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Archive for the ‘buttock augmentation’ Category

Techniques for Improved Safety in Fat Injection Buttock Augmentation

Sunday, January 21st, 2018


Buttock augmentation by injection fat grafting, known by the urban term of Brazilian Butt Lift or BBL, has been the fastest growing body contouring procedure in the past decade. Because it is ‘fat recycling’ procedure offers the dual benefit of reduction of undesired body contours by the liposuction harvest and the increase in buttock size by its relocation to this body area.

But despite its popularity and wide spread use, it has proven to also be a procedure that is not without its risks. Recent studies have shown that there are more major complications from this procedure than is commonly known with the highest mortality rate of any modern day cosmetic surgery procedure. Such events are related to pulmonary fat emboli in most cases. At roughly a death in every 3500 procedures done this is unacceptable in cosmetic surgery.

In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Staying Safe During Gluteal Fat Transplantation’. In this paper the authors review the important techniques of more safely performing fat injections to the buttocks based on patient selection, instrumentation, patient positioning and injection techniques based on buttock anatomy and vasculature. This is fundamentally about avoiding injuring deep gluteal vessels and inadvertently getting the fat transfer into them.

The anatomy of the buttocks is divided into superficial and deep levels. The superficial level consists of the gluteus maximus, gluteus minimus and tensor fascia late muscles. The deep muscles are smaller and include the piriformis, gemellus superior and inferior and quadratus femoris. The inferior and superior gluteal vessels originate from below the prirformis but emerge out onto the outer surfaces of the gemellus and piriformis. Most relevantly are these deeper gluteal veins which are surprisingly big (5 to 6m) and are felt to be the most common entrance for fat emboli from fat injections.

The danger one in buttock augmentation is a triangle between the posterior superior iliac spine superiorly, the greater trochanter laterally and the inferior ischial tuberosity. Deep fat injections should be avoided in this area in particular as that is where the deep gluteal vessels lie.

Preoperative patient selection should be on avoiding patients that have a history of deep vein thrombosis, pulmonary emboli, large varicose veins or sciatic nerve symptoms.

Fat injection buttock augmentation is done in the prone position with the hips flexed. (jack knife position) In this position the knees should be bent to avoid venous polling in the calfs. This position also allows for more certainty that the fat is injected into the subcutaneous and superficial muscles.

The injected fat should be done using larger cannulas. (blunt tipped and greater than 4mm in diameter) This cannula size combined with a continuous back and forth cannular motion significantly decreases the risk of venous injury and fat introduction. The buttocks should also not be filled to the point of high internal pressure where the fat comes squirting back out from the skin entrance site. By my own personal experience i would also only inject from a superior direction which, in the jackknife position, ensures a superficial injection plane and no change to get under the gluteus maximus muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Buttock Implant Replacements

Wednesday, December 27th, 2017


Background: Buttock augmentation is most commonly and appropriately done by fat transfer. (BBL) But not every buttock augmentation patient has the needed amount of fat to do a successful procedure nor does fat always survive in a predictable manner. For the thin patient with little fat, buttock implants are the only alternative treatment option. For the failed BBL patient implants also become the alternative approach.  I don’t know what percentage of fat injected buttock enhancement patients go on to have implants. But having seen it more than a few times, it clearly is not zero.

While the biggest issue of debate in buttock implants usually revolves around whether their placement should be above (subfascial) or in the muscle (intramuscular) position, this issue actually becomes secondary to implant size. With larger buttock implants sizes, the intramuscular position becomes moot as they simply will not fit into the pocket. And even if they do the muscle over them will atrophy with the pressure and the implant will end up in the subfascial position anyway. While the absolute number on implant size for the intramuscular position differs amongst patients based on their body and buttock size, the range of 400c to 450cc is a good guideline for the upper limit of intramuscular buttock implant size.

If larger buttock implants are desired based on the patient’s goal and the subfascial position is where they will need to be, the issue then becomes the buttock implant itself. Is it if adequate size and shape? While a variety of gluteal implants sizes and shapes exist, some patients may find that their aesthetic needs can not be met by them.

