Buttock enhancement is one of the most popular cosmetic body procedures and the fastest growing operation due to its relative newness.  The most common method of buttock augmentation today is fat injections but the most predictable is that of inserting an actual implant. Implants do not resorb and provide a permanent result but they take greater surgical skill and experience to place properly and have a complication-free result.

The level of surgical difficulty of buttock implant augmentation was most recently illustrated by a story published in the New York News and video posted online. In this video, a women is shown revealing her buttock and demonstrating how she could rotate and flip her buttock implants with simple manual manipulation. Rotating the implant  from its round outer convex side to its flat inner side created quite a buttock deformity, clearly not the result she was hoping to get.

While the buttock implants were not infected or had any wound healing complications, how does such a result happen. In short, this case demonstrates numerous points about the use of buttock implants and how to use them properly…or in this case improperly.

First, the highest rate of long-term success of any synthetic implant placed in the body is when they are placed into deeper tissues. Having a thicker and more vascularized soft tissue is always a friend of an implant. The very fact that she can move or flip her implants around indicates that they are in a subcutaneous pocket. While this is the easiest place to put buttock implants, it is far from the best. The best location for buttock implants is in an intramuscular pocket. It is harder surgery to do and the recovery is longer, but the results are much better with lower risks of such problems as infection, fluid collections and implant displacement. Having breast implants in a subcutaneous pocket is one thing, but when you have to sit on your implants takes on a different level of stress on them.

Secondly, the size of her buttock implants is enormous. Big buttock implants, larger than 350cc or 400cc, can not be placed in an intramuscular pocket no matter how large the patient is. While patients often ask for large implants or the largest available, they do not really understand what they are asking for. It can be very impressive how much difference a 300cc or 350cc implant can make in an intramuscular location. While large buttock implants are manufactured (up to650cc), and they obviously are made based on surgeon demand, I see little reason for them. A very large buttock implant  not only stretches out the skin but causes fat tissue atrophy, potentially leaving the implant merely covered with skin. When this happens the implant can have great mobility, rotating around the pocket like a ball bearing.

Thirdly, and an unknown factor in this case, is the recovery process. It is critically important to let the tissues around the implant heal so a stable pocket is obtained. This is as true above the muscle as it is inside the gluteal muscle. The recovery from buttock implants should not be confused with that of breast implants. It is easily two to three times longer, particularly as it relates to significant physical activity. One should be prepared to have a recovery process that includes a month of no exercise and limited sitting. Patinets should not undergo the procedure unless one has a real commitment to the healing process. Getting a good capsule around the implants is a key to preventing the exact problem illustrated in this video.

Implants are the most reliable method of buttock enlargement but requires an experienced surgeon and a committed patient to get an uncomplicated and satisfying result.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The size and shape of the buttocks is an important part of the aesthetics of one’s body. The importance of size and shape varies amongst different cultures and ethnic groups. This has led to the popularity of buttock augmentation procedures, using either the insertion of an intramuscular implant or fat injections. Fat injections, known as the Brazilian Butt Lift, is the more popular due to its use of one’s own body tissues and the generous availability of donor material in most patients.

But regardless of one’s ethnic or racial background, a completely flat buttocks is not viewed as aesthetically desireable. Such a flat buttocks, and sometimes even an indented one, is prone to occur in those that are thin and lean. To no surprise, a thinner overall fat distribution in one’s body can lead to minimal fat over the buttocks as well. While the gluteal muscles are not small, much of buttock volume comes from the amount of fat between the skin and the muscles.

In the thinner woman who desires a buttock augmentation, specifically a Brazilian Butt Lift technique, the lack of sizeable donor material is a limiting factor. For very thin women, this procedure is an impossibility and an implant is the only treatment option. But moderately lean to average-size women may have a fat injection buttock technique if they recognize that the buttock size obtained will be more modest and always less than they ideally desire.

