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Abstract: Autologous Buttocks Augmentation with Fat Grafting

Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 437e
The demand for gluteal fat augmentation has
increased in recent years, with 9993 reported
procedures in 2013 and 11,505 in 2014 in
the United States.1 Many plastic surgeons have
published their methods to achieve a larger glu-
teal contour with great outcomes. However, there
have been recent concerns about the systematiza-
tion of this technique2 and many reported fatal
complications in patients being submitted to this
procedure.3 The purpose of this study was to pro-
vide a thorough analysis of the literature regarding
the use of fat grafting for gluteal augmentation,
review the different steps of the procedure,
describe commonly used and effective protocols,
and identify potential sources of concern in the
hopes of preventing major complications.
Disclosure: The authors declare no conflicts of
interests with respect to the authorship and/or
publication of this article. The authors received no
financial support for the research and/or authorship
of this article.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002435
Alexandra Condé-Green,
Vasanth Kotamarti, B.S.
Kevin T. Nini, M.D.
Philip D. Wey, M.D.
Naveen K. Ahuja, M.D.
Mark S. Granick, M.D.
Edward S. Lee, M.D.
Newark and New Brunswick, N.J.
Background: With the increasing demand for gluteal fat augmentation, reports
of fatal complications have surfaced. Therefore, the authors proposed to ana-
lyze the published techniques and compare different protocols, to identify
those of potential concern.
Methods: A systematic review of the literature was performed with a search
of 21 terms on the PubMed, MEDLINE, Cochrane, and Scientific Electronic
Library Online databases. Nineteen articles meeting our predetermined cri-
teria were analyzed, and data from the different steps of the procedure were
classified, allowing evaluation and comparison of techniques. Independent-
samples t test and one-way analysis of variance were used for statistical analysis.
Results: Seventeen case series and two retrospective studies including
4105 patients were reviewed. Most articles were authored in Colombia, Mexico,
and Brazil. Most procedures were performed on adult female patients under
general anesthesia. Fat was harvested using a tumescent technique from the
lower extremities and the back, with machine-vacuum suction. A mean of 400 ml
of decanted lipoaspirate was injected into each gluteal region, mostly subcutane-
ously and intramuscularly with 60-ml syringes. Most patients rated their results
as “excellent.” The mean complication rate was 7 percent (6.7 percent minor,
0.32 percent major), with no significant relation to the planes of injection.
Conclusions: Fat grafting is an effective and predictable way to remodel the
gluteal region; however, the procedure is not without risks. Avoiding gluteal
vessel damage may prevent most feared complications, such as fat embolism.
Accurate analysis, systematization of the procedure, and reporting cases in
the fat grafting registry may provide the foundation for optimization of out-
comes. (Plast. Reconstr. Surg. 138: 437e, 2016.)
From the Division of Plastic Surgery, Department of General
Surgery, Rutgers New Jersey Medical School; and Plastic
Surgery Arts of New Jersey.
Received for publication January 11, 2016; accepted April
12, 2016.
Fat Grafting for Gluteal Augmentation:
A Systematic Review of the Literature
and Meta-Analysis
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery September 2016
The foundation for this review was a system-
atic method for finding and evaluating the litera-
ture on the use of fat grafting for aesthetic gluteal
augmentation. A comprehensive search was con-
ducted by two independent authors in December
of 2015 using the following terms alone or in com-
bination in the PubMed, MEDLINE, and Cochrane
databases: “gluteal,” “gluteus,” “Brazilian buttock,”
“buttocks,” “gluteoplasty,” “fat grafting,” “contour,”
“lift,” “re-contouring,” “recontouring,” “enhance-
ment,” “reshaping,” “remodeling,” “lipograft,”
“lipoinjection,” “lipotransfer,” “fat transfer,” “fat
transplant,” “lipostructure,” “lipofilling,” and “aug-
mentation.” Because one of the authors is fluent in
French, Portuguese, and Spanish, filters were set to
include all articles in English, French, Portuguese,
and Spanish. In addition, the above-mentioned
terms translated in Portuguese and Spanish were
used in the Scientific Electronic Library Online,
a database of Brazilian and Latin American scien-
tific journals and the Revista Brasileira de Cirurgia
Plástica, the official journal of the Brazilian Society
of Plastic Surgery, to search relevant articles.
Prospective inclusion criteria were the use of
autologous fat grafting for aesthetic augmenta-
tion of the gluteal region. Data collected included
patient population information (i.e., age, sex,
body mass index) and all pertinent information
on the fat grafting procedure performed, such as
type of anesthesia; antibiotic use; donor site; fat
harvesting, processing, and injection techniques;
volume of transplanted fat; postoperative care and
evaluation; complications; and patient satisfaction.
Single case reports, description of operative
techniques with no specific patient data, proce-
dures combining gluteal implants and fat graft-
ing, and articles reporting the use of fat grafting
for correction of cutaneous depressions or gluteal
lipoatrophy related to antiretroviral therapy were
excluded from this study. Articles that could not
be accessed in their entirety were also excluded.
