Original Article By Jolene Edgar.

The so-called “year of the rear” has spanned nearly half a decade now, and while the galvanizing force behind it is debatable (belfies? twerking?), one thing is clear: our pygophilia is not a passing fad, but a bona fide fact.

Exhibit A? The meteoric rise of the Brazilian Butt Lift (BBL), a two-part surgery featuring liposuction and fat grafting, intended to augment one’s gluteus to the max. According to the American Society of Plastic Surgeons (ASPS), the number of BBLs logged by its members has more than doubled in the last five years, making it one of the fastest-growing plastic surgery procedures. The phenomenon—spectacle and science in equal measure—recently inspired a study (exhibit B, if you will) published in the journal Plastic and Reconstructive Surgery, aiming to pinpoint the precise characteristics of an attractive posterior. Through a population analysis of 989 respondents (48.7 percent women, 51.3 percent men), researchers discovered new ideal waist-to-hip ratios more dramatic than those previously reported, heralding “an important preference paradigm shift” in the proportions of the butt—one that plays to the BBL’s strengths.

See, unlike most modern cosmetic tweaks, the BBL doesn’t strive for no-one-will-know subtlety, but rather a swift and striking change in the size and shape of the derrière. “It does a great job of rounding out the buttocks and bringing in the waist to create an exaggerated hourglass effect,” says Newport Beach, CA plastic surgeon Matthew J. Nykiel, MD. And while curvy celebrities plainly fuel the trend, some experts believe the scope of the movement to be more seismic. “This isn’t about Kim Kardashian or J.Lo,” says Boston plastic surgeon Daniel Del Vecchio, MD. “It has to do with the buttocks long being a symbol of social standing, youth, fertility, and sexual authority. This is a global boom, and it’s just beginning to take off.”

As demand for the BBL continues to mount, however, so does uncertainty surrounding its safety. Shouldering an alarmingly high fatality rate of one in 3,000 and a string of recent casualties resulting from pulmonary fat emboli (which cut off blood flow to the lungs), the procedure prompted an urgent warning this past summer from the MultiSociety Task Force for Safety in Gluteal Fat Grafting, an international group of doctors from five plastic surgery societies charged with investigating BBL complications and sponsoring safety research. Last October, following the deaths of two British women who sought BBLs abroad, the British Association of Aesthetic Plastic Surgeons called a moratorium on the procedure in the UK, pending more data. While studies are currently underway, the task force has firmly declared that harvested fat should only ever be injected into the subcutaneous tissue, or superficial fat layer, of the bottom—never into or below the muscle, as invading this zone risks nicking gluteal veins, and opening a siphonic portal to the heart and lungs for any fat globules in the area. “These emboli are not like ordinary clots, which can be dissolved with drugs—there is no pharmacologic treatment for them,” explains Eugene, OR plastic surgeon Mark Jewell, MD. “When fat gets into the lungs, patients suffer a loss of pulmonary function. It’s a God-awful problem, and those who are lucky enough to survive it almost always have ongoing lung issues.”

Taking the muscle out of play “is absolutely necessary, as it maximizes safety,” says New York plastic surgeon Adam Kolker, MD, “but it does limit the size increase we can achieve during a single procedure.” The reason is twofold: meager surface area and poor blood supply. The tight pocket between the skin and the muscle can hold only so much new fat, he explains, and the tissue that lives there isn’t as vascular as the muscle itself, so grafts may struggle to bloom in this less-nourishing environment. Still, “there’s no justification for injecting fat into the muscle,” adds Dr. Jewell. “Surgeons want to please their patients, but pushing the envelope with fat grafting can create irreversible problems,” including some still unforeseen.

“While a patient’s own fat appears to be the best material for buttock augmentation, long-term outcomes with this technique have not been studied, especially the effects of weight gain and hormone replacement treatments,” says Dr. Jewell. “Patients who have BBLs could find themselves with enormous growth of the gluteal area during the perimenopausal years or later.”

