Tuesday, February 5, 2013

Brazilian Butt Lift - Buttock Augmentation Implants and Injections

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Fertility dolls with large hips and buttocks have been found dating back to the pre-dynastic Egyptians of 4000 B.C.

Doll statues and carvings were often placed near a couples bed or on the family altar with suitable offerings that would ask the fertility goddess to work in their favour.

With colonization of Africa in the 1800s women's clothing styles in Europe aimed to accentuate a thin waist with large hips and buttocks. At first this was accomplished by layering clothes on top of each other (petticoats). These could become quite heavy so caged or hooped underskirt frames (crinolines) followed by bustles and then corsets were introduced.

The American W. S. Thomson patented the metal cage crinoline in the USA, France and Britain in 1856 to free women from the heavy petticoats. It became hugely popular among all classes of women. At the height of its popularity enough steel was produced in Sheffield England to make half a million hoops a week.

In the early 1880s the bustle was introduced. It consisted of a straw filled cushion sewn into the skirt with a series of steel half hoops inserted in the skirt lining down to the ground and another loop that went around the waist. This had the effect of throwing the skirt out almost horizontally from waist level behind. The effect was to exaggerate the buttocks even more. This bustle is still frequently seen today in wedding dresses.

This infatuation for accentuated buttocks continues today but now we have surgery to do the job that was previously done by clothing. Silicone implants were used in the buttocks for the first time in 1969 but these were breast implants placed in the fat layer just below the skin. They had high rates of implants moving out of position, asymmetry and capsular contractures. By the early 1980s surgeons began placing them in the muscle. Some of the buttock craze is fueled by the constant exposure to celebrities with such assets like Beyonce, Kim Kardashian and Jennifer Lopez but this look has been a goal for many women for centuries. Pippa Middleton, the younger sister of Kate Middleton, experienced huge fanfare after donning a white clingy, sheath dress in the royal wedding that indicated a large backside. The Pippa Middleton Ass Appreciation Society Facebook fan page then appeared with more than 243,000 "likes." The topix.com forum on plastic surgery has more comments on buttock injections than any other topic. One thread has more than 14,000 comments. The American Society for Aesthetic Plastic Surgery counted 2,100 buttock augmentation procedures in 2004. RealSelf  searches for butt augmentation procedures, including the Brazlilan butt lift, were No. 1 in 2011, and surged by 28% in 2012. According to American Society for Aesthetic Plastic Surgery statistics Americans spent more than $31 million on buttock augmentation surgeries in 2010, a 40 percent jump from the year before. According to the American Society of Plastic Surgery (ASPS), the number of legitimate buttock implantations, which cost up to $15,000, rose by 43 percent between 2010 (806 reported cases) and 2011(1,149 reported cases) and more than 140 percent from 2000 to 2010. That compares to 4,546 people who got buttock lifts in 2011, and 301,000 who got breast augmentation. In Brazil aesthetic buttock surgery increased 20% between 2008 and 2011.

Around World War II, silicone shots were used to boost bustlines, predating today's breast implants. Silicone was used by the military to insulate electrical transformers and some of this material found its way into the busts of local women in Japan. This practice spread to the US in the 1950s and 1960s. In 1965 the FDA banned liquid injectable silicone, and today board-certified plastic surgeons won't inject silicone into any body part. Instead, for those looking to enhance their rear view, buttock implants and fat transfers are the only doctor-approved procedures. In the 1980s and 1990s male to female transsexuals began injecting silicone into their buttocks in large numbers. Some of these individuals then became injectors themselves and the practice of illegal buttock injections flourished.There is no data on the number of illegal silicone butt injections, but anecdotal evidence suggests the recent recession may have led many people to try these injections which can cost $300 to $1000 vs. $15,000 for legitimate buttock augmentation. More recently the injection mixed has been converted to more toxic mixes of chemicals such as fix a flat which is used for flat tires.

