55. Local anesthesia in elastic gluteoplasty
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 EP4 Elasticum thread and the two-tipped Jano cannula (Korpo).
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.
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.
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 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 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.
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. 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. (2022): Local anesthesia in elastic gluteoplasty CRPUB Medical Video Journal. Elastic Plastic Surgery section. www.crpub.org.
What further evolutions has elastic gluteoplasty had?
In addition to the standardization of local anesthesia, a third thread is sometimes implanted. The upper circle has a good persistence of the effect. The lower circle sometimes does not keep the given shape perfectly because the thread is longer. To overcome this phenomenon we can use safety pins, already used in elastic neck lifts. The pins keep the elastic threads of the two circles out of the tissues at the point where the two circles separate. A 3-0 polyester suture joins the two elastic threads. In this way the compacting structure of the soft tissues is consolidated. The third thread can also be joined to the other threads, using the safety pins, to consolidate the containing structure of the elastic gluteoplasty.
Another innovation is the replacement of the microsurgical scalpel with a 16G or 14G needle. The holes made by the needles do not leave any scars. 16 G needles are also used in elastic rhinoplasty, elastic canthopexy, elastic cheek lifting, etc.
What advice do you give to colleagues who wish to carry out this intervention?
I recommend to see the previous video publications for the execution modalities.
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