307
CLINICS IN
History of Gluteal Augmentation
J. Abel de la Peña, MD, FACS*, Omar V. Rubio,
Jacobo P. Cano, MD, Mariana C. Cedillo, MD,
Miriam T. Garcés, MD
- Brief history of the ideals of female beauty
- History of gluteal augmentation
Brief history of the ideals of female beauty
The concept of female beauty has changed through-
out time, but the form and size of the breasts and
gluteal region have remained constant as symbols
of maximum femininity. In art, the origins of hu-
man aesthetics go back to antiquity. Sculptures
and prints show us feminine figures that are volu-
minous, sometimes to the point of deformity, and
reflect human history’s interest in fertility.
Among the oldest discoveries that allude to the an-
cient ideal of feminine beauty is a print found near
Oslo, Norway, that reproduces the figure of a woman
being daubed with reindeer fat (Fig. 1). Austria was
the location for discovery of the well-known Venus
of Willendorf (Fig. 2), which is perhaps one of the
first female forms to be sculpted. It is the most famous
among the Venuses of the ‘‘steatopygic’’ type, which in
Greek means ‘‘fat in the gluteal area.’’ The exaggerated
feminine shape of this figure symbolizes woman’s
force in the crucial struggle for human survival.
Found in the French Blue Coast area, the Venus of
Grimaldi (Fig. 3)—with her protuberant breasts,
prominent stomach, and plump gluteal area—is sym-
bolic of the possibility of childbearing, which guaran-
tees the continuation of future human life. In ancient
Egypt, the refinement of the aesthetic ideal for
women led to images of Nefertiti (Fig. 4), the beauti-
ful queen who gained mythic stature.
Institute for Plastic Surgery, Mexico City, Hospital Angeles de Las Lomas, Vialidad de la Barranca s/n, cons 490,
Col. Valle de las Palmas, Huixquilucan, Edo. Mex.ico C.P. 52763
* Corresponding author.
E-mail address: joseabel@avantel.net (J.A. de la Peña).
0094-1298/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 33 (2006) 307–319
MD,
- References
Ancient Greece had a different view of classical
beauty that was so powerful it has influenced later
cultures and been reflected in their artistic ideals.
The Greeks originated the concept of female aes-
thetics that spread throughout Europe (Fig. 5),
and the Greek rules of beauty did not tolerate accu-
mulation of fat in the trunk, but they did in the glu-
teal area. The Venus de Milo, discovered on the
Greek island of Melos and dating to c. 130 BC, is
the sculptural embodiment of the Greek ideal of
the female body as exemplified by the goddess of
love and beauty. In the Roman Empire, human
beauty became something of an obsession, and
pampering the body was not exclusive to the femi-
nine sex. All Romans indulged in rituals that en-
hanced their appearance and sexuality (Fig. 6).
The glorification of the human body and physical
aesthetics seem to have lost their importance in the
Middle Ages, at least in their art, probably because
of the frequent epidemics and wars that occupied
much of the world. The lack of great art is one rea-
son this centuries-long period is referred to as the
Dark Ages. But the Renaissance in Europe saw
a burst of artistic activity in understanding human
aesthetics. Beauty embraced everything, and was
embraced by everyone. The beauty of the human
form was part of the harmony of the natural world.
Standards of beauty clearly change depending
on the times, cultures, and locations. For example,
doi:10.1016/j.cps.2006.04.003
308 de la Peña et al
Fig. 1. Ancient prints show females with voluminous
buttocks and thighs and allude to an interest in fem-
inine beauty that dates from early history. The central
figure (with the necklace and bracelet) is being
daubed with reindeer fat, probably by a woman
(without jewelry) who serves her.
the small feet viewed as a characteristic of femi-
nine beauty by the Chinese did not appeal to
the eyes of an African. Instead, steatopygia and
a narrow neck have been ideals in the model of
beauty for many African cultures. Even with such
Fig. 2. The Venus of Willendorf is perhaps the earliest
female form sculpted in history that still survives.
Fig. 3. The Venus of Grimaldi was a symbol of fertility,
as represented by her prominent gluteal, abdominal,
and breast areas.
differences within and between cultures, studies
have demonstrated the presence of certain similar
patterns of what humans find physically appeal-
ing, which suggests that there is some common
base for a universal understanding or appreciation
of an aesthetic ideal. The standards of harmony
and proportion have been used by Western cul-
tures for at least 2500 years by artists, philoso-
phers, and mathematicians.
Polykleitos, a great sculptor and art theorist of the
early fourth century BC, created works that are ad-
mired for their exquisite beauty and perfection of
symmetry and balance, all of which are essential vir-
tues in classical art. He put down his aesthetic the-
ories in a book called the Kanon, which has not
survived but is referenced by others. Although the
unit of measurement he used as the basis of his the-
ories is lost, it involved complicated mathematical
rules of proportion and balance. His most famous
statue, the Doryphoros or Spear-Bearer (Fig. 7),
embodied his ideal of athletic and muscular perfec-
tion. Polykleitos’ sculptures emphasized a counter-
balance of tension and relaxation through the

