Gluteoplasty Research Articles

Sciatic Nerve Transection Following Prosthetic Buttock Augmentation: First Reported Case and Review of the Literature

Abstract Gluteal augmentation is typically carried out by implant placement or autologous fat grafting. Over recent years, there has been a significant increase in the number of gluteal augmentations being performed. However, as the number of procedures has increased, so too have the number of complications. We present a case of a 33-year-old female with an implant infection with concomitant sciatic nerve transection following bilateral gluteal augmentation with implants leading to a permanent foot-drop. While transient sciatica due to compression has been described as a complication of gluteal augmentation, this is the first reported case, to our knowledge, of transection. The many unusual management decisions that had to be made when faced with this rare and devastating complication are highlighted and the relevant literature on gluteal augmentation is discussed. Patients and surgeons alike need to take particular care when considering this procedure.

Multidisciplinary Experience for Gluteal Fat Grafting.

Gluteal fat grafting, colloquially known as Brazilian Butt Lift, has experienced a significant rise in popularity in recent years. Despite this increase, potential complications associated with the procedure have also been observed, necessitating a thorough examination of the current practices and outcomes. This study collected experiences of a multidisciplinary group of surgeons through a detailed survey sent in April 2022. This study aimed to shed light on the practices employed by these surgeons, the frequency and types of complications they encounter, and the overall outcomes of their procedures. Of the 100 surgeons surveyed, 86 responded. The study identified that pulmonary fat embolism (PFE) was the most serious complication, with fatality due to PFE recorded at a rate of 1:23,878. Liposuction site seromas were the most common complications, with an overall rate of 2.45%. Although there were no overall differences in complications between plastic and non-plastic surgeons, plastic surgeons were found to have a sixfold increase in the odds of experiencing a liposuction seroma. The survey also revealed substantial practice variations, particularly regarding fat preparation methods, recipient-site preparation, antibiotic use, and postoperative care protocols. Despite known complications, a strong tendency to continue performing these procedures was observed among surgeons, demonstrating the sustained demand and acceptance of the procedure. This study underscores the need for continued surveillance and research to enhance the safety and effectiveness of gluteal fat grafts. The experiences and data gathered from practicing surgeons provide valuable insights, paving the way for refining techniques, building consensus, and facilitating informed discussions with patients about the risks and benefits of the procedure. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Subcutaneous Washout Procedure (SWOP) for Treating Severe Complications of an Aesthetic Gluteal Augmentation with a Copolyamide Filler

Apart from surgical procedures for breast and buttock augmentation, copolyamide fillers can be locally injected for an increase in volume. This method is especially popular in Asia. A 39-year-old female patient had received a buttock augmentation by injection of a copolyamide filler. She presented with multiple abscesses six years after the augmentation. She had developed multiple fistulas and the filler had migrated down to the thigh muscles. In the presented case, the patient experienced multiple complications such as abscess formation, filler migration and chronic infection, with a significant time delay. Complete removal of the filler is only possible by removing surrounding tissue as well. Surgical treatment with repeated debridements and administration of an intravenous broad-spectrum antibiotic are the current standard of care. In contrast, the SWOP technique presented here appears to be less invasive and less likely for local recurrence. A breast or buttock augmentation with copolyamide fillers is associated with a high risk of abscess and fistula formation leading to a permanent disfigurement of the patient.

Black women, Brazilian butt lifts and body image: A qualitative study on the role social media play in promoting the thick ideal

Black women, Brazilian butt lifts and body image: A qualitative study on the role social media play in promoting the thick ideal

Brazilian Butt Lift: An Experience Over 3000 Patients.

The Brazilian Butt Lift (BBL) is a safe technique that entails body reshaping through buttock augmentation using autologous fat transfer. Between 2018 and 2022, 3000 patients underwent surgery. Each procedure commenced with the patient in supine position, starting with abdominal liposuction, followed by fat transfer to hips. Subsequently, the patient was repositioned to a prone stance. Liposuction of the back and waist ensued, concluding the surgery with fat transfer to the buttocks. Stringent precautions were implemented to ensure the safety of the patient throughout the procedure. Eighty-six percent of patients express satisfaction with their outcomes, while seventy percent of the transferred fat calls survive in the buttocks. One serious complication and some minor complications have been encountered and effectively managed through conservative measures. BBL proves to be a safe and satisfactory surgery when performed by experienced surgeons who adhere to fundamental principles. LEVEL OF EVIDENCE 3: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Buttock Augmentation with Ultrasonic Liposuction and Ultrasound-Guided Fat Grafting: A Retrospective Analysis Based on 185 Patients.