Statistical Analysis
Statistical analysis was performed using IBM
SPSS Version 23 (IBM Corp., Armonk, N.Y.). Data
were analyzed using an independent-samples t test
and a one-way analysis of variance using a Bonfer-
roni correction. The threshold for significance
was set at α = 0.05, and a modified α of 0.017 was
used for the Bonferroni correction to protect sig-
nificance levels. Data were graphed using Micro-
soft Excel for Mac 2011 version 14.5.7 (Microsoft
Corp., Redmond, Wash.).
The primary search yielded 822 articles, of
which 142 duplicates were removed. One hun-
dred ninety-three articles remained after screen-
ing of titles, and their abstracts were reviewed. A
total of 79 articles were read in their entirety and
their references scoured for those that escaped
our primary search criteria. Nineteen articles met
our predetermined criteria and were included in
this study (Fig. 1). Countries that contributed the
most articles were Colombia,4–8 Mexico,9–13 and
Brazil.14–16 The remaining articles were authored
in France,17 Italy,18 Belgium,19 The Netherlands,20
Egypt,21 and one from a combined effort of the
United States of America and Brazil22 (Fig. 2).
Seventeen studies were case series of Level IV
evidence, and two studies were retrospective com-
parative studies of Level III evidence. Eighteen
articles were published in plastic surgery journals
Fig. 1. Flow diagram of the search and selection strategy of
included articles for gluteal fat augmentation.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 138, Number 3 Fat Grafting for Gluteal Augmentation
and one was published in the journal Dermatologic
Surgery (Table 1).
Data from a total of 4105 patients are reported.
The mean age was 33.63 ± 5.94 years (range, 16 to
72 years) and the mean body mass index was 24.3
± 3.72 kg/m2 (range, 17 to 32 kg/m2). The major-
ity of patients (98.2 percent) were female patients,
and 1.8 percent were male patients. Complete
description of all the steps of the procedure was
not found in all articles. Of the 19 retained articles,
nine reported detailed preoperative, intraopera-
tive, and postoperative steps. Pertinent findings
from this systematic review of the literature and
meta-analysis are reported below.
Preoperative Period
The majority of articles reported the use of gen-
eral (46.7 percent), locoregional (40.0 percent),
Fig. 2. Worldwide geographic distribution of included articles on gluteal fat augmentation.
Table 1. List of Retained Publications with Their Study Population and Their Journal Distribution
No. of Patients with Gluteal Fat
Augmentation Journals
Pereira and Radwanski, 199614 140 Aesthetic Plastic Surgery
Cárdenas-Camarena et al., 1999966 Plastic and Reconstructive Surgery
de Pedroza, 20004879 Dermatologic Surgery
Perén et al., 200010 40 Aesthetic Plastic Surgery
Roberts et al., 200122 566 Aesthetic Surgery Journal
Cardenas Restrepo and Muñoz Ahmed, 2002596 Aesthetic Surgery Journal
Murillo, 20046162 Plastic and Reconstructive Surgery
Valeriani, 200418 132 Acta Chirurgiae Plasticae
Cárdenas-Camarena, 200511 179 Aesthetic Plastic Surgery
Wolf et al., 2006721 Aesthetic Plastic Surgery
Ali, 201121 40 Annals of Plastic Surgery
Avendaño-Valenzuela and Guerrerosantos, 201112 225 Aesthetic Surgery Journal
Cárdenas-Camarena et al., 201113 811 Aesthetic Plastic Surgery
Nicaretta et al., 201115 351 Aesthetic Plastic Surgery
Ho Quoc et al., 201317 24 Annales de Chirurgie Plastique Esthétique
Hoyos et al., 20138136 Aesthetic Surgery Journal
Willemsen et al., 201320 21 European Journal of Plastic Surgery
Abboud et al., 201519 110 Aesthetic Surgery Journal
Rosique et al., 201516 106 Plastic and Reconstructive Surgery
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery September 2016
sedation, and local (13.3 percent) anesthesia for
the procedure. Seven studies reported the use of
preoperative antibiotics, which mostly consisted
of first-generation cephalosporin. Eight articles
described placing the patient in the prone posi-
tion, and two described first placing the patient in
the supine position followed by the prone position.
Fat Harvesting
Most studies reported harvesting fat from
multiple donor sites, mainly the lower extremities
(35 percent), back (17 percent), hips (13 percent),
trochanteric regions (13 percent), flanks (13 per-
cent), and abdomen (9 percent). The infiltration
solutions used were normal saline with epineph-
rine (56 percent), Klein solution (12.5 percent),
lactated Ringer solution with epinephrine
(12.5 percent), Hunstad solution (6.25 percent),
and a modified Klein solution using mepivacaine
(6.25 percent) according to the tumescent tech-
nique in 78.6 percent and superwet technique in
21.4 percent. Machine-generated vacuum-assisted
liposuction was reported in 40 percent, combined
use of machine-generated vacuum and syringe
was reported in 26.7 percent, syringe liposuction
was reported in 20 percent, and ultrasound and
power-assisted liposuction was reported in 6.7 per-
cent each. Three articles reported setting the
machine-generated vacuum at approximately 500
mmHg, and one article describing syringe liposuc-
tion specified pulling the syringe’s plunger at 1 cc
from the harvested fat to generate less negative
pressure. Cannulas 3, 3.5, and 4 mm in diameter
were used in 68.8 percent; cannulas 2.5 mm in
diameter were used in 18.8 percent; and cannulas
5 and 6 mm in diameter were used in 12.5 percent.