Fig. 4. Nefertiti was the epitome of beauty among the
early Egyptians, to a point that a mythology devel-
oped around her legendary image. This painted lime-
stone bust demonstrates her elongated neck.
shoulders and hips that became the standard of
proportions for Greek, Roman, and Renaissance
sculptors. All of the body weight rests on one leg
so the figure appears to be relaxed but also ready
to spring into action. This position, called contra-
posto, incorporates what is known as chiastic bal-
ance; the statue’s balance seems to be both active
and passive.
Vitruvius, an architect of the first century BC, was
an expert on Polykleitos’ system and a student of
proportions that he applied to his designs ranging
from temples and arches to water pipes to screws.
His studies culminated in his description of the
ideal proportions of the human body, which was
necessary to understand because humans occupy
buildings. Vitruvius’ mathematical description was
adapted and extended centuries later into a drawing
by Leonardo da Vinci in his famous Man of Vitru-
vius or Vitruvian Man (Fig. 8). Leonardo applied
mathematics in all of his work, including his ap-
proach to defining the perfect human form. Among
Leonardo’s many areas of genius, he was probably
the first great anatomist (Fig. 9).
Albrecht Dürer (1471–1528), the most famous
painter and engraver of Reformation Germany,
History of Gluteal Augmentation 309
Fig. 5. The Venus de Milo (or Aphrodite of Melos) rep-
resents the ultimate beauty among the ancient
Greeks. Although excess fat in the waist and trunk
was not tolerated, we get a sense of plump buttocks
beneath her drape.
made measurements of the Greek classic sculptures,
which he believed embodied ‘‘purity, harmony,
beauty and knowledge of the perfect shapes.’’ His
goal was to use geometry and measurement to un-
derstand human beauty, which is illustrated in
Fig. 10. His notes and drawings were compiled in
his, Four Books on Human Proportions, that reveal Dü-
rer as a student of Vitruvius. To help refine his the-
ories, Dürer measured thousands of men, women,
and children to obtain typical values that determine
proper human proportions. One of his volumes
also illustrates deviations from the ideal in illustra-
tions of the extremely fat and thin.
As part of the mathematical approaches to quan-
tifying beauty, the Fibonacci sequence of numbers
is applicable. This unending series of integers, be-
ginning with 1,1,2,3,5,8,13. is a system in which
each number is the sum of the preceding two. When
a number in the Fibonacci sequence is divided by its
310 de la Peña et al

Fig. 6. This ancient Roman vase il-

lustrates that the quest for beauty
was not exclusive to the feminine
sex in this culture.

