**9. Gluteal contouring**

Contouring the gluteal area is synonymous with the Brazilian Buttock Lift (BBL). Fat has gained popularity in its use, as a method of adding volume to the gluteal area becoming one of the fastest growing procedures in aesthetic surgery, and it is often performed as an adjunct to body contouring [34]. In 1987, Toledo presented one of the first studies investigating fat transfer in buttock augmentation in the USA [35].

To reduce the risks associated with injecting fat in the buttocks, we inject the fat above the muscle using a 5 mm cannula approaching in an acute angle. This angle of approach makes it more difficult to penetrate the deeper gluteal muscles layer.

When transferring fat to the buttocks, it is of paramount importance to utilise handheld high-definition ultrasound to determine the plane and depth of injection.

In our practice, we do not utilise silicone implants to contour the buttocks as we see fat transfer to be a more practical and safer option when performed by appropriately trained Plastic surgeon/s [36].

In our opinion and the collective opinion of others, fat transfer is the gold standard for gluteal augmentation, as we feel it gives a natural look to the gluteal area with high patient satisfaction [37].

The procedure has been made even safer with the advent of handheld high-definition ultrasound, which gives a visual on the anatomical location, and depth of the transferred fat into the buttocks, thus avoiding the gluteal muscles and reducing risks of embolus and vascular origin complications [38–41].

In our practice, VASER is used when harvesting fat for BBL. BBL is usually the final stage of 360-body contouring. For simplicity of description, we had attributed the terminology the fourth dimension for this combination of surgery (**Figure 10**).

**Figure 10.**

*Twenty-four-year-old female. Six months following VASER 360 liposculpture of abdomen, flanks and back with 800 cc fat transfer each buttock area, Brazilian butt lift (BBL).*

The reason of leaving BBL to the end of the sequence of operative procedures is for avoidance of the patient being on her buttocks for the duration of a relatively lengthy surgery, thus avoiding unnecessary pressure on the transferred fat.

#### **10. Patient selection**

The criteria of patients' selection for body contouring are unchanged from our last published chapter in Enhanced Liposuction New Perspective and Techniques 2022 [42]. However, when we are considering fat transfer be it for breasts, abdomen or gluteal region, we take into account four criteria.

For the sake of clarity, we have listed these criteria as anatomical structures from the most superficial tissue layer to the deepest.

These criteria include:


Why is this important to us?

The skin plays a major role in outcomes. For example, if the skin quality is poor, then the skin may need further non-surgical tightening, one example is the use of monopolar radiofrequency. In our practice, we use INDIBA Deep-care as our monopolar radiofrequency device of choice for its ease of use with very low risks and almost non-existent downtime. If the skin has significant excess, then surgical removal is warranted, examples are mastopexy and abdominoplasty.

The liposuction of the deep fat is for the aim of debulking the envelope; however, liposuction of the superficial fat is for sculpturing it to re-create shadows and light reflections to a near perfect body contouring. When adding volume in the relevant space/s, we create the fourth dimension.

#### **11. Patient safety**

How do we uphold the highest safety levels when considering patients for body contouring including VASER liposculpture, fat transfer and excisional surgery?

This starts with patient selection and the appropriate surgery in addition to having the relevant instrumentations. Accurate planning is a prerequisite for successful cosmetic surgical outcomes. Precise meticulous execution of the surgical plan is paramount in achieving the best aesthetic outcomes.

Let us not forget in this equation that the surgeon's and team safety is equally as important as the patient. One simple example is the distance the surgeon's arm travels when performing a large volume liposculpturing procedure.

We calculated the distance travelled in 4–5 hours of 360-body contouring procedure could be in the region of 10 miles; however, if the height of the table is adjusted *Body Contouring and VASER Technology, the Fourth Dimension DOI: http://dx.doi.org/10.5772/intechopen.108935*

by few centimetres, this could reduce the distance the surgeon/s hand and upper limb travelled by ~25%.

One must remember that a surgeon's journey is 20–25 years in practice, and this type of surgery weighs heavily on his/her joints of the hand and upper limb in addition to the neck. Hence, one must protect the surgeon and the team as they experience the same stresses on their physique during such time intensive surgery with high concentration levels, and the environment must be relaxing and harmonious.

#### **12. Summary**

Selecting the right patient for the relevant procedure, using the appropriate instrumentations whilst having the necessary skills and expertise, is of profound importance. Additionally, it is a must to have a well-trained, cohesive team, which functions at the highest levels of governance.

These two factors will further contribute to patients' safety and good surgical aesthetic outcomes, whilst minimising risks and potential complications.

On the one hand, such provision of service must have at its foundation an ethical patient-centred approach.

On the other hand, aspiring to the continuous development of the team involved in the patient journey from the first point of contact and until discharge is of profound importance. This is the ethos on which we have built our practice.

### **Author details**

Ali Juma1 \*, Jamil Hayek<sup>2</sup> and Simon Davies3

1 Consultant Plastic Surgeon, The Clinic @51, Liverpool, United Kingdom

2 Plastic Surgeon, Hayek Clinic, Kaunas, Lithuania

3 Solta EMEA, Barcelona, Spain

\*Address all correspondence to: alijuma@me.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
