Buttock Contouring With Liposuction And Fat Injection (BBL)
Today, liposuction has a completely different philosophy that involves fat redistribution as well as selective anatomic suctioning to create hills and valleys at the muscular borders. The shadowing created will highlight the anatomic zones, creating a sculpted three dimensional result. The harvested fat is used to enhance, contour and reshape zones.
Preoperative preparation;
Routine preoperative medical evaluation and lab tests appropriate for age are performed. The patient is instructed to stop all medications and products that affect platelets at least 4 weeks prior to treatment. Bowel preps are not routinely given.
Markings of Esthetic Units;
The abdomen is defined by three major muscle groups that can be appreciated on the surface anatomy; the rectus abdominus, the external oblique and the transversalis muscle. When it comes to the posterior zones, there are 10 esthetic units found to the posterior region.
Total three-dimensional body contouring will focus on the abdomen, the waist, and the buttock. The patient is marked in the preoperative holding room the day of surgery in the standing position. The highlight points are identified in the abdomen and the areas to have liposuction in the posterior area are identified.
Medications;
Preoperative medicines may include precaution for fat embolism, antibiotics, anti- nauseaand anti- reflux drugs.
Preparation in Operating Room;
The patient is prepped circumferentially while in the standing position. Sterile sheet is placed on the OR table on top of a water-based warming pad. The best setting is 41.6 °C.
A draw sheet is also placed to help turn the patient during the procedure. All pressure points are padded; pneumatic stockings are connected. A Foley catheter is inserted for fluid status monitoring. It is during this time that the fat collection canister is prepared since the fat needs to be collected during the suction process. There are a number of collection systems for obtaining fat cells
Surgical Technique;
The technique involves a visualization exercise whereby the surgeon visualizes the deep and superficial layers in the mind. Suctioning will then proceed in a layered and anatomic sequence, but throughout the process the physician is visualizing the position of the cannula in the respective layer.
It is crucial to separate the deep from the superficial layer during this procedure since the entire deep layer needs to be cleared out. The superficial layer is mainly to establish the contour definition. Both layers are freed and broken up with Vaser or with pre- and post-tunneling. Suctioning begins in the deep layer and gradually moves more superficial . VASERlipo® is a device with a technique using ultrasound energy for minimally invasive contouring for dramatic results with less pain and downtime rather than traditional liposuction. We try to mechanically break up the strong fatty dermal association by using one of the following disruptive approaches, separately or in combination: Vaser ultrasound and power-assisted specialized cannulas. The Vaser, power-assisted machine and specialized cannula are very valuable when we run into very fibrous or dense fat. It also works well for that fluffy fat that is difficult to extract (typical of the massive weight loss patient). We use the Vaser in most of my cases and the power-assisted machine in every case. In my experience, the use of the power-assisted and ultrasound-assisted technologies results in the destruction of about more of the fat cells when compared to the standard machine suction.
Liposuction will be performed in the supine, lateral decubitus and prone positions. Each position has a specific purpose and technical goal.
Supine Position,
This position addresses the abdomen, zones overlying the external oblique, some of the flank, and lateral chest wall. In the supine position the suction focuses on defining the abdomen as well as trying to define the lateral chest wall.
Lateral Decubitus Position,
The most important zones to contour in gluteal esthetics are the lower backs, the upper lateral buttocks, sacrum and the posterior flanks.
Prone Position,
This position will help contour the V zone, remaining fat in the posterior flank triangle, and remaining fat in the upper buttock, lower sacrum, lower back and, if present, the lower inner gluteal fold excess.
Straining, syringe loading depending on fat density and loading take place on the afterwards.
Fat injections;
The fat injections will serve two purposes; to help shape/ contour the gluteus and to add volume to the buttock. Liposculpture is working on the frame of the buttock, laying out a well-defined and contoured frame, but the gluteus itself also has to be shaped. The fat transfer is always done by a repetitive back and forth motion. The syringe is in constant motion while the fat is slowly injected in a linear threading type fashion (no stagnant globular injections). Fat transfer in supine, lateral decubitus and prone positions are completed.
Postoperative Care;
Drains;
The sacrum tends to produce a bloody aspirate and is extremely prone to seromas. We use a total of three or four drains. The most important drain of all is placed in the sacrum through the open access superior intergluteal fold incision. When the patient returns to the supine position, the anterior drains are placed. These drains are kept for 5-7 days and the patient is maintained on PO antibiotics while drains are in place.
Recovery Room;
The patient is kept in the supine position until they are awake and able to control their airway. The recovery room focuses on body temperature and fluid status. We have a low threshold for monitoring hemoglobin levels.
Sitting/Sleeping;
Pressure will destroy the transferred fat, so the patient’s main requirement is to keep pressure off the buttock for at least 6 weeks.
Sitting is permitted for 10 days (except for using the bathroom) but after this they can sit with modifications; a pillow is placed at the posterior hamstrings (not touching the buttock), this keeps the buttock in the air and avoids pressure.
With this technique they can return to work, drive, and go to movies at 10 days, only with a sitting pillow but traditional sitting is not allowed for 6 weeks.
Similarly, transport home and for postoperative follow up should be in the prone or lateral decubitus position or whenever they stand for the first 3 days.
Postoperative Instructions;
The patient is to wear a compression garment for 4–6 weeks;
Patients are told not to go clothes shopping for 3 months, but in reality the final results are not seen until 6 months.
