Solid-silicone implants are the only realistic choice for amplifying the buttocks, and great things can be done with them.

In the past few years, gluteal augmentation has been one of the faster-growing aesthetic-surgery procedures. The public wants to learn more about this procedure, but few well-trained surgeons have experience with it and can meet the demands of the patient population. Only recently has peer-reviewed information been available to surgeons interested in the procedure.

Early buttock augmentation can be traced to surgeons in Mexico and South America, where buttock appearance is more of a focus of sensuality and beauty than in the United States. Outside the United States, silicone-gel implants are routinely used to augment the buttocks. Gel implants provide a natural, soft feel, along with a pleasing shape.

Silicone-gel implants are not available in the United States for gluteal augmentation, and will most likely not be available for many years to come. Currently, no clinical trials are in progress, and no manufacturer appears to be interested in spending the resources necessary to gain US Food and Drug Administration (FDA) approval for buttock gel implants.

Implants and Filler Problems

One of the problems with gel implants is their potential to rupture, which can lead to complications such as secondary infection, silicone migration, granulomas, and eventually, additional surgery to remove the gel. Occult rupture is also a problem: Imaging studies using magnetic resonance or sonograms are often needed to determine whether the implant is intact. Another impediment is that seromas and small hematomas cannot be managed with needle aspiration in the presence of a gel implant due to the risk of implant perforation and leakage.

Likewise, the use of saline implants for gluteal augmentation is not approved by the FDA. I have seen patients from other countries who had undergone gluteal augmentation with saline implants that needed to be removed because of a poor aesthetic result. In addition, a saline implant is susceptible to rupture from trauma or wear because it is not durable enough to withstand mechanical forces in the gluteal region. For these reasons, solid implants are the only ones available for gluteal augmentation in the United States.

Buttock augmentation using transplanted fat has yielded mixed results. In many thin patients, not enough fat is available to significantly increase the projection in the gluteal region. However, in heavier patients, liposuction can provide large amounts of fat that can be injected into the gluteal region.

The fate of this transplanted fat varies from complete reabsorption within several months—requiring additional fat grafting—to partial graft survival. However, fat grafting is beneficial for contouring small defects and contour irregularities that do not require an implant.

The use of fillers to augment the buttock has produced poor results. Currently, no biocompatible, long-lasting injectable material can be used to augment the gluteal region.

Liquid and Solid Silicone

Liquid silicone has been used as an “injectable implant” to augment the gluteal region. However, large-volume silicone injections can lead to severe complications, including granuloma formation, skin necrosis, infection, deformity, and silicone migration. These complications are not easily treated and, in some cases, require surgical debridement that produces significant morbidity.

The early results from gluteal augmentation using solid implants were mixed. The implants tended to produce a high, unnatural look when they were positioned under the muscle. Subcutaneous implant placement led to capsular contracture and a poor shape. In addition, reports of complications such as infection, scarring, asymmetry, and potential nerve damage left most surgeons in the United States believing that gluteal augmentation was a risky procedure.

This perception has changed as mainstream, well-trained plastic surgeons in the United States have reconsidered the procedure and approached it scientifically. As a result, more information on proper technique and postoperative management of gluteal-augmentation patients is now available to surgeons. This focus has led to better surgical outcomes and the standardization of best practices.

Candidates for the Procedure

The best candidates for gluteal augmentation with solid-silicone implants are normal-weight patients who desire more fullness in the gluteal region and lack central projection. They should have ample soft tissue to provide durable coverage of the implant. The region should be free from chronic skin irritation and infection.

However, HIV infection is not a contraindication to this surgery. Many of these patients suffer from HIV-associated lipo­atrophy of the gluteal region and can benefit from gluteal augmentation, provided that their medical condition is satisfactory.

The obese patient is not a good candidate for gluteal augmentation with an implant for reasons other than generally poor health. One is that shear force in the buttocks are greater than normal in obese patients, which make seromas more common and wound healing problematic.

Patients with uncontrolled diabetes should not undergo gluteal augmentation because of the increased risk of infection. Other contraindications include patients who are noncompliant, have unrealistic expectations, are in poor health, or are not willing to accept the possibility of postoperative complications.

In patients with minimal buttock ptosis and good skin elasticity, gluteal implants may improve the appearance of the buttock by creating lift and filling out the involuted region. In patients with greater degrees of ptosis, implants may exacerbate buttock sagging and produce a poor result. These patients are better treated with a buttock lift. In some instances, insertion of a buttock implant with a subsequent infragluteal-fold skin excision can be beneficial.

Before the Implantation

Preoperatively, the patient is examined and the buttock’s size and shape are evaluated. The need for liposuction of the lower back or hips is considered. Patients with a long buttock may require an oval gluteal implant, whereas patients with a short buttock would normally benefit from a round implant.

Almost all male pa­tients are suitable for a round implant. Oval im­plants are more likely to be used in women who have a long buttock that requires inferior-aspect fullness.

An array of sizers should be available in the examination room to determine the most appropriate implant (Figure 2). The implant should have the correct base diameter to adequately augment the buttock without providing too much lateral fullness, which, with a solid implant, will be more likely to produce visible edges.

The buttock’s height-to-width ratio should be considered when choosing an implant. Placing sizers on the buttock allows the surgeon to determine the implant’s proper shape and the volume needed to augment the gluteal area. In addition, patients are made aware of the available choices.