In 2002 a Coral Gables Florida salon owner had her first set of buttock injections at a cost of about $3,000. She went to a local "spa" recommended by her clients and had up to 600cc of industrial silicone injected into her buttocks. She chose that method because the cost was lower and the promised recovery time shorter than conventional surgery. She had another set of injections in 2009. Shortly after that she began to feel a deep itching in her buttocks that she could not scratch. Then they turned purple and then grey as the skin began to crust and painfully peel off. A few months later her buttocks drooped down and collapsed in on themselves. She was too embarrassed to see a doctor. Then one day at the salon she took a client into a back room to show her what it looked like back there. Seeing the look on her client's face she decided to see a surgeon to rectify the problem. After multiple doctors refused to treat her she found a surgeon who agreed to take on her case. After surgery and almost $70,000 later she has improved but is scheduled for more surgery and additional costs.

On November 29, 2009, 38 year old Solange Magnano, who won the title of Miss Argentina in 1994 died after undergoing a buttock augmentation procedure at a plastic surgery clinic in Buenos Aires. She was rushed to the hospital from the clinic after sustaining a blood clot or the movement of injected liquid to the lungs and died 3 days later in intensive care. After winning the title she participated in the 1994 Miss Universe contest and then modeled in Paris and other cities. She left behind a husband and 8 year old twins.

In 2004 a 38 year old Los Angeles  cosmetologist paid a "pumper" to inject industrial grade silicone  to enhance her buttocks.  her friends also used silicone injections.  During a hair appointment, her hair sytlist showed off her new derriere and recommended the pumper. The cosmetologist knew that the pumper wasn't a doctor; she was a salon client. But the lure of larger buttocks clouded her judgement.

For her first injection she went to the pumper's two-story home outside Los Angeles. The pumper sent her into her teenage daughter's bedroom, where an assistant filled syringes with what she assumed was silicone. The pumper injected her several times in the crease between the butt and the thigh. The pumper then instructed her to massage the area regularly to settle the silicone and to wear cheek-exposing shapewear to help reduce any swelling. A month later when she returned for round two, because she did not see enough improvement, it was more painful.

Over time the injected area became intensely irritated and painful, and the skin blackened. At first she was too embarrassed to tell her doctor what she had done, waiting almost a year before seeking help. By that time she was desperate to have the silicone removed but  none of the doctors referred by her HMO would agree to do the surgery because the procedure is risky and often leads to disfigurement.

In the summer of 2011 she woke up feeling lethargic and was suffering from a shortness of breath. Her family rushed her to the emergency room where she was diagnosed with septic shock from necrotizing soft tissue infection secondary to infected foreign material. Tissue from her lower back down to her midthigh was dying from a barrage of bacteria from the silicone. Over the next few weeks she underwent over 20 operations to save her life.

The medications used to sustain her life with a viable blood pressure cut off the circulation to her lower arms and legs and she ended up with amputations from the shins downward and forearms downward. She recalled seeing her hands in the hospital, thinking, "Oh, my God. I am going to lose my hands. I looked at my feet ,and they were dead, too." She lost her hands, feet and most of her buttocks in 27 operations performed to save her life. Studies of the material removed showed it was bathroom caulking. Now she spends her days at home on disability. Determined to warn others about the risks of silicone injections, she established the Apryl Michelle Brown Trust, an organization that hosts self-esteem workshops and motivational speaking engagements.

 She appeared on a recent episode of the Katie talk show.

The San Francisco victim of such an injection described an incident that took place at the non-physician injector's home, where a buttock augmentation procedure was performed  by  injecting her buttocks with liquid to make them “bigger” as she stood near the dining room table in view of the injector, "Dr. Carlos's", mother. This resulted in infections in her buttocks that lasted one year. She went back and was injected two more times. He used toilet paper and glue to seal her wounds. During one procedure he allegedly broke off a piece of a cannula, into her right buttock and left it in place. Nine months later, it protruded from her skin and she was able to grab it to remove it. Another victim paid $10,000 for a breast and buttock augmentation and liposuction, which were allegedly performed in Tijuana, Mexico, in January 2011. According to testimony, the victim could not recall who actually performed the procedures in Mexico. However, Dr. Carlos allegedly took a flight with her from San Francisco to San Diego, and then a train to Tijuana where the procedure was performed.

