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There has been increased interest in buttock contouring and augmentation in recent years, which has translated into increased demand for these procedures. In addition, we are witnessing a growing number of patients from all ethnic groups requesting cosmetic surgery in the United States. Buttock aesthetic surgery today consists of either augmentation or recontouring of the gluteal region by one of three methods: (1) liposuction (if only reductive shaping is required); (2) liposuction and augmentation by micro fat grafting; and (3) gluteal implants. Whereas there certainly exists a “universal ideal” of beauty in buttock augmentation, there are fundamental ethnic differences that must be recognized to achieve a desirable surgical outcome. We present an article reviewing current trends in buttock aesthetic procedures and discuss issues relevant to the ethnic populations.
Aesthetic surgery of the buttocks is one of the fastest growing segments of plastic surgery today.1 The buttock area has received much media attention in recent years, which has increased patient demand for buttock contouring and augmentation. In addition, the growing popularity of bariatric procedures and massive weight loss programs has increased the demand for body and buttock contouring procedures. Therefore, any discussion about cosmetic surgery in the ethnic population is not complete without an in-depth look at buttock aesthetic procedures.
Although standards of beauty change depending on the times, cultures, and locations, the iconic representation and allure of the hourglass female figure withstands the test of time and crosses cultural barriers.2,3 In fact, Singh proposed that there is one female body shape (full buttocks and narrow waist) that men universally find most attractive, and he theorized and gave extensive evidence to support the concept, that a waist-to-hip ratio (WHR) of 0.7 was the universal ideal female shape.4 The waist-to-hip ratio is defined as the ratio of the circumference of the waist at its narrowest to the circumference of the thighs at the level of the maximum prominence of the buttocks. The evidence supporting his theory is quite strong; in fact, Roberts et al showed that successful buttock augmentation is achieved when a woman's WHR is recontoured close to the ideal 0.7 regardless of her ethnic background.5 What was different among different ethnic backgrounds was the size of the buttocks, whether the lateral buttocks should be full, and whether fullness of the lateral thighs (trochanteric area) was desirable (Table 1).
Therefore, any aesthetic procedure must not only adhere to the universal aesthetic ideal but also must embrace various ethnic differences to achieve a desirable outcome. Here, we will review current trends in buttock aesthetic procedures and discuss issues relevant to ethnic populations.
Buttock aesthetic surgery today consists of either augmentation or recontouring of the gluteal region by one of three methods: (1) liposuction (if only reductive shaping is required); (2) liposuction and augmentation by micro fat grafting; and (3) gluteal implants.3 These three modalities can be used in combination to achieve the desired outcome and can also include fixation, lifting, and skin resection, much the same way as for breast aesthetic surgery. The early work on gluteal augmentation was performed by plastic surgeons in Mexico, Brazil, Peru, and other South American countries, and their innovations and techniques have led to better implants and more reproducible aesthetic results. Even today, there are significant differences in how buttock augmentations are performed here in the United States and in other parts of the world. For example, in other parts of the world, implant augmentation, especially the subfascial technique, is more common and can achieve excellent aesthetic results because of the availability of softer cohesive gel implants. These subfascial results cannot be duplicated with the semisolid implants available here in the United States.
Regardless of the method, aesthetic surgery of the gluteal region begins with careful surgical evaluation. One approach is that of Cuenca-Guerra and Lugo-Beltran who studied numerous photographs of female nude buttocks and identified four defining features that stood out as consistent features of beauty: (1) lateral depression formed by the lateral border of the gluteus maximus, the quadratus femoris, and the insertions of the gluteus medius and vastus lateralis to the greater trochanter; (2) infragluteal fold created by the ischial tuberosity, the insertions of the semitendinous muscle and long belly of the biceps femoris, and the lower border of the gluteus maximus; (3) supragluteal fossettes (one on either side), over the posterior superior iliac spine, created by the multifidus muscle, the lumbodorsal aponeurosis, and the insertion of the gluteus maximus; and (4) V-shaped crease, arising in the proximal portion of the gluteal crease.6 In addition, lumbar hyperlordosis, the hyperextension of the spine in the lumbosacral region, was found to be a desirable feature specific to people of African descent. They then went on to perform anthropometrical analysis of the gluteal projection and devised five categories of buttock characteristics that would determine the appropriate surgical intervention (Table 2). The foundation behind this categorization is the projection ratio, which is defined as the ratio of the distance from the greater trochanter to point of maximal projection of the mons pubis, to the greater trochanter to the point of maximal gluteal projection. Then, depending on the type of buttock, the right combination of liposuction, implant augmentation, and/or adjunctive procedures are used.
