Көксік пластикасы және түзету хирургиясы

Cosmetic and corrective surgery

Gluteoplasty (Greek gloutόs, rump + plassein, to shape) denotes the plastic surgery and the liposuction procedures for the correction of congenital, traumatic, and acquired defects/deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement (by augmentation or by reduction) of the contour of the buttocks. The corrective procedures for buttock augmentation and buttock repair include the surgical emplacement of a gluteal implant (buttock prosthesis); liposculpture (fat transfer and liposuction); and body contouring (surgery, liposculpture, and Sculptra injections) to resolve the patient's particular defect or deformity of the gluteal region. Gluteoplasty has also been applied in the praxis of sexual reassignment surgery.

The functional purpose of the buttocks musculature is to establish a stable gait (balanced walk) for the person who requires the surgical correction of either a defect or a deformity of the gluteal region; therefore, the restoration of anatomic functionality is the therapeutic consideration that determines which gluteoplasty procedure will effectively correct the damaged muscles of the buttocks. The applicable techniques for surgical and correction include the surgical emplacement of gluteal implants; autologous tissue flaps; the excision (cutting and removal) of damaged tissues; lipoinjection augmentation; and liposuction reduction—to resolve the defect or deformity caused by a traumatic injury (blunt, penetrating, blast) to the buttocks muscles (gluteus maximus, gluteus medius, gluteus minimus), and any deformation of the anatomic contour of the buttocks. Likewise, the corrective techniques apply to resolving the sagging skin of the body, and the muscle and bone deformities presented by the formerly obese patient, after a massive weight loss (MWL) bariatric surgery procedure; and for resolving congenital defects and congenital deformities of the gluteal region.

The motor innervation of the gluteus maximus muscle is performed by the inferior gluteal nerve (a branch nerve of the sacral plexus) and extends from the pelvis to the gluteal region, then traverses the greater sciatic foramen (opening) from behind and to the middle to then join the sciatic nerve. The inferior gluteal nerve divides into three collateral branches: (i) the gluteus branch, (ii) the perineal branch, and (iii) the femoral branch. The first ramification—the gluteus branch—is a branch nerve that is very close to the emergence of the inferior gluteal nerve to the area, next to the inferior border of the pyramidalis muscle. As it arises, the inferior gluteal nerve then divides into four or more fillets (bands of nerve fibres) that travel (in a crow's foot configuration) between the gluteus maximus muscle and its (front) anterior fascia; the thickest nerve bands are the superior most and the inferior most fillets. The superior most fillet runs almost vertically, near the sacrum, and innervates the superior portion of the gluteus muscle; the inferior most fillet, which has the greatest calibre, travels very close and parallel to the sacrotuberous ligament; the inferior most fillet provides fine gauge branch nerve ramifications that innervate the gluteus muscle through its anterior (front) face. In surgical and body contouring praxis, the plastic surgeon creates the implant pocket—either for the gluteal prosthesis or for the injections of autologous fat—by undermining the gluteus maximus muscle with a dissection technique that avoids the sacrum, the sacrotuberous ligament, and the tuberosity of the ischium; which, if accidentally cut, might isolate the posterior (back) portion of the muscle and lead to denervation, the loss of nerve function and of innervation.

