Augmentation Gluteoplasty A Brazilian Perspective

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
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According to the latest American Society of Plastic Surgeons1 and American Society for Aesthetic Plastic Surgery2 data, augmenta-
tion gluteoplasty continues to gain popularity in 
the U.S. International Society of Aesthetic Plastic 
Surgery data also confirm that buttock augmen-
tation is a fast growing trend globally.3 In 2014, 
nearly 40 percent of augmentation gluteoplasty 
cases were performed in Brazil.3 Although the 
United States and Europe doubled their con-
tribution since then,4 Brazil is still a reference 
country in buttock augmentation because most 
of the procedures (26 percent of the total pro-
cedures worldwide in 2016) are performed here, 
and these procedures have now been performed 
for 30 years in the country.5 Will this trend con-
tinue or has it already reached its peak? The 
answer depends on how future procedures will 
be performed.
HISTORY OF BUTTOCK FAT GRAFTS
In 1986, Gonzalez and Spina first published 
in Portuguese the technique for buttock augmen-
tation using fat graft, its machinery, and some 
important principles, such as fat injection in mul-
tiple planes and avoiding fat lakes.6 In 1988, Mat-
sudo and Toledo first reported in English their 
experience with fat augmentation gluteoplasty.7 
The following year, Rosique started to graft fat in 
the buttocks, and we learned the technique from 
this author. In 1999, Cardenas-Camarena et al. 
first published the technique in the Journal.8
Over the following decade, augmentation glu-
teoplasty started receiving attention in the United 
States through studies by Roberts et al.9 and Mend-
ieta.10 In 2015, we published a part of our expe-
rience and received the Plastic and Reconstructive 
Disclosure: The authors have no financial interest 
to declare in relation to the content of this article.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004809
From Rosique Plastic Surgery.
Received for publication October 9, 2017; accepted March 
1, 2018.
Presented at Plastic Surgery The Meeting 2015, Annual 
Meeting of the American Society of Plastic Surgeons, in 
Boston, Massachusetts, October 16 through 20, 2015; and 
Plastic Surgery The Meeting 2016, Annual Meeting of 
the American Society of Plastic Surgeons, in Los Angeles, 
 California, September 23 through 27, 2016.
Augmentation Gluteoplasty: A Brazilian Perspective
Supplemental digital content is available for 
this article. Direct URL citations appear in the 
text; simply type the URL address into any Web 
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Rodrigo G. Rosique, M.D., 
Ph.D.
Marina J. F. Rosique, M.D., 
Ph.D. 
Ribeirão Preto, São Paulo, Brazil
Summary: According to recent data, augmentation gluteoplasty continues to 
gain popularity in the United States and globally, especially in procedures in-
volving fat grafts. However, serious concerns about its safety have been raised 
over the past 2 years. Will this trend continue or has it already reached its 
peak? The answer depends on how the technique is going to be performed 
hereafter. In this article, the following seven learning objectives for perform-
ing gluteal augmentation safely and effectively are covered: (1) the concept 
of what is a beautiful buttock and how to select the patients who will have 
better outcomes; (2) diagram each patient’s needs for liposuction and graft; 
(3) use maneuvers for contouring and projection; (4) compare specific indi-
cations for fat graft and gluteal implants; (5) evaluate ptosis grade to indicate 
whether volume repositioning is sufficient; (6) formulate care protocols for 
risk management; and (7) develop lasting and high-satisfaction-rate results. 
It is pivotal to recognize each patient’s body characteristics and ability to 
achieve a good result, and to work on her expectations preoperatively and 
accordingly to perform the procedure in the safest manner possible. (Plast. 
Reconstr. Surg. 142: 910, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
SPECIAL TOPIC
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Volume 142, Number 4 • Augmentation Gluteoplasty 
911
Surgery Best Cosmetic Paper Award.11 This article 
aims to share a Brazilian perspective on augmen-
tation gluteoplasty, a world trend not to be missed.
WHAT IS A BEAUTIFUL BUTTOCK?
According to Singh,12 an attractive woman 
should have an hourglass figure and a waist-to-hip 
ratio of approximately 0.7. These characteristics 
matter more than body mass index for attractive-
ness. This finding is universal, being observed in 
most cultures and economic backgrounds, and is 
constant throughout history, where many ancient 
cultures depict women with the 0.7 waist-to-hip 
ratio. In a recent survey with respondents from 
around the world,13 Heidekrueger et al. confirmed 
the 0.7 waist-to-hip ratio as the most desired.