Another way to evaluate the gluteal region is to use the classification system devised by Mendieta in which the buttocks are viewed as two separate removable structures: the frame, which consists of fat, bone and skin, and the detachable gluteus maximus muscle.7 The evaluation is then divided into four tasks. The first task involves evaluating the frame based on pelvic height and four different frame types: round, square, A-shape, or V-shape. The second task involves evaluating the gluteus muscle for height, width, and volume, and the third task involves evaluating the four junction points (upper inner gluteus/sacrum, infragluteal fold/thigh, lower lateral gluteus/thigh, and lateral mid-buttock/lateral thigh) between the muscle and the frame. Finally, the degree of ptosis, if present, is evaluated. The type of procedure required then can be deduced from this analysis.
Roberts et al propose yet another method of evaluating the gluteal region.5 As previously discussed, Roberts et al found that a WHR of ~0.7 creates attractive, youthful buttocks. In his practice, Roberts attempts to adjust the WHR close to the ideal 0.7. In addition, he found several buttock characteristics that appealed to all ethnic groups: smooth inward sweep of the lumbosacral area and waist, a feminine cleavage as the buttocks separate superiorly and inferiorly, maximum prominence in the mid to upper buttock (or at the junction of medial and central thirds of the buttocks in cross section), and minimal infragluteal crease without ptosis above this line. Sacral dimples may be present in an attractive youthful buttock but are not a determinant of an attractive buttock.
Evaluation and treatment of the gluteal aesthetic unit is highly dependent on the surgeon's level of comfort and expertise with various operative techniques. In addition, there is great variability in patient preference and her view of the ideal buttocks, which crosses ethnic boundaries. However, as discussed above, there are only a limited number of treatment modalities for buttock augmentation/recontouring today, which can be used alone or in combination to achieve desired results. These modalities include gluteal implants, liposuction, and autologous micro fat grafting. Contrary to popular beliefs, exercise will not increase buttock size or significantly improve shape. In fact, reduction in fat volume seen with aggressive exercise can make buttocks become smaller. Therefore, surgical intervention becomes the only option for these patients.
Use of gluteal implants is the most common method of buttock augmentation worldwide.8 Implants can give good immediate results and can be used in conjunction with liposuction and/or fat grafting, which is especially beneficial for those patients who desire increased volume for projection to counter the flattening effect seen in massive weight loss individuals.9 However, certain limitations must be respected. Implant placement must be done first, then care must be taken not to penetrate the implant pocket with either the liposuction cannula or the fat grafting, or the risk of seroma and/or infection will increase. The history of gluteal implant development is quite colorful and has been described thoroughly elsewhere in the literature.2 The search for the ideal implant continues today, both in the type of implant being used as well as in the technique by which the implant is placed. The types of implants (Table 3) and various surgical techniques of implant placement (Table 4) are summarized below along with their advantages and disadvantages.
