A patient in her late twenties came to me on video. She had a lipo 360 with fat transfer to the buttock two years ago with another surgeon. Good projection. But under each buttock there was a second fold, and she wanted her hips lower and rounder, a pear instead of an hourglass. I am publishing the exchange nearly as it happened, identifiers removed, because almost nobody knows this operation exists.
The visit
Her: I gained about forty pounds in the last two, three years. I’m working hard on losing that weight, but I’m scared it will get worse with weight loss. Do you think it’s best to do the surgery now?
Me: “Let’s talk about what we want to achieve. I know that you want to get rid of the, kind of like this double butt crease, this area right here.”
Her: Yeah, that area stresses me out a lot.
Me: “So for this, we would do the thong lift, the Miami thong lift. It’s an incision that goes right here. I do a little bit of lipo here, and then we tuck that in so it kind of does a circle inside. So that would be the fix for that.”
Me: “You wanted to reduce the size here a little bit? The upper hips? Yeah, so we could do lipo here to take that out.”
The crease question
Her: Could we, like on the bottom of my butt, make it more round? Could we move fat around? Because I have no crease. You know this crease? I don’t have that, so I was wondering if we could put fat here.
Me: “So the crease here is actually good, it’s good when it’s short. If you look at very sexy buttocks, this crease is short. When it gets long, it’s because the buttock has fallen down, so it folds. So you actually, you’re good with that. I think that part’s fine.”
Me: “I do see that this is a little flat, like here, and you’re full here. Your projection is good. So really it’s just giving it a little bit of shape. So maybe removing a little here, adding a tiny bit here, and the rest for projection. And then lifting this up would make it look really nice.”
Me: “There’s a lot of different ways to describe it. Some people say like frog butt or elephant because of this, but we can fix that. I’m one of the few surgeons that does this procedure, the Miami thong lift. So where are we going to get fat from? Your back and your arms? Okay.”
The pear shape question
Her: Would it be possible to add fat to my outer thighs? I want to look like a pear rather than an hourglass.
Me: “I just don’t think you have enough, because we’re taking from your upper back and your arms. So we can add whatever fat we get there, or if we don’t have enough, we can use the allograft, which is the donor fat, and we can inject that into the saddlebag area to create more curviness lower down. So more like a heart shape.”
Her: A lot of other BBL doctors I asked, they declined to do that area, to inject fat in there.
Me: “We do it routinely because sometimes, you know, I get patients that have very skinny thighs. And if we just do the buttock, it looks funny, it looks like a chicken. So routinely we add to that area.”
Her: Oh, like to the thighs, not just the hips. And I can do everything at once?
Me: “You could, yeah.”
The fibrosis question
Her: I have pretty bad fibrosis on my stomach from my second round of lipo. What is fibrosis caused by?
Me: “So a lot of times it’s, number one, when they do too much lipo. Number two, if any of the fluid gets caught and it doesn’t come out, it creates like a capsule and scar tissue. So that’s why I really recommend doing lymphatic massages after the liposuction.”
Her: I didn’t also wear my faja. Is that also why?
Me: “That’s another one, yeah. It’s a lot of the aftercare. Number one, if you do too much lipo, then you get that really bumpy look. And number two is the aftercare. It really prevents the fibrosis.”
Her: Thank you, doctor. I learned a lot today.
My exam note that day: a double butt crease deformity, flat hips with fuller saddlebags, mild cellulite, good buttock projection.
What I tell everyone about the scar
To another patient the same year who had hip implants placed elsewhere and the same second fold: “On the posterior view, you do have a little bit of a double butt crease deformity. So to make this kind of go up and look more rounded instead of having that second bump, it would be the Miami thong lift. The incision goes right in the middle, on either side, but it hides completely when you are standing in the nude.”
“It is actually gonna pull up almost like a wedgie, so it will pull up everything and make it up and rounded. And it usually ends right about here, so you really don’t see any scars on the outside.”
And on why she had never heard of it: “That’s a procedure that very few surgeons do and very few people know about. And sometimes the surgeons just don’t know how to make it better.”
Surgery is about three to three and a half hours under general anesthesia, and you go home the same day. No drains. Five to seven days to light activity and driving, about four weeks to exercise, a compression garment for four weeks, and two weeks of sitting on your thighs with a cushion instead of on the buttock. In about four to six weeks you should be able to put on a bathing suit.
That is the whole subject. The second crease is not a volume problem, it is a position problem, and more fat makes it worse. A short hidden incision, a little lipo above it, and fat moved to where the shape needs it.
I am a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.
Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
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