Fat Processing
The most common fat preparation technique
reported was decantation (58 percent), followed
by centrifugation at high or low speed (21 per-
cent), washing (16 percent), and rolling (5 per-
cent). Four studies reported mixing antibiotics
(aminoglycoside, clindamycin, or cefazolin) to
the lipoaspirate. One study reported the addition
of platelet-rich plasma to the lipoaspirate.
Fat Injection
Most articles reported injection of fat into
both subcutaneous and intramuscular planes
(46.7 percent), intramuscular only (26.7 percent),
subcutaneous only (20 percent), or subfascial
and subcutaneous planes (6.7 percent). A mean
of 402.6 ± 179.2 ml of fat (range, 28 to 1260 ml)
was injected in each gluteal region. The use of
3-mm-diameter blunt cannulas was reported in 46
percent of articles, 2-mm and 4-mm blunt cannu-
las each in 15 percent, and 5-mm cannulas in 7.5
percent. Three articles mentioned the use of can-
nulas with three holes and one article mentioned
the use of a cannula with one hole. Cannulas were
attached to syringes of 60 ml in 54.5 percent, fol-
lowed by 10-ml syringes in 18.2 percent, 60-ml and
10-ml syringes in 9.1 percent, a 60-ml gun fat injec-
tor in 9.1 percent, and 3-ml syringes in 9.1 percent.
Five studies specified using tunneling techniques
for fat injection. Techniques to avoid subjecting fat
grafts to excess shear forces during injection were
not reported. Injection volumes ranging from
0.3 to 20 ml for each pass of the cannula to mini-
mize the risk of fat necrosis were reported in six
articles. In addition, three articles reported con-
trolled, continuous retrograde injections, to avoid
transferring large amounts of fat in one area. One
article reported kneading the injected area to pro-
mote even distribution of the grafted fat.
Postoperative Period
Postoperative antibiotics (ciprofloxacin or first-
generation cephalosporin) were used in 15.8 per-
cent of articles for 7 days (66.7 percent) or 10 days
(33.3 percent). Ten percent of studies used drains.
The use of anticoagulants for deep venous throm-
bosis prophylaxis was not reported. Compression
garments were used in 78.9 percent of studies for 4
to 8 weeks. Massage of the treated areas, lymphatic
drainage, and endermology were reported in 21.1
percent of studies. Patients were instructed to avoid
pressure to the gluteal region for at least 2 weeks
in 44.4 percent of studies, whereas there was no
position limitation in the other articles. Two stud-
ies reported admitting patients for 24 hours. Nine
articles reported their average follow-up period,
with an overall mean of 23.4 ± 16.9 months.
Methods of Evaluation
All articles showed preoperative and postop-
erative photographs as a method of evaluating
their results. Objective preoperative and postop-
erative measurements including gluteal circum-
ference and projection were reported in 21.1
percent of articles. Standardized protocols for
circumference measurement were reported in
three articles, and one article described a method
for gluteal projection measurement. Two studies
used magnetic resonance imaging in a sample of
their patients for evaluation of graft retention.
Patient satisfaction was reported in 52.6 percent
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 138, Number 3 Fat Grafting for Gluteal Augmentation
of articles using either a standardized question-
naire or open-ended questions. Standardized,
unvalidated questionnaires were used in three
articles. Notably, two studies compared patient
satisfaction of their results to surgeon evaluation
of their outcomes. There was a significant likeli-
hood of patient satisfaction as a result of the pro-
cedure (F2,24 = 11.962, p < 0.0001, hp2 = 0.499).
Two studies reported improved psychological
well-being postoperatively; however, the use of a
validated method for evaluation of psychological
health was not reported. The majority of patients
rated their satisfaction as “excellent” and “good.”
There was no significant difference between these
two ratings (p = 0.043); however, there was a sig-
nificant difference when compared with those few
patients that rated their outcomes as not satisfac-
tory (p < 0.017) (Fig. 3).
Eight articles reported having to address
undercorrection with secondary fat grafting pro-
cedures. For a total of 1380 patients mentioned
in these articles, 6.5 percent underwent a second
gluteal fat grafting procedure.
Eighteen of the 19 articles reported their com-
plications. In a total of 4084 patients, the minor
complication rate was 6.7 percent and the major
complication rate was 0.32 percent. Minor compli-
cations represented 95.5 percent of the total. The
most common, in descending order, were seroma,
2.4 percent; erythema, 1.3 percent; pain, 0.76 per-
cent; contour irregularities, 0.64 percent; and fat
necrosis, 0.56 percent. The major complications
were fat embolism, 0.12 percent; anemia, 0.12
percent; symptomatic hypovolemia, 0.05 percent;
and septic shock, 0.02 percent (Table 2). In addi-
tion, other major complications were published
as single case reports in seven articles,23–29 and
Cárdenas-Camarena et al.,30 in their investiga-
tion of deaths following gluteal fat augmentation,
reported 22 mortalities consequent to fat embo-
lism after surveying members of their plastic sur-
gery societies and their national forensic reports.
