Welcome back to our series on gender affirming surgeries and procedures. We started with prepping for bottom surgeries and will end with office visit procedures such as fillers and botox. Last week we talked about surgery for a flatter chest, and today we’re talking about adding some oomph to butts, hips, and pecs using implants. Make way for the booty train!
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
The What:
Much like breast augmentation, the enhancement of butts, hips, and pecs uses silicone implants. Fat transfer and liposuction may be used alone or in addition to implants for contouring and volume.
Behold the Booty: Buttock Implants
Gluteal augmentation with silicone implants was first performed in the late 1960s. In the United States, the implants used are somewhat firmer than those available internationally. Like breast implants, they are available in round or shaped forms and with smooth or textured surfaces.
Did you know that cultural studies on the proportions of the ideal booty have been researched and published? (Rosique) Your aesthetic goal for your waist, hips, and butt is all you, and we support your body autonomy. Your plastic surgeon has some tools to help pick the size and shape of implants to achieve your goals, whether to achieve a specific waist-to-hip ratio, fill in a dip, or have the bubble you’ve always wanted…
Your surgeon will want to know:
- the angle that you want the top curve of your booty to form
- how far you’d like your booty to pop (projection)
- at what height level of your pelvis you’d like the most volume
- the shape and length of your infragluteal fold (where your butt meets the top of your thighs)
They will then suggest the implant size and shape that they believe will be the most successful in getting you your most bodacious bum. They’ll also discuss where they will place the implant, and if they recommend additional procedures. Liposuction and fat transfer are frequently used for body contouring during buttock augmentation surgery. Other procedures commonly done include lifts and changing the infragluteal fold length.
The current trend is towards more fat grafting and less implant use, as fat grafting, when carefully applied, is seen as less likely to have complications. The history of butt augmentation, especially in gender diverse populations, has, unfortunately, seen significant risk. The “BBL” or Brazilian Butt Lift involved high-volume fat grafting, which could be extremely dangerous. Improvements in the field, including refinements in grafting technique and limitations on the volume of fat transferred, have improved patient safety.
Pumping
Pumping, or injection of free silicon, is an option for reshaping your body. It can create fullness and curves. It is often very cost-effective as it is not provided in medical facilities. Medical providers do not offer this option due to both short and long-term potential health consequences. We recommend you speak with a knowledgeable healthcare professional prior to participating in a pumping procedure. This way, you can weigh the potential benefits and risks and make an informed decision about what works for you. Check out our Express Yourself: Tips and Tools for Gettin’ Curvy Without A Prescription and Gettin’ Curvy: Workouts for Flexibility, Strength, and BOOTY blogs for additional ways to emphasize a curvy figure.
How Do Surgeons Choose An Implant?
Which shape implant?
Your surgeon will consider your buttock length – that’s mostly dependent on your pelvic structure and how “tall” your pelvis is. Oval implants are best suited for long buttocks, while round implants are better suited for short buttocks.
Where’s the implant pocket?
Your body type will help determine where the implant is placed. You may hear the following terms:
- submuscular – under the muscle
- subfascial – under the fascia, which is a layer of connective tissue that surrounds muscles and organs
- intramuscular – inside the muscle
- dual-plane – both submuscular and intramuscular (Aslani)
If you are slimmer-figured, your surgeon will likely recommend placing the implant in or under your gluteal muscles, as you probably have less tissue over the muscle, which means that the implant may be more easily seen or felt.
There are pros and cons to each placement. A deeper implant is less likely to be seen or felt, but is more likely to approach the sciatic nerve, raising the risk of sciatica. Sciatica is a pain in the ass (and leg!)
Intramuscular implants (implant is placed under or inbetween muscle layers):
- harder to feel and see the edges
- the implant pocket is less likely to stretch over time
- may provide less fullness in the lower butt
- are closer to the sciatic nerve, and could trigger nerve pain
Subfascial implants (implant is placed over the muscle, but under the tough tissue that surrounds the muscle and):
- edges may be easier to see and feel
- less complicated surgery
- more all-over oomph
- the implant pocket is more likely to stretch
- higher risk of implant moving
Submuscular (implant is placed under the gluteus maximus muscle)
- least risk of implant being seen or felt
- allows for a more natural slope to the upper buttock
- not appropriate for individuals with a wide or short pelvis
Dual-plane (submuscular at the top, intramuscular at the bottom)
- good coverage for identifying edges
- less risk of implant moving
Many surgeons prefer placing the main incision at the top of the buttock crease, either vertically or angled. (Drawing is approximate)
Prep and Recovery for Glute Implants
Preparation will include a consultation with your surgeon, blood tests, and a physical exam. If you are a smoker, you will be asked to stop prior to surgery and for a period of time after surgery. You may need to stop other medications prior to surgery, as well. You can likely go home the same day after surgery.
Healing after glute augmentation may be difficult due to position restrictions, especially if fat transfer is part of the procedure: very limited sitting for up to three weeks. You may be able to sit using a cushion that keeps pressure off of any areas with fat transfer. You will also need to wear compression garments for up to several weeks. You may have exercise and activity restrictions for several weeks.
Hip AF
Hip augmentation adds fullness to the sides of the pelvis and upper thigh. Hip augmentation may be done with fat transfer, silicone implants, or a combination of both. When implants are used, they are custom-made for each individual.
Implants are generally placed in a subfascial pocket over the thigh muscle. You may have heard about pelvic-plasty, which is a titanium implant attached to the iliac crests of the pelvis. This is a new procedure developed in South Korea. There isn’t much data on it and very few first-person reports, so all we’re comfortable saying is “stay tuned!”
