C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 33 (2006) 435–447

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Submuscular Gluteal Augmentation:17 Years of Experience With Geland Elastomer Silicone ImplantsJorge E. Hidalgo, MDa,b,c,*

- Indications- Preoperative markings- Anatomy- Surgical procedure- Surgical technique- Postoperative care- Choice of implants

- Results- Complications- Discussion- Summary- Aknowledgments- References

Dr Jose Robles from Buenos Aires, Argentina, firstdescribed submuscular gluteal augmentation withimplants in 1984 [1]. In 1988, we had the opportu-nity to have Dr Robles perform his procedure onone of our patients in our Juvencia Clinic in Miami.We used general anesthesia, although he preferredepidural. Dr Robles also suggested not using exces-sive padding beneath the patient, particularly in theregion of the pelvis, to avoid overstretching of glu-teal muscles. After the incision and limited lateralsubcutaneous undermining, he proceeded to sepa-rate the muscle fibers until reaching the submuscu-lar space. Using 4 � 4 gauze squares on a ‘‘ringclamp,’’ he very quickly developed the submuscularpocket with blunt and blind dissection, which hethen packed with ‘‘baby laps.’’ After doing the samein the opposite buttock, he removed the packing,which was practically dry, and introduced siliconegel implants. After his ‘‘routine’’ closure (which willbe discussed below), he had completed the proce-dure in less than 1 hour with an excellent result.

0094-1298/06/$ – see front matter ª 2006 Elsevier Inc. All rightplasticsurgery.theclinics.com

Over the years, we have modified Robles’ mark-ings and surgical technique. We have also addressedthe problem created when silicone gel implantswere banned in the United States by the Food andDrug Administration by designing solid elastomerprostheses approved for gluteal use in the UnitedStates. Our early experience was presented at the1992 annual meeting of the Lipoplasty Society ofNorth America in Washington, DC [2].

Indications

Our patients have all been women, between 23and 55 years of age, who presented with small,flaccid, or flat buttocks that lacked superior full-ness and therefore the defined break betweenthe lower back and the gluteal region. Such pseu-doptotic buttocks can be corrected by increasingthe volume, similar to breast ptosis that can beimproved with implants alone. Real buttock pto-sis cannot be corrected with gluteal augmentation

I have no type of financial interest with Silimed, Inc.a Faculty of Medicine, Peruvian University San Martin de Porres; Lima, Perub Juvencia Clinic, Av. Juan de Aliaga 455, Lima 17, Peruc GABLES AS, PA, 7600 SW 57 Avenue, Suite 304, Miami, FL 33143, USA* Juvencia Clinic, Av. Juan de Aliaga 455, Lima 17, Peru.E-mail address: juvencia@ec-red.com

s reserved. doi:10.1016/j.cps.2006.04.001

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alone and requires a secondary procedure that in-volves some skin excision. This is best performedat a later stage after insertion of implants has ad-dressed the problem of volume deficiency.

When planning a gluteal augmentation, takenote of any asymmetry of the pelvis that is fre-quently associated with a lateral gluteal depression

Fig. 1. Dr Baroudi’s markings on the left buttock andDr Robles’ on the right.

Fig. 2. Dr Hidalgo’s lines of reference and markingsfor intergluteal incision and area of deep subcutane-ous undermining on the left buttock.

Fig. 3. Horizontal line represents the marking be-tween the tip of coccyx and the greater trochanter.The red line is the location of the muscle incision.

Fig. 4. The horizontal line corresponds to the inferiorborder of the piriformis muscle and the exit of the sci-atic nerve below.

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(LGD), which may be more prominent on one side.Most moderate LGD may be corrected with im-plants alone. A more noticeable LGD usually re-quires liposuction of the hips and lateral thighs.Liposuction contouring of the lower back and waistarea may be needed as well.

Preoperative markings

Markings recommended by Baroudi [3] are illus-trated on the left buttock in Fig. 1. Line ‘‘A’’ is drawnbetween the spine of the posterior iliac crest and thecoccyx; a second line ‘‘B’’ runs perpendicular fromthe midpoint of line ‘‘A.’’ The implant location isoutlined above line ‘‘B,’’ which is probably too highfor most patients. The right buttock seen in Fig. 1shows the markings proposed by Dr Robles [1].Line ‘‘A’’ is the same, but line ‘‘B’’ is between themid point of line ‘‘A’’ and the greater trochanter.