Fig. 7. The Doryphorus, or Spear-Bearer, by Polykleitos is known

through copies such as this. The right leg and left arm are active
(tense) while the left leg and right arm are passive (relaxed). Other
works by Polykleitos that represent the same sense of balance and
proportion are also preserved through copies, including the Diadu-
menus, a man binding a ribbon about his head, and an Amazon.
 History of Gluteal Augmentation 311

Fig. 8. The ideal physical propor-

tions of humans devised by Vitru-
vius were translated by Leonardo
da Vinci in his Man of Vitruvius
drawing.

preceding number, the result is always 1.618, which The analysis of human beauty through diagrams
is an irrational number with multiple names: Phi or pictures has its limitations, as does the applica-
(4), golden ratio, golden mean, and divine propor- tion of mathematics. However, we should consider
tion. The golden ratio, expressed as 1 to 1.618, the artistic terms of harmony, form, balance, symme-
appears frequently in the natural sciences, mathe- try, proportion, tension, movement, force, color and
matics, music, and art. Shapes, including human mass. Although artists have studied forms via lines,
forms, proportioned according to the golden ratio axes, planes, and curves for centuries, we have
are considered aesthetically pleasing and represent
a natural balance and symmetry. It is believed that
Leonardo’s Mona Lisa employs the golden ratio in
its geometric equivalents, and human faces consid-
ered beautiful can be analyzed according to the di-
vine proportions illustrated in Fig. 11. If one applies
the golden ratio to a human figure that is unappeal-
ing, chances are excellent that the ratio is violated in
some area so the figure seems out of balance or
distorted.
The plastic surgeon and the sculptor both work in
three dimensions and are accustomed to perceiving
three-dimensional figures with the purpose of
‘‘sculpting’’ forms, sizes, and planes that are well
balanced and harmoniously proportioned. Symme-
try is the identical disposition of units on any side
of a plane or an axis. Vitruvius suggested that sym-
metry resides in the correlation of the measures of
several elements of a plane and between each one
of those elements. Fig. 9. Leonardo da Vinci.
312 de la Peña et al
newer tools available to us, including holograms
and radiology, combined with geometric, mathe-
matical, and logarithmic models, as well as knowl-
edge of the physiology and psychology of vision
and perception. Such tools give us more resources
for quantifying the aesthetics of the human form
as our patients seek more harmonious proportions.
History of gluteal augmentation
Women innately understand the necessity of bal-
ance between the volume and the form of the tho-
rax, breast, hips, and buttocks. In addition, the arms
and thighs should be in a symmetrical and satisfac-
tory relationship with the thorax. Modification of
the body to achieve such balance and improve one’s
physical image may be accomplished by multiple
methods, such as clothing, hairstyle, makeup, exer-
cise, and surgery. Perception of an ideal is undoubt-
edly influenced by mass communications and the
media. In modern life, having a harmonious figure
can be important to the point that a lack of balance
in proportions may have psychological impli-
cations for some people. However, the final
Fig. 10. Adam and Eve 1507, oil on
panel, by Albrecht Dürer. This paint-
ing demonstrates Dürer’s mastery
of human forms and proportions.
perception of harmony, beauty, and proportion re-
main in the human eye [1].
In primates other than humans, the gluteus max-
imus muscle is relatively small and attaches only to
the ischium tuberosity. The muscle acts as an exten-
sor of the hip to pull it back and give an appropriate
alignment for climbing trees. However, the muscle
cannot maintain simians in an upright position
for very long. In contrast, humans have a very
strong and large gluteus maximus muscle that is at-
tached at multiple points, including the ilium, coc-
cyx, sacrum, and gluteal tuberosity of the femur and
iliotibial tract. The strength of the muscle’s fixation
gives us lateral rotation of the thigh and helps brace
the knee. It provides the support necessary to walk
upright.
For females, the gluteal region and the breasts are
the bodily areas that have been emphasized
throughout human history and serve as a source
of inspiration in multiple artistic disciplines: litera-
ture, painting, sculpture, and dance, among other
expressions of the human form. In earlier times
and different cultures, the concept of beauty of
the gluteal area often involved a disproportionately
 History of Gluteal Augmentation 313

Fig. 11. These drawings illustrate the golden

ratio (1:1.618) as applied to the human face.
This ratio appears throughout the natural
world, from flowers to spiral galaxies, and
from insects to humans. The ideal propor-
tions of all areas of the human body can be
defined by this ratio based on the Fibonacci
sequence, which is best illustrated by Leonar-
do’s Vitruvian Man.

