Plastic Surgery
Dr. Barry Eppley

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

Posts Tagged ‘buttock enhancement’

The Illegal Practice of Black Market Buttock Injections

Tuesday, January 28th, 2014


On the surface, no one would say to themselves…please inject my body with some foreign substance (of which I don’t know what it is or even care) in an unsterile/unclean hotel room or in a house or aprtment by someone who has no medical training at all. That does not sound like a good idea to any reasonable person. And, of course, it isn’t.

But yet that is exactly what is happening all across America in every major city. The pursuit of a quick fix to a bigger and more shapely buttocks has driven many women to pursue unscrupulous injectors who for the sake of a quick buck prey upon the aesthetic needy and often financially challenged. Driven by fashion and cultural trends, the buttock has taken on great significance for many women (and even a few men) and the pursuit to have a better one forces some to take unknowing risks.

To no surprise, non-medical grade materials injected into the buttocks can and often does cause problems. From granulomas that cause hard lumps to infections and immunologic reactions that result in infection and skin loss, irreversible buttock tissue problems can develop. Such problems can result in medical and aesthetic deformities that far exceed the seemingly simple injection session. In some cases, these injected people have even died from foreign material emboli and septic shock due to massive infection.

The illegal buttock industry has been highlighted in a recently released short film entitled ‘ Buttloads of Pain’. This film chronicles the seedy underworld where these back room procedures are performed on the unsuspecting and ill-informed. The film highlights where these illegal buttock entrepreneurs operate the most, in the places where buttock envy runs rampant from South Florida to Brazil. The type of substances run the gamut from silicone oil to caulking compounds, almost anything that can be bought cheaply in a hardware store.

While not every such buttock injection material elicits an immediate reaction, those that don’t can still do so years later. Known as a chronic inflammatory reaction, the body eventually develops an overt reaction to the material that has been smoldering for years. Cysts, draining boils, skin discoloration and severe lumpiness and pain are common scenarios. Such buttock problems are very difficult to treat as the only sure cure is wide excision of the involved tissues which would leave a massive buttock contour deformity. In addition, few plastic surgeons want to tackle these foreign body buttock problems due to their management difficulty and protracted course.

While the allure of black market buttock injections is that they are far less costly and have a quicker recovery than the medically accepted treatments of fat injections or implants, their real cost may make these legitimate buttock surgeries seem like a bargain. Hopefully this film will prevent a few people from becoming victims of this despicable cosmetic practice.

Dr. Barry Eppley

Indianapolis, Indiana

The Increasing Popularity of Buttock Enhancement

Thursday, September 27th, 2012


While the overall number of plastic surgery procedures continue to slowly rise each year, some procedures have increased more than others. One such procedure is buttock augmentation, up nearly 40% last year.  Plumping procedures have always been popular in plastic surgery and the buttocks represents the biggest body part to plump of them all.  Whether it is higher, rounder or just smoother, there is a growing number of people who want a better one.

While increasing buttock size has been around for some time, the use of implants to do it limited the number of people who wanted to undergo it. One should not confuse the surgery and the recovery process of buttock implants with that of breast implants. While very effective and permanent, it is a harder procedure to go through with more discomfort and a longer recovery.  After all, having to sit on your implants after surgery is much different than having them merely placed onto the front part of your chest.

What has led to a dramatic increase in buttock augmentation is two main factors. In an ever increasing multi-cultural society, the buttocks is a greater focus of body aesthetics and shaping. Amongst Black, Latino, gay and transgender people, the size and shape of the buttocks takes on increased emphasis. Add to that the exposure that certain Hollywood stars, such as Kim Kardashian and Jennifer Lopez, have placed on a shapely derriere and the public is sure to follow. The second factor for the procedure increase is the method now most commonly used to do it, fat injections.

Fat injections offer a more appealing alternative to the use of implants for buttock augmentation, not only because it is a more natural material but also because of the concomitant benefit of fat reduction and body contouring achieved at the same time. Getting fat for the injections requires a liposuction harvest and a generous amount to do it since the fat must be concentrated for injection. This always results in a significant body contouring effect, usually on the abdomen, flanks and along the upper back. This alone can make the buttocks look bigger or more shapely because the body is reduced around them. In essence, buttock augmentation with fat is a redistribution effort.

