Buttock augmentation

What is buttock augmentation?

Buttock augmentation is an operation carried out to change the volume and shape of the buttock area by transferring a person's own fat or by placing an implant.¹ Fat grafting to the buttocks is also called a BBL; an implant is a foreign material placed in the body.¹ The choice of method depends on the person's tissues and on their goal.²

With fat grafting, the safety assessment carries particular weight because of reports of pulmonary fat embolism and death.³ An implant has separate problems relating to the wound, to its position, and to later removal or replacement.⁴⁵

A buttock lift, which removes excess skin, is not the subject of this article.¹ Despite the word "lift" in its name, the fat transfer of a BBL is not the same operation as a lift carried out by removing skin.¹

Who is it suitable for?

It is assessed in people who want a change in the volume or shape of the buttocks and who are able to weigh the limits and risks of the operation.⁶ State of health, the amount of fat available, the quality of the skin and any excess present affect the suitability of the method.² Where the area available for taking fat is insufficient, an implant may need to be assessed; this does not mean that an implant is suitable for everyone.⁴

The decision should not be made to meet someone else's wish or to fit a particular body shape.⁶ Greater volume is not a more suitable goal for everyone; the person's anatomy and the risk they can accept are considered together.²

What does the examination assess?

The starting volume, shape, skin elasticity and asymmetry of the buttocks are assessed; where fat grafting is being considered, the areas fat can be taken from are examined as well.² Previous operations, any injections given to the buttock area, medication in use and health problems are declared.⁷ The change wanted and the change the operation can achieve are addressed separately.⁷

How much sitting the person's work requires, transport home, the sleeping arrangement and the need for help in the first days are planned. Adding volume and removing excess skin are different aims; where there is marked excess skin, the limits of augmentation are explained.¹

How is the operation planned?

Where is the fat taken from and how is it transferred?

The donor area varies with the individual; the abdomen, waist, hips or thighs are usually assessed. The fat is taken by liposuction, processed and transferred to the buttocks.² The operation does not consist only of the entry points on the buttocks; the incisions in the areas fat is taken from, and the care they need, are part of the plan as well.²⁸

The volume of fat that can be delivered is not a measure of success. The plan is assessed together with the fat available, the state of the skin and the person's goal.²

Which plane is the fat delivered into, and what is the role of ultrasound?

The fat is delivered into the subcutaneous space above the gluteal fascia. This is the plane above the muscle; fat is not injected into the muscle.³ The intramuscular or submuscular position described for an implant is not an option that can be applied to fat.³⁴

The joint statement of 18 August 2022, published by the American Society of Plastic Surgeons (ASPS), The Plastic Surgery Foundation, The Aesthetic Society and the Aesthetic Surgery Education and Research Foundation, supports delivering the fat only in this subcutaneous plane and monitoring the tip of the cannula with real-time ultrasound during injection.³ Ultrasound monitoring is intended to show which plane the cannula is in; it is not the same practice as carrying out an ultrasound scan before surgery only.³ The injection plane, and how it will be monitored during the procedure, are clarified in the safety discussion.

Where is the implant placed?

The pocket prepared for an implant can be within the muscle, under the muscle or under the fascia covering the muscle; these are not the same position.⁴ Fewer problems being reported for a particular plane in one publication does not show that the plane is superior or free of risk for everyone.⁴

Hardening of the capsule that forms around an implant over time, movement of the implant, or its becoming markedly palpable can require further assessment and sometimes further surgery.⁵ The plan therefore covers not only the initial volume but how problems arising later will be addressed.

How are the incision and the limits of a buttock lift determined?

The entry points used for fat transfer and the incision through which an implant is placed are different.² The implant incision can be planned in the crease between the buttocks or, according to the technique chosen, along another crease; its position and length are explained in the operative plan.² Its lying in a crease does not mean that the scar will disappear.⁹

Where skin needs to be removed, the incision and healing burden of that are assessed separately.¹ Augmentation and skin excision are not used interchangeably under the same operation name.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁰ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹¹ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹² Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹³ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁴ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁴ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Transport on discharge, using the toilet and the arrangement for resting at home are organised in advance according to the sitting and lying plan given for fat grafting or for an implant. The general preparation advice does not take the place of the pressure restriction specific to the method.

What is recovery like?

The operation is carried out under general anaesthesia. 2-3 hours are planned for the operation and 1-2 nights for the hospital stay. This timetable is the clinical framework covering both the fat grafting and the implant options; the scope of the procedure to be carried out and the course of healing are assessed separately.

The first check-up takes place within the first week. Stitch removal is planned within 1-2 weeks, with the incision checked. The dressing is continued according to your surgeon's advice until the wound has healed.

7-10 days are expected for bruising to settle and 2-4 weeks for marked oedema to subside. The shape becomes assessable within 2-4 months; residual slight swelling can last 3-4 months. Assessing the shape does not mean that all swelling has ended or that the result will no longer change. The 4-6 weeks given for a full return to daily life is not the time in which the maturing of the scars is complete either.

After fat grafting: The healing of the buttocks and of the areas fat was taken from is followed together.⁸ Because part of the transferred fat can be absorbed, early fullness is not taken as the volume that will remain.⁹

After an implant: Healing of the incision and the position of the implant are assessed separately; a wound problem or movement of the implant can require further treatment.¹⁵ The retention percentage belonging to fat grafting is therefore not used for the result of an implant.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Dressings and checking the incision: The dressing is continued according to your surgeon's advice until the wound has healed. The care given for the entry points in the areas fat was taken from, and for the buttock entry points or the implant incision, is followed separately. Where a drain has been used, its care and the timing of its removal are arranged according to the surgical team's instructions; it is not assumed that a drain is or is not used routinely.⁸ The drain is not tugged, is not removed on your own initiative, and its connections are not altered outside the instructions given. Where the incision cannot be checked by eye, help is taken.

Sitting: Prolonged sitting is avoided for about 2 weeks. When you do have to sit, a cushion or similar support is placed under the hamstring muscles so that direct pressure is not put on the buttocks. With fat grafting, the reason for this restriction is that prolonged pressure can affect the transferred fat.⁸ With an implant, the incision and the position of the implant are the concern; the arrangement to be applied for each method is set out separately in the discharge plan. The sitting restriction is not an instruction to remain motionless in bed all day; a walking and movement plan is given separately.

Compression garment: It is worn for 2-4 weeks, including at night. The arrangements for putting it on, taking it off and cleaning it are determined by the surgical team's instructions. The support arrangement for the areas fat was taken from and for the buttocks is explained separately; which area the garment supports, and which area no pressure is to be applied to, are shown in the discharge plan. The garment is not tightened on your own initiative in the belief that firmer use will give a better result. Where the pressure leads to marked pain, a change in skin colour or difficulty breathing, assessment is requested. Finishing the period of compression garment use does not mean that the sitting or sport restrictions have ended as well.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Lying, specific to the buttocks: In the first days, lying face down or on the side is preferred. Elevating the head does not mean that you should lie on your back or that direct pressure should be put on the buttocks; in this operation, lying on the side or face down is the starting position rather than one to return to. The placing of supports and a suitable position for lying are arranged according to the plan shown by the surgical team. The areas fat was taken from are taken into account in the same plan.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Shower timetable: A return to showering is assessed within 1-2 weeks, according to the state of the wound and the dressing. The instructions given for the entry points in the areas fat was taken from and for the buttock incisions are followed separately; crusts are not picked off.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There can be tenderness, tightness and pain in the buttocks.¹⁶ The painkillers given are used as instructed. Pain that markedly prevents walking or changing position is reported to the team; rather than abandoning the movement plan altogether, pain control and the need for help are assessed. No new painkiller or additional medicine is started on your own decision.

Returning to work and sport: 2-4 weeks are set aside for a return to work. In jobs involving constant sitting or strain on the buttock area, suitability is assessed separately; the timetable for returning to work does not lift the sitting restriction by itself. A return to sport is planned in stages within 4-6 weeks. 4-6 weeks are expected for a full return to daily life. Being able to walk without pain does not mean that sitting for long periods or all sporting movements are permitted.

Driving: A return can be assessed within 2-4 weeks. There must be no effect of medication reducing attention, no dizziness and no pain preventing movement. You need to be able to sit with a seat belt in the manner allowed, to check your surroundings and to brake suddenly or manoeuvre comfortably. Where the sitting restriction still applies, the driving timetable running its course is not enough on its own. Someone accompanies you home on discharge.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the buttock area, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Bruising, swelling, tightness and altered sensation around the incision can occur.¹⁶ What matters is that the findings are decreasing. Swelling that grows rapidly, is painful, or gathers markedly on one side should not be attributed to the healing period given alone. Where there is a new fullness, no attempt is made to press on the area to drain fluid.

How are early walking and prevention of clots planned?

Walking is begun 6-8 hours after leaving the operation, on the assessment of the healthcare team. This early walking is not the same thing as a return to sport. The need for rest does not mean remaining motionless in bed throughout the day; the movement plan given by your surgeon is a basic part of care. Help is taken at the outset; where there is dizziness or marked weakness, you do not push on and the team is informed.

The risk of clots is assessed routinely before surgery. A compression stocking is put on before the operation; after surgery it is removed by the surgeon's decision once you have begun to walk comfortably. A compression garment and a compression stocking are not products used for the same purpose and are not used in place of one another.

Where operations will be long, or where there are risk factors creating a predisposition to clots, prevention with medication is assessed. Which measures are applied together is determined according to the person's risk. Following the movement plan should not be neglected; equally, walking or any other measure should not be thought of as removing the possibility of a clot altogether.

How do the scars change?

With fat grafting a scar can remain at the entry points where fat was taken and delivered, and with the implant method at the implant incision.²¹⁶ The use of a small entry point does not mean that no scar will form.⁹

Scars can fade over time, but a visible scar can remain.⁹ 6 months to 1 year is expected for a scar to mature. The course of the scars in the areas fat was taken from and that of the implant incision do not have to be the same; thickening or indentation is assessed separately at check-ups.

Scar care: Silicone gel or a silicone sheet is used after the wound has closed and your surgeon considers it suitable. No product is applied on your own initiative to an incision that is open, discharging or not yet healed. Which form of product is used, when and how, is determined by the check-up findings. Where irritation develops, an assessment by your doctor is sought regarding use of the product.

Applying silicone may help to reduce redness and the raised appearance of a scar; it does not mean that the scar will be erased entirely.¹⁷ This care is for the incision scar; it is not an instruction to apply pressure to the buttocks or to massage the transferred fat.

Risks and complications

The risks of fat grafting and of an implant are assessed separately. Death, fat embolism, a wound problem and further surgery are different outcomes; their rates are not added together to calculate a single personal risk.¹⁸⁴ Describing the risks does not mean that these events will develop in everyone.

Fat embolism and the dated safety data

During fat injection into the buttocks, fat entering the circulation and affecting the lungs can be fatal.³ This event is not the same as a blood clot forming in a leg vein and travelling to the lungs. The injection measures directed at fat embolism and the plan for preventing clots do not take the place of one another.³¹⁶

In the warning issued by the American Society of Plastic Surgeons (ASPS) on 6 August 2018, the frequency of death was estimated as reaching as high as 1 in 3,000 procedures.¹⁹

Lower rates were reported in the survey conducted after the technical safety recommendations published in 2017.¹⁸ In the study by Rios and Gupta comparing survey reports from 2017 and 2019, pulmonary fat embolism fell from 1 in 1,030 procedures to 1 in 2,492, and this difference was statistically significant, with a P value of 0.02.¹⁸ In the same study, the fall in the estimate of death from 1 in 3,448 procedures to 1 in 14,952 was reported as a trend.¹⁸ The proportion of surgeons reporting that they injected into deep muscle also fell from 13.1 per cent to 0.8 per cent; these percentages show what surgeons reported, not the number of procedures.¹⁸

In a more recent systematic review and meta-analysis of procedures carried out under ultrasound guidance, no death or fat embolism was reported among 6,235 women across 4 studies.²⁰ In the same review, minor complications were reported at 6.32 per 100 people (95 per cent confidence interval 3.23-10.27), seroma at 2.94 per 100, infection at 0.23 and fat necrosis at 0.09.²⁰ These are the results reported in studies of ultrasound-guided gluteal fat grafting.²⁰

Volume, tissue and wound problems in fat grafting

Fat necrosis is the loss of viability of part of the fatty tissue; fluid accumulation, infection, haematoma, asymmetry and altered sensation can also develop.¹⁶ A reduction in volume through absorption of the transferred fat is not the same problem as infection or fat necrosis.⁹¹⁶

Wound and shape problems can also be seen in the areas fat was taken from; following the appearance of the buttocks alone is not enough.²¹⁶ New firmness, pain or one-sided growth is not left to wait on the assumption that it is the expected absorption or swelling.

Capsule, movement and further surgery with an implant

Hardening of the capsule that forms around an implant is called capsular contracture. Movement of the implant, its becoming markedly palpable, or asymmetry can require the position of the implant to be corrected or the implant to be replaced.⁵ Infection, wound dehiscence and haematoma are also problems reported with implant surgery.¹⁵ Sciatic pain has been reported in a selected series in which implants were replaced; this is not a frequency belonging to everyone having an implant placed for the first time.⁵

In the abstract of the retrospective series by Elsaftawy and colleagues covering 80 women who had submuscular implants placed, 7 people were reported to have undergone surgical revision and no implant was removed.¹⁵ 2 people were reported to have needed antibiotic treatment alone; this figure should not be taken as a single rate for all infections.¹⁵ The follow-up period is not given in the abstract. No implant having been removed does not mean that further surgery was not needed, or that removal will not be needed in the long term.¹⁵

In the abstract of a meta-analysis covering 32 publications and 2,682 people undergoing implant-based augmentation, the implant removal rate was reported as 1.05 per cent for all positions and 5.23 per cent for subfascial placement.⁴ A single average conceals that difference: the same abstract gives seroma at 22.25 per cent and wound dehiscence at 27.07 per cent for subfascial placement, with lower rates reported for intramuscular and submuscular positions.⁴ Only the abstract of this study could be accessed; the study-level spread, the confidence intervals and the follow-up periods could not be read, so the rates cannot be used to show that one position is superior for everyone.⁴ The removal rate does not cover all further surgery either; replacing the implant, correcting its position and repairing the wound again are not the same outcome heading.¹⁵⁵

Clots, anaesthesia and general surgical risks

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Problems related to anaesthesia and cardiac and respiratory complications are also assessed.¹⁶ Following the stocking and movement instructions given for preventing clots does not make a newly starting breathing complaint unimportant.

Problems relating to shape, scars and added procedures

Asymmetry, a marked scar, prolonged swelling, altered sensation or lasting pain can develop.¹⁶ Where an expectation is not met, further surgery may be needed; it is not guaranteed that every goal will be achieved with the first procedure.⁹

Taking fat, placing an implant and any added skin excision carry separate risks and separate care burdens.²¹⁶ Rates from different techniques and different patient groups are not set side by side in order to show that one method is safer for everyone.¹⁸⁴

Does the result change over time?

Retention and a further session with fat grafting

Part of the transferred fat is absorbed; the volume of the fat that remains can also change with weight gain and loss.⁹ Early fullness and the volume that remains afterwards are therefore not the same.⁹

In the abstract of the prospective study by Wang and colleagues covering 35 women, the retention rate calculated by three-dimensional imaging after buttock fat grafting into the subcutaneous plane only was reported as 77.9 per cent at 3 months and 64.7 per cent at 6 months.²¹ These are measurements from the same study at different follow-up times; they do not mean that retention of between 64.7 and 77.9 per cent is to be expected across individuals.²¹ The study is not a meta-analysis and these values cannot be used as rates predicting anyone's result.²¹

A general retention percentage specific to the buttocks, with the study spread and the pooled value verified together, is not given here. The rates from facial or breast studies are not carried across to the buttocks. Where the volume remaining after absorption, or the shape, does not meet the goal, a further session can be assessed; it cannot be said that this will be needed in everyone.⁹ The decision on a second session is considered together with the area fat can be taken from again and the risks of the new procedure.²³

Durability and replacement with an implant

The volume achieved with an implant is not assessed by a fat retention rate. Further surgery can be needed because of movement of the implant, a capsule problem or other unwanted outcomes.⁵ The possibility of the implant being removed or replaced is explained at the time of the first decision.⁴⁵

Although a lasting change can be aimed for, ageing and change in the tissues continue.⁹ No promise is made that a change will be needed in everyone at the end of a particular year, or that an implant will remain trouble-free for life.⁴⁹

What can be expected from the result?

The change expected is limited by the person's starting volume, their skin and the method chosen.²

The aim is not for everyone to reach the same buttock shape or a particular waist-to-hip ratio.⁶ Alongside the volume expected, the embolism risk of fat grafting, the possibility of further surgery with an implant, and the effect of the sitting and lying arrangement on daily life are also part of the decision.³¹⁵⁸

Returning to work, a full return to daily life, assessment of the shape and maturation of the scar are separate processes. A decision on the final result is not made from an early appearance. It should be known that further correction may be needed with either method and that there is no guarantee of a definite result.⁹

When should you contact a doctor?

In the situations below, the planned check-up is not waited for.

• Rapidly increasing swelling or tightness in the buttocks or in the area fat was taken from
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• The wound opening or bleeding that does not stop
• Newly developing marked pallor, darkening or blistering of the skin
• A newly developing marked change in shape at the implant site
• Steadily increasing pain and pressure under a compression garment or support

These findings may require assessment for bleeding, infection, or problems relating to the tissue or the implant.¹⁶¹⁵ No attempt is made to correct a new swelling by massaging or compressing it.

One-sided leg pain and swelling, sudden shortness of breath or chest pain are emergencies. Where there is a sudden breathing problem, urgent assessment should not be delayed while trying to reach your doctor.⁸ A breathing complaint after fat grafting is not taken as part of the ordinary swelling timetable; no attempt is made at home to tell a blood clot and a fat embolism apart.³

About the numbers in this article

The intervals given for the operation, hospital stay, stitches, showering and return to activity, together with those for bruising, swelling, shape and scars, are the clinical framework approved by the surgeon. The follow-up months in the research are not the source of this care timetable. The method-specific instructions for sitting, lying and the compression garment are explained separately in the discharge plan.

The 2018 mortality estimate comes from an institutional warning, the 2017-2019 comparison from surgeon surveys, and the figures for ultrasound-guided procedures from a systematic review and meta-analysis; each group is read within its own method and period.¹⁹¹⁸²⁰ Implant removal, further surgery and fat retention are different outcomes; their figures are not added together or used in place of one another.¹⁵⁴²¹

The shared paragraph on smoking cessation reports research covering a range of operations. The relative risk reduction is not an absolute complication rate specific to buttock augmentation, nor does it mean that every nicotine product has been studied separately with the same effect.¹¹¹²¹³

References

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