Fig. 12. In the early days of gluteal reconstruction, Bartels used Cronin-style mammary implants to achieve but-
tock asymmetry [2].
314 de la Peña et al
Fig. 13. Lateral gluteal depressions treated by Bartels
with Cronin breast implants [2].
large volume that—to our modern eyes—reflects
a lack of balance between the trunk and the extrem-
ities. It probably violates the golden ratio. Our cur-
rent ideal of female buttocks implies a small waist
so the gluteal area has appealing posterior
Fig. 14. (A) Early implants had Dacron patches on the
underside in an attempt to solve the problem of im-
plant displacement. (B) The Lise style breast implant
was also used for early gluteal augmentation [3].
Fig. 15. Hypotrophy of the right buttock [4].
projection but without disproportionate width in
the side-to-side dimension. This is the exact oppo-
site of the concept of beauty in pre-Colombian so-
ciety, which valued a large expansion of buttock
width and small posterior projection. Today, we
greatly prefer an athletic build, where the gluteal sil-
houette acquires a firm and round form that is in
balance with the rest of the body.
Today’s body-contouring surgery is directed at
improvement of the aesthetic characteristics of the
extremities, breasts, abdomen, flanks, upper and
lower back, and the gluteal area. The different pro-
cedures available for contouring these regions in-
clude augmentation, reduction, fixation (-pexy),
lifting, and skin resection. For cases of lipodistro-
phy or gluteal ptosis, the buttocks can be recon-
toured in much the same way as the breasts,
specifically augmenting or reducing the volume
and lifting the skin and subcutaneous tissue.
The clinical practice of gluteal augmentation be-
gan in 1969 with the placement of a round mam-
mary implant for reconstructive purposes. Bartels
and colleagues [2] published a case in which a uni-
lateral gluteal augmentation was performed with
a Cronin-style mammary implant to correct an
asymmetry caused by atrophy of the left gluteal
muscle. The implant was inserted through the infra-
gluteal fold. The aesthetic result (Fig. 12) was so sat-
isfactory that the reconstructed buttock looked
better than the contralateral side.
Four years after Bartels and colleagues’ report,
gluteal augmentation was performed for cosmetic
purposes. Dr William Cocke and G. Ricketson [3],
in 1973, described the use of mammary implants
for correcting lateral gluteal depressions (Fig. 13).
The implants used had Dacron patches on the un-
derside for better fixation (Fig. 14A), although
other types of breast implants were also tried
(Fig. 14B). Cocke and Ricketson’s procedure was
the first description of placing implants in the
 History of Gluteal Augmentation 315

Fig. 16. Gonzalez Ulloa was the

first to refer to ‘‘sad’’ buttocks (left
side of image). Presumably, aug-
mentation would create ‘‘happy’’
buttocks (right side of image) [4].

Fig. 17. (A, B, C) In this gluteal prosthesis design, the implant had fixation ears at the ends that could be sutured
in place [4].
316 de la Peña et al
Fig. 18. Attempts at gluteal augmentation with injec-
tions of silicone or other substances caused serious fi-
brosis and deformation of gluteal area [4].
subcutaneous plane. However, the use of mammary
implants produced less than optimal aesthetic re-
sults, which is not surprising since the breast and
gluteal areas are different anatomically, physiologi-
cally, and mechanically.
Fig. 19. (A, B, C) Since gluteal augmentation began a few decades ago, a variety of surgical approaches for place-
ment of the implants have been devised [4].
The early years of gluteal augmentation saw few
published reports that described the procedure
technique, follow-up, or possible complications.
But developments continued as surgeons began ex-
perimenting with different anatomical planes for
implant placement: the subcutaneous, submuscu-
lar, intramuscular, and subfascial planes. Develop-
ments in the design of gluteal implants followed
a history similar to that for breast implants, which
were initially round and smooth but evolved to in-
clude anatomical shapes and textured surfaces. To-
day, gluteal implants are specially designed for the
gluteal area and come in round, oval, and anatom-
ical shapes with varying dimensions for low, mod-
erate, or high projection. They can be made of
soft solid silicone elastomer or filled with cohesive
silicone gel to prevent the risk of silicone extravasa-
tion in case the gel implant ruptures.
In 1977, González-Ulloa [4] referred to a hypo-
trophic gluteal area (Fig. 15), as well as a ‘‘sad but-
tock’’ (Fig. 16) and proposed using a specially
designed implant that had fixation ‘‘ears’’ at the