While buttock fat injections is an obvious plumping procedure, it has gotten a more commonly known name that is really a misnomer  and even a bit misleading.  Called the Brazilian Butt Lift and other such lifting names, it is not really a lift at all. It is no more of a lift than one would consider a breast implant as a breast lift. To some degree, there is a mild lifting effect from filling out the skin but it is primarily a volumizing effect.

It is also the one operation where being a little overweight is beneficial providing more donor fat to harvest. There are even some patients who gain weight for the procedure although I do not advocate that approach. At the least, it is not an operation like a tummy tuck or liposuction where you want the patient to have done everything beforehand to be as lean as possible to get the maximum benefit.

For those patients who do not have enough fat, however, buttock implants are the only way to do it. The good news is that buttock implants today are far more advanced with gel-like softness and a large number of sizes and shapes to use. Employing an intra-muscular plane of insertion, results are better and the risk of implant-related complications such as infections and fluid collections much reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Lower Buttock Lift for the Saggy Derriere

Friday, July 20th, 2012

Background:  Buttock enhancement has become a popular contemporary procedure, offering improvements to a body part that historically has been thought of as having few choices. People have numerous aesthetic buttock concerns including size, shape and tone/firmness issues. Buttock augmentation with fat injections (aka Brazilian Butt Lift) is most well known today as it has become fashionable to have a rounder fuller buttock, particularly amongst Hispanic and African-Americans.

But not all buttock concerns are about size. The saggy buttock  is an unflattering shape that is associated with being flat and having skin that has slide off of the gluteal muscle onto the posterior thigh area. This happens as the buttock is affected by weight loss and aging. Weight loss causes the skin to fall as the volume support vanishes with fat absorption. Aging has its own  volume loss but the skin sags as it loses elasticity after having been exposed to repetitive stretching over a lifetime.

One important aesthetic feature of the buttock is the inferior gluteal fold. Like the inframammary fold in the breast, it serves as the transition point between two anatomic structures…the buttock and the thigh. It exists because there are attachments from the underside of the skin along the crease to the muscle below. This allows the more fibrofatty tissue to remain over the buttock where it is needed for padding support. Loss of the inferior gluteal fold attachments allows the buttock skin to sag down onto the thighs.  

Case Study: This 35 year-old female wanted to improve the shape of her buttocks. She had adequate volume but did not like the lower end of her buttocks because it was ‘saggy’. She wanted the bottom part to tuck in more and have a well-defined crease. She was willing to accept a scar for that improvement.

Under general anesthesia she underwent a lower buttock lift using an ellipitical excision technique. The underside of the skin was sewn to the fascia overlying the gluteal muscle to help create a well-defined crease and invert the incisional closure. All sutures were under the skin in a subcuticular fashion. Her only dressing afterward was surgical tapes that were glued over the incision line. This was an outpatient procedure with few restrictions afterward other than avoiding strenuous activities that involved bending over greater than 90 degrees at the waistline for three to four weeks after surgery.

She had an uneventful recovery with no wound separation problems. She had fine line scars along the natural inferior gluteal crease that faded to white by six months after surgery. In profile she had a well-defined break at the crease between the buttocks and the posterior thigh.

Of the available buttock enhancement procedures, the lower buttock lift is the least commonly performed. While it is the one buttock procedure that has the longest history in plastic surgery, it is less desired than buttock augmentation that provides volume by an implant or fat injections. But for the patient who has effacement of their inferior gluteal fold and a saggy lower buttocks, this simple lift procedure can provide a significant improvement. It can also be performed in conjunction with either of the buttock augmentation procedures since its surgery site is away from where implants or fat are placed.  

 Case Highlights:

1)      A common buttock deformity is ptosis or the sagging buttock due to skin falling over the gluteal  crease or descent of the gluteal crease itself.

2)      Excision of loose and overhanging skin can recreate the inferior gluteal fold and create a clear transition between the buttocks and the posterior thigh.

3)      Inferior gluteoplasty or lower buttock lift requires a minimal recovery other than avoiding severe stretching of the incision line.

