Buttock Augmentation Case Studies of Fat Injection Monitored by Magnetic Resonance Imaging

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Techniques in
Cosmetic Surgery
Buttock Augmentation: Case Studies of
Fat Injection Monitored by Magnetic
Resonance Imaging
William L. Murillo, M.D.
New Orleans, La.; and Cali, Colombia
This article examines the injection of megavolumes of
autologous fat cells as a means of buttock augmentation
in 162 patients over a 7-year period. The author docu-
ments the use of magnetic resonance imaging in six pa-
tients to visualize the intramuscular location, integration,
and duration of the injected fat. With the patient under
epidural or general anesthesia, fat cells were harvested
with a 5-mm blunt cannula and then stored in an empty
sterile intravenous bag or bottle trap. Decantation was the
only process used to separate the fat cells from the saline
and serosanguineous components. Up to 1260 cc of fat
cells were been injected into each buttock, the largest
amount of fat grafting ever reported. Clinical assessment
estimated a 20 percent loss of augmentation effect during
the first 4 months. Patients were generally pleased with the
final shape and volume of the buttock contour. In fol-
low-up evaluation, magnetic resonance imaging sup-
ported the clinical indicators that the injection of large
quantities of fat cells appears to be a safe and effective
method for buttock enhancement. This process has in-
herent advantages; nevertheless, further research is re-
quired to clarify our understanding of the predictability
and longevity of this technique. (Plast. Reconstr. Surg.
114: 1606, 2004.)
Surgical enhancement of body image in the
context of proportion and contour has success-
fully met patient expectations in the breast,
abdomen, and thigh areas. Social approval
linked to successful results has led to a growing
demand for techniques to enhance the gluteal
region as well.
Silicone prosthetics have been widely used
for buttock augmentation, with reports of ini-
tial success. Patients complained that the im-
plants were perceptible in tight clothes and
swimwear, with overprojection of the upper
buttock and flatness of the lower portion. The
controversy raised by previous U.S. Food and
Drug Administration concerns and the linger-
ing problems with leakage discourage many
eligible patients.
Many surgeons have reported on the transfer
of autologous fat from other body zones as an
alternative to prosthetic augmentation of the
buttocks.1–6 The work of Guerrero-Santos4 sup-
ports the premise that fat injected into muscle
will benefit from the better vascularization and
subsequent host integration. Superficial irreg-
ularities may require direct subcutaneous
infiltration.2,5
PATIENTS AND METHODS
Patients
In 1996, the author discontinued his previ-
ous use of buttock prosthetics in favor of au-
tologous fat injection. By the year 2002, the
study included 158 women and four men aged
17 to 70 years. Ethnic origins varied, but only
six patients of African descent needed or re-
quested augmentation of the buttocks—less
than 4 percent of 162 patients in our study
group. The availability of fat donor sites was an
important selection factor.
From the Division of Plastic and Reconstructive Surgery, Louisiana State University Health Science Center, and the Division of Plastic and
Reconstructive Surgery, Universidad del Valle. Received for publication May 23, 2003; revised February 17, 2004.
Presented at the Annual Meeting of the Louisiana Society of Plastic Surgeons, in New Orleans, Louisiana, January 25, 2003, and at a meeting
of the Division of Plastic and Reconstructive Surgery of Harvard University, at Beth Israel Hospital, in Boston, Massachusetts, May 27, 2003.
DOI: 10.1097/01.PRS.0000138760.29273.5D
1606
In the process of developing the buttock
augmentation technique, we followed a learn-
ing curve. In other words, we started with con-
servative volumes of fat injection, such as 250
to 350 cc per side. With more surgical confi-
dence and growing patient satisfaction,
amounts were gradually increased to meet tis-
sue requirements. Quite a few required 1000 to
1260 cc in each buttock, the largest amount of
fat grafting ever reported, to the best of our
knowledge. The current average is 700 cc per
side.
Clinical observation and measurement with
standardized photographic comparison indi-
cated safety and effectiveness. To improve un-
derstanding of graft behavior, magnetic reso-
nance imaging (Figs. 1 and 2) was used. Funds
were available for only six patients.
Over a 3-week period of 25 consecutive pa-
tient requests, four preoperative and two re-
cent postoperative patients agreed to have the
magnetic resonance imaging series at no cost
to them. Patients were informed that the pur-
pose of this study was to observe the efficacy of
the lipoinjection technique and document the
results.