Deaths occurred during surgery or within the first
24 hours among patients with a mean age of 39.5
years and a mean body mass index of 24.1 kg/m2,
and who had liposuction of 3697 cc (range, 2000
to 7200 cc) and injection of 214 ml of fat (range,
120 to 300 ml) into the gluteal region. Autopsy
reports following immediate mortality showed
evidence of macroscopic fat embolism in the set-
ting of damage to the gluteal vessels, particularly
the gluteal veins. The complications from these
case reports and the survey were not included in
our calculations to reduce selection bias, as deter-
mined by our exclusion criteria.
Because of recent concerns of increased risk
for morbidity when fat is injected intramuscu-
larly,30 complication rates where fat was injected
intramuscularly and/or subcutaneously were
compared. Thirteen articles that mentioned
both the planes of injection and the complica-
tion rates were analyzed. Seven articles described
fat injection in both intramuscular and subcuta-
neous planes, three in only the intramuscular
plane, and three in only the subcutaneous plane.
Fewer complications occurred after fat injection
into the subcutaneous plane only (4.1 percent)
in comparison with fat injection in the intramus-
cular plane only, or the intramuscular and sub-
cutaneous planes (28.7 percent). This result did
not achieve significance (p = 0.059) (Fig. 4 and
Table 3). We were unable to compare rates of fat
embolism or fat embolism syndrome according to
planes of injection, as only one article reported a
case of fat embolism syndrome and specified the
plane of injection, which was intramuscular and
Media attention in recent years has created
an increased patient demand for gluteal contour-
ing and augmentation worldwide. In 2014, but-
tock augmentation was ranked thirteenth of all
surgical procedures performed by members of
the International Society of Aesthetic Plastic Sur-
gery.31 As the number of fat grafting procedures
Fig. 3. Patient satisfaction after gluteal fat augmentation. Post
hoc, pairwise t tests, using Bonferroni correction (α adjusted to
0.017 to protect signicance levels). Error bars represent ±1 SEM.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery September 2016
has increased significantly, gluteal fat augmenta-
tion has become increasingly popular and a pref-
erence of many surgeons and patients32 because
of the ease of the technique, rapid recovery, and
great results. However, with this growing trend,
reports of fatal complications have surfaced, mak-
ing us aware that this procedure is not without its
risks if not performed cautiously with the proper
techniques in a well-chosen patient.
For many lean patients, gluteal augmenta-
tion with autologous fat grafting is not an option
because of the lack of donor tissue.33 The ideal
candidate is slightly overweight but in good
health. Patients who present obvious excess fat
in the sacrum, lower back, and posterior triangle
(bordered by the superior iliac crest inferiorly, the
twelfth rib superiorly, the lumbar muscle medially,
and the internal oblique laterally) have the most
impressive results.34 Liposuction of these regions,
including the waist and flanks, improves the
upper contour of the gluteal region, accentuating
the effects of the gluteal fat transfer. Injecting fat
subcutaneously and above the muscle fascia cre-
ates projection and contour improvement. How-
ever, volume is better achieved with intramuscular
fat injection. Therefore, a combination of sub-
cutaneous, subdermal, and intramuscular injec-
tions35 is commonly performed to achieve greater
outcomes. Although fat survival is greater when
injected into muscles, this increases the risk of fat
embolism syndrome or fat embolism as a result
of damage to gluteal vessels, the consequences of
which are usually very serious.30
Fat embolism syndrome and fat embolism
are two distinct entities with unique pathophysi-
ologies and clinical manifestations. Fat embolism
syndrome is caused by a systemic inflammatory
response that may be managed without major
sequelae. Fat embolism is a consequence of the
mechanical blockage by fat particles in medium
to large vessels, which may present with rapid car-
diopulmonary changes. The high degree of vascu-
larity of the gluteal region, with the gluteal vein
in the subpiriformis and suprapiriformis chan-
nels, represents a considerable risk for infiltration
of fat particles into the bloodstream. Therefore,
intramuscular lipoinjection should be performed
carefully to avoid injuring the deep gluteal vessels.
Fat should preferably be injected in the subcuta-
neous and superficial muscle planes, maintaining
the cannula parallel to the gluteal surface so that
entry into the channels may be prevented.30 Slow,
continuous, repetitive injections may further
improve fat graft take by subjecting the tissue to
less shear stress.36
Table 2. Complications Reported in the Literature
following Gluteal Fat Augmentation
Complications No. of Cases
Seroma 100
Gluteal erythema 55
P a i n 31
Contour irregularities 26
Fat necrosis 23
Mild cellulitis 12
Local infection of injected fat 6
Intermittent burning sensation 5
Superficial local infection 4
Sacral and lower back edema 3
Abnormal skin retraction secondary 2
Hardened area over buttocks 2
Abscess 2
Recurrent edema 1
Hematoma 1
Hyperpigmentation 1
Mycobacterium fortuitum infection 1
Fat embolism 5
Severe anemia 5
Symptomatic hypovolemia 2
Septic shock 1
Complications published in a survey of
mortalities following gluteal fat aug-
mentation and 7 case reports*
Fatal fat embolism 23
Bilateral sciatic nerve axonotmesis 1
Mycobacterium chelonae infection 2
Mycobacterium abscessus infection 1
Gluteal necrotizing fasciitis and occipital
bilateral meningitis 1
Sepsis with gluteal abscess and oil cysts 1
*Not included in our calculations.