Background: The popularity of gluteal augmentation has surged in recent decades, primarily due to satisfactory aesthetic results. Objectives: The primary goal of this retrospective analysis was to present the key characteristics of a large patient cohort from Europe, comprising 185 female patients who underwent gluteal augmentation with ultrasound-guided fat grafting. Methods: A retrospective analysis was conducted on 185 female patients who underwent gluteal augmentation with ultrasonic liposuction and fat grafting from February 2020 to July 2023. The procedures were performed in accordance with the latest safety recommendations. Results: Information concerning the patient demographic, volume of fat graft, and complications was analyzed. Additionally, patient satisfaction was evaluated through a questionnaire. The mean Body Mass Index (BMI) of the patients was 23.00 kg/m2 (SD = 2.62). Furthermore, the volume of transferred fat graft ranged from 500.00 mL to 800.00 mL, with a mean of 596.75 mL (SD = 67.29). The most frequent complication was the formation of seroma (5.41%). All complications were treated successfully. Conclusions: Using ultrasonic liposuction and ultrasound-guided fat grafting to enhance buttock contours is a reliable technique. Nevertheless, it is crucial to exert caution and take all necessary steps to reduce the risk of potentially life-threatening complications.

Gluteal Fat Grafting Technique and Mortality Update Among Surveyed ABCS Surgeons

Background: The demand for gluteal fat grafting (colloquially known as Brazilian butt lift [BBL]) has seen a dramatic increase in the past decade. Brazilian butt lift has been the fastest-growing cosmetic procedure in the United States for several years. During this time, the incidence of pulmonary fat embolisms (PFEs) associated with this procedure has raised safety concerns. Several professional organizations have responded to these concerns with investigational reports to identify the causes and provide recommendations to decrease the mortality associated with this popular cosmetic procedure. Awareness and implementation of these safety recommendations have been a cornerstone to decreasing the mortality rate associated with gluteal fat grafting. Objectives: To provide a comparison of current technical approaches and a mortality update on gluteal fat grafting among surgical members from the American Board of Cosmetic Surgeons (ABCS) within the last 6 years. Also, to determine if specific technical changes in the manner this procedure is performed are improving safety. Methods: An online (emailed) survey regarding perioperative gluteal fat grafting techniques and postoperative outcomes performed by ABCS surgeons within the previous 3 years was collected in 2 different 3-year time frames. Initial data were collected in 2019 for the preceding 3 years 2016-2019. The survey was again repeated in 2022 to collect similar data as before from ABCS member years 2019-2021. The data, which included the total # of BBLs performed, incidence of major infection or fat emboli, cannula size, and injection methods details was compared for each 3-year period. Both sequential studies provided a comparison of the techniques employed as well as morbidity and mortality outcomes. Results: Sixty-four ABCS surgeons who reported performing BBLs responded to the survey in 2019 and reported performing a total of 22 800 (BBLs) gluteal fat grafting cases in a previous 3-year window from 2016 to 2018. More surgeons used a closed system peristaltic pump in the second part of the study as compared to the first (51% vs 22%) ( P < .01). Two cases required in-hospital treatment of infection in the first survey while zero cases were reported for the second survey period ( P = .07). Twenty-five of 64 (39%) reported injecting fat at least into superficial gluteal muscle during this earlier time frame. In this earliest study, there were 3 total cases of PFE reported (2 fatal PFEs and 1 nonfatal PFEs). In 2022, 85 ABCS surgeons who reported performing BBLs responded to the survey. Around 12 172 gluteal fat grafting cases were reported in the second 3-year study from 2019 to 2021 compared to 22 800 in the first study ( P < .01). There was a total of 34 972 BBLs during the entire 6-year study. Most surgeons (82 of the 85) in the second-phase 3-year study reported injecting fat “exclusively” above the muscle ( P < .01). There were no fatal and non-fatal PFEs reported in the follow-up 3-year study in 2022 of ABCS member data from 2019 to 2021 ( P = .03). Conclusions: The mortality report associated with gluteal fat grafting from this survey among surgical members of the ABCS suggests using the current safety recommendations proposed, including injection of fat in the subcutaneous layer only, have led to a decreased risk of PFEs associated with gluteal fat grafting. The mortality rate was zero (0 out of 12 800) when 96% were injecting above muscle only compared to a mortality rate of 1:11 400 (2 of 22 800 cases) when 39% of 22 800 BBLs performed had fat injected into muscle. While there were more BBLs performed during the earlier 3-year study ( P = .07). The mortality rate significantly decreased in the years when only a small minority of cases had fat injected into the muscle. This study adds to other existing literature from professional organizations’ reports on the safety of gluteal fat grafting using the proper safety measure and recommendations.