Dr. Barry Eppley

Indianapolis, Indiana

Buttock Enhancement Through Combination Liposuction And Fat Injections

Tuesday, October 18th, 2011

Enhancement of the buttocks has become enormously popular over the past decade. Most methods of cosmetic buttock surgery are perceived as that of increasing its size through either implants or, more commonlytoday, fat injections. But buttock enhancement is as much about contouring and reshaping as it is about size increase alone. Large poorly-shaped buttocks are far less appealing than slightly smaller ones that have a more desireable shape.

When evaluating the buttocks, it is best to see it as an anatomic structure with different areas as zones that can be modified. There are essentially six aesthetic zones to the buttocks which can be described as follows: zone 1 is the midline lower back/sacral area, zone 2 is the upper lateral region or low flanks often also called the muffin tops, zone 3 is the middle lateral region where the muscle inserts, zone 4 is the low lateral or greater trochanter area, zone 5 is the upper inner thighs, and zone 6 is the amount of buttock projection seen in the side view.

The relevance of these buttock zones is that they all represent areas of either reduction (liposuction) or augmentation. (fat injections) Zones 1 and 2 are the areas of greatest liposuction fat removal while zones 3, 4 and 6 are the primary areas of fat injection augmentation.

Improving buttock shape is more than just injecting a lot of fat all over the entire buttocks. Skillful reshaping by fat removal combined with fat augmentation is a more successful approach. In many patients, it just isn’t possible to place enough fat or have enough of it consistently survive to create a better shape by simple volume addition alone.

In improving the shape of the buttocks the contour of the hips is a key area. Buttock projection can look diminished when the hip and back area has a good thickness of fat. This obscures any appearance of an upper gluteal shelf. When liposuction is done to reduce the hip and back fat, an inward skin retraction occurs. This creates an inward indentation or concavity which can match the curve of the lower of the lower buttocks as it dips inward towards the posterior thigh. By so doing, the illusion of a greatee central buttock projection is created. This can be further enhanced by concurrent fat injections into this central mound. This is a good example of the ‘ying and tang’ approach to increasing any body contour. The combination is always better than either approach alone.

The survival of fat injections in the buttocks is always an issue of concern. While there are numerous methods of processing fat prior to injection, none have been shown to be better than another. Some method of concentration is important to eliminate excess oils and fluids. In the buttocks, unlike many other face and body areas where fat is injected, there is a choice of injecting into the subcutaneous fat layer, the muscle, or both. The buttocks have a large gluteus maximus muscle and most of the fat injected should be into it. This will ensure the most amount of injected fat survival due to the better intramuscular blood supply.

Buttock augmentation is best done through a combination of zonal liposuction reduction and intramuscular fat injections. This is best for those patients that have an excess of fat around the buttocks in the hips, back and waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Buttock Implant Incision Location and Scar

Tuesday, March 10th, 2009

When one wants assured buttock enhancement, the use of a synthetic implant is needed. Whether the implant is placed above the muscle (subfascial) or inside it (intramuscular), an incision is needed to get to the desired recipient site. The standard incision for buttock implants is placed at the apex of the gluteal crease and extends upward to the very low back region for a total length of about 7 cms. Closure of this incision and the use of postoperative drains is critical in preventing postoperative problems with it.


The few inches of the intragluteal incision is surprisingly all that is needed to insert the soft and flexible buttock implants. Because it is a single incision that provides dual access for both implants, how it is closed is absolutely critical. All layers must be carefully reapproximated from fascia up to skin to provide tissue separation of the two implants and to be able to resist the shearing forces from sitting and sliding across this area in the early postoperative period. While some minor incisional separations can occur, major wound breakdown is to be avoided. The concomitant use of drains, one under each implant, is important with the placement of buttock implants to prevent the most common complication from their use, that of fluid accumulation or seroma formation. They will exit from the sides of the incision, about one to 2 cms to the side, until they are removed 7 to 10 days after surgery.


Understandably, most patients are concerned about how these scars will look after surgery. This scar is mostly well hidden in the crease with only a small part just above the ‘crack’ area. The drain tube exit scars appear as small circles just to the side of the vertical scar. While these scars will be red for up to six months after surgery, eventual fading of them will make their appearance as a fine white vertical line and small white dots. Most patients consider these scars as negligible and a very small trade-off to make for the benefits of a larger and more shapely buttocks appearance.


Dr. Barry Eppley

Indianapolis, Indiana

The Brazilian Butt Lift for Buttock Augmentation

Sunday, March 1st, 2009

Buttock augmentation surgery continues to grow in popularity. One of these techniques is the Brazilian Butt Lift which helps to enlarge and reshape the buttocks to a more prominent and youthful appearance. Ironically, it is not a buttock lift in the traditional sense but a method of fat injections to do the reshaping and the ‘lifting’.

This method of buttock augmentation reshapes the tissues overlying the gluteus muscles by using one’s own fat in a transfer method. For thin patients who do not have enough fat to harvest and transfer, they will need to enlarge their buttocks by the insertion of a silicone implant. In a good candidate for the Brazilian Butt Lift, liposuction is first done in areas around the buttocks such as the hips, lower back, and on the posterior thigh up to the lower buttock crease. The removed fat is then carefully prepared and concentrated through differing methods of purification and isolation. (there is no universal agreement as to the best fat concentration method) The fat is then re-injected back into the gluteal area for reshaping and augmentation. The method of fat injection is important and I prefer placing small amounts of fat at different depths with the hope of decreasing the amount of fat absorption after surgery.

The procedure is usually performed all in one surgery. While multiple smaller injection sessions may lead to better fat volume retention, this approach is usually not economically practical for most patients. However, additional or touch-up injections months later can enhance the results or correct any minor deficiencies or irregularities that may remain.

The aesthetic objective of buttock fat transfer is to give the buttocks more of a bowl shape in its central regions. This means that the identified central region of the buttocks receives the most fat and it is tailored out from there. While no one knows a magic number as to how much volume of fat can be injected that will ideally survive, 250 to 300 ccs is what I usually inject. This will make most buttocks fairly tense and tight at that volume and more than that seems that one is only injecting ‘ free fat into free fat’.

Most patients can return to work and activities fairly quickly, one week for work and ten days for exercising. Any discomfort is more from the liposuctioned sites than it is from the injected buttock area.

Dr. Barry Eppley

Indianapolis, Indiana

Subfascial and Intramuscular Placement of Buttock Implants

Monday, January 12th, 2009

The desire for a pleasing appearing buttocks is an historic one. The ancient Greeks had a name for it…callipygeny…meaning beautiful buttocks. A well-developed buttock is uniquely human and developed as a result of standing erect on two feet. The buttock shape is primarily a result of the underlying muscle (gluteus maximus) and the amount of fat between the skin and the muscle. Among different ethnic groups and cultures, there are significant variations in the size and shape of the buttocks. Today, buttock augmentation is more popular than ever as a result of improved implant materials and the popularity of fat grafting. Improved surgical technique has also led to fewer complications, making implant enhancement in particular, more successful and more commonly done than in the past.


Buttock augmentation with implants is a very effective procedure but has not risen to the popularity of other body implants such as breast augmentation. There are many reasons for this but historically, buttock implants, had a significant rate of complications. Some of these were related to the implant material and shape but more were the result of the location of implant in the buttocks itself. Placing the buttock implant right under the skin (subcutaneous approach) and under the gluteus muscle (submuscular approach) cause significant medical and cosmetic problems and have largely been abandoned by most plastic surgeons. Accepted approaches today include implant placement in the gluteus muscle (intramuscular) and between the muscle and its covering. (subfascial)


If you are considering buttock implant enhancement, the question of whether your implants should be placed in the intramuscular or subfascial location is an important one. As a general rule, intramuscular implant placement is reserved for those with a flat buttocks and with little fat between the muscle and the overlying skin. It is important to have a good pad of tissue to cover the implant so deeper in the muscle is a good choice with this type of anatomy. More often than not, thin Caucasian patients need intramuscular placement. For patients who have more buttock substance in both shape and fat content, subfascial placement is acceptable. Enough fat exists already to provide good implant coverage. Usually this approach is used in African-Americans and Hispanics who may already have more than just a flat buttocks to begin with and desire enhancement of  their existing buttock size.

Dr. Barry Eppley

Indianapolis, Indiana

Implants for Buttock Augmentation

Tuesday, December 25th, 2007

Enhancing the Shape and Size of the Buttocks with Butt Implants (Gluteoplasty)

For those women, and rarely for a few men, the desire for a larger more shapely buttocks is more prevalent today than ever in the history of plastic surgery. This buttock enhancement trend is undoubtably fueled by fashion style issues such as the well known ‘J-Lo Butt’ and the northern influence by immigration of Hispanic and South American cultures, which is a larger buttock with no crease underneath. (known as the Brazilian buttocks) As a result, buttock size increase can be done with either implants or fat injections. I will talk here only about the use of buttock or gluteal implants for buttock enhancement or medically known as, implant gluteoplasty.

Buttock implants or gluteal implants are semisolid, rubbery silicone implants that have several basic shapes and sizes for the buttock area. They are not liquid filled nor should any surgeon ever use those type of implants for anything other than the breast. The buttock implants are fairly soft and flexible and don’t feel that much different from dense buttock tissue. The main plastic surgery issue with buttock implants is the surgical technique by which they placed. This has been controversial over the years. Should the buttock implant go into the gluteal muscles (intramuscular) or on top of them? (subfascial) While some controversy probably still exists, I think the best technique is intramuscular where the implant is completely surrounded by well vascularized muscle. The only downside to this technique is that the size of the implant is limited to about 300cc to 350cc in even the largest patients.

Through a midline incision in the upper buttocks crease, a pocket is carefully developed in the gluteus maximus muscle. The pocket is developed with an instrument staying within carefully determined markings done prior to surgery with the patient standing. The size and shape of the buttock implant (round or oval) is determined prior to surgery during the initial consultation based on the size and shape of the buttocks and what area of the buttock needs to be increased in size the most. The buttock implant is then slipped into this carefully made pocket. No type of compression garments is needed after surgery. Walking and sitting are allowed after 24 hrs. Sleeping should be done on the patient’s side for 1 week and driving is allowed after 7 days. Working out and running should not be resumed for at least one month after surgery.

I have found buttock implant surgery to be very gratifying for most patients, However, be aware that buttock implant surgery is painful and some sufficient recovery time is needed. The most common complication of buttock implant surgery is fluid collection (seroma) around the implant which may require drainage.

Dr Barry Eppley


Buttock Reshaping – Different Operations for Different Problems

Monday, November 5th, 2007

The shape of the buttocks has taken on great interest in the past decade. Whether it be too big, too flat, or sagging with age, the interest in changing one’s buttock has never been greater. Each of these buttock problems are treated differently.

By far, the ‘simplest’ buttock problem to treat is the one in which the buttock is too big. The problem is ‘simple’ only because the only treatment approach is that of liposuction. The results from liposuction of the buttocks is usually modest and the patient must not have to high an expectation. Contrarily, one must avoid too aggressive liposuction as this may cause the skin of the buttocks to sag after being ‘over-deflated’ by the fat removal.

The flat buttock is treated either by buttock implants or fat injections. Solid rubbery implants (which cannot leak) can be placed inside (intramuscular) or on top of the muscle (subfascial) through a small incision in the upper buttock crease. Buttock implants are best for those patients who don’t have enough fat to transfer and want extra fullness in the upper portion of the buttocks. The implants generally don’t add much fullness to the lower portion of the buttocks. The discomfort with buttock implants is not insignificant and physical activity must be restricted for several weeks after surgery. Exercise can not be resumed for about 6 weeks after surgery. Surgical risks include infection, bleeding, fluid collections (seroma) around the implants, shifting of the implants, and uneven appearance between the two sides. Once you have buttock implants, removing them (if necessary) will lead to further disfigurement due to sagging skin. Conversely, fat injections are useful when only a small increase in buttock size is needed. It is unpredictable how much injected fat will survive and multiple surgery sessions may be needed to get the desired result. Usually fat is simply redistributed……sucked from one undesired location and transferred to the buttocks. This gets a double benefit of contouring two areas which creates a better overall result.

The sagging buttock can be treated by two types of lifts. When only a small amount of skin is sagging over where the crease joins the back of the thigh (banana roll). This more limited buttock lift creates a scar in this crease and helps shape this lower buttock area. When the entire buttock needs to be lifted (usually in the bariatric surgery patient where a large amount of weight has been lost), a more aggressive lift is done by creating a ‘cutout’ of upper buttock and back skin (often done in conjunction with a tummytuck around the front, thus creating a 360 degree scar, a.k.a. a body lift). The buttock skin is then lifted and sewn upward, providing a lift to more of the entire buttocks.

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