In a population assessment study, with 93 per-
cent of the respondents from the United States, 
Wong et al.14 showed that the most desirable waist-
to-hip ratio in the lateral view was also 0.7, with 
the posterior prominence positioned at the but-
tocks’ midpoint. In the posterior view, the most 
attractive lateral prominence position was at the 
inferior gluteal fold. Regarding attractiveness, 
another lateral view landmark is the lumbar cur-
vature, shown by Lewis et al.15 as optimal when the 
angle between the vertical body and sacral bone 
axes (buttocks’ upper part) is 45 degrees.
Roberts and colleagues16 analyzed buttock 
characteristics of each ethnic group. Brazil is one 
of the few countries where there was a true eth-
nic mixture, giving rise to buttocks with different 
characteristics, including those that met the cri-
teria to qualify as a beauty standard for buttocks.
APPROPRIATE PATIENT SELECTION
Almost every patient is eligible to undergo 
this procedure, but excellent results depend on 
the presence of proper patient characteristics. 
The first characteristic is the body fat percent-
age: when it is low (<20 percent), patients do not 
have enough fat, so we use prostheses. If the fat 
percentage is high (>30 percent), patients need 
to lose weight to diminish the fat and exercise to 
increase the amount of muscle. However, when 
the percentage is between 20 and 30 percent, we 
have the ideal scenario to obtain excellent results 
just with fat.
The second characteristic is the amount of fat 
available, which is the body mass index. If the body 
mass index is under 20 kg/m2, we use a prosthesis 
because of the absence of fat. If it is above 30 kg/m2, 
the patient has too much fat. For security reasons, 
the Brazilian government released a law limiting 
the liposuction volume to 7 percent of the ideal 
weight. Thus, for a good result, the patient needs 
to lose weight. If the body mass index is between 
20 and 30 kg/m2, we can safely remove the excess 
fat, enough to obtain an excellent result.
The third consideration is that bodies are 
sculpted with fat hanging on a bony framework. 
Thus, if it is too flat, it will not have the support to 
build curves, such as in “banana” or “apple” body 
shapes. In these cases, we try to lower the patient’s 
expectations preoperatively.
Lastly, all these fats will be covered by the skin, 
which should be present in an adequate amount 
and with good elasticity. When there is excess skin, 
such as in massive weight loss patients, the results 
are not optimal with isolated augmentations, with 
either fat or implants. Massive weight loss patients 
require additional skin excision procedures, 
which are a subject of another study. Choosing 
the right candidate (low body fat percentage, low 
body mass index, pear or hourglass body shape,and no excess skin) leads to better outcomes with 
minimal morbidity while being conservative and 
primarily working with fat graft.
DIAGRAM EACH PATIENT’S NEED FOR 
LIPOSUCTION AND GRAFT
The grafted area is located mainly between 
the sacrum lateral border, iliac wing, and femo-
ral neck and over the gluteus maximus and the 
fossa between the maximus, medius, and tensor 
fasciae latae. The area to be grafted usually is oval 
in shape, slightly displaced above (to lift) and 
laterally (to fill and complete the lateral curve). 
Moreover, it is advisable to graft the depression 
over the greater trochanter until it turns flat. The 
area to be suctioned involves the upper torso, 
flanks, sacrum, and occasionally the saddlebags 
and inner thighs. The transition zone is seagull-
like, beginning in the intergluteal cleft apex, and 
is not touched (Fig. 1).
MANEUVERS FOR CONTOURING OR 
AUGMENTING PROJECTION
We prefer to operate under epidural anesthe-
sia because of its proven beneficial effect in pre-
venting thromboembolic events.17 We administer 
antibiotic prophylaxis and infiltrate with a solu-
tion of 0.9% saline and epinephrine 1:500,000, 
in the same amount we plan to suction. We avoid 
using local anesthetics because there are some 
reports that it can impact adipocyte viability18,19 
and the neural block prevents pain.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
912
Plastic and Reconstructive Surgery • October 2018
The technique used was as follows. (See Video, 
Supplemental Digital Content 1, which demon-
strates the operative technique and maneuvers 
used for gluteal contouring and projection aug-
mentation through autologous fat grafting, avail-
able in the “Related Videos” section of the full-text 
article on PRSJournal.com or, for Ovid users, 
available at http://links.lww.com/PRS/C979.) We 
perform the liposuction from as few ports as pos-
sible. In the trunk, usually two ports are used: one 
in the bra line for the upper trunk and waist, and 
the other at the apex of the intergluteal cleft in 
a fan-shape fashion. In these areas, we try to suc-
tion all the fat that we can. From the intergluteal 
cleft, we aspirate fat in the sacrum and flank using 
a gentle pressure with the palm of the hand over 
the area. We try to suction in a crisscross manner 
toward the other port’s areas. From the port of 
each infragluteal fold, we suction the fat from the 
saddlebags, but deeper than that in the trunk to 
avoid visible superficial irregularities, until we get 
a continuous line starting in the lateral knees. 