Abdominoplasty, Liposuction and Brazilian Butt Lift (BBL) in Kinshasa in the Democratic Republic of Congo. My Experience in This Aesthetic Plastic Surgery with Black African Women in a Low-Income Country

Abdominoplasty, Liposuction and Brazilian Butt Lift (BBL) in Kinshasa in the Democratic Republic of Congo. My Experience in This Aesthetic Plastic Surgery with Black African Women in a Low-Income Country

Plastic Surgery Tourism: Complications, Costs, and Unnecessary Spending?

The liability of plastic surgery tourism in patient health and postoperative resource allocation is significant. Procedures completed within the context of medical tourism often lack rigorous quality assurance and provide limited preoperative evaluation or postoperative care. Not only does this jeopardize the patient's well-being, but it also increases the financial burden and redirects invaluable resources domestically through often unnecessary diagnostic tests and hospitalizations. This manuscript will examine the complications and associated costs following plastic surgery tourism and highlight unnecessary expenses for patients with outpatient complications. A retrospective review was conducted of all patients 18 years or older who underwent destination surgery and were seen within 1 year postoperatively in consultation with plastic surgery at our health system between January 11, 2015 and January 7, 2022. Patient admissions were reviewed and deemed necessary or unnecessary after review by 2 physicians. The inclusion criteria were met by 41 patients, of whom hospitalization was deemed necessary in 28 patients vs unnecessary in 13 patients. The most common procedures included abdominoplasty, liposuction, breast augmentation, and "Brazilian butt lift." The most common complications were seroma and infection. Patients deemed to have a necessary admission often required at least 1 operation, were more likely to need intravenous antibiotics, were less likely to have the diagnosis of "pain," necessitated a longer hospitalization, and incurred a higher cost. The total financial burden was $523,272 for all 41 patients. Plastic surgery tourism poses substantial health risks, the morbidities are expensive, and it strains hospital resources.

Complications From Fat Grafting and Gluteal Augmentation in Outpatient Plastic Surgery: An Analysis of American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, QUAD A) Data.

Gluteal augmentation with autologous fat grafting, colloquially referred to as Brazilian butt lift (BBL), is an increasingly common procedure with a highly reported complication profile. In this study we aimed to analyze the prevalence and characteristics of complications that accompanied these surgeries at ambulatory surgery facilities. Adults patients who experienced fat grafting complications from 2019 to 2021 were identified in QUAD A, formerly known as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, Highland Park, IL, USA), database. Patients and complications were analyzed based on sociodemographic, surgery-, and facility-specific variables with descriptive statistics and logistic regression. Overall, 436 fat grafting procedures with complications were reported to QUAD A, with an overall complication rate of 0.94%. Of these complications, 164 (37.6%) were confirmed to be from gluteal augmentation procedures. Notably, the number of gluteal augmentation with fat grafting complications decreased from the year 2019 (48) to 2020 (36), then nearly doubled from 2020 to 2021 (69). The majority of patients were female (96.7%), with a mean age of 42.0 years and a mean BMI of 28.3 kg/m2. Wound infection was the most commonly documented complication (22.3%). Of the patients who experienced complications, 35.9% presented to a hospital for their complications and 12.6% required reoperation. Four deaths were described. There was no association between sociodemographic or surgical variables and increased odds of readmission or reoperation (P > .05), except for increasing surgeon number and reoperation (P = .02). Gluteal augmentation accounts for a large proportion of complications from fat grafting procedures. Increased reporting requirements may aid in future determination of incidences of complications and improve patient safety.

The Buttock Lift with Hyaluronic Acid and Threads

The Buttock Lift with Hyaluronic Acid and Threads

Gluteoplasty With Lumbar Gluteal Flap Associated With Liposuction and Fat Grafting: A Safe Technique for Massive Weight Loss Patients.

