Drs. Mofid et al. report the findings of a survey sent to plastic surgeons who perform buttock augmentation with implants.1 The title is misleading; this is really a survey of surgeons, not patients. Nineteen respondents (25 percent response rate) estimated that they had performed 2226 cases in their careers, with over half performed by one surgeon. The authors conclude that the overall complication rate compares favorably with breast implants. Mofid et al. repeatedly comment that gluteal augmentation suffers from a reputation of a high rate of complications, “despite the fact that there have been no studies published to date to support this impression.”1 At the same time, they report a 38.1 percent complication rate from their surveys and reference two of their own studies that include a 30 percent risk of wound dehiscence,2 a 28 percent seroma rate,3 and a 6.5 percent infection rate.3 An unreferenced recent study reveals an alarming 97 percent rupture rate of silicone gel buttock implants (not used in the United States) detected at reoperation.4
Unfortunately, there is a credibility problem in buttock augmentation surgery, starting with the name. “Brazilian butt lift” is neither Brazilian5 nor a butt lift. At their consultations, prospective patients often show photographs of dramatic results that they have found on the Internet. These photographs are typically quite different from those published in our professional journals,2,3,6 often demonstrating exaggerated, even cartoonish results.7 There is often no indication of how many fat injection and liposuction treatments were used or the postoperative time interval.8,9 Sometimes, adhesive strips and bruising reveal that the photographs were taken shortly after surgery at the time of maximum swelling.8 Photographs are seldom standardized, so that different body positions (e.g., the patient flexed at the hips in the after photograph and the waist rotated) contribute to the appearance of a reduced waist-to-hip ratio,7 even less than the idealized 0.70 figure.9 In reality, measurements on standardized images reveal that the average reduction of the subcutaneous fat layer at the waistline produced by a single liposuction treatment is 45 percent,10 reducing horizontal width by 1.3 cm, on average,11 and contributing to a pleasing but modest improvement in the waist-to-hip ratio when combined with fat injection (Fig. 1).
Anonymous surgeon surveys, which are heavily influenced by selection and recollection bias, cannot be compared with the clinical patient data provided by a breast implant manufacturer. Buttock implants are no longer new; yet there is not a single published outcome study evaluating patient satisfaction. This is certainly not the case for breast augmentation, a procedure that enjoys a very high rate of patient satisfaction.12 Wound separation, seromas, and infection are rare occurrences after breast augmentation.12
Patient photographs after buttock augmentation with implants sometimes do not include posterior views.8 Underwear may hide the buttock cleavage and prevent scar assessment. Today, in an effort to reduce the risk of wound separation, many surgeons use two parasacral incisions rather than a single midline intergluteal incision.1,6,9 We would never consider such scars in the cleavage area of breasts; why should we accept them here?
The authors point to an increased popularity of this procedure. However, statistics provided by the American Society of Plastic Surgeons reveal a 25 percent decrease in the number of buttock implant cases performed compared with 2 years ago, to fewer than 1000 in 2012.13 Inexplicably, a new chapter on buttock augmentation, co-written by two of the study authors, provides plenty of photographs of complications but no before-and-after photographs of uncomplicated buttock implant surgery.9 Dr. Mendieta’s Web site does not feature women treated with implants; fat injection is promoted instead.7 Such omissions seem inconsistent with the authors’ endorsement of buttock implants. Their conclusion that the procedure is safe and effective compared with breast augmentation1 is at odds with the evidence and cannot be substantiated by a small unrepresentative selection of surgeon surveys even if it were true (and the limited survey data suggest it is not). The claim that the procedure has a high patient satisfaction rate1 is unsupported; the patients themselves were never surveyed. Many variations in technique have been attempted in an effort to reduce the complication rate to acceptable levels.6 Silicone gel implants are prone to rupture.4 Perhaps the message is not to keep trying, but to recognize the obvious—fat injection combined with liposuction is a better option.
Buttock fat injection is increasingly popular.9 It is remarkably safe, with a low rate of complications.9 However, patient expectations need to be tempered by reality (Fig. 1). Exaggerated results promote unrealistic patient expectations and make good outcomes appear inadequate. We all benefit when real clinical results are published (and advertised).14
The author has no financial interest to declare in relation to the content of this communication. No external funding was received.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG, Senderoff DM, Jorjani S. Buttock augmentation with silicone implants: A multicenter survey review of 2226 patients. Plast Reconstr Surg. 2013;131:897–901
2. Mendieta CG. Gluteoplasty. Aesthet Surg J. 2003;23:441–455
3. Senderoff DM. Buttock augmentation with solid silicone implants. Aesthet Surg J. 2011;31:320–327
4. Daniel MJB, Junior IM. What is the durability of gluteal prostheses? Qual a durabilidade da prótese glútea? Rev Bras Cir Plast. 2012;27:93–96
5. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue augmentation. Plast Reconstr Surg. 1989;84:921–934 discussion 935
6. Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast Surg. 2006;33:423–434
9. Bruner TW, de la Peña Salcedo JA, Mendieta CG, Roberts TLNeligan PC, Warren RJ. Buttock augmentation. Plastic Surgery. 2013;Vol. 23rd ed London Elsevier Saunders:599–616
10. Swanson E. Assessment of reduction in subcutaneous fat thickness after liposuction using magnetic resonance imaging. J Plast Reconstr Aesthet Surg. 2012;65:128–130
11. Swanson E. Photographic measurements in 301 cases of liposuction and abdominoplasty reveal fat reduction without redistribution. Plast Reconstr Surg. 2012;130:311e–322e discussion 323e–324e
12. Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166
14. Goldwyn RM. Wanted: Real clinical results. Plast Reconstr Surg. 2004;114:1000–1001
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