Case Study: This young female had buttock implants placed previously in the subfascial location. While she had no medical problems with them, she did not like their ‘shelving’ effect due to their round profile. Custom implants were designed that were 19 cms in height, 15.5 cms in width and 4.5 cms maximum projection with a total implant volume of almost 620cc. They were anatomic in shape with the maximum projection point being located 1/3 vertical distance from the bottom edge of the implant.

Under general anesthesia the new custom buttock implants replaced her indwelling wound implants with pocket expansion as well. The immediate effects of the implant exchange were obvious with lessening of the round buttock implant look to a more natural shape.

The dimensions of relevance in buttock implants are its size (total volume), shape (round vs anatomic) and the footprint or outline of the implant. Externally what matters is how big does the patient want the buttocks to be, do they want a high round shape or a lower anatomic shape and does the implant go far enough outward towards the hips. When standard buttock implants by their placement has not met the patient’s aesthetic needs, custom replacement implants should able to do so.


1) Custom buttock implants may be needed in some cases of buttock implant replacements to meet the patient’s aesthetic needs.

2) Anatomic buttock implants are useful to decrease a very round buttock shape from prior implants.

3) Custom buttock implants are made in prior implant patients based ink knowing what the indwelling implant dimensions are.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Buttock Implants

Wednesday, December 6th, 2017


While the most common form of buttock augmentation today is fat grafting (Brazilian Butt Lift surgery or BBL), buttock implants still have a role to play. They are the only other method of surgical buttock augmentation for those patients who do not have enough fat to harvest for a BBL or have failed previous BBL efforts due to fat absorption.

Like all aesthetic implants used in the body, buttock implants provide permanent volume in a single surgical effort. But the final outcome both in volume and shape is determined by that of the implant’s design. Buttock implants come in both round and anatomic designs and volumes up to 700ccs. While the pocket location can be either intramuscular or subfascial, larger buttock implants sizes have to be placed on top of the gluteus maximus muscle.

One of the design problems in larger buttock implants is that they often can result in a ‘bubble butt’ appearance. This is caused by the high projection compared to the base diameter of the implant. While breast implants are designed to look spherical, such an appearance for the buttocks is not as desired by most patients. To get a more natural look, custom buttock implants have a wider base diameter with less projection. The concept is that in the buttocks, the diameter of the implant is more important than its projection.

Custom buttock implants are designed to be used in the subfascial location. Their broad base diameters, up to 18 cms, cover more buttock surface area and blend in more naturally to the surrounding tissues. This is particularly important out laterally into the hip area. With a broader base diameter the projections can often be lower than 6 cms or less.

The base diameter of custom buttock implants mandates that they be placed in the subfascial position rather than in the intramuscular location. This also allows for a greater influence on the hip region that would otherwise be obtainable.

Dr. Barry Eppley

Indianapolis, Indiana

Revisional Buttock Implant Surgery

Wednesday, February 8th, 2017


Like implants placed anywhere on the body, buttock implants can also have complications. When one compares the two methods of buttock augmentation, fat injection vs implants, it is no surprise that the placement of an implant is associated with a higher rate of potential complications. But for those women and men who have inadequate fat harvest sites, buttocks implants are their only buttock augmentation option.

As overall buttock augmentation surgery has become more prevalent, the number of buttock implants being placed has also increased. As a result the number of implant complications has expectantly risen as well. Buttock implant complications include medical problems of wound dehiscence, infection, hematomas an seromas as well as aesthetic concerns of  size and shape. How well patients do with buttock implant revisions and their outcomes has not been previously studied or published.

