13 - 30 Ott 2022 - GLUTEOFILLER

Aesth Plast Surg https://doi.org/10.1007/s00266-022-03166-1

ORIGINAL ARTICLE

NON-SURGICAL AESTHETIC

Gluteal Augmentation with Hyaluronic Acid Filler: A Retrospective Analysis Using the BODY-Q Scale Adriano Santorelli1 • Fabio Cerullo1 • Giovanni Salti2 • Stefano Avvedimento1

Received: 28 July 2022 / Accepted: 30 October 2022 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2022

Abstract Introduction Minimally invasive techniques, such as filler injection, are now available for posterior body contouring.

However, limited data on the outcome of gluteal augmentation with hyaluronic acid (HA) are available in the literature.

Material and Methods We performed a retrospective analysis of 43 patients with Body Mass Index B 30, and low-grade ptosis or no ptosis who underwent gluteal augmentation with HA at our clinics. Treatment response was evaluated with a patient-reported assessment scale (BODYQ) at baseline, and after 6 months.

Results Patients were satisfied with treatment as observed by a statistically significant increase in mean BODY-Q scores at 6 months (8.14 ± 2.19 vs. 14.40 ± 2.38, p \ 0.0001). Such increase was more pronounced in patients who were treated with a higher number of vials (8–12 vials vs. 14–20 vials). No serious complications were observed during or after treatment.

Conclusion Gluteal augmentation with hyaluronic fillers is a safe, minimally invasive procedure with good aesthetic results.

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Keywords Hyaluronic acid Gluteal augmentation Gluteal contouring Filler injection

Introduction Body contouring is one of the main reasons why patients visit aesthetic surgeons. Demand for gluteal augmentation and posterior body contouring has been increasingly growing during the last decade due to changes in the perception of the ideal body. Techniques such as silicone implants and autologous fat grafting are commonly used for gluteal augmentation; however, these are invasive procedures with a high complication rate [1].

The development of large particle hyaluronic acid (HA) fillers has allowed to apply minimally invasive techniques to posterior body contouring. This approach shows evident advantages to the patients, who usually prefer less invasive procedures. Gluteal augmentation with filler injection is also valuable for clinicians because it implies minimal risk for the patient if performed with the necessary precautions.

Nevertheless, currently, there are no guidelines published describing the procedure, and limited data on the outcome of gluteal augmentation with hyaluronic acid (HA) are available in the literature [2].

Therefore, the objective of this study was to assess the outcome of this type of intervention, and describe the technique used.

& Stefano Avvedimento stefavve@hotmail.it 1

Academy of Aesthetic Sciences, Via Raffaele Morghen, 88, 80129 Naples, Italy

2

Medlight Medical Institute, Via Claudio Monteverdi, 2, 50144 Florence, Italy

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Material and Methods A retrospective observational study was performed in two centers: one in Naples, and one in Florence, Italy. We selected all consecutive patients who underwent the procedure over a two-months period, between September 1, 2021, and October 31, 2021. Therefore, we retrieved patients’ data and information at baseline (first visit), and at their 6-month follow-up visits (corresponding to a period between March 1, 2022, and April 30, 2022).

Patient Selection Patient selection has an important role in obtaining successful results with HA fillers for gluteal augmentation.

Indeed, the tissue must present several characteristics that allow HA fillers to modulate the gluteus: good skin coverage (preferably in the absence of lipodystrophic panniculopathy), good muscle tone, and no gluteal ptosis or at most low-grade ptosis (1 or 2) [3].

For these reasons, patients with Body Mass Index (BMI) [ 30, high-grade ptosis (grade 3 or higher), and steatopygia were not allowed to undergo the procedure. For each patient, age, sex and BMI were collected.

Assessment Treatment efficacy was assessed with the BODY-Q scale [4].