Case Study: This 31 year-old female had long been bothered by her flat buttocks. She had tried to build up her buttock size through different exercises but without success. She did have some excess fat on her stomach and around her waistline and wondered if this would be enough for a Brazilian Butt Lift. On feeling her stomach and flanks, it was felt that maybe a liter of fat aspirate could be obtained but not much more. She wanted to proceed with surgery as she did not want to have synthetic implants.

Under general anesthesia she first underwent liposuction harvest of the entire abdomen and flank regions in the supine position. A total of 1,150cc of aspirate was obtained after initial Hunstad infiltration. She was then turned over into the prone position where additional liposuction was done across the top of the buttocks, in the sacral triangle and below the buttocks in the infragluteal fold. This brought the fat aspirate to 1,275ccs.

The fat aspirate was processed by passing it through a sieve and draining off the excess fluid. This brought the concentrated fat amount to 450cc. Using an injection cannula, 225cc of the concentrated fat was injected into each buttock. The injection amount combined with surrounding buttock liposuction fat reduction gave her a visible amount of buttock enhancement.

When seen at her three month follow-up, her final result showed a slightly more rounded buttock shape and size. Her overall buttock shape was more pleasing even if it was not dramatically bigger.

An important question when considering the Brazilian Butt Lift is how much fat will end up being injected into the buttocks. As a general rule, expect only 1/3 to ½ at best ending up being the concentrated amount of fat available for injection. This means that one has to have at least a mimimum of 1,000cc to 1,200 available for removal. It is better that 1,500cc to 2,000cc can be harvested. When only 150cc to 250cc of fat is available for each buttock, the patient needs to appreciate that the buttock size gain will be modest. Some improvement will also come from the buttock sculpting obtained by the liposuction. It is the combination of both that creates the final result. In thinner women, the Brazilian Butt Lift is more of an overall buttocks reshaping effort than exclusively an augmentation outcome.

Case Highlights:

1) The results of fat injection buttock augmentation is limited by the size of the donor harvest areas. These come primarilyfrom the abdomen and hip rolls.

2) In thinner women, the enhancement of the buttock is contributed to as much by the surrounding fat reduction as the buttock size achieved by fat injection.

3) The Brazilian Butt Lift in thinner women is better thought as buttock reshaping than buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Enhancement of the buttocks has become enormously popular over the past decade. Most methods of cosmetic buttock surgery are perceived as that of increasing its size through either implants or, more commonlytoday, fat injections. But buttock enhancement is as much about contouring and reshaping as it is about size increase alone. Large poorly-shaped buttocks are far less appealing than slightly smaller ones that have a more desireable shape.

When evaluating the buttocks, it is best to see it as an anatomic structure with different areas as zones that can be modified. There are essentially six aesthetic zones to the buttocks which can be described as follows: zone 1 is the midline lower back/sacral area, zone 2 is the upper lateral region or low flanks often also called the muffin tops, zone 3 is the middle lateral region where the muscle inserts, zone 4 is the low lateral or greater trochanter area, zone 5 is the upper inner thighs, and zone 6 is the amount of buttock projection seen in the side view.

The relevance of these buttock zones is that they all represent areas of either reduction (liposuction) or augmentation. (fat injections) Zones 1 and 2 are the areas of greatest liposuction fat removal while zones 3, 4 and 6 are the primary areas of fat injection augmentation.

Improving buttock shape is more than just injecting a lot of fat all over the entire buttocks. Skillful reshaping by fat removal combined with fat augmentation is a more successful approach. In many patients, it just isn’t possible to place enough fat or have enough of it consistently survive to create a better shape by simple volume addition alone.

In improving the shape of the buttocks the contour of the hips is a key area. Buttock projection can look diminished when the hip and back area has a good thickness of fat. This obscures any appearance of an upper gluteal shelf. When liposuction is done to reduce the hip and back fat, an inward skin retraction occurs. This creates an inward indentation or concavity which can match the curve of the lower of the lower buttocks as it dips inward towards the posterior thigh. By so doing, the illusion of a greatee central buttock projection is created. This can be further enhanced by concurrent fat injections into this central mound. This is a good example of the ‘ying and tang’ approach to increasing any body contour. The combination is always better than either approach alone.

