Reply: Composite Buttock Augmentation: The Next Frontier in Gluteal Aesthetic Surgery

Sir: I very much appreciate Dr. Senderoff’s comments regarding my and my colleague’s article.1 First, our interest in combining implants and fat stemmed from appreciating the soft-tissue coverage limitations seen in gluteal implant augmentation and from our experience with the same phenomenon seen in the breast. As proponents of subfascial buttock implant augmentation, we are confident that Dr. Senderoff appreciates the important role of soft-tissue coverage over implants. Our interest in this topic has never been influenced by the risk of pulmonary fat embolism seen in cases of fat grafting to the gluteal region (i.e., Brazilian butt lift), because we are certain that the risk of such problems is manageable through proper surgical technique. This managed risk is in contrast to the unmanageable risk of abdominoplasty, which will forever carry an inherent risk of deep venous thrombosis/pulmonary embolism that cannot be eliminated because humans have a circulatory system. There will always be some level of thrombosis with surgery. Lastly, we believe the mortality risk of Brazilian butt lift is biased and is based on assumptive methodology and on improperly analyzed data. Regarding his comments on vasoconstriction, we would recommend actually differentiating between subcutaneous injection of adrenaline versus topical application on a gauze sponge as we advocate. To our knowledge, there are no data on dosing epinephrine as it relates to soaked sponges; and as such, we do not see tachycardia or other systemic ramifications of alpha-adrenergic overload when we perform this maneuver. We have deliberately abstained from mentioning implant brands because a core message that we were hoping to bring across in our article was that the composite approach makes the achievable result less dependent on the implant shape and brand. This message is less about the implant (which is country dependent) and more about the combination of implant and fat, which is a universal concept without borders. We wanted to avoid the impression of promoting any implant brand, but we will endeavor to list corresponding implant brands in our future communications on implants, which are coming forthwith. We are aware of the gluteal implant limitation in the United States, and as the plastic surgery world continues to get smaller, we all appreciate the differences in regulatory issues and in what is available in our respective countries. Although European surgeons such as the first author (A.A.) have the liberty of choosing between cohesive gel and solid implants, we are not aware of any practitioner in Europe that would even consider using solid implants. Because U.S. surgeons are currently limited to solid implants because of regulatory issues, we are concerned that any discussion in favor of solid implants might be clouded by user bias and considered to be of limited credibility. We are thankful to Dr. Senderoff for pointing out this important point regarding postoperative infection that we may have failed to clarify sufficiently. We use a single shot of both metronidazole and cefuroxime intravenously preoperatively in addition to oral cefuroxime for 7 days after the operation. Furthermore, we rinse the implant pockets with gentamicin. Having said this, we are aware that there is no evidence to support that this has any effect on reducing infection risks. Although we are thankful for Dr. Senderoff`s comments, we believe we have had the privilege of publishing our experience in a prestigious surgical journal, and for this we are grateful. We do of course primarily consider patient preference for our decision-making. Although Dr. Senderoff disagrees with our indications for performing this procedure, we stand by our indications that this is a great option in patients with inadequate fat and for patients with inadequate projection. Cosmetic surgery is still 0 percent out of necessity and 100 percent by choice. If a patient has no or very little fat to transfer and yet wants a noticeable change, the only real choice the patient has is to choose implants alone, composite surgery, or no surgery. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.