43. Elastic gluteoplasty with the Elasticum thread and Jano cannula under local anesthesia: basic procedure
KEYWORDS: elastic gluteoplasty, butt lift, gluteal lifts surgery, Elasticum suture, Jano canula
This patient's bottom looks hollowed and drooping. An elastic gluteoplasty procedure will lift and firm up the soft tissues of the buttocks. This is done by means of the EP5 Elasticum thread and the two-tipped Jano cannula.
The preoperative design of the pathways of the elastic threads to be implanted is the same as the one we used in the first elastic gluteoplasty with two circular sutures, which was published on CRPUB in 2013.
Two loops are drawn – one upper and one lower. The upper loop extends from the point where the skin of the buttock meets that of the lumbar region down to about a palm's width from the gluteal sulcus. This loop lifts and firms the upper portion of the buttock.
The lower loop partially follows the same pathway as the upper loop, but extends further down - to about 3 cm from the gluteal sulcus. This second loop lifts the lower portion of the buttock.
Local anesthesia with 2% mepivacaine is carried out at the two points of incision where the knots of the threads will be lodged. Anesthesia is also carried out in depth.
The operator now carries out local anesthesia along the preoperative design, where the threads will be implanted. Before the elastic threads are implanted, a dilute anesthetic solution is prepared by adding three 10 mL vials of 2% mepivacaine and 1 mg of epinephrine to 500 mL of lactate Ringer or physiological solution. This is injected by means of a 10 mL syringe and a 21G needle.
The solution is injected 5 mL at a time along the pathways of the elastic threads, in both directions.
Using a finger, the operator feels for the points where the anesthetic has already taken effect, and continues to inject at these points, so that the injections will be painless.
Having completed local anesthesia along the pathways of the elastic threads, the operator uses a number 15 blade to make two skin incisions of about 5 mm. A Klemmer is then used to create a space that will be deep enough and wide enough to house the knots.
Now, pre-tunnelling begins. This is done with a two-tipped rod, which has depth marks on the shaft. The rod is inserted perpendicularly into the skin incision and travels through the subcutaneous tissues at the depth at which the elastic thread will be implanted, about 2 cm. When the two-tipped rod has to emerge or change direction, the tip comes into contact with the dermis; the assistant uses an SM67 microsurgery scalpel to make an incision parallel to the rod, so that the tip can emerge. These tiny incisions of little more than 2 mm will no longer be visible after a few months.
The elastic thread will be implanted at the greatest depth (2 cm) in the lower horizontal pathways. If the buttocks are heavier and have a thicker adipose layer, the depth of implantation may be increased slightly.
The depth marks on the shaft of the rod enable the rod to be kept at the desired depth. When the fourth depth mark is visible, which means that 2 cm of the tip remains in the tissues, the rod is rotated and follows the preoperative design. If moving the rod slightly up and down creates skin introflections, the pathway is too superficial. In this case, the operator draws the rod back and reinserts it into the subcutaneous tissue at a greater depth.
The aim of pre-tunnelling is to facilitate the subsequent implantation of the elastic thread. In the more fibrous subcutaneous tissue, further down, where the patient sits, the rod is passed through several times, in order to create an easier pathway for the two-tipped cannula to which the elastic thread is attached.
Having completed pre-tunnelling of the larger loop, the operator finishes pre-tunnelling of the smaller loop, which will make the upper portion of the buttock firmer. Two more small incisions are made with the microsurgery scalpel.
During the procedure, the operator moves from one side of the bed to the other, so as to pass the two-tipped rod more easily through the subcutaneous tissue.
If carried out correctly, pre-tunnelling saves time and avoids straining the Jano cannula and the elastic thread as they pass through the fibrous subcutaneous tissues.
Once pre-tunnelling is complete, the elastic thread is implanted. The operator carefully inserts the Jano cannula along the same pathway created by the two-tipped rod. It is essential to follow exactly the same pathway created during pre-tunnelling.
As always, a Klemmer is fixed to the end of the elastic thread.