Fig. 4. Overall complication rates of subcutaneous and intra-
muscular gluteal fat transfer. Gluteal lipoinjection into only the
subcutaneous plane resulted in a lower mean complication rate
than injection including the intramuscular plane. This result
was not signicant (independent samples t test, t11 = 1.334,
p = 0.059, r2 = 0.1393). Error bars represent ±1 SEM.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 138, Number 3 Fat Grafting for Gluteal Augmentation
Table 3. Summary of Included Gluteal Fat Augmentation Articles with Their Strengths and Weaknesses
References Study Strengths Study Weaknesses
Pereira and
Radwanski, 199614 Large sample size (n = 140) Lack patients’ BMI
No mention of antibiotic coverage
No mention of harvesting cannula orifices
No mention of postoperative recommendations
No patient satisfaction data
No specific follow-up duration
et al., 19999
Detailed procedure
Adequate mean follow-up (17 mo)
Comparison of patient satisfaction
with surgeon evaluation of outcomes
Lack patients’ age, BMI
de Pedroza, 20004Large sample size (n = 879) Lack patients’ BMI
Objective preoperative and postopera-
tive measurements Lack type of anesthesia, antibiotic coverage
No mention of harvesting cannula orifices
No mention of plane of injection, postoperative recommen-
dations, follow-up duration
No patient satisfaction data
Perén et al., 200010 Detailed procedure Lack patients’ BMI
No mention of harvesting cannula orifices
No follow-up duration
No patient satisfaction data
Roberts et al., 200122 Large sample size (n = 566) Lack patients’ sex, age, BMI
Lack type of anesthesia, antibiotic coverage
No mention of specific donor site or harvesting cannula
No follow-up duration
No patient satisfaction data
Cardenas Restrepo
and Muñoz
Ahmed, 20025
Large sample size (n = 96) Lack patients’ sex and BMI
Lack type of anesthesia
Limited mean follow-up (11 mo)
No mention of harvesting cannula orifices
Murillo, 20046Large sample size (n = 162) Lack patients’ age, BMI
Adequate mean follow-up (24 mo) No mention of antibiotic coverage
MRI follow-up for 6 patients No mention of harvesting cannula orifices
Valeriani, 200418 Large sample size (n = 132) Lack patients’ BMI
Adequate mean follow-up (12 mo) No mention of harvesting cannula orifices
MRI follow-up for 3 patients No patient satisfaction data
200511 Large sample size (n = 179) Lack patients’ age, BMI
No mention of harvesting and processing methods
No mention of fat injection (equipment, plane)
No postoperative recommendations, follow-up duration
Unclear whether complications occurred in patients with
gluteal fat grafting
No patient satisfaction data
Wolf et al., 20067MRI follow-up for 10 patients Lack patients’ BMI
with detailed description of method
and imaged area No mention of source of suction for harvesting
(e.g., vacuum, syringe) or harvesting cannula orifices
No follow-up duration
No complications documentation
No patient satisfaction data
Ali, 201121 Objective preoperative and postopera-
tive measurements
Adequate mean follow-up (12 mo)
Lack patients’ BMI
No mention of source of suction for harvesting
(e.g., vacuum, syringe) or harvesting cannula orifices
and Guerrerosan-
tos, 201112
Large sample size (n = 225 patients
that had gluteal fat augmentation)
Objective preoperative and postopera-
tive measurements
Lack patients’ BMI
Lack type of anesthesia, antibiotic coverage
Unclear whether complications occurred in patients with
gluteal fat grafting
No follow-up duration
No patient satisfaction data
et al., 201113 Large sample size (n = 811) Lack patients’ BMI
No mention of donor sites, plane of injection
No follow-up duration
Unclear whether some complications occurred in patients
with gluteal fat grafting
Ho Quoc et al.,
201317 Adequate mean follow-up (12 mo) No mention of antibiotic coverage, plane of injection
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery September 2016
With other gluteal augmentation procedures
such as the use of silicone implants37,38 or gluteal
lifts,39 these complications are reduced. Combi-
nations of techniques with gluteal implants, lipo-
suction, and gluteal fat grafting have achieved
great results40 without the need to inject exces-
sive amounts of fat. In addition, to avoid inject-
ing large volumes of fat and decrease resorption
rate, efforts have been made to enrich fat with
stromal vascular cells.41,42 However, in the gluteal
region, few authors enriched fat with either adi-
pose-derived stem cells35 or platelet-rich plasma,20
as this has not been shown to be beneficial in this
region in comparison with other areas such as
the face. The use of cryopreserved fat has been
described in one study.43
There were no randomized controlled or case-
control studies. However, the studies included in
our analysis allowed us to classify data from the
different steps of the procedure to determine the
most common approaches and methods used.
We were also able to determine the strengths and
weaknesses of each article, allowing comparison
of techniques to build stronger, more detailed
articles in the future (Table 3). Other published
descriptions of operative techniques provided
elaborate details of the procedure and objective
information from the authors’ experiences34,35;
however, the lack of patient data limited the util-
ity of the reports and the replicability and gener-
alizability of the results. Case reports describing
correction of deep gluteal depressions44 resulting
from injections of medications such as penicil-
lin45 and corticoids,46 sequelae of silicone injec-
tion,47 retractions and scars following trauma,48
lipodystrophies secondary to antiretroviral drugs,49
and deformities caused by cellulites50 were not
included in our calculations, as they were recon-
structive procedures.