Weight loss leads to excessive flaccidity, volume loss, and tissue descent in the gluteal region. Translated autologous flaps during lower body lifting have been utilized in patients; they address sagging tissue and the lack of volume. However, sometimes use of these autologous flaps does not provide adequate gluteal projection, and a second procedure with fat injection may be required. The authors describe their technique of a lower body lift with a lumbosacral flap in association with liposuction and lipofilling for gluteoplasty. A prospective series of 23 post-bariatric surgery individuals who underwent a lower body lift with lumbosacral flap gluteal augmentation, liposuction, and lipofilling between January 2021 and September 2022 were described. The satisfaction rate and complications were assessed 6 months postoperatively with a validated questionnaire (BODY-Q scale). The patients had a mean age of 38.18 (range, 28-56 years) and median body mass index of 26. Four patients with dehiscence were diagnosed and treated conservatively. All wound breakdowns were observed in the paramedian plane of the torsoplasty. No reoperations were performed. The mean satisfaction percentage of the BODY-Q scale transformed score was 97.5. A technique for a lower body lift with buttock augmentation combined with liposuction and fat grafting was presented. In future studies other techniques to maximize gluteal contouring should be investigated.

FRI695 Hypercalcemia Mediated By Granulomatous Disease Due To Polymethylmethacrylate (pmma) Injection Utilization For Gluteal Augmentation

Abstract Disclosure: T. Mishra: None. J. Craven: None. Introduction: While etiologies for hypercalcemia commonly include hyperparathyroidism, malignancy or vitamin D intoxication, unusual causes should also be considered. We present a case that describes a patient who presented with hypercalcemia in the setting of granulomatous reaction to PMMA filler for gluteal augmentation. Clinical case: A 52 year old female with a past medical history of hypertension, stage III chronic kidney disease, nephrolithiasis, depression was admitted to the hospital with a peak calcium of 15.8 mg/dl (n: 8.4-10.4mg/dl). Hypercalcemia was incidentally noted while she was undergoing workup for her chronic kidney disease. Initial testing revealed PTH of 22 pg/ml (n: 22-94). 25 hydroxy vitamin D 24ng/ml, (n: 30-80), 1, 25 dihydroxy D2 markedly elevated at 258 pg/ml (n: 19-79). SPEP/UPEP normal. PTHrp was found to be 5.9 pmol/L(n: 0-3.4pmol/L). High-resolution CT chest did not show evidence of granulomatous disease or lung masses. A PET scan was obtained which showed extensive hypermetabolic activity in the bilateral gluteus medius and maximus muscle consistent with her history of PMMA injection for buttock augmentation. She was placed on aggressive maintenance intravenous fluid hydration. In addition, Lasix, zoledronic acid and calcitonin were administered. With these measures her calcium improved to a level of 10.7mg/dl. She did not tolerate high dose glucocorticoids. With her treatment intolerance and progressive renal disease in mind, plastic surgery has been consulted to explore surgical options for PMMA debulking. Conclusion: This represents a case of hypercalcemia mediated by elevated levels of calcitriol due to granulomatous inflammation caused by a foreign body reaction to PMMA injection. Polymethylmethacrylate is primarily used in South/Central America as a synthetic filling agent in cosmetic procedures, but is not FDA approved for gluteal injection. To our knowledge, there is only one other case report of MMA mediated hypercalcemia in the US. Given the rise in cosmetic tourism and the lag time between PMMA injection and development of hypercalcemia (mean time to presentation of 7 years), this complication is likely to become increasingly prevalent in North America. Presentation: Friday, June 16, 2023

Interdisciplinary aspects of abdominal and plastic surgery- what does the (abdominal) surgeon need to know?

