Gluteal Augmentation and Enhancement of the Female Silhouette: Analysis and Technique

Gluteal Fold: Cadaveric Dissection of the Superficial Fascial System in the Buttock and Anatomy-Based Gluteal Liposculpture

BACKGROUND

The anatomy and formation mechanism of the gluteal fold (GF) remain unclear. Given that understanding the anatomy of the superficial fascial system (SFS) may facilitate the improvement of liposuction techniques, this study aimed to clarify and define the anatomical components of the GF.

METHODS

A total of 20 fresh female buttocks and thighs were dissected sagittally to observe the changes of the SFS along the GF and were dissected horizontally to observe the SFS on the upper, middle, and lower levels of the buttock.

RESULTS

Through these dissections, 2 patterns of the SFS in the GF region were identified. The retinaculum cutis (RC)-dominant SFS, named the fascial condensation zone, features an extremely dense and tough RC, originating from the bony structures (eg, the ischium) and radially anchored by the dermis. The fat-dominant SFS features a classic double-layered SFS structure. The RC-dominant SFS is mainly distributed at the medial GF, thus forming the depressed fold. It gradually disappears along the GF and the SFS becomes fat-dominant, making the fold increasingly less visible. At the lateral buttock, the SFS of the buttock and thigh reach an identical status in terms of morphologic features, showing a smooth curve between the buttock and the thigh instead of a fold. Thus, based on these findings, different liposuction methods were formulated to manage GF contouring.

CONCLUSIONS

The SFS of the GF region shows a regional variation pattern. Topographic anatomy of the SFS in the GF region helps us understand GF contour deformities and provide an anatomical basis for surgical correction.

A Bibliometric Analysis of the Top 100 Papers on Gluteal Augmentation

Background

Gluteoplasty or gluteal augmentation is a popular cosmetic procedure that is used to improve the volume, shape, and contour of the buttocks.

Objectives

This bibliometric analysis aims to characterize emerging research trends and to assess the methodological quality of the highest impact gluteoplasty research.

Methods

The 100 most-cited publications in gluteoplasty were identified on Web of Science, across all available journal years (from Inception to August 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence Based Medicine level of evidence (LOE) of each study was assessed.

Results

The 100 most-cited publications regarding gluteoplasty were cited by a total of 2375 publications. Citations per publication ranged from 5 to 176 (mean 23.75 ± 25.86), with the highest-cited study being authored by Simonacci, discussing autologous fat grafting (n = 176). Most publications were LOE 5 (n = 55), representative of the large number of case series and reports. The number of publications for LOE 1, 2, 3, and 4 was 1, 9, 13, and 22, respectively. The main content focus was "surgical technique" in 38 publications, followed by "outcomes" (n = 34) and "risk factors/prognosis" (n = 10). Patient-reported outcome measures (PROMs) were used in 20 publications, and 33 publications reported aesthetic outcome measures.

Conclusions

This analysis demonstrates a need for improvement in research methodologies regarding gluteoplasty research. This advancement would be facilitated by robust, high-quality research through randomized control trials and multicenter studies, as well as the further development of validated PROMs for gluteoplasty.

Level of Evidence 2

Analysis of the Thigh Aesthetic Profiles: One of Physical Ideal Body Proportions

BACKGROUND

The contour of the thigh is increasingly being recognized as crucial component of the ideal human physique, giving rise to heightened interest in attaining the perfect thigh profile. Notwithstanding, the contemporary landscape of cosmetic surgery appears to be bereft of efficient and precise objective methodologies to evaluate the outcomes of thigh contouring treatments. The present study is aimed to investigate the aesthetic appeal of varying thigh contours, employing specialized software as an indispensable instrument for quantitative and qualitative analysis.

METHODS

Standardized photographs of the lower body were obtained from a sample of 200 healthy volunteers. A linear analysis was conducted, examining aspects such as the vertical length and transvers width of the thigh, as well as angular measurements including the posterior gluteal angle (PGA) and lateral angle thigh (LAT). Variables relating to thigh measurements and body mass index (BMI) were documented, with the relationships between them ascertained through Pearson's correlation and regression analysis.