From the same port, we suction the subgluteal fat 
in the posterior thighs, pressing it with our fin-
gers. Finally, we move the cannula medially to suc-
tion the inner thighs, with the skin spread by the 
assistant, while we press the area with our whole 
hand.
Ozsoy et al.20 showed that adipocyte viability 
increases according to the diameter of the can-
nula used in suctioning up to 4 mm and in graft-
ing up to 2.5 mm. Erdim et al.21 confirmed these 
Fig. 1. With the patient in the standing position, we mark the 
most pronounced point or line to be suctioned or grafted and 
we draw concentric areas around it. Green indicates the upper 
liposuction area, yellow indicates the lower liposuction area, 
and black indicates the graft area. The blue line is the transition 
area, or “no-touch” area. Of note, most of the graft goes to the 
lateral area over the gluteus maximus (black). In some patients, 
it is advisable to graft also over the greater trochanter (red oval), 
especially if this area depresses during hip flexion.
Video. Supplemental Digital Content 1 demonstrates the operative 
technique and maneuvers used for gluteal contouring and projec-
tion augmentation through autologous fat grafting, available in the 
“Related Videos” section of the full-text article on PRSJournal.com or, 
for Ovid users, available at http://links.lww.com/PRS/C979. 
http://links.lww.com/PRS/C979
http://links.lww.com/PRS/C979
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 142, Number 4 • Augmentation Gluteoplasty 
913
findings, but added a 6-mm cannula, with increas-
ing and proportional adipocyte viability. For this 
reason, we prefer to use 4- and 5-mm cannulas 
during harvesting.
The lipoaspirate decants for almost 30 minutes, 
while the liposuction is being performed, to sepa-
rate the supernatant fat from the underlying liquid 
in a glass container with a closed circuit, and open-
ing it only when it is time to graft. Strong et al.22 
showed that no significant difference in retention 
between centrifugation, filtration, or sedimenta-
tion or even between different donor sites exists. 
Sinno et al.23 showed that no difference exists 
between washing and centrifuging, but showed 
that low-shear devices maintain fat structural integ-
rity, which is important for the fat filling effect.
With the patient in the prone position, the fat 
is grafted superficially to give contour and shape, 
beginning laterally in multiple planes, delivering 
small amounts of fat in each pass of the 3.5-mm 
cannula. After the most lateral part is filled, we 
begin to fill toward the middle. If the medial but-
tock is hypoplastic, we inject fat even near the 
intergluteal fold but always in the subcutaneous 
plane. Eventual lumps of fat are spread by press-
ing the fingers over them. The amount of grafted 
fat for each case is determined visually, filling 
from lateral to medial and injecting in a fan-shape 
manner. Only the intergluteal port is used to graft 
the fat, in order to do it in a centrifugal mode.
Finally, the fat is grafted deeper, toward the 
lateral part of the gluteal muscles, to increase its 
projection, but keeping the cannula parallel to 
the plane of the sacrum with an angle less than 
30 degrees to avoid injecting too deeply. Approxi-
mately 20 to 30 percent of the fat is spared for 
deeper grafts. Deeper grafts toward the central 
parts are never performed, to avoid damage or 
pressure on the gluteal vessels. When graft is 
placed laterally into the muscle, the fat naturally 
spreads along the muscle fibers toward the central 
part but without pressure or vessel embolism.
Cannulas with an internal diameter of approxi-
mately 3 mm are preferred because the classic the-
ory of lipograft survival published by Carpaneda 
and Ribeiro24 in 1993 and the recent substitution 
theory25 agree that fat threads should have, at most, 
a 1.5-mm radius to achieve long-term retention. 
Toledo published his 30-year experience,26 showing 
that injecting 500 cc in each buttock is enough to 
achieve a good result while keeping the complica-
tion incidence very low. Interestingly, this amount 
is exactly the average volume we injected. We agree 
that when a patient needs much more than that, 
which is unusual, a second procedure is advisable.
Murillo27 and Wolf et al.,28 using magnetic res-
onance imaging, showed a fat reabsorption rate 
between 20 and 36 percent, although the fat was 
injected completely inside the muscle. Swanson29 
evaluated retention of fat injected in the subcuta-
neous plane through ultrasound scans and found 
a mean 33 percent reabsorption rate.
COMPARISON OF FAT GRAFTS AND 
GLUTEAL IMPLANTS
The prosthesis, because it is placed inside the 
gluteus maximus muscle, gives volume mainly to the 
medial part with other areas empty. Thus, prosthesis 
boundaries are sometimes visible with an unnatural 
appearance, even when placed inside the muscle.
