Aesthetic surgery of the buttocks

Aesthetic surgery of the buttocks encompasses many forms. Patients may seek to enhance buttock shape with buttock implants, autologous fat transfer, autologous tissue flaps, excisional procedures, or liposuction. Patients with traumatic buttock injuries and contour deformities from injections also require reconstruction, often with fat injections, autologous tissue flaps, and alloplastic implants. The dramatic increase in body contouring after massive loss associated with bariatric surgical treatments for obesity has also extended to buttock contouring. Skeletal and weight loss–associated gluteal deformities are often severe in nature and have also increased interest in these procedures.

The function of the buttock musculature in stability and gait is an important consideration and often has an impact on the procedure chosen for correction in reconstructive procedures. Its impact on aesthetic procedures is less clinically relevant. The history, definition, frequency, etiology, pathophysiology, clinical presentation, aesthetics, classification, and surgical treatment options are discussed in this article.

History of the Procedure

Throughout history, artistic endeavors have documented our preoccupation with the human form as a representation of femininity and fecundity. Careful analysis, mathematical interpretation, and recreation of the human form have remained popular pursuits. Recent studies in evolutionary biology have suggested a strong correlation between the "hour-glass" figure and not only female reproductive potential but also general physical health and psychological health. This correlation is best summarized by an ideal waist-to-hip ratio of 0.7 that transcends cultures, is temporally stable, and is cross-generational. The callipygian form best represents this history.

Buttock contour surgery, in contrast, has a short history compared with the field of plastic surgery or art history. Pressure sores and traumatic deformities of this area have been treated for some time, but buttock contour improvement has become an acceptable and frequent request as demands for body improvement have increased. Patients' desire to look their best and the increased safety of liposuction and other body contouring techniques have dramatically increased the awareness of contour problems of the buttock. Recently, demographic changes in the United States coupled with changing societal fashion preferences, codification of aesthetic norms, as well as procedural improvements have increased interest in buttock contouring surgery by patients and surgeons alike.

The first reported attempts to surgically contour the buttock region in the medical literature were described by Bartels and colleagues in 1969. A mammary implant was placed unilaterally in the subcutaneous plane of the gluteal region to correct a deformity. This was closely followed by bilateral placement for aesthetic correction of platypygia. Problems associated with implant migration, capsular contracture, and migration quickly led to alternative placement in a submuscular plane between the gluteus maximus muscle and the gluteus medius muscle. A small submuscular space and anatomic constraints limited significant augmentation with a round implant. The inherent limitations of this procedure led to the development of intramuscular as well as subfascial planes for gluteal contouring with both silicone gel and silicone elastomer implants with more anatomic shapes.

Contemporaneously, liposuction emerged as the most popular body contouring technique. Liposuction was used to reduce the accumulation of fat in all regions of the body. Specifically, it was successfully applied to the flanks and back and the surrounding aesthetic units of the gluteal region. The success of these interventions in improving buttock contouring quickly led to its adoption as the primary form of contouring this region. Increasing reports of success with autologous fat transfer techniques and the popularity of liposuction led to adoption of aesthetic gluteal contouring with fat injections.

Recently, the dramatic increase in body contouring after massive weight loss associated with bariatric surgical treatments for obesity has also extended to buttock contouring. These severe deformities have accelerated the recent development of various autologous tissue flaps and excisional body contouring procedures to treat this patient population. The limitation of implant design availability in the United States and associated complications have limited the widespread adoption of implant augmentation of the gluteal region.

Problem

Buttock contour defects are common, and patients often seek some form of correction. The treatment choices must match the patient's concerns while not interfering with the necessary function of this area. Long-term approaches are an important consideration, as are scarring and unreasonable expectations. The patient may be concerned with a cellulite-contour irregularity of the skin and desire correction that may not be obtainable. Superficial corrections should be performed with great care to avoid further contour irregularities and detachment of the skin from underlying structures. The inferior fullness below the infragluteal crease or fold is one problem area. Many patients seek contouring of this area, yet excess removal may result in buttock ptosis, which is difficult to correct.

Patients seeking augmentation or enhancement of the buttock should recognize the consequences of implants that are required to withstand a person's weight and activity requirements. The same concerns apply to corrections of traumatic depressions and treatment by fat injections. Lastly, a round buttock with a convex surface demonstrates a groove and depression if a scar crosses the convexity. Restoring the projection and smooth characteristics of the buttock is difficult when normal curvature is distorted.

Frequency

Body contouring of the buttock increased dramatically from 1997-2005. Gluteal augmentation has increased 10% in the last year, but statistics have only recently been collected. Buttock lifts have increased 142%, and body lifts have increase 459% over this same period. The refinement of liposuction, autologous fat transfer, autologous flaps, excisional procedures, and alloplastic implants has contributed to the increase in the number of successful treatments. Liposuction and its progeny of ultrasonic-assisted and superficial liposuction have also had an impact. Codification of gluteal aesthetic standards has added the finesse necessary to achieve the balance between form and function.