The outcome of a breast augmentation with fat-graft injections depends upon proper patient selection, preparation, and correct technique for recipient site expansion, and the harvesting, refining, and injecting of the autologous breast filler fat. Technical success follows the adequate external vacuum expansion of the recipient-site tissues (matrix) before the injection of large-volume grafts (220–650 cc) of autologous fat to the breasts. [ 134 ]  After harvesting by liposuction, the breast-filler fat was obtained by low G-force syringe centrifugation of the harvested fat to separate it, by density, from the crystalloid component. The refined breast filler then was injected to the pre-expanded recipient site; post-procedure, the patient resumed continual vacuum expansion therapy upon the injected breast, until the next fat grafting session. The mean operating room (OR) time was 2-hours, and there occurred no incidences of  infection , cysts,  seroma ,  hematoma , or tissue necrosis. [ 131 ]


The breast-volume data reported in  Breast Augmentation with Autologous Fat Grafting: A Clinical Radiological Study  (2010) indicated a mean increase of 1.2 times the initial breast volume, at six months post-procedure. In a two-year period, 25 patients underwent breast augmentation by fat graft injection; at three weeks pre-procedure, before the fat grafting to the breast-tissue matrix (recipient site), the patients were photographed, and examined via intravenous contrast  MRI  or  3-D volumetric imaging , or both. The breast-filler fat was harvested by liposuction (abdomen, buttocks, thighs), and yielded fat-graft volumes of 220–650 cm 3  per breast. At six months post-procedure, the follow-up treatment included photographs, intravenous contrast MRI or 3-D volumetric imaging, or both. Each woman had an increased breast volume of 250 cm 3  per breast, a mean volume increase confirmed by quantitative MRI analysis. The mean increase in breast volume was 1.2 times the initial breast volume measurements; the statistical difference between the pre-procedure and the six-month post-procedure breast volumes was (P< 00.0000007); the percentage increase basis of the breast volume was 60–80% of the initial, pre-procedure breast volume. [ 131 ]


In 2003, the  Thai  government endorsed a regimen of self-massage exercises as an alternative to surgical breast augmentation with  breast implants . The Thai government enrolled more than 20 women in publicly funded courses for the teaching of the technique; nonetheless, beyond Thailand, the technique is not endorsed by the mainstream medical community. Despite the promising results of a six-month study of the therapeutic effectiveness of the technique, the research physician recommended to the participant women that they also contribute to augmenting their busts by gaining weight. [ 135 ]


In every surgical and nonsurgical procedure, the risk of  medical complications  exists before, during, and after a procedure, and, given the sensitive biological nature of breast tissues (adipocyte, glandular), this is especially true in the case of fat graft breast augmentation. Despite its relative technical simplicity, the injection (grafting) technique for breast augmentation is accompanied by post-procedure complications – fat necrosis, calcification, and  sclerotic nodules  – which directly influence the technical efficacy of the procedure, and of achieving a successful outcome. The Chinese study  Breast Augmentation by Autologous Fat-injection Grafting: Management and Clinical analysis of Complications  (2009), reported that the incidence of medical complications is reduced with strict control of the injection-rate (cm 3 /min) of the breast-filler volume being administered, and by diffusing the fat-grafts in layers to allow their even distribution within the breast tissue matrix. The complications occurred to the 17-patient group were identified and located with  3-D volumetric  and  MRI  visualizations of the breast tissues and of any sclerotic lesions and  abnormal tissue  masses (malignant neoplasm). According to the characteristics of the defect or abnormality, the sclerotic lesion was excised and liquefied fat was aspirated; the excised samples indicated biological changes in the intramammary fat grafts – fat necrosis, calcification,  hyalinization , and  fibroplasia . [ 136 ]


The complications associated with injecting fat grafts to augment the breasts are like, but less severe, than the medical complications associated with other types of breast procedure. [ dubious  –  discuss ]  Technically, the use of minuscule (2-mm) incisions and blunt- cannula  injection much reduce the incidence of damaging the underlying breast structures (milk ducts, blood vessels, nerves). Injected fat-tissue grafts that are not perfused among the tissues can die, and result in necrotic cysts and eventual calcifications – medical complications common to breast procedures. [ citation needed ]


When the patient's body has insufficient adipocyte tissue to harvest as injectable breast filler, a combination of fat grafting and breast implants might provide the desired outcome. Although non-surgical breast augmentation with fat graft injections is not associated with implant-related medical complications (filler leakage, deflation, visibility, palpability,  capsular contracture ), the achievable breast volumes are physically limited; the large-volume, global bust augmentations realised with breast implants are not possible with the method of structural fat grafting. Global breast augmentation contrasts with the controlled breast augmentation of fat-graft injection, in the degree of control that the plastic surgeon has in achieving the desired breast contour and volume. The controlled augmentation is realised by infiltrating and diffusing the fat grafts throughout the breast; and it is feather-layered into the adjacent pectoral areas until achieving the desired outcome of breast volume and contour. Nonetheless, the physical fullness-of-breast achieved with injected fat-grafts does not visually translate into the type of buxom fullness achieved with breast implants; hence, patients who had plentiful fat-tissue to harvest attained a maximum breast augmentation of one bra cup size in one session of fat grafting to the breast. [ 120 ]


A contemporary woman's lifetime probability of developing breast cancer is approximately one in seven. [ 137 ]  However, there is no causal evidence that fat grafting to the breast might be more conducive to breast cancer than are other breast procedures; because incidences of fat  tissue  necrosis and calcification occur in every such procedure: breast  biopsy , implantation,  radiation therapy ,  breast reduction ,  breast reconstruction , and liposuction of the breast. Nonetheless, detecting breast cancer is primary, and calcification incidence is secondary; thus, the patient is counselled to learn self-palpation of the breast and to undergo periodic mammographic examinations. Although the mammogram is the superior diagnostic technique for distinguishing among cancerous and benign lesions to the breast, any questionable  lesion  can be visualized  ultrasonically  and  magnetically  (MRI);  biopsy  follows any clinically suspicious lesion or indeterminate abnormality appeared in a  radiograph . [ 120 ]


Breast augmentation via autologous fat grafts allows the  oncological  breast surgeon to consider conservative breast surgery procedures that usually are precluded by the presence of alloplastic  breast implants , e.g.  lumpectomy , if cancer is detected in an implant-augmented breast. In previously augmented patients, aesthetic outcomes cannot be ensured without removing the implant and performing mastectomy. [ 138 ] [ 139 ]  Moreover,  radiotherapy  treatment is critical to reducing cancerous recurrence and to the maximal conservation of breast tissue; yet, radiotherapy of an implant-augmented breast much increases the incidence of  medical complications  –  capsular contracture , infection, extrusion, and poor cosmetic outcome. [ 120 ]


After mastectomy,  surgical breast reconstruction  with autogenous  skin flaps  and with breast implants can produce subtle deformities and deficiencies resultant from such global breast augmentation, thus the  breast reconstruction  is incomplete. In which case, fat graft injection can provide the missing coverage and fullness, and might relax the  breast capsule . The fat can be injected as either large grafts or as small grafts, as required to correct difficult axillary deficiencies, improper breast contour, visible implant edges, capsular contracture, and tissue damage consequent to radiation therapy. [ 120 ]


Reduction mammoplasty  (also  breast reduction  and  reduction mammaplasty ) is the  plastic surgery  procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional  bust  that is proportionate to the patient's body, the critical corrective consideration is the  tissue viability  of the  nipple–areola complex  (NAC), to ensure the functional sensitivity and  lactational  capability of the breasts. The indications for breast reduction surgery are three-fold – physical,  aesthetic , and psychological – the restoration of the bust, of the patient's  self-image , and of the patient's  mental health . [ 1 ]


In corrective practice, the surgical techniques and praxis for reduction mammoplasty also are applied to  mastopexy  (breast lift). [ 2 ] [ 3 ]


The patient with  macromastia  presents heavy, enlarged breasts that sag and cause chronic pains to the head, neck, shoulders, and back; an oversized  bust  also causes secondary health problems, such as poor  blood circulation , impaired  breathing  (inability to fill the lungs with air); chafing of the skin of the chest and the lower breast (inframammary intertrigo); brassière-strap indentations to the shoulders; and the improper fit of clothes.