That "Dr. Carlos" was charged with 17 felonies, including practicing medicine without a license out of a San Francisco clinic (Derma Clinic), identity theft, assault, rape, sexual penetration by an unknown object against the victim’s will and unlawful oral copulation. Nine alleged victims were connected with the case.

In February 2011, British tourist Claudia Aderotimi died after receiving a cosmetic buttocks injection at a Hampton Inn in Southwest Philadelphia.

In early 2011 a 49 year old successful Dallas real estate broker who owned two homes, a luxury car, an SUV and a small office building underwent liposuction and fat grafting by an internal medicine doctor, Hector Molina.  After a more-than-nine-hour liposuction and fat-transfer surgery, Molina and a doctor assisting him abandoned her in his office "without any medical supervision or monitoring. Her friend found her "short of breath, unable to stand" and in severe pain in her legs and feet. She was rushed to the emergency room and transferred to a trauma center. So much fat was injected into the muscles in her buttocks, it caused the compartment syndrome, which Molina failed to diagnose. She needed 27 more surgeries to treat the compartment syndrome and related complications and spent a month and a half in the hospital. A year and a half later she was out of work, had to use a walker and wheelchair to get around and had nothing left to her name.  The money she earned selling real estate, which she did starting at age 25, went to pay medical bills, because complications from cosmetic surgery aren't covered by insurance. She now lives off $698 a month in disability benefits. In April 2012 a Texas Medical Board disciplinary panel found his "entire knowledge" of the procedure consisted of reading a book provided by the manufacturer of the liposuction equipment, completing an online program over two weeks, passing an online exam and completing one procedure under the direct supervision of another surgeon and prohibited him from performing any more cosmetic surgery.

In June 2011, 36-year-old Whalesca Castillo was sentenced to a year in prison after pleading guilty to operating without a license and injecting women’s breasts and buttocks with liquid silicone from her home in the Bronx.

A Baltimore exotic dancer was hospitalized in October 2011 when she experienced shortness of breath after receiving buttock injections. Doctors found fluid in her lungs and treated her for pneumonia. The liquid was reportedly made of silicone often found in paint or furniture polish. The injector was not a doctor and was injecting non-FDA approved material in hotel rooms in various cities including Baltimore, New York and Washington D.C. for $500 to $1,600 per treatment. After being arrested in a Washington D.C. hotel the injector pleaded guilty, in March 2012, to charges of conspiring to introduce and deliver into interstate commerce an adulterated and misbranded device, for which she faces a maximum of five years in jail and a $250,000 fine.

Also in 2011a Venezuelan woman tried to resurrect a failing marriage by having 560cc injected into each buttock in Venezuela for the equivalent of $800 US. Despite getting her husband back she continues to have problems with the injections, cannot take her clothes off in front of her husband and can no longer have sex. Since 2011 15 people have died from these type of injections in Venezuela. The practice is so pervasive there that 15 year old girls get buttock and breast injections for their birthdays. A gym trainer in San Cristobal, Venezuela had these injects to make his chest muscles look bigger but the material migrated into the muscles between his ribs limiting his breathing so he has been flat in bed since 2011. Finally the Venezuelan government outlawed these injections in 2012 but that has not slowed down the business of body injections in that country.

Between June and October 2012 a Palm Beach Florida man obtained weekly buttock injections in a motel room by an untrained ex-convict transvestite for $100 per session. In October 2012 he began to develop open sores at the injections sites. Medications given to him by the injector did not help so he went to the hospital in November 2012. Multiple bacterial infections were found in his buttocks, some of which were antibiotic resistant MRSA so parts of his buttocks were surgically removed. When police came to interview this victim in December 2012 they had to do so with him lying in a fetal position in his hospital bed. This injector was finally arrested and formally charged in January 2013.

On November 1, 2012 a woman was seen at a Flushing, New York home decorated like a doctor's office and had what was later determined to be either silicone or paraffin injected into her buttocks for $2,300. After experiencing pain and seepage for several days she returned and again was injected with penicillin and another substance. The injector then tried to seal the leaking injection sites with Krazy Glue. The woman then went to a hospital and was diagnosed with a massive infection and gangrene. The injector was charged with assault, reckless endangerment and unauthorized practice of medicine in Queens Criminal Court and faces seven years in jail if convicted. A surgeon at the hospital stated that he had seen patients who had been injected with brake fluid or caulking silicone used to seal plumbing fixtures.

