buttocks. The related word leptosomatic describes a slender body or slender build.
Dolichopygia (dolicho-, long) designates long buttocks. Skaphepygia indicates boat-shaped buttocks.
The preoperative topographic markings are generally composed of two sets of nested concentric annular patterns. These highlight the two principal topologic formations: the large proximomedial mounds (mountains) and the inferolateral bulges (foothills). Buttocks that have large random bumps (moguls) may require additional sets of circles to achieve the smoothest results (Figures 36-4 and 36-5).
Merely tracing an outline of an area to be treated by liposuction without detailed representation of cosmetically important features of surface anatomy is amateurish and lacks aesthetic sensibility. Nugatory markings that merely outline the periphery of the targeted area, ignoring valuable topographic information about internal geography, predispose to disappointing results. An outline is not sufficiently detailed (Figure 36-6).
Intraoperative positioning for liposuction of the buttocks is a modified or approximate version of the anatomic position. The patient is prone with a pillow placed under the pelvis. This position elevates the pelvis and produces slight flexion of the hip. This presents advantageous access to the entire volume of fat and facilitates symmetry and smooth results (Figure 36-7).
Providing thong-type examination panties covers the perineum while allowing easy surgical access to the buttocks.
Tumescent infiltration of the buttocks should be thorough, with all levels of the fat being well anesthetized. After infiltration is complete, an elapsed time of 20 to 30 minutes is required before the anesthesia and vasoconstriction are sufficient and the tissues are sufficiently detumescent.
The goal of tumescent liposuction of the buttocks is to achieve a pleasing reduction in size and bulk. In attempting to achieve a noticeable reduction in posterior projection of the buttocks, the surgeon must be cautious to avoid both excessive removal and asymmetric removal of fat. Liposuction will not lift or elevate the buttock to any noticeable degree. Superficial liposuction is not done.
Using microcannulas, the goal is to remove fat gradually and deliberately to maximize the chances of smooth, uniform results. One buttock is treated first until the desired degree of reduction is achieved relative to the untreated side. The contralateral buttock is then treated until it is the mirror image of the first buttock.
Gradual uniform reduction is accomplished by careful technique that removes fat incrementally, with the entire buttock slowly decreasing in size. Through each microincision, a limited number of radiating cannula thrusts are accomplished, with the cannula paths fanning out and crisscrossing with the pattern of the adjacent incision. After a limited number of radiating thrusts (e.g., 10 to 20) the cannula is withdrawn and placed in another incision or adit.
At each stage the surgeon must check the surface for smoothness and shapeliness. A cavalier approach to liposuction of the buttock can lead to grotesque results (Figure 36-8).
In the early days of liposuction, surgeons had a well-founded fear of doing liposuction on the buttock using large, 6-mm to 10-mm cannulas. The “Bermuda Triangle” of the buttocks was an area off limits to liposuction. This area, bounded by an equilateral triangle with its base along the infragluteal crease and its apex at the lumbosacral junction, was regarded as high risk when liposuctioned with large cannulas. Large cannulas would frequently create a lumpy, furrowed derriere.
The use of microcannulas for tumescent liposuction of the buttocks has disproved the Bermuda Triangle theory, consistently yielding smooth and natural-looking results.
The location of incisions for microcannulas is generally determined by convenience and accessibility for the surgeon and by cosmetic considerations. Although no fixed location exists for microincisions, they are preferably placed at least 6 to 8 cm (2½ to 3¼ inches) lateral to the midline intergluteal crease to facilitate use of absorptive pads.
To achieve natural-looking results, the surgeon uses a conservative approach. It is important to leave a thick blanket of superficial fat to prevent dimpling. The targeted fat is the midlevel 40% to 60% of the buttock fat. The most superficial 20% to 30% of the fat deposit is avoided.
The path of a microcannula should be directed along a plane that is generally tangential to muscle. With a little care and attention, it is unlikely that a cannula will ever penetrate into muscle.
The banana-form folds are best treated using 16- and 14-gauge microcannulas, which can be advanced in deep, crisscrossed paths extending from the lateral thigh or buttock. Transverse tunnels or excessive liposuction can produce cosmetically unacceptable, double infragluteal creases. Liposuction of the banana-form fold must be done as conservatively as possible (see following discussion). Patients are told that, to prevent a double infragluteal crease, no more than a 50% improvement can be attempted with liposuction of the banana-form fold (Figure 36-9).
If the buttock is one of several areas being suctioned on a given day, the surgeon should change gloves before treating another area.
Postoperative care involves the use of appropriate absorbent pads and compression. The surgeon should avoid placing microincisions any closer than 6 to 8 cm from the midline intergluteal crease to facilitate postoperative drainage. If incisions are too close to midline, it is both difficult to position the pads and uncomfortable and inconvenient for the patient to wear them (Figure 36-10).
Pitfalls and Special Considerations
As a general rule, no more than 30% to 50% of the existent buttock fat should be removed by liposuction. Too much liposuction will leave an unacceptable degree of ptosis and residual skin irregularities.
The goal is never to remove the maximal volume of fat but rather to produce the smoothest, most natural, well-proportioned result possible. Finesse is more important than mass. Until the surgeon has extensive experience, it is best to be conservative and avoid any risk of inadvertently removing too much fat from the buttock (Figure 36-11).
Infragluteal Banana-form Fold
The fat below the horizontal infragluteal crease, the banana-form fold, must be approached with great caution during liposuction. Removing too much fat from the infragluteal banana-form fold will produce a redundant or double infragluteal crease (Figure 36-12).
