ORIGINAL ARTICLE Cosmetic Gluteal Augmentation with Polymethyl Methacrylate: A 10-year Cohort Study Roberto Chacur, MD* Honório Sampaio Menezes, MD, Background: Many techniques for buttocks augmentation have been developed PhD† and published, for a more natural, satisfactory, and safe result for the patient. It Nívea Maria Bordin da Silva Cha- has been a challenge to find a technique that presented not only volume gain but 06/09/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3z4CBEZThIGxYCbmdFRNDJym7PMeS+Klc5g5ZXenjw/E= by https://journals.lww.com/prsgo from Downloaded cur, MD* also gluteal remodeling. Danuza Dias Alves, MD‡ Methods: A total of 1,681 patients who underwent gluteal augmentation with Polymeth- Downloaded Rodrigo Cadore Mafaldo, MD‡ yl methacrylate (PMMA) between 2009 and 2018 were selected for this retrospective co- Leandro Dias Gomes, MD‡ hort study. Data collected included demographics, procedures data, and postoperative from Gisele dos Santos Barreto, BSc‡ outcomes. Side effects were calculated and compared using the Student’s t test. https://journals.lww.com/prsgo Results: A total of 1,681 patients (1,583 women and 98 men) who underwent 2,770 gluteal fillings had their cases retrospectively analyzed. They were injected with 540,751.00 mL of PMMA injected. The patients’ mean age was 39 years, and the mean volume injected in each section was 237 mL during the first procedure and 147 mL during the second procedure. The authors observed 52 cases presenting by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3z4CBEZThIGxYCbmdFRNDJym7PMeS+Klc5g5ZXenjw/E= side effects, representing a rate of 1.88% of 2,770 procedures carried out. The statistically significant P( = 0.02) presence of side effects was detected in relation to the total filling volume. Conclusions: This study has demonstrated that gluteal augmentation with PMMA is one of the best options for this type of procedure. In addition, the findings suggest that the guidelines concerning gluteal augmentation must include PMMA filler as an option because PMMA proved to cause few side effects, as demonstrated by this patient cohort. (Plast Reconstr Surg Glob Open 2019;7:e2193; doi: 10.1097/ GOX.0000000000002193; Published online 31 May 2019.) INTRODUCTION satisfaction was high, as was in the study conducted by Plastic surgery for improving body contour of the glu- Gonzáles-Ulloa,6 who noted a considerable improvement teal region has been increasingly sought-after. Badin and in the postoperative period in relation to patient/surgeon Vieira1 have described a surgical technique for the place- satisfaction. ment of high-cohesive round silicone implants using vid- According to the study by Chacur, it is possible to aug- eo assistance. Moreover, Jaimovich et al.2 have described ment and shape the buttocks using injectable implants anchoring sutures, and Sozer et al.3 described the use of with various formulations. Fillers may be used in different musculocutaneous flap to increase the buttock in the mid- regions of the body and face, and in each region, prod- dle portion and to decrease fat necrosis. ucts with different properties may be used, such as PMMA, In an attempt to find an ideal surgical technique, Serra which is used in large muscle groups.7 et al.4 described easily identifiable anatomical landmarks Lemperle et al.8 studied the histological reaction with on 06/09/2019 that may assist the surgeon in performing gluteoplasty. several substances for filling soft tissues: collagen (Zyplast, By using a different surgical technique, Sozer et al.5 Allergan, Irvine, CA), hyaluronic acid (Restylane, Q-med, carried out a retrospective study with 10 patients who were Uppsala, Switzerland), PMMA microspheres (Artecoll, submitted to a buttock lift using the skin flap. Patient Canderm Pharma Inc., Canada), silicone oil (PMS 350, Vikomed, Germany), polylactic acid microspheres (New- From the *Leger Clinic, Rio de Janeiro, Brazil; †Leger Clinic, São Fill), dextran microspheres (Reviderm Intra, Medical In- Paulo, Brazil; and ‡Leger Clinic, Porto Alegre, Brazil. ternational, Netherlands), polymethylacrylate (Dermalive, Received for publication November 22, 2018; accepted January 30, Dermatech, Paris, France), polyacrylamide (Aquamid, 2019. Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Disclosure: The authors have no financial interest to de- Inc. on behalf of The American Society of Plastic Surgeons. This clare in relation to the content of this article. is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original Supplemental digital content is available for this ar- work is properly cited. ticle. Clickable URL citations appear in the text. DOI: 10.1097/GOX.0000000000002193 www.PRSGlobalOpen.com 1 PRS Global Open • 2019 Contura – Denmark), polyvinylhydroxide microspheres Declaration of Helsinki and its later amendments or similar suspended in acrylamide (Evolution), and calcium hy- ethical standards and approved by the ethical committee droxyapatite (FN). The host reacted differently to differ- (CAAE protocol number 86722118.8.0000.5291). Patients ent fillers; however, all substances, being resorbable or were assessed regarding demographics, procedure data, nonresorbable, appeared to be clinically and histological- and outcomes. Data were obtained by chart review. ly safe, even though all presented undesirable side effects. In this retrospective cohort study, cases of 1,681 pa- Surgical indications of reconstruction and contouring tients who underwent 2,770 gluteal augmentation with of the buttocks due to malformation, asymmetry, trauma, PMMA procedures at the Leger Clinic (in Rio de Janeiro, and radiotherapy may require corrections made by regu- São Paulo, and Porto Alegre, Brazil) from 2009 to 2018 lar implants, liposuction or lipoinjection, and skin flaps. were analyzed. Buttock implants for aesthetic purposes are widely used, There are 3 brands of PMMA allowed in Brazil re- especially in South America. Buttock implants are easy to place and present high success rate, whereas liposuction leased by ANVISA (Federal Regulation Agency in Brazil), and lipoinjection procedures require considerable experi- Biossimetric, MetaDerm (formerly Meta Crill) and Lin- ence of the surgeon in fat injection.9 nea Safe. The ANVISA releases the products for exclu- The technique of placement of intramuscular silicone sive medical use where the volume varies as required and implants provided good results, which resulted in increas- evaluation. ing number, consequently, of these procedures in Brazil. In this study, gluteal filling with PMMA (Linnea Safe However, the data available in the medical literature re- 30% or Meta Crill 30%) is performed under local anes- veal high rates of wound complications, in particular se- thesia, with the patient awake accompanying by watching romas and dehiscence. According to the study by Serra et the results through a mirror and actively participating in al.,10 the use of adhesive points and the maintenance of the decisions (see video, Supplemental Digital Content good vascularization in the sacral region are the founda- 1, which demonstrates a gluteal augmentation technique tions for reducing complications in gluteoplasty with sili- with PMMA filling, http://links.lww.com/PRSGO/B42). cone implants. The anesthetic and product infiltrations are per- According to the study by Chacur, PMMA has been formed with a 1-mm atraumatic blunt-tipped microcan- used in medicine for more than 70 years. Among its uses nula, which causes no vascular or nervous lesions in the are bone cements, contact and intraocular lenses, bone gluteal muscles and no permanent scarring. screw fixation, filling of bone cavities and defects of the PMMA procedures gluteal filling is contraindicated skull, and stabilization of vertebrae in patients with osteo- in a pregnant patient, local infection, systemic infection, porosis or fractures.7 Even though there are several new promising alloplastic materials, the versatility and reliabil- local active herpes, autoimmune disease, treatment with ity of PMMA allow it to remain a popular and frequently immunosuppression, history of keloid formation,history used material.11 of nodule formation after use of PMMA, use of anticoagu- Hilinski and Cohen12 demonstrated improved biocom- lant, in oncologic treatment and history of allergy to the patibility as a result of increased size and uniformity of components of the formula. PMMA microspheres. This enhanced biocompatibility Student’s t-test was used to verify the data obtained. results in fewer adverse events after the placement of Ar- Analysis of the recorded data took place at the Research teFill (Canderm Pharma Inc, Canada), thus providing a Unit of the clinic by using the IBM SPSS Version 22.0 (IBM permanent volume increase because the nonabsorbable microspheres stimulate the fibroblasts that synthesize and cause collagen deposition around them. A similar study was also conducted by Mcclelland et al.13 The appropriate technique includes deep subcutaneous implantation, with total correction, which is gradually achieved over several treatments. Complications are limited to the formation of nodules, which are easy to handle, and, in most cases, it can be done with conservative interventions. In a histological study, Lee et al.14 claim that the mix- ture of PMMA and cross-linked dextran in hydroxypropyl methylcellulose