In November 2012, Florida police arrested 30-year-old Oneal Ron Morris of Miami and charge her with manslaughter in the death of one injection patient as well as charges of practicing health care  without a license and causing serious bodily injury for allegedly injecting at least two women with a toxic mixture of Fix-a-Flat tire sealant, mineral oil and cement in a backroom attempt at buttock enhancement.

You can see her resemblance to the 1880s bustle in these police mugshots.

This is a November 2012 Toronto, Canada police safety alert.

This is a video of in improperly placed buttock implant posted on YouTube in November 2012.

In December 2012 a Hialeha FL couple were arrested for practicing medicine without a license and injecting buttocks.

Buttock enhancement is not just for women. In the 1990s a marketing student at Pepperdine University got the idea for men's underwear with enhancement padding while studying the marketing of Wonderbra padded bras. The first line of men’s underwear with enhancement padding in the seat was offered by Go Softwear in 1996. The Go Softwear Super Padded Brief ($37.50) has 5-by-7- inch oval pads quilted into them. Men accounted for 6.2 percent of cosmetic buttock procedures in 2012 vs. only 2.2 percent in 1997. A change in men's views of their backside is corroborated by buttocks-enhancing underwear accounting for more than 6 percent of men’s underwear sales at the online store Freshpair vs. less than 1 percent five years ago. Other companies have introduced buttock lifting and enhancing underwear for men including Calvin Klein's Body Boost Butt Trunk ($22) and the 2(x)ist Lift No Show Brief ($24).

According to the American Society for Aesthetic Plastic Surgery, 7,286 buttock augmentation procedures, and about 3,655 fat grafting buttock lifts, were performed in 2012. The public has gone buttock crazy with disastrous results and ever increasing numbers of prosecutions for injecting non-approved substances into the buttocks in the unlicensed practice of medicine. At times this takes on the picture of drug seeking behavior with injections performed in seedy motel rooms. The ethnic groups that most commonly go to these injectors are African Americans and Latinos. Sometimes the alien material, infected with bacteria, has to be removed from the body by cutting out the tissue it is embedded in, causing massive disfiguration.

The buttock area is best analyzed like a picture in a frame with the skin and fat layers being the frame on one side, the deep bones making up the frame on the other side and the buttock muscle taking the space of the painting itself. Prior to any surgery every component needs to be examined in order to individualize a surgical treatment plan.

This photo shows the frame of fat outside the buttock muscle and the bone deep to the muscle.

The frame comes in various shapes: square, A-shape, V-shape and round and can be asymmetric as shown in the round example.
The alignment of points A, B and C govern the frame shape and tell the surgeon where fat needs to be removed or added. In the A shaped example above fat needs to be removed from points C and B. In the V shaped example fat needs to be added to point C (the mid-lateral buttock depression) .

The bone portion of the frame is assessed by the vertical height between points A and D. If the height is large fat is removed from A and put in D.
It is also assessed by the tilt of the pelvic bone, The more tilted the bone is the less fat needs to be removed from the lower back area.

The muscle shape can also be A, V, square or round and can be deficient in any of 4 quadrants. If it is deficient in the lower outer quadrant that is the B point which can be grafted with fat. Lastly the point of maximal outward projection should be at the level of the pubic bone in front. You can see that in the 2 left pelvic tilt photos above.
This is an example of someone with an asymmetric A frame but a V shaped muscle and a high point A to point D height. The ideal option would be remove fat from points A and B and in the lower back and put fat into point C and just behind point B.

Aesthetic buttock surgery at the time of a body lift after massive weight loss is not covered in this blog but will be covered in a future blog.

Contrary to popular belief, exercise cannot increase the size of the buttocks or significantly improve their shape. In fact, fat reduction associated with aggressive exercise may lead to a decrease in the size of the buttocks.

