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Fat grafting of the buttocks is an effective technique that achieves good results, with minimal postoperative pain and high patient satisfaction. Buttock augmentation techniques took the top spot for the most significant increase in the number of procedures performed over the course of 1 year. I am very pleased with the results I am obtaining and so are my patients. It is interesting that a technique we developed more than 30 years ago, and the “Brazilian Buttock,” a term that I coined in 2000, has become internationally recognized as a new procedure. I do over inject into the buttocks, keeping in mind that there should be an interstitial space for neovascularization of the fat graft. Recent studies show potential fatalities due to intravascular fat injection causing pulmonary embolism. We prevent complications by carefully following our injection technique and by using the right instruments. We have performed this technique for over 30 years with good results and the international acceptance shows that it is a reproducible procedure to improve body contour.

The author started injecting large quantities of fat in the breasts, thighs, and buttocks in 1985. The Brazilian Buttock technique was first presented in 1987; since then, The author has been writing and lecturing about it worldwide. In the past few years, the technique became very popular; it has changed the ideal of beauty in many countries. Recently, The author started using adipose-derived stem cell-based therapies for buttock augmentation to improve the results of fat graft survival.

This article outlines the experience of authorities on emerging techniques in plastic surgery that are discussed within this issue, such as mesotherapy and lipodissolve, Russian threads, radiofrequency, and "laser lipo." Readers are invited to analyze the findings and determine whether there is something that could apply to their practices.

In many countries, lipoplasty is the most frequently performed aesthetic procedure. It has been promoted as a safe, easy-to-learn, outpatient procedure. Although plastic surgeons have developed safety measures to perform the technique, there are serious risks, including death at a rate of 1/5000 procedures. Life-threatening complications include pulmonary embolism, hemorrhage, perforation, infection, lidocaine toxicity, epinephrine toxicity, third space fluid shifts, and fat embolism syndrome. Aesthetic complications include undercorrection (insufficient fat removal), overcorrection (excess fat removal), irregular fat removal with palpable and visible irregularities, edema, hematoma, seroma, local infection, cutaneous slough, hyperpigmentation, vasculopathies, and permanent color changes in the skin. In this article we present methods to prevent and, when possible, treat these complications.

Low-level laser-assisted liposuction (LLLL), known as the Neira 4 L technique, is an excellent adjuvant tool for the surgeon practicing liposculpture. A low-level laser is used to create a transitory pore in the cell membrane of the adipocyte to move fat from inside the cell to the interstitial space outside without killing the cell. LLLL has been performed successfully in in-vitro and human adipose tissue cultures. It protects the patient from the surgical trauma of liposuction by protecting and preparing tissues for the surgical trauma; modulating the inflammatory response to prevent short and long-term side effects of surgery; and improving the quality and quantity of the healing process by accelerating recovery time, modulating secondary cicatrization, and preventing postoperative neuralgias.

In the last 20 years, several different techniques of lipoinjection have been developed. Nevertheless, a standard procedure has not been adopted by all practitioners. There is no agreement as to the best way of processing the fat to ensure maximal take and viability of the graft. Other controversial issues include the ideal cannula for harvesting and reinjection, the presence of blood in the transplanted fat, trauma, air exposure, contamination of the graft, durability, and fat cell survival. Newly emerging approaches to fat tissue engineering with the use of cultured autologous preadipocytes may improve the technique of fat injection and transplant.

Guidelines issued by the American Society for Aesthetic Plastic Surgery and other professional organizations have helped to reduce complications associated with lipoplasty. However, current guidelines for lipoplasty do not address the issue of hypothermia, which can be aggravated by infiltration of large amounts of anesthetic vasoconstrictive solution. In this article, we review the mechanisms of hemostasis and the pathophysiology of hypothermia and suggest measures by which to minimize the effect of hypothermia on coagulation during and after lipoplasty.