In the February 2017 issue of the journal Plastic and Reconstructive Surgery, the first paper on this topic was published entitled ‘Revision Buttock Augmentation: Indications, Procedures, and Recommendations’.  In this paper the author reviews his twelve year experience in 43 patients who had revisional buttock implant replacement. The indications for buttock implant replacment were prior loss of implant (42%), asymmetry (37%) and size change. (21%) Revision buttock implantation procedures done were implant removal (24), implant replacement (19), implant exchange (18), capsulotomy (6), size change (5) and capsulorraphy. (1) Complications after the 24 buttock implant removals included contour irregularities that required fat grafting (2) but no infections o wound dehiscences were seen. Of great interest is what happened in the 19 buttock implant replacement patients. Infections occurred in 25% of them. Complications after buttock implant exchange was hematoma. (5%)

In primary buttock implant surgery the most dreaded complication is that of infection. Once it is diagnosed the recommendation is to remove the implant immediately and wait at least 6 months until it is replaced. Trying to replace the implant too early (just months after its removal) is associated with a higher rate of recurrent infection.

Implant asymmetry was seen equally in both subfascial and intramuscular locations. Its resolution requires either capsulotomies to expand the space or implant shape change.

Aesthetic buttock implant exchange for size and shape requires a good understanding of postoperative expectations. Oval shaped implants are good when the buttocks is long and lacks lower pole fullness. Oval implant rotation is treated by a round implant replacement. The typical implant size increase was 100cc with an additional cm in implant width.

The need for revisional buttock implant surgery is always a potential sequelae of primary implant augmentation and includes management strategies for the timing of primary implant removal and secondary implant replacement due to infection and seromas. Aesthetic implant revision must be tempered with balancing the potential risks vs how much buttock size and shape change will result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Intramuscular Placement of Buttock Implants

Monday, December 19th, 2016


Background: Buttock implants are the alternative to the more popular BBL (Brazilian Butt Lift) procedure which uses fat injections to create the augmentation effect. The use of fat for buttock augmentation is preferred and should always be the first consideration as it is a natural material and has a very low risk of complications.

But when one has inadequate fat to harvest, implants become the only other buttock augmentation option. The use of buttock implants poses very different technical and outcome options than that of fat. While the placement of an implant into the buttocka assures volume retention, there are tissue constraints as to how big the augmentation can become.

The biggest decision in buttock implants is pocket placement. The options are either subfascial (on top of the muscle) or intramuscular. (inside the muscle) Subfascial placement allows for much larger implants but is also associated with a higher rate of complications. Intramuscular placement allows for only smaller size implants but have a much lower rate of potential complications.

intramuscular-buttock-implants-incision-dr-barry-eppley-indianapolisCase Study: This 26 year-old female wanted buttock augmentation but did not have enough fat to harvest. She preferred implants but wanted them placed in an intramuscular location. Under general anesthesia and in the prone position, 330cc intramuscular soft solid silicone gel implants were placed through a double intergluteal incision. The buttock implants were of an anatomic style. (wider base with lower projection0

tb-buttock-implants-oblique-view-dr-barry-eppley-indianapolistb-buttock-implants-side-view-dr-barry-eppley-indianapolisHer four month result showed a moderate buttock augmentation result. The implants created greater roundness and a natural looking result.

Intramuscular buttock implants are far more technically challenging to place and it is very difficult (and not advised) to try and place implants much bigger than the mid-300cc range. Recovery from implants in the intramuscular pocket also carries with it a significant recovery. These features make the intramuscular pocket less appealing than that of above the muscle but the long-term benefits of better vascularized tissue cover are worth it for many patients.


1) Buttock implants in the intramuscular location are smaller in size than some patients may want.

2) Manipulation of the gluteus maximus muscle creates a longer recovery than one may anticipate.

3) The intramuscular location works best with anatomic shaped buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Intramuscular Buttock Implants

Monday, October 17th, 2016


Background: Buttock implants offer a method of buttock augmentation when one has inadequate fat to harvest. It has become more popular over the past decade than ever before as the patient demand for buttock augmentation has risen dramatically. But unlike fat transfer there are multiple considerations when buttock implants are considered. These include size, shape and implant location.