Fat grafts are not restricted to muscle anatomy 
and can be used wherever they are needed, espe-
cially on lateral depressions. A gluteal implant is a 
good choice when there is no fat to harvest, such 
as in patients with a low body mass index and low 
fat percentage, or when there is not enough fat 
to receive all the grafted volume, such as in male 
patients or those with vaccine scars that promotedfat resorption and fibrosis (Table 1).
Our approach to gluteal implant placement 
follows Gonzalez’s XYZ intramuscular technique30 
because of its lower incidence of complications. 
We make a 0.5-cm-wide and 6-cm-long fusiform 
skin incision along the intergluteal fold and incise 
the subcutaneous tissue at 45 degrees to preserve 
the sacral cutaneous ligament that will be deepi-
thelialized and sepulted during wound closure to 
remake the fold. Once fascia is exposed, we incise 
it along the muscular fibers, undermining with the 
index finger to reach the middle of the muscular 
mass. From this point, a blunt dissector opens the 
implant pocket without direct vision. After intro-
duction of the implant, we suture all layers.30
A multicenter review31 involving experienced 
gluteal augmentation surgeons reported a 38.1 
percent rate of total complications with prosthesis 
use. A systematic review by Sinno et al.32 showed 
complication rates of 21.6 percent with implants 
and 9.9 percent with fat grafts. A meta-analysis by 
Table 1. Indication for Gluteal Implants*
No donor fat
 Low BMI
 Low BFP
No recipient fat
 Men
 Scars
BMI, body mass index; BFP, body fat percentage.
*Situations where there is no fat to harvest or there is not enough fat 
to embrace all the grafted volume.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
914
Plastic and Reconstructive Surgery • October 2018
Condé-Green et al.33 showed a 7 percent compli-
cation rate using fat graft.
Interestingly, in our practice, patients are pro-
gressively avoiding the implant option. For exam-
ple, 28.6 percent of gluteal augmentations were 
performed with implants in 2011, but this propor-
tion continually dropped and was 4.5 percent in 
2016. Nowadays, patients who were classic candi-
dates for prosthesis (Table 1), but refuse it, prefer 
to undergo two rounds of fat grafting to achieve 
the desired projection (Fig. 2). [See Figure, Sup-
plemental Digital Content 2, which shows a 21-year-
old patient with a low body mass index who was a 
classic candidate for a prosthesis but refused it. She 
was advised that probably two rounds of fat grafting 
would be required. First, 660 cc was injected into 
each buttock; after 6 months, an additional 360 cc 
was grafted, achieving the result she wanted with-
out implants (left, preoperatively; right, 1 year post-
operatively), http://links.lww.com/PRS/C980.] 
Fig. 2. A 22-year-old patient with a low body fat percentage who did not want implants. First, 500 cc was injected into 
each buttock and, because she still wanted more volume, a second round was done and 540 cc was injected into each side 
(above, preoperatively; below, 5 years postoperatively).
http://links.lww.com/PRS/C980
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 142, Number 4 • Augmentation Gluteoplasty 
915
BUTTOCK PTOSIS
The lateral length of the infragluteal fold mea-
sures the degree of buttocks ptosis.34 Ramanadham 
and Rohrich35 showed that, in the face, volume is 
lost and the tissues sag down toward the central 
line as we age, producing jowls and marionette 
lines, which are signs of an aging face. The treat-
ment should not focus on the central and lower 
parts; otherwise, it would worsen the appearance. 
Volume should be restored toward the upper lat-
eral regions to give a youthful appearance.
The same principles apply to the ptotic but-
tocks. If the ptosis is mild to moderate, its appear-
ance can be improved by restoring the volume 
toward the upper lateral regions (Fig. 3). If the 
degree of ptosis is moderate to accentuated, such 
Fig. 3. A 26-year-old patient with a body mass index of 21.2 kg/m2, and with an appearance of a buttock detached from her 
flanks and mild buttocks ptosis, was subjected to buttocks fat grafting with 420 cc into each side. This case exemplifies how 
we can diminish the length of the infragluteal fold and consequently the degree of buttocks ptosis by restoring volume 
toward the upper lateral regions, delivering a more youthful appearance, with a continuity of her torso lines (above, preop-
eratively; below, 3 years postoperatively).
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
916
Plastic and Reconstructive Surgery • October 2018
as in the face, an excisional procedure needs to be 
performed to pull up the tissues.
FORMULATE CARE PROTOCOLS TO 
MANAGE THE RISKS
Between January of 2011 and January of 2016, 
our group (three surgeons) performed 845 but-
tock fat grafts, either isolated or combined with 
anterior procedures, in patients with a mean age 
of 34 years, a mean body mass index of 25 kg/m2, 
and a mean volume of 498 cc grafted into each 
side. With regard to minor complications, 4 per-
cent had sacral seromas and none had an infec-
tion or fat necrosis. Major complications included 
two cases of deep vein thrombosis confirmed by 
Doppler scan; two cases of pulmonary thrombo-
embolism confirmed by computed tomographic 
angiography, in which the symptoms appeared 7 
and 9 days postoperatively (fat embolism appears 
in the first 48 hours); and symptomatic hypovole-
mia requiring intravenous hydration in 8 percent 
of the cases. No deaths have been reported since 
1989.
