Buttocks Contouring

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.

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. The popularity of fat grafting in the buttock region has grown, including such specific methods and names such as "Brazilian butt lift" and others, all designed to enhance the shape of the buttocks using fat grafting techniques. ^[1]

The dramatic increase in body contouring after massive weight loss associated with bariatric surgical treatments for obesity has 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.

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

According to The Aesthetic Society, in 2021 there were an estimated 61,387 buttock augmentation procedures (fat grafts and implants) in the United States, a 37% increase from 2020. ^[2]

The etiology of buttock contour defects can be genetic, traumatic, or acquired. A disproportionately large buttock significantly affects some young men and women; often, these persons are unable to wear fitted clothes or participate in desired activities. The genetically absent buttock (often as significant a genetic defect as a disproportionately large buttock) is also equally undesirable because it does not adequately fill out clothing. Uncommonly, genetic lipodystrophies also affect the gluteal region.

Traumatic defects of the buttock that produce contour problems obscure the curve of the buttock and often create a notch or groove that is clearly visible in swimwear and knit fabric clothes. The patient seeks correction and states a desire to return to the preinjury form. Automobile and workplace accidents and animal bites are common etiologies of contour defects. Iatrogenic deformities caused by failure to accurately repair all anatomic layers during surgical procedures in the trochanteric and gluteal region are also commonly seen.

A scar or defect that crosses the curvature of the buttock usually leaves a depression and groove that requires some form of correction. Furthermore, contour irregularities and overresection associated with liposuction are common causes of gluteal deformities. The authors still see patients with depressions from steroid injections and undrained, resolving hematomas of the buttock. Gluteal compartment syndrome is also a rare but serious clinical condition associated with traumatic injuries.

Acquired gluteal deformities are often associated with aging, menopause, weight gain, sun damage, skeletal deformities associated with obesity, and massive weight loss associated with bariatric surgical procedures. Aging, sun damage, and massive weight loss usually lead to skin laxity and buttock ptosis. Menopause and skeletal changes associated with obesity usually leads to a diminished gluteal aesthetic that is more refractory to surgical interventions.

The pathophysiology of the traumatic defect is relatively simple. A hematoma that remains unrecognized produces a pressure point from within, which reduces the normal fat levels of the buttock form. When the hematoma is drained or resorbed, a depression remains. Traumatic defects from loss of tissue that is either surgically closed or allowed to secondarily resolve often result in contour irregularities. Steroid injections placed within the fatty portion of the buttock can cause absorption and atrophy of fat cells, which also produce a marked depression and thinning of the skin.

Contour defects of the buttock include the above conditions and genetic increases, decreases, and asymmetries that reflect society's range of shapes.

The patient seeks a plastic surgeon to correct contour deformities of the buttock. The discussion may involve an overly large buttock or a buttock that does not adequately fill out jeans. The range of superficial contour irregularities, from an absent buttock crease or infrabuttock fold to a square buttock, also may include the patient declaring that his or her cellulite creates an uneven and unsmooth buttock. The surgeon should listen intently to the patient's comments and expectations of results.

Often, patients seeking liposculpture of the body ask about the buttock, unaware of the many possibilities of correction available to reshape the buttock. Emphasize and discuss the proportions of the patient, and attempt to maintain the patient within a proportional frame.

The large buttock that severely affects a young woman, preventing her from feeling comfortable in swimwear and knit clothing, and the small buttock that prevents the patient from filling out jeans are examples of culture's negative physiques. The patient may vocalize more on the superficial components of the buttock shape with absent definition and asymmetry. The surgeon must be cautious about specific demands regarding a matched symmetric shape.

Indications for treatment include a prominent, deficient, or misshapen buttock. As expertise in minute corrections has improved, indications have also increased to allow minor asymmetries, absent creases and folds, and square shapes. All of the above situations are appropriate indications for treatment.

Use caution with superficial irregularities that are more confined to the skin and superficial levels. The patient may describe this as cellulite. Many attempts to correct these deformities have failed and may actually worsen the other initial defects. Caution also must be emphasized concerning the fullness just inferior and parallel to the buttock (the so-called banana deformity). Many patients seek liposuction of this area to create a better fold and contour. However, this area often supports the buttock, and removal leads to further ptosis that is difficult to correct. The surgeon must be cautious in accepting these indications for treatment.

Common indications include large and prominent buttocks, deficient and flat buttocks, lack of or an uneven buttock crease and fold, depressions in the buttock, square buttock shapes, and an irregularly shaped buttock. Possible indications include superficial irregularities and asymmetric or uneven minor ptosis of the buttock.

Because buttock contour surgery is an elective procedure, significant medical problems that could increase the surgical risk are relative contraindications.