We have simplified the markings (Fig. 2) bydrawing two horizontal lines from the tip of thecoccyx to the greater trochanter. This line corre-sponds to the inferior border of the piriformis mus-cle, below which the sciatic nerve exits (Figs. 3and 4). As shown in Fig. 2, the horizontal line is

Fig. 5. Anatomy of the gluteal region with the im-plant in the submuscular space.

Fig. 6. Preoperative surface markings.

the limit of the inferior pocket dissection, and theimplant is located just above this line to ensure thatthe sciatic nerve is not injured or irritated. This po-sitioning also avoids excessive fullness in the supe-rior pole of the buttocks.

Anatomy

Gluteal anatomy is described in a separate article ofthis volume and has been previously reviewed byMendieta [4]. In addition to this information, Istrongly recommend viewing the video by Dr Bar-oudi [3]. It shows an excellent cadaver dissectionof the entire gluteal region and a clear demonstra-tion of the tissue planes in which gluteal implantsmay be placed.

In submuscular augmentation, the roof of thecavity or pocket where the implant is placed is thegluteus maximus. The floor consists of the gluteusmedius and the superior aspect of the piriformismuscles (Fig. 5).

Surgical procedure

We typically use epidural anesthesia, which is be-gun with the patient under mild IV sedation in

Fig. 7. Lateral subcutaneous undermining over themuscle fascia.

Fig. 8. Incision of the fascia following the direction ofthe muscle fibers.

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the operating room. The catheter that delivers theepidural anesthesia is left in place for postoperativeanalgesia during the first 24 hours following sur-gery. Patients also routinely wear intermittent pneu-matic compression boots during surgery and in theimmediate postoperative period.

The patient is placed in a prone position witha pillow beneath her chest and pelvis. Other pres-sure points—such as the elbows, knees, and dor-sum of feet—should also have adequate padding.

After routine preparation and draping, a gauzepad soaked in iodine is sutured in place to coverand isolate the anus. This gauze is covered and se-cured with a second 4 � 4 gauze.

The intergluteal incision is marked in the midlinefrom the tip of the coccyx cephalad for 5 to 7 cm,depending on the size and type of implant to beused. Above the standard horizontal markings, theposition of the implant is drawn with its medialborder 4 to 5 cm from the midline and extendingfor 8 to 10 cm laterally. This represents the area ofsubcutaneous undermining that will allow suffi-cient muscle exposure and an adequate incision tofacilitate insertion of the implant. The incision

Fig. 9. Initial spreading of the muscle fibers witha long hemostat.

Fig. 10. Deeper spreading of the muscle fibers withretractors.

and the area immediately overlying the muscle fas-cia are infiltrated with local anesthesia using 30 to40 cc of xylocaine 1% with epinephrine 1:200,000.

The instruments required for gluteal augmenta-tion have been described by Mendieta [4]. They in-clude a long hemostat, long Adson Brown forceps,one straight and one curved long ring forceps,#22 urethral sound, 2 Army-Navy retractors, 2 longDeavers, 1 Harrington retractor, a head light orlighted retractor, bipolar insulated forceps, and anAiache gluteal dissector. The Aiache dissector is veryuseful for performing sweeping lateral movementsthat help develop the superior aspect of the sub-muscular pocket where the muscle fibers are morefirmly attached. Aiache introduced me to thisinstrument (Dean Medical, California) when I wasinvited to participate in a surgical demonstrationat the 7th Symposium of Recent Advances ofAesthetic Surgery in Beverly Hills, California, in1992 (A. Aiache, personal communication, 1992).

Surgical technique

Our surgical technique was filmed in 1993 and isavailable through the Plastic Surgery EducationalFoundation of the American Society of Plastic Sur-geons [5].

The incision is made straight down to the presac-ral fascia. Undermining then proceeds laterally for8 to 10 cm directly over the muscular fascia, whichmust be preserved because of its importance duringclosure. The fascia is incised following the directionof the muscle fibers, which are gently separated us-ing the long hemostat and Army-Navy and Deaverretractors down to what Robles called the ‘‘submus-cular cellular space’’ [4], or the fine layer of fatty tis-sue (Figs. 6–11).

