Aesth. Plast. Surg.
30:98 103, 2006
DOI: 10.1007/s00266-005-0098-9
Innovative Techniques
Hip and Buttock Implants to Enhance the Feminine Contour for Patients
with HIV
J. Benito-Ruiz, M.D., Ph.D.,1 J. Fontdevila, M.D.,1 M. Manzano, M.D.,2 and J.M. Serra-Renom, M.D., Ph.D.1
1
Department of Plastic Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
2
Private practice
Abstract. The antiretroviral therapy for patients with hu-
man immunodeficiency virus (HIV) causes lipodystrophy,
or a change in the distribution of body. Treatment for the
facial changes is well addressed and covered in the recent
literature, but female patients also report changes in their
buttocks and lower limbs. There is no treatment for the
lower limb deformity, but plastic surgeons can do some-
thing for the buttock. The authors propose a classification
for the deformities of these patients and a new solution to
improve the contour of this area and to reduce the social
impact of deformity on women with HIV. This consists of
placing two silicone implants, in the buttock and on the hip,
to give a rounder appearance. The authors think that hip
implants may be indicated also for gender reassignment
surgery and for women with masculine features.
Key words: Buttock implants—Hip implants—HIV—Lip-
odystrophy
Since the introduction of the highly active antiretro-
viral therapy for human immunodeficiency virus
(HIV) infection in 1996, a range of adverse effects
collectively termed ‘‘lipodystrophy’’ have been de-
scribed, including metabolic (dyslipidemia, insulin
resistance) and physical alterations [2,9]. These can be
divided into central adiposity and peripherical atro-
phy. The atrophy is especially visible in the face and
in the lower extremities, where it is characterized by
thin legs with very noticeable veins and buttock
flatness. Although several pathogenic hypotheses
Correspondence to J. Benito-Ruiz M.D., Ph.D. Depart-
ment of Plastic Surgery, Hospital Clinic, c/Villarroel 170,
08036, Barcelona, Spain; email: benito@clinic.ub.es
have been proposed, none is wholly able to explain
the syndrome [1]. Therefore, until currently, no etio-
logic treatment has been available. Consequently, our
efforts have focused on palliative treatments for the
physical changes.
Currently, a wide variety of procedures are avail-
able for facial atrophy treatment, including the use of
autologous [4,5] or synthetic materials [6,7]. For the
buttocks, the reported experience with gluteal im-
plants is limited [3]. Men can compensate for the lack
of fatty tissue by hypertrophying the muscle, but in
women, this might produce a masculine appearance.
Buttock implants alone are not able to provide the
typical rounded contour of the feminine hips, so we
devised a method to enhance both the front and the
profile contours.
Technique
All markings and designs are made with the patient
upright (Fig. 1A). All the operations were performed
by the first author.
The technique for buttock enhancement is the same
as that described by Vergara and Marcos [8]. A 5-cm
incision is made in the coxis sacrum area 2 cm cra-
nially to the anus. A subcutaneous dissection is per-
formed until the muscle is reached. A tunnel is made
through the muscular fibers following the slope of the
bone. When we feel we have reached a depth of
approximately 3 cm within the muscle, we create the
pocket bounded by a line joining the coxis with the
hip, the iliac crest, and the lateral edge of the gluteus
muscle. The pocket is therefore intramuscular. The
implant is placed, and the wound is closed in layers.
We do not leave any drainage.
J. Benito-Ruiz et al.
For hip implants, we center the pocket on the great
trochanter. Before the operation is started, the
markings have to be redrawn because they become
higher with the patient in the prone position. A 4-cm
incision is made on the edge of the iliac crest, pos-
terior to the anterior iliac spine and at the level of the
tensor fascia lata muscle (Fig. 1B and C). The fascia
of this muscle is identified and sectioned. Dissection
follows downward under the fascia, and the pocket
for the implant is created just over the hip joint
99
Fig. 1. (A) Markings in a typical
case. The pocket for the hip im-
plant is centered over the major
throchanter. (B) The incision is
at the level of the iliac crest, just
behind the anterior iliac spine.
(C) The 100-ml oval implant is
ready to be placed.
Fig. 2. Drawings showing the
procedure. S, skin incision; F,
fascial incision; T, tunnel under
the fascia; IMP, implant on the
trochanter
(Fig. 2). Great care must be taken not to connect the
buttock pocket with the throchanteric pocket. The
implant is placed under the fascia of the tensor
muscle. The wound is closed in layers.
In all cases, we also use liposuction in the lumbar
area and at the bottom edge of the buttock (banana
fold) to enhance the projection of the buttock. In
48 h, the patient can sit. The patient must wear a
compressive girdle for 1 month and refrain from
physical activities (exercise) for 5 weeks.
100 Hip and Buttock Implants

Fig. 3. Mild case. Note that the

buttock is flattened, but its pro-
jection is more or less the same
as that of the sacrum. Postoper-
ative result 4 months after
placement of 250-ml round im-
plants for the buttocks and 100-
ml oval implants for the hips.

Fig. 4. Moderate case. The pro-

jection of the buttock is less than
that of the sacrum. Postoperative
result 4 months after placement
of 250-ml round implants for the
buttocks and 100-ml oval im-
plants for the hips. The left side
has slipped slightly upward, but
the patient is not concerned, and
she has not requested a touch-
up.

Results for both buttocks and hips. All the patients were
women with HIV lipodystrophy. Round implants of
We have managed three cases with buttock 240 to 300 g were implanted for buttock augmenta-
enhancement only, and five cases with enhancement tion in all cases (Figs. 3 6), but one case of severe
J. Benito-Ruiz et al. 101

Fig. 5. Moderate case. Postoperative result 2

months after placement of 250-ml round im-
plants for the buttocks and 100-ml oval im-
plants for the hips.

Fig. 6. Severe deformity. Post-

operative result 4 months after
placement of 250-ml round im-
plants for the buttocks and 100-
ml oval implants for the hips.
102
lypodystrophy required the use of 240-ml oval im-
plants (Fig. 7).
For hips, we used 100-ml oval implants in all cases.
In one case, the hip implant slipped into the buttock
pocket. The patient underwent surgery again, and we
discovered a connection between the buttock and hip.
The implant was positioned on the fascia latae, and
the connection was closed. A capsular contracture of
the implant developed on this side.
The longest follow-up period for our patients has
been 6 months. In one case, one of the hip implants
became slightly displaced. No limitation in ambula-
tion or sitting developed in any case.
Discussion
Female patients with HIV lipodystrophy report a
lack of buttocks projection, causing problems with
clothing and social activities because these patients
prefer not to show this area in any circumstance. The
typical deformity includes an excess of fat in the
lumbar area, flatness of the buttock and hip areas,
and ptosis of the fold. The severity of the deformity
depends on the degree of fat atrophy. We propose a
classification adapted for these patients:
Hip and Buttock Implants
Fig. 7. Severe deformity. Skeletonization and
severe ptosis of the skin. Postoperative result 6
months after placement of 240-ml oval implants
for the buttocks and 100-ml oval implants for
the hips.
 Mild: The profile shows a flattening of the buttock,
with its projection at the level of the sacrum (Fig. 3).
 Moderate: The projection of the buttock is less than
that of the sacrum, and a slight ptosis appears
(Figs. 4 and 5).
 Severe: There is complete atrophy of the fat, with
skeletonization and the appearance of furrows in the
bottom of the buttock, as shown in Figs. 6 and 7.
We cannot solve the problem of fat atrophy in the
limbs, but we can do something for the buttocks.
Buttock implants fill in the upper two-thirds of the
buttock. Implants (Polytech-Silimed, Dieburg, Ger-
many) are chosen depending on the shape and vol-
ume of the buttock. Round implants are preferred for
mild and moderate degrees of lipodystrophy. We
think that oval implants are more suitable for severe
cases because they have less projection (2 cm),
giving a more natural contour than the Robles im-
plants, which are round with an average projection of
3 cm. The round implant can result in an unnatural
transition between the implant and the lower third.
Moreover, the HIV deformity gives the illusion of a
long buttock, so the oval implants are best suited for
these severe deformities. We combine the implant
with liposuction to the lumbar area and the lower
J. Benito-Ruiz et al.
edge of the buttock (banana fold). In some cases, we
fill in the transitional area between the middle and
lower third of the buttock with fat micrografting.
The antiretroviral treatment produces some chan-
ges in the body fat distribution, resulting in some
deformities that are difficult to treat. We realized that
despite the improvement of the buttock area, the
patients have complained that they were not able to
fill the hip area when dressed up. Silicone implants
give more projection in this area and provide a lateral
curvilinear contour. There are no specific implants
for this area, but the gluteal oval implant works well
for this purpose. The implant must be strictly under
the fascia of the tensor fascia latae muscle to avoid
visualization of the edges of the implant. Subcuta-
neous positioning gives worse results, with visuali-
zation of the edges of the implant and encapsulation
(as happened in one of our cases). Extreme care in
creating the pocket is necessary to avoid connecting
the space under the fascia lata and that under the
gluteus maximus muscle.
We realize that the results cannot be perfect,
especially in severe cases, and we are working to
improve the results. However, the patients feel satis-
fied because they are able to wear clothes as before
development of the disease.
Conclusion
To our knowledge, the use of silicone implants in the
hip area to enhance or achieve a more feminine
contour has not been described. We propose a new
technique to achieve this for these difficult HIV pa-
103
tients, and we believe that this technique also may be
indicated for gender reassignment patients and for
female patients with masculine features.
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