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IAesthetics Technical Article
Water-jet assisted lipocontouring(WAL) of the gluteal region:Technique and long-term results Authors: Dr med. Alexander Aslani, Dr med. Felipe Schmitt Sánchez,
Dr med. Ewa Siolo, Dr med. Alexander Hamers
The surgical options for aesthetic contouring of the buttocks include silicone implants, dermolipectomy and autologous fat transfer with the latter generally achieving good results for contouring of the buttocks.
The success of this procedure is a result of the ideal properties of the gluteal region, which has a large amount of muscle tissue and is thus well suited to absorb large amounts of grafted material. In this article the authors present their technique for large-volume autologous fat grafting based on water-jet assisted liposuction (WAL), centrifugation of the added cells and a fan-shaped placement of the grafted material.
Aesthetics Technical Article I
The selection of the patients for this procedure de-
2 months after surgery 6 months after surgery pends partly on their desired buttock shape and size.
What is important for this indication is, of course,that there is sufficient subcutaneous reserve fatavailable. The BMI (Body Mass Index) provides arough guide. Another advantage is also a high per-centage of superficial (subcutaneous) fat as well asa somewhat ‘wider' structure of the buttocks, that is,an A or C shape. Another important parameter is theratio of the circumference below the 12th rib (waist)to the greatest circumference at the height of thetrochanter, the so-called ‘hourglass index'.
The authors recommend that patients have a BMI > 26. With a lower body mass index there is a rela- 2 months after surgery 6 months after surgery tively high risk of the patient being unsatisfied withthe enlargement that can be achieved. For this rea-son, candidates with a BMI less than 26 should haverealistic expectations of the achievable results be-forehand.
If the patient has a BMI between 23 and 26, the au-thors' recommendation depends on the result the pa-tient wants to achieve. If a patient wants a very sig-nificant result, a combination of a silicone implantand autologous fat transplantation is recommended.
According to the authors' experience, with a BMI ofless than 23 it is very difficult to meet patient expec- tations using autologous fat transfer alone.
2 months after surgery 6 months after surgery For transfer volumes of less than 2,000 ml, the au-thors recommend local anesthesia with sedationwhile for larger volumes general anesthesia is pre-ferred. The use of spinal anesthesia is not establishedin practice for this procedure, not least because ofthe patient's repositioning usually required.
The surgery starts with the patient in a supine posi-tion to have better access to the subcutaneous ab-dominal fat. The authors start with pre-infiltration through stab incisions in the bikini zone and navel us-ing the body-jet evo system (human med, Schwerin, means the harvesting procedure is not only faster but Fig. 1a–c: Gluteoplasty by means of
Germany) at a rate of about 60 jets/min. For this pre- also more precise. For the next step, the authors an autologous fat transfer, injection infiltration a cannula with a single hole and a slight switch to a fat suction cannula (fat harvest). This is a of 1,200 cc using the water-jet angle (45°) is used. The pre-infiltration is performed sharp cannula with a central opening for infiltration assisted technique; results two to with Klein's solution, except for use of a general anes- and lateral slits for suctioning, facilitating the simul- six months after surgery with almost thesia. In such a case, a lidocaine-free solution is used taneous infiltration and suction. The second genera- identical volume.
to minimize the chemical trauma for the fat cells.
tion of hydrojet, the body-jet® evo, has a specific pro- Compared to conventional liposuction, only small in- gram for lipotransfer in which the system automati- filtration volumes are required. As a guideline for be- cally holds the suction pressure below 350 mmHg.
ginners in this technique, use a pre-infiltration vol- Typical areas where liposuction is used are the ab- ume corresponding to about 10 per cent of the fat domen and the back and flanks (fat deposits). Con- that is expected to be harvested. If the surgeon plans, touring these zones considerably improves the aes- for example, to harvest 1,000 cc of pure fat, a pre-in- thetic outcome. The body-jet device is connected to a filtration with 100 cc during the five minutes before filter system ("LipoCollector") that separates the fat starting fat harvesting is more than adequate. This and fibrous tissue, producing fat that can be immedi- low pre-infiltration volume is one of the most signif- ately grafted.
icant advantages of the water-jet technique (hydro- The LipoCollector was originally designed in a way jet) because there is no swelling of the tissue. This that any additional processing of the harvested fat is IAesthetics Technical Article
The grafting procedure
2 months after surgery 10 months after surgery What is important when grafting autologous fat is touse fan-shaped, layered deposits. The authors injectabout 80 per cent of the volume of grafted fat intramuscularly. For intramuscular infiltration, 10 cc syringes with a BEAULI lipotransfer cannula (14G, human med) are used. The intramuscular autologousfat augmentation increases the size of the buttocksbut has minimal effect on the shape. Therefore, autologous fat injections into the superficial layersare particularly important to achieve the desired rounding. This superficial layer is not very well vascu-larized, making the fat grafting technically difficult.3, 6 2 months after surgery 10 months after surgery On the hips a rather superficial and subcutaneous in-filtration is required. For this reason, the authorsswitch to 5 cc syringes and 16 G cannulae. This injec-tion technique certainly is a little laborious, but it delivers better results in terms of the shape and size.
To optimize the good result, the tissue should mostdefinitely not be oversaturated. An overcorrectiondoes not increase the ultimately remaining volume offat, but merely results in necrosis of the fatty tissueand formation of cysts. If the area that is being treatedstarts to become hard, under no circumstances should the surgeon continue to inject fat.