Since the task force advisory last July, “many plastic surgeons have been scrambling for competitive BBL alternatives,” says Toronto plastic surgeon Stephen Mulholland, MD. The best options surmised thus far, he adds, deliver “more modest and gradual results than a surgical BBL—perhaps 50 percent of the payoff if you’re lucky—but they’re still far safer.” Another plus, the latest glute-enhancers carry little to no downtime (unlike the BBL, which bans sitting for four to six weeks), and can be combined to customize the effect. Here, let us explain…

“While the traditional BBL is still the gold standard of butt augmentation, I’ve seen quite a few cottage cheese–like results from fat that has not been distributed evenly,” says Beverly Hills, CA dermatologist Sameer Bashey, MD. Contour irregularities are not uncommon, as generally “only about half of grafted fat survives,” he adds, and there’s no way to ensure it takes uniformly. Sculptra Aesthetic, on the other hand, is praised for its ability to enhance the topography of the region by “stimulating collagen production to improve elasticity and the overall quality of the skin,” says New York dermatologist Neil Sadick, MD. The filler is made from poly-l-lactic acid, the same material composing absorbable sutures. Though its use on the body is considered off-label, its “safety and efficacy [for the face] have been established in numerous clinical trials” since it arrived on the scene in 1999, Dr. Sadick notes, “and it’s a great option for anyone seeking lift, projection, natural contour, and smoothness without surgery or downtime.”

Doctors dilute the drug significantly with sterile water, encouraging a good amount of spread, and slashing the likelihood of lumps. The water gives an instant but fleeting boost, which dwindles within a week. It then takes the particles of poly-l-lactic acid within the suspension six to 12 weeks to construct the scaffolding needed to grow new collagen in the area. “We’re essentially putting in a foreign body, which triggers fibroblasts to build collagen around it,” explains New York dermatologist Estee Williams, MD. While patients may notice some degree of change at the six-week mark, full effects take six months to show.

“Most people need three treatments, four to eight weeks apart,” Dr. Sadick says. While a subtle shaping may require five to 10 vials per visit (at roughly $1,000 a vial), injectors sometimes push up to 60 vials at a time if chasing a more voluptuous goal. Doctors can also use Sculptra Aesthetic to fine-tune key aspects of the anatomy, perking up just the tops of the cheeks, say, or fleshing out pronounced hip dips. Shifts in size can be hard to predict, but “we can usually achieve a 20 to 50 percent increase, depending on how much we inject, the number of sessions and how vigorously the patient responds to the drug,” says Dr. Bashey. Complications from Sculptra Aesthetic are rare, he notes, because it is so heavily diluted (and, thus, lacks clogging capacity), and it’s typically injected with shallow-reaching needles, which keep a safe distance from vulnerable vessels.

Still, some experts worry that Sculptra Aesthetic’s favorable track record for the face may give injectors a false sense of security when using it on the body. In reality, there’s very little published evidence supporting its use in the butt, particularly at such high doses. We also spoke to doctors who advise against using synthetic filler of any kind in the tush, citing a long history of disastrous consequences. As Dr. Jewell stresses, “The clinical outcomes from off-label use of synthetic tissue fillers for buttock augmentation have simply never been studied with regards to long-term aesthetics, safety or patient satisfaction.”

Since winning FDA-clearance for strengthening, toning and firming the abdomen and butt, Emsculpt has mastered the Insta takeover, filling our feeds with Boomerangs of undulating bodies and posts of pros touting its benefits. Using high-intensity focused electromagnetic energy, the device is said to activate 20,000 contractions in a 30-minute span, working our muscles more wholly and intensively than we, as mere mortals, are physiologically capable of doing on our own. (It’s a pain-free experience, both during and after, but seeing your muscles move independently can be oddly unsettling.) “The contractions thicken and strengthen existing muscle fibers, as well as build new fibers, to increase muscle mass by 16 percent after four treatments,” says New York dermatologist Bruce Katz, MD.

Like most of-the-moment body-contouring tools, Emsculpt is also engineered to whittle fat, but only in select situations. There are two distinct protocols: one for the stomach, another for the butt. The ab-targeting program includes “a series of ultra-long stimulations that cause the muscle to ripple and fibrillate in a way that promotes fat burning,” says Beverly Hills, CA plastic surgeon Brian Kinney, MD, lead researcher on the Emsculpt trials. The butt protocol truncates those prolonged contractions, “leading to minimal fat loss while sustaining the muscle effects,” Kinney adds, supposedly preserving precious padding in the rear while bulking up glutes for a pert booty that “feels firm when contracted and soft when relaxed.” In a company-funded, multi-center study, 85 percent of subjects who were initially unhappy with the appearance of their bums reported significant improvement following the fourth treatment, and were still satisfied one month later.

Chicago dermatologist Carolyn Jacob, MD, co-author of the aforementioned study, says the greatest change in volume is generally seen in the upper portion of the butt—it gets rounder and firmer, pulling up the crease where butt meets thigh to give people the lift they’re looking for. “Results can be seen after three or four treatments, spaced over two weeks,” she adds, and further improve for up to six months following as the muscles continue to get stronger. (Evidence of sustained results at six months and one year is currently being reviewed for publication in a peer-reviewed journal.)