Preoperatively, oral contraceptive or hormone 
intake is interrupted for 30 days,36 and aspirin 
intake is interrupted for 7 days. If the patient needs 
to lose weight, she is advised to rely on exercises 
and not on diets, to avoid anemia and low-protein 
conditions. Laboratory tests, electrocardiography, 
and abdominal wall ultrasound scan to rule out 
hernias are requested.
Cárdenas-Camarena et al.37 reported 21 deaths 
related to intramuscular lipoinjection, which led 
us to conclude that injections into deep muscle 
planes should be avoided. This fatal complication 
has also occurred in California,38 Florida, and Bra-
zil.39 Thus, there are reports of deaths related to 
fat embolism in all countries were most buttock fat 
grafts are performed according to International 
Society of Aesthetic Plastic Surgery. We proposed 
the following “BRAZIL” safety maneuvers to avoid 
mortality in patients40:
B. Blunt: Use only blunt cannulas with at least 
3-mm internal diameter attached to low-pres-
sure syringes.
R. Retrograde: Infiltrate in a retrograde fashion, 
always from the highest and most superficial 
point, the intergluteal crease, in a centrifugal 
orientation, and with slow movements to pre-
vent vessel damage.
A. Abundant: Keep the patient well hydrated with 
a urinary output between 1 and 2 cc/kg/hour 
throughout the first 24 hours to diminish the 
need of the vessels for external fluids and to 
dilute small amounts of fat eventually aspirated.
Z. Zone: Avoid injecting deeper into the danger 
zone, which is a pyramidal area with its apex 
between the sacral dimples and its base along 
the medial two-thirds of the infragluteal fold, 
on both sides. This area begins from the sacral 
bone apex, passes through the ischial spine, 
and reaches the femur in the subgluteal fold. 
Within this area, all major vessels are located in 
the gluteal region, except the superior gluteal 
artery and vein, which are very deep and high 
in the iliac wing inferior edge (Fig. 4).
I. Implant: In patients who lack subcutaneous tis-
sue that could lead us to inject mainly into the 
muscle, and do not accept a second procedure, 
we prefer to use prostheses inside the muscle 
and fat only in the subcutaneous plane.
L. Larger: Prioritize contour by injecting the 
larger part into the subcutaneous layer first. Set 
apart 20 to 30 percent to inject inside the lat-
eral part of the muscles for projection.
Massive fat embolisms occur if free fat and 
damaged vessels with negative pressure are inside. 
If subcutaneous injection is prioritized, there will 
hardly be vessels large enough tosuction a great 
Fig. 4. Danger zone: superficial (left) and bone (right) landmarks. 
The danger zone for deep fat graft in buttocks has a nearly pyra-
midal shape, with its apex in the middle point between sacral 
dimples. Its base goes along the gluteal fold, compromising the 
thighs’ medial two-thirds. The lateral lines connect the apex to 
its base passing over the ischial spine.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 142, Number 4 • Augmentation Gluteoplasty 
917
amount of fat into the lungs. Rodríguez-García 
et al.41 published an anatomical study of the glu-
teus maximus showing that it had only 3 cm of 
thickness at most. If cannulas are not kept paral-
lel to the sacrum’s surface, chances are that they 
are accessing the submuscular plane, where large 
vessels and nerves are present. Recent anatomical 
studies in cadavers by Ramos-Gallardo et al.42 con-
firmed our danger zone, published 2 years ago,40 
by showing that more lateral injections inserting 
the cannula at the intergluteal crease and with 
an angulation less than 30 degrees place the fat 
away from major vessels, with no colorant around 
them. Usually, there is an involuntary and subtle 
muscle contraction when the cannula perfo-
rates the outer fascia of the gluteal muscles, but 
certainty this is achieved only using ultrasound 
intraoperatively.
Fig. 5. Gluteal fat graft associated with anterior procedures in a 25-year-old patient with a body mass index of 20.6 kg/
m2, subjected to augmentation mastopexy (255-cc implants), miniabdominoplasty, liposuction (3 liters), and gluteal aug-
mentation with 540 cc into each side (above, preoperatively; below, 1 year postoperatively, showing no compromise of fat 
graft survival).
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
918
Plastic and Reconstructive Surgery • October 2018
Compression socks and garments are used from 
the end of the procedure until 1 and 2 months, 
respectively. Starting at the recovery room, patients 
rest over their buttocks. Pereira and Radwanski43 
showed in 1996 that, clinically, one can associate 
anterior procedures while letting the patient lie 
over her buttocks without jeopardizing the graft. 