The available surgical options are:
  • liposuction of the frame only
  • liposuction plus fat grafting
  • implants with or without liposuction
By narrowing the waist and the area just above the buttocks in the midline (presacral, prelumbar) a significant change in the buttock contour will result. Depending on the patient this can account for 70% of the end result no matter what is done to the buttocks themselves.

Fat fillers are the typical procedure for buttocks augmentations, not silicone injections. For reasons unbeknownst to me fat grafting is currently referred to as Brazilian butt lift. Industrial silicone and other materials are being injected by illegal pumpers. It is highly unlikely that any of these pumpers would know or do the critical analysis I have described above prior to injecting someone and without which a good aesthetic result is seldom achieved.  Furthermore they are injecting unsterile material in a way that allows it to enter the bloodstream and travel to other organs as in the case of the Baltimore exotic dancer who was hospitalized in October 2011.

For an optimal fat grafting result the fat should be harvested under low pressure, minimally manipulated or exposed to air after harvesting and injected in small aliquots close to or into the muscle in multiple layers using a blunt instrument preferably as it is being withdrawn. Injecting fat in a large clump increases risk of infection with or without abscesses that need draining, decreases fat survival, increases risk of forming cysts of oil after the fat cells die and leak out their contents and therefore increases the risk of indents or lumps. If large clumps are injected into a muscle with sharp needles the muscle compartment pressure can increase from blood and fat leading to the problems experienced by the Dallas patient described above. That is why i use a ratchet injector with a blunt tube to inject fat. Each advancement of the ratchet injects only a small piece of fat and the chances of fat clogging the tube so the injector keeps pushing till a large piece of fat is injected does not happen. Fat injecting really allows the surgeon to fine tune the procedure as all components can be adjusted.

The main drawback to fat grafting is a large amount of fat is usually required, anywhere from 500cc to 1500cc for each side of the body. This can be challenging to impossible to achieve in thin patients without causing problems at the harvest sites or bizarre body contours. Also no matter how good the surgeon the more fat you inject the more likely some is going to get into the blood stream. If this amount is sufficient it can cause a fat emboli syndrome. I saw this once in another surgeon's patient and that patient had to be admitted to an intensive care unit on a respirator for a few days. Fortunately they did well and it did not affect the end result. However even that complication is something your surgeon needs to be prepared for and you will not get that with discount surgery by non-qualified or non-licensed individuals.

Buttock implants have always been controversial amongst plastic surgeons. They think they are fine or think they are dangerous. Few surgeons are in the grey zone between these two opinions. Because of the infrequency of this surgical procedure being performed in training programs and most surgeons' offices, there is little bibliography about it. A literature search in the Plastic Reconstructive Surgery journal only yielded a couple of articles. For the same reason, the training of many professionals in this specific area, and especially in the correct placement of gluteal implants, and in the proper evaluation of the patient preoperatively is, in many cases, deficient. For this reason, in the great majority of cases, the results are not what the patients really expected.

The implants come in round and anatomical or oval shapes much like breast implants and in sizes

 ranging from 10.6 to 14.5cm diameters with projections of 3.8 to 5cm which corresponds to 280 to 460cc.

Buttock implants are placed via a 6 to 7cm incision between the buttocks with preservation of the midline ligament by leaving intact a 5mm strip of de-epithelialized skin along the incision in order to maintain the trough. Without this strip you would be left with a uni-butt. The dissection is continued off to the sides and then into the muscle beginning 4cm off the midline. Separate intramuscular pockets are created on each side of the body. The pockets are placed so the patient will not usually sit directly on the implant. A well defined pocket lowers the risk of implant migration, visible/palpable implant edges and later drooping. Implants can be placed subcutaneous (in the fat layer), subfascial, submuscular, or intramuscular. Intramuscular is probably the best option. Skin sutures stay in 10 to 14 days and activity restrictions such as no lying on your back are enforced for 60 days . There is no sitting for long periods for 10 days.  As you can imagine no matter who does the surgery it is associated with high rates of suture dehiscence (up to 30% of intramuscular implants and 15–30% of subfascial implants), seroma, infection and implant displacement. So separate skin cuts are required for liposuction and for any drains related to liposuction. Because of the seroma rate most patients are better served with drains after surgery. Because of the location of the incision and placement of foreign material meticulous hygiene is required even after recovery is completed. It is a good idea to clean out your bowels with something like magnesium citrate before surgery so you will not soil the area for some days after surgery.