In the patient affected by  gigantomastia  (>1,000 gm overweight per breast), the average breast-volume reduction diminished the oversized bust by three brassière cup-sizes. [ 4 ]  The surgical reduction of abnormally enlarged breasts resolves the physical symptoms and the functional limitations imposed by a bodily disproportionate bust; thereby, it improves a patient's physical and  mental health . [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ]  Afterwards, the patient's ability to comfortably perform physical activities previously impeded by oversized breasts improves emotional health ( self-esteem ) by reducing  anxiety  and lessening  psychological depression . [ 10 ]


The medical history records the patient's age, the number of children the patient has borne, the patient's  breast-feeding  practices, plans for pregnancy and nursing of the infant, medication allergies, and tendency to bleeding. Additional to the personal medical information are the patient's history of  tobacco smoking  and concomitant diseases, breast-surgery and breast-disease histories, family history of  breast cancer , and complaints of neck, back, shoulder pain, breast sensitivity, rashes, infection, and upper extremity numbness. [ citation needed ]


The physical examination records and establishes the accurate measures of the patient's  body mass index , vital signs, the mass of each breast, the degree of inframammary intertrigo present, the degree of  breast ptosis , the degree of enlargement of each breast, lesions to the skin envelope, the degree of sensation in the  nipple–areola complex  (NAC), and discharges from the nipple. Also noted are the secondary effects of the enlarged breasts, such as shoulder-notching by the brassière strap from the breast weight,  kyphosis  (excessive, backwards curvature of the  thoracic region  of the  spinal column ), skin irritation, and skin rash affecting the breast crease (IMF). [ 11 ]


Large breasts are usually developed during  thelarche  (the pubertal breast-development stage), but they can also develop postpartum, after gaining weight, at  menopause , and at any age. Macromastia usually develops in consequence to the  hypertrophy  (overdevelopment) of  adipose fat , rather than to milk-gland hypertrophy. Moreover, many are  genetically  predisposed to developing large breasts, the size and weight of which are often increased, either by  pregnancy , by weight gain, or by both conditions; there also exist  iatrogenic  (physician-caused) conditions such as post– mastectomy  and post– lumpectomy  asymmetry. Nonetheless, it is statistically rare for a young person to experience virginal mammary hypertrophy that results in massive, oversized breasts, and recurrent  breast hypertrophy . [ citation needed ]


The abnormal enlargement of the breast tissues to a volume in excess of the normal bust-to-body proportions can be caused either by the overdevelopment of the  milk glands  or of the  adipose tissue , or by a combination of both occurrences of hypertrophy. The resultant breast-volume increases can range from the mild (<300 gm) to the moderate (ca. 300–800 gm) to the severe (>800 gm). Macromastia can be manifested either as a unilateral condition or as a bilateral condition (single-breasted enlargement or double-breasted enlargement) that can occur in combination with sagging,  breast ptosis  that is determined by the degree to which the nipple has descended below the inframammary fold (IMF). [ 12 ]


Breast hypertrophy (macromastia and gigantomastia) does not respond to medical therapy, but a weight-reduction regimen for the certain patients can alleviate some of the excessive size and volume of abnormally enlarged breasts. [ 13 ]  Physical therapy provides some relief for neck, back, or shoulder pain. Skin care will diminish breast crease inflammation and lessen the symptoms caused by moisture, such as irritation, chafing, infection, and bleeding. [ citation needed ]


The traditional surgical techniques for breast reduction remodel the breast mound using a skin and glandular (breast tissue) pedicle (inferior, superior, central), and then trim and re-drape the skin envelope into a new breast of natural size, shape, and contour; it produces long surgical scars upon the breast hemisphere. In response, L. Benelli, in 1990, presented the round block mammoplasty, a minimal-scar periareolar incision technique that produces only a periareolar scar – around the NAC, where the dark-to-light skin-color transition hides the surgical scar. [ 14 ]


A  reduction mammoplasty  to re-size enlarged breasts and to correct  breast ptosis  resects (cuts and removes) excess tissues ( glandular ,  adipose ,  skin ), overstretched  suspensory ligaments , and transposes the NAC higher upon the breast hemisphere. During  puberty , the breast grows in consequence to the influences of the  hormones   estrogen  and  progesterone ; as a  mammary gland , the breast is composed of lobules of glandular tissue, each of which is drained by a  lactiferous duct  that empties to the nipple. Most of the volume (ca. 90%) and rounded contour of the breasts are conferred by the adipose fat interspersed amongst the lobules, except during  pregnancy  and  lactation , when  breast milk  constitutes most of the breast volume. [ 12 ]


Surgically, the breast is an  apocrine gland  overlaying the chest – attached at the nipple and suspended with ligaments from the chest – which is integral to the skin, the  body integument  of the individual. The dimensions and weight of the breasts vary with age and habitus (body build and physical constitution); hence, small-to-medium-sized breasts weigh approximately 500 gm, or less, and large breasts weigh approximately 750–1,000 gm. [ 15 ] [ 16 ] [ 17 ]  Anatomically, the  breast topography  and the hemispheric locale of the NAC are particular to each individual; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).


The  arterial blood  supply of the breast has medial and lateral vascular components; it is supplied with blood by the  internal mammary artery  (from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th  intercostal perforating arteries . Drainage of  venous blood  from the breast is by the superficial vein system under the  dermis , and by the deep vein system parallel to the artery system. The primary  lymph  drainage system is the retromammary lymph plexus in the  pectoral fascia . Sensation in the breast is established by the  peripheral nervous system innervation  of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal  nerves , and  thoracic spinal nerve 4  ( T4 nerve ) innervates and supplies sensation to the NAC. [ 18 ] [ 19 ]


In realizing the breast-reduction corrections, the plastic surgeon takes  anatomic  and  histologic  account of the  biomechanical , load-bearing properties of the glandular, adipose, and skin tissues that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility ( Poisson's ratio of ~0.5 ).


Reduction mammoplasty , either surgery or lipectomy, proportionately re-sizes the enlarged, sagging breasts of a patient affected with  macromastia  (>500 gm [ clarification needed ]  increase per breast) or with  gigantomastia  (>1,000 gm increase per breast). Breast reduction surgery has two technical aspects:  (i)  the  skin-incision pattern  and the  skin- and glandular-tissue excision technique  applied for access to and removal of breast  parenchyma  tissue. The incision pattern and the area of skin-envelope tissue to be removed determine the locales and the lengths of the surgical scars;  (ii)  the final shape and contour of the reduced breast are determined by the area of the tissues remaining in the breast, and that the skin- and glandular-tissue pedicle has a proper supply of  nerves  and blood vessels ( arterial  and  venous ) that ensure its  tissue viability . [ 11 ]


The specific reduction mammoplasty procedure is determined by the volume of breast tissues ( glandular ,  adipose ,  skin ) to be resected (cut and removed) from each breast, and the degree of breast ptosis present:  Pseudoptosis  (sagging of the inferior pole of the breast; the nipple is at or above the inframammary fold);  Grade I: Mild ptosis  (the nipple is below the IMF, but above the lower pole of the breast);  Grade II: Moderate ptosis  (the nipple is below the IMF; yet some lower-pole breast tissue hangs lower than the nipple);  Grade III: Severe ptosis  (the nipple is far below the IMF; no breast tissue is below the nipple). The full, corrective outcome of the surgical re-establishment of a bodily proportionate bust becomes evident at 6-months to 1-year post-operative, during which period the reduced and lifted breast tissues settle upon and into the chest. The post-operative convalescence is weeks long, depending upon the corrections performed; and some patients may experience painful breast-enlargement during the first post-operative  menstruation .


Breast reduction surgery cannot be performed if the patient is  lactating , or has recently ceased lactating; if the patient's breasts contain unevaluated  tissue masses , or unidentified microcalcifications; if the patient has a  systemic illness ; if the patient is unable to understand the technical limitations of the plastic surgery; or, if the patient cannot accept the possible  medical complications  of the procedure. Additionally, recent research has indicated that mammograms should not be done with any increased frequency in patients undergoing breast surgery, including breast augmentation, mastopexy, and breast reduction. [ 21 ]


The  inferior pedicle  (central mound) features a blood vessel supply (arterial and venous) for the NAC from an inferior, centrally-based attachment to the chest wall. [ 22 ]  The skin pedicle maintains the  innervation  and  vascular  viability of the NAC, which produces a reduced, sensitive breast with full  lactational  capability and function. [ 23 ]  The volume and size reduction of  hypertrophied breasts  is performed with a periareolar incision to the NAC, which then extends downwards, following the natural curve of the breast hemisphere. After cutting and removing the requisite quantities of tissue (glandular, adipose, skin), the NAC is transposed higher upon the breast hemisphere; thereby, the inferior pedicle technique produces an elevated bust with breasts that are proportionate to the patients's person. Breast-reduction with an inferior pedicle occasionally produces breasts that appear squared; despite this, the technique effectively reduces the very enlarged breasts of macromastia and gigantomastia. [ citation needed ]