The aim was to reflect the established interdisciplinary aspects of general/abdominal and plastic surgery by means of a narrative review. Methods: (i) With specific references out of the medical literature and (ii) own clinical and perioperative as well as operating technical and tactical management experiences obtained in surgical daily practice, we present a choice of options for interdisciplinary cooperation that could be food of thought for other surgeons. - Decubital ulcers require pressure relieve, debridement and plastic surgery coverage, e.g., by a rotation flap plasty, V-Y flap or"tensor-fascia-lata"(TFL) flap depending on localization (sacral/gluteal defects, ischiadic tuber).-Coverage of soft tissue defects, e.g., after lymph node dissection, tumor lesions or disturbance of wound healing can be managed with fasciocutaneous or muscle flaps.-Bariatric surgery: Surgical interventions such as butt lift, tummy tuck should be explained and demonstrated in advance and performed commonly after reduction of the body weight.-Abdominoperineal rectum extirpation (APE): Holm's procedure with greater circumferential extent of resection at the mesorectum and the insertion site of the levator muscle at the anal sphicter muscle resulting in a substantial defect is covered by myocutaneous flap plasty.-Hernia surgery: Complicated/recurrent hernias or abdominal wall defect can be covered by flap plasty to achieve functional reconstruction, e.g., using innervated muscle. Thus, abdominal wall can respond better onto changes of pressure and tension.-Necrotising fasciitis: Even in case of suspicious fasciitis, an immediate radical debridement must be performed, followed by intensive care with calculated antibiotic treatment; after appropriate stabilization tissue defects can be covered by mesh graft of flap plasty.-Soft tissue tumor lesions cannot be resected with primary closure to achieve appropriate as intended R0 resection status by means of local radical resection all the time-plastic surgery expertise has to be included into interdisciplinary tumor concepts.-Liposuction/-filling: Liposuction can be used with aesthetic intention after bariatric surgery or for lipedema. Lipofilling is possible for reconstruction and for aesthetic purpose.-Reconstruction of lymphatic vessels: Lymphedema after tumor operations interrupting or blocking lymphatic drainage can be treated with microsurgical reconstructions (such as lympho-venous anastomoses, lympho-lymphatic anastomoses or free microvascular lymph node transfer).-Microsurgery: It is substantial part of modern reconstructive plastic surgery, i.e.,surgery of peripheral nerves belongs to this field. For visceral surgery, it can become important for reconstruction of the recurrent laryngeal nerve.-Sternum osteomyelitis: Radical debridement (eventually, complete sternal resection) with conditioning of the wound by vacuum-assisted closure followed byplastic surgery coveragecan prevent chronification, threatening mediastinitis, persisting infectious risk, long-term suffering or limited quality of life. The presented selection of single topics can only be an excerpt of all the options for surgical cooperation in daily clinical and surgical practice. An interdisciplinary approach of abdominal and plastic surgery is characterized bya highly developed cooperationin common surgical interventions including various techniques and tactics highlighting the specifics of the two fields.

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli. This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures. An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform. The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality. Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

Office-based anesthesia: a contemporary update on outcomes, incentives, and controversies.

The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies. Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates. The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery.

Aesthetics across cultures: implications for practitioners in multicultural Britain

From rhinoplasties to tanning, and from buttock augmentation to eyelids, this comment piece looks at aesthetics perspectives across cultures and what they may imply for cosmetic practitioners in multicultural Britain

Infectious and Noninfectious Complications After Gluteal Augmentation Surgery

Abstract Public demand for gluteal autologous fat grafting, also known as a “Brazilian butt lift,” has increased over time, but these surgeries are not without risk of complications. Surgical infections range from 1.9% to 5% of the total complication rate for gluteal augmentation, including both superficial and deep infections. We present a case of Staphylococcus lugdunensis infection after gluteal autologous fat grafting and review the literature to discuss pertinent infectious and noninfectious complications of this procedure. Staphylococcus lugdunensis is a common cause of skin and soft tissue infections and is probably underrated by many doctors and laboratories. Hence, S lugdunensis should be accepted as a significant pathogen in skin and soft tissue infections and should be looked for in all routine bacteriological examinations, and clinicians should be able to be acquainted with the name and the pathology of the bacterium. With increasing popularity of fat grafting for buttock augmentation, it is more important than ever to continue researching and learning to safeguard the satisfaction and safety of our patients.

New Data Show Board-Certified Cosmetic Surgeons Safely Performing Brazilian Butt Lift Surgery

New Data Show Board-Certified Cosmetic Surgeons Safely Performing Brazilian Butt Lift Surgery

Subfascial/Intramuscular Dual-Plane Gluteal Implantation and Supplemental Fat Grafting: A Novel Technique for Buttock Augmentation.

Much debate exists within the current literature as to which plane is safest and most effective for gluteal implant buttock augmentation. A novel subfascial/intramuscular (SF/IM) dual-plane technique appears to combine the benefits of each plane. The aim of this study was to describe our experience with SF/IM plane gluteal implantation, and to discuss its indications, efficacy, and safety, and offer recommendations on its proper use. A retrospective chart review was conducted of 175 consecutive cases of gluteal augmentation with solid silicone implants in the SF/IM pocket, with and without supplemental autologous fat transfer. Outcomes from all patients were analyzed to determine the rate of complication and need for surgical revision. In 175 cases of bilateral buttock augmentation with gluteal implantation using the SF/IM pocket, the most common complication was infection. This complication was seen in 13 cases (7.43%), 7 (4%) of which were superficial and did not require surgical intervention. Other complications included dehiscence, seroma, capsular contracture, and implant migration. The SF/IM gluteal implantation, in combination with liposculpture and autologous fat transfer into the overlaying subcutaneous space, allows for a durable cosmetic augmentation of the buttocks in patients lacking sufficient volume for augmentation with fat transfer alone. This technique was found to have complication rates similar to those of other established augmentation techniques, as well the cosmetic advantages of a large, stable pocket with thick, soft tissue coverage of the inferior pole.