The major drawback of implant augmentation is the substantially high rate of complications associated with its techniques. Many of the early proponents of the procedure were not open to discussing complications. It was not until Mendieta, who reported the first large American series on buttock implants and its complications, that open communication between surgeons led to discussion of these complications and their possible solutions.10 The most common complication of implant augmentation is wound dehiscence, which occurs in up to 30% of intramuscular augmentation and between 15% and 30% in subfascial augmentation. After much thought and “soul searching,” the consensus among several surgeons who study and perform gluteal implant surgery (Roberts, De La Pena, Mendieta, Young, and Centano) is that the predisposing element is the fact that the intergluteal cleft (where the incision is traditionally placed) is a “watershed area” in terms of blood supply. Because the unusual anatomic situation that the underlying sacrum has no perforating vessels, all flow must come from laterally and diminishes to just capillaries as it approaches the midline. All we can do to minimize the risk of dehiscence is careful patient selection and atraumatic handling of the wound margins, avoiding desiccation and excessive traction.11 This rate is increased to 80% in overweight patients and also is very high in patients in which an implant of more than 350 cc or more than 3.5 cm projection is used.12 Other complications include seroma, infection, implant malposition/palpability, and loss of implant, bringing the major complication rate to 15 to 25% with intramuscular and to 35% with subfascial augmentation.11 Although cohesive gel implants are less palpable, the dehiscent rate remains ~30%, and these silicone gel implants are not available in the US, nor will they be in the predictable future.13
Liposuction is an integral aspect of successful gluteal aesthetic surgery. It is needed to define not only the buttocks but also the area around the buttocks, such as the flanks, the presacral area, the hips, the inner and outer thighs, to optimize results and improve patient satisfaction. However, liposuction of the infragluteal area (banana roll) must be avoided at all costs as it is the supporting pillar for the buttocks, reduction of this “banana roll” by liposuction will inevitably cause ptosis of the buttocks over the infragluteal crease. It is useful for defining and contouring the buttocks region and, in certain patients, can be used in conjunction with lifting and/or skin resection. However, most patients require and desire increased projection along with improved contour. Liposuction alone cannot provide for projection or augmentation of the region as seen with either implants or fat grafting and, therefore, must be used in conjunction with either of these modalities.
Many plastic surgeons in North America believe that autologous fat grafting is the best option for obtaining the ideal buttock shape.5,14,15 The tissue is readily available by liposuction (if obtained correctly: see later). One author believes it can be stored for future use for up to 3 months.9 However, percentage survival must decrease with time and the risk of infection must increase. The senior author of this article presented the first large, well-documented series of micro fat grafting for moderate buttocks augmentation and the complications associated with this volume of grafting.14 There are two primary reasons why implants cannot achieve the aesthetic results seen with fat grafting. As previously discussed, creation of the inward sweep of the lower back and the cleavage where the upper buttocks separate superiorly is very important for a successful procedure. This requires aggressive liposuction of the presacral area, which can be done routinely at the time of autologous fat grafting. Simultaneous liposuction of this area is not an option at the time of implant augmentation because of the increased risk of vascular compromise of an area already at high risk for dehiscence and seroma associated with implants.11,14
Autologous micro fat grafting may be the safer alternative in comparison with implant augmentation, with a major complication rate of 7% with current techniques.14 However, fat grafting requires a major investment of time and is labor intensive. In addition, implants can achieve good results for augmenting the upper and central portion of the gluteal region but they cannot augment nor is it technically feasible to place them in the lateral buttocks and the lateral thigh regions, which is routinely requested by Hispanic and African American patients. However, implants may be the only option when a patient does not have adequate fat donor sites or is unwilling to gain weight.
Autologous fat grafting is also ideal for correcting isolated defects, surface irregularities, and volume deficiencies in the gluteal region, such as the retrotrochanteric depression that many patients find objectionable, although it is a natural anatomic entity.9 Some surgeons are also using a combination of implant augmentation and fat injection to improve overall results. When doing so, one must always be cognizant of the increased risk of infection and dehiscence, and therefore, a staged approach is highly recommended when using multiple modalities for gluteal recontouring and buttock augmentation.
The specific operative technique for fat grafting varies with each surgeon and is performed according to his preference. There are slight variations in how the fat is harvested, processed, and injected. There are other varying opinions such as the use of antibiotics in the aspirate, use of stored harvested fat, and concomitant use of implants with grafting technique. Our recommended technique for autologous fat grafting was published previously and is summarized in Appendix A of this article.5
Buttock augmentation is a major surgical procedure with the potential for major complications, including serious infections, wound dehiscence, exposure of implant, hematologic and metabolic disturbances, pulmonary disturbances, and electrolyte imbalance. Some of these complications are associated with gluteal augmentation regardless of technique. However, many of the complications are technique dependent and/or the complications may present differently depending on whether implants or fat grafting technique was used. A detailed discussion concerning the complications of gluteal augmentation is beyond the scope of this article, but readers are encouraged to refer to an article by Bruner et al on the complications of buttocks augmentation for further details.11
Lastly, we want to address specific issues pertaining to various ethnic populations. The view expressed in this article is by no means universal or complete, as there is a tremendous variability among patient and surgeon preferences around the world. However, the issues presented here are some of the more common findings that can be generalized to the various ethnic populations regardless of individual differences.5 Note that bringing the WHR close to the ideal 0.7 is important in obtaining the ideal results in all ethnic groups.