The biggest consideration in using buttock implants is whether they should be placed above (subfascial) or into the muscle. (intramuscular) Each implant location has its own advantages or disadvantages. The intramuscular location offers the lowest risk of long-term implant complications but the longest after surgery recovery. Its other ‘disadvantage’ is that the implant size  will be more limited. The intramuscular pocket does not allow for much bigger implants than about 350ccs of volume. This us unlike the subfascial location where much larger buttock implants can be placed.

Case Study: This 26 year-old female wanted a larger buttocks but knew she did not have enough fat to get a good result. She was aware of the concept of subfascial vs intramuscular pockets and wanted the implants placed inside the muscle. She had a flat but moderate-sized buttock shape and preoperative measurements indicated that a 300cc to 350cc implant could be placed.

intramuscular-buttock-implants-incision-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, a 7 cm. intergluteal incision was made. The intramuscular pockets were created by a muscle splitting approach. Soft solid silicone 330cc anatomic buttock implants were placed on both sides. No drains were used.

tb-buttock-implant-results-back-view-dr-barry-eppley-indianapolistb-buttock-implants-oblique-view-dr-barry-eppley-indianapolisHer two month results show a fuller and more rounded buttock shape. Her buttocks were bigger in the upper pole with increased fullness. She had a rather long recovery as it took her about a month to get back to most physical activities. She developed a partial incisional dehiscence about 3 weeks after surgery of the lower half of her incision. It was treated by topical silvadene and went out to fully heal three weeks later.

tb-buttock-implants-side-view-dr-barry-eppley-indianapolisFor those patients considering intramuscular buttock implants it is important to realize that the recovery period will be significant. It is a muscular injury in an area that will need to be sat on as well as important for many other bodily movements as well.


1) Buttock implants offer a reliable and permanent method of buttock augmentation

2) The intramuscular placement of buttock implants offers the least complications long-term but has a significant surgical recovery.

3) Intramuscular buttock implants have size restrictions and are only indicated in patients that are not eligible for a fat transfer buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Asian Buttock Implants

Wednesday, October 12th, 2016


Buttock augmentation today has taken on a near significance as to that of breast augmentation. It is the second most augmented body part next to that of the breasts. Debates can be had as to why this is so but it is a phenomenon that crosses many ethnic and cultural groups.

What constitutes buttock beauty is more than that of just size. The curve of the buttocks as transitions into the back and hips are features that may be as aesthetically valuable as pure size alone. A pleasing curvature from the back into the upper buttocks, increased hip volume and a rounder plumper shape are important aesthetic goals as well.

Currently injectable fat grafting offers the best method to try and achieve all of these buttock augmentation goals as the volume placement can cover a broader surface area. But not everyone is a good candidate for fat grafting due to inadequate tissue or failure of sufficient fat to survive. This leaves buttocks implants as the only other buttock augmentation option.

buttock-implants-indianapolis-dr-barry-eppleyIn the September 2016 issue of the Annals of Plastic Surgery, an article on buttock augmentation was published entitled Buttock Reshaping With Intramuscular Gluteal Augmentation in an Asian Ethnic Group: A Six-Year Experience With 130 Patients’. In this paper the authors performed an intramuscular implant technique using the well known XYZ method for pocket creation and implant positioning. The buttock implants used were of the oval-shaped smooth-surfaced silicone type. Most of the patients also had  lipsouction performed as well.The aesthetic results were determined using serial photography and by the patient’s own assessment on a 5-score scale.

The mean rating for patient satisfaction with the procedure was 4.6 of 5. (92%) The ratings of two independent plastic surgeons showed a mean score of 4.2 of 5. (84%) The authors conclude that intramuscular gluteal augmentation technique using solid silicone implants resulted in high patient satisfaction and good cosmetic reshaping of the buttocks.

asian-buttock-implants-result-back-view-dr-barry-eppley-indianapolisasian-buttock-implants-result-side-view-dr-barry-eppley-indianapolisThe unique aspect of this paper is that it describes the use of buttock implants in Asian women. What is unique in buttock augmentation about Asian women is that they often do not have enough fat to harvest for a BBL procedure and implants would be their only treatment option. Fortunately their size goals are usually more modest and a rounder shape is more important than a significant increase in size. This is the type of effect that is achievable with buttock implants and explains the high satisfaction rate for the procedure in this patient population.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Buttock Reconstruction with Dermal-Fat Grafts

