We thank Dr. Bertheuil and his team for their interesting response to our article.1 In their letter, they stated that they “use a simple and fast technique for achieving moderate augmentation without using flaps, implants, or lipofilling” and they describe their technique as “moving the central buttock tissues in an outer to inner direction.” Although this approach is interesting, we do not believe that it is an optimal gluteal augmentation technique for several reasons. First, in their original article,2 Bertheuil et al. did not provide objective proof of gluteal augmentation using their rotational maneuver. We are convinced that instead of increasing the buttock’s projection, they are reducing it by removing skin and fat without adding any additional tissue to the deflated buttock. In fact, in 2017, we demonstrated objectively using three-dimensional imaging that closing the back skin primarily resulted in a loss of 9.6 mm of buttock projection, whereas using gluteal flaps translated into the buttocks allowed preservation of the original gluteal projection, and gluteal implants resulted in a 4.9-mm gain of buttock projection.3 Based on these objective findings, we are convinced that by using Bertheuil et al.’s technique that consists of moving the gluteal skin medially, the buttock’s shape may be improved but not its projection, which is doomed to decrease or (in the best scenario) remain the same. Until they provide objective proof of increased gluteal projection using their technique, we will not incorporate their approach into our gluteal augmentation algorithm. Second, moving the lower incision skin medially creates a discrepancy between the upper and the lower wound edges, resulting in incongruity and accumulation of skin medially around the gluteal cleft. This creates skin irregularities that may take many months to smooth out. Third, we do not agree with Bertheuil et al.’s technique because they treat all of the patients with the same surgical approach.2 We think it is unreasonable to treat different buttock morphologies using the same surgical technique. Therefore, we divided the body-lift patients into four types based on their gluteal morphology and back fat distribution and used a different surgical approach for each type.
Also, Dr. Bertheuil and his team stated that their complication rate was lower than our complication rate.1 Their total complication rate was 32.78 percent and ours was 33 percent in the group with gluteal augmentation and 29 percent in the group without gluteal augmentation, with a total mean of 32.5 percent.4 Thus, in total, by tailoring the treatment to each patient, we had a lower total complication rate. They also stated that their “posterior complication rates are lower than those of Schmitt et al. (32.86 percent for gluteal flap, 38.46 percent for implants, and 25 percent for lipofilling).” This statement is inaccurate and erroneous and based on false percentages, as these stated percentages are not “posterior complication rates” but total complication rates involving both the “posterior” and the “anterior” complications.
They also noted that “the complication rate decreases with reduced operating time, which is difficult when performing buttock augmentation.”1 At our institution, the mean duration of a body-lift procedure is 2 hours 40 minutes without gluteal augmentation and 3 hours 10 minutes with gluteal augmentation using autologous flaps. In comparison, Bertheuil et al. reported a mean operative time of 3 hours 49 minutes without gluteal augmentation.2 Thus, with enough practice, we were able to augment the buttock of our patients while being 39 minutes faster than Bertheuil et al., therefore theoretically reducing the complication rate even while performing buttock augmentation.
Fourth, we do not agree with Dr. Bertheuil and his team that “given the high rate of complications, surgeons must think carefully before proposing buttock augmentation” as we believe that gluteal augmentation is a key component of every body-lift operation. Careful patient selection and preoperative analysis using a standardized algorithmic approach may optimize aesthetic results and decrease the complication rate.
All participating patients gave written informed consent.
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication.
Samer Jabbour, M.D.Taliah Schmitt, M.D.Department of Plastic and Reconstructive SurgeryGroupe Hospitalier Paris Saint JosephParis, France
1. Schmitt T, Jabbour S, Makhoul R, Noel W, Reguesse AS, Levan P. Lower body lift in the massive weight loss patient: A new classification and algorithm for gluteal augmentation. Plast Reconstr Surg. 2018;141:625636.
2. Bertheuil N, Chaput B, De Runz A, Girard P, Carloni R, Watier E. The lipo-body lift: A new circumferential body-contouring technique useful after bariatric surgery. Plast Reconstr Surg. 2017;139:38e49e.
3. Levan P, Bassilios Habre S. Gluteal implants versus autologous flaps in patients with postbariatric surgery weight loss: A prospective comparative study of 3-dimensional gluteal projection after lower body lift. Aesthet Surg J. 2017;37:10121021.
4. Schmitt T, Jabbour S, Makhoul R, Noel W, Reguesse AS, Levan P. Lower body lift in the massive weight loss patient: A new classification and algorithm for gluteal augmentation. Plast Reconstr Surg. 2018;141:625636.