The Jano cannula is inserted perpendicularly into the main incision, where the knots will be lodged. When the desired depth has been reached, the cannula turns through 90° and passes through the subcutaneous tissue, following the preoperative design.
The operator pinches the skin, so that the tip of the cannula can emerge at the correct depth.
The two-tipped cannula partially emerges from the small incision. It is very easy to maintain the correct depth where the pathway of the elastic thread changes direction. The Jano cannula is extracted until the point of attachment of the thread becomes visible and the posterior tip of the cannula has entered the subcutaneous tissue. The elastic thread is pulled through. The cannula is extracted up to the fourth depth mark, which means that 2 cm of the tip remains in the subcutaneous tissue. The Jano cannula then rotates and continues along its pathway.
The elastic thread is pulled through and placed under tension. The assistant makes sure that the thread does not become knotted and that there is nothing to prevent the thread from passing through the small incisions.
The Jano cannula must be extracted gradually, without snatching; otherwise, the elastic thread could become detached or be damaged.
The cannula is extracted up to the fourth depth mark; it then rotates and continues along its pathway, emerging from the entry incision.
The two ends of the elastic thread are placed under tension. The operator checks that there are no evident skin introflections. If there are any visible defects, the thread should be extracted and reimplanted.
A closed Klemmer is inserted perpendicularly into the incision to facilitate knotting of the elastic thread in depth. The operator ties five or six simple loops and presses the knot down into the cavity.
The upper portion of the buttock has been lifted and firmed up.
The operator now implants the elastic thread that lifts the gluteal fold. The Jano cannula is inserted vertically into the incision and follows the preoperative design. By means of this second suture, the operator can slightly modify the curvature of the buttock.
The elastic thread is pulled through and placed under tension.
When the fourth depth mark becomes visible, the Jano cannula rotates and continues along its pathway. The cannula must be handled with care, so as to avoid bending. If it is difficult to pass through the subcutaneous tissue, the operator grasps the anterior half of the cannula with a gauze.
If the subcutaneous tissue is particularly fibrous, making it difficult to advance the cannula, the operator inserts the two-tipped rod through the next small incision and runs it back and forth a few times, in order to facilitate advancement of the cannula. In the areas that offer the greatest resistance to the passage of the Jano cannula, when the point of attachment of the elastic thread to the cannula emerges from the skin, it is advisable for the operator to grasp both the thread and the cannula with two fingers, so as to prevent the strong traction exerted from causing the thread to detach or snap. However, to avoid exerting excessive traction, the elastic thread is pulled through only after the posterior tip of the cannula has entered into the subcutaneous tissue. During pre-tunnelling, the operator should, in any case, run the two-tipped rod several times through the very fibrous areas of the subcutaneous gluteal tissue, in order to facilitate passage of the cannula.
As the Jano cannula is rotated, it encounters an accumulation of tissue and must be pushed through forcibly.
As the tip emerges, the cannula must not be allowed to shift gradually toward the surface; rather, it must reach the dermis from beneath. This is easy to do when the pathway changes direction: that is to say, at the corners. As we have already said, in curved pathways, this is achieved by pinching the tissues. This manoeuvre prevents skin introflections from forming at the turning points when the threads are placed under tension.
Along the lower horizontal lines, the elastic thread is not normally implanted at a depth of less than 2 cm. Along the medial vertical lines, however, it may be implanted at a lesser depth; this will place greater traction on the superficial tissues. It must be borne in mind that the thread always follows the tip of the cannula, and that the cannula must be rotated when the tip is at the desired depth.
The second loop has now been completed. The two ends of the elastic thread are placed under tension and knotted under the guidance of a Klemmer, which is inserted perpendicularly into the entry incision. The knot is pressed down into the cavity. Lifting of the right buttock is now complete.
Before being implanted, the elastic thread is soaked in physiological solution containing a small quantity of iodo-vinylpyrrolidone. This accelerates colonisation of the elastic thread by fibrohistiocytic cells, facilitating its transformation into a ligament. The elastic thread consists of a silicone monofilament sheathed in four layers of polyester. It has the same consistency as the subcutaneous tissues, is impalpable and does not cut into the tissues. Its transformation into a ligament ensures that the result remains stable over time.