The survival of fat injections in the buttocks is always an issue of concern. While there are numerous methods of processing fat prior to injection, none have been shown to be better than another. Some method of concentration is important to eliminate excess oils and fluids. In the buttocks, unlike many other face and body areas where fat is injected, there is a choice of injecting into the subcutaneous fat layer, the muscle, or both. The buttocks have a large gluteus maximus muscle and most of the fat injected should be into it. This will ensure the most amount of injected fat survival due to the better intramuscular blood supply.

Buttock enhancement is best done through a combination of zonal liposuction reduction and intramuscular fat injections. This is best for those patients that have an excess of fat around the buttocks in the hips, back and waistline.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Enlargement of the buttocks has been one of the fastest growing procedures in body contouring over the past decade. While implants have been historically used for gluteal augmentation, the injection of fat has now become the most popular method. While fat injections have been used for numerous applications, mainly in the face, its use in the buttocks poses a new variable not seen elsewhere…the need for large volumes. Because of the need for large volume injections in the buttocks, new techniques and methods have evolved.

In the August issue of Plastic and Reconstructive Surgery journal, a 14 year experience of buttock fat grafting was published. The authors report the evolution of their buttock fat grafting technique over this period of time. The study was divided into three stages according to the infiltrated areas and the evolution of infiltration, stage I was infiltration into the upper gluteal region, stage II was infiltration into the upper and lower gluteal regions, and stage III included stage II location as well as the trochanteric and subgluteal regions. A total of 789 patients were treated over a 14 year period. In stage I, 492 patients received 120cc to 320cc of fat injections. In stage II, 132 patients received 210cc to 460cc of fat injections. In stage III, 165 patients received 220cc to 1,160cc of fat injections.

The relevance of this study is that they looked at postoperative complications with buttock fat injections including infection, fat necrosis, gluteal erythema and fat embolism syndrome. What they found was that the incidence of these complications was statistically higher and more serious in the stage I patients which, ironically, had the smaller volumes of fat injected. They concluded that the reason is the broader surface area of fat distribution. Rather than injecting just into one concentrated buttock area, it is much better both aesthetically and for survival of the fat to be placed over broader gluteal regions in different infiltration planes. Complications have decreased despite increasing the amount of fat injected because it is distributed in more extensive areas and in different layers which allows for better revascularization of more fat.

As buttock fat grafting has evolved, it has become apparent that there is a significant aesthetic component to it in the injection technique. While the harvesting and processing of the fat is important, how it is introduced into the buttocks is just as significant. There is definitely an artistic or sculpting skill in enhancing the buttocks with fat that is not easily taught. Incorporating an overall buttocks approach with multiple area enhancement produces better results. Sometimes the limiting factor is in how much fat the patient has to give based on their available donor sites. But it does not appear, as this study shows, that there is a limit to how much fat can be injected into the buttocks.