The breast reduction performed with the vertical-scar technique usually produces a well-projected bust featuring breasts with short incision  scars  and a NAC elevated by means of a pedicle (superior, medial, lateral) that maintains the  biologic  and  functional  viability of the NAC. The increased projection of the reduced bust is achieved by medially gathering the folds of the skin-envelope and suturing the inner and outer portions of the remaining breast gland to provide a support pillar, and upward projection of the NAC . The vertical-scar reduction mammoplasty is best suited for removing small areas of the skin envelope and small volumes of internal tissues (glandular, adipose) from the lateral and the inferior portions of the breast hemisphere; thus the short incision scars. [ citation needed ]


The breast reduction performed with the horizontal-scar technique features a horizontal incision along the inframammary fold (IMF) and a NAC pedicle. To elevate the NAC, the technique usually employs either an inferior pedicle or an inferior-lateral pedicle, and features no vertical incision (like the anchor pattern). The horizontal-scar technique best applies to the patient whose oversized breasts are too large for a vertical-incision technique (e.g. the lollipop pattern); and it has two therapeutic advantages: no vertical incision-scar to the breast hemisphere, and better healing of the periareolar scar of the transposed NAC. The potential disadvantages are box-shaped breasts with thick (hypertrophied) incision scars, especially at the inframammary fold. [ citation needed ]


The breast reduction performed with the free nipple-graft technique transposes the NAC as a  tissue   graft  without a blood supply, without a skin and glandular pedicle. The therapeutic advantage is the greater volume of breast tissues (glandular, adipose, skin) that can be resected to produce a proportionate breast. The therapeutic disadvantage is a breast without a sensitive NAC, and without  lactational  capability. The medically indicated candidates are: the patient whose health presents a high risk of  ischemia  (localized  tissue   anemia ) of the  NAC , which can cause  tissue necrosis ; the  diabetic  patient; the patient who is a  tobacco smoker ; the patient whose oversized breasts have an approximate NAC-to-IMF measure of 20 cm; and the patient who has macromastia, requiring much resecting of the breast tissues. [ citation needed ]


The breast reduction performed with the  liposuction-only  technique usually applies to the patient whose oversized breasts require the removal of a medium volume of internal tissue, and to the patient whose health precludes the extended  anaesthesia  typical of surgical breast-reduction operations. The ideal lipectomy candidate is the patient whose low-density breasts are principally composed of  adipose tissue , have a relatively elastic skin envelope, and manifest mild  ptosis . The therapeutic advantages of the liposuction-only technique are the small incision-scars required for access to the breast interior; hence, a shorter post-operative healing period for the incision scars. The therapeutic disadvantage is limited breast-reduction volumes. [ 12 ]


The  medical treatment records  for the reduction mammoplasty are established with pre-operative, multi-perspective photographs of the oversized breasts, the sternal-notch–to-nipple distances, and the nipple-to–inframammary-fold distances. The patient is instructed about the purposes of the breast reduction surgery; the achievable corrections; the expected final size, shape, and contour of the reduced breasts; the expected final appearance of the breast reduction  scars ; possible changes in the sensation of the  NAC ; possible changes in  breast-feeding  capability; and possible  medical complications . The patient also is instructed about post-operative matters, such as convalescence, and the proper care of the surgical wounds to the breasts. [ citation needed ]


Incision-plan delineation: to the breasts of the standing patient, the plastic surgeon delineates the  mosque dome  skin-incision plan, and the area representing the superior pedicle (composed of skin and glandular tissues), the breast midline, the inframammary fold (IMF), and the vertical axis of the breast, beneath the IMF. The upper edge of the (future) NAC is marked slightly below the IMF-level, and a semicircle of 16-cm maximum diameter. In relation to the vertical axis, the mosque dome incision plan displaces the breast to the middle and to the side; the peripheral limbs of the incision plan are marked so that they approximate (join) at no less than 5-cm above the inframammary fold. The circumference of the (future) NAC is delineated around the nipple, and a superior pedicle (10-cm wide minimum) is delineated at the upper-border of the future NAC circumference; the incision-plan delineation continues down as a cone, and around the marked circumference. [ citation needed ]


The patient is laid supine upon the operating table so that the surgeon can later raise them to a sitting position that will allow visual comparison of the drape of the breasts, and an accurate assessment of the post-operative symmetry of the reduced and lifted bust. Afterwards, the pedicle epidermis surrounding the NAC is cut, and adipose tissue is liposuctioned from the breast. The medial, lower, and lateral segments of the breast are resected (cut and removed), by undermining the skin below the lower curved line. Then, the NAC is transposed higher upon the breast hemisphere. The pillars of  parenchymal tissue  are approximated (joined), and the skin envelope is sutured. [ 24 ] [ 25 ] [ 26 ]
There is no evidence to support using drains during breast reduction surgery. [ 21 ]


The patient is instructed to resume normal life activities, and to eat a light diet, post-operative, on the day of the breast reduction surgery; to resume washing in a shower at 1-day post-operative; to avoid strenuous physical activity, and to wear a sports brassière; the convalescence regimen is for three-months post-operative. The patient is also informed that the wrinkles at the bottom of the vertical limb of the scar usually resolve and fade within one–six months post-operative, but some cases may require surgical revision of the vertical scar. Scheduled follow-up consultations ensure a satisfactory outcome to the breast reduction surgery, and facilitate the early identification and management of medical complications. [ citation needed ]


Limited evidence shows no significant benefit in the use of wound drains after reduction mammoplasty. [ 28 ]


The post-operative complications occurred include  seroma ,  wound dehiscence ,  hematoma ; partial NAC  necrosis  occurred in 10 per cent of the reduced breasts, but, after refinement of the Lejour technique, the study  Vertical Mammaplasty: Early Complications After 250 Personal Consecutive Cases  (1999) reported a reduced incidence rate of 7.0 percent in the 324 breast reductions performed in 167 patients. [ 29 ]  Moreover, the incidence of such post-operative complications is greater among the patients whose breasts required large-volume resection of the  parenchyma ; in patients who were  obese ; in patients who were  tobacco smokers ; and in young patients. [ 30 ] [ 31 ]  Furthermore, wound dehiscence, epidermolysis,  adipose tissue  necrosis, and  infection  occur less among patients who undergo Lejour-technique breast reduction than among patients who undergo a periareolar, anchor pattern breast-reduction, or an inferior-pedicle breast reduction. Nonetheless, bottom-edge asymmetry occurs more among Lejour-technique patients; the revision surgery rates can be up to 10 percent. Moreover, the liposuctioning of the breast does not increase the rate of local medical complications; decreased NAC sensitivity occurs in 10 percent of patients, and total NAC insensitivity occurs in 1.0 per cent of women. [ 32 ]


The reliability of the lipectomy procedure was confirmed in two studies. The first,  Tumescent Technique, Tumescent Anesthesia & Microcannular Liposuction  (2000), reported that tumescent  liposuction  is a reliable reduction mammoplasty procedure, which yields consistent results of size, appearance, and texture of the reduced-volume breasts. [ 33 ] [ 34 ]  The second study by Daniel Lanzer,  Breast Reduction with Liposuction  (2002), about a 250-patient cohort, reported that the application of tumescent liposuction, as the sole reduction-mammoplasty procedure, yielded consistent results wherein none of the patients had loose breast-skin envelopes, irregular breast-shape, permanent loss of sensation (either glandular, dermal, or of the NAC), scars, tissue  necrosis ,  or infection. [ 35 ]


After fat cells are suctioned away via  liposuction , it was quoted in the  Obesity journal  that overall  body fat  generally returned to the same level as before treatment, [ 36 ]  despite maintaining the previous diet and exercise regimen. While the fat returned somewhat to the treated area, most of the increased fat occurred in the abdominal area. Visceral fat - the fat surrounding the internal organs - increased, and this condition has been linked to life-shortening diseases such as diabetes, stroke, and heart attack. [ 36 ]


The reduction of oversized breasts by liposuction only ( lipectomy ) is indicated when a minor-to-moderate volume-reduction is required, and there is no  breast ptosis  to correct.  However, in a 2001 study of 250 patients, nipple and breast elevation of between 3 cm and 15 cm was reported. [ 35 ]    Further indications for lipectomy are presented by: (i) the patient who requires a large-volume reduction, and wants un-scarred, sensate breasts, but will accept a degree of ptosis; (ii) the patient who requires a secondary mammoplasty to correct an asymmetric breast, by up to one brassière cup-size; and (iii) the patient affected by  virginal breast hypertrophy , as a temporary procedure performed before the conclusion of  thelarche  (the pubertal breast-growth phase), given the hypertrophy's high rate of recurrence. [ citation needed ]