This tissue plane is not always easy to identify.However, if one is at least 3 cm deep, use the curvedring forceps first and then a moist gauze to beginthe blunt dissection at the superior edge of the

Fig. 11. Separation of the gluteus maximus fibersdown to the submuscular cellular space.

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Fig. 12. After initial dissection of the submuscular pocket with a ring forceps (A), the Aiache dissector, witha folded 4 � 4 gauze on its tip, is used to complete the superior pole dissection (B).

incision. Follow the path of least resistance butmaintain the depth of the plane of dissection. Afterthe initial dissection, we continue dissecting cepha-lad; one may use an Aiache dissector, or keep thefield in direct vision with a headlight and Deaver re-tractor or a lighted retractor. Bleeders are controlledwith the bipolar insulated forceps. Superior lateraldissection should be done with caution to avoidperforating the muscle or becoming too superficial(Fig. 12A, B). The inferior pole dissection is easier.One should always refer to the external markingline as the limit of the submuscular pocket to avoiddissecting too low.

After careful hemostasis is achieved, a sizer is in-troduced into the cavity to verify the limits of dis-section as well as the shape and volume of theimplant. The sizer should be completely coveredby muscle without protruding through the muscleor the incision. After removing the sizer and check-ing hemostasis again, introduce the selected im-plant into the submuscular pocket (Fig. 13).

The same procedure is performed in the oppositebuttock. Once the sizer is introduced carefullycheck the patient for symmetry to make sure the

Fig. 13. Insertion of a folded elastomer siliconeimplant.

location and projection of the implants are as sym-metrical as possible. At this point, the urethralsound is helpful for making final adjustments tothe pockets.

With both implants in place and hemostasis en-sured, the muscle fibers are approximated withthe intact overlying fascia using a running sutureof 3-0 Vicryl to obtain a tight closure. (Figs. 14and 15).

Before closing the incision, make sure that metic-ulous hemostasis of the subcutaneous tissues is ob-tained in each buttock. Also check the skin marginsto see if the retractors compromised the skin. Anyskin margin damage should be excised until healthytissues are reached to avoid later wound dehiscence.

The midline incision is closed in three layers. Thefirst deep line of closure should take bites in the pre-sacral fascia using 3-0 Vicryl to avoid dead spaceand recreate the intergluteal fold. The second lineof closure, also with 3-0 Vicryl, is in the deep der-mis. The third layer closes the dermis with a runningintradermal 5-0 Vicryl.

We do not use drains. Antibiotic ointment, 4 � 4gauze pads, and an abdominal elastic binder areused for a dressing.

Fig. 14. Preoperative posterior view.

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Postoperative care

During the first 72 hours after surgery, patients arerequired to be at rest except for bathing and goingto the bathroom. Thereafter, ambulation is allowedas tolerated. Patients are told to rest and sleep ina prone or lateral position and avoid sitting for pro-longed periods of time during the first 3 weeks ofthe postoperative period. Patients also wear a tightgirdle for 3 weeks to support the implants duringhealing.

Postoperative oral antibiotics, usually cephalo-sporin, analgesics, and muscle relaxants are pre-scribed for the first postoperative week.

Choice of implants

Several companies in the United States manufac-ture gluteal implants, including Hanson Medical,Inc (Kingston, WA); AART, Inc (Reno, NV); andSpectrum Designs Medical (Carpinteria, CA). How-ever, we typically use Silimed implants (Silimed,Inc, Rio de Janeiro, Brazil, and Dallas, TX). Table 1provides details on the types and sizes of implantsplaced in the patient series reported here.

Fig. 15. Intraoperative view after implants are inplace.

The Robles implant made by Silimed is a roundcohesive silicone gel-filled device with a thick andresilient smooth shell (Fig. 16A, B). Its main advan-tage is that it produces more projection and a verysoft natural feel. The potential disadvantage is thepossibility of rupture. However, we have not hada diagnosed rupture in our series of patients.

