Article Published In: The American Journal of Cosmetic Surgery , Vol. 14, No. 4, 1997

Nikolas V. Chugay, D.O.

Introduction: The traditional method of buttock enlargement, which involves making an incision in the lower portion of the buttock in the infragluteal fold, frequently results in secondary infections and long recovery times.

Because of the proximity of the incision to the rectum and the pressure on the incision, the patient usually requires several days of bed rest. In some instances, it is necessary to extract an otherwise satisfactory implant to correct an infection. The author has overcome this problem by placing an incision in the center of the buttock in the intergluteal fold. A custom-designed solid silicone prosthesis is then placed between the gluteus medius and the gluteus maximus in a space provided by the anatomical design of these two large muscles. The gluteus also proved a good sling for the prosthesis, thus preventing future drooping of the prosthesis. More than 20 buttock enlargements have been successfully performed using this technique with no major complications. Use of this new technique decreases the risk of infection from the anal region and produces a softer, more natural look. This technique is also resistant to possible rupture such as may occur with nonsolid gel silicone augmentation.

History of Buttock Augmentation

In the era of increasing interest in body contouring, as early as 1969, plastic surgeons were reporting on their attempts to improve the shape of the lateral gluteal regions using prosthesis of the same consistency as the Cronin breast prosthesis. Among the first published reports of attempting aesthetic buttock augmentation were articles by Bartels et al (1969), Douglas et al (1975), and Cocke and Ricketson (1975), who utilized a version of the Cronin NFP design prosthesis. These early attempts at gluteal implants had complications such as secondary infections, sag as the patient grew older and, in some cases, actual rupture during serious falls.⁴ Each of these authors concluded that there was a need for a long-term, safer type of prosthesis.

In some of the early buttock augmentations by Cocke and Ricketson,  the implants were not placed over the weight-bearing areas. Bartels et al utilized the gel silicone implants, but there was still the danger of the silicone implant rupturing or of secondary infection because of the location of the incision.² In the majority of these early procedures, the patient required hospitalization and 5-7 days of bed rest.

By the early 1970s, Gonzales-Ulloa₅ had developed a procedure that would provide a correctly positioned gluteal prosthesis for enlargement of underdeveloped buttocks. He recognized that the thickness and resistance of the covering of the augmented prosthesis had to withstand the pressure exerted when the patient sat down abruptly and should have the same consistency as the area when palpated. A large number of Gonzales-Ulloa’s procedures were performed on patients who had suffered severe damage and/or deformation of the gluteal region due to silicone, collagen, or guaiacol injections or adipose tissue transplants. His method for correcting this procedure was most satisfactory, but some patients suffered secondary infections because of the proximity of the incision to the anal region.

Lewis (1992) perfected the use of autologous fat grafting to correct deep gluteal depression and to provide a continuous, smooth S-curve to the buttock. His technique aided in the correction of underdeveloped buttocks but did not resolve the problem of secondary infections when a gluteal prosthesis was implanted. There remained the need to continue to improve on the techniques developed by Gonzales-Ullao, Lewis and others.

Concerned because buttock enlargements were becoming more popular, and the threat of secondary infections still prevailed, I took the matter under serious consideration. Using knowledge of anatomy, two other possible locations on the buttock were identified where the incision could successfully be made. Since 1990, 22 buttock enlargement augmentations have been successfully completed using the new technique, with no major complications caused by infection, rupture, or displacement.

Materials

Buttock augmentation is performed with a flexible solid silicone prosthesis designed by me and manufactured by ABT Corporation. Each prosthesis is custom made, with the most commonly used size being 14.9 cm in length, 12.2 cm in width, and 2.8 cm in depth. Any measurement can be ordered to accommodate patient desires. The solid ABT subgluteal prosthesis can easily be positioned between the gluteus maximus muscle and the gluteus medius muscle.

Method and Technique

Buttock enlargement is generally carried out with the patient under general anesthesia. The approximate location of the implant is marked over the buttocks with a marking pen. An incision is made in the intergluteal fold.

The plane of dissection is developed between the gluteal maximus and the gluteal medius to avoid the sciatic nerve. The sciatic nerve runs deep to the pyriformis muscle (inferior to gluteus medius muscle), and at the inferior edge of the pyriformis muscle and medial to the midline of the buttock, the nerve becomes more superficial but deep to the gluteus maximus muscle just superior to the ischial tuberosity. The nerve then courses laterally to the ischial tuberosity (into the midline of the upper thigh).

A spatula dissector is used to make a pocket under the gluteus maximus muscle. Meticulous hemostasis is secured with a bipolar cautery. The prosthesis is introduced beneath the gluteal maximus muscle and over the gluteal medius muscle. The fascia is closed with 3-0 Vicryl suture, and the skin is closed with a double running 4-0 Vicryl suture. Steri-strips are applied to the skin. Light-pressure dressing is applied and held in place with stretch tape. To decrease the possibility of infection, intravenous cephalosporin is given during surgery, and a 7-day postoperative course of oral antibiotics is also prescribed. During the recuperation period, the patient remains mobile, but strenuous activities are restricted.

Complications / Dissatisfaction

After having the prosthesis placed over the gluteus maximus muscle by another physician, one patient with a very thin fat pad was displeased because the margins of the prosthesis were noticeable through the skin, and there was sagging. The superficial prosthesis was extracted and placed subgluteally, yielding satisfactory results. There have been no instances of sagging when the prosthesis is placed under the gluteus maximus muscle. Persistent seroma occurred in two cases and required multiple needle aspirations of serous fluid. One patient who had five separations of serous fluid requested that the prosthesis be extracted.

One patient neglected to take postoperative antibiotics and developed infection. The implants were extracted. Persistent pain (9 months) radiating down the posterior left leg occurred in one patient. Revision surgery will be to place the inferior portion of the implant more laterally because of possible pressure on the sciatic nerve.