Breast reduction by liposuction only cannot be performed upon a patient whose  mammogram  indicates that the oversized breast is principally composed of hypertrophied  milk glands . Furthermore, liposuction mammoplasty also is contraindicated for any patient whose mammograms indicate the presence of unevaluated  neoplasms ; likewise, the presence of a great degree of breast ptosis, and an inelastic skin envelope. [ 12 ]


Consultation: the plastic surgeon evaluates the elasticity of the skin envelope of each breast, and determines the degree of breast ptosis present. The patient is informed of the alternative,  surgical  reduction techniques available for diminishing oversized breasts; of the consequent surgical  scars ; of the possible loss of breast sensation; of the possible impairment of  lactation  capability; and of the possible impairment of  breast-feeding  functions. The patient is further informed of the possible medical complications, and is shown surgical photographic records of the average outcomes of breast-reduction surgery. The surgeon answers the patient's questions to assist in establishing realistic expectations ( self-image ) about the breast-reduction outcome possible with a lipectomy procedure; and that, should lipectomy not satisfactorily reduce the breast volume, a secondary, surgical breast-reduction procedure can be performed later. [ citation needed ]


The measures of the bust: a liposuction mammoplasty procedure does not feature a surgical-incision plan delineated upon the patient's breasts, chest, and torso, but the measures of the bust are established in order to determine the required degree(s) of correction; thus, with the patient sitting erect, for each breast, the surgeon records the jugular-notch-to-nipple distances, the nipple-to-inframammary-fold distances, and any asymmetries. Afterwards, the  anaesthetized  patient is laid supine upon the operating table, arms laterally extended (abducted), in order to fully expose the breasts. [ citation needed ]


Anaesthestic preparation: to limit bleeding during the liposuction, the proper degree of vasoconstriction of the breast's circulatory system is established with an  anaesthetic  solution ( lidocaine  +  epinephrine  in  saline solution ) that is infiltrated to the deep and the superficial plains of each breast. Using a blunt-tip, multi-perforation  cannula , the anaesthetic infiltration begins at the deep plane of the breast, and continues as the cannula is withdrawn towards the superficial plane of the breast. The entire area of the breast is infiltrated with the anaesthetic solution until the tissues become tumescent (firm). Moreover, as required by the patient's physique, an intravenous (IV) pressure bag can be applied to hasten the infiltration; after the anaesthetic has numbed the breast, the plastic surgeon begins the lipectomy breast-reduction. [ citation needed ]


The surgeon effects a stab incision just above the lateral aspect of the inframammary fold (IMF), piercing the skin 2-cm above the inframammary fold, in the midline. The pre-tunnelling is performed with the blunt-tip, multi-perforation cannula used to infiltrate the  anaesthetic  solution to the breast tissues. A blunt-tip, 4-mm cannula, connected either to a medical-grade vacuum pump or to a syringe, is used to aspirate the  adipose fat . The cannula is maneuvered laterally (in fanning movements), beginning in the deep plane of the breast and concluding in the superficial plane of the breast; the  adipose fat  sucked from the breast is a yellow, fatty, bloodless fluid; the liposuction concludes upon drawing the required volume of fat, or when the fat becomes bloody. [ citation needed ]


After the liposuction, the superficial layer of  adipose fat  is undermined with a blunt-tip, 3-mm cannula (which is not connected to a vacuum pump). The breast ptosis is corrected by stimulating the controlled retraction of the incision scar, by undermining the superficial fat of the medial and the lateral upper areas of the breast; the maneuver tightens (retracts) the skin envelope of the breast. Procedurally, the liposuction-only breast reduction procedure concludes with the application of an elastic, foam-tape dressing that molds the reduced breast into its new shape, and lifts it higher upon the chest. [ citation needed ]


Technical note: for the reduction of very enlarged breasts, the plastic surgeon makes a supplementary incision just above the medial aspect of the inframammary fold. Procedurally, the placement of this incision later allows converting the lipectomy breast-reduction procedure into an  inferior-pedicle breast reduction  surgery, if liposuction proved inadequate to satisfactorily reducing the volume of the very enlarged breasts. [ 12 ]


The patient is discharged from hospital either the same day or the day after the breast reduction operation. Because the liposuction-only procedure featured only a few, small, surgical incisions, the patient quickly recovers their health, usually resuming daily life activities at 14 to 28 days post-operative – when the breast-molding dressings are changed; the patient also resumes their personal hygiene regimen, to include washing under a water shower. In the initial convalescence period, the surgical-incision wounds are inspected at 1-week post-operative, during which time the patient has continuously worn a strapless brassière to contain and immobilize the corrected breasts; afterwards, the patient continuously wears a strapped brassière for 30 days after the breast-reduction operation. [ citation needed ]


Early complications include  infection  and  hematoma  (blood outside the vascular system); late complications include an unsatisfactory breast-volume reduction that might require either  surgical  or  liposuction  revision. As with other liposuction procedures, the final result of a liposuction-only breast reduction becomes evident at 6-months post-operative; although the  edema  usually subsides at 2–3 weeks post-operative. To date, no incidence of  tissue   necrosis  has been reported; likewise, there have been few reports of lessened nipple sensation. Generally, the long-term rate of patient-satisfaction is high, provided that the indications for the liposuction-only technique are abided with proper patient selection. [ 13 ] [ 37 ]


Gluteoplasty  (Greek   gloutόs ,  rump  +  plassein ,  to shape ) denotes the  plastic surgery  and the  liposuction  procedures for the correction of  congenital ,  traumatic , and acquired defects/deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement (by augmentation or by reduction) of the contour of the  buttocks . [ 1 ]


The corrective procedures for buttock augmentation and buttock repair include the  surgical  emplacement of a  gluteal implant  (buttock prosthesis);  liposculpture  (fat transfer and  liposuction ); and  body contouring  (surgery, liposculpture, and  Sculptra  injections) to resolve the patient's particular defect or deformity of the gluteal region.


Gluteoplasty has also been applied in the practice of  sexual reassignment surgery .


The functional purpose of the  buttocks musculature  is to establish a stable  gait  (balanced walk) for the person who requires the surgical correction of either a defect or a deformity of the gluteal region; therefore, the restoration of anatomic functionality is the therapeutic consideration that determines which  gluteoplasty  procedure will effectively correct the damaged muscles of the buttocks. The applicable techniques for  surgical  and correction include the surgical emplacement of gluteal implants;  autologous tissue-flaps ; the excision (cutting and removal) of damaged tissues; lipoinjection augmentation; and  liposuction  reduction—to resolve the defect or deformity caused by a traumatic injury ( blunt ,  penetrating ,  blast ) to the buttocks muscles ( gluteus maximus ,  gluteus medius ,  gluteus minimus ), and any deformation of the anatomic contour of the buttocks. Likewise, the corrective techniques apply to resolving the sagging skin of the body, and the muscle and bone deformities presented by the formerly  obese  patient, after a massive weight loss (MWL)  bariatric surgery  procedure; and for resolving  congenital defects  and  congenital deformities  of the gluteal region. [ 2 ]  Known as the BBL " Brazilian Butt Lift " surgery mimicks what steotopygia a normal way people of afrodescent distribute fat around their lower body leading to large buttocks with a shelf like shape , steep triangular hips and large curvileaner  thighs


Anatomically, the mass of each  buttock  principally comprises two muscles—the  gluteus maximus muscle  and the  gluteus medius muscle —which are covered by a layer of  adipose body fat . The upper aspects of the buttocks end at the  iliac crest  (the upper edges of the wings of the  ilium , and the upper lateral margins of the  greater pelvis ), and the lower aspects of the buttocks end at the  horizontal gluteal crease , where the buttocks anatomy joins the rear, upper portion of the thighs. The gluteus maximus muscle has two points of insertion: (i) the one-third superior portion of the (coarse line)  linea aspera  of the thigh bone ( femur ), and (ii) the superior portion of the  iliotibial tract  (a long, fibrous reinforcement of the deep  fascia lata  of the thigh). The left and the right gluteus maximus muscles (the butt cheeks) are vertically divided by the  intergluteal cleft  (the butt-crack) which contains the  anus . [ 2 ]


The  gluteus maximus muscle  is a large and very thick muscle (6–7 cm) located on the  sacrum , which is the large, triangular bone located at the base of the  vertebral column , and at the upper- and back-part of the  pelvic cavity , where it is inserted (like a wedge) between the two  hip bones . The upper part of the sacrum is connected to the final  lumbar vertebra  (L5), and to the bottom of the  coccyx  (tailbone). At its origin, the gluteus maximus muscle extends to include parts of the  iliac bone , the sacrum, the coccyx, the sacrosciatic ligament, and the  tuberosity of the ischium . [ 3 ]