2 months after surgery 10 months after surgery The authors use compression pants specially devel-oped for this type of surgery (Colombia Fajas,Barcelona, Spain) for six weeks after surgery. Thestandard adhesive tapes (Kinesio tapes) used inphysiotherapy are also applied on the first day fol-lowing surgery. However, the authors avoid apply-ing Kinesio tapes in the operating room becausethey have often observed tape blisters due to thepost-operative swelling.
Fig. 2a–c: ‘Brazilian butt lift' with a
not required. The authors, however, have modified The authors evaluate the outcome of the surgery us- grafted fat volume of 950 cc on each the lipocollecting process. Although it is not strictly ing photovolumetry (Canfield Mirror System). Based side; results after two and necessary when working with the LipoCollector, on the volume, they document, on average, a post- ten months respectively with they achieve an improved quality of the material to operative fat retention of 80 per cent six months af- unchanged volume.
be grafted by manual centrifugation. Based on the ter the procedure. Similarly good results have previ- authors' experience, this is a particularly gentle type ously been documented for water-jet assisted autol- of processing. For this purpose, 60 seconds are suf- ogous fat grafting.5 ficient to concentrate the fat transplant by an addi- In patients with a BMI between 26 and 30, the satis- tional 10 per cent.10 A longer centrifugation time faction index is very high. For patients with a BMI less does not result in a higher concentration but instead than 26, the results for autologous fat transfer are produces more oil, an indication of fat necrosis.
good and the patients are generally very happy with The quality of the fat obtained by means of the wa- the result. Even for large volumes, no patient treated ter-jet is excellent. In liposuctions using the water- in the authors' clinics has yet complained about ex- jet technology, the authors obtain a total fat vol- cess volume. In contrast, it is not unusual that even ume from which, on average, up to 80 per cent can patients who have had a volume of > 1,000 cc grafted be grafted. They add 1 per cent Platelet-Rich have expressed a desire to further augment the vol- Plasma (PRP) to the fat.
ume in a second sitting.
Aesthetics Technical Article I
6 months after surgery 12 months after surgery Because of its extensive area and the high propor-tion of muscle tissue, the gluteus muscle is the idealregion for autologous fat grafting. For patients witha BMI > 26, the authors prefer autologous fat trans-fer because of its higher success rate and fewer com-plications compared to implants. Contouring the but-tocks using autologous fat is a very rewarding proce-dure for surgeons and patients alike, and for this rea-son it is surprising that there are so few publicationson this subject. There are a number of methods forharvesting the fat including tumescent liposuction using low pressure, vibration (power-assisted), ultra-sound and water jet (hydrojet).
6 months after surgery 12 months after surgery In the authors' practice, the WAL has proven to be su-perior to the alternative techniques. Using this tech-nique a larger volume of fat is harvested while ensur-ing the harvested cells suffer minimal mechanical andchemical trauma. The rapid removal of the fat is alsoan important benefit.
For surgeons interested in large-volume autologoustissue transfer, the water-jet assisted method is ahighly effective option. The authors recommend making several adaptations to the original process.
6 months after surgery 12 months after surgery Although the manual centrifugation and the switchto a thin cannula for injection into the superficial lay-ers increase the surgery time, this is compensated forby a very good attachment of the injected fat in theparticularly important areas and a higher success ratefor fat transfer in the subcutaneous sites._ [1] Coleman SR. Long-term survival of fat transplants: controlled de- monstrations. Aesthetic Plast Surg 1995;19:421-5.
[2] Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. Combi- ned gluteoplasty: liposuction and lipoinjection. Plast ReconstrSurg 1999;104:1524-31.
Fig. 3a–c: Gluteal contouring using
[3] Chajchir A, Besaquen I. Fat-graft injection for soft-tissue aug- autologous fat transfer of 1,150 cc on mentation. Plast Reconstr Surg 1989;84:921-34.
each side six months and one year [4] Mendieta C: The Art of Gluteal Sculpting. Quality Medical respectively after surgery with Publishing Inc; 2011:149-2445.
Alexander Aslani
excellent consistency of volume.
[5] Ueberreiter K, von Finckenstein JG, Cromme F, et al. BEAU- Head of Department LITM—eine neue Methode zur einfachen und zuverlässigen Fett- What must be noted is that this Plastic, Aesthetic and zell-Transplantation (BEAULITM —a new and easy method for patient reported a post-operative large-volume fat grafts). Handchir Mikrochir Plast Chir Reconstructive Surgery weight loss of a little over 5 kg, which Hospital QuirónMálaga did not have a permanent effect on [6] Chang KN. Surgical correction of post-liposuction contour irregu- AvdaImperio Argentina 1 the volume constancy.
larities. Plast Reconstr Surg 1994;94:126-36.
29004 Málaga, Spain [7] Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower limbs. Aesthetic Plast Surg 1996;20:409-16.
[8] Roberts TL 3rd, Toledo LS, Badin AZ. Augmentation of the buttocks by micro fat grafting. Aesthet Surg J 2001;21(4):311-9.
[9] Gasparotti M, Lewis CM, Toledo LS: Superficial liposculpture: ma- nual of technique. New York: Springer-Verlag; 1996:83-9.
[10 ] Aslani A, Hamers, Ortiz Abello M, Marin I. Brazilian butt lift—Large volume fatgrafting with Water Jetstream assisted liposuction,Plastic and Maxilliofacial Surgery News, Vol.1, Issue 6, pp.17-19


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The Journal of Neuroscience, May 1, 1999, 19(9):3423–3429 Regulation of Calcitonin Gene-Related Peptide Secretion by aSerotonergic Antimigraine Drug Paul L. Durham and Andrew F. Russo Department of Physiology and Biophysics, University of Iowa, Iowa City, Iowa 52242 We have investigated the regulation of calcitonin gene-related