Buttock Augmentation with Implants and Fat Grafting: A Comparative Study

Autologous fat grafting for buttock augmentation is one of the fastest growing plastic surgery procedures, but has also received significant publicity for the relatively high mortality rate secondary to fat emboli. The literature has grown exponentially in the past 5 years on this subject, helping to clarify our knowledge and providing recommendations to minimize risks, including avoiding intramuscular injections, placing the patient in the jackknife position, and utilizing larger-bore cannulas. Since the application of these recommendations, the rate of pulmonary fat embolism has decreased from 0.097% to 0.04%, with a current mortality of 1 in 14,921, making it statistically safer than abdominoplasty. Despite the evolution in our knowledge, techniques, and outcomes, it remains of utmost importance to properly select and educate patients about the safety of fat grafting for buttock augmentation. Level of Evidence: 4.

Autologous fat grafting is an increasingly popular procedure used for facial rejuvenation and body contouring. The purpose of this article is to perform an evidence-based review to determine fact from fiction for the hot topics in autologous fat grafting. A comprehensive literature search was performed. The following key words were then searched: "fat grafting," "autologous fat grafting," "autologous fat transfer," "lipotransfer," "liposculping," and "lipofilling." The authors then assessed each modality individually for the level of evidence that exists and whether the majority of evidence supports or refutes it. A review of the literature demonstrated that there is no standard test for determining fat viability or volume augmentation after grafting. Furthermore, there is no difference in cell viability seen between syringe aspiration and liposuction pump aspiration harvest techniques (Level II). The decision to wash or centrifuge the fat plays very little role in fat graft survival (Level III). There is no difference between cell viability as a function of harvest location (Level IV). Nearly all studies show no significant effect of local anesthesia on adipocyte cells (Level IV). There are excellent data that support the fact that low-shear devices maintain fat structural integrity (Level IV). There is quality evidence that supports longevity of fat grafted to the breast (Level III). Two studies support large-volume fat grafting longevity but fail to prove their results using objective measures or with sufficiently large sample sizes (Level IV). External preexpansion devices improve total graft survival rate (Level IV). There is quality evidence to support that fat should be injected soon after harvesting, as properties of fat begin to change after processing (Level IV). Microneedling (preconditioning) before fat grafting has been demonstrated to improve fat survival (Level III). Currently, the highest levels of evidence derive from human studies of clinical trials and animal studies using human fat. The evidence presented here helps to address the need for accurate and quantitative viability assays. These assays would facilitate a systematic evaluation of each procedural step during fat graft harvest, processing, and grafting to improve the overall viability and predictability of fat grafts.

Background:Diverse surgical techniques can be used to correct tuberous breast deformity (TBD). This study aimed to analyze lower pole expansion using breast implants and fat grafting with radial scoring for TBD correction.Methods:This retrospective study included patients who underwent TBD surgery between 2018 and 2022. All patients in whom a breast implant was used were included. Two groups were considered according to the use of fat grafting. Patients and surgeons assessed aesthetic outcomes at follow-up using the Aesthetic Items Scale.Results:Sixty-two patients (median age of 30 y) were included in the study. Fat grafting was performed in 42 (67.7%) patients, and the volume of fat used was 65 (35 –120) mL. No significant differences existed in radial scoring use (16 [80.0%] versus 35 [83.3%]) between the groups. In the fat grafting group, the Aesthetic Items Scale improved in shape, volume, symmetry, and total score. No patients reported altered sensitivity, and only 1 (1.6%) required revision surgery.Conclusions:Combining diverse surgical techniques (implants, fat grafting, radial scoring) was associated with good aesthetic outcomes in TBD correction. This approach may be considered a feasible surgical approach for TBD.