Like every pelvic-area muscle, the gluteus maximus muscle originates from the pelvis; nonetheless, it is the sole pelvic muscle not inserted to the  trochanter  (head of the femur), and is approximately aligned to the  femur  and the  fascia lata  (the  deep fascia  of the thigh); the tissues of the gluteus maximus muscle cover only the rear, lateral face of the trochanter, and there form a bursa (purse) that faces the interior of the  thigh . [ 4 ]


The motor innervation of the gluteus maximus muscle is performed by the  inferior gluteal nerve  (a branch nerve of the  sacral plexus ) and extends from the pelvis to the gluteal region, then traverses the  greater sciatic foramen  (opening) from behind and to the middle to then join the  sciatic nerve . The inferior gluteal nerve divides into three collateral branches: (i) the  gluteus branch , (ii) the  perineal branch , and (iii) the  femoral branch . The first ramification—the gluteus branch—is a branch nerve that is very close to the emergence of the inferior gluteal nerve to the area, next to the inferior border of the  pyramidalis muscle . [ 5 ]  As it arises, the inferior gluteal nerve then divides into four or more  fillets  (bands of nerve fibres) that travel (in a crow's-foot configuration) between the gluteus maximus muscle and its (front) anterior fascia; the thickest nerve-bands are the superior-most and the inferior-most fillets. The superior-most fillet runs almost vertically, near the sacrum, and innervates the superior portion of the gluteus muscle; the inferior-most fillet, which has the greatest calibre, travels very close and parallel to the  sacrotuberous ligament ; the inferior-most fillet provides fine-gauge branch-nerve ramifications that innervate the gluteus muscle through its anterior (front) face. [ citation needed ]


In surgical and body contouring praxis, the plastic surgeon creates the  implant-pocket —either for the gluteal prosthesis or for the injections of autologous fat—by undermining the gluteus maximus muscle with a dissection technique that avoids the  sacrum , the  sacrotuberous ligament , and the  tuberosity of the ischium ; which, if accidentally cut, might isolate the posterior (back) portion of the muscle and lead to denervation, the loss of nerve function and of innervation. [ 4 ] [ 6 ]


The  superior gluteal artery , the  inferior gluteal artery , the  superior gluteal veins , and the  inferior gluteal veins  irrigate the gluteus maximus muscle with  arterial  and  venous  blood. The vascularization, the entrance of the blood vessels to the muscle tissues, occurs at the anterior (front) face of the muscle, very close to the  sacrum . As the arteries and the veins enter the mass of the gluteal muscle, they divide into narrower blood-vessel ramifications (configured like the horizontal branches of a tree), most of which travel parallel to the muscle fibres. [ 7 ]


In surgical and body contouring praxis, the plastic surgeon effects the implant-pocket undermining of the gluteus maximus muscle by carefully separating the muscle fibres to avoid severing the pertinent blood vessels, which would interfere with the blood irrigation of the muscle tissue. Therefore, to create an implant-pocket, either for a gluteal prosthesis or for lipoinjection, a low-angle muscle-dissection is performed in order to avoid the risk of severing any major branch— superior  or  inferior —of the gluteal artery, which travels very close to the  sacrum  and to the  sacrotuberous ligament . [ 4 ]


While the resolution of the defects and deformities of the  gluteal region  can be realized surgically, the assessment of the degree of severity of the injury organizes treatment therapies into three types: (i) buttocks augmentation,  (ii) buttocks reduction, and (iii) contour irregularity treatments that combine surgery and liposculpture ( liposuction  and fat-injection). [ 2 ]


The augmentation of the buttocks is realized with a  gluteal implant , which is emplaced under each  gluteus maximus muscle ; the insertion of the buttock prosthesis is through a midline incision (5–8-cm-wide) over the tailbone ( coccyx ). Augmentation with a gluteal implant is the method most effective for enlarging the buttocks of a patient whose body possesses few stores of excess  adipose fat  in the lower portion of the trunk, the  buttocks  and  thighs , the anatomic regions where the human body usually stores excess body fat. Post-operatively, because of the cutting (incising) into the flesh of the tailbone muscles, the full healing of the augmented tissues can be approximately 6–8 months, in the course of which the gluteal-muscle tissues relax, and the settled buttocks prostheses are integrated to the gluteal region. [ 8 ]  The implantation procedure can be performed upon a patient who is either  sedated  or  anaesthetized , either under  general anaesthesia  or under  local anaesthesia . The usual operating-room time for a buttocks augmentation procedure is approximately 2 hours. The procedure can be managed either as an overnight in-patient treatment or as a hospital outpatient treatment. Given the nature of the surgical incisions to the gluteus maximus muscles, the therapeutic management of post-surgical pain (at the surgical-wound sites) and normal tissue-healing usually require a 4–6-week convalescence, after which the patient resumes their normal-life activities. [ 2 ]


The augmentation and contouring of the buttocks with  autologous fat transfer  (lipoinjection) therapy is realized with the excess  adipose-fat tissue  harvested from the  abdomen , flanks, and  thighs  of the patient. In 1987 Dr. Eduardo Krulig, a Venezuelan plastic surgeon, described the technique, using the name "lipoinjection" for the first time, mentioning the regions of the body where the technique is useful. [ 9 ]  The gentle liposuction applied to harvest the autologous fat minimally disturbs the local tissues, especially the  connective-tissue layer  between the skin and the immediate subcutaneous muscle tissues. Then, the harvested fat is injected to the pertinent body area of the gluteal region, through a fine-gauge  cannula  inserted through a small surgical incision, which produces a short and narrow  scar . Lipoinjection contouring and augmentation with the patient's own body fat avoids the possibility of tissue rejection, and is physically less invasive than buttocks-implant surgery. Therefore, depending upon the health of the patient, the convalescence period allows them to resume daily, normal-life activities at 2-days post-operative, and the full spectrum of physical activity at 2-weeks post-operative. Furthermore, the liposuction harvesting of the patient's excess body fat improves the aesthetic appearance of the body fat donor-sites. [ 10 ]  Nonetheless,  physiologically , the human body's normal, health-management chemistry does resorb (break down and eliminate) some of the injected adipose-fat tissue, and so might diminish the augmentation. According to the degree of diminishment of the volume and contour caused by the fat-resorption, the patient might require additional sessions of fat-transfer therapy to achieve the desired size, shape, and contour of the buttocks. [ 2 ]


In common parlance, lipoinjection into the buttocks for aesthetic purposes is often called a "Brazilian butt lift" (BBL). [ 11 ]  This name is suggested to originate from the Brazilian surgeon  Ivo Pitanguy , who pioneered the surgery in the 1960s. The popularity of the surgery significantly increased during the 2010s as a result of social media trends. [ 12 ]


The augmentation of the buttocks, by rearranging and enhancing the pertinent muscle and fat tissues of the gluteal region, is realized with a combined gluteoplasty procedure of  surgery  (subcutaneous  dermal-fat flaps ) and  liposculpture  (fat-suction, fat-injection). Therapeutically, such a combined correction-and-enhancement procedure is a realistic and feasible lower-body-lift treatment for the patient who has undergone massive  weight loss  (MWL) in the course of resolving  obesity  with  bariatric surgery . [ 13 ] [ 14 ] [ 15 ]  In the case of the patient who presents under-projected, flat buttocks ( gluteal hypoplasia ), and a degree of gluteal-muscle ptosis (prolapsation, falling forward), wherein neither gluteal-implant surgery nor lipoinjection would be adequate to restoring the natural anatomic contour of the gluteal region, the application of a combined treatment of autologous dermal-fat flap surgery and lipoinjection can achieve the required functional correction and aesthetic contour. [ 2 ]


The methods for reducing the size of the buttocks include the varieties of  liposuction , such as  lipectomy  (with and without  ultrasonic  enhancement) to reduce excess body fat, and  superficial liposculpture , to reshape, refine, and re-establish the natural contour of the body. The usual buttocks-reduction treatment is lipectomy with applied  tumescence  and  anaesthesia , wherein the body fat is harvested by aspiration (suction) through a small-gauge cannula (2–4 mm) that is inserted through a small incision, either to the  intergluteal sulcus  (the butt-crack), or to the upper area of the  gluteus maximus muscle  proper. [ 2 ]