While some dermatologists question the machine’s efficacy and staying power (as the tech is still very new and the data is limited), others are cautiously enthusiastic. “It’ll be interesting to see, once the early excitement dies down, which patients keep coming in for it,” says New York dermatologist Heidi Waldorf, MD. (Ballpark per session is $1,000, and maintaining longterm results requires touch-ups beyond the initial four-pack.) “I did my research; I didn’t rush in. But I knew as soon as I demo’d it that I wanted this machine, even if only for my personal use, because I think what it can do for core strength is exciting. And yeah, it would be nice to have a toned butt, too.” On the horizon: Aesthetics giant Allergan is said to be developing its own muscle-conditioning technology to augment its popular fat-freezing CoolSculpting device, which it expects to launch within the next three years.

Wary not only of the BBL’s checkered past, but of how such bloated bottoms will fare in the future, Santa Monica, CA dermatologist Karyn Grossman, MD steers patients away from surgery, recommending instead radiofrequency (RF) treatments, like Thermage. “RF is not going to add fullness,” she stresses, “but it can give a more toned, youthful-looking butt in the short-term while slowing down the aging process over time.”

By deep-heating both the skin and the septa—the bands of connective tissue running through the fat layer, which attach the skin to underlying structures—RF boosts collagen throughout to tighten everything up. “As the lower half of the butt raises up, you get more projection on top,” Dr. Grossman says, adding that most patients can score this low-key lift in one or two appointments ($3,500 each). “But if you’re not seeing much improvement at that point, it’s probably not going to give you what you want.”

Not on its own, anyway, but RF can help take other treatments to the next level. New York dermatologist Dendy Engelman, MD says she often combines “Emsculpt for heavy lifting of the muscle with radio frequency for an airbrushing of the skin.” Dr. Mulholland relies on RF to bolster the butt-elevating effects of thread lifts and injections, explaining that “if the overall shape of the bum is good, but it’s just starting to sag a bit, then dissolvable polydioxanone (PDO) threads paired with Sculptra Aesthetic, Emsculpt and a RF-based heating regimen can work together to safely lift and support the skin.” The use of threads on the body is largely unproven, we should note, and Dr. Mullholland offers this additional caveat: “PDO threads are not very resilient and usually take six weeks to recruit new collagen and develop the tensile strength needed to resist everyday pressures.” Sitting, lying on your backside, or exercising before that time can cause threads to snap, sabotaging your results. (For a more in-depth look at thread lifts, click here.)

We say “implant,” you say… probably not “butt.” We get it: The association is pretty flimsy, as “butt implants have never really been more than a fringe procedure,” says New York plastic surgeon David Shafer, MD. Only about 1,300 operations were performed in 2017—that’s 56 percent fewer than the previous year, according to data from ASPS. Dr. Nykiel, for instance, performs only a couple of butt-implant augmentations each month compared to six-plus BBLs weekly. But given the limitations of the modern BBL, could silicone butt implants perhaps become more of a contender? “If you weigh all of the risks and benefits, implants can still be a good long-term shaping option for certain people,” says Dr. Mulholland—particularly very thin patients, with a BMI less than 20, who lack the fat needed for a BBL, and those wanting a truly bubble-esque backside. Because barring multiple rounds of fat grafting, says Dr. Nykiel, nothing gives more oomph than implants: “Fat is soft and fluffy, and can push the butt out only so much,” he explains. “It can’t create the same degree of projection as a firm, structural implant.” Implants come with their own set of drawbacks, however: The surgery is more invasive than a BBL (implants are generally inserted directly into the gluteal muscle), scarring is inevitable and patients can’t sit on their bottoms for two weeks post-op. “Gluteal implants also carry a very high incidence of complications,” notes Dr. Jewell, with studies estimating rates upwards of 38 percent. The main risks include infection, rotation, capsular contracture (the formation of a hard sheath of scar tissue around the implant), and extrusion (a concern primarily with too-large implants). And then there’s the matter of comfort: “Imagine having a thick wallet tucked in your back pocket and sitting on it all day,” says Dr. Shafer. Still, some believe butt implants are ripe for evolution. “I think we’ll soon see a push from manufacturers to come up with an implant that makes sense—something durable and safe that actually feels like a bum,” says Dr. Mulholland. Until then, though, review the pros and cons of every potential procedure with a board-certified plastic surgeon, and be sure to prioritize safety over size.

Emsculpt Alternative Fort Lauderdale