The Safe Gluteoplasty

Anatomic Landmarks to Predict the Superior and Inferior Gluteal Veins

Claude Muresan, MD; Jared M. Davis, MD; Andrea R. Hiller, MD; Brittany E. Patterson, BS; Christina N. Kapsalis, BS; Meghan F. Ford, MD; Eric W. Anderson, MD; Swapnil D. Kachare, MD, MBA; Ron Hazani, MD; Bradon J. Wilhelmi, MD, FACS


ePlasty. 2019;19(e8) 

In This Article

Abstract and Introduction


Objective: The increase in demand for gluteal fat grafting seen in recent years in the United States has not been met with an equal gain in knowledge of the perils of this anatomic territory. The purpose of this study was to identify anatomic landmarks that can be readily used by surgeons to identify the takeoff of the superior and inferior gluteal veins.

Method: Six fresh cadaveric gluteal specimens were dissected at the University of Louisville anatomy laboratory. A question mark incision was made for exposure, followed by identification of the sciatic nerve in the proximal thigh. This was traced retrograde to the sciatic forearm. The piriformis muscle was identified dividing the foreman into superior and inferior portions, which corresponded to the takeoff of the superior and inferior gluteal vessels, respectively. The distance of the gluteal vessels from the one-third point of a line from the mid-sacrum to the greater trochanter was measured.

Result: Our cadaveric dissection series demonstrated that the superior and inferior gluteal veins were on average 3.28 cm (2-5.9 cm) and 1.25 cm (0-3.5 cm) away from the point one third the distance from the mid-sacral border to the greater trochanter.

Conclusion: The mid-sacrum and the trochanter of the femur are the anatomic landmarks used to identify the large gluteal vein trunks. Understanding the location and trajectory of these deep gluteal structures with use of readily identifiable landmarks may assist surgeons in avoiding inadvertent injection of fat to these veins during fat grafting.


Gluteal augmentation with fat grafting is a procedure that has seen a dramatic increase in popularity in recent years, ranking 10th of all surgical procedures performed by members of the International Society of Aesthetic Plastic Surgery in 2016.[1] Similarly in 2016, the United States saw a 26% increase, more than 18,000 operations, from the prior year.[2] The aesthetic appeal of a small waist and full buttocks is far from a novel concept, as these features have been idealized by numerous cultures and ethnicities due to their association with female reproductive potential and physical well-being.[3,4] According to Wong et al,[5] the new ideal waist-to-hip ratio is 0.6 and 0.65 compared with 0.7, which represents a shift in preference to a "curvier" silhouette. Increased interest in gluteal augmentation has been fueled by a greater focus on body image due to modern fashion trends, such as thong swim suits, and popular media that sensationalize women with ample buttocks as the standard for beauty.[6,7] While patient satisfaction with gluteal augmentation is reportedly very high, the procedure is not without risks.[8,9]

As the number of gluteal augmentation procedures performed has increased, reports have surfaced linking a number of patient fatalities directly to gluteal fat grafting.[10–12] The first case report on fatal pulmonary fat embolism (PFE) due to gluteal fat grafting was published in the Journal of Forensic Sciences in 2015.[12] However, this complication did not gain widespread attention until Cárdenas-Camarena et al[10]published a retrospective study reporting 22 deaths in Mexico and Columbia over a 15-year period attributed to PFE after gluteal fat grafting. Because of increasing awareness of significant patient morbidity and mortality, the Aesthetic Surgery Education and Research Foundation (ASERF) formed a task force to examine the risk of PFE associated with gluteal fat grafting. Their data suggest the annual mortality rate from PFE secondary to gluteal fat grafting to be 1:3448, although they estimate the actual mortality rate may be as high as 1:2351 or greater.[11]

To avoid PFE during gluteal fat augmentation, it is imperative that plastic surgeons have a deep understanding of both the technique and gluteal anatomy, particularly gluteal vein trajectory.[3,13] There is still much debate regarding the safest technique for gluteal augmentation.[13,14] While there have been descriptions of large "danger areas" to avoid during gluteal augmentation, these zones often encompass 40% or more of the gluteal surface, making enhancement challenging, if not impossible, with complete avoidances of the areas. Furthermore, having a danger zone so large defeats the purpose of alerting the operator to a precise area peril.[9,15] Our study aims to identify simple and reproducible exterior anatomic landmarks for identification of the superior and inferior gluteal veins. With reliable landmarks, surgeons can proceed with an increased awareness of this precise "danger zone" and reduce the risk of inadvertent injection of fat into the gluteal vessels during buttock augmentation with fat grafting.