Most of our buttock augmentations are performed 
with abdominoplasties, breast reductions, or breast 
augmentations without jeopardizing the effective-
ness and satisfaction of the procedure (Fig. 5). 
[See Figure, Supplemental Digital Content 3, 
which shows a gluteal fat graft associated with ante-
rior procedures in a 35-year-old patient with a body 
mass index of 25 kg/m2, subjected to abdomino-
plasty, breast symmetrization with implants, lipo-
suction (4 liters), and gluteal augmentation with 
300 cc into each side (left, preoperatively; right, 4 
years postoperatively, showing no compromise of 
fat graft survival), http://links.lww.com/PRS/C981.] 
A possible explanation for why pressure over 
the graft does not affect it is based on the Pascal 
principle, whereby pressure sores are prevented 
by using an air or liquid mattress (i.e., when an 
enclosed liquid is subjected to an external force, 
this force will be broken into several small forces 
spread all over the enclosed surface). Thus, when 
we enclose the grafted fat using compression gar-
ments, the force applied by lying over the buttocks 
will be broken into several minor forces that are 
not strong enough to prevent graft survival.
Evidence about pressure and fat came to light in 
2013, when Lee et al.44 showed that pressure up to 6 
atm did not affect graft viability, but slow injections 
with low shear stress significantly increased viability. 
Banyard et al.45 showed that mechanical forces actu-
ally modulate progenitor phenotypes associated 
with pluripotency, adding the regenerative benefits 
to the traditional lipofilling effect of fat grafts.
According to the latest deep venous thrombo-
sis risk factor assessment,46 because of the associa-
tion with other procedures, such as tummy tuck or 
breast surgery, most of our procedures last more 
than 3 hours, which represents at least five points of 
the Caprini score, putting the patient at the highest 
risk level and requiring the complete prophylaxis 
regimen. Consequently, patients remain with inter-
mittent pneumatic compression for 12 hours,47 and 
40 mg of low-molecular-weight heparin36 is admin-
istered subcutaneously daily for 7 days.
We encourage patients to ambulate as soon as 
possible, drink plenty of liquids (approximately 4 
liters per day) during the first week, and maintain 
the urine clear. Massages over the grafted area are 
avoided.
CONCLUSIONS
To develop lasting results with high satisfac-
tion rates in augmentation gluteoplasty, surgeon-
related factors (e.g., multiple tunnel injections 
and fat lake avoidance) and patient-related issues 
(e.g., maintaining weight, use of compression gar-
ments around the buttocks, and avoidance of mas-
sage over the graft) should be considered. Finally, 
satisfaction is a balance between what we can give 
and what the patient expects from the procedure. 
Thus, it is important to recognize each patient’s 
body characteristics and ability to achieve a good 
result and work on her expectations preopera-
tively and accordingly to perform the procedure 
in the safest manner possible.
Rodrigo G. Rosique, M.D., Ph.D.
Rosique Plastic Surgery
Avenue Antonio Diederichsen, 400, Conj. 1204
Ribeirão Preto, São Paulo, Brazil 14020-250
rodrigo@rosique.com.br
PATIENT CONSENT
Patients provided written consent for the use of their 
images.
ACKNOWLEDGMENT
The authors would like to thank Ilson Rosique, 
M.D., M.Sc., for teaching them the basics about the 
fat graft technique and for contributing to the casuistic 
analysis.
REFERENCES
 1. American Society of Plastic Surgeons. 2016 national plastic 
surgery statistics. Available at: https://www.plasticsurgery.
org/documents/News/Statistics/2016/2016-plastic-surgery-
statistics-report.pdf. Accessed September 13, 2017.
 2. American Society for Aesthetic Plastic Surgery. 2016 cosmetic 
surgery national data bank statistics. Available at: https://
www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf. 
Accessed September 13, 2017.
 3. International Society of Aesthetic Plastic Surgery. 
International survey on aesthetic/cosmetic procedures per-
formed in 2014. Available at: https://www.isaps.org/Media/
Default/global-statistics/2015 ISAPS Results.pdf. Accessed 
September 13, 2017.
 4. International Society of Aesthetic Plastic Surgery. 
International survey on aesthetic/cosmetic procedures per-
formed in 2015. Available at: https://www.isaps.org/Media/
Default/global-statistics/2016 ISAPS Results.pdf. Accessed 
September 13, 2017.
 5. International Society of Aesthetic Plastic Surgery. The 
international study on aesthetic/cosmetic procedures 
performed in 2016. Available at: https://www.isaps.org/
wp-content/uploads/2017/10/GlobalStatistics2016-1.pdf. 