The main disadvantage of augmentation gluteoplasty with silicone implants is the substantially high rate of complications. The most common complication being wound dehiscence. I recently reviewed a case of a plastic surgeon who placed buttock implants and the patient had a very bad infection with breakdown of the suture line. A brazilian study published in 2012 showed a high rate of implant rupture begining 7 years after placement of silicone gel buttock implants. The other problem with buttock implants is they only affect the muscle portion and can only increase muscle projection. To address the frame or transition areas between the frame and muscle you still need liposuction and possibly fat grafting.

This is a patient of mine in whom I performed fat grafting to the buttocks at the same time as a body lift.

The question arises whether aesthetic buttock surgery can be performed at the same time as a tummy tuck. That depends on the type of abdominoplasty and what type of buttock surgery. If large amounts of fat need to be grafted to the buttock area and a significant amount of that fat will have to come from the abdomen it is safer to do the buttock surgery first and come back some months later to do the abdomen unless all or most of that fat can be harvested from the tissue that is removed at the time of the tummy tuck.

Another area I have not addressed is the use of hyaluronates or Sculptra injectable fillers in the buttocks. So far this has not been performed very much because the cost is prohibitive and the results are temporary.

As for surgery to correct problems after buttock injections the type of surgery depends on the condition of the tissue at the time of presentation. Problems can arise decades after the injection when the patient cannot remember what was injected or who injected it. There are reports of patients showing up 15 years after their buttock injections with tender, warm, swollen and discolored/hyperpigmented buttocks. The usual process requires an MRI to show exactly where the material is followed by surgery to remove all of the material. If the buttock reactions are accompanied by intermittent, low-grade fever and episodes of arthralgias (joint pains) that involve ankles, hips and/or knees the injected foreign substance is producing a generalized inflammatory response. In such cases the patient needs to see a rhuematologist prior to surgery to obtain blood tests and be prescribed medications to treat Human Adjuvant Disease. This is a crucial requirement for a smooth recovery after surgery. In such cases the disease does not get cured, but the symptoms can go into remission. It is difficult to impossible, in many cases, to completely remove the injected material.

It is crucial that no matter which procedure you have fat grafting, buttock implant or injection that you do not have an IUD in place at the time of surgery. I reviewed a case where the patient had an IUD and no one recognized it except for myself and the radiologist. The IUD was a source of actinomycosis infection that required multiple operations, months of antibiotics and months in the hospital to limit the damage of the infection. All of that could have been prevented if the IUD was removed prior to buttock surgery. If you have an IUD make sure your surgeon knows about it before surgery!!

April 3, 2013 Addendum:
A review of 2,226 cases of buttock augmentation with silicone implants published in the April 2013 issue of Plastic and Reconstructive Surgery, had 848 complications, or a 38.1% complication rate. The most common complication reported was separation of the incision site(7.9%). The rate of infection requiring buttock implant removal was 1.7%. The study did not allow comparison of complication rates between subfascially and intramuscularly placed implants. The author concluded that buttock implants should be 330cc or less in order to avoid incision site separation.

June 24, 2013 Addendum:
In April 2013 a 28 year old south Florida woman went to a strip mall medical spa for buttocks injections at a cost of $1500. She returned a few weeks later for a second session of injections of the oily yellow substance. Shortly after that she felt dizzy and 10 hours later she was dead.

July 23, 2013 Addendum:

This woman performed the procedure in Houston while out on bail for practicing medicine without a license. Some people never learn.

Betty Pino, a popular Miami-based DJ, had previously injected silicone removed from her buttocks in June. She became infected in August and fell into a coma due to the bacteria in her blood stream. She was taken off life support and passed away August 7.