RESULTS

In males, the LAT was measured at 168 ± 3.9, and the PGA at 170 ± 3.4, while in females, these measurements were 166 ± 2.8 ve 166 ± 2.8, respectively. Linear analyses, including the vertical length of thigh (VLT), transverse width of thigh (TWT), lateral width (LW), and posterior width (PW), were conducted. Based on the LW inferior/LW superior ratio values, the most commonly observed thigh types were Type III (0.90) at 45% and Type II (0.85) at 24.75% while the least common was Type V at 4% (0.99). PW inferior/PW superior was 84.7%. The PWI/PWS ratio was highest for Type V, at 0.99, accounting for 84.70% of the total. Furthermore, an increase in the LWI/LWS ratio leads to an increase in the PWI/PWS ratio.  The frequency of the VLT/TW1 ratio 0.31-0.35 (Type 3) was found to be on the left side and Type 4 on the right side. A strong correlation was found between BMI and all thigh indexes, with a significant positive correlation between the index and factors tied to the buttocks and upper thigh.

CONCLUSIONS

The concept of an ideal thigh may vary based on an individual's gender, race, country of residence, and self-esteem, aiming to achieve a more natural silhouette. Focusing on the different ratios of hip and thigh varieties in the study is quite intriguing. Further inquiry and rigorous exploration are warranted to delineate the optimal techniques and methodologies for attaining ideal thigh proportions.

LEVEL OF EVIDENCE IV

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 .

Augmented Safety Profile of Ultrasound-Guided Gluteal Fat Transfer: Retrospective Study With 1815 Patients

BACKGROUND

Gluteal augmentation with autologous fat transfer is one of the fastest growing aesthetic surgical procedures worldwide over the past decade. However, this procedure can be associated with high mortality from fatal pulmonary fat embolism events caused by intramuscular injection of fat. Ultrasound-guided fat grafting allows visualization of the transfer in the subcutaneous space, avoiding intramuscular injection.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of gluteal fat grafting performed with ultrasound-guided cannulation.

METHODS

A retrospective chart review of all patients undergoing ultrasound-guided gluteal fat grafting at the authors' center between 2019 and 2022 was performed. All cases were performed by board-certified and board-eligible plastic surgeons under general anesthesia in ASA Class I or II patients. Fat was only transferred to the subcutaneous plane when over the gluteal muscle. Patients underwent postoperative follow-up from a minimum of 3 months up to 2 years. Results were analyzed with standard statistical tests.

RESULTS

The study encompassed 1815 female patients with a median age of 34 years. Controlled medical comorbidities were present in 14%, with the most frequent being hypothyroidism (0.7%), polycystic ovarian syndrome (0.7%), anxiety (0.6%), and asthma (0.6%). Postoperative complications occurred in 4% of the total cohort, with the most common being seroma (1.2%), local skin ischemia (1.2%), and surgical site infection (0.8%). There were no macroscopic fat emboli complications or mortalities.

CONCLUSIONS

These data suggest that direct visualization of anatomic plane injection through ultrasound guidance is associated with a low rate of complications. Ultrasound guidance is an efficacious adjunct to gluteal fat grafting and is associated with an improved safety profile that should be considered by every surgeon performing this procedure.

LEVEL OF EVIDENCE: 3

Static Injection, Migration, and Equalization (SIME): A New Paradigm for Safe Ultrasound-Guided Brazilian Butt Lift: Safer, Faster, Better

BACKGROUND

Although the Brazilian butt lift (BBL) is one of the most popular procedures in body contouring, it has been associated with the risk of pulmonary fat embolism when fat graft is injected into the gluteal muscles. The subcutaneous plane has been identified as a safe site for fat graft injection, but deaths from fat embolism continue to occur because there is no mechanism to confirm consistent subcutaneous placement.

OBJECTIVES

The aim of this paper was to determine if real-time intraoperative ultrasound could accurately identify the subcutaneous gluteal anatomic landmarks and permit a single surgeon to consistently target fat graft placement in the subcutaneous space.

METHODS

In total, 4150 BBLs were performed with real-time intraoperative ultrasound being used to confirm the subcutaneous position of a static cannula during fat graft injection. Serial deposits of fat graft were performed in each buttock. Ultrasound confirmed that fat graft consistently remained above the deep gluteal fascia and migrated through the deep subcutaneous space. These fat graft deposits were then equalized with a moving cannula to correct any contour deformities. Operative times were recorded and compared with BBL performed by expansion vibration lipofilling without ultrasound.

RESULTS

Real-time intraoperative ultrasound allowed for the visual confirmation of consistent subcutaneous fat graft deposition and the targeting of fat graft into specific gluteal subcutaneous compartments.