Fig. 20. The submuscular plane of implant placement
was first described by Robles and colleagues [5]. In his
procedure, the implant could be in touch with the sci-
atic nerve.
ends (Fig. 17). This design accounted for the phys-
ical and mechanical characteristics that differentiate
the gluteal region from the breasts. He proposed
the use of such implants for patients who had suf-
fered severe damage as a result of augmentation
Fig. 21. (A, B, C) The surgical markings developed by Vergara and Marcos for intramuscular implant positioning.
(From Vergara R, Amezuca H. Intramuscular gluteal implants: 15 years’ experience. Aesthetic Surg J 2003;23:86–
91; with permission.)
History of Gluteal Augmentation 317
injections of silicone, collagen, or other substances
that caused serious fibrosis and deformation of the
gluteal area (Fig. 18).
González-Ulloa [4] also described use of the sub-
cutaneous plane for implantation, as well as three
important surgical approaches: (1) supragluteal ac-
cess from both sides of the coccyx, which has a re-
duced thickness of fatty tissue (Fig. 19A); (2) the
infragluteal fold, which facilitates drainage and
helps hide the scar (Fig. 19B); and (3) within the
intergluteal crease to avoid evident scars (Fig. 19C).
Subcutaneous placement of a gluteal implant has
serious disadvantages. Fixation of the skin to the
deep tissues is constituted by aponeurotic expan-
sions that go from the gluteal aponeurosis to the
dermis. However, problems arise when creation of
the implant pocket is performed in this space. The
aponeurotic expansions are cut, which leaves laxity
in the skin, and implants are not likely to maintain
a correct position over time. In addition, the im-
plants are very visible.
Fig. 22. Vergara and Marcos
designed gluteal implants with
an almond-shaped design. (From
Vergara R, Amezuca H. Intramus-
cular gluteal implants: 15 years’
experience. Aesthetic Surg J 2003;
23:86–91; with permission.)
318 de la Peña et al
Fig. 23. The subfascial plane developed by De la Peña.
The aponeurotic expansions are visible in this image.
(From de la Peña JA. Subfascial technique for gluteal
augmentation. Aesthetic Surg J 2004;24:265–73; with
permission.)
The complications associated with subcutane-
ous positioning include implant exposure, infec-
tion, and inferior displacement of the implant.
The second generation of implants had Dacron
fixation patches in the base that were supposed
to keep the implants properly positioned in the
pocket; however, those patches did not solve the
problem of implant migration. The next genera-
tion of implants were designed with an area that
could be sutured to the deep tissues, but the re-
sults obtained were not natural looking and the
implants were visible. Because of the many com-
plications reported with the placement of im-
plants in the subcutaneous plane, it is rarely
used anymore [4].
In 1984, Robles and colleagues [5], from Argenti-
na, described placement of gluteal implants in
a submuscular pocket beneath the gluteus maximus
and medius muscles. As shown in Fig. 20, this po-
sitioning preserves the aponeurotic system of fixa-
tion between the skin and deep tissues, and has
the advantage of reducing the formation of capsular
contracture. The submuscular position, however,
has the disadvantage of being a small space and
therefore limits the use of large implants and carries
Fig. 25. The aponeurotic expansions that must be
identified for subfascial augmentation run between
the gluteal fascia and the dermis along the axes of
the red lines drawn on the skin.
the potential risk of impinging on the sciatic nerve
that emerges near the area of pocket dissection just
below the inferior border of the piriformis muscle.
Consequently, implants should not be placed be-
low this level. They therefore add volume primarily
in the upper gluteal region.
In 1996, Vergara and Marcos [6] described place-
ment of gluteal implants in an intramuscular space.
The incision is made in the intergluteal crease
(Fig. 21), through which the gluteus maximus apo-
neurosis is identified and the muscle fibers sepa-
rated to create an implant pocket in the
intramuscular space. The objective is to leave
a thickness of 2 to 3 cm beneath the superior gluteal
aponeurosis to pad the implant. Vergara also de-
signed his own implants with an almond shape
(Fig. 22).
The reported advantages of this intramuscular
position include avoidance of dissection around
the sciatic nerve, coverage of the implant with
a thick layer of muscle that maintains the implant
in position, and prevention of ptosis and irregular-
ities in the gluteal surface. The primary complica-
tion is seroma, which develops because of the
extensive disruption of muscle fibers. Another
Fig. 24. (A, B) The anatomic
shaped implants for gluteal
augmentation in the De la
Peña system includes tem-
plates, sizers, and implants
made of solid silicone elas-
tomer or filled with cohe-
sive silicone gel.