Buttock enhancement with fat, also known as the Brazilian Butt Lift, will remain a popular procedure even though its volume retention is not always completely predictable. Such variability is tolerated because there is also the body contouring benefits obtained from the liposuction harvest areas. While further refinements in its methods will undoubtably be achieved in the future, fat injection distribution over a broader gluteal area is a foundational technique.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Enhancement of the buttocks is most consistently done with a gluteal implant. Despite its predictable improvement in the size and shape of the buttocks, buttock implants are not without complications. Intramuscular implant placement makes recovery more uncomfortable and having to sit on the implant predisposes it to positional shifting and the formation of fluid collections and possible infection.
Because of these concerns, the alternative treatment of fat injections or free fat grafting has emerged. Fat grafting to the buttocks has numerous potential advantages such as the elimination of the need for a synthetic implant, the use of a patient’s own body tissues, an easier recovery with few limitations, a simultaneous benefit of cosmetic emhancement of the donor site, and a very low risk of bleeding or infection. All of these advantages of free fat fat grafting is counterbalanced by one significant disadvantage….an unpredictability of after surgery shape and size. How much fat survives and is retained is widely variable. No plastic surgeon can guarantee or predict with 100% accuracy how much fat will survive on a consistent basis. I prefer to inject no more than about 300cc per buttock as I think much volume than that results in greater volume loss.
The burning question through the past several decades is…how to make fat grafting work better. The injection technique is, of course, important but is only half of the answer. How the fat is prepared after harvest in the oeprating room is the other half. Everyone agrees that concentration is very important after harvest. This is the mechanical process of removing the liquids from the more solid fat components. Whether this is done by a centrifuge or passing the fat aspirate through a strainer or sieve are two methods of which one has not been proven to be better than the other. Additives to the fat are theoretically appealing but there is no universal magical additive. Currently, I add platelet-rich plasma (PRP) to the concentrated fat prior to injection. Whether this aids fat survival is not proven but since it is a product of the patient, there is no risk in so doing. PRP is a concentrate of a patient’s own blood done at the time of surgery. While there is no standardized amount of PRP to add to fat, I typically use 3cc of PRP per buttock graft site.
If a patient opts for buttock augmentation with fat injections, they must accept that the amount of fat that will survive is unpredictable. It may require more than one injection session to obtain the best result. Most fat grafting methods will not achieve the degree of volume enhancement that a gluteal implant will.
Dr. Barry Eppley

Indianapolis, Indiana

Gluteoplasty by Autologous Fat Injections

I have previously discussed buttock enlargement through the use of implants, known as implant or alloplastic gluteoplasty. Another popular option is buttock enlargement through the use of fat injections or transplants, known as autogenous gluteoplasty. Fat injections as a method for soft tissue volume enhancement is well known and has a good track history in the face where smaller amounts of fat are needed, usually in the range of 1 to 10ccs. In the buttocks, however, much larger amounts of fat are needed to make a significant size difference, usually in the range of hundreds of ccs per buttock.

Here in my practice in Indianapolis, I always discuss the merits of buttock implants vs fat injections for buttock enlargement. Fat injections to the buttocks have several advantages. First, it eliminates the need for a synthetic implant and all the inherest risks such as infection, implant malpositioning, and notoriously a seroma build-up or fluid collection. Second, the buttock enlargement operation is much simpler, less invasive and has less pain after surgery. Thirdly, the amount of recovery is dramatically different with no activity limitations after surgery unlike implants. Fourth, there is an added cosmetic bonus from the harvest at the donor site. Some other body area gets to be reduced at the same time, usually the abdomen, waistline, or thigh areas. A two-for-one bonus if you will.

However, despite these significant advantages, fat injections to the buttocks for enlargement has one big potential disadvantage. How much of the fat will survive and get the volume that was put in at the time of surgery? That is an unknown question. And the issue of volume retention of injected fat has persisted with the use of this fat technique since its inception. What we do know for certain is this; 100% of the fat will not survive. Somewhere in the range of 1% – 99% will be the amount of fat that will persist. In larger fat injection volumes, such as the buttocks (and there is no larger amount of fat that is injected anywhere), a good result is probably in the 50 – 60% range for most patients. Therefore, I always tell my patients here in Indianapolis this: I will over-correct with fat injections to the buttocks (I don’t think you can ever inject too much fat or get the buttocks too big as they will only hold so much) and be prepared that it will likely take more than one fat injection session to get the best volume improvement. Unlike a buttock implant, which remains the same after one surgery, fat injections to the buttocks are unstable and require more than one surgery to get close to the same result.

The most important question for patients who want to avoid a buttock implant by undergoing fat injections for buttock enlargement then is; is the price and recovery from possibly two surgeries better than having a buttock implant? That is a question that each patient has to decide on their own in consultation with their plastic surgeon.

Dr Barry Eppley

Indianapolis, Indiana