CONCLUSIONS

Real-time intraoperative ultrasound allows the surgeon to confirm a subcutaneous-only fat graft injection, target specific gluteal subcutaneous compartments, and take advantage of the unique architecture of the deep subcutaneous space to create gluteal projection and correct contour deformities.

Complications of Fat Grafting Versus Implants in Gluteal Augmentation: A Retrospective Review and Lessons Learnt

There have been various studies and literature reviews about gluteal augmentation, possibly due to the high complication rates associated with the procedure. But in the recent past, there has been extensive work in an effort to reduce the complications and various different methods have been developed for this purpose. This article brings to view the procedure followed in our surgery centre for fat grafting and implants for gluteal augmentation. We have compiled the complications we encountered with these procedures and the lessons we learnt to prevent them. LEVEL OF EVIDENCE III: 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 .

What Makes a Beautiful Buttock Beautiful? A Case-Control Study Comparing Buttocks Models versus Normal Women by Magnetic Resonance Imaging, Photography and Anthropometry

OBJECTIVES

To describe characteristics of women with aesthetically ideal buttocks and differentiate them from women with normal buttocks.

METHODS

Case-control study comparing anatomy of women with ideal buttocks (buttocks models) to women with normal buttocks using magnetic resonance images, anthropometric measurements and photography.

RESULTS

Comparing to normal women, buttocks models have a narrower waist, narrower iliac crest, wider C point, wider hips and bigger and thicker gluteus maximus muscle (GMM). A bigger GMM adds more projection to the C point, point of maximum projection in the lateral view is 2.7 cm higher than the pubic bone. The amount of subcutaneous fat was equal in models and controls.

CONCLUSIONS

Our study provides new knowledge regarding the tridimensional aspects of the beauty of the buttocks area. A beautiful buttock is a conjunction of adequate bony shape, muscle development, subcutaneous fat layer, and tight skin. Comparing to normal women, buttocks models have a narrower waist, narrower iliac crest, wider C point, wider hips and bigger and thicker Gluteus Maximus Muscle. Accurate understanding of the aesthetic goals in a given patient can guide surgical technique.

LEVEL OF EVIDENCE III

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 .

Combining Gluteal Shaping with High-Definition Liposuction: New Concepts and Techniques

Gluteal contouring has been subject to numerous publications in aesthetic plastic surgery. Not only the female but also the male features that govern such procedures have been thoroughly described by different authors. In this article, we will provide the reader with an updated account of how gluteal contouring blends with High Definition Liposculpture (HDL). We discuss the most current techniques for buttocks reshaping through a holistic approach of new anatomical and artistic concepts. We will dive into new techniques to perform multiplanar and 4-dimensional Fat Grafting and equalization of the buttocks and surrounding areas, which we believe might help plastic surgeons to improve the quality of their patient outcomes. In effect, a proper understanding of the anatomical structures and its variations among different gender and ethnicities, will both help the surgeon to individualize the procedure based on patient preferences.

Aesthetic Ideals of the Female Buttocks: Concepts and Techniques

This article explores the importance of understanding the tridimensional artistic anatomy of the back, pelvis, and thighs in gluteal surgery. It emphasizes the need for plastic surgeons to have a comprehensive knowledge of these anatomic structures to achieve successful outcomes. The authors highlight the significance of ethnic differences in determining ideal aesthetic results and stress the importance of considering and respecting these variations. Individualization of treatment is a key principle in gluteal surgery, as each patient has unique preferences and needs. Effective communication and collaboration between the surgeon and the patient are crucial in determining desired aesthetic goals and achieving satisfactory outcomes.

Static Injection, Migration, and Equalization: A New Paradigm for Safe Ultrasound-Guided BBL: Safer, Faster, Better

Static injection, migration, and equalization allows for always subcutaneous-targeted fat grafting to either the deep or the superficial subcutaneous spaces.

Ultrasound-Guided Gluteal Fat Grafting: A to Z

Low-cost, high-resolution ultrasound systems allow surgeons to visualize and manipulate the subcutaneous space and inject fat graft with millimeter accuracy.