A large redundant infragluteal crease probably cannot be repaired easily. On the other hand, some slight to moderate redundant infragluteal creases might be candidates for simple surgical repair. A fusiform excision located in the posteromedial portion of the infragluteal fold is least likely to produce a visible scar (Figure 36-13).
Aggressive liposuction of the banana-form fold often creates a plication of redundant skin and a second horizontal infragluteal crease. This secondary crease is difficult to repair without significant scarring.
The recommended approach for liposuction of the banana-form fold is to be conservative and to direct the microcannulas obliquely at 45 degrees to the horizontal infragluteal crease. The surgeon should not remove too much fat and should avoid doing liposuction transversely across the posterior thigh (Figures 36-14 and 36-15).
Infragluteal Horizontal Crease
An infragluteal horizontal crease, the visible manifestation of fibrous septa that connect the skin of the infragluteal crease to deeper fat and muscle fascia, is not present in all women.1
Most patients and some surgeons do not appreciate the difficulty and aesthetic risks involved in attempting to create or modify a horizontal infragluteal crease. Liposuction in this area has often resulted in asymmetry and dissatisfied patients. Too much liposuction along the infragluteal crease produces a scooped-out, furrowed, unnatural depression that is most noticeable when the patient bends over or flexes at the hip and stretches the affected area (Figure 36-16).
A liposuction surgeon should not attempt to create an infragluteal crease. Suctioning subcutaneous fat cannot produce a realistic infragluteal crease. Removing too much fat from the infragluteal crease will result in pain when the patient sits on a hard surface because of insufficient fat overlying the ischial tuberosity.
Too much liposuction in the infragluteal crease cannot be repaired. The cosmetic risks of attempting to create an infragluteal crease outweigh the possible benefits.
For other procedures, however, with mastery of microcannulas, tumescent liposuction of the buttock can become a technique of finesse and can provide consistently reproducible, smooth results (Figure 36-17).
- Lack E: Lecture at the Annual Meeting of the American Academy of Dermatology, San Francisco, 1997.
Figure 36-1 Parasagittal section through female buttock shows superficial mantle fat, deep fat compartment, and multiple sheets and bands of fibrous suspensory ligaments. Horizontal infragluteal crease is coalescence of fibrous tissue that attaches dermis to deep muscle fascia. Liposuction cannot realistically create a horizontal gluteal crease on a patient who lacks such a crease. Directing a liposuction cannula transversely in this area is likely to produce an undesirable furrow that becomes visible when patient bends forward or flexes at hip.
Figure 36-2 Buttocks and landmarks of superficial anatomy: B, buttock (proximomedial); ILB, inferior lateral buttock; BN, banana-form fold; H, hip; T, thigh (lateral).
Figure 36-3 The Callipygian Venus, a famous marble statue of a female nude discovered in Roman house of Emperor Nero and now displayed at Museo Nationale (National Museum of Archaeology) in Naples. Callipygian is derived from Greek adjective kallipygos (kallos, beautiful; pyge, rump).
Figure 36-4 A, Topographic contour diagrams of buttock, hips, waist, and outer thighs. B, Lateral view of buttock before liposuction. C, After tumescent liposuction using microcannulas. Orthogonal grid pattern of straight lines helps to achieve uniform tumescent infiltration.
Figure 36-5 Topographic maps of buttocks showing contour lines that indicate depth of subjacent subcutaneous fat. A, Posterior view. B, Lateral view. Orthogonal grid pattern facilitates uniform infiltration of tumescent local anesthesia.
Figure 36-6 A, Merely outlining area to be treated is insufficient when marking patient before tumescent liposuction. B, Cosmetic results can be disappointing without precise topographic contour diagrams.
Figure 36-7 Patient in prone position with pillow under pelvis to elevate buttock and provide easier access for liposuction cannula.
Figure 36-8 A to C, Three patients with deformed buttocks resulting from careless liposuction using largediameter cannulas and minimal number of incisions.
Figure 36-9 A, Congenital asymmetry of buttocks was corrected by unilateral liposuction. B, Patient was satisfied with outcome despite double infragluteal crease, the necessary result of extensive liposuction.
Figure 36-10 Avoiding microincisions too close to midline facilitates placement of postoperative absorptive compression pads. All adits should be lateral to the two vertical paramedian lines, as shown.
Figure 36-11 Withered and wrinkled buttocks after excessive liposuction.
Figure 36-12 Double infragluteal creases resulting from excessive liposuction of banana-form fold in A, obese patient, and B, thin patient.
Figure 36-13 Repair of small, medial, double infragluteal crease. A, Double infragluteal crease of left thigh was result of excessive liposuction. B, To repair defect, small fusiform excision was diagrammed. C, One week after surgical repair. Reduced visibility of scar was achieved by placing incision in posteromedial aspect of thigh. Lateral extension of double infragluteal crease is difficult, if not impossible, to correct.
Figure 36-14 A, Small, medial, double infragluteal crease below right buttock. B, Small fusiform area of skin to be excised. C, Immediately after repair.
Figure 36-15 Liposuction of banana-form fold should be done conservatively and with great caution. Overaggressive liposuction in transverse direction risks creating secondary horizontal infragluteal crease. Microcannulas, directed medially and obliquely from above or below at about 45 degrees, help to minimize this risk.
Figure 36-16 Excessive liposuction in attempt to modify shape of infragluteal crease resulted in distorted buttocks with double infragluteal crease. A, Posterior view. B, Lateral view.
Figure 36-17 Buttocks before and after tumescent liposuction with Capistrano microcannulas. Hips and lateral thighs were also treated. A and C, Preoperative lateral and posterior views. B and D, Postoperative lateral and posterior views 10 weeks after surgery. Medial thighs and medial knee had been treated 4 weeks previously during a separate tumescent liposuction procedure.