Sagittal, coronal, and axial cut scans were
obtained preoperatively and/or at the 1-, 4-, 8-,
and 12-month operative intervals. In these six
patients, findings supported the clinical im-
pression that fat cells injected into muscle had
been consistently integrated into the host tis-
sue, enhancing the external buttock contour in
each patient.
FIG. 1. Sagittal and coronal magnetic resonance imaging views obtained preoperatively (left) and 8 months
after 540-cc fat injection (right).
Vol. 114, No. 6 / BUTTOCK AUGMENTATION 1607
Clinical assessment showed an approxi-
mately 20 percent loss of augmentation effect
between the 1-month and the 4-month interval
but none thereafter. In each of the six series,
topographic characteristics of the buttocks re-
mained stable and unchanged from the fourth
through the twelfth months.
Technique
Surface marking and surgical preparation
with povidone-iodine (Betadine) soap and
then Betadine solution are performed with the
patient standing. Then, with the patient under
epidural (90 percent of cases) or general anes-
thesia, saline solution with epinephrine
1:500,000 without lidocaine7 is infiltrated at the
anterior and posterior trunk. To avoid local
distortion and possible overperformance, the
thighs are not infiltrated.
Conventional liposuction is performed with
a 5-mm blunt cannula attached either to a
liposuction machine at medium vacuum or to a
60-cc syringe. When the harvesting is per-
formed by syringe, the fat is collected into
sterile intravenous bags; when using the lipo-
suction machine, a 1000-cc sterile bottle trap is
adapted to the liposuction hose (Fig. 3). Con-
tainers are kept closed to prevent contact with
the ambient air, minimizing oxidation and pro-
moting viability of the fat cell.8
Although the medical literature is replete
with different methods of manipulating fat,
decantation was the only process used to sepa-
rate the fat cells from the saline and serosan-
guineous components that are discarded. Ac-
cording to Chajchir,9 it appears to be the least
harmful method of handling the fat cell.
A low sacral midline incision is made. With
the same 5-mm blunt cannula (to minimize
destruction of the fat cells), the fat is infiltrated
in a fan-like pattern into the upper two-thirds
of the gluteus muscle layer, avoiding the course
of the sciatic nerve (Fig. 4). After each 250-cc
or 300-cc fat injection, the assistant blocks the
incision while the surgeon vigorously kneads
the whole gluteal region to further distribute
and contour the fat until there is no leakage
when the incision is released as the surgeon
keeps kneading the area. According to Car-
paneda and Ribeiro,10 the percentage of graft
viability depends on the fat thickness and its
geometric shape and is inversely proportional
FIG. 2. Sagittal and axial magnetic resonance imaging views obtained 4 months (left) and 1 year (right) after 1260-cc fat injection.
1608 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004
to the graft diameter when greater than 3 mm.
Our intent is to minimize loculation and sterile
abscess formation and to promote integration.
During the massage, some fat can spread out
to the previously liposuctioned regions, espe-
cially the sacral and trochanteric regions. It is
thereforerecommended that these areas be
cleared out with a repeat gentle liposuction.
Failure to do this could cause increased sacral
seroma (lipolysis) and trochanteric saddlebag
formation (fat integration). In cases where the
vicinity of the buttock is not needed as a fat
donor area, it is preferable to perform fat graft-
ing on the buttock first and then to perform
liposuction on its surrounding areas. Patients
are instructed to use an elastic garment for the
first postoperative month, with no restriction
on sitting or sleep postures.
Follow-Up
The 162 patients have been followed for 6 to
48 months, with an average follow-up of 24
months. Cost limited the six magnetic reso-
nance imaging follow-ups to a 12-month
period.
RESULTS
Magnetic resonance imaging findings for the
six patients studied confirm their clinical and
photographic status. The magnetic resonance
imaging allowed us to compare the tissue com-
position of the buttock before and after fat
injection; to demonstrate that the fat was actu-
ally injected intramuscularly; to determine
whether the improved volume persists; and to
measure, with a standardized scale, the in-
crease of buttock bulk after the procedure.
FIG. 3. (Left) Fat harvesting with liposuction machine and collection into a 1000-cc sterile bottle trap. (Right)
Decantation of collected fat in 500-cc intravenous sterile bags after harvesting with a syringe.
FIG. 4. Fat injection in a fan-like pattern.
Vol. 114, No. 6 / BUTTOCK AUGMENTATION 1609
Patient Satisfaction
To determine the level of satisfaction, we
asked our patients to write down their assess-
ment on their own charts. We tried to contact
all of the 162 patients. Of them, we could not
find 25, 14 lived abroad, and 123 did provide a
written opinion.