Ultrasonically assisted liposuction can quickly remove a large volume of  body fat  for the correction of a notable occurrence of  lipodystrophy , a deposit of adipose fat to the buttocks and related anatomic areas. The  ultrasonic  liposuction machine liquefies the excess fat tissue, and so more readily facilitates its removal with conventional suction-lipectomy. The quick fat-harvesting allowed by the ultrasonic lipectomy technique has eliminated the larger (long and wide) surgical incisions that once were required for removing a large volume of adipose tissue. Nonetheless, because of the sensitivity of the gluteal-region tissues, the skin of the pertinent donor-site is cooled in order to prevent ultrasonic heat damage caused by the liquefying and removal of the excess adipose fat. [ 2 ]


Reshaping the buttocks with liposculpture is performed with a small cannula (2 mm) specifically for contouring superficial body fat, the configuration of which (number of open ports) is determined by the type and the degree of gluteal correction to be realized. To sculpt rounded contours to square-shaped buttocks muscles, superficial liposculpture allows the plastic surgeon to control the injection-rate of the fat-volume. Moreover, superficial  liposuction  can be combined with other treatment methods for contouring the gluteal region to achieve the required functional, anatomic correction, and the aesthetic enhancement sought by the patient, such as reshaping the lateral area of the buttocks into an athletic form. [ 16 ] [ 17 ]  The study  Contouring the Gluteal Region with Tumescent Liposculpture  (2011) indicated that effective, gluteal-region contouring is best achieved by tailoring the liposuction-reduction and the lipoinjection-augmentation techniques to the anatomic topography of the body areas to be corrected. [ 18 ]  Furthermore, the study  Contouring of the Gluteal Region in Women: Enhancement and Augmentation  (2011) indicated that natural contours of the buttocks and the thighs are effectively achieved with a combined gluteoplasty of selective liposuction and lipoinjection, which reduces the need for aggressive surgical procedures, decreases the risk of medical complications, abbreviates wound-recovery-time, and lessens post-operative scarring. Combined with any buttocks-correction method, superficial liposculpture facilitates the treatment of contour irregularities, the surgical revision of scars, and the correction of gluteal-region contour depressions. [ 19 ]


To meet the functional requirements and the aesthetic expectations ( body image ) of the patient, the plastic surgeon establishes a realistic and feasible surgery plan by which to correct the anatomic contour deficiencies of the gluteal region. The surgeon and the patient determine the location of the surgical-wound  scars , and determine the best operative position, to allow the proper exposure of the pertinent anatomy to be corrected. Because the surgical procedure requires the  tumescence  and  anaesthesia  of the gluteal-region area to be corrected, the physician and the  anaesthesiologist  determine the volumes of the anaesthetic and  tumescent  fluids to be administered to the patient during the procedure, and so avoid the risks of drugs overdose and toxicity. [ 2 ]


Once the patient is atop the operating table, the surgeon positions him or her to best expose the pertinent gluteal-region area that is to be corrected or contoured, or both; the usual operative position is the prone (face down) position, but the patient can also be positioned laterally (on his or her side). The surgical correction plan can be delineated and marked to the patient's body when he or she is awake (before sedation or anaesthesia) or it can be delineated when the patient is on the operating table (already  sedated  or  anaesthetized ). In operative praxis, the second option allows the plastic surgeon greater freedom to properly manipulate the patient into the position best suited for performing the body-contouring surgery. [ citation needed ]


Once the patient is in the operative position, the surgeon begins the liposuction correction by making incisions to the marks of the surgical-correction plan, and then infiltrates (injects) a solution of anaesthesia- and tumescence-inducing drugs, usually a combination of  lidocaine  and  epinephrine . The volume of the anaesthetic-tumescent solution is gradually infiltrated to the pertinent gluteal area, in order to avoid the nerves and the deeper anatomic structures of the gluteus maximus muscle. The particular anatomic features to be contoured determine the types of cannula (gauge, size, grade) used to effect and control the harvesting of excess adipose fat from the patient's body. [ citation needed ]


For a lipoinjection augmentation, the surgeon first dissects and prepares the augmentation-pocket to which will be injected the autologous fat-tissue. The surgical creation (muscle dissection) of the augmentation-pocket avoids the gluteal innervation ( superior gluteal nerve  and  inferior gluteal nerve ) and the vascular system ( venous  and  arterial ) of the  gluteus maximus muscle . Afterwards, the surgeon  sutures  the dissection-incision and secures it with adhesive tape to ensure that the augmentation-pocket remains open, as dissected, ready to receive the injections of adipose fat. For the revision of scars, with surgery and injections of autologous fat, or with allopathic synthetic fillers, the surgeon applies subcuticular closures to the incision wounds, which then are bandaged. [ 2 ]


After completing the surgical corrections and the lipoinjection contouring of the pertinent area(s) of the gluteal region, the surgeon thoroughly examines the patient to ensure his or her general recovery from the operation; and examines each surgical incision to ascertain that it is correctly sutured and taped, in order to facilitate the uneventful healing of the gluteus-muscle tissues, without medical complications. The patient is advised to avoid exercise and strenuous physical activity until 3-weeks post-operative; how to properly care for surgical-incision wounds; and how to wear a compression garment that will keep in place the surgically corrected tissues, and so ensure their healing as a whole anatomic unit of the gluteal region. [ 2 ]


The physician advises the patient who has undergone a  surgical contouring  of the buttocks with gluteal implants, that, although immediate results can be observed, the final, corrected body contour usually is observed at 6-months post-operative, and at 1-year post-operative, depending upon the tissue-healing capabilities of the patient's body. The  liposculpture  patient usually requires approximately 6 months, and occasionally 1 year before producing the final, corrected body contour. For both procedures, at approximately 1-month post-operative, marked aesthetic improvement is noticeable in the corrected body areas, as is the elimination of the initial, post-operative weight gain caused by the body's retention of the infiltrated,  anaesthetic  and  tumescent , fluids. The patient is advised to wear a compression garment to contain swelling and to immobilize the corrected tissues, so that they heal as one anatomic unit of the gluteal region. Moreover, throughout the convalescence, to facilitate shrinking the skin to the new, corrected body contour, and to resolve unevenness, wrinkles to the skin, and localized swelling, the continual application of massage and (occasional) ultrasound treatments can facilitate the diminishment of the post-operative conditions. [ 2 ]


Of the three general methods of gluteal augmentation procedures, including implants, flaps and fat graft, a 2019 systemic literature review with meta-analysis of 46 publications revealed fat graft with the least complication rate (7%) while implants associated with highest complication rate (31%). [ 20 ]    The surgical and liposculpture contouring of the human body presents possible medical complications such as: the psychological—unmet  body image  expectations of aesthetic improvement; the physical—uneven contour, local and general; the physiologic—toxic reactions to the  anaesthesic  and the  tumescent  drugs; and the nervous— paresthesia , localized areas of perduring numbness in the corrected portion(s) of the gluteal region. [ 2 ]  The medical complications possible to a  surgical buttocks augmentation  procedure, the submuscular emplacement of a gluteal implant, include  infection ,  surgical-wound dehiscence  that exposes the implant, revision surgery, rupture of the implant,  seroma  (a pocket of clear serous fluid),  capsular contracture , asymmetry of the corrected area, shifting of the implant, surgical over-correction, injury to the  sciatic nerve , and  paresthesia  (tingling skin). The medical complications possible to a  liposculpture buttocks augmentation  include the bodily resorption of some of the injected adipose fat, asymmetric contour of the corrected body area, an irregular contour to the body, seroma,  abscess  (pus enclosed by inflamed tissue),  cellulitis  (subcutaneous connective-tissue inflammation), and paresthesia. [ 2 ]


Like most medical procedures, buttock augmentation come with risks some of which can be life-threatening. A total of 413 Mexican plastic surgeons reported 64 deaths related to liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent) occurred during lipoinjection, whereas the remaining five (38.4 percent) occurred within the first 24 hours. In Colombia, six deaths (77.7 percent) occurred during surgery and three occurred (22.2 percent) immediately after surgery. [ 21 ]  Secondary lymphoedema of the lower extremities has been reported as an unusual side effect of liquid silicone injection on the hips and buttock while thromboembolism, implant displacement and explosion has also been listed as some of the dangers. [ 22 ] [ 23 ]


In the surgical praxis of body contouring therapy, the patient's  body-image  expectations can be different from the contoured body that is the outcome of the performed surgical operation. Such unmet aesthetic expectations can be avoided at the pre-operative consultation stage, whereby, with informed consent, the physician and the patient jointly establish a realistic and feasible surgery plan to achieve a mutually satisfactory corrective outcome (functional and aesthetic) of the operation to the gluteal region, the buttock- and thigh-areas. [ 2 ]


Contour problems of the corrected gluteal region can be prevented with the operational use of small-gauge cannulas (ca. 2.0 mm) specifically for superficial liposuction; and with the application of cross-pattern harvesting of the excess body fat, to avoid removing too much  adipose fat  tissue, which might disfigure the contour of the patient's fat-donor area. The possible contour problems that might arise from ultrasonic liposuction are skin burns and hypertrophic scarring, which might occur if the fat-donor area skin is not cooled and protected during the fat harvest. To that end, the infusion of a tumescence-inducing solution to the fat-donor area(s) assists in cooling the patient's skin during the ultrasonic lipo-harvesting; likewise, the application of moist towels, a skin protector, and the constant cooling-fluid infiltration of the cannula in an integrated sheath. [ 2 ]


The infiltration of a solution of  anaesthesia - and  tumescence -inducing drugs can present medical complications such as a fluid overload of the tissues, the inadequate replacement of the infiltrated solution, and the partitioning (separation) of a single infiltration into several pools, which then are removed by suction lipectomy. Moreover, during anaesthesia, maintaining the patient's stable blood pressure can be difficult, which increases the possibility of bleeding, and the possibility that  anaesthetic toxicity  can occur if excessive doses are administered by infiltration; the symptoms are manifested as  central nervous system  (CNS) occurrences of drug-induced  anxiety , apprehension, restlessness, nervousness, disorientation, confusion, dizziness, blurred vision, tremors,  nausea , vomiting, shivering, and seizures; likewise, as manifestations of drowsiness, unconsciousness, respiratory depression, and respiratory arrest. Furthermore, the toxicity symptoms of a tumescence-inducing drug (e.g.  epinephrine ) might cause such CNS symptoms, for which reason the operative application of a tumescent drug is limited throughout the operation. [ 2 ]


Post-operatively, local areas of numbness ( paresthesia ) might occur in the contoured portion(s) of the gluteal region, and might perdure for a long time after the surgery. Hence, the patient is advised to facilitate the re-sensitizing of the numb area(s) with applications of gentle massage, to prevent the development of a  neuroma  complication, and to alleviate pain. Nonetheless, depending upon the tissue-healing capabilities of the patient, he or she can recover in full at 2-years post-operative. [ 2 ]


The outcome of a buttocks-contouring procedure depends upon the specific defect or deformity that can be effectively corrected with liposculpture,  ultrasonic  or not. Nonetheless, depressed scars and deep  morphological  defects are difficult to correct because of the curvature of the buttocks as an anatomic unit, and because of the scar-contracting elements of the tissues across the gluteal curvature. In such a case, although the injection of (autologous or artificial) tissue fillers to correct the defect or the deformity might be impermanent—it usually will remedy the functional and aesthetic shortcoming(s) required by the patient, which is the therapeutic purpose of gluteoplasty. [ 2 ]


In common parlance, "Brazilian butt lift" (BBL) is often used to describe  lipoinjection  into the buttocks for aesthetic purposes. [ 24 ]  This name is suggested to originate from the Brazilian surgeon  Ivo Pitanguy , who pioneered the surgery in the 1960s. The popularity of the surgery significantly increased during the 2010s as a result of social media trends. [ 25 ]


Catherine Cando  (June 7, 1995 – January 10, 2015) was an  Ecuadorean  beauty queen who won the Queen of  Durán   pageant . A prize for the winner was a free  liposuction procedure . Cando died as a result of  complications  during the operation.


Cando had no  weight problems  as child, and her sister-in law asked her to enter the Queen of Durán contest. There, she met Dr Ecuador, a  plastic surgeon  who worked with the Duran government and was a  judge  on the pageant's panel. Ecuador allegedly convinced Cando to undergo the liposuction after she had first refused, with promises that she might become his assistant at some later time (Cando wished to enter the medical field). Cando died on the operating table; Ecuador told Cando's family that the cause was brain  edema , but staff later stated the cause of death was  cardiac arrest  as the result of a botched operation. [ 1 ]


Cando's death sparked outrage in Ecuador against plastic surgery. [ 2 ] [ 3 ] [ 4 ]


This biographical article about a contestant in a beauty pageant is a  stub . You can help Wikipedia by  expanding it .


Cellulite  or  gynoid lipodystrophy  ( GLD ) is the  herniation  of subcutaneous  fat  within fibrous  connective tissue  that manifests as skin dimpling and  nodularity , often on the  pelvic  region (specifically the  buttocks ), lower limbs, and  abdomen . [ 1 ] [ 2 ]  Cellulite occurs in most postpubescent females. [ 3 ]  A review gives a prevalence of 85–98% of women of European descent, [ 4 ]  but it is considerably less common in women of East Asian descent. [ 5 ] [ 6 ]  It is believed to be  physiological  rather than  pathological . It can result from a complex combination of factors, including  diet ,  sedentary lifestyle ,  hormonal imbalance  or  heredity , among others.


The causes of cellulite include changes in  metabolism ,  physiology , diet and exercise habits, obesity, alteration of  connective tissue  structure,  hormonal  factors,  genetic  factors, the microcirculatory system, the  extracellular matrix , and subtle  inflammatory  alterations. [ 1 ] [ 3 ] [ 7 ]


Hormones play a dominant role in the formation of cellulite.  Estrogen  is thought to be an important hormone in the development of cellulite, and it has been proposed that an imbalance of  estrogen  relative to  progesterone  may be associated with cellulite. However, there has been no reliable clinical evidence to support the claim that  estrogen  levels are linked to cellulite, and many women with elevated estrogen levels do not get cellulite. [ 8 ]  Other hormones—including  insulin , the  catecholamines   adrenaline ,  cortisol  and  noradrenaline ,  thyroid hormones , and  prolactin —are believed to participate in the development of cellulite. [ 1 ]


There is a genetic element in individual susceptibility to cellulite. [ 1 ]  Researchers have traced the genetic component of cellulite to particular  polymorphisms  in the  angiotensin converting enzyme  ( ACE ) and  hypoxia-inducible factor 1A  ( HIF1a ) genes. [ 9 ]  Evidence for the heredity of cellulite is supported from studies showing that both the presence and degree of cellulite is similar between females within the same family. [ 6 ]


Several factors have been shown to affect the development of cellulite.  Sex ,  ethnicity ,  biotype , distribution of subcutaneous fat, and  predisposition  to  lymphatic  and circulatory insufficiency have all been shown to contribute to cellulite. [ 1 ]  It has been found to be considerably less common in women of East Asian descent, than in white women. [ 5 ]


A high- stress  lifestyle causes an increase in the level of  catecholamines , which have also been associated with the development of cellulite. [ 1 ]  Inactivity can cause vascular stasis, contributing to cellulite formation. [ 5 ]  Excessive carbohydrate consumption may also be related to cellulite in some instances. [ 5 ]


Cellulite can be resistant to a variety of treatments. [ 10 ]  Aside from "topical" products (creams,  ointments ) and injectables ( collagenase ), treatments for cellulite include  non-invasive therapy  such as mechanical suction or mechanical massage. Energy-based devices include  radio frequency  with deep penetration of the skin, ultrasound, [ 11 ]  cryotherapy chambers, [ 12 ]  laser and pulsed-light devices. [ 13 ] [ 14 ]  Combinations of mechanical treatments and energy-based procedures are widely used. [ 13 ]   Ionithermie , a form of  electrotherapy  using  electrical muscle stimulation , has been described as ineffective. [ 15 ] [ 16 ]  More invasive 'subcision' techniques utilize a needle-sized  microscalpel  to cut through the causative fibrous bands of connective tissue. Subcision procedures (manual, vacuum-assisted, or laser-assisted) are performed in specialist clinics with patients given local anaesthetic. [ 14 ]


In European populations, cellulite is thought to occur in 80–90% of post-adolescent females. [ 9 ] [ 17 ]  Its existence as a real disorder has been challenged, [ 18 ]  and the prevailing medical opinion is that it is merely the "normal condition of many women". [ 19 ]  It is rarely seen in males. [ 1 ]


The growing interest in cellulite has historically been linked to the growth of the cosmetic industry in the west, as well as globalization. The term was first used in the 1920s by spa and beauty services to promote their services, and began appearing in English-language publications in the late 1960s, with the earliest reference in  Vogue  magazine , "Like a swift migrating fish, the word  cellulite  has suddenly crossed the Atlantic." [ 20 ]  According to Italian researcher Martina Grimaldi, cellulite has often been pathologized as a "disease" in Western European news media, and it has been shown that French magazines promoting this misinformation are often funded by pharmaceutical companies that manufacture anti-cellulite skincare products. [ 21 ]  American journalist  Susan Faludi  notes that the Western beauty advertisements have attempted to portray cellulite as a symptom of women's social progress; that cellulite is caused by being a working, independent woman. Faludi writes that such messaging is motivated by a fear within the cosmetic industry that women's social progress might lead to declining profits in the beauty industry as a whole, noting that profits did decline in the 1970s and 1980s, the era of  second-wave feminism . [ 22 ]