Excess fat in the lower and medial portions of both buttocks is drawn off by means of liposuction. If necessary, liposuction can also be carried out in the lower and lateral portions. In this patient, it is not necessary. In some patients, liposuction is performed immediately before the elastic threads are implanted. An antibiotic ointment is applied to the incisions and to the sticking plasters.
For a few months, the patient will need to wear "push-up" panties, which lift the buttocks. This lifting effect ensures that the threads and the tissues are not under tension and reduces post-operative pain. For a few days after the procedure, the patient will have to sleep face down or on her side, and sit on her ischial bones. She must also refrain from riding a bicycle or doing physical exercises that stretch the gluteal muscles.
The slight skin alterations will disappear within a few months. The buttocks appear rejuvenated and have a more pleasing shape. The results of basic elastic gluteoplasty can be further improved by means of liposuction and Adipofilling, which enhance the shape and symmetry of the buttocks, or even by implanting further elastic threads.
Capurro S. (2019): Elastic gluteoplasty with the Elasticum thread and Jano cannula under local anesthesia: basic procedure. CRPUB Medical Video Journal. Elastic Plastic Surgery section, www.crpub.org.
How does this new video publication differ from the previous 2013 publication Capurro S. (2013): Lifting the buttocks by means of the elastic thread and the two-tipped cannula through two 5 mm incisions. CRPUB Medical Video Journal. Elastic Plastic Surgery section.
First of all, only one entry incision is used in order to create both loops. The small incisions are made with an SM67 microsurgery scalpel, which is more precise than a number 11 blade.
Secondly, pre-tunnelling, which greatly facilitates the passage of the Jano cannula through the fibrous subcutaneous tissues of the buttock, had not yet been adopted. Thirdly, the elastic thread is soaked several times in dilute iodo-vinylpyrrolidone, and not in much more costly antibiotic solutions. Fourthly, the skin sutures are all absorbable. Finally, the new video publication clearly explains how to rotate the Jano cannula so as to change direction or to follow a curved pathway without shifting towards the surface. Indeed, as the cannula is rotated and the posterior tip becomes anterior, any shift towards the surface will result in a skin introflection, which must be avoided.
Was the elastic gluteoplasty in the video performed under local anesthesia?
Yes. Sometimes, we administer 10 drops of benzodiazepine to keep the patient calm. We carry out anesthetist-assisted local anesthesia only on request.
Is there any risk of infection?
There are always risks in this region. You have to disinfect the operating field thoroughly with iodo-vinylpyrrolidone and to prescribe antibiotic therapy, starting on the evening before the procedure. In addition, a mupirocin-based antibiotic ointment must be applied to all the incisions for a few weeks.
Finally, the patient must scrupulously maintain local hygiene by using specific products. She should also take a few days off work; going to work the day after the procedure will increase the risk of infection.
What needs to be done if there is an infection?
Infection is very rare. However, if it does arise, you have to follow the protocols on soft tissue infections. This normally means using two antibiotics: one for Gram-positive and one for Gram-negative bacteria. Locally, you can inject dilute teicoplanin or dilute gentamicin plus clindamycin, both with a small amount of lidocaine. If the infection tends to recur, despite antibiotic treatment, it will be necessary to remove the threads through two small incisions.
How do you treat post-operative pain?
The pain is subjective. At the end of the procedure, an analgesic can be injected: 1 mL of tramadol + ketorolac tromethamine. If the pain persists the following day, another 1 mL dose can be injected. For the next three days, the patient takes sublingual ketorolac tromethamine. If localised pain is still felt after these three days, intradermal neural therapy is implemented with procaine exactly at the point where the pain is felt. However, this eventuality is rare. We add a small amount of epinephrine to the procaine, to eliminate the vagal effects of this anaesthetic.
In any case, after a few days, the pain of gluteoplasty is tolerable.
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