Procedural details and data are both critical
for understanding how to refine the technique
and improve outcomes. Therefore, with the intro-
duction of the General Registry of Autologous Fat
Transfer registry, a U.S.–based nationwide registry
of fat grafting for aesthetic and reconstructive pro-
cedures, compilation of meaningful data recorded
and submitted by all plastic surgeons performing
these operations will improve our understand-
ing and expertise of this technique and increase
patient safety.51 Similar efforts should be estab-
lished in other countries around the world.
In this analysis of the literature on fat graft-
ing for gluteal augmentation, 17 articles of Level
IV evidence and two articles of Level III evidence
were reviewed, including procedures performed
in 4105 patients. Typical patients benefiting from
this procedure were healthy female patients in
their 30s with normal body mass indexes. Most
procedures were performed under general
anesthesia, in prone position. Fat was harvested
mostly from the lower extremities and the back
using a tumescent technique with cannulas 3 to
4 mm in diameter attached to machine-vacuum
suction. A mean of 400 ml of decanted lipoaspi-
rate was injected into each gluteal region, mostly
subcutaneously and intramuscularly, using 3-mm
blunt cannulas attached to 60-ml syringes. The
mean overall complication rate was 7 percent, the
Hoyos et al., 20138Large sample size (n = 136) Lack patients’ BMI
Lack type of anesthesia
No mention of harvesting cannula orifices
No mention of fat grafting quantity, plane of injection,
postoperative recommendations
No follow-up duration
Willemsen et al.,
201320 Adequate mean follow-up (44 mo) Lack type of anesthesia, antibiotic coverage
Numerical outcome evaluation system
by patients and surgeons
Abboud et al., 201519 Large sample size (n = 110) No mention of antibiotic coverage
Detailed procedure
Adequate mean follow-up (20 mo)
Nicareta et al., 201115 Large sample size (n = 351) No mention of harvesting cannula orifices
Detailed procedure
Adequate mean follow-up (4.9 yr)
Numerical outcome evaluation system
Rosique et al., 201516 Large sample size (n = 106) No mention of harvesting cannula orifices
Numerical outcome evaluation system
by patients and surgeons No specific follow-up duration
BMI, body mass index; MRI, magnetic resonance imaging.
Table 3. (Continued)
References Study Strengths Study Weaknesses
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 138, Number 3 Fat Grafting for Gluteal Augmentation
majority of which were minor. A higher complica-
tion rate was observed with intramuscular injec-
tion; however, this was not significant. Precautions
to avoid serious complications such as fat embo-
lism may include subcutaneous and superficial
muscular injections, pulling back on the syringe
plunger to ensure no entry in the vessels.
Most articles reported preoperative antibi-
otic coverage, the use of postoperative compres-
sion garments, and photographic evaluation of
results, with most patients rating their satisfac-
tion as “excellent.” Objective evaluation of out-
comes may be best performed by a combination
of ultrasound, measurements, and standardized
photographs, as cost-intensive modalities such as
magnetic resonance imaging are not practical on
a large scale. Furthermore, a protocol for obtain-
ing measurements in the mid- to long-term follow-
up period (3 months, 6 months, 1 year, 3 years,
and 5 years) may improve documentation and
reporting of outcomes. Use of standardized sur-
veys adapted from validated questionnaires such
as the BREAST-Q assessing the appearance, feel,
texture, and presence of masses or induration
in the treated areas may improve replicability of
Fatalities reported recently in the literature
have made our peers more conscious of report-
ing their cases through yearly questionnaires and
surveys from medical specialty societies. Accurate
analysis and systematization of the steps of the
procedure provide the foundation for precise
operative planning and great results. This article
ideally will orient plastic surgeons on their choice
of techniques and encourage them to report all
future cases in the fat grafting registry to further
optimize outcomes and limit complications.
Alexandra Condé-Green, M.D.
Division of Plastic Surgery
Department of General Surgery
Rutgers New Jersey Medical School
Newark, N.J. 07103
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ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background: Buttock augmentation is gaining increasing popularity in aesthetic surgery . The relativ ely high incidence of complications af ter silicone implant placement lead to the increased use of lipofilling techniques, y ielding v ariable results with respect to graf t take rate and long-term stability . Platelet-rich plasma (PRP) has been shown to hav e benef icial ef f ects on wound healing and angiogenesis in the past. Theref ore, we aimed at inv estigating the long-term results and patient satisf action af ter PRP-enriched lipof illing f or buttock augmentation. Methods: Twenty -f our bilateral gluteal augmentations with PRP-enriched autologous f at were perf ormed. Additionally , contour shaping was achiev ed by liposuction of the adjacent zones. Post-operative results and complications were recorded, and satisfaction with buttock shape was estimated by a patient questionnaire. Results: Mean follow-up time was 44 months, and mean amount of transf erred f at was 481 cc f or both sides. No seroma or hematoma f ormation, inf ection or liponecrosis were reported during the post-operativ e f ollow-up. Subjectiv e patient satisf action in general increased f rom preoperativ ely to 3 months postoperativ ely and declined only slightly in the long-term course. Satisf action lev els in general were specif ic f or each patient. Patient recovery was quick, and the majority of patients returned to work within 10 day s af ter surgery . Conclusion: PRP-enhanced lipof illing of the buttocks prov ed to be a saf e procedure including a low complication rate and consistent results. Howev er, subjectiv e patient expectations hav e to be taken into account when choosing the indication. Further large volume studies are needed to elucidate the potential and benefit of PRP in this context. Lev el of Ev idence: Lev el V.