This is a patient-reported outcome instrument designed to measure patient perceptions of weight loss and/or body contouring. BODY-Q Buttocks scale is made of 5 items that measures patient’s satisfaction with the appearance of their buttocks. Using the BODY-Q Buttocks scale, the patients express their opinion about the size, shape, and skin, as well as how the buttocks looked from the side. Maximum satisfaction corresponds to a score of 20 (4 points per item). The BODY-Q scale was used with permission of Memorial Sloan-Kettering Cancer Center, New York, USA. Patients answered the BODY-Q Buttocks scale questionnaire at baseline (first visit, before treatment), and at their 6-month follow-up visits.

Characteristics of the Filler The gluteal region is an extensive area. Its volume restoration requires large particle HA fillers to be injected deep into the skin, naturally lifting the tissue. These particles induce increased volume due to the possibility of ‘‘trapping’’ water molecules in their ‘‘cross-linked’’ nets.

This implies a noteworthy volumising effect. Moreover,

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due to its characteristics, HA filler is capable of producing a greater per cc volume increase compared to fat.

For all patients, we used macromolecular HA manufactured using soft shell technology (Naturelize Body Intense, Naturelize GmbH, Germany). Gluteal augmentation with HA filler was performed through injection, a noninvasive method. However, due to the large volume needed to achieve an optimal aesthetic result, the HA filler behaves not as a filler but as an implant after being injected. Since HA filler undergoes minimal cellular infiltration, the product remains surrounded by a uniformly thin capsule [5], and as a result, the body recognizes it as a foreign body, circumscribes, and attacks it. Therefore, HA filler has the characteristic to preserve its volume through time. It is critical to take advantage of this implant-like behavior.

Technique Our approach was tailored to the patient’s needs. We chose the treatment area with the patient’s collaboration. We asked the patient to contract the buttocks to assess the presence of a volume deficit during motion. The areas to be augmented were marked with the help of a mirror and photographs.

Once the areas to treat were identified, the cannula entry holes were oriented cephalically and centrifugal to the areas to be treated (approximately, 2 o’clock to each area of the right buttock and 10 o’clock to the left buttock). We used a 16G or 18G cannula.

The injection was performed according to the sterility techniques required for surgical procedures. The whole area was disinfected with chlorhexidine. The entry hole was marked, and a mix of local anesthetic and adrenaline was applied, specifically 0.5 ml of lidocaine 1% (10 mg/ ml) with adrenaline 1\500,000). The skin was cut with a blade 11, and the cannula was inserted. The cannula was used to apply another 10 ml of local anesthetic with adrenaline 1\500,000 to each area for a maximum of 20 ml of lidocaine 1%. The anesthetic was inserted with a tunnel technique borrowed from the infiltration of liposuction.

Skin detaching on the entire area to be treated was performed with the help of the cannula after the anesthetic is finished. After about 10 min, treatment began by inserting a vial containing 10 ml of HA filler.

We performed HA filler injection using the multilayer tunneling technique through the cannula in a fan-like way both horizontally, and in depth to cover all the fat layers.

The area to be treated was always and only gluteal fat without ever reaching the muscle. The HA filler was released with fan-like movements.

Aesth Plast Surg

Once the injection was finished, an energetic massage was performed to best distribute the filler while firmly pressing a finger on the entry hole. Small stitches (prolene 5\0) of suture or dermal patches were used to close the small access holes.

A containment sheath was used as a dressing.

Figure 1 provides a description of the main steps of the injection technique. Images are collected in 5 projections: back, right and left profile, and 45 degrees rear left and right.

For each patient, the overall number of vials used for each buttock was recorded, and was decided according to the patient characteristics, for a maximum volume of 20 vials for each buttock.