INTRODUÇÃO: Frente ao aumento na demanda por gluteoplastia de aumento com implantes nos últimos anos, é importante que haja profissionais treinados e capacitados para realizar tal procedimento e suas associações com lipoaspiração/lipoenxertia, com o intuito final de melhorar o contorno do quadril. MÉTODO: Ao ver na residência médica o local de ensino apropriado para tal prática, elaboramos o estudo de 20 casos tratados por médicos residentes em treinamento sob supervisão, a fim de observar a aplicabilidade e exequibilidade do método e seus resultados. RESULTADOS: Alcançamos melhoria do contorno glúteo em todos pacientes, o que foi corroborado pelo nível de satisfação elevado de 100% delas e pequena taxa de complicações, compatíveis com a literatura. Há certo receio no início do aprendizado, devido ao descolamento intramuscular às cegas, mas guiados por parâmetros técnicos e anatômicos precisos e sob supervisão qualificada, conseguiu-se a realização da cirurgia no plano intramuscular adequado, associando a lipoaspiração e lipoenxertia em alguns casos, o que proporcionou ótima cobertura do implante e resultados naturais no contorno final do quadril. CONCLUSÃO: O estudo demonstrou a grande aplicabilidade do ensino da gluteoplastia de aumento com implantes ao residente em formação, visto a necessidade de uma formação adequada, completa e segura, para atender à crescente demanda por implantes glúteos observada no mercado atual.<br>INTRODUCTION: Facing the increasing demand for buttocks augmentation with implants in recent years, it is important that there are enough trained and qualified to perform such a procedure and their associations with liposuction/ fat grafting with an ultimate aim of improving the contour of the hip. METHODS: Seeing in the residency teaching sites suitable for such a practice, we make a study of 20 cases treated by resident physicians in training under supervision in order to observe the applicability and feasibility of the method and its results. RESULTS: Achieved the improvement of the gluteal contour in all patients, which was corroborated by the high level of satisfaction 100% of them and low rate of complications, consistent with the literature. It is known that there is a certain fear in the beginning of learning, due to detachment in blind, but guided by precise anatomical and technical parameters and under qualified supervision, we had the surgery in the plan adequate intramuscular associated with liposuction and fat grafting in some cases, which provided excellent coverage of the implant and natural results in the final contour of the hip. CONCLUSION: The study showed the wide applicability of the teaching of buttocks augmentation with implants, to the resident in training, given the need for adequate training to meet the growing demand in the market today.

INTRODUCTION: Many studies of gluteal augmentation techniques have been published in recent decades, including case reports, retrospective and prospective case series, and multicenter survey reviews. However, to date, there has been no study of the overall complications or satisfaction rates associated with the wide spectrum of techniques. This comprehensive literature review aims to determine outcomes and complications of gluteal augmentation techniques, including patient satisfaction. MATERIALS AND METHODS: A search on PubMed/Medline was performed with the following search algorithm: ((gluteoplasty) OR (buttock augmentation) OR (gluteal augmentation)) AND ((etiology) OR (epidemiology) OR (classification) OR (indications) OR (treatment)). The inclusion criterion was clinical studies in which techniques of gluteal augmentation were described. Excluded from the study were publications not dealing with surgical procedures, review articles, and reports on secondary interventions. RESULTS: Forty-four studies, published from 1969 through 2015, were included; this represented 6909 treated patients. Five gluteal augmentation techniques were identified from these studies: gluteal augmentation with implants (n=4071), autologous fat grafting (n=2394), local flaps (n=349), hyaluronic acid gel injection (n=69), and local tissues rearrangement (26). The overall complication rates of the two most commonly utilized techniques were 24.3% for gluteal augmentation with implants and 8.6% for autologous fat grafting. The most common post-operative complications included wound dehiscence (5.1%) after gluteal augmentation with implants and seroma of the donor site (3.5%) after autologous fat grafting. Patient satisfaction was reported as consistently high for all the five techniques. CONCLUSIONS: There is great heterogeneity of surgical methods for gluteal augmentation, which yield different outcomes. Implant-based gluteal augmentation is associated with high patient satisfaction despite a high complication rate. Autologous fat grafting is associated with lower complication rate, although provides variable results in terms of volume retention. Further prospective studies with preoperative randomization of patients are required to compare different techniques and establish best practices.