The original incision placement was horizontally above the buttock medial to the posterior/superior iliac spine. Although the scar was acceptable and distant from the anal region, the author developed the intergluteal fold approach to better camouflage the scar, which can widen. The intergluteal incision is in closer proximity to the anal region and theoretically presents and increased risk of infection compared to the suprabuttock incision.

Discussion

In buttock augmentation, the patient is seeking a continuous, harmonious, S-shaped, curved buttock that is wider at the hips and has no indentations or indications that a prosthesis has been inserted. This requires that the prosthesis be positioned between the muscle and that the incision be placed where it will not cause bulges or depressions in order to create the rounded shape the patient seeks to make clothes fit properly.

The danger of infection following buttock augmentation has been one of the primary problems of past procedures. The solution is to place incisions in areas where infection can be avoided. With this technique, patients are satisfied with the scars, and the recovery period is significantly shortened.

I performed 22 buttock augmentations. In 12 instances, the incision was made on the upper portion of the buttock medial to the posterior/superior iliac spine. In 10 cases, the incision was made in the intergluteal fold. The risk of infection has been significantly reduced by using these two new incision points because of their distance from the anal region.

Additionally, smoother appearance of the buttocks is achieved by placing the prosthesis underneath the gluteus maximus muscle. This procedure is somewhat analogous to placing the prosthesis underneath the gluteus maximus muscle. This procedure is somewhat analogous to placing a breast prosthesis under the pectoralis muscle. There is no show-through of the margins of the implants when it is placed under the gluteus maximus muscle. Since the gluteus provided an excellent sling for the prosthesis, there is no drooping of the prosthesis (Figures 4-6).

Conclusion

An incision site in the intergluteal fold is superior to one in the subgluteal fold, because there is less chance of infection. Placement of the prosthesis under the gluteal maximus and above the gluteal medius results in an excellent contour with little chance of slippage. Patients have been quite satisfied with the procedure.

References

1. Bartels RJ, O’Malley JE, Douglas WM, Wilson RG: An unusal use of the Cronin breast prosthesis. Plast Reconstr Surg 1969;44(1):500.

2. Douglas WM, Bartels RJ, Baker JL Jr.: An experience in aesthetic buttocks augmentation. Clin Plast Surg 1975;3(3):471-476.

3. Cocke, Ricketson G: Gluteal augmentation. Plast Reconstr Surg 1975;3(3):93.

4. Ford RD, Simpson WD: Massive Extravastion of traumatically ruptured buttock silicone prosthesis. Ann Plast Surg 1992;29(1):86-88.

5. Gonzales-Ulloa M: Torsoplasty. Aesthetic Plast Surg 1979;3:357-358.

6. Gonzales-Ulloa M: Gluteoplasty: a ten-year report. Aesthetic Plast Surg 1991;15:85-91.

7. Lewis C: Correction of deep sluteal depression by autologous fat grafting. Aesthetic Plast Surg 1992;16:247-250.

Commentary:

The modifications Dr. Chugay has made in the implantation of buttock prosthesis should increase patient satisfaction. Although the implants are placed under the gluteus maximus muscle, if the inferior portion of the implant is lateral to the midline of the buttock, there should be no problem of sciatic nerve irritation. This new position of the customized implants will prevent the buttock droop that has discouraged surgeons from using this operation. The intergluteal incision should minimize the risk of infection, and, certainly, antibiotics are necessary after an implant of this type.

The buttock implant is useful for the patient with flat “male type” buttocks. There is also an ethnic cosmetic consideration, such as in Hispanics, where the fuller buttock is desirable. The goal of prosthesis implantation is to approximate an individual’s self-body image, which this operation can accomplish.

Melvin A. Shiffman, MD., J.D.
Tustin, California

Response:

As mentioned in the article, we have had a minimal amount of discomfort or pain in the legs of patients. Only one patient still under observation has had some pain radiating down a leg. The key, again, is positioning the implant more laterally to avoid placing any pressure on the sciatic nerve. We have found that patients are quite pleased with the buttock enhancement, especially with the large implant that I usually place in the buttocks.The gluteus maximus muscle serves as a strong sling, supporting the prosthesis well and maintaining a natural, youthful shape. As far as the usefulness of the implants, I find that it is universal. There are many males who would like to have their buttocks enhanced. I also find that many Anglo women do have rather flat behinds and are very pleased to have fuller buttocks.

Again, Doctor Shiffman’s comments are greatly appreciated, as are his support and suggestions in formulating this article.

Nikolas V. Chugay. D.O.
Long Beach, California

Commentary:

This is an excellent paper and reviews a subject that is quite important and one that is very frequently requested by patients. Unfortunately, very few physicians will attempt this surgery because, although infrequently, complications do occur. Personally, I have performed about fourteen buttock augmentations and have had four complaints requiring removal of implants. Three were infections and one was a broken solid implant made by ABT. The implant had been scored for easier insertion. A solid implant requires a large incision. I am glad to see that Dr. Chugay places the incision at the superior pole. This has been my technique for years. However, because of the complications, I have tried to avoid this surgery. I am quite impressed and very pleased with both the technique of and results obtained by Dr. Chugay.

Benito B. Rish, M.D.
Yonkers, New York

Response:

Thank you for your commentary. I appreciate the input and positive feedback. The prosthesis should not be scored because the weakness of the integrity of the implant will result from the scoring. We did have one case of infection out of 22 cases, and that was attributed to the patient’s failure to use prophylactic antibiotics. To insert a large implant, an intergluteal incision about 4 cm. in length is made. This will adequately admit the prosthesis. Again, thank you for your kind remarks.

Nikolas V. Chugay. D.O.
Long Beach, California