The Hidalgo implant, also made by Silimed, isround with a smooth surface and composed of softsilicone elastomer. The concave undersurface facil-itates its introduction into the implant pocket be-cause it folds over on itself (Fig. 17A–C). Itsmain advantage is that it cannot rupture. However,placement of the Hidalgo implant requires a moreaccurately sized submuscular pocket so the im-plant cannot move around. Other disadvantagesare that it provides less projection (compared withthe Robles implant), and it produces a more firmbuttock. Patients have thus far not objected tothe firmness.

We have not used implants with an anatomicalshape because of concerns about proper orienta-tion and the thickness of the tissue coverage (skin,fat, and muscle). We think the shape of a glutealimplant is less important than making sure it isproperly positioned and of the correct size orvolume.

Table 1: Volumes and dimensions of Silimedgluteal implant types used in thispatient series

Robles – cohesive gelfiller (width at widestpoint 3 thickness)

Hidalgo – soft siliconeelastomer composition(width at widest pointby thickness)

240 cc: 10.9 � 3.9 cm 250 cc: 11.6 � 2.6270 cc: 11.4 � 3.9 cm 290 cc: 12.1 � 2.9300 cc: 11.8 � 4.0 cm 340 cc: 12.5 � 2.9

Fig. 16. (A, B) Two views of the Robles type cohesive gel silicone implant with its thick resistant shell.

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Fig. 17. (A–C) Hidalgo-type soft elastomer prosthesis with concave undersurface to facilitate folding andinsertion.

Results

Between February 1988 and April 2005, we per-formed submuscular gluteal augmentation in 97patients. Of the 42 patients operated on in Miami,Florida, 20 received the round silicone elastomerHidalgo implants. Of the 55 women operated onin Lima, Peru, all except 2 received the silicone gelRobles implants. (Table 2). Photographs that illus-trate results obtained with silicone elastomer im-plants are seen in Figs. 18 and 19. Patients shownin Figs. 20–22 received the Robles silicone gelimplants.

For the elastomer implants, the sizes used mostfrequently are the 290 cc, followed by the 340 cc.

Table 2: Types of implants used in 97 patients

In UnitedStates

42patients

22 with gel20 with elastomer

In Peru 55patients

53 with gel2 with elastomer

Totals 97patients

75 patients with gel22 patients withelastomer

For the silicone gel implants, the 270 cc is usedmost often, followed by the 300 cc. However, ourearlier gel implant patients in this series most fre-quently received the 240-cc volume. Now, we usethis volume only in patients with a small pelvicframe.

Complications

The complications that occurred with the siliconegel implants in 75 patients are as follows:

� Malposition, ptosis: 1

� Lateral bulge, herniation: 1

� Superficial wound dehiscence: 5

� Intergluteal wound infection: 2

� Submuscular wound infection: 1

� Transient sciatic pain: 2

The complications that occurred in 22 patientswith silicone elastomer implants are as follows:

� Submuscular hematoma: 2

� Subcutaneous seroma: 1

� Superficial wound dehiscence: 1

� Transient sciatic pain: 2

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Fig. 18. (A, C) Preoperative views of a 41-year-old woman before gluteal augmentation. (B, D) Photos were taken8 month after she received 290-cc silicone elastomer implants. Her results could be improved with liposuction ofthe hips and lateral thighs.

The malposition or ptosis and the lateral bulge orherniation complications were treated with eithercapsulorrhaphy or reoperation and exchange fora larger implant. Superficial wound dehiscence andinfections at the incision sites were treated with rou-tine wound care and antibiotics based on the cultureand sensitivity findings. In all cases, the woundswere allowed to heal by secondary intention. In allcases of transient sciatic pain, satisfactory treatment

was achieved with a single administration of intra-muscular corticosteroid (Dexametazona).

We have had only one case of early postoperativebilateral submuscular pocket infection. This wassuccessfully treated with removal of the implants,appropriate antibiotic therapy, and re-implantationafter 6 months.

In the smaller group of patients with silicone elas-tomer implants, the two submuscular hematomas

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Fig. 19. (A, C) A 28-year-old woman with ‘‘long’’ buttocks and asymmetry that includes a more prominent leftLGD. (B, D) Postoperative photos 10 months after she received 290-cc silicone elastomer implants.

required return to the operating room for open evac-uation. The subcutaneous seroma was safely treatedwith needle aspiration.

Discussion

In our overall experience, we have found that glu-teal augmentation patients report high satisfactiondespite the initial postoperative pain and the in-convenience of being unable to sit for lengthy pe-riods of time in the early postoperative period.

