**4. Candidates for gluteal enhancements**

 As patients age, the buttock undergoes changing due to multiple factors including generics, gravity, weight gain and weight loss. The vast majority of patients experience fat hypertrophy in the peri-gluteal areas and a flattened buttock shape. One of the most important things for a surgeon is to categorize the patient based on their buttock shape. There are four major shapes identified. The "A" shape which the most desired shape as it typically follows the 0.7 waist-to-hip ratio. The "square" shape which is very common seen in those patients with excess waist circumference from increased adipose tissue around the waist and lower back region. The "O" shape is usually made up by a full and round buttock. Finally, the "V" shape buttock is often seen in the massive weight loss patient or in patients who have an atrophic buttock with excess fat adiposity in the "love handle" area (**Figure 4**). Another

#### **Figure 14.**

*A square buttock is very common and often is marked by a distinct inferior oblique groove that is observed in the lower pole and close to the medial third as shown There is usually excess fat on either side of the oblique groove. The square shape is mostly created from excess hip or flank fat.* 

#### **Figure 15.**

*Fat grafting should not be limited to the central buttock for best results. As shown, fat can be added to the oblique groove if present, posterior as well as lateral buttock and greater trochanter depression. Occasionally, fat may need to be blended even further down the patient's thigh.* 

remarkable finding is the inferior oblique gluteal crease that is most prominently seen in the "square" buttock (**Figure 14**). It is an oblique groove that is observed in the lower pole and close to the medial third. There is usually excess fat on either side of the oblique groove (**Figure 15**).

There are certain changes that take place in the gluteal and peri-gluteal region that take place over time which begin to change the buttock shape into a less ideal one. One of them is the loss of the inward curves at the level of the waist and also the inward sweep in the mid-line of the lower back (lumbosacral area). Another unaesthetic change of the aging buttock is the elongation of the infragluteal crease. One of the

#### *The Art of Body Contouring*

 most aesthetic of a buttock is the "lifted" look which is why most buttocks that are considered attractive have their most prominent part in the upper to middle third. However, with aging and changes in weight, the buttock may become ptotic with most of its projection in the lower third and likely overhanging over the infragluteal crease.