Accessed September 13, 2017.
 6. Gonzalez R, Spina L. Grafting of fat obtained by liposuction: 
Technique and instruments. Rev Bras Cir. 1986;76:243–250.
http://links.lww.com/PRS/C981
mailto:rodrigo@rosique.com.br
https://www.plasticsurgery.org/documents/News/Statistics/2016/2016-plastic-surgery-statistics-report.pdf
https://www.plasticsurgery.org/documents/News/Statistics/2016/2016-plastic-surgery-statistics-report.pdf
https://www.plasticsurgery.org/documents/News/Statistics/2016/2016-plastic-surgery-statistics-report.pdf
https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf
https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf
https://www.isaps.org/Media/Default/global-statistics/2015 ISAPS Results.pdf
https://www.isaps.org/Media/Default/global-statistics/2015 ISAPS Results.pdf
https://www.isaps.org/Media/Default/global-statistics/2016 ISAPS Results.pdf
https://www.isaps.org/Media/Default/global-statistics/2016 ISAPSResults.pdf
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 142, Number 4 • Augmentation Gluteoplasty 
919
 7. Matsudo PK, Toledo LS. Experience of injected fat grafting. 
Aesthetic Plast Surg. 1988;12:35–38.
 8. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. 
Combined gluteoplasty: Liposuction and lipoinjection. Plast 
Reconstr Surg. 1999;104:1524–1531; discussion 1532–1533.
 9. Roberts TL III, Toledo LS, Badin AZ. Augmentation of the 
buttocks by micro fat grafting. Aesthet Surg J. 2001;21:311–319.
 10. Mendieta CG. Gluteal reshaping. Aesthet Surg J. 
2007;27:641–655.
 11. Rosique RG, Rosique MJ, De Moraes CG. Gluteoplasty with 
autologous fat tissue: Experience with 106 consecutive cases. 
Plast Reconstr Surg. 2015;135:1381–1389.
 12. Singh D. Universal allure of the hourglass figure: An evo-
lutionary theory of female physical attractiveness. Clin Plast 
Surg. 2006;33:359–370.
 13. Heidekrueger PI, Sinno S, Tanna N, et al. The ideal buttock 
size: A sociodemographic morphometric evaluation. Plast 
Reconstr Surg. 2017;140:20e–32e.
 14. Wong WW, Motakef S, Lin Y, Gupta SC. Redefining the 
ideal buttocks: A population analysis. Plast Reconstr Surg. 
2016;137:1739–1747.
 15. Lewis DMG, Russell EM, Al-Shawaf L, Buss DM. Lumbar cur-
vature: A previously undiscovered standard of attractiveness. 
Evol Hum Behav. 2016;36:345–350.
 16. Roberts TL III, Weinfeld AB, Bruner TW, Nguyen K. 
“Universal” and ethnic ideals of beautiful buttocks are best 
obtained by autologous micro fat grafting and liposuction. 
Clin Plast Surg. 2006;33:371–394.
 17. Hafezi F, Naghibzadeh B, Nouhi AH, Salimi A, Naghibzadeh G, 
Mousavi SJ. Epidural anesthesia as a thromboembolic prophy-
laxis modality in plastic surgery. Aesthet Surg J. 2011;31:821–824.
 18. Moore JH Jr, Kolaczynski JW, Morales LM, et al. Viability of fat 
obtained by syringe suction lipectomy: Effects of local anes-
thesia with lidocaine. Aesthetic Plast Surg. 1995;19:335–339.
 19. Keck M, Zeyda M, Gollinger K, et al. Local anesthetics have a 
major impact on viability of preadipocytes and their differenti-
ation into adipocytes. Plast Reconstr Surg. 2010;126:1500–1505.
 20. Ozsoy Z, Kul Z, Bilir A. The role of cannula diameter in 
improved adipocyte viability: A quantitative analysis. Aesthet 
Surg J. 2006;26:287–289.
 21. Erdim M, Tezel E, Numanoglu A, Sav A. The effects of the 
size of liposuction cannula on adipocyte survival and the 
optimum temperature for fat graft storage: an experimental 
study. J Plast Reconstr Aesthet Surg. 2009;62:1210–1214.
 22. Strong AL, Cederna PS, Rubin JP, Coleman SR, Levi B. 
The current state of fat grafting: A review of harvesting, 
processing, and injection techniques. Plast Reconstr Surg. 
2015;136:897–912.
 23. Sinno S, Wilson S, Brownstone N, Levine SM. Current 
thoughts on fat grafting: Using the evidence to determine 
fact or fiction. Plast Reconstr Surg. 2016;137:818–824.
 24. Carpaneda CA, Ribeiro MT. Study of the histologic altera-
tions and viability of the adipose graft in humans. Aesthetic 
Plast Surg. 1993;17:43–47.