October 16, 2013 Addendum:
Last month, after receiving a crime stopper tip, police in south Florida found a man in a hotel with 15 bottles of silicone liquid, 47 bottles of lidocaine local anesthetic, syringes, Super Glue, gloves, needles and $18,000 in a suitcase. Police estimate he was performing 6 unlicensed procedures a day and charging between $100 and $1,200 for each procedure. He was charged with practicing medicine without a license, unlicensed practice of a health care profession, dispensing prescriptions without a license and drug possession.

October 31, 2013 Addendum:
Police in South Texas arrested a woman, after an FBI-FDA undercover sting, who was travelling between homes, spas and massage parlors along the Texaco Mexico border injecting clients in the lips, buttocks and legs allegedly with silicone rubber. She was charged with practicing medicine without a license. Many of these clients were illegal aliens. Police found she had left advertisements at these establishments for collagen injections starting at $250. One of her clients was hospitalized with burning in her ankles and difficulty breathing after an injection session on October 9, 2013. She underwent surgery to remove the substance after doctors contemplated amputating one of her legs.

January 27, 2014 Addendum:
A study was just published on the use of Non-Animal Stabilized Hyaluronic Acid (NASHA Macrolane patented and produced by Q-Med AB, Uppsala, Sweden)for buttock augmentation. 61 patients had a total of 200 to 420ml of the material injected and were followed for 24 months. Patient satisfaction with buttock size, shape, firmness, and general appearance was higher after injection than it was before before injection at all the times over the 24 months, with a peak of 70 % of patients satisfied 1 month after treatment. At 24 months 40% still reported their buttock appearance improved and 33% were satisfied with the result. The material shifted out of position in only 1 patient. For those patients who do not have enough body fat elsewhere to inject into the buttocks it looks like hyaluronic acid will be the answer as long as the price point is not too high. Using currently available restylane, juvederm etc. the price of buttock augmentation with hyaluronates is much more expensive than fat grafting.

March 11, 2014 Addendum:
A Woodridge NJ beautician was charged in a Manhattan Criminal Court with 2nd degree manslaughter and 1st degree assault in the July 2013 death of a 22 year old college student from Queens NY. The student met the beautician in a Manhattan hotel room for the 4th session of her buttock augmentation injections. During the injection the student had a seizure after which the beautician called 911 and then walked away. The student was barely alive when paramedics arrived and died at the hospital a short time later. An autopsy found that the injected silicone had entered the bloodstream, traveled to her lungs and asphyxiated her. Detectives found the beautician by tracing the credit card used to pay for the room and viewing security camera footage of the 2 meeting at the hotel.

April 19, 2014 Addendum:
A Venezuelan lawyer woke up one day with a bump the size of a football in her lower back. She could not walk or bend down, and the pain was intense. Even before seeing a doctor she knew it was related to the 2006 silicone injects to her buttock. The silicone had migrated to her back and was putting pressure on her spine.

The Venezuelan government banned buttock silicone injections in 2012. Despite  the ban up to 30% of Venezuelan women between 18 and 50 still have these injections, according to the Venezuelan Plastic Surgeons Association. They estimate that at least a dozen women die every year from these injections. These injections are dangerous because the silicone gel can migrate (even years after the initial injection) unlike silicone implants where the silicone cannot freely migrate but the injections are much cheaper and quicker without a prolonged recovery time. An injection can cost as little as 2000 bolivares (£191, $318) and the whole procedure doesn't take more than 20 minutes. In Venezuela removal of tissue affected by the injection can cost 30 times the cost of the injection and this is not covered by health insurance.

August 29, 2014 addendum:
Tracey Lynn Garner of Jackson Mississippi was convicted of depraved heart murder and conspiracy to commit wire fraud in the killing of a Georgia women through illicit silicone buttocks injections. She was sentenced to life in prison. The Georgia woman was referred to Garner by Natasha Stewart, an adult entertainer also known as Pebbelz Da Model. Stewart was convicted of manslaughter in this case and sentenced to seven years in prison.

February 25, 2015 addendum:
The American Society of Plastic Surgeons procedural statistics for 2014 revealed the number of buttock augmentations, which use fat grafts (injections of fat from other parts of the body), rose to 11,505, up 15 percent from the previous year. Buttock silicone implants (not injections) went up to 1,863, a 98 percent increase from 2013, and the number of buttock lifts reached 3,505, up 44 percent from 2013. In 2014 total buttock augmentation procedures increase 3400 percent compared to 2002,  just over a decade.

May 17, 2015 addendum:
I was bracing for the onslaught of problems related to the increased number of procedures described in my February addendum but this one came out of nowhere. I just reviewed the case of another well trained surgeon whose patient developed actinomycosis infection of the buttocks after fat grafting to the buttocks due to an old IUD. 5 or 6 operations later she has lost most of her buttocks and has to still take antibiotics for a year. If you are you going to have cosmetic buttocks surgery or even and abdominoplasty please be safe and remove your IUD first.

September 23, 2015 addendum:

October 1, 2015 addendum:
The New York City Medical Examiner has ruled that the death of a Maryland woman during a botched butt injection at the hands of a quack Queens, N.Y. doctor was a homicide. 34 year old Kelly Mayhew a freelancer for the BET Networks drove from Maryland to New York with her mother on May 30, 2015 to undergo the ill fated procedure, that was arranged by a family friend. They arrived at a Queens two-family home on Dickens St. in Far Rockaway that doubled as the phony plastic surgeon’s office at 5p.m.. She had silicone buttock injections in a basement apartment of the residence and almost immediately began gurgling and struggling to breathe. Her mother performed CPR and demanded the “doctor” call 911 but the fake doctor grabbed her keys, ran out of the house and sped away in a gray SUV. The mother called 911 and her daughter was taken to a local hospital where she expired. The quack doctor is believed to have fled the country and an extradition proceeding will likely take place.

February 25, 2016 addendum:
The American Society of Plastic Surgeons survey of members showed significant increases in cosmetic buttock surgery in 2015 over 2014. In 2015 a buttock procedure was performed in the US every 30 minutes of every day.

April 26, 2016 addendum:
This May's issue of Allure describes 5 buttock shapes and recommends wearing a different under wear for each.

  1. Heart
  2. curve to the outer hips, but with more volume in the lower part of the hip The best bottoms are briefs, boy shorts, hipsters, or bikinis with a lower-cut leg opening.
  3. Round 
  4. The best bottoms have extra fabric in the back for full coverage — to prevent, the crotch of your underwear from shifting backward - and are tangas and thongs, as well as briefs and boy shorts with four-way stretch, a center back seam
  5. Square
  6. the line between your hip bone and outer thigh runs perpendicular to the ground. The best bottoms are boy shorts, bikinis, tangas, and thongs can be comfortable and flattering
  7. V-shape
  8. the line between your pelvis and hips angles inward. The best bottoms are briefs, boy shorts, hipsters, or bikinis without high-cut leg holes, which won't provide quite enough coverage for your butt cheeks. Because a V-shaped butt can make your cheeks look like they're sagging, make sure your underwear's leg opening cups the bottom of your buns for extra definition.
  9. A-shape
  10. butts that widen below the hip bones. The best bottoms are tangas, bikinis, or boy shorts made from stretchy lace, or seamless, laser-cut edges because A-shaped butts tend to stem from fuller thighs. The most comfortable underwear styles have high-cut legs with larger leg holes. 
 April 29, 2016 Addendum:
A just published medical literature review of the subject found:
buttock implant complication rates
Complication Rate (%)
Dehiscence 9.64
Seroma 4.63
Infection 1.94
Implant revision 1.68
Sciatica 1.01
Implant removal 0.72
Hematoma 0.63
Implant rotation 0.59
Asymmetry 0.51
Capsular contracture 0.55
Implant palpability 0.42
Total                        21.6
Rate by implant location
Subfascial               62.1
Submuscular           28.6
Intramuscular         18.8
Modified Intramuscular 8.8

Buttock Fat-Grafting Complications
Complications Rate (%)
Seroma 3.50
Undercorrection 2.19
Infection 1.96
Asymmetry 0.67
Sciatalgia 1.68
Liponecrosis 0.56
Fat embolism 0.08
Total                  9.9

Clearly fat grafting is a better option than buttock implants and if you are going to get buttock implants it is best to place them at an intramuscular level.

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