Buttock augmentation can be done by two different methods. The most popular method today is the Brazilian Butt Lift (BBL), more generically known as fat injection buttock augmentation. It is popular because many people have excessive fat and this is a method of fat redistribution that creates improved body contours. Conversely buttock implants is less commonly done and with a longer recovery time. It is reserved for those women who do not have enough fat for a BBL buttock augmentation procedure.
While often seen as an either/or approach, buttock implants and the Brazilian Butt Lift can be complementary to each other in certain patients. In women that do not have enough fat to harvest for a significant buttock augmentation effect, buttocks implants can be initially placed. Often this will be adequate for many patients. But for those buttock implants placed in the intramuscular location, the size limitations of the pocket or the lack of adequate lateral volume near the hip area may create a desire for a second stage fat injection treatment.
While the amount of fat a patient has may be inadequate for a full BBL procedure, most patients will have enough for a smaller contouring BBL procedure after buttock implants. A few hundred ccs of fat injected around the upper and outer perimeter of the buttock implants can create a fuller and more shapely buttock augmentation result. This is perfectly safe as the plane of the fat placement remains above the muscle and well away from the implant pocket.
Injecting around buttock implants that are above the muscle (subfascial plane) is a bit more treacherous. While fat injections can still be done, it is critically important the injected fat does not violate the implant capsule. If that should happen, there is a substantial risk of creating an implant infection.
Buttock augmentation by fat injections, more commonly known as the Brazilian Butt Lift (BBL), has become widely popular over the past decade. The simultaneous body contouring by a liposuction fat harvest and the use of the fat for buttock augmentation offers a dual body contouring benefit. Compared with the use of buttock implants, a fat transfer can create a better buttock shape with a lower risk of complications and a faster recovery.
To achieve a successful Brazilian Butt Lift, a fair amount of fat needs to be harvested. To make it really worthwhile from a size standpoint, as much as 500 to 1000ml of fat is needed per side. And this represents concentrated fat not just liposuction aspirate harvest. To get an adequate fat harvest in many patients, it is an effort dependent process on the part of the surgeon. The use of power-assisted liposuction (PAL) makes it less fatiguing for the surgeon and has become my liposuction device of choice in large liposuction harvests such as is needed in BBL surgery.
In the November/December 2015 issue of the Aesthetic Surgery Journal the article entitled ‘Power-Assisted Gluteal Augmentation: A New Technique for Scultping, Harvesting, and Transferring Fat’ was published. In this paper the authors describe their technique to large volume buttock augmentation that combined power-assisted liposuction (PAL) and fat harvesting of the zones around the buttock with autologous fat transfer. In 110 patients liposculpting and fat harvesting were done with a power-assisted liposuction device. Fat was then transferred to the buttocks with simultaneous power-assisted vibration and tunnelization. Harvested liposuction volumes ranged from 1400 to 5000mls and injection volumes ranged from 300ml to 900ml per buttock. Patients were followed for an average of 20 months. Complications included a persistent burning sensation (5%), persistent swelling in the lower back (3%) and a mild infection in one patient. (1%)
While the use of PAL for far harvest is well known, the use of the power-assisted device for fat injection/placement has not been described previously. Previous studies have shown that fat harvested from PAL offers superior fat cell yields to that of non-power assisted methods. Injecting the fat through a 3mm liposuction cannula under the vibration of the device is an interesting approach to the multiplanar delivery of fat to the buttock tissues. Whether this truly improves the fat graft survival rates has not been proven, and this study certainly does not do so, but it appears to have a good mechanical effect at dispursing the fat throughout the buttock tissues. It certainly appears to be easier to place the fat than through traditional syringe injection methods.
Background: One of the most commonly requested body contouring surgeries today is that of the Brazilian Butt Lift. (aka BBL) While sounding both Brazilian and touting a butt lift, it is really buttock augmentation by fat injections. Fat is derived from liposuction of any body area that one wants reduced. The buttock augmentation is then done by processing the harvested fat in a concentrated fashion and then injecting it in a dual plane location both at the subcutaneous as well as the intramuscular buttock locations.
While may patients have an ideal or dream goal for their buttock augmentation, the limiting factor is always how much fat does one have to harvest. Thinking in an incrementally decreasing fashion, the final result of any BBL procedure is a function of the original fat harvested reduced by a factor of 4. Less than half of the fat aspirate harvested will be able to be used for injection. (in females the capture rate for the injectate is usually about 40% of what is harvested) Then, on average, if only 50% of the fat survives that will be the final buttock augmentation retained. Thus, for example, a 2000cc fat harvest becomes 400cc injected per buttock with the final volume retention of 200cc. That would be a small but noticeable buttock augmentation improvement.
Case Study: This 32 year old female desired a Brazilian Butt Lift procedure. She wanted the fat harvested from her abdomen and flanks which she had been unable to lose since her pregnancies. She approached her BBL surgery with the concept that the most important goal was the waistline contouring and any increase in her buttock size would be a bonus.
Under general anesthesia power-assisted liposuction (PAL) was used to harvest far from her abdomen and flanks. A total of 1,875cc f far aspirate was obtained. When filtered and double washed with Lactated Ringer’s solution a total of 700cc of concentrated fat was availablee for injection. That was split between her two buttocks for a total of 350cc per side.
At three months after surgery her buttocks showed a nice shape improvement with an overall modest size increase. Much of her buttock dimpling had been improved. Her apparent buttock size increase is as much a function of the waistline reduction as it is the actual increase in buttock size. This dual effect creates the BBL result for many patients who have less than large amounts of fat to harvest.
1) The success of a Brazilian Butt Lift depends on how much fat one has to harvest and how well it survives.
2) For many patients the success of Brazilian Butt Lift surgery is a function of the waistline narrowing above and the buttock augmentation below the waistline.
3) Many BBL surgeries (fat injections buttock augmentation) surgeries produce noticeable but more modest improvements which are quite satisfying to the patient.
Buttock enlargement by fat injections (aka the Brazilian Butt Lift) is the most popular method for this procedure. The dual benefit of the body contouring effect from the liposuction harvest to obtain the fat needed for injection is one of its most appealing attributes besides its non-implant method. But it is not a complication free procedure and there are risks of infection, fat necrosis and oil cysts as well as the uncertainty of how much of the far will actually take.
Death from buttock injections is most commonly associated with the injection of silicone oil and other unapproved materials. Intravascular injection of the materials with pulmonary emboli is the usual identified cause of the fatal outcome. But such adverse events with fat injections from BBL is far more rare.
In the July 2015 issue of the journal Plastic and Reconstructive Surgery the paper entitled ‘Deaths Caused by Gluteal Lipoinjection : What Are We Doing Wrong?’ In this paper from South America the authors polled Mexican and Coliumbian plastic surgeons for deaths from fat injection buttock augmentation. Between these two countries a total of 64 deaths were reported from liposuction with 13 specific deaths related to buttock fat injections. All deaths occurred wither during surgery or within the first 24 hours after surgery. Autopsy results from some of the patients showed very evident fat pieces/particles in the lungs. The authors conclude that injecting fat into the deep muscle planes of the gluteal muscles was the source of the fat emboli and its subsequent morbidity.
The goal of injecting fat into the buttocks is to achieve maximum fat survival. One of the techniques to help achieve that end is to place some of the injected at into the muscles. The greater number of blood vessels in the buttock muscles compared to that of the subcutaneous fat is believed to result in improved fat survival. However deep in the gluteal muscles are the subpiriformis and supraprirformis channels were larger blood vessels exist.
What this paper alerts plastic surgeons to is that, while injecting fat into the buttocks can be beneficial for fat survival, it should be done only in the superficial part of the gluteus muscle just after piercing its fascia lining. Deep fat injections runs the risk of inadvertently piercing the large gluteal vessels with risk of lethal fat embolism..
Background: Buttock augmentation has emerged over the past decade as the fastest growing body contouring procedure that now rivals breast augmentation on overall interest and number of procedures performed. While implants can be used for the buttock augmentation material, fat grafting is by far more common and popular. Injection fat grafting offers a natural and potentially more effective buttock augmentation material than implants as it can provide a greater volumetric effect for many patients.
Fat injection buttock augmentation, better known as the Brazilian Butt Lift (BBL), has the unique quality of providing a dual body contouring benefit. The need for large amounts of fat obtained through liposuction creates an aesthetically desireable body contouring/thinning above the waistline. The more aggressive that liposuction is performed the more fat that is available to be injected and the greater the surrounding body shape reduction is. Any buttock augmentation result will appear bigger if the waistline above it is smaller.
But no matter how much fat is obtained for a BBL, the result will ultimately depend on the percent of injected fat that survives. While there are numerous methods of fat harvest, preparation and injection, the optimal method for fat grafting to any body area remains up for debate.
Case Study: This 38 year-old male wanted a combination of buttock augmentation and contouring of multiple body areas. While she already had a wide buttocks the overall volume and projection was lacking. She previously had been through breast reduction and a tummy tuck by other surgeons previously with satisfactory results.
Under general anesthesia, she initially had extensive liposuction done on the full abdomen, flanks and back obtained 5,500cc of aspirated fat. The fat was concentrated down to 1,600cc by a filter and double wash method with Lactated Ringer’s solution. The in the prone position 800cc of fat was injected into each buttock and hip areas.
When seen at 15 months after surgery, her buttock augmentation result was impressive. While the body contouring effect above it was extremely helpful in enhancing the size of the buttocks, the volume of fat take created much of the BBL result seen. While there is no way to really estimate what volume of fat survived, it is fair to say that as much as 75% may have lived. At over one year after surgery, this retained buttock fat volume would be deemed permanent.
1) The success of the Brazilian Butt Lift depends on how much fat can be harvested and injected.
2) The take of fat in the Brazilian Butt Lift procedure can be 50% or higher for many patients.
3) The body contouring effect around the buttock augmentation result enhances the overall buttock enlargement effect.
Buttock augmentation is most commonly done today using fat injections. (aka Brazilian Butt Lift or BBL) It is popular because it not only offers a natural method of buttock enlargement but has a concomitant benefit of body contouring through the liposuction fat harvesting. Many good buttock augmentation results from this procedure are the result of the combination of both effects and no just the fat grafting itself. Waistline narrowing and buttock enlargement together can create a powerful change in the lower trunk/pelvic region.
This combination of waist and hip change has long been regarded as attractive in many cultures around the world. A waist-hip ratio of 0.7 in females is the aesthetic ideal and may be achievable with a BBL surgical approach. The question is how effective is this procedure in reaching this aesthetic ideal and how successful is the fat that is injected maintained.
In the May 2015 issue of the journal Plastic and Reconstructive Surgery, the article entitled ‘Gluteoplasty with Autologous Fat Tissue: Experience with 106 Consecutive Cases’. In this paper the authors looked at 106 consecutive female patients who underwent a BBL procedure over a three year period. One key inclusion factor is that they could not have a weight change greater than 10% during the follow-up period. The degree of satisfaction (patient and surgeon) was assessed on a scale of 1 to 4 with four being the highest rating. The average age of the patients was 33 years old and the average amount of fat injected into the buttocks was 505ccs. No patients experienced any medical complications. Five patients (4%) developed a seroma in the liposuction harvest area. The vast majority of the patients (103 out of 106, 97%) has high satisfaction ratings of 3 and 4. Only one patient (1%) reported aesthetically troubling fat volume loss months after the procedure. Two patients (2%) had revision procedures for excessive gluteal fullness at the sides of the buttocks.
As can be seen in this study, BBL surgery has a high satisfaction rate with a very low incidence of any major problems. The autologous nature of the procedure is undoubtably the reason for few complications. Their experience shows that such fact injections are sustainable and not prone to a high rate of resorption after surgery. The one aesthetic problem that they did encounter infrequently was too much lateral fullness. This can be avoided by drawing a line laterally between the anterior and posterior hip area and not injecting in front of this line.
The authors point out that removal of excessive fat from the lumbosacral region is an important factor in obtaining a good buttock shape and must be done in every patient. This is the importance of performing the procedure in the prone position prior to the fat grafting.
Fat grafting to the buttocks is known to have a lower rate of resorption than that which occurs in the face. The exact reason is not known but may be a function of a larger muscle mass and higher volumes of fat injected. As a result, BBL surgery usually has better results and higher patient satisfaction than facial fat grafting. The fat redistribution effect is also more likely to achieve a pronounced recontouring than just fat grafting alone.
It is important to point out that no patients in this study was injected with mega volumes of fat (1,000ccs or greater) nor ws there an attempt to balloon out the buttocks to very large proportions. The success in this study’s patients may not translate to high volume buttock fat injections.
Buttock augmentation has gained tremendous popularity as a surgical procedure in just the past decade. This has largely been due to the use of fat injections for buttock augmentation, an approach that offers a diametric effect with enlargement of one body area (injection site) and reduction of many other body areas (liposuction harvest) during the same procedure. While buttock implants have been around much longer, their use is a fraction of that of fat injections due to a more invasive procedure with greater risks and a longer recovery.
But despite the popularity and success of buttock fat injections (aka the Brazilian Butt Lift or BBL), it is not for everyone that desires buttock enlargement. The biggest reason is lack of adequate fat to harvest. Thin or even medium build patients may not have enough to harvest by liposuction to make an immediate or sustained buttock enlargement result. Gaining weight for a BBL can be a flawed approach since such fat volumes can be lost after surgery with dieting an exercise.
Buttock implants will continue to play a small but important role in buttock augmentation. And more buttock implants are done today than ever before because of the overall societal desire for larger and more shapely buttocks. But the rise in buttock implant procedures has given risen to some misunderstandings with their use. The main issue to consider is the pocket into which they are placed. Understanding the implications between subfascial and intramuscular location is the most important buttock implant decision.
The subfascial buttock implant location has several advantages. It is technically easier for the surgeon to perform, has somewhat shorter and less uncomfortable recovery and permits the placement of much larger buttock implant sizes. Its disadvantages are that the development of seroma and the risks of infection are higher. The use of postoperative drains are critical to educe these risks. In addition, the occurrence of capsular contracture and implant ‘show‘ is also higher as well as that of chronic discomfort. An important anatomic key is that one should have good soft thickness between the skin and the deeper fascia for this buttock implant location.
The intramuscular buttock implant has several advantages. It has a lower risk of seroma and infection due to a partial muscular cover. It also has no risk of implant show and probably has the best long-term retention due to its thicker soft tissue cover. Its disadvantages are that it is technically harder for the surgeon to master, limits the size of implant that can be placed (rarely bigger than 350ccs) and has a longer and more uncomfortable recovery. Patients that have thin tissues over the buttock with a scant subcutaneous fat layer or only want a more modest buttock augmentation result are the best candidates for the intramuscular implant position.
As can be seen by their various advantages and disadvantages, buttock implant augmentation results are highly influenced by the pocket location. Besides the recovery, the biggest difference is the size of the implant that can be placed.
The use of implants is one effective method for buttock augmentation. It is far surpassed by fat injections (aka Brazilian Butt Lift, BBL) in number of buttock enhancements done, however, due to the appeal and usual availability of adequate fat to harvest to do the procedure. The exact numbers are not known but I would estimate that for every 25 to 50 BBL surgeries done in the U.S., only several buttock implant procedures are done. It is probably a 10:1 ratio of BBL to implant surgeries.
But the tremendous rise of BBL surgeries has also led to an increase in buttock implant surgeries. This is because some people are not good candidates for fat injections because they do not have an adequate donor source of material. There may also be some ‘failures’ in BBL surgeries due to fat absorption and minimal augmentation outcomes as a result.
Buttock implants is the most reliable method of buttock enhancement because the implant’s volume is stable and does not change after surgery. Unlike BBL surgery, implants can achieve only a certain amount of augmentation due to the limits of implant sizes made and the tissue pockets that can be created to contain them.
Like breast implants, there are two locations in which the buttock implants can be placed. Buttock implants can be placed either intramuscular (not beneath but inside the gluteus maximus muscle) or subfascial. (above the gluteus maximus muscle) There are advantages and disadvantages to either implant location. Neither implant location is necessarily better than the other and each patient must be considered individually based on their buttock shape, tissue thickness and their buttock enhancement goals.
Historically subfascial buttock implant placement has been most commonly done. It is somewhat simpler to technically perform, has a less painful recovery, and enables the largest buttock implant sizes to be placed. Since the implant is more superficial with less tissue coverage, it is best to place in patients that have some subcutaneous fat tissue thickness. Its disadvantages are that it has a higher rate of infection and seromas and the outline of the implants could be more visible. If intergluteal wound dehiscence occursm the implants are at greater risk of infection. It also has a higher long-term risk of tissue thinning and greater implant profile visibility.
Intramuscular buttock implants is becoming a more common surgical technique but it is still done far less than subfascial buttock implants. It has the advantages of providing good vascularized tissue coverage of the implants and has a lower risk of infection and seroma formation as a result. Because the implants are placed deep, one can still have fat injections done above them for further augmentation later if desired. Its disadvantages are that it is a more ‘complex’ surgical technique to master and its is more painful with a more difficult recovery in the first few weeks after surgery. Its most limiting aspect is that the intramuscular space offers only a limited capacity to handle implant size with the upper limits in the 300cc to 350cc range.
Buttock implants will never rival fat injections but they have a significamt role to play in buttock augmentation. They remain as the only option for those patients that have inadequate fat stores for the BBL procedure.
Background: Two of the most popular body contouring procedures today is one from the past and a relatively new one. Tummy tuck surgery has been around for over five decades and is highly successful at reshaping the abdominal wall often in a dramatic fashion. Conversely, buttock augmentation by fat injections (aka Brazilian Butt Lift) has been available now for only a decade and is the fastest growing body contouring procedure in total number done being done compared to just five years ago.
While a tummy tuck works by removing and discarding unwanted tissues, a Brazilian Butt Lift works by recycling/redistributing them. Fat removal by liposuction is part of many tummy tucks to help extend its contouring effects around the waistline and is an additive ‘bonus’ to the procedure. Conversely, fat harvest by liposuction is an essential part of a Brazilian Butt Lift and the more fat that can be harvested the better the buttock augmentation result will be.
It is not uncommon that the desire for abdominal reshaping and buttock augmentation exist in the same patient. The first question is whether a tummy tuck and buttock augmentation can be safely done at the same time. Depending upon the magnitude of the liposuction harvest and the extent of the tummy tuck, the answer would be yes if neither one was particularly extensive.
The other question is whether any part of the excised portion of the tummy tuck can be used for the buttock augmentation. This is a debate between aggressively harvesting fat from under the tummy tuck prior to its excision or using the tummy tuck discard as a dermal-fat graft ‘autoimplant’ in the buttocks. The vast majority of plastic surgeons today would use liposuction to harvest fat at the same time as the tummy tuck. There are growing numbers of reports in which the tummy tuck segment is being recycled and used like a buttock implant.
Case Study: This 30 year-old female wanted to have a tummy tuck to reshape her abdominal waistline as well as a buttock augmentation at the same time. It was agreed that she did not really have an optimal amount of fat to harvest to achieve a substantially larger buttocks. But she wanted to take any fat that could be harvested and place it into the buttocks as a ‘bonus’ to the procedure.
Under general anesthesia, liposuction was initally done very aggressively under the tummy tuck portion which was to be removed. Liposuction was also done around the waistline and into the flank areas to harvest as much fat as possible. The tummy tuck procedure was then completed. The harvested fat was processed and concentrated, obtaining a total volume of 480cc. Each buttock was injected with 240cc in a cross tunneling fashion.
Her recovery was typical for a tummy tuck and the buttock augmentation do not prolong it. At three months afterwards, she showed marked improvement in her abdominal contour and mild enhancement of her buttock size. While the increase in her buttock size was not substantial (nor was it expected), its effect was greater due to reshaping of the waistline above both buttocks.
Some buttock augmentation procedures are done as a ‘bonus’ to other body contouring efforts. While the amount of fat that is often obtained by liposuction may be inadequate to justify a ‘stand alone’ Brazilian Butt Lift, some patients may want the fat used for the buttocks with the attitude that it can not hurt and anything they get is more than they currently have.
1) Combining a tummy tuck with a Brazilian Butt Lift is not uncommon and can safely be performed together.
2) The planned excisional portion of the tummy tuck can be aggressively liposuctioned as part of the donor fat for the Brazilian Butt Lift.
3) Like all Brazilian Butt Lifts, the result is a combination of how much fat can be harvested and how much fat survives.
There are two effective and well established techniques for either buttock or hip augmentation. They are either fat injections using your own liposuction harvest (Brazilian Butt Lift) or soft silicone elastomer implants that can neither rupture or leak. Each has their own advantages and disadvantages, as does every surgical technique, but both may not be appropriate considerations for every patient. For some only fat injections will work and for others implants may be the only option. Each patient must be considered individually based on their anatomy and the desired buttock or hip augmentation size they want to achieve.
Fat injection augmentation is, by far, the most commonly performed buttock/hip augmentation method because of its natural appeal, the side benefit of the body contouring from the liposuction harvest, and a quicker recovery. It has few real complications other than how well it works. The key qualifier is how much fat does one have to harvest. For those that try to gain weight for the surgery, be aware that the fat that you will lose first will be that which was gained as you return to your baseline weight…and it will be from your buttocks. Thus gaining weight for a Brazilian Butt Lift is a flawed approach. You either have enough fat to do it or you don’t.
In addition, at least 50% of the injected fat will be absorbed within months after surgery regardless from what part of the body from which it is harvested. This can even occur despite the best harvest and concentration methods. As a general rule, for every 1000cc (or liter) of fat that is harvested only about 30% to 40% will distill down to what should be injected. Better fat concentration equates to improved survival but a lower total volume of fat available to be injected.
When you simply don’t have enough fat, an implant approach is the only option. And that is how the decision for an implant should be primarily made. Buttock and hip implants have been around for a while now and the quality and size options of implants are so much better today. The implants are very safe but where they are placed and the surgeon’s skill and experience in placing them can significantly impact the rate of potential complications. Because they are implants, by definition, they will have a higher rate of complications (infection, hematoma, capsular contracture) than that of fat injections.
Implants will also have a longer recovery because placing them is more ‘invasive’ and involve areas that impact functions such as sitting and walking. Specifically for buttock implants, they should be placed within the gluteus maximus muscle. In this location, the implant will not be able to be felt nor sag or migrate later. Buttock implants on top of the muscle have an easier recovery but carry with it a higher incidence of problems later.
If you are a borderline candidate for fat injections or are uncertain if you have enough fat, make sure you have a consultation with a plastic surgeon that provides both fat and implant methods of buttock and hip augmentation. In this way your surgeon has no bias either way and will have enough experience to choose which method is best for you… rather than just the method or surgical procedure that they can do. There is no doubt that just about every buttock augmentation patient wants to use their own fat and it is easy to fall into the trap of hoping it will work out when it may never have had a chance to be as successful as you wanted.
There is also a combined approach with implants placed in the muscle and fat injections added above the muscle in the subcutaneous fat layer. This may be considered when one only has a modest amount of fat to harvest but a very flat buttocks and wants to maximize volume. This makes anatomic sense and can be successfully done. There is the question of whether it should be done together or as a staged technique. This must be considered on an individual basis as there are some increased risks of implant infection.
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.