Joseph P. Hunstad, MD Richard A. D'Amico, MD Luiz S. Toledo, MD Peter A. Vogt, MD Dr. Hunstad: The first patient, a young woman concerned with the fullness of her neck, was treated with liposuction. Photographs show platysma bands and an unnatural, over-corrected appearance of the neck (Figure 1). Dr. D'Amico, would you discuss isolated liposuction of the face and neck? Figure 1 A and B , A 38-year-old woman concerned with the fulness of her neck underwent liposuction in the submental region. Postoperative photographs reveal platysma bands and an irregular contour in the submental area. Dr. D'Amico: Facial fat is a precious resource, and rarely would I remove it. The neck, however, presents a different situation. I believe that judicious and conservative fat removal in the neck can be appropriate. Unfortunately, the postoperative defect seen in this patient is all too common. When performing liposuction, we need to be careful to leave some subcutaneous fat in the neck. If this patient is dissatisfied with the results, I would consider performing a platysma band plication. At a later time, if needed, I would consider a filler procedure-structural-type fat grafting would probably be my first choice. Dr. Hunstad: Dr. Toledo, does liposuction have a place when treating a young patient who is primarily concerned with her neck? Dr. Toledo: If the patient also has a fat face and you remove only the fat in the neck, the patient will end up with a very slim neck that is disproportionate to her face, which seems to be the case here. Therefore, when performing a corrective sling procedure, I use an endoscope, which enables me to pass a Gore-Tex® strand from mastoid to mastoid, passing through the cervicomental angle. If there is excess skin, it should be managed with either superficial liposuction or skin removal. …

Syringe liposculpture has enabled plastic surgeons to approach abdominal lipodystrophy in a significantly less invasive fashion. With proper patient selection, the classic abdominoplasty and limited abdominoplasty have been supplanted with this procedure. The disadvantages of not being able to effectively deal with skin excess and muscle aponeurotic flaccidity must be weighed against this less invasive procedure resulting in minimal scarring.

We report on our experience with 22 video-endoscopic facelift cases. We prefer the term facelift to rhytidoplasty because with the endoscopic facelift facial wrinkles are not eliminated by resecting skin but by elevating facial structures, treating the facial muscles, and improving facial contour. We treat the frontal region subperiosteally by elevating the eyebrows, minimizing wrinkles, and avoiding the coronal incision. The midthird of the face is treated subcutaneously by dissecting the skin from the SMAS, from the ear to the nasolabial fold. The endoscope is inserted through one incision and a cautery through the other. Blood vessels are cauterized. Plicating the SMAS and premalar fat pads to the temporal fascia treats the nasolabial fold and the "jowl." In the cervical region we treat the plastysma, and, with superficial liposculpture, remove excess fat and provoke skin retraction, which allows us to treat older patients who have a more flaccid skin tone. The endoscope is used to help the cauterizing and the suturing. The platysma can be sutured in the midline, if necessary. The cervical mental angle can be redefined with a Goretex 0 suture that passes from mastoid to mastoid. Modified instruments and different approaches to this technique can be expected, but we believe video endoscopy is going to have an important impact on the future of plastic surgery.

Autologous fat grafting has been a controversial subject for a long time. A century after it was first performed and 25 years after the first injection of fat obtained from liposuction, it seems that the technique is finally being accepted by the plastic surgery community. Fat grafting has strong advocates as well as strong critics. It has always been clear that fat should be the best substitute for soft tissue loss, but the initial attempts to transplant fat were considered a failure, because of the partial loss of the original graft. It was the pessimistic way to look at the technique; instead of seeing the cup half full they were seeing it half empty. Once a 50% survival of a fat graft was acceptable, we started improving the technique and getting better results. With the development of liposuction, the process of harvesting fat became an outpatient procedure. The difficulty was to establish the technique’s uniform parameters. Since our first cases, we have been developing a system to harvest, treat, and inject the fat without damaging the cells to obtain a safe and reliable result. There are three different phases of the technique. They are all important and should be performed with care. Recently the development of adipose stem cell techniques promises great improvement and the possibility of harvesting, growing, and injecting fat. The technique is relatively new and needs further studies to guarantee its safety.

Thomas L. Roberts III, MD Jose Abel de la Pena, MD Juan Carlos Cardenas, MD Joseph P. Hunstad, MD Luiz S. Toledo, MD Dr. Roberts: The first patient is a 20-year-old college student who wants more fullness in the entire buttocks (Figure 1). Dr. Cardenas, would she be a good candidate for buttock implants? Figure 1 This 20-year-old woman would like more shape and fullness to her buttock area. Dr. Cardenas: She is a good candidate for buttock implants, but my first choice would be autologous fat injection. I think she would benefit greatly from lipoplasty of her waist or abdominal region and fat injection to the buttocks. A minimum of 400 mL injected into each side would give her an excellent appearance. Dr. Roberts: Ten years ago, if you were using an implant, would you have used a solid silicone or a gel implant? And what would have been your choice of incision? Dr. Cardenas: I am not an expert in gluteal silicone implants, but I would have used oval silicone-gel implants, and I would have made a 5-cm incision between the buttocks. Dr. Roberts: What would have been your choice of implant placement 10 years ago, below the muscle or above the muscle? Would you have used drains? Dr. Cardenas: I would have placed the implant beneath the muscle. I never use drains in that region. I prefer excellent hemostasis and avoid any contact between the interior and the exterior. Dr. Roberts: Has your implant technique changed since then? Dr. Cardenas: I still use silicone-gel implants with the same incision and usually in the submuscular plane, although, in some patients, I use intramuscular or subfascial placement. Dr. Roberts: Dr. de la Pena, what type of implant and implant position would you have used 10 years ago, and how have you …

Background Requests for buttock augmentation are increasing in the United States because of changes in lifestyle and fashion that emphasize the “gluteal aesthetic unit.” Objectives We review the use of micro fat grafting for enhancing the buttocks in a series of 566 patients. Methods Tumescent solution (1 mg epinephrine per 1000 mL saline solution) was infiltrated; for small cases the volume used was less than half the amount of expected fat to be harvested. Harvesting was accomplished either manually with a syringe or with a liposuction pump that allowed precise control of the vacuum. The fat was injected both intramuscularly and subcutaneously into all levels of the desired area for augmentation of the buttocks. The typical augmentation averaged 300 to 400 mL per side but ranged from 175 mL to about 800 mL, depending on the patient's desires and the amount of donor fat available. Results Patient and physician satisfaction with the results was high. Approximately 50% to 75% of the fat grafted remains in the long term. Complications included cellulitis (1.9% of cases), which responded promptly to treatment with cephalosporin, and infrequent seromas and hematomas (0.8% of cases). Conclusions Buttock augmentation by micro fat grafting is a safe, simple procedure. Compared with implant placement, the advantages of micro fat grafting include greater flexibility in the size and placement of augmentations, less pain and faster recovery for the patient, and less risk of complications. The technique is limited only by the amount of donor fat available.

The author discusses his experience with the variety of methods in liposuction, the technique of syringe liposculpture, anesthesia, the use of the cannula, and liposculpture of the buttocks and thighs. The approach to body contouring does not rely on one surgical technique alone. It is a combination of different procedures to obtain the best possible result.

The aesthetic and functional treatment of the abdominal region has always been one of the main concerns of plastic surgeons. Some patients belong in a "gray area" where there is no clear indication of which technique should be applied. Individual variations in anatomy should be the first consideration in determining the correct procedure. The Type I abdomen can be treated by lipoplasty alone. Types II, III, and IV are considered to be in the "gray area," because we can use different approaches and techniques based not only on this classification system but also on patients' preferences. Types V and VI can be treated by dermolipectomy with or without lipoplasty.

Despite the existence of basic clinical standards in plastic surgery, specific guidelines for body contour photography have not been detailed previously. In this report we propose standard and supplemental views for positioning of the subject for suction-assisted lipectomy and body contour surgery. Also demonstrated are specialty views for the face, where liposuction has become an integral component of the procedures. Finally, recommendations for photographic documentation of skin "textural" changes and "cellulite" improvement with liposuction, as well as regions requiring lipectomy, are discussed. A professional photographic studio and a model were utilized. Proper lighting, equipment, and backgrounds are described to achieve such standards. General principles for clinical photography are reviewed. We present standard and supplemental views for suction-assisted lipectomy and body contour surgery, with an emphasis on methods to address advanced liposuction techniques (i.e., superficial suction lipectomy) that may affect texture and contour of the skin. These techniques provide consistency for all practitioners, allowing comparison of results and techniques.

It took a long time for plastic surgery to discover the right application for the endoscope. Surgeons like to make incisions that allow for visualization of the operative field. Many surgeons are used to identifying the anatomical structures and operating on these structures the way they were taught on the anatomy lab benches.

Plastic surgery techniques changed radically after the introduction of liposuction. Many existing concepts were reevaluated, the most significant being that it was no longer necessary to produce a large scar to alter the shape of the body. In the late 1970s dermolipectomies usually involved extensive scarring. The advent of liposuction made it possible for us to modify the body contour with minimal incisions, no skin resections, more natural results, and happier patients. Liposuction has seen many refinements, in technique and instruments. We prefer syringe liposuction; it is, in our hands, a much more gentle and precise method of fat removal, allowing us to treat more accurately small pair adiposities, such as the breasts

In the late 1980s important innovations improved the scope of reduction mammoplasty and mastopexy. The return of the periareolar incision and the introduction of liposuction,1 and later syringe liposculpture,2 are some of the technical advances that allowed us to provide shape improvement and shorter scars. Liposuction disproved the old concept that, to change form, a long incision is necessary. In the same way we were able to change the indication for abdomen der- molipectomies, we could also apply the same principles to breast surgery. Many breast hypertrophies are caused by excess fat. It is possible today to reduce fatty breasts considerably by liposuction alone, without the need for any other incisions.