Although autologous fat grafting is a feasible surgical technique to improve facial deformity in patients with localized scleroderma, its success is limited by the low graft retention induced by the local inflammatory environment. This study investigated the potential effect of adipose-derived stem cells (ASCs) on skin fibrosis and fat retention in a localized scleroderma mouse model. BALB/C nude mice that were induced by bleomycin to establish a localized scleroderma model were divided randomly into five groups: blank control; fat grafting; and low, moderate, and high doses of ASC-assisted fat grafting. The backs of the mice were subcutaneously injected with phosphate-buffered saline or fat, or fat with low, moderate, and high doses of ASCs (1 × 10 5 /mL, 5 × 10 5 /mL, and 25 × 10 5 /mL, respectively). The skin fibrosis and fat retention were analyzed after 1 month or 3 months, respectively. Compared to the disease model group, the fat-grafting group, and the low- and moderate-dose ASC-enriched groups, the high-dose ASCs significantly attenuated skin fibrosis, inhibited the production of type III collagen and transforming growth factor-β1, increased fat graft retention, enhanced the expression of angiogenesis-related cytokines and angiogenesis, and increased the expression of adipogenesis-related cytokines. The results demonstrated that high-dose ASCs attenuated skin fibrosis and improved fat retention in a localized scleroderma model by reducing inflammation and by promoting angiogenesis and adipogenesis. The authors further demonstrated that ASCs enhanced adipogenesis through the AKT/ERK signaling pathway. Fat grafting has been used to treat localized scleroderma patients but with low fat retention. In this study, ASC attenuated skin fibrosis and improved fat retention in the localized scleroderma model, providing evidence for cell therapy in future application of localized scleroderma treatment.

Fat survival following autologous fat transfer to the native breast: A systematic review and meta-analysis.

IntroductionFat grafting is a valuable tool for oncologic breast reconstruction, as it enhances aesthetic outcomes. However, concerns regarding oncologic safety and challenges in postoperative imaging have limited the adoption of immediate oncoplastic breast reconstruction (IOBR) with fat grafting. This approach can reduce the need for additional surgeries, shorten recovery time, improve aesthetics, and help mitigate the adverse effects of adjuvant radiation therapy. This study evaluates postoperative, radiological, aesthetic, and patient-reported outcomes of immediate fat grafting in oncoplastic breast reconstruction following lumpectomy.MethodsWe conducted a retrospective study of patients undergoing IOBR with immediate fat grafting following lumpectomy (2020–2022). The plastic surgery team performed reconstruction simultaneously with lumpectomy by breast surgeons. Patient satisfaction was assessed using the Breast-Q questionnaire, while expert surgeons evaluated aesthetic outcomes. Lesion characteristics, specimen weight, and postoperative radiation details were recorded. Postoperative breast imaging was reviewed for fat grafting-related abnormalities.ResultsFifteen patients were included, with 87% undergoing postoperative radiotherapy. No major complications or readmissions occurred within 30 days. Breast imaging follow-up showed 91.1% had benign post-surgical changes, while 8.9% required short-term radiologic follow-up. Post-lipoid injection findings appeared in 37.8% of cases, none with calcifications. Patient satisfaction was high (average Breast-Q Score was 74.5), with only one patient requesting additional fat grafting post-radiation. Expert assessments confirmed improved aesthetic outcomes.ConclusionIOBR with immediate fat grafting is a useful technique for lumpectomy defects across all breast quadrants, demonstrating low complication rates, high patient satisfaction, and positive aesthetic outcomes. Postoperative imaging follow-up revealed no adverse effects related to fat grafting, supporting its potential role as an additional tool in oncoplastic breast reconstruction.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00266-025-04790-3.

