**6.2 Gluteal implants**

First, the patient's upper and lower gluteal crease are marked. Then, the patient is asked to sit down to mark a horizontal line when the buttocks is touching the chair. The skin marking are made with a custom-designed template. The template fits perfectly into the gluteal area just above the horizontal line previously marked on the skin. Medial extend of the implant is ~2 cm lateral from the external rim of the sacral bone. Once the patient has been put under general anesthesia, foot pumps are applied for deep vein thrombosis prophylaxis and 2 g of cefazolin (Ancef) is given. If allergic to penicillin, clindamycin 600 mg IV is given as antibiotic prophylaxis.

Next, the skin is prepared in a normal sterile fashion and tumescent anesthesia is infiltrated into the sacral and gluteal areas. One single, vertically oriented, 6 cm incision is made in the midline of the sacral region in the intergluteal crease. The incision is made through skin, subcutaneous tissue and proceeds laterally until the lateral borders of the sacral bone and the medial border of the gluteal maximus is identified. A 4–6 cm incision is made intramuscularly blunt dissection is then performed intramuscularly laterally, caudally and in a cephalad direction to create the implant pocket.

 This is performed bilaterally. The implants are then introduced into the pocket through the small incisions using a plastic funnel (**Figure 20**). The position of the implant is verified with palpation and the aesthetics of the augmentation is assessed from multiple angles. The implant can be adjusted slightly up or down to a limit. Often, a Latino female may want her implants slightly lower than what would be preferred by an African American female (**Figure 21**). Next, the implants are secure in place using a non-resorbable suture to the underlaying fascia. Layered closure is followed.