The superior gluteal artery, the inferior gluteal artery, the superior gluteal veins, and the inferior gluteal veins irrigate the gluteus maximus muscle with arterial and venous blood. The vascularization, the entrance of the blood vessels to the muscle tissues, occurs at the anterior (front) face of the muscle, very close to the sacrum. As the arteries and the veins enter the mass of the gluteal muscle, they divide into narrower blood vessel ramifications (configured like the horizontal branches of a tree), most of which travel parallel to the muscle fibres. In surgical and body contouring praxis, the plastic surgeon effects the implant pocket undermining of the gluteus maximus muscle by carefully separating the muscle fibres to avoid severing the pertinent blood vessels, which would interfere with the blood irrigation of the muscle tissue. Therefore, to create an implant pocket, either for a gluteal prosthesis or for lipoinjection, a low angle muscle dissection is performed in order to avoid the risk of severing any major branch—superior or inferior—of the gluteal artery, which travels very close to the sacrum and to the sacrotuberous ligament. The implantation procedure can be performed upon a patient who is either sedated or anaesthetized, either under general anaesthesia or under local anaesthesia. The usual operating room time for a buttocks augmentation procedure is approximately 2 hours. The procedure can be managed either as an overnight in patient treatment or as a hospital outpatient treatment. Given the nature of the surgical incisions to the gluteus maximus muscles, the therapeutic management of post surgical pain (at the surgical wound sites) and normal tissue healing usually require a 4–6 week convalescence, after which the patient resumes his or her normal life activities. The gentle liposuction applied to harvest the autologous fat minimally disturbs the local tissues, especially the connective tissue layer between the skin and the immediate subcutaneous muscle tissues. Then, the harvested fat is injected to the pertinent body area of the gluteal region, through a fine gauge cannula inserted through a small surgical incision, which produces a short and narrow scar. Lipoinjection contouring and augmentation with the patient's own body fat avoids the possibility of tissue rejection, and is physically less invasive than buttocks implant surgery. Therefore, depending upon the health of the patient, the convalescence period allows them to resume daily, normal life activities at 2 days post operative, and the full spectrum of physical activity at 2 weeks post operative. Furthermore, the liposuction harvesting of the patient's excess body fat improves the aesthetic appearance of the body fat donor sites. Nonetheless, physiologically, the human body's normal, health management chemistry does resorb (break down and eliminate) some of the injected adipose fat tissue, and so might diminish the augmentation. According to the degree of diminishment of the volume and contour caused by the fat resorption, the patient might require additional sessions of fat transfer therapy to achieve the desired size, shape, and contour of the buttocks. In the case of the man or woman who presents under projected, flat buttocks (gluteal hypoplasia), and a degree of gluteal muscle ptosis (prolapsation, falling forward), wherein neither gluteal implant surgery nor lipoinjection would be adequate to restoring the natural anatomic contour of the gluteal region, the application of a combined treatment of autologous dermal fat flap surgery and lipoinjection can achieve the required functional correction and aesthetic contour. The study Contouring the Gluteal Region with Tumescent Liposculpture (2011) indicated that effective, gluteal region contouring is best achieved by tailoring the liposuction reduction and the lipoinjection augmentation techniques to the anatomic topography of the body areas to be corrected. Furthermore, the study Contouring of the Gluteal Region in Women: Enhancement and Augmentation (2011) indicated that natural contours of the buttocks and the thighs are effectively achieved with a combined gluteoplasty of selective liposuction and lipoinjection, which reduces the need for aggressive surgical procedures, decreases the risk of medical complications, abbreviates wound recovery time, and lessens post operative scarring. Combined with any buttocks correction method, superficial liposculpture facilitates the treatment of contour irregularities, the surgical revision of scars, and the correction of gluteal region contour depressions.

To meet the functional requirements and the aesthetic expectations (body image) of the patient, the plastic surgeon establishes a realistic and feasible surgery plan by which to correct the anatomic contour deficiencies of the gluteal region. The surgeon and the patient determine the location of the surgical wound scars, and determine the best operative position, to allow the proper exposure of the pertinent anatomy to be corrected. Because the surgical procedure requires the tumescence and anaesthesia of the gluteal region area to be corrected, the physician and the anaesthesiologist determine the volumes of the anaesthetic and tumescent fluids to be administered to the patient during the procedure, and so avoid the risks of drugs overdose and toxicity. The surgical and liposculpture contouring of the human body presents possible medical complications such as: the psychological—unmet body image expectations of aesthetic improvement; the physical—uneven contour, local and general; the physiologic—toxic reactions to the anaesthesic and the tumescent drugs; and the nervous—paresthesia, localized areas of perduring numbness in the corrected portion(s) of the gluteal region. Secondary lymphoedema of the lower extremities has been reported as an unusual side effect of liquid silicone injection on the hips and buttock while thromboembolism, implant displacement and explosion has also been listed as some of the dangers.

In the surgical praxis of body contouring therapy, the patient's body image expectations can be different from the contoured body that is the outcome of the performed surgical operation. Such unmet aesthetic expectations can be avoided at the pre operative consultation stage, whereby, with informed consent, the physician and the patient jointly establish a realistic and feasible surgery plan to achieve a mutually satisfactory corrective outcome (functional and aesthetic) of the operation to the gluteal region, the buttock and thigh areas.