 25. Khouri RK Jr, Khouri RE, Lujan-Hernandez JR, Khouri KR, 
Lancerotto L, Orgill DP. Diffusion and perfusion: The keys 
to fat grafting. Plast Reconstr Surg Glob Open 2014;2:e220.
 26. Toledo LS. Gluteal augmentation with fat grafting: The 
Brazilian buttock technique: 30 years’ experience. Clin Plast 
Surg. 2015;42:253–261.
 27. Murillo WL. Buttock augmentation: Case studies of fat 
injection monitored by magnetic resonance imaging. Plast 
Reconstr Surg. 2004;114:1606–1614; discussion 1615–1616.
 28. Wolf GA, Gallego S, Patrón AS, et al. Magnetic resonance 
imaging assessment of gluteal fat grafts. Aesthetic Plast Surg. 
2006;30:460–468.
 29. Swanson E. Prospective controlled study of buttock fat trans-
fer using ultrasound and photographic measurements. Plast 
Reconstr Surg Glob Open 2016;4:e697.
 30. Gonzalez R. Augmentation gluteoplasty: The XYZ method. 
Aesthetic Plast Surg. 2004;28:417–425.
 31. 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.
 32. Sinno S, Chang JB, Brownstone ND, Saadeh PB, Wall S Jr. 
Determining the safety and efficacy of gluteal augmentation: 
A systematic review of outcomes and complications. Plast 
Reconstr Surg. 2016;137:1151–1156.
 33. Condé-Green A, Kotamarti V, Nini KT, et al. Fat grafting for 
gluteal augmentation: A systematic review of the literature 
and meta-analysis. Plast Reconstr Surg. 2016;138:437e–446e.
 34. Gonzalez R. Etiology, definition, and classification of gluteal 
ptosis. Aesthetic Plast Surg. 2006;30:320–326.
 35. Ramanadham SR, Rohrich RJ. Newer understanding of 
specific anatomic targets in the aging face as applied to 
injectables: Superficial and deep facial fat compartments. 
An evolving target for site-specific facial augmentation. Plast 
Reconstr Surg. 2015;136(Suppl):49S–55S.
 36. Iorio ML, Venturi ML, Davison SP. Practical guidelines for 
venous thromboembolism chemoprophylaxis in elective 
plastic surgery. Plast Reconstr Surg. 2015;135:413–423.
 37. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H, 
Cuenca-Pardo J. Deaths caused by gluteal lipoinjection: What 
are we doing wrong? Plast Reconstr Surg. 2015;136:58–66.
 38. Astarita DC, Scheinin LA, Sathyavagiswaran L. Fat transfer 
and fatal macroembolization. J Forensic Sci. 2015;60:509–510.
 39. de Lima E Souza R, Apgaua BT, Milhomens JD, et al. Severe 
fat embolism in perioperative abdominal liposuction and fat 
grafting. Braz J Anesthesiol. 2016;66:324–328.
 40. Rosique RG, Rosique MJ. Deaths caused by gluteal lipoin-
jection: What are we doing wrong? Plast Reconstr Surg. 
2016;137:641e–642e.
 41. Rodríguez-García F, Miranda-Villera C, Peynado-Vila Á, 
Prado-Cantillo D. Anatomía quirúrgica del músculo glú-
teo mayor: Espacio Intramuscular de FROD. Cir Plást Ibero-
Latinoam. 2016;42:149–156.
 42. Ramos-Gallardo G, Orozco-Renteria D, Medina-Zamora P, et 
al. Prevention of fat embolism in fat injection for gluteal aug-
mentation: Anatomic study in fresh cadavers. J Invest Surg. 
2018;31:292–297.
 43. Pereira LH, Radwanski HN. Fat grafting of the buttocks and 
lower limbs. Aesthetic Plast Surg. 1996;20:409–416.
 44. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph 
MA, Austen WG Jr. The effect of pressure and shear on autol-
ogous fat grafting. Plast Reconstr Surg. 2013;131:1125–1136.
 45. Banyard DA, Sarantopoulos CN, Borovikova AA, et al. 
Phenotypic analysis of stromal vascular fraction after 
mechanical shear reveals stress-induced progenitor popula-
tions. Plast Reconstr Surg. 2016;138:237e–247e.
 46. Caprini JA. Risk assessment as a guide to thrombosis prophy-
laxis. Curr Opin Pulm Med. 2010;16:448–452.
 47. Hartman JT, Pugh JL, Smith RD, Robertson WW Jr, Yost RP, 
Janssen HF. Cyclic sequential compression of the lower limb 
in prevention of deep venous thrombosis. J Bone Joint Surg 
Am. 1982;64:1059–1062.