Conventional buttock lifting is invasive, so it is difficult to recommend it to patients especially to those who do not have severe gluteal ptosis. In addition, the gluteal area is a large area change among the joints. Therefore, this surgery can cause pain during hip flexion after lifting using a conventional thread. The authors report on buttock lifting using an elastic thread with high satisfaction from patients. From July 2016 to June 2017, 60 patients were enrolled in this study. The degree of gluteal ptosis was graded from Grade 0 to Grade 6. All patients underwent lifting of both buttocks using Elasticum®. We drew a circle along the outer edge of the buttock and another small circle inside the first circle. A stab incision was done at 5 points (A, B, C, C', and D), and then according to the circle, lifting was done. Postoperative grade changes and complications were evaluated. Grades 2-5 were lifted to at least Grade 2 after surgery, but Grade 6 was at most Grade 3 (14.2%), with 85.8% of these to either Grade 5 or Grade 6. Seven patients (11.67%) complained of postoperative pain, and 6 patients (10.00%) showed skin dimpling or creases 10days after surgery, all of which disappeared at 1month after surgery. Buttock lifting with elastic thread is effective in pre-ptosis to moderate gluteal ptosis. Because of the elasticity of the thread, postoperative pain is low on hip flexion, so the lifting is done naturally. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fat graft transfer in children's facial malformations: A prospective three-dimensional evaluation

24 - Fat grafting to the breast

In this article, Handschin et al. [1] promote several modifications to the inferior buttock lift techniques previously described by Gonzalez [2] and Huemer et al. [3]. The main modifications include the division of the deepithelialized infragluteal crescent into upper and lower segments. The other adjustment is the subsequent anchoring of the deepithelialized flaps into the gluteal fascia instead of the ischial periosteum in order to recreate the inferior gluteal fold and provide the buttock lift. The authors describe the procedure in a series of eight patients with very good aesthetic results by postoperative analysis and patient satisfaction report and no recorded complications after a 2month follow-up. The inferior gluteal lift is a very powerful and effective tool in the appropriate candidate. It improves the inferior gluteal fold and the skin and subcutaneous tissue of the superior posterior thigh. The procedure is indicated in patients with mild buttock ptosis with excess skin and subcutaneous tissue in the inferior gluteal fold or ‘‘banana fold.’’ It can also be used to improve a double infragluteal fold, to correct infragluteal fold asymmetry, or to shorten a long buttock when combining it with an upper buttock lift. It is indicated when the maximum point of buttock fullness is at the mid to upper portion of the buttocks, which should coincide with the level of the pubic symphysis [4]. If the maximum point of fullness falls below this line, then a superior approach and/or augmentation should be contemplated [5]. Furthermore, the inferior gluteal lift technique is contraindicated when the excess skin and subcutaneous tissue extends laterally toward the trochanteric area because this would force the incision to extend laterally, resulting in a long infragluteal fold. It has been widely accepted that one of the features of aesthetically pleasing buttocks is a short infragluteal fold that does not extend past the union of the semitendinous muscle with the biceps femoris, which is medial to the midaxial line of the thigh [4]. The postoperative results depicted in the article demonstrate a successful creation of an inferior gluteal fold and improvement in the contour of the inferior buttock and posterior thigh skin. Yet, the resulting inferior gluteal fold is long and extends into the trochanteric area. Unfortunately, only one patient was depicted in the postoperative images. We agree that avoidance of anchoring the dermal flaps to the periosteum of the ischial tuberosity would result in less postoperative pain as described by the authors. We routinely extend horizontal medial thigh lifts posteriorly into the inferior gluteal crease to create an improved infragluteal fold and lift the skin and subcutaneous tissue of the medial posterior thigh. In our experience with inferior gluteal lifts and horizontal thigh lifts, we have avoided scar migration and recurrence of ptosis by anchoring the superficial fascial system of the lower skin flap to the ischial periosteum with satisfactory long-term results [6]. We are concerned with the ability of the gluteal fascia to withstand the gravitational and muscle pull over a period of time. In their study, the patients were followed postoperatively for 2 months. It would be interesting to know whether the authors have experienced sustained long-term results without scar migration or ptosis recurrence. S. O. Sozer (&) F. J. Agullo Department of General Surgey, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA e-mail: doctor@elpasoplasticsurgery.com