Post-intervention Period

Fig. 1 Injection technique (step-by-step). Anatomy of the gluteal region (a). Identification and marking of target areas and insertion site (b). The same insertion site is used for local anesthesia (c), and for

treatment (d). Injection is performed using a retrograde and multilayer technique both horizontally and vertically without reaching the gluteal muscle (e). (Credits: Dr. Adriano Santorelli)

After the procedure, every patients followed a therapeutic protocol. Specifically, amoxicillin 1 g twice daily for 5 days, prednisone 25 mg once daily for 3 days, and paracetamol 1 g if necessary in case of pain.

Post-intervention care was minimal for this type of procedure but was necessary to achieve the desired results.

As the only precaution, patients were asked not to sit during the first 4 h post-intervention, and to avoid sports and sauna over the following two days in order to reduce the risk of product displacement, swelling or hematoma.

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Complications Patients were monitored for a period of six months in order to promptly identify both major and minor complications related to the procedure.

Statistical Analysis SPSS software version 17.00 (SPSS Inc., Chicago, USA) was used for statistical analysis. Data were presented in absolute frequency and percentage, or analyzed as means and standard deviations (SD). Comparisons between baseline and 6-month time point were performed using unpaired-samples t-test. A value of p \ 0.05 was considered statistically significant.

Results Between September 1, 2021, and October 31, 2021, 43 patients underwent gluteal augmentation with HA filler. All patients were female (43, 100%). Patient’s age ranged from 19 to 57 years, with a mean of 34.12 years [Standard Deviation (SD), ± 8.79]. BODY-Q score assessed at baseline ranged from a minimum of 5 to a maximum of 12, with a mean of 8.14 (SD, ± 2.19). The mean number of vials used for patient for each buttock was 14.74 (SD, ± 3.52), ranging from 8 to 20.

Six months later, a statistically significant increase in mean BODY-Q score was observed (8.14 ± 2.19 versus 14.40 ± 2.38, p \ 0.0001) (Fig. 2).

BODY-Q score ranged from a minimum of 9 to a maximum of 19. Such increase was more pronounced in

Fig. 3 Mean BODY-Q scores at 6 months: comparison between treatments (8–12 vials vs 14–20 vials)

Fig. 4 Patient A picture before treatment

patients who were treated with a higher number of vials (8–12 vials vs. 14–20 vials) (Fig. 3).

No major complications were described. Minor and transient complications were described in 3 patients (7.0%). Specifically, excessive firmness was observed in 2 (5.9%) patients, supposedly due to a remarkable cellular infiltration of the capsule surrounding the product with its subsequent retraction. Massage therapy with arnica gel was suggested. Delayed granuloma formation was seen in one (2.3%) patient. Treatment consisted of a drainage using a 21G needle, which led to complete resolution.

Fig. 2 Mean BODY-Q scores at baseline and after 6 months

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The overall cost of the complete treatment ranged from 1200 (8 vials) to 3000 euros (20 vials).

Figures 4, 5, 6, 7 show two different patient’s pictures taken before treatment (Figs. 4, 6), and after treatment (Figs 5, 7).

Discussion

Fig. 5 Patient A picture after a treatment at 6 months with 160 ml of HA filler

Fig. 6 Patient B picture before treatment

Fig. 7 Patient B picture after a treatment at 6 months with 180 ml of HA filler

In this retrospective analysis, 43 patients underwent gluteal augmentation with HA fillers. Self-assessment was provided by patients at baseline and after 6 months in order to measure the outcome of the intervention. A statistically significant increase in mean BODY-Q scores was observed at 6 months after the procedure, which indicates that patients were happy with the results of HA filler injection.

Gluteal augmentation with HA is a relatively recent technique. HA fillers are considered safe to use in cosmetic medicine. The versatility of HA gel is a major advantage compared to permanent implants. HA can be used both for augmentation and contouring purposes. Furthermore, due to its biodegradable nature, HA can be also used as an indicator of the effect that can be achieved with permanent implants [6].

The use of HA gel injections for gluteal augmentation has been previously investigated in two prospective studies, one of which was multicenter [6, 7]. These studies showed that gluteal augmentation is a safe and effective treatment for temporary aesthetic augmentation of the buttocks yet limited by the cost of the injectable in relation to the huge volume required to achieve optimal results.