Unlike breast augmentation patients, very few withgluteal implants are willing to share their experi-ence with others and prefer to keep their augmen-tation secret.

We believe that using round implants in the sub-muscular plane produces results that are quite satis-factory, as long as they are located according to theplacement diagram shown in Fig. 2. This positioncreates a nice transition between the lower backand buttocks and gives the upper pole and overallcontour of the buttocks a natural appearance.

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Fig. 20. (A, C) A 36-year-old woman with ‘‘long’’ buttocks and excess subcutaneous fat. (B, D) Postoperative views6 months after the patient received 270-cc silicone gel implants, liposuction of the waist and flanks, and revisionof an abdominal scar.

If gluteal implants are placed in a plane above thegluteus maximus muscle, the prosthesis obviouslyhas to be much softer than is possible with siliconeelastomer. In the subfascial plane, the firmness ofthe elastomer and palpability of the implant wouldlikely erode patient satisfaction [6]. In the UnitedStates, gluteal implants made of silicone elastomerare the only ones available. Because of this, submus-cular positioning is the best option for surgeons per-forming gluteal augmentation in the United States.

Implants made of cohesive silicone gel that areplaced in the inferior pole of the buttocks,

regardless of the implantation plane, have a higherrisk of rupture because they are regularly subjectedto the pressure of sitting. We have not suspected ordiagnosed this complication in our series of pa-tients with gel implants placed in the superior poleof the buttocks. We also have not seen a singlecase of capsular contracture with submuscularaugmentation.

However, it is pertinent to mention that, similarto subpectoral breast implants, some degree ofdistortion should be expected when the glutealmuscles are contracted. This has not been

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Fig. 21. (A, C) Preoperative view of a 47-year-old woman. (B, D) Postoperative photos 3 months after she received270-cc silicone gel implants and revision of lateral ‘‘dog ears.’’

a significant issue with our patients. More impor-tant is that the submuscular position and its richblood supply provides a natural barrier against in-fection [4].

We completely agree with De la Pena [7] and Ver-gara [8] with respect to the subcutaneous placementof any kind of implant. This position is more proneto complications, capsular contracture, distortion,poor contour, and palpable borders. In addition,

disruption of the aponeurotic fibers may cause dis-placement, malposition, and even extrusion.

Summary

Submuscular gluteal augmentation with round sili-cone gel or elastomer implants produces good aes-thetic results when properly performed. Theprocedure is associated with minimal serious

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Fig. 22. (A, C) This 23-year-old woman with ‘‘long’’ buttocks desired more upper pole fullness. (B, D) Postoper-ative photos 4 months after receiving 240-cc silicone gel implants and liposuction of her hips.

complications and a high degree of patient satisfac-tion. It is therefore a good alternative when com-pared with other implant procedures presented inthis volume.

Acknowledgments

I acknowledge the teaching, friendship, and kind-ness of Dr Jose Robles and dedicate this article inmemory of him and his dear family.

References

[1] Robles JM, Tagliaprieta JC, Grandi MA. Gluteo-plastia de aumento: implantes submusculares.Cir Plast Iberolatinoamericana 1984;10:365–9.

[2] Hidalgo JE. Submuscular augmentation gluteo-plasty. Presentated at the 10th Annual Meetingof the Lipoplasty Society of North America,Washington DC, 1992.

[3] Baroudi R. Buttocks augmentation [video #6124].Lipoplasty Society of North America.

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[4] Mendieta C. Gluteoplasty. Aesthetic Plast Surg2003;23:441–55.

[5] Hidalgo JE. Submuscular augmentation gluteo-plasty [video #9513]. Plastic Surgery EducationalFoundation. Aesthetic Body Contouring Series.

[6] Roberts T III, de la Pena JA, Cardenas JC, et al.Cosmetic surgery of the buttocks region

[panel discussion]. Aesthetic Plast Surg 2003;23:381–7.

[7] De la Pena JA. Subfascial technique for glutealaugmentation. Aesthetic Plast Surg 2004;24:265–73.

[8] Vergara R, Amezcua H. Intramuscular gluteal im-plants. Aesthetic Plast Surg 2003;23:86–91.