Fashion and pop culture are drivers for cosmetic procedures and buttock augmentation has been around for over 40 years, although its popularity has surged in the past 5 years. What constitutes the “perfect” butt? Is it gender, racially, age specific? Can’t it just be produced by lunges?

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Essential to successful gluteal shaping is the classification of the derriere into a variety of aesthetic units, which must be brought into harmony by either “reduction” (liposuction) or “augmentation” (silicone elastomeric implants or lipografting).

No two butts are identical however it is generally agreed that the preop type will determine what procedures are suggested and how successful the outcomes will be. It’s not only the shape, projection and size, but also the maintenance of the waist:hip ratio of 0.7. Among younger, athletic white females, the (upside down) “heart” shaped is most favored, however the ascendence of Kim Kardashian, JLo and Nikki Minaj has launched the “round” high projecting derriere. Square butts tend to look more masculine because of the profile flatness; selective liposuction over the “muffin tops”, “banana rolls” and “love handles” can restore the classic 0.7 waist: hip ratio and uncover the “heart shaped” butt. The least attractive is the “V” or “beetle butt”, where the waist thickness tapers to a point, often with trochanteric contour depressions laterally; regrettably, these are the most difficult to improve. Who are the aesthetic male ideals? Chris Hemsworth, Tom Brady.

The algorithm for buttock contouring include selective liposuction, silicone implants (for thin individuals who lack suitable fat grafting donor sites), Brazilian butt lift (= selective liposuction and fat grafting). Most women are elated to repurpose unwanted fat from the abdomen, flanks, thighs, however the basics of grafting still need to be respected. Microribbons of fat maximize oxygen uptake when injected into a well vascularized bed (i.e. muscle). Since fat graft survival depends on establishment of new blood supply, fat grafts larger than 0.16cm are observed to have central necrosis or cell death. Similarly, although it’s tempting to grow the “booty” in one sitting, augmentation of large volumes >200cc fat raise interstitial fluid perfusion pressure; once it exceeds 9mm, oxygen diffusion and capillary perfusion ceases.

Considering the logistics of fat grafting for BBL, Mommy Makeover candidates should realize that lying supine, for prolonged periods, to recover for abdominoplasty, breast procedures may jeopardize your tush because pressure prevents reestablishment of blood supply. Fat grafts always retain their genetic potential of their site of origin and persistently stubborn fat sites from the flanks, abdomen and knees are frequently chosen because of this characteristic. Like any procedure, there are patient factors (availability of adequate donor sites and willingness to follow postop instructions), surgeon factors (experience and interest) and the inevitable “wild card”, healing factors (sufficient revascularization, low incidence of fat cysts, fat necrosis, cellulitis, etc.)

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At the end of the day, everyone must make good choices if we wish to feel comfortable in our bodies. The recent initiation by ASPS of “GRAFT”, a national registry to track outcomes in fat grafting should be applauded by patient and physician. Change is inevitable. Gravity always wins. Of the choices for buttock enhancement, liposuction, fat grafting and implants are vastly preferable to unsupervised injection of industrial silicone or caulking by lay practitioners. Complications inherent to fat grafting include granulomas (hard knots), oil cysts, abscesses, impermanence of results. Although infrequent, the stakes for Brazilian butt lifts are higher and include pulmonary emboli (clots which travel from the fat grafting site to the lungs) and death have been documented.

Sobering? Indeed. It has been suggested that potential “drivers” of our obsession with big butts are not only a preoccupation with rap culture but also a more subliminal return to nature. Caveat emptor (let the buyer beware).

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