Aesthetic Units and Zones of Adherence, Relevance to Planning Incisions in Body Contouring Surgery

Background

Aesthetic units (AUs) and zones of adherence (ZAs) have been previously noted in the face and torso. A systematic classification of common AUs and ZAs has not been previously described for the torso and extremities. Contour and scars are equally important in obtaining the best result. Therefore, the six principles to consider in body contouring surgery (BCS) are that the resulting scar be anchored at a zone of adhesion; at the interface of AUs; concealed within flexion or extension skin creases, or placed according to conventional usage and experience; positioned on the medial aspect of a limb; hidden when nude, topless, or in a variety of clothing such as one-piece and two-piece swimsuits, crop tops, short sleeves, etc; and positioned to avoid a contracture across a flexion joint crease or a dehiscence across the extension aspect of a joint.

Methods

Images of male and female massive weight loss (MWL) patients with a history of MWL were reviewed and analyzed.

Results

AUs and Zas are described and codified. An algorithm is provided to aid in planning incisions for BCS.

Conclusion

With the increase in BCS after MWL, a classification of AUs and ZAs is considered useful in planning surgery and optimizing the aesthetic result.

Brazilian Butt Lift-Associated Mortality: The South Florida Experience

BACKGROUND

Brazilian butt lift (BBL) surgery has been the fastest growing aesthetic surgical procedure over the past decade. By 2017, the risk of death from pulmonary fat (PFE) was identified, earning the BBL the highest mortality rate of any aesthetic surgical procedure. South Florida carries the highest BBL mortality by far in the nation.

OBJECTIVES

The purpose of this study was to explore the factors involved in making South Florida an outlier in terms of BBL mortality.

METHODS

The anatomic findings of the gluteal dissections from 11 post-BBL surgery autopsies (22 hemibuttocks) were assessed for commonalities. The public records of patients who died from BBL-related fat emboli were examined to determine commonalities.

RESULTS

All BBL PFE cases had fat grafts injected into the gluteal musculature in multiple different levels. Another commonality involved the location where the surgery took place, with the great majority of patients (92%) undergoing surgery at high-volume, budget clinics located in South Florida. Short surgical times of approximately 90 minutes appeared to be the norm for these cases.

CONCLUSIONS

South Florida has experienced 25 BBL-related fat emboli deaths between 2010 and 2022; however, 14 of these occurred after publication of the Aesthetic Surgery Education and Research Foundation's 2018 guidelines and the 2019 Florida Board of Medicine's BBL "subcutaneous-only" rule. The working environment at the clinics, and the short surgical times for these cases, may be the most important contributors to the BBL mortality in South Florida.

Safety and Efficiency of Minimally Invasive Buttock Augmentation: A Review

BACKGROUND

Volume restoration and enhancement of the gluteal region appearance has become nowadays a popular concern in particular for many women. Several options are available, none however are without complications and side effects. Volume enhancement with soft tissue fillers of the gluteal region is emerging as a highly attractive minimally invasive modality. It has led unfortunately to more unlicensed, nonmedical practitioners administering illicitly injections for buttock augmentation at relatively low costs.

MATERIALS AND METHODS

To determine safety, efficacy, and cost effectiveness of mostly used soft-tissue fillers for buttock augmentation, a systematic literature search of PubMed, Medline, and Embase was conducted to identify the mostly used fillers for gluteal augmentation. It was complemented by searching for each of the identified filler material separately to retrieve any missed reports. References of clinical studies and trials, reviews, and consensus reports were reviewed as well for the same objective.

RESULTS

In the final analysis 12, mostly strongly biased clinical reports providing a low level of evidence, were identified for inclusion in the review. Two studies involved Polymethylmethacrylate (PMMA), 5 Poly-L-lactic acid, 1 Calcium hydroxyapatite and 4 hyaluronic acid filler injection. No studies were identified involving liquid silicone or Polyacrylamide hydrogel. The little available evidence provided by this review indicates that a specific brand of PMMA in Brazil has a demonstrable relatively good safety, efficiency, and cost-effectiveness record superior to surgical alloplastic gluteal augmentation or to lipofilling only when injected by experts.

CONCLUSION

Gluteal augmentation with soft tissue fillers is not as simple and innocuous as advertised. Serious complications may occur. Moreover, optimal buttock contouring entails not only volume augmentation but also volume removal; thus, volume augmentation with soft tissue fillers may not be ideal. Popularizing this modality must also be approached with great care. Serious complications do occur; they become inevitable when performed illegally by non-specialized, non-authorized, and unscrupulous practitioners in non-accredited facilities. Patients must be warned that adherence to regulations is critical and that only well-trained certified experts practicing legally in accredited facilities can address safely and efficiently their concerns.