Long-lasting results can be obtained up to 24 months.

De Meyere et al. observed that, although the substance degrades over time, 24 months after treatment a good proportion of patients rated their buttocks as improved (40%), and expressed satisfaction (33%) [6]. Similarly, Camenisch et al. observed the treatment was well tolerated, and investigator’s and patient’s perception of aesthetic gluteal augmentation continued high, even if small volumes of HA remained [7].

Cerqua et al. showed that at 8 months post-injection, a 60–70% correction persisted in 90% of the patients. They asserted that filler injections are a predictable, safe, and long-lasting non-surgical procedure to fill contour defects that arise after liposuction [8]. Moreover, Scaperrotta et al. analyzed patients that underwent breast augmentation with HA injection and showed that the resorption rate varied between subjects. However, after 24 months, a mean of approximately 20% of the injected volume remained in the breast. Even after more than four years, small amounts of Macrolane were still visible on magnetic resonance imaging or ultrasound in some patients [9].

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In our retrospective analysis, no major complications were observed, and only 7.0% of patients reported minor and transient complications. However, the HA injection is not free from complications [10]. Indeed, when the treatment is performed in specific body regions (such as the face), and large quantities of product are injected, the risk of complications increases.

Recently, much attention has been paid by the scientific community to cases of death following the procedure of gluteal augmentation with fat grafting [11, 12]. The risk of embolism is related to the injection of fat into deep muscular and intramuscular planes. In our opinion, it is necessary to emphasize the concept of a danger zone. The danger zone is a nearly pyramidal area with its height along the intergluteal cleft and its base following the medial twothirds of each gluteal fold. This area contains most of the larger gluteal vessels. The superior and inferior gluteal veins that drain into the internal iliac system are largecaliber vessels that can be 4 mm or more as they transit the gluteus maximus and medius interface towards the iliac wing. Near the sciatic notch, large-caliber veins that are 6 mm or larger may appear as venous lakes or varices [13].

The muscles in the danger zone—which is the area where most of the larger vessels are located—should be avoided.

For this reason, it is critical to inject in the subcutaneous tissue, avoiding a deeper plane. Filler injection must be performed in a retrograde fashion, using a slow movement to prevent vessel damage and the entrance of fat into the bloodstream [14]. For this reason, our technique uses a centrifugal and cephalic-oriented injection of HA. Based on this evidence and our clinical experience, we believe that gluteal augmentation with HA should be managed as a prosthetic implant procedure, particularly within the first two years. Indeed, any treatment that uses at least 30 ml of HA, either normal or large particle, should be performed with maximum sterility techniques required for surgical procedures. Although the intervention is minimally invasive, operators should be very aware of that.

Furthermore, the treatment should be performed in qualified surgical clinics, carrying out proper disinfection and post-operative treatment, including prednisone, a supportive therapy with a broad-spectrum antibiotic, analgesic therapy as needed, and dressing the injection access points.

A limitation of this study is the retrospective design.

However, the study also presents some strengths. To our knowledge, this is one of the largest study to have studied the effect and outcome of patients treated with HA for gluteal augmentation. In addition, the outcome of the intervention was quantified with BODY-Q Buttocks scale,

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a body contouring specific self-reporting scale, which we believe allowed us to assess patient satisfaction better.

Conclusion In this study, we observed that gluteal augmentation with HA fillers is a safe, minimally invasive procedure with good aesthetic results.

Acknowledgments Statistical analysis and editorial assistance were provided by ERA ms S.r.l. and funded by MR Devices.

Funding This study was funded by MR Devices.

Declarations Conflict of interest There are no conflicts of interest to declare regarding this article. All the other authors have nothing to disclose.

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14. Rosique RG, Rosique MJF (2016) Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg 137:641e–642e Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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