Objectives: HIV-associated lipodystrophy is a common comorbidity in HIV-infected patients, having a profound impact on every aspect of patients’ lives, particularly when involving the face. Hence, it is of the utmost importance to evaluate the result of any potential therapies that may help solve HIV-associated facial lipodystrophy. The aim of this article was to evaluate the outcome of patients undergoing facial lipodystrophy correction surgery within our institution. Methods: A retrospective analysis of the clinical charts and iconographic information of patients regarding demographics, morphologic changes, surgical option, postoperative complications, results, and patient satisfaction assessed by a 1- to 10-point scale and by the Assessment of Body Change and Distress questionnaire. Results: Twenty-three patients were operated on from March 2011 to April 2015. Seventy-five percent of cases were treated with fat graft injection, whereas dermis-fat grafts were applied in 25% of patients. The former had their fat harvested more commonly from the abdomen, whereas in the latter case, the graft was harvested mostly from the inner aspect of arms. The mean volume of fat injected on each side of the face was 28.5 ± 22.7 mL. On a scale from 1 to 10, mean patient satisfaction was 7.7 ± 2.8. The Assessment of Body Change and Distress questionnaire revealed statistically significant improvements. Complications occurred in 25% of cases, the most frequent being significant reabsorption. No major complications occurred. Conclusions: Treatment of HIV-associated facial lipodystrophy with autologous fat or dermis-fat compound graft is a safe procedure with long-lasting results and unquestionable aesthetic and social benefits.

Sir: We thank Dr. Laloze et al. for their kind and insightful letter regarding our recent article identifying the finding that supplementation with extracellular vesicles derived from adipose-derived stem cells increases fat graft survival and browning by which extracellular vesicle–polarized M2 macrophages secrete catecholamines to promote beige adipose regeneration.1 Laloze et al. describe the limits of the method we used to measure the survival rate of fat grafts, and suggested that the main tools used as the gold standard are imaging with magnetic resonance imaging or computed tomography with three-dimensional volumetric computer analysis. We agree with this view that intuitively evaluates the volume retention under noninvasive conditions, although we have provided evidence that adipose-derived stem cell extracellular vesicles promote the survival rate of fat grafts by pathologic detection. As suggested by Laloze et al., it is necessary to perform a comparative study between the different methods of lipofilling enrichment in large-animal models first, and then in humans to compare the differences between adipose-derived stem cell extracellular vesicles and adipose-derived stem cells in regulating the survival and outcome of fat grafting, and to clarify which methods present the best clinical result. The comparative study between adipose-derived stem cell extracellular vesicles and adipose-derived stem cells is of great interest to us. Indeed, we compared the effects of both adipose-derived stem cells and adipose-derived stem cell extracellular vesicles to fat grafting in a model of nude mice. We co-grafted 100 μg/ml adipose-derived stem cell extracellular vesicles and 5 × 105 adipose-derived stem cells with 0.3-ml purified liposuction into the scalps of nude mice. The volume retention rate of adipose-derived stem cell–treated grafts was approximately 20 percent higher than that treated by adipose-derived stem cell extracellular vesicles at postoperative week 12. However, it is difficult to obtain convincing evidence in this comparative experiment because of the difference in dose units between adipose-derived stem cells (number of cells) and adipose-derived stem cell extracellular vesicles (protein concentration). We only hypothesize that adipose-derived stem cell extracellular vesicles and other secretion groups derived from stem cells could replace stem cell therapy under the premise of appropriate doses and times in the models and that transplanted stem cells play only a paracrine role and not homing or differentiation. For the application of adipose-derived stem cell extracellular vesicles in fat grafting and other ischemic diseases, researchers should pay more attention to extracting extracellular vesicles with increased biological function by optimizing the microenvironment of cell culture. It is a feasible method for simulating the microenvironment of transplanted stem cells in vitro. Because transplanted stem cells participate in tissue regeneration almost only by means of paracrine rather than directional differentiation in fat grafting,2 we used hypoxia incubator and serum-free medium to simulate the ischemic and hypoxic microenvironment of transplanted adipose-derived stem cells in our previous study. Adipose-derived stem cell extracellular vesicles cultured under hypoxia possess a stronger ability to promote angiogenesis both in vitro and in a fat grafting mouse model compared with that cultured under normoxic conditions.3 In addition to hypoxic preconditioning, any treatment to simulate the microenvironment of transplanted stem cells, such as three-dimensional culture, oxidative stress stimulation and the intervention of a variety of cytokines may also alter the biological function of adipose-derived stem cell extracellular vesicles. The potential therapy of adipose-derived stem cell–derived exosomes in obesity and diabetes by means of promoting M2 polarization of macrophages was studied by Zhao et al.4 Intraperitoneal administration of adipose-derived stem cell–derived exosomes led to a resistance to sustained weight gain in mice fed a high-fat diet, and significantly inhibited the mass growth of both visceral and subcutaneous white fat pads. In addition, treatment with adipose-derived stem cell–derived exosomes decreased the levels of serum triglyceride and total cholesterol in serum of mice fed a high-fat diet, and showed significant improvement in glucose tolerance and insulin sensitivity even before the reduction in obesity progression. In our study, we also formed beige fat with increased oxygen consumption from the treatment of conditioned medium of adipose-derived stem cell extracellular vesicle–polarized M2 macrophages. Thus, we prudently hypothesize that M2 polarization of macrophages could be used as an auxiliary scheme for the therapy of obesity or type 2 diabetes, and adipose-derived stem cell extracellular vesicles could be used as the inducing factor of M2 polarization. However, targeted therapy for the secretory function of hypertrophic adipocytes should also be evaluated because the secretion of hypertrophic adipocytes is responsible for the accumulation of M1 macrophages.5,6 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. The authors received no funding support for this work. Yang-Yan Yi, M.D.Department of Plastic SurgerySecond Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, People’s Republic of China