LEVEL OF EVIDENCE III

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 .

Body Feminization Combining Large-Volume Fat Grafting and Gluteal Implants

BACKGROUND

With the increase in popularity of fat transfer to the buttocks in body contouring surgery, new patient subsets are emerging. The gender confirmation patient has specific characteristics that must be addressed to achieve the best outcomes.

METHODS

The authors performed an observational prospective study including 36 consecutive patients who underwent body feminization as a gender affirming operation using large-volume fat transplantation with or without gluteal implants.

RESULTS

Thirty-six consecutive male-to-female transgender patients have undergone large-volume fat transplantation to the buttocks performed by the authors, between July of 2016 and January of 2019. In 12 of these 36 cases, large-volume fat grafting was supplemented by intramuscular placement of silicone implants. The mean waist-to-hip ratio before surgery was 1.11, and this improved to 0.81 after surgery (fat transfer-only group, 0.88; fat transfer plus implants group, 0.75).

CONCLUSIONS

The transgender patient is a unique patient requiring a specific set of surgeon's skills and intraoperative strategies to achieve good outcomes. Composite solutions with both implants and lipofilling lead to better outcomes in terms of waist-to-hip ratio in these patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Innovation in Aesthetic Plastic Surgery: An International Collaborative Effort

An overview of the importance of international contributions to the advancement of aesthetic plastic surgery is presented, with emphasis on why, how and where in our specialty does innovation take place. The reason for innovating is clear: to improve on the quality of care patients receive today, through research and education. In order to do so, innovators must be either visionaries, advancers or popularizers of a new technique and they must have an exhaustive knowledge in a specific field, an intrinsic motivation to pursue work in that field and a capacity to solve problems in an original way.  The four areas of advancement in aesthetic plastic surgery are outlined, including better aesthetic results, better and faster patient recovery, increased patient safety and better surgeon experience. The three stages of development of our specialty are described as well, beginning with the creation stage in the late 1870s, in which the correction of evidently altered structures was undertaken; the establishment stage, which began in the late 1960s with the study and correction of surgical stigmata, the detailed analysis of surface aesthetics and later with the rise of minimally invasive procedures; and finally, the refinement stage that we have witnessed over the past few years, in which natural movement and feel are also considered essential in order to achieve successful aesthetic outcomes. LEVEL OF EVIDENCE V: 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Gluteal Augmentation with Fat Grafting: Literature Review

BACKGROUND

The buttock is the second sex feature of the human body, and the graceful buttock curve gives people confidence. Although the safety of gluteal augmentation with autologous fat grafting is still controversial, the proportion of operations is increasing year by year.

PURPOSE

To provid a comprehensive and detailed review of the literature on gluteal augmentation with fat grafting.

METHODS

A comprehensive review of the published literature through September of 2020 was performed in PubMed database, with the search terms "gluteal augmentation," "buttock augmentation," "Brazilian buttock lift," "fat grafting," "fat transfer," "gluteal AND aesthetic," "gluteal AND anatomy."

RESULTS

A total of 64 articles were included. On the basis of the information obtained, surgical recommendations are proposed to achieve buttocks as close as possible to aesthetic standard and improve surgical safety.

CONCLUSION

With a good grasp of the anatomical structure of the buttocks, complications can be reduced. At the same time, based on the theoretical basis of buttock aesthetics, better postoperative results can be obtained.

LEVEL OF EVIDENCE III

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 .

Autogenous Fat Grafting to the Breast and Gluteal Regions: Safety Profile Including Risks and Complications

Given the widespread utility and therapeutic potential of autogenous fat grafting, plastic surgeons should be familiar with its safety profile and associated adverse events. This article provides a critical review of the literature and delineates risk factors associated with various complications when grafting to the breast and gluteal regions. The majority of adverse events are related to fat necrosis and require minimal diagnostic or therapeutic intervention. Larger graft volumes, as in cosmetic augmentation, are associated with higher incidences of fatty necrosis. The oncologic safety of fat grafting is supported by multiple clinical studies with thousands of breast cancer patients, albeit predominantly retrospective in nature. Although less frequent, serious complications include fat emboli during gluteal augmentation. Identification of associated risk factors and implementation of proper surgical techniques may minimize the occurrence of life-threatening complications.