Their responses included the following: im-
provements in self-esteem, increased amounts
of flattering comments, and changes in cloth-
ing measurements. The results were as follows:
excellent, 112 (91.1 percent); good, seven (5.7
percent) (overcorrected); fair, three (2.4 per-
cent) (asymmetry); and poor, one (0.8 per-
cent) (no significant change).
Complications
During the 7-year interval, of the 162 pa-
tients, only one major complication occurred.
One unilateral aseptic abscess was observed on
the fifth postoperative day. This resolved with a
single-needle aspiration. The resulting asym-
FIG. 5. Case 1. Before (left) and 1 year after (right) injection of 540 cc of fat into each
side. Lipoinjection in the inner thighs was also performed. Magnetic resonance imaging
was performed preoperatively and postoperatively.
1610 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004
metry was corrected 1 year later with a second
fat injection.
Our contour liposuction technique is aggres-
sive. For example, harvesting 3 liters of aspirate
from the trunk of patients who are less than 10
percent over normal weight is not unusual.
Easily treated seromata are seen commonly.
Variable fluid volumes in abdominal and sa-
cral seromata were observed in 64 patients (ap-
proximately 40 percent of cases). From these,
39 patients (60.9 percent) had their seromata
resolve spontaneously, eight (12.5 percent) re-
quired needle aspiration, and 17 (26.6 per-
cent) required vacuum drainage.
Also, 10 percent of patients reported tran-
sient sacral numbness. These percentages were
almost constant in our liposuction cases, re-
gardless of whether or not fat injection was
FIG. 6. Case 2. Before (left) and 1 year after (right) injection of 1260 cc of fat into
each side. Magnetic resonance imaging was performed only postoperatively.
Vol. 114, No. 6 / BUTTOCK AUGMENTATION 1611
performed. Seromata formation decreased
dramatically when vacuum drainage was per-
formed until collection was less than 30 cc per
day for up to 5 days postoperatively.
Seroma formation that is well managed may
not become an actual complication of liposuc-
tion. Formation may be linked to lipolysis,
which continues in the postoperative period;
lymphatic trauma; and retention of tumescent
fluid. We believe that many seromas in liposuc-
tion are not diagnosed or are not reported.
DISCUSSION
There has been extensive controversy over the
benefits of fat injection. Some claim that fat in-
jection does not work and report noticeable ab-
sorption over time after injection.11,12 In contrast,
others defend the benefits of fat injection, en-
couraged by the positive results obtained with the
procedure.1,13 Both groups support their argu-
ments either with experimental studies or with
visual observation, supplying a sound basis for
their viewpoints.
FIG. 7. Case 3. Before (left) and 1 year after (right) injection of 800 cc of fat into each
side. Magnetic resonance imaging was performed preoperatively and postoperatively.
1612 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004
Furthermore, some authors2,6,8 believe that
fat grafting longevity is determined by the size
and lipogenic activity of the fat cells, the vascu-
larity and mobility of the recipient site, and the
degree of local fibrosis and number of viable
cells grafted. When compared with the use of
silicone implants, autologous tissue helps to
reduce the documented complications14,15 re-
lated to the former, such as rupture, extrusion,
capsular contracture, flat contouring of the
inferior part of the buttock, and additional
patient precautions with intramuscular phar-
maceutical buttock injections.
CONCLUSIONS
Fat injection has mainly been used to re-
store facial characteristics.16,17 Its use on a
large scale in corporal contouring may offer
new insights into this field. Monitoring with
magnetic resonance imaging supports fat
grafting as a safe and effective procedure for
buttock augmentation (Figs. 5 through 8).
Nevertheless, it is evident that further discus-
sion and research are required to clarify our
understanding of the predictability and lon-
gevity of the technique.
FIG. 8. Case 4. Before (left) and 1 year after (right) injection of 720 cc of fat into
each side. Magnetic resonance imaging was performed only postoperatively.
Vol. 114, No. 6 / BUTTOCK AUGMENTATION 1613
William L. Murillo, M.D.
Division of Plastic and Reconstructive Surgery
Louisiana State University Medical Center
1542 Tulane Avenue
New Orleans, La. 70112
Servicio de Cirugı́a Plástica
Hospital Universitario del Valle
Calle 5 No. 36-08, 4 piso
Cali, Valle, Colombia
williamurillo@hotmail.com
ACKNOWLEDGMENTS
The author is grateful to Robert J. Allen, M.D., and Ken-
neth Dieffenbach, M.D., for comments and suggestions.
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1614 PLASTIC AND RECONSTRUCTIVE SURGERY, November 2004