There are two additional advantages to the circumareolar approach for mastopexy or reduction. The first is the enhanced access to the interior of the breast for palpation and possible biopsy, and a more efficient expansion and break-up of the fibrocystic component. Because the incidence of breast cancer is neither increased nor decreased in patients with mastopexy, reduction, or breast implants, the addition of a breast prosthesis for creation of the fullness preferred by most American mastopexy candidates is in this respect an additional plus, because the patient can do a more efficient self-examination: small breast lesions are more easily palpated with the fingertip technique in implant patients than in those without implants. In fact, a certain degree of capsular contracture makes breast examination easier.

I proposed a classification for breast augmentation candidates that was published in 1978,6 1983,7 and 19898; the classification system was designed to indicate which patients suffered ptosis as an effect of the ageing process in subsequent years, and what should be offered: simple breast augmentation versus the lifting of the areola, or mastopexy. No mention was made of the circumareolar technique in this earlier text.

The shape of the breast is determined by the balance between its contents, gland and fat, and the skin that covers it. The periareolar approach, widely used by Davidson1 and others for excision of glandular pathologies, or for insertion of mammary implants, has lately been reintroduced as a technique for reduction mammoplasties and mastopexies.

Proper equipment is necessary for any successful operation. The syringe enables surgeons to remove subcutaneous fat more easily, more precisely, and less traumatically than with a suction pump. There is a sound basis for this conclusion.

Syringe liposculpture is a method that combines two relatively new techniques of plastic surgery: syringe liposuction and fat grafting. We can reshape the face and the body by removing localized fat deposits and reinjecting this fat where needed. When we do not reinject, we call the technique reduction liposculpture. In 1989 we introduced a new technique--superficial syringe liposculpture--to treat patients with flaccid skin, superficial irregularities or depressions, "cellulite," and liposuction sequelae. The technique combines syringe liposculpture, superficial liposuction, and our method of treating skin irregularities by breaking the fibrous adherences and injecting fat superficially.

Armand A. Lucas, MD Renato Saltz, MD Joseph P. Hunstad, MD Luiz S. Toledo, MD Dr. Lucas: The first case is that of a 42-year-old woman requesting abdominoplasty; she has sustained an 87-lb weight loss (Figure 1). Because obesity at the time of abdominoplasty can adversely affect outcome, is weight loss mandatory prior to body contouring surgery? Figure 1. Front and lateral views of a 42-year-old woman requesting an abdominoplasty after an 87-lb weight loss. Dr. Saltz: Certainly not in all cases, because patients are very disappointed when you insist on a weight-loss routine. If they are not morbidly obese, I will treat them. However, for those patients who are more than 25% overweight, I refer them to my nutritionist and prescribe a rigorous exercise program, usually with a personal trainer. Dr. Lucas: Dr. Toledo, is there an upper limit that would cause you to decline surgery? Dr. Toledo: My upper limit for treating heavy patients is 30% over the ideal weight. We should not remove more than 5% to 8% of total body weight with liposculpture. When I combine abdominoplasty with liposculpture, I will obviously go higher if I have to. Dr. Lucas: Dr. Hunstad, what would your surgical plan be for this patient? Dr. Hunstad: You can clearly see the lateral border of the rectus in the frontal photograph, which shows the muscle laxity. She has lost intra-abdominal as well as extra-abdominal fat, and a very aggressive plication of the medial and possibly the lateral borders of the rectus would significantly enhance her waistline. Concurrent lipoplasty, particularly of the hip rolls, would give her a very good result. Dr. Lucas: Does the lipoplasty include the abdominal flap? Dr. Hunstad: Yes. Dr. Lucas: Dr. Toledo, would you perform lipoplasty at the same time? Dr. Toledo: I perform lipoplasty separately from abdominoplasty. …

Eighteen months' experience with the injected fat grafting technique used in 208 patients to correct various problems such as buttocks (augmentation and reshaping), trochanteric depressions, breast augmentation, scar depressions, thighs and legs (calf and ankle augmentation), small wrinkles and depressions of the face (Romberg's disease), nasolabial fold, upper outer breast quadrant, liposuction sequela, fingers and hands is presented. This method shows major advantages with few complications. Some technical details and recommendations for successful fat grafting are also presented.

The major dilemma of reduction mammoplasty and mastopexy has been the difficult choice between a procedure that yields an ideal shape of the breast versus the size of the scar. With our technique, selected breasts can now be reduced through liposuction and the mastopexy performed through a periareolar incision, resulting in virtually imperceptible scarring.