What can be done to address my butt and crease?

Question

I’m 37 years old. I’ve always had a flat butt, no matter how hard I’ve worked to grow one. I currently started working out again after about a year or so because I saw myself from behind and was horrified at how my butt looked. I’m a thin and healthy person at baseline so I don’t gain weight or get fat. I have noticed my butt is getting rounder, but the divot in my crease isnt changing. I’m 5’5” 115-120#. How can I fix this, surgically or otherwise? Is it anitomical anomaly?

Luis Suarez, MD · Answer

It is important to know if you have had any fluctuation in your weight during the last few years, which would help us identify if there’s any loose skin if you do have loose skin around the back area a good option would be posterior tummy tuck with fat transfer, this will help lift the skin to give it a better appearance and fat transfer to inject to the buttocks for projection and volume.
If in fact, you have not had any fluctuation and weight loss and there’s no loose skin in the lower back. Some fat transfer could be done to help with the shape, but unfortunately, in that under area of the butt, it’s hard to be able to fix that crease unless it to lift or actually cut a piece of skin under that area which would mean an additional incision which I personally wouldn’t think it’s worth it.

Ryan A. Stanton, MD · Answer

Allow me to answer your question as best i can based upon your photos. However, please keep in mind that an in-person, or at least a virtual, consultation with physical exam is first necessary before any legitimate evaluation or final surgical recommendations can be made.

The butt crease “divot” you are concerned about typically comes from either the aging process, as the bottom-outer half starts to succumb to and sag from gravity, and/or a genetic variation of normal. Either way, the best surgical treatment is to add volume to the entire buttock to take up the slack and smooth out the “divot”. In cases like yours, an otherwise fit and lean patient, your most reliable, predictable, relatively safe and permanent option is to place buttock implants.

Please read on for more general information.

There are currently only two FDA approved surgical options for augmenting the buttock/hip area:  1) Buttock and cosmetic Hip Implants (which are soft semi-solid silicone rubber implants that cannot rupture &/or leak) and 2)Brazilian Butt Lift (aka BBL) - which utilizes the patients own fat from liposuction then transfers this fat into the buttock. On the other hand, BBL using fillers such as hyaluronic acids, Sculptra, etc… is a dangerous, guaranteed waste of money, and is NOT FDA approved. So what it comes down to, like any surgery, is proper patient selection and long-term results. Implants provide the only guarantee for a sustained permanent result and tend to be ideal for perking up not only lean or deflated buttocks but also providing substantial projection to any butt, which is what every single patient wants. Typically a combination of sculpting the waistline with liposuction and augmenting the buttock with implants +/- the hips with implants provides the best chance for a long lasting and desirable "hour-glass" figure.  Based upon your photos, a Stanton Anatomic®️ shape buttock implant may serve you best.

Unfortunately, fat typically melts away leaving disappointing results after 12 months, often sooner.  Unless your BBL surgeon is injecting only 200 to 300 ccs of fat into each buttock cheek, a large percentage of that fat is going to die.  Dead fat leads to dents and dimpling like cellulite, unevenness, loss of projection, and fatty necrotic oil cysts which are hard marbles and can be very tender 
Unfortunately, because ~70+ % of the fat transferred will melt away within a year or two, most patients are not good candidates for BBL because they lack an adequate amount of fat to harvest. Beware, if a surgeon asks you to purposely gain weight (i.e. fat) before BBL, know that the fat you lose first as you get back to your baseline weight after surgery is that very same fat that was transferred into your buttock, hence your new buttock shrinks first, the fastest, and the most...so please do not fall victim to this recommendation. Even those patients that had adequate amounts of fat pre-operatively, still end up seeking buttock implants after a year or so because most of the fat transferred melted away leaving them with minimal result.  Fillers such as Sculptra are cost prohibitive, provided enough volume is injected (i.e. at least 400 cc of active ingredient costing over $300,000) and last only 12 - 18 months.  Additionally, any physician promoting “biostimulators” for buttock enhancement is just a joke, and any board certified plastic surgeon promoting such, should not be trusted with your butt.  So, if you're looking for a reliable, predictable, and long-term permanent option that also provides projection in the central buttock and hips, buttock and hip implants are your solution. Please note that an extremely few number of board certified plastic surgeons specialize in buttock or hip implants, so you may need to travel far and away from home to find this particular surgeon.  Getting it done right the first time around is not only the best chance for success, but also will save you from a lot of headaches and money in the future. Glad to help.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question.  In young patients, the most common "go to surgery" is a Brazilian butt lift-fat transfer, however you have very little fat transfer.  The idea of gaining weight to add and then losing the weight always results in the fat atrophying back down to its normal baseline.  You are actually an excellent candidate for buttock augmentation with an implant.  You should be able to have an excellent result.  Best wishes to you.

Zoran Potparic, MD · Answer

You have well defined normal anatomy of the buttock/hip areas. An augmentation with fat grafts (you have enough fat for that) in the hands of an expert would make nice improvement. Good luck.

Mats Hagstrom, MD (license on probation) · Answer

I don’t think there are any easy straightforward procedures for you.
Your lean, which I think is great and I would encourage you to not gain weight.
Because you have very thin layers of subcutaneous, fat grafting or fat transfer a.k.a. BBL is not going to be a good procedure.
One of the issues I see from your pictures is the inner lower part of your buttocks is drooping.
I don’t know of a good medical term for this, but one of the gluteal augmentation experts in our field Dr. Constantine Mendieta has a really good YouTube video entitled the Miami thong lift.
It describes the condition and his recommended treatment option for it well.
In regards to that one area of droopiness in your lower inner buttocks recognize that grafting or other treatments are not going to work.
Getting a bigger bottom is really only possible with grafting, fat or using implants and I pretty much recommend avoiding implants.
As I mentioned, fat grafting, probably isn’t a viable option unless you’re OK with having a very modest improvement after liposuction of your entire body.
I really do not recommend gaining weight for the purpose of having fat transfer.
Stay fit and enjoy the athletic party that you have and don’t worry too much about small imperfections.
I would be careful and reluctant for surgeons who are enthusiastic or claim they can give you significant improvements.
Before contemplating any surgical intervention, you should ask providers to open up their portfolio and show you their entire collection of before, and after pictures of previous patients who had similar body characteristics to your own.
Bring Pictures of yourself to use as a reference during the consultation.
Highly experienced plastic surgeons should’ve access to 100s of before, and after pictures to choose from.
A lack of before and after pictures is a big red flag to keep moving.
As I mentioned previously, my best recommendation would be reassurance and not do surgery.
Best,
Mats Hagstrom MD

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