These women have a strong and consistent ideal of very large buttocks. In addition, lumbar hyperlordosis is a desirable feature in addition to fullness of the upper buttocks. A full, prominent trochanteric area of the lateral thighs is desired and is still seen as a sign of fertility or fecundity. This lateral trochanteric area is uniquely called “the hip” among African Americans but most other cultures call the iliac crest “the hip.” Figure Figure11 is representative of many African American patients we see: large framed, and requesting substantial enlargement of all areas of the buttocks and very full lateral thighs (“hips”), but as small a waist as possible. Another common request that is uniquely African American is to create an extreme prominence of the upper buttocks (“shelf”), as seen in Fig. Fig.22.
These patients prefer small to moderate-size buttocks, and fullness in the lateral buttocks or lateral thigh is almost never desired (Fig. 3). Moreover, the shape of the buttocks and its relative proportion to the overall body frame is very important to this ethnic group. They are usually shorter and smaller than other ethnic groups so even small changes in size or shape of the buttocks can have dramatic results. Figure Figure44 shows an Asian patient with a little more fat available, who wanted fuller buttocks but still no fullness in the lateral buttocks or lateral thigh.
These patients generally want buttocks that are full but not extremely large. Fullness of the lateral thigh is an undesirable characteristic, but in regard to the lateral buttocks, Caucasians fall into two categories: some prefer more feminine, full, rounded buttocks (Fig. 5), whereas others prefer flat or hollow lateral buttocks, which give a more athletic look (Fig. 6). Neither of these two types of patients desire fullness in the lateral thigh.
These patients, at least in the United States, prefer buttocks and lateral buttocks that are very full and prefer a slight fullness in the lateral thigh (Fig. 7). Compared with the much fuller lateral thighs requested by African Americans, Hispanic patients desire slight to moderate lateral thigh fullness. In a patient with more excess fat, the surgical plan should include generous liposuction of the lower chest, low back and waist to obtain a smooth hourglass curve and to emphasize the new fullness of the buttocks (Fig. 8).
It is the observation of the senior author that these ethnic ideals are so strongly imprinted, in even the most sophisticated woman, that the only exception to the African's typical request (i.e., very full lateral thighs and lateral buttocks and very large overall size of buttocks) have been in women who either (1) move in a social group that is largely Caucasian or (2) are in a significant relationship with a Caucasian.
Conversely, the only times a Caucasian woman has requested very full lateral thighs were when she moved in a predominately African-American social group or was in a significant relationship with an African American.
We have presented an overview of ethnic considerations in buttock aesthetic procedures. We are seeing an increase in the demand for buttock augmentation procedures as well as increasing popularity of aesthetic procedures among Caucasian and non-Caucasian patients in this country. A proper understanding not only about the techniques but also of the ethnic differences is integral to safe and effective practice of aesthetic buttock procedures. Readers are strongly encouraged to attend an instructions course offered by Roberts, Young, Mendieta, De La Pena, and colleagues at the American Society of Aesthetic Plastic Surgery future annual meetings for the most current techniques for buttock aesthetic procedures.
Although the surgery is planned as an outpatient procedure, there must be a competent caregiver with the patient at all times for at least 3 to 4 days. The patient must also remain in town for 2 weeks, as gram-negative infection may not present until postoperative days 7 to 14.
This surgery is a physiologic challenge for the patient due to the extensive liposuction usually required. Therefore, monitor patients carefully in the recovery room (O2 saturation, EKG, blood pressure, and urine output), and discharge patient only when certain standard criteria are met.
Instruct the patient on the use of an incentive spirometer preoperatively, which must be used every hour postoperatively. Leave the Foley catheter in overnight. Record drain output and strip drains frequently. The patient must lie prone or be up on her feet—not sitting.