If there is one place where large cannulas should be prohibited, it is certainly the buttocks. Several surgeons refuse to operate on this area because they have achieved poor results, such as sagging buttocks, a curved gluteal fold, skin full of irregularities, or other unsightly complications. This is because they are unaware of the best way to approach this area. In a serious medical journal, the author, a renowned plastic surgeon, admitted that the buttocks were a forbidden zone for liposuction. He should have titled his article: “The buttocks are a challenging area for liposuction, but not forbidden. Inexperienced surgeons, please refrain.”
Here is the procedure for sculpting beautiful buttocks:
Carefully assess the work to be done, by drawing diagrams that clearly map out the so-called severity zones and the grazing zones;
Use fine cannulas, never exceeding 3 mm in diameter;
Work in the direction of gravity, not transversely, which could lead to skin irregularities, i.e., waves.
Unlike the saddlebags, where one must flatten an exaggerated roundness, for the specific area of the buttocks, it is necessary to preserve a beautiful roundness that is characteristic of a natural curve. A flat buttock would not at all meet the current criteria of beauty.
The defect that patients often complain about is located at the “apple” of the buttock, as it is commonly referred to in popular language! It is a bump at the infero-lateral part of the buttock that becomes more pronounced with age, responding to the laws of gravity. Over the years, the weight of the buttock, both muscle and fat, causes the buttock to deviate outward. Obviously, diligent exercise will prevent the muscular portion of this problem, but judicious liposuction can address the fatty portion. I say judicious liposuction because the gluteal muscle is a large muscle, responsible for a significant part of the buttock. The surgeon must take this into account and not believe that the buttock is a bottomless pit of fat that can be aspirated at will. Forgetting this could result in nothing less than flat buttocks.
Due to the weight of the gluteal fat, nature has provided ligaments that hold the buttock in place; these are the Jacques ligaments. The female breast also has similar ligaments, called Cooper’s ligaments.
With age and the weight of the fat, the same goes for the breast; these ligaments lose their elasticity, and their gradual relaxation leads to a sagging of the buttock, especially the apple of the buttock. Liposuction will relieve these tired ligaments by allowing the buttock to regain its position. I do not say rise, because the buttock does not rise spectacularly, unlike the abdomen, which will always continue to surprise me.
However, these ligaments make the buttock more sensitive, which is why it must be very well anesthetized; otherwise, a slight sensation of electric shocks will make the liposuction unpleasant for the patient. Before the procedure, it is important to have a photo that clearly shows the gluteal fold, as it is not always perfectly vertical due to a hip problem, one leg being shorter than the other, or simply an anatomical defect. Sometimes, it is noticed that one buttock is lower than the other. Most often, patients had never noticed these slight defects, and without this photo evidence, they might mistakenly believe that the liposuction caused this imbalance.
Another peculiarity that is sometimes encountered is that the fat does not seem to have been placed in the right place on the buttocks. The buttock is flat, very cellulitic, and at the sacrum, just above the buttocks, there is a mass of fat, sometimes significant and unsightly, which I have disrespectfully nicknamed “the bumper.” It is as if the fat, by a whim of nature, never descended to its proper place.
Liposuction will do a great service by permanently aspirating this excess, restoring a much more natural contour to this region. The buttock will not be corrected since it is not touched, but it will appear less flat, freed from this fatty protrusion. To correct gluteal cellulite, one can also use a special cannula called “Toledo,” which cuts the adhesions responsible for the cellulite in place. (cf fig. 152)
The distribution of fat on the body is genetic. Women of African descent are particularly endowed in the buttocks area, and I have sometimes removed nearly a liter of fat from each buttock, with excellent results. The position of the patient during the procedure is particularly important for the buttocks if one wants results close to perfection. This is why, when I ask my assistant: “Take the buttock position!”, she understands very well that the patient must be lying face down, with a special cushion under her pelvis, which places the buttocks well in view and allows the cannula to reach every nook and cranny. We have already discussed the sub-gluteal banana with the thigh, since this banana forms the junction between the thigh and the buttock. Here, the subcutaneous work is still of great precision.
The treatment of this banana requires a lot of finesse, as it is partly a support for the buttock in addition to the Jacques suspensory ligaments, but I add that if the liposculptor approaches this anatomical site too cavalierly, by not staying superficial with the cannula, he may cause the buttock to sag or create a double or triple fold with the sub-gluteal fold, more scientifically called the gluteal fold.
As I have already mentioned, each anatomical site has its “quirks,” and it is the way the liposculptor handles all these delicate areas that will determine the perfection of the results.