Hip augmentation is an outpatient procedure, with most patients going home the same day. Recovery includes
- time off from work may be as little as one week
- no baths, swimming, or hot tub/jacuzzi soaks for three weeks
- sleep on stomach or back for three weeks
- compression garments for up to six weeks
- restricted exercise for six to eight weeks
Post Your Pecs
Pec (pectoral) implants were first developed in the 1980s and have become increasingly popular ever since. As with other enhancement surgeries, pec augmentation may be done with an implant, liposuction and fat transfer, or through a combination of both methods. Implants are silicone, and may be custom made.
At consultation, your surgeon will measure your pectoral muscle. A discussion of desired look and shape combined with your current size and shape will help decide what implants are best suited to your goals.
During surgery, the incision will be made in the armpit in an existing skin fold, and will be about 2″ long. The placement is submuscular. The pocket for the implant will be slightly smaller than the implant.
Surgery is usually outpatient. Compression garments will be worn for about a month. Lifting and exercise restrictions will be strongest for the first month and then gradually lessen.
Our blog Building a Broader Physique: Exercises For Angles can help strengthen your upper chest musculature in preparation for pec implants.
The How: Surgeon and Insurance Requirements
Until very recently, these procedures have been considered “cosmetic,” and coverage would likely be denied by most insurance plans. WPATH issued SOC8 (Standards of Care) in September, 2022 with the inclusion of gluteal, hip, pectoral, and calf implants in their list of gender affirming surgeries. The result is that, as of 2023, more insurance policies will cover these surgeries when they are deemed to be “medically necessary.” They will most likely need prior authorization.
The paperwork to have a procedure approved as medically necessary may, of course, be difficult. For this, we recommend reviewing your insurance coverage documents to learn what their prior authorization and coverage requirements are. Prior authorizations are submitted by your hormone prescriber or surgeon and typically include a narrative describing why the desired procedure is necessary and providing supportive guidelines and medical literature.
You will likely need one or more letters from a mental health provider and one from your hormone provider for both insurance and your surgeon with information about your experience of dysphoria, if you are taking hormones, and your ability to understand the risks and benefits of your treatment choices.
Pre-op, you will have a consultation, a physical exam, and blood tests. If you smoke, you will need to stop, and if you have diabetes, your blood sugars will need to be well-controlled. You may need to stop other medications such as blood thinners for a short time prior to surgery. Your surgeon may want to know your housing and support plans for after surgery. You’ll need to arrange transportation home from surgery.
The Who: Finding a Surgeon
There are a great many plastic surgeons to choose from. As surgical technique can be both subtly and significantly different for transgender patients, and affirming medical teams can greatly impact your experience and healing, you are likely to have a better experience with surgeons who have experience working with transgender patients.
Surgeons who specialize in genital surgeries might not provide these procedures, so you may need to look in other places. However, they may work in institutions or clinics that also offer non-genital procedures.
- talk to others in the community
- gender care centers at academic institutions such as OSHU, UCSF, UW
- well-known private practices such as Align Surgical,
- FTMSurgery.net
- MTFSurgery.net
- TransHealthCare.org
- findplasticsurgery.org
- aedit.com
- WPATH Provider Directory
- OutCare Health
- The r/TransSurgeries wiki on Reddit
Accessed Articles
- Senderoff DM. Aesthetic Surgery of the Buttocks Using Implants: Practice-Based Recommendations. Aesthet Surg J. 2016 May;36(5):559-76. doi: 10.1093/asj/sjv251. PMID: 27069241.
- Aslani, Alexander MD1; del Vecchio, Daniel MD2; Bravo, Miguel G. MD1; Zholtikov, Vitaly MD3; Palhazi, Peter MD, PhD4. The Dual-Plane Gluteal Augmentation: An Anatomical Demonstration of a New Pocket Design. Plastic and Reconstructive Surgery 151(1):p 45-50, January 2023. | DOI: 10.1097/PRS.0000000000009790
- Rosique, Rodrigo G. M.D., Ph.D.; Rosique, Marina J. F. M.D., Ph.D.. Augmentation Gluteoplasty: A Brazilian Perspective. Plastic and Reconstructive Surgery 142(4):p 910-919, October 2018. | DOI: 10.1097/PRS.0000000000004809
- Ogley SC, DJohn J, Goldman JJ. Pectoral Implants. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562323/
- del Vecchio, D. , Bravo, M. , Mandlik, V. & Aslani, A. (2022). Body Feminization Combining Large-Volume Fat Grafting and Gluteal Implants. Plastic and Reconstructive Surgery, 149 (5), 1197-1203. doi: 10.1097/PRS.0000000000009049.
- Clinical Anatomy in Aesthetic Gluteal Contouring, Robert F. Centeno MD, MBA, Aditya Sood MD, MBA and Vernon Leroy Young MD. Clinics in Plastic Surgery, 2018-04-01, Volume 45, Issue 2, Pages 145-157.
- Submuscular Gluteal Augmentation, Jorge E. Hidalgo MD, Clinics in Plastic Surgery, 2018-04-01, Volume 45, Issue 2, Pages 197-202.
- Intramuscular Gluteal Augmentation, Raul Gonzalez M, Ricardo Gonzalez MD, Clinics in Plastic Surgery, 2018-04-01, Volume 45, Issue 2, Pages 217-223.
- Subfascial Gluteal Implant Augmentation RSS Download PDF
- Jose Abel de la Peña Salcedo MD, FACS
- , Guillermo J. Gallardo MD
- and Guillermo Ernesto Alvarenga MD
- Clinics in Plastic Surgery, 2018-04-01, Volume 45, Issue 2, Pages 225-236
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