Monday, October 10th, 2016


Background: Fat grafting to the buttocks is most commonly done for aesthetic reasons as in the well known Brazilian Butt Lift (BBL) procedure. Large numbers of patients treated around the world has shown that it can be very successful with relatively high amounts of fat retention in many patients. Less is well known, however, about fat grafting into the deformed or scarred buttocks for reconstructive purposes. (although a lot is known about fat grafting in breast reconstruction)

The most common use for fat grafting in buttock reconstruction is in the management of illicit silicone oil injections. While the injected silicone material can never really be removed the purpose of the fat injections to break up the scar contractures and introduce healthier tissue amongst them. Its effects are not really for volume augmentation per se. But injectable fat grafting is still effective for these purposes.

The rare condition of cojoined twins (one in 200,000 births) is a congenital condition that may require secondary buttock reconstruction. One type of cojoined twins is pygopagus (iliopagus) where they are joined back to back at the buttocks. This is reported to occur in about 20% of cojoined twin cases. Their separation ends up creating buttock scars and contour deformities as would be expected that awaits secondary reconstruction.

Case Study: This 26 year-old female presented with buttock scar contractures from having been separated at birth from her twin. Both buttocks had significant indentations, wide scarring and very visible suture track marks.

buttock-reconstruction-with-dermal-fat-graft-dr-barry-eppley-indianapolisbuttock-reconstruction-with-dermal-fat-grafts-back-view-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, all of her buttock scars including the track marks were excised. The deeper tissues were released and skin flaps raised. A large dermal-fat graft was harvested from the lower abdomen. The graft was de-epithelized and placed in a dermal up side position into both buttock defects and sutured into place. The incisions were closed in more narrow and linear line closures.

buttock-reconstruction-with-dermal-fat-grafts-result-bvack-view-dr-barry-eppley-indianapolisbuttock-reconstruction-with-dermal-fat-grafts-result-left-side-view-dr-barry-eppley-indianapolisHer four month after surgery results show that the fat grafts had been maintained as the buttock contours obtained in surgery persisted. The scars remained hyperpigmented as would be predicted give her ethnicity.  Secondary scar recision can be done later if desired.

While injectable fat grafting is most commonly used in the buttocks, scar contractures present different challenges. Wide scars and severe indentations may be better served by excision and deep scar release. This creates an open defect into which the need for traditional dermal-fat grafting must be used to create volumetric fill. These larger dermal-fat grafts take well in my experience.


1) Buttock contour deformities due to scarring can be effectively treated by fat grafting.

2) Injectable fat grafting to a deformed buttocks may require more than one injection session to optimize the buttock shape.

3) Dermal-fat grafting to the buttocks allows for scar revision and release at the same time but also requires a donor site harvest and scar.

Dr. Barry Eppley

Indianapolis, Indiana

Complication Rates in Buttock Augmentation

Thursday, April 7th, 2016


Buttock augmentation has become the fastest growing cosmetic body procedure over the past five years. While the us of fat injections (aka Brazilian But Lift) accounts for the majority of these buttock augmentation procedures, buttock implants also has a role for thinner patients who have inadequate fat stores for harvest.

Buttock Implants Indianapolis Dr Barry EppleyJust like fat grafting the number of buttock implant procedures has also dramatically increased compared to just a few years ago. With the rise in the number of buttock implant requests from patients has been greater scrutiny and investigation by plastic surgeons of the various techniques to perform it. By history, buttock implants have a relatively high complication rate. This contrasts relatively sharply with fat grafting which, as an autologous technique, would be expected and is known to have a fairly low number of complications.  But newer buttock implant augmentation techniques are believed to be much better than what has occurred in the past.