Fig. 26. The markings for subfascial augmentation
must follow the anatomic shape of the gluteal re-
gion. The incision is made in the intergluteal crease.
disadvantage is the difficulty of knowing the precise
thickness of the muscle overlying the implant be-
cause the dissection cannot be visualized.
To solve the problems found in the subcutane-
ous, submuscular, and intramuscular planes, the
primary author [7,8] has published his experience
with the concept of using a subfascial anatomical
plane for gluteal augmentation (Fig. 23). He also
developed a system for gluteal augmentation that
includes templates, sizers, and an anatomically
shaped implant designed specifically for subfascial
placement (Fig. 24).
The aponeurosis covers the gluteus maximus
muscle, which is the largest and most superficial re-
gional muscle responsible for projection in the glu-
teal area, and the upper two thirds of the gluteus
medius muscle, which also contributes volume to
the superior third of the buttocks. The gluteal apo-
neurosis insertions are on the posterior iliac, sacral,
and coccyx bones, on the lateral limit inserts of the
greater trochanter, and along to the iliotibial line
(Fig. 25). Because the aponeurosis is stronger at
the insertion sites and softer in the middle, placing
History of Gluteal Augmentation 319
an implant in this plane helps to achieve a natural-
looking result. The incision for implant placement
begins at a point 3 cm above the anus, correspond-
ing to the level of the coccyx, and extends cephali-
cally for approximately 6 cm. At this point the
fascia of the gluteus maximus is identified and in-
cised for dissection of the implant pocket (Fig. 26).
The most important goal in plastic surgery is
meeting a patient’s expectations. Sometimes these
are not entirely realistic, and despite excellent surgi-
cal technique, the patient will be dissatisfied with
the results. To increase the chances of meeting a pa-
tient’s expectations, it is important for the surgeon
to thoroughly explain to patients what can realisti-
cally be achieved with a procedure and the precau-
tions to take during the postoperative period to
prevent complications.
References
[1] Tolleth I. Harmony and proportion in the female
form. In: Hetter GP, editor. Lipoplasty: the theory
and practice of blunt suction lipectomy. 2nd ed.
Boston: Little, Brown; 1990.
[2] Bartels RJ, O’Malley JE, Douglas WM, et al. An un-
usual use of Cronin breast prosthesis. Case report.
Plast Reconstr Surg 1969;44:500.
[3] Cocke WM, Ricketson G. Gluteal Augmentation.
Plast Reconstr Surg 1973;52:93.
[4] González-Ulloa M. Gluteoplasty: a ten year report.
Aesthetic Plast Surg 1991;5:85–91.
[5] Robles J, Tagliapietra J, Grandi M. Gluteoplastia
de aumento: implante submuscular. Cir Plast
Iberolatinoamericana 1984;10:365–9.
[6] Vergara R, Marcos M. Intramuscular gluteal im-
plants. Aesthetic Plast Surg 1996;20:259–62.
[7] De la Peña JA. Subfascial technique for gluteal
augmentation. Aesthetic Surg J 2004;24:265–73.
[8] De la Peña JA, López HM, Gamboa LF. Augmenta-
tion gluteoplasty: anatomical and clinical consid-
erations. Key Issues in Plastic Cosmetic Surgery
2000;17:1–12.