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Autologous Gluteal Augmentation after Massive Weight Loss

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Colwell, Amy S. M.D.; Borud, Loren J. M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1516-1518
doi: 10.1097/01.prs.0000305370.60949.ae
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Sir:

We thank Drs. Le Louarn and Pascal for their comments regarding our article, “Autologous Gluteal Augmentation after Massive Weight Loss: Aesthetic Analysis and Role of the Superior Gluteal Artery Perforator Flap” (Plast. Reconstr. Surg. 119: 345, 2007). Their 2002 article1 contributed significantly to our field by introducing the concept of combined resection and augmentation in gluteal contouring. However, when we attempted to use their technique, our flaps were always too superior and often resulted in a “double-bubble” where the inferior ptotic gluteal tissue sagged beneath the projecting superior portion. The Pascal-LeLouarn flap simply does not allow the surgeon to position the flap in the ideal location to fill the inferior medial quadrant of the buttocks, which is the most important area of volume loss in the massive weight loss patient. The purpose of our article was to use knowledge of vascular anatomy to improve and extend the design of autologous gluteal augmentation flaps and optimize gluteal contour by medializing the rotation point. In addition, we sought to include standard key information on our patient group, which was lacking in the Le Louarn and Pascal article, including maximum and current body mass index, age, smoking status, combined procedures, detailed accounting of complications, aesthetic analysis, and satisfaction with the procedure.

To design our flap, we reviewed the literature and found several cadaver dissections of the gluteal artery perforator blood supply to the buttocks.2–4 The perforator supply to the gluteal region is robust, with 13 to 20 vessels per gluteal region (Fig. 1). Therefore, flaps based on medial perforators are very reliable and have been used extensively to cover sacral pressure sores and lumbosacral defects. As an additional safeguard in our early experience, we used Doppler ultrasound to confirm the location of medial perforators, to optimize our ability to undermine and thus mobilize our flaps. If there is any factual question of whether the key superior gluteal artery perforators are present at approximately 7 cm and 9 cm, we invite anyone to simply confirm this with their own Doppler examination based on the landmarks outlined in our article. We do deliberately sacrifice lateral perforators of the superior gluteal artery during this process; however, they are not necessary for flap viability, and if preserved, they prevent adequate mobilization of the flap into the inferomedial quadrant of the buttocks. We did have one case of significant fat necrosis in one of our early patients. This was attributable to a technical error and not inadequacy of the concept for the flap, as dozens of flaps have been used since the publication of our article and no patient has suffered this complication. We no longer routinely use Doppler ultrasound to locate the perforator blood supply because the two key perforators are so reliably found between 5 and 10 cm from the midline on each side.

Fig. 1.
Fig. 1.:
Perforator anatomy of the gluteal region. The buttocks are subdivided into five regions. Circles represent perforator vessels in each region. As can be observed, the perforator blood supply of the gluteal region is robust and evident in both the medial and lateral quadrants. GT, greater trochanter. The medial perforators in region 4 are medial to a line drawn between the posterior superior iliac spine and greater trochanter, and these represent the two key perforators within 10 cm of the midline that provide vascular supply to our superior gluteal artery perforator flap design. Reproduced with permission from Allen, R. J., Guerra, A. B., Erhard, H. A., et al. Superior gluteal artery perforator flap. In P. N. Blondeel, S. F. Morris, G. G. Hallock et al. (Eds.), Perforator Flaps: Anatomy, Technique, and Clinical Applications. St. Louis, Mo.: Quality Medical Publishing, 2006. P. 489.

The authors seem to be confused regarding the undermining of the inferior gluteal pocket. To clarify, we undermine tissue in the medial quadrant of the buttock in a plane just superficial to the gluteal muscle from the lower body lift line inferiorly extending to within 5 cm of the inferior gluteal crease. It is interesting to note that in their communication, Le Louarn and Pascal have modified their original illustration to show more inferior undermining. We have not experienced any cases of buttock numbness after the procedure and the cutaneous sensory nerves have not been visualized in our dissections, as these nerves are located closer to the inferior gluteal crease than in our dissection. We do typically switch from electrocautery to a combination of blunt and scissor dissection in the most inferior portion of the pocket, and this may help avoid any thermal injury to nerves in the vicinity.

In our experience, the basis of the superior gluteal artery perforator flap in sound anatomy offers superior versatility in the design of autologous augmentation flaps to optimize gluteal aesthetics in patients following massive weight loss (Fig. 2). We look forward to seeing a peer-reviewed journal article of Le Louarn and Pascal’s experience of gluteal autoaugmentation in 255 patients managed without the use of drains and with no cases of fat necrosis. If this builds on their initial experience of 41 patients with no complications, this will truly be an incredible result for any operation in plastic surgery, and one that will no doubt be hard to reproduce.

Fig. 2.
Fig. 2.:
The superior gluteal artery perforator flap for autologous gluteal augmentation.

Amy S. Colwell, M.D.

Loren J. Borud, M.D.

Harvard Medical School

Beth Israel Deaconess Medical Center

Boston, Mass.

REFERENCES

1. Pascal, J. F., and Le Louarn, C. Remodeling body lift with high lateral tension. Aesthetic Plast. Surg. 26: 223, 2002.
2. Koshima, I., Moriguchi, T., Soeda, S., et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast. Reconstr. Surg. 91: 678, 1993.
3. Kankaya, Y., Ulusoy, M. G., Oruc, M., et al. Perforating arteries of the gluteal region: Anatomic study. Ann. Plast. Surg. 56: 409, 2006.
4. Nojima, K., Brown, S. A., Acikel, C., et al. Defining vascular supply and territory of thinned perforator flaps: Part II. Superior gluteal artery perforator flap. Plast. Reconstr. Surg. 118: 1338, 2006.

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