Full-text available
Background: A simple and reproducible surgical technique for gluteal shaping and augmentation with autologous fat is needed. Objectives: The authors describe a novel approach to large-volume gluteal augmentation that combines power-assisted liposculpting and fat harvesting of the zones around the buttock with autologous fat transfer. Methods: One hundred ten patients who underwent gluteal augmentation were evaluated in a prospective study. Liposculpting and fat harvesting were performed with power-assisted liposuction. Fat then was transferred to the gluteal region with simultaneous power-assisted vibration and tunnelization. A questionnaire to assess patient satisfaction was administered at 6 months postoperatively. Results: The mean body mass index of the patients was 30 kg/m(2) (range, 26-36 kg/m(2)). Liposuction volumes ranged from 1400 to 5000 mL, and injection volumes ranged from 300 to 900 mL per side for each session. Operating times ranged from 60 to 120 minutes. Patients were monitored for an average of 20 months (range 12-48 months). Complications included a burning sensation in 5 of 110 patients (4.5%), persistent swelling in the lower back in 3 patients (2.7%), and a mild infection in 1 patient (0.9%). Conclusions: Power-assisted gluteal augmentation with autologous fat is an efficient, safe, and reproducible procedure that produces an aesthetically pleasing gluteal projection and contour. Level of evidence: 4 Therapeutic.
Full-text available
Introdução: O tratamento de pacientes portadores da síndrome da imunodeficiência adquirida deve ser integral e se basear no controle da doença e das complicações relacionadas ao uso de medicações antirretrovirais, como a lipodistrofia. Esse estudo tem como objetivo avaliar as principais queixas, os aspectos epidemiológicos e os procedimentos cirúrgicos realizados para corrigir a lipodistrofia em pacientes em uso crônico de antirretrovirais. Método: Estudo retrospectivo, no qual foram coletados dados dos prontuários de 27 pacientes submetidos a 36 procedimentos cirúrgicos relacionados à correção de lipodistrofia no período de março de 2010 a junho de 2014 no serviço de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Resultados: A idade média dos pacientes foi 47,2 anos, 22,2% homens e 77,8% mulheres. O tempo médio de uso da terapia antirretroviral (TARV) foi de 12,1 anos. As queixas mais encontradas foram: giba dorsal (44,4%), lipodistrofia abdominal (44,4%) e lipoatrofia glútea (37,04%). Na maioria dos pacientes (70,4%), foi realizada uma cirurgia. Quanto às cirurgias, a lipoaspiração de giba foi realizada em 48,1% dos pacientes, seguida da lipoaspiração de abdome, dorso ou flancos (44,4%) e gluteoplastia (22,2%). Entre todos os 36 procedimentos realizados, apenas dois apresentaram complicações. O tempo médio de seguimento pós-operatório foi de 11,2 meses. Do total, 70,4% dos pacientes mostraram-se satisfeitos após os procedimentos. Conclusões: O sucesso do tratamento cirúrgico da lipodistrofia causada pelo uso da TARV baseia-se na seleção pré-operatória adequada e em seguimento constante e prolongado. A melhoria da autoestima facilita a adesão ao tratamento com antirretrovirais. ■ RESUMO Descritores: Lipodistrofia; Terapia antirretroviral; Síndrome da imunodeficiência adquirida; Lipoaspiração; Procedimentos cirúrgicos reconstrutivos.
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Introduction. Medical tourism for aesthetic surgery is popular. Nontuberculous mycobacteria (NTM) occasionally cause surgical-site infections. As NTM grow in biofilms, implantations of foreign bodies are at risk. Due to late manifestation, infections occur when patients are back home, where they must be managed properly. Case Report. A 39-year-old healthy female was referred for acute infection of the right gluteal area. Five months before, she had breast implants replacement, abdominal liposuction, and gluteal lipofilling in Mexico. Three months postoperatively, implants were removed for NTM-infection in Switzerland. Adequate antibiotic treatment was stopped after seven days for drug-related hepatitis. At entrance, gluteal puncture for bacterial analysis was performed. MRI showed large subcutaneous collection. Debridement under general anaesthesia was followed by open wound management. Total antibiotic treatment was 20 weeks. Methods. Bacterial analysis of periprosthetic and gluteal liquids included Gram-stain plus acid-fast stain, and aerobic, anaerobic and mycobacterial cultures. Results. In periprosthetic fluid, Mycobacterium abscessus, Propionibacterium, and Staphylococcus epidermidis were identified. The same M. abscessus strain was found gluteally. The gluteal wound healed within six weeks. At ten months’ follow-up, gluteal asymmetry persists for deep scarring. Conclusion. This case presents major complications of multisite aesthetic surgery. Surgical-site infections in context of medical tourism need appropriate bacteriological investigations, considering potential NTM-infections.
