News Updates from the World of Cosmetic and Plastic Surgery

Solange Magnano, a former Miss Argentina, made headlines when she died Nov. 29, 2009, reportedly from complications of buttocks augmentation. In her late 30s and the mother of young twins, Ms. Magnano went to a clinic in Buenos Aires, Argentina. She died, reportedly, of a pulmonary embolism after receiving injections of a "liquid" named in some news reports as silicone, and in others as polymethylmethacrylate, or PMMA.

Cases like Ms. Magnano's are less likely to occur in the United States, where the Food and Drug Administration has not approved the use of any filler for buttocks augmentation. However, doctors experienced in the procedure say things can go wrong here, too, especially when unlicensed, nonmedical providers use unapproved products, such as industrial silicone, to augment the buttocks.

Even though buttocks augmentation is among the least-commonly performed cosmetic procedures in the United States, ranking 36th out of 39 procedures, according to 2008 American Society for Aesthetic Plastic Surgery (ASAPS) statistics, educating consumers about the potential dangers of this procedure is a concern among cosmetic surgeons.

As a result, professional associations of plastic surgeons, facial plastic surgeons, oculoplastic surgeons and dermatologists have joined to form Physicians Coalition for Injectable Safety, a group charged with educating consumers about safe cosmetic injections and eradicating the use of counterfeit or illegally imported cosmetic injectables.

Coalition member and ASAPS President Renato Saltz, M.D., says Ms. Magnano's procedure was performed by a co-esthetic physician, which would be equivalent in the United States to a master esthetician.
"In one death, here in the U.S., an individual who was not even a physician was injecting women's breasts and buttocks in his basement," Dr. Saltz says.

At his practice in Utah, where there is a large Central American population, Dr. Saltz says he has seen patients who have received industrial silicone for buttocks augmentation in Costa Rica and Mexico.

"They go to unknown physicians and/or poorly trained individuals who do the injections, which initially offer patients sought-after changes," he says. "But later, the silicone progresses into abscesses, infection, skin slough, because this is an industrial product — not a medical product."

Core cosmetic surgeons who inherit these cases in the United States find them problematic, according to Dr. Saltz.

"You cannot go in and just scoop out the silicone," he says. "The two patients I saw had horrible infections. One had to go to the operating room and have the area drained; the other improved just with an oral antibiotic. But you know it is a problem that might recur, because that product will never be completely removed from the tissues."

The message that he and colleagues in the coalition are trying to send to consumers and practitioners: Use products that are safe and recognized as good for buttock augmentation.

"You are not going to find any individual with a good practice in buttock augmentation using fillers or injectables. Most of us either use fat from the patient's own body, rotation flaps from the lower back, or gluteal implants," Dr. Saltz says.

A COMPLEX ANATOMY Even experienced cosmetic surgeons should not take buttocks augmentation lightly, according to Robert Weiss, M.D., who practices in Baltimore and is immediate past-president of the American Society for Dermatologic Surgery and associate professor of dermatology at Johns Hopkins University School of Medicine.
"The buttocks have a very different anatomy, very different vascular structures, and augmenting them requires advanced training," Dr. Weiss says.

In order to get desired results, cosmetic surgeons need to inject fat deep into the tissue, where the body houses large veins and arteries.

"So, one has to be very careful not to inject intravascularly," Dr. Weiss says.

With no filler approved in the United States for buttocks augmentation, autologous fat is the standard. Successful fat augmentation, according to Dr. Weiss, requires someone experienced in fat transfer.

"It has to be a technique where you have a lot of living cells and it has to be large volume. There are some new devices that use water jets, where they inject saline as they are removing the fat; then, you can harvest fat in much larger quantities for buttocks or breast augmentation," he says.

A TEDIOUS TECHNIQUE

Buttocks augmentation using autologous grafts is a tedious, technique-dependent procedure, according to Robert H. Gotkin, M.D., a New York plastic surgeon.
"The survival of autologous fat grafts anywhere in the body has to do with adequate vascularization of the graft, whether it is a skin, bone, cartilage or fat graft. In order to survive, it has to become vascularized by the vasculature in the recipient site; in this case, we are talking about the buttocks," Dr. Gotkin says.

Basically, surgeons make many little tunnels for microdroplets of fat — in tenths of ccs, according to Dr. Gotkin.

"If you put a bolus of 5 or 10 ccs in one location, you have this big liquid globule of fat. The majority of that deposit of fat is not exposed to the surrounding native tissue. As a result, the interior fat is not going to vascularize. That is one of biggest problems with fat transfer," he says.
Dr. Gotkin says he uses small, blunt-tipped cannulas and goes back and forth inside the recipient tissue, at all levels.

"Using the microdroplet technique eliminates a lot of the complications of autologous fat injection, including necrotic fat accumulation," he says.

The bottom line? Cosmetic surgeons who do not have experience in buttocks augmentation should observe experts before performing it on their patients, Dr. Weiss says.

"Saying, 'Well, I can inject into the nasolabial folds, so why not translate that into injecting into large areas like the buttocks?' — that is the absolutely wrong conclusion," he says

Three women who received buttock-enhancing injections at an unlicensed North Carolina clinic subsequently developed kidney failure, reports news source HealthDay News.

According to the HealthDay News report, the facility was not only unlicensed, but the person who administered the injections was untrained and not medically supervised. Investigators could not determine exactly what was in the injections.

The three women eventually recovered, but HealthDay News reports that the incidents indicate the potential hazards that can occur when untrained personnel at unlicensed facilities perform cosmetic procedures.

The three North Carolina cases were reported in the May 2 issue of the Centers for Disease Control (CDC) and Prevention’s Morbidity and Mortality Weekly Report (MMWR), which notes that the three women received injections in December 2007 at the same facility. A North Carolina Division of Public Health investigation revealed multiple problems with infection-control procedures, among other issues, at the facility. The substance injected was purported to be silicone oil, but investigators could not confirm this. The MMWR report states that since silicone oil has never been linked to kidney failure, another substance probably was present.

MMWR also reports that there was no evidence that the clinic’s practitioner, trained as a radiology technician, had been trained in performing cosmetic procedures or was medically supervised.

According to the CDC, health officials in North Carolina have banned the facility from administering any injections. The practitioner has been arrested and charged with practicing medicine without a license.