In the April 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Determining the Safety and Efficacy of Gluteal Augmentation: A Systematic Review of Outcomes and Complications’. In this paper the authors performed a literature search on published papers that reported buttock augmentation techniques and their outcomes. Forty-four (44) papers were reviewed. The most common complications of buttock implants in 2,375 patients were wound dehiscence (10%), seroma (5%), infection (2%) and temporary sciatic nerve dysfunction. (1%) The overall complication rate with buttock implants was around 22%. In 3,567 fat grafting patients the most common complications were seroma (4%), undercorrection (2%), infection (2%) and sciatic nerve pain. (2%) The overall complication rate with buttock fat grafting was 10%.

Buttock Implants (intramuscular) Dr Barry Eppley IndianapolisRecent advancements in surgical techniques for buttock implants, particularly the intramuscular method, has definitely lowered their complication rates. While this study shows what appears to be a ‘high’ complication rate of 22%, the reality is that it compares favorably to that of breast implants. Yet the average patient or plastic surgeon would not view breast implants as having an unacceptably high number of problems. It is just a reality that autologous tissues like fat will always have a lower complication rate than a synthetic implant for any form of body augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Ultimate Buttock Makeover

Saturday, March 26th, 2016


Background: Aesthetic buttock deformities consist of two types of undesired structural changes. Inadequate volume is the far more recognized buttock problem which can occur from either inadequate natural development (or natural development that one sees an inadequate) or from volume loss due to aging or weight loss. The other is tissue sag over the infragluteal crease (known as banana rolls) which can also occur from aging and weight loss. An induced cause is a result of the sequelae from liposuction of the lower buttocks.

The treatment of lack of adequate buttock size is either fat injections (BBL surgery) or buttock implants. While fat and implants may seem interchangeable in buttock augmentation, they are not. Implants are reserved for those patients who simply do not have enough fat to do BBL surgery. When using buttock implants the decision is whether to go into or above the muscle. When placed in the intramuscular position, it is possible to combine fat injections with buttock implant surgery.

Lower buttock sag is occurs when the superior skin and fat ‘fall’over the fixed infragluteal fold. Buttock ptosis or sag can also occur when the infragluteal fold attachments are lost or disrupted. In either case, a lower buttock lift or tuck is done to remove the overhanging tissues and recreate a fixed infragluteal fold position.

Case Study: This 48 year-old male wanted to improve the appearance of his buttocks. He had lost some weight over the past several years and his buttocks had gone flat. He also did not like the tissue overhang on the bottom of the buttocks. (the sagging)

Ultimate Buttock Makeover intraop result one sideUnder general anesthesia in the supine position he initially had his abdomen and flanks aspirated of fat by liposuction. Once moved into the prone position his flanks was also aspirated. Total liposuction aspirate was 1,800ccs. Once processed by filtering and washing a total of 360ccs of concentrated fat was available for injection. Through an infraguteal incision, solid silicone 270cc buttock implants were placed in the intramuscular position. A lower buttock lift was done on each side removing a predetermined strip and skin and fat. Through suturing to the muscular fascia, the infragluteal fold was remade. Lastly, 180ccs of concentrated fat was injected in various locations of the buttocks that had not been previously undermined for the placement of the buttock implants.

Ultimate Buttock Makeover intraop left oblique viewUltimate Buttock Makeover intraop left side viewUltimate Buttock Makeover intraop result back view Dr Barry Eppley IndianapolisHis immediate intraoperative results showed a significant improvement in the size and shape of his buttocks. While the amount of fat that will be retained remains to be determined, the contributions of the buttock implants and the lower buttock lift will be retained.

This case of buttock augmentation demonstrates the concept of the ultimate buttock makeover. Between implants, fat grafting and a buttock lift, there is no more aesthetic changes that can be performed on the buttocks at one time.


1) Genetics and aging affects the buttocks like any other body area with loss of volume and sagging.

2) Intramuscular buttock implants can be combined with subcutaneous fat injection grafting for an overall buttock augmentation effect.

3) Buttock augmentation can be combined with a lower buttock lift to create the ultimate buttock makeover.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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