The amount of soft tissue available to cover the implant should be evaluated during the preoperative visit. In men with a paucity of subcutaneous fat and in extremely thin women, consideration should be given to intramuscular implant placement. In patients with ample subcutaneous tissue, subfascial placement of the implant may be appropriate.

In patients with a low buttock, it is necessary to place the implant inferiorly; this makes intramuscular-implant placement difficult because of its proximity to the sciatic nerve. In patients with a low buttock, placing the implant subfascially will enable it to be positioned low enough to augment the buttock’s inferior aspect while avoiding injury to the sciatic nerve. Subcutaneous implant placement is not recommended.

Patients are given a preoperative antibacterial soap. They are instructed to shower the night before and the morning of surgery, and to apply the soap to the gluteal region. A bowel prep is not required.

Outpatient Surgery

The surgery is performed on an outpatient basis in a fully accredited surgical facility. Prior to surgery, the size of the chosen implant is outlined on the patient in the standing position. The implant should be centered at the point of maximum projection.

General endotracheal or epidural anesthesia is administered. The patient is placed on the operating table in the prone position with adequate padding between the pressure points and the table.

Sequential compression devices are applied to the lower extremities and intra­venous antibiotics are administered. Following a routine preoperative surgical scrub, a sterile prep of the buttocks is performed.

A 6- to 7-cm vertical midline intergluteal incision is marked superiorly from the tip of the coccyx. The area is then infiltrated with local anesthesia containing epinephrine to aid in hemostasis.

An incision is made down to the sacrum, and enough soft tissue is preserved to allow the wound to close. Lateral dissection is then performed away from the midline incision in the subfascial space using a lighted fiber-optic retractor and a long-tip electrocautery.

The fibers of the gluteus maximus muscle are divided parallel to their orientation, and an intramuscular pocket is developed with 2 to 3 cm of muscle coverage. A combination of blunt and electrocautery dissection is used. Blunt dissection is recommended inferiorly to avoid injury to the sciatic nerve.

If subfascial implant placement is planned, the dissection is continued in the subfascial space until the limits of the skin markings are reached. The newly created periprosthetic space is then packed with laparotomy sponges while the implants are prepared for insertion.

The implants are rinsed in saline and povidone-iodine prior to insertion. The laparotomy pads are removed, and hemostasis is obtained. The implants are then inserted into the intramuscular or subfascial space.

In the case of intramuscular placement, the gluteus maximus muscle is closed over the implant with a strong, absorbable running suture to provide complete muscle coverage. For both types of implant placement, a closed suction drain is used in most patients to minimize the risk of seroma.

The midline wound is closed in several layers to create a tension-free closure. Patients can usually be discharged 1 to 2 hours after surgery.

During the postoperative period, patients are encouraged to ambulate to reduce the risk of lower-extremity blood clots and muscle spasm. Oral analgesics are prescribed. Patients are instructed to avoid strenuous activity and pressure on the area for several weeks. The drains are removed when less than 25 mL of fluid is present over a 24-hour period. Com­pression shorts are recommended for the first 2 to 3 weeks after surgery.

Medical, Aesthetic Complications

In a series of 40 surgeries I performed from 2001 to 2004, the most common complication following buttock augmentation with solid-silicone implants was seroma formation.1 The incidence of this complication was reduced by using closed suction drains liberally in subsequent patients and by extending the time the drains were in place. In several patients who were very active after the drain was removed, it was necessary to reinsert the drain after several weeks.

Infection is rare; it occurred in 5% of the patients in the 3-year series.1 A superficial cellulitis can be treated with antibiotics. Periprosthetic implant infection, however, requires periprosthetic-space drainage and implant removal. The implant can be reinserted several months after the infection has resolved.

Wound-healing problems, including major wound dehiscence, have been reported anecdotally by several surgeons. This complication can be minimized by tension-free multilayer closure and appropriate implant selection. Capsular contracture is rare and is more likely to occur after the subcutaneous placement of a gluteal implant.

Implant migration is a rare complication and can occur as a result of overaggressive dissection of the subfascial or intramuscular space. In patients with very strong gluteal muscles, the implant can be displaced laterally; this condition is difficult to correct.

The most common aesthetic complication following gluteal augmentation with a solid-silicone implant is asymmetry due to improper implant placement. The inexperienced surgeon will often place the implant too high. creating too much upper-pole fullness and a hollow inferior pole. The implant may settle over time, but revision surgery may be required to create a better pocket for the implant.

Another aesthetic complication is implant ptosis with visible implant edges. This can result from skin laxity from the implant’s weight that develops several months after it has been placed. Moving the implant from the subfascial position to the intramuscular position may improve this condition.

Scarring is minimal when the incision is placed in the intergluteal region. However, implant placement through bilateral infragluteal incisions is not recommended. This approach can produce unacceptable scarring and can lead to other complications, such as inferior displacement of the implants and sciatic-nerve injury.

Rewards and Responsibilities

Gluteal augmentation with solid-silicone implants can be a rewarding procedure for patients and surgeons when basic principles and best practices are followed. As with all procedures, each surgeon has a learning curve with respect to surgical technique and handling of common postoperative problems.

Although many surgeons will not choose to adopt this new procedure, it is important that they are aware of and understand the different options available to meet the needs of patients who seek gluteal augmentation. PSP