Cell-assisted lipotransfer (CAL) is novel and controversial technique for breast augmentation. This review and meta-analysis aimed to assess the clinical efficacy of CAL as compared with conventional lipotransfer. PubMed databases were searched with no restrictions for randomized controlled trials (RCTs) and observational studies with control groups. Keywords included "fat graft," "lipotransfer," "lipofilling," "autologous fat," "fat transplantation," "stromal vascular fraction (SVF)," "stem cell," "adipose tissue-derived stromal cell (ADSC)," "adipose tissue-derived stromal cell (ASC)," "called adipose derived progenitor cells (ADRC)," "cell-assisted," "progenitor-enriched," "cell-enhanced" and "breast." Review Manager software (RevMan, version 5.3) was used to compute the pooled effect estimates for fat survival rate and complication rates. Outcomes were expressed as standard mean differences (SMDs) or odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were performed based on different methods of cell-enhanced fat preparation. Six studies were included (ntotal = 353 adult patients). The fat survival rate was significantly higher in the CAL group than in the control group (SMD = 1.79, 95% CI = 0.28, 3.31; P = 0.02). There were no significant differences in complication rates between the CAL group and the control group (OR = 1.34, 95% CI = 0.65, 2.73; P = 0.43). Subgroup analyses found no significant differences between the SVF and control groups in fat survival rate (SMD = 1.52, 95% CI = -0.21, 3.24; P = 0.08) among both manual and automatic subgroups (P = 0.28 and P = 0.10, respectively). The data analysis showed a significant heterogeneity between manual and automatic subgroups (I2 = 57.0%, P = 0.15). This study suggests that cell-assisted lipotransfer is superior to conventional lipotransfer for improved fat survival rate in breast augmentation. However, analyses comparing the SVF-enhanced fat graft with the conventional fat graft noted no differences in fat survival rate. It is necessary to determine which protocol is most beneficial for patients, establish standardized methods of SVF isolation or adipose tissue-derived stromal cells (ADSCs) culture, and a constant percentage of injected cells in the graft. The long-term efficacy and safety of CAL should also be evaluated in further studies, and additional RCTs with larger sample sizes and better comparability are needed. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.