Intramuscular gluteal lipoinjection has become one of the most commonly used surgical procedures for achieving improvement in the gluteal contour; however, there are few studies that report and analyze the causes of secondary death from this surgical procedure. An analysis of secondary deaths from gluteal lipoinjection procedures was performed in Mexico and Colombia over periods of 10 and 15 years, respectively. In Mexico, the study was performed through a survey of all members of the Mexican Association of Reconstructive, Plastic and Aesthetic Surgery. In Colombia, the study was performed through an analysis of deaths and autopsies documented by the National Institute of Legal Medicine and Forensic Sciences Regional Bogotá. A total of 413 Mexican plastic surgeons reported 64 deaths related to liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent) occurred during lipoinjection, whereas the remaining five (38.4 percent) occurred within the first 24 hours. In Colombia, six deaths (77.7 percent) occurred during surgery and three occurred (22.2 percent) immediately after surgery. In the Colombian autopsy results, seven cases of macroscopic fat embolism and two cases with a microscopic embolism were reported, with abundant fatty tissue in the infiltrated gluteal muscles. In this study, the authors found that intramuscular gluteal lipoinjection is associated with mortality caused by gluteal blood vessel damage allowing macroscopic and microscopic fat embolism; therefore, buttocks lipoinjection should be performed very carefully, avoiding injections into deep muscle planes. Therapeutic, V.
The female waist-hip ratio of around 0.7 is reachable through liposuction and gluteal fat grafting. The authors evaluated the reliability of this technique. Prospective evaluation was performed of all female patients subjected to gluteoplasty with autologous fat tissue between July of 2010 and July of 2013 without a weight change greater than 10 percent during follow-up. Results were evaluated through photographs. The degree of satisfaction (patient and surgeon) was assessed on a scale of 1 (poor outcome) to 4 (excellent improvement), and agreement was measured by Kappa statistics. The technique involved epidural anesthesia, tumescent infiltration, liposuction around the buttocks, fat decantation, and grafting with retrograde injection in different planes. A total of 106 patients were included. Patient age ranged between 18 and 62 years (mean, 33 years). The preoperative body mass index was between 19 and 31.6 kg/m (mean, 24.8 kg/m). The volume grafted to the buttocks ranged between 180 and 840 cc (mean, 505 cc). There were no medical complications. Five patients (4.7 percent) had seroma in the donor area, 103 patients felt satisfied (97.1 percent), scoring 3 and 4, one patient (0.94 percent) complained of volume resorption 4 months postoperatively, and two patients (1.88 percent) asked to diminish their lateral gluteal volume (score 2) and underwent revision surgery 6 months postoperatively. This gluteoplasty technique is simple and inexpensive, with minimal morbidity and excellent results. A good result depends on harmoniously combining fat elimination by liposuction and fat grafting for buttocks sculpting, with lasting results. Therapeutic, IV.
The author started injecting large quantities of fat in the breasts, thighs, and buttocks in 1985. The Brazilian Buttock technique was first presented in 1987; since then, The author has been writing and lecturing about it worldwide. In the past few years, the technique became very popular; it has changed the ideal of beauty in many countries. Recently, The author started using adipose-derived stem cell-based therapies for buttock augmentation to improve the results of fat graft survival. Copyright © 2015 Elsevier Inc. All rights reserved.
The gluteal muscles have been very important throughout the evolution of mankind for the adoption of the bipedal posture. Over the past 15 years, the intramuscular technique has become popular and has been improved, with enhanced results and reduced levels of postoperative complications. The insertion of gluteal implants within the musculature may be an intrinsic compression factor of these muscles. The objective of the present study was to evaluate the gluteus maximus function and its variation over a 12-month period after the insertion of the implant. This was a prospective, controlled, clinical study. All subjects were female patients, with anthropometric characteristics and body mass index within preset limits to establish similar groups. Isokinetic test gluteus computed tomographic scans and clinical nutritional assessment were conducted in four stages during the study period: preoperatively and 3, 6, and 12 months after surgery. The study group presented 6.14 percent muscle atrophy to the left and 6.43 percent muscle atrophy to the right after the procedure. Muscle strength presented differences in hip flexion and adduction tests. The gluteus maximus muscle presents atrophy secondarily to gluteal augmentation surgery with implants. Variations in gluteus maximus muscle strength should not be attributed primarily to the surgical procedure or to the implants; physiologic and multifactorial variations should also be considered. Strength and volume variations did not show a significant correlation. Gluteal augmentation with implants was effective in improving the waist-to-hip ratio and in changing the anthropometric pattern from android to gynoid. Therapeutic, II.
Fat embolism is usually associated with long bone fractures or other trauma. The diagnosis is usually clinical, and in most cases, emboli are not fatal and not usually seen on gross examination. At the Los Angeles County Coroner's Office, we autopsied the victim of fatal macroscopic fat embolization to the lungs. The patient died during buttock enhancement surgery when fat from liposuction was injected into her buttocks. Fat embolism from liposuction and fat injection is reportedly rare, and macroscopic embolization is rarer still. Varicose veins can occur in the area of the sciatic notch and are known to cause painful sciatica symptoms. We suggest them as a potential conduit for macroscopic fat to reach the lungs. Simple pre-operative questioning for sciatica symptoms and possible radiologic study to rule out sciatic varices seem prudent before undertaking buttock-enhancing surgery. Careful fat injection with pre-aspiration is always advised.