Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘buttock implants’ Category

Managing Postoperative Buttock Implant Incision Dehiscences

Sunday, January 21st, 2018


Buttock implants have had an increasing role in buttock augmentation due to the popularity of Brazilian Butt Lift (BBL) surgery. It has greater awareness of surgical buttock augmentation. But when the results from fat grafting are inadequate or one does not have enough fat to harvest, implants are the remaining buttock enhancement option.

While buttock implants comes in different styles and sizes and there is debate about implant location (subfascial vs intramuscular), they all must be placed through an intergluteal incision regardless of style size and pocket location. This incision can be a single midline incision through which both right and left implants are placed. An alternative is two paired intergluteal incisions, separated by a thin midline island of skin over the sacrocutaneous ligament, to keep totally separate the right and left implant pockets.

But whether there is one or two incisions at the intergluteal crease, they are exposed to shearing forces from sitting and sliding. This exposes the incisional closures to separation after surgery (wound dehiscence), which often does not occur until weeks later. Its occurrence is not uncommon and I counsel my patients to expect some degree of it 100% of the time.

These intergluteal incision separations do not expose the implants, even in the subfascial pocket, because there is as three layer closure of tissues between the skin closure at the implant pocket. But it will be associated with exposure of fatty tissue and the weeping of fluid. Once the incision separates trying to reclose it by secondary suturing will not work as the inflamed tissues will not hold sutures.

Such buttock implant incision dehiscences are best treated by the application of 1% Silvadene cream, a well known topical burn care treatment. Its combination of sulfa and silver is a potent antimicrobial that is also a wound debriding agent that helps to create more granulation tissue. It is this granulation tissue that must fill up the wound before the surrounding skin edges will finally close the wound. This is a process that can easily take 4 to 6 weeks to achieve a fully healed wound.

No matter what closure technique is used for intergluteal buttock implant incisions, they all are associated with some percentage of postoperative wound separations. While this can be scary and frustrating to the patient, successful healing can be achieved with topical wound care and patience.

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

OR Snapshots – Hourglass Figure Surgery

Wednesday, November 29th, 2017


Altering the shape of a woman’s body has been a part of plastic surgery for over fifty years. This has traditionally meant such procedures as breast augmentation, liposuction and tummy tucks. In the most contemporary forms of female body contouring the role of the buttocks and hips, once deemed undesirable, have become popular. This has added buttock and hip augmentation using either fat transfer and implants to the options available for body reshaping.

The hourglass figure shape is one in which there is larger breasts, a narrow waist and hip widths similar to that of the breasts. In its most extreme form it has an appearance to that of an actual hourglass with a wide upper and lower half and being narrow in circumference between the two halves. Some deem such a female body shape as more desirable than others. Between the options available in plastic surgery and the use of traditional corsets the hourglass shape today is more attainable than it has ever been.

One newer addition in hourglass figure surgery in is that of rib removal. Reductions in the lengths of ribs #10, 1 and 12 removes the last rigid anatomic restriction to maximal horizontal waistline reduction. This procedure is only appropriate when the more traditional use of liposuction has already been done to reduce any fat collections around the waistline. When combined with other body contouring procedures such as buttock augmentation (in this picture with buttock implants), the hourglass figure may become a reality.

Hourglass figure surgery has numerous options to both augment the upper and lower half as well as narrow what lies in the middle. Larger breast implants, custom buttock implant designs and rib removal represent options for those women that seek a maximal approach to altering their body into more of the hourglass shape..

Dr. Barry Eppley

Indianapolis, Indiana

Custom Buttock Implants

Friday, May 26th, 2017


Buttock augmentation is most commonly done using fat injections. Known by the term, Brazilian Butt Lift or BBL for short, large volume fat injections can be done to increase buttock size over a broad surface area. While limited by how much fat the patient has to harvest and how much of that injected fat will survive the transplantation process, buttock augmentation by fat injection is usually more successful than not.

When fat injections is not an option for buttock augmentation due to inadequate fat stores or a prior fat injection procedure that has not been successful, buttock implants are the only other buttock augmentation option. Buttock implants offer an assured permanent size increase through the dimensions and volume of the non-resorbable solid implant material.

Buttock implants come in a variety of volume sizes. They can be as low in volume as 250cc up to as high as 700ccs amongst the two U.S. manufacturers. As a general rule, implants under 400ccs can be placed in an intramuscular location but bigger buttock implants have to be placed in a subfascial tissue plane.

While this range of buttock implant sizes can fulfill most buttock augmentation needs, they are not adequate for every patient’s anatomy and size goals. Between the base diameter (width of the implant) and the desired volume, the use of custom buttock implant designs may be needed. With the computer design process, implant dimensions can be tailored to any individual patient needs. Rather than being locked into what is available off-the-shelf, the base diameter and the projection of the implant can be designed from which the final volume can then be calculated.

Most custom buttock implants are larger but the incision needed to insert them remains the same. (7cm intergluteal incisional length) For this reason using a funnel insertion device is important to prevent tearing the low durometer solid silicone gel material whose diameter often exceeds the incisional opening by a factor of 2X.

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

Intramuscular Buttock Implants

Wednesday, August 17th, 2016


The most common form of buttock augmentation is by fat injections. Known worldwide as BBL surgery (Brazilian Butt Lift), it offer a natural buttock enhancement procedure with the dual benefit of reductive body contouring from the fat harvest. But despite its appeal not everyone is a good candidate for it. It requires a certain amount of body fat to create the volume needed for a visible buttock size inrcrease.

In thinner patient with low body fat, buttock augmentation can only be done with implants. Buttock implants have a very checkered history with relatively high complication rates for a variety of reasons. But today’s method of placing buttock implants in the intramuscular location offers a much lower rate of complications and the need for revision surgery or subsequent implant removal.

Intramuscular buttock implant surgery, however, has three key differences from past techniques that are very important for patients to understand. These are pocket location, size expectation and postoperative recovery.

Buttock Implants Indianapolis Dr Barry EppleyIntramuscular Buttock Implant Placement Dr Barry Eppley IndianapolisUnlike breast implants, the placement of buttock implants is inside the muscle not under it. This is not a natural tissue plane and creating the intramuscular pocket requires experience in doing it. It is a much harder technique to learn than placing the implants above the muscle. (subfascial location) Learning the technique in cadavers at a training course is really the best way to develop expertise in this form of buttock augmentation.

Female Buttock Implants intraop result left side view Dr Barry Eppley IndianapolisFemale Buttock Implants intraop result right oblique view Dr Barry Eppley IndianapolisBecause the intramuscular pocket is more confining than the subfascial pocket, the amount of buttock size increase will be less. As a general rule the largest size of intramuscular buttock implant that can be placed is in the range of 300cc to 330cc for most patients. This more ‘modest’ buttock size increase is a very important concept for patients to understand. For a permanent result that has much fewer complications a smaller buttock size must be accepted.

Separating the gluteus maximus muscle to make an implant pocket does carry a more significant recovery than any other form of buttock augmentation. While Marcaine and Exparel local anesthetic injections definitely help reduce discomfort right after surgery this is a significant muscle injury on a body part that has to be compressed (sit on) at some point after surgery. It is important that patients do not under estimate the recovery period from intramuscular buttock implants.

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits