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Background: While fat injections is the most popular form of buttock augmentation (BBL surgery) it is not the only one. When inadequate fat reserves exist for harvest or prior fat injections have had inadequate survival buttock implants are the alternative treatment. While once little used with a high rate of complications buttock implants have evolved in both surgical techniques and implant materials.

When using buttock implants two pocket locations exist somewhat similar to breast  implants. Unlike breast implants the pure under the muscle pocket in buttock implants can not be used due to the presence of the sciatic nerve. As a result the intramuscular pocket was developed to gain the benefits of the muscular coverage but to keep some tissue interface between the implant and the sciatic nerve. While the risks of infection, seroma and implant migration are diminished with the intramuscular pocket its one main liability is the size limitation of the implant that can be placed. The intramuscular pocket is far more restrictive than placing the implant on top of the muscle.

An effective strategy to overcome the tighter intramuscular pocket in buttock implants is the concept of serial implant expansion. The first implant acts like a tissue expander so a larger implant can be placed later. A general rule is that 50% more volume can be obtained the second time with allowing six months between the two implant surgeries. An interesting question is can be be done a third time? Will the second implant allow as much volume increase for a third implant placement?

Case Study: This male patient had a prior history of intramuscular buttock implants with an initial size of standard 450ccs placed followed by the exchange into custom 730cc implants several years later. (62% increase) He now desired a third set of larger buttock implants after another two years. The same implant foot print was used but the central projection was increased to 6.5cc from 5.0ccs with an additional  volume increase to 1000ccs. (plus 270ccs or 37% increase) 

Through his existing intergluteal incision, the existing buttock implants were remove and replace with the 1000cc implants. Their large size necessitated a funnel technique to get them past the relatively small incision. Their size comparison showed that the volume was in the amount of central projection.

His immediate intraoperative results showed the difference between his existing and new buttock implant projections.

While it would be rare to ever move onto a third buttock implant exchange for a larger size, this case shows that it is possible. Of note is that the third implant increase should be less than that which was obtained in the first implant replacement. Thus a good guideline should be a 50% increase from the first to second implant and a 33% increase from the second to third implant. 

Case Highlights:

1) The intramuscular pocket for buttock implants has implant size/volume limitations unlike the more superficial subfascial pocket.

2) Staged implant exchanges can be done for intramuscular buttock implants to acquire larger sizes. 

3) In this case a male patient went from 450cc to 730cc to 1000cc intramuscular buttock implants over a several year period.

Dr. Barry Eppley

Indianapolis, Indiana

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