Circumcision  is a  procedure  that removes the  foreskin  from the  human penis . In the most common form of the operation, the foreskin is extended with  forceps , then a circumcision device may be placed, after which the foreskin is  excised . Topical or locally injected  anesthesia  is generally used to reduce pain and  physiologic stress . [ 1 ]  Circumcision is generally  electively performed , most commonly done as a form of  preventive healthcare , as a  religious obligation , or as a  cultural practice . [ 2 ]  It is also an option for cases of  phimosis , other  pathologies  that do not resolve with other treatments, and chronic  urinary tract infections  (UTIs). [ 3 ] [ 4 ]  The procedure is  contraindicated  in cases of certain genital structure abnormalities or poor general health. [ 4 ] [ 5 ]


The procedure is associated with reduced rates of  sexually transmitted infections [ 6 ]  and  urinary tract infections . [ 1 ] [ 7 ] [ 8 ]  This includes reducing the incidence of  cancer-causing  forms of  human papillomavirus  (HPV) and reducing  HIV transmission  among  heterosexual men  in high-risk populations by up to 60%; [ 9 ] [ 10 ]  its prophylactic efficacy against HIV transmission in the  developed world  or among  men who have sex with men  is debated. [ 11 ] [ 12 ] [ 13 ]  Neonatal circumcision decreases the risk of  penile cancer . [ 14 ]  Complication rates increase significantly with age. [ 15 ]  Bleeding, infection, and the removal of either too much or too little foreskin are the most common acute complications, while  meatal stenosis  is the most common long-term. [ 16 ]  There are various  cultural, social , and  ethical  views on circumcision. Major medical organizations hold variant views on the strength of circumcision's prophylactic efficacy in developed countries. Some medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while other medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. [ 17 ] [ 18 ] [ 19 ] [ 20 ]


Circumcision is one of the world's most common and oldest medical procedures. [ 2 ]  Prophylactic usage originated in  England  during the 1850s and subsequently widely spread, becoming predominately established as a way to prevent sexually transmitted infections. [ 21 ] [ 22 ]  Beyond use as a prophylactic or treatment option in healthcare, circumcision plays a major role in many of the world's cultures and religions, most prominently  Judaism  and  Islam . Circumcision is among the  most important commandments in Judaism . [ 23 ] [ 24 ]  In some  African  and  Eastern Christian denominations  male circumcision is an established practice, and require that their male members undergo circumcision. [ 25 ] [ 26 ]  It is widespread in Australia, Canada, the United States, South Korea, most of Africa, and parts of Asia. [ 2 ]  It is relatively rare for non-religious reasons in parts of Southern Africa, Latin America, Europe, and parts of Asia. [ 2 ]  The origin of circumcision is not known with certainty, but the oldest documentation comes from  ancient Egypt . [ 2 ] [ 27 ] [ 28 ]


Around half of all circumcisions worldwide are performed for reasons of prophylactic healthcare. [ 4 ]


There is a consensus among the world's major medical organizations and in the academic literature that circumcision is an efficacious intervention for HIV prevention in high-risk populations if carried out by medical professionals under safe conditions. [ 30 ] [ 12 ] [ 9 ]


In 2007, the WHO and the  Joint United Nations Programme on HIV/AIDS  (UNAIDS) stated that they recommended adolescent and adult circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV, as long as the program includes " informed consent ,  confidentiality , and absence of  coercion " — known as voluntary medical male circumcision, or VMMC. [ 30 ]  In 2010, this was expanded to routine neonatal circumcision, as long as those undergoing the procedure received assent from their parents. [ 18 ]  In 2020, the World Health Organization again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. As a result, the promotion of prophylactic circumcision has been a priority intervention in that region since the WHO's 2007 recommendations. [ 30 ] [ 18 ]  The International Antiviral Society–USA also suggests circumcision be discussed with  men who have insertive anal sex with men , especially in regions where HIV is common. [ 31 ]  There is evidence that circumcision is associated with a reduced risk of HIV infection for such men, particularly in low-income countries. [ 6 ]


The finding that circumcision significantly reduces female-to-male HIV transmission has prompted medical organizations serving communities affected by endemic HIV/AIDS to promote circumcision as an additional method of controlling the spread of HIV. [ 19 ]


Major medical organizations hold varying positions on the  prophylactic efficacy  of the elective circumcision of minors in the context of  developed countries . [ 19 ]  Literature on the matter is polarized, with the cost-benefit analysis being highly dependent on the kinds and frequencies of health problems in the population under discussion and how circumcision affects them. [ 20 ] [ 32 ] [ 33 ]


The  World Health Organization  (WHO),  UNAIDS , and American medical organizations take the position that it carries prophylactic health benefits which outweigh the risks, while European medical organizations generally hold the belief that in these situations its medical benefits are not counterbalanced by risk. [ 17 ] [ 18 ] [ 19 ] [ 20 ]  Advocates of circumcision consider it to have a net health benefit, and therefore feel that increasing the circumcision rate is "imperative". [ 34 ]  They recommend performing it during the neonatal period when it is less expensive and has a lower risk of complications. [ 32 ]  The  American Academy of Pediatrics ,  American College of Obstetricians and Gynecologists ,  and  Centers for Disease Control and Prevention  stated that the potential benefits of circumcision outweigh the risks. [ 1 ] [ 35 ] [ 36 ]


The World Health Organization in 2010 stated: [ 18 ]


There are significant benefits in performing male circumcision in early infancy, and programmes that promote early infant male circumcision are likely to have lower morbidity rates and lower costs than programmes targeting adolescent boys and men. [ 18 ]


Circumcision is also used to treat various pathologies. These include pathological  phimosis , refractory  balanoposthitis  and chronic or recurrent  urinary tract infections  (UTIs). [ 3 ] [ 4 ]


Circumcision is  contraindicated  in certain cases. [ 5 ] [ 4 ] [ 37 ]


These include infants with certain  genital  structure abnormalities, such as a misplaced  urethral opening  (as in  hypospadias  and  epispadias ), curvature of the head of the penis ( chordee ), or  ambiguous genitalia , because the foreskin may be needed for reconstructive surgery. Circumcision is contraindicated in  premature  infants and those who are not clinically stable and in good health. [ 5 ] [ 4 ] [ 37 ]  If an individual is known to have or has a family history of serious bleeding disorders such as  hemophilia , it is recommended that the blood be checked for normal  coagulation  properties before the procedure is attempted. [ 4 ] [ 37 ]


The  foreskin  is the double-layered fold of tissue at the distal end of the  human penis  that covers the  glans  and the  urinary meatus . [ 2 ]  For adult medical circumcision, superficial wound healing takes up to a week, and complete healing 4 to 6 months. For infants, healing is usually complete within one week. [ 37 ]


For infant circumcision,  devices  such as the  Gomco clamp ,  Plastibell  and  Mogen clamp  are commonly used in the USA. [ 1 ]   These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial  orifice  to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin ( preputial epithelium ) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a  dorsal slit ), which remains until blood flow has stopped. Finally, the foreskin is  amputated . [ 1 ]  For older babies and adults, circumcision is often performed surgically without specialized instruments, [ 37 ]  and alternatives such as  Unicirc  or the  Shang ring  are available. [ 38 ]


The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes, [ 39 ]  so the use of  analgesia  is advocated. [ 1 ] [ 40 ]  Ordinary procedural pain may be managed in  pharmacological  and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. [ 1 ] [ 41 ] [ 42 ]  The  ring block  and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than  EMLA  (eutectic mixture of local anesthetics) cream, which is more effective than a  placebo . [ 41 ] [ 42 ]  Topical creams have been found to irritate the skin of  low birth weight  infants, so penile nerve block techniques are recommended in this group. [ 1 ]


For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a  sucrose  or non-sucrose pacifier are more effective at reducing pain than a placebo, [ 42 ]  but the  American Academy of Pediatrics  (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques. [ 1 ]  A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell. [ 42 ]  The available evidence does not indicate that post-procedure pain management is needed. [ 1 ]   For adults,  topical anesthesia , ring block, dorsal penile nerve block (DPNB) and  general anesthesia  are all options, [ 43 ]  and the procedure requires four to six weeks of abstinence from  masturbation  or intercourse to allow the wound to heal. [ 37 ]


Neonatal circumcision is generally a safe, low-risk procedure when done by an experienced practitioner. [ 44 ] [ 45 ] [ 46 ]


Male circumcision reduces the risk of  human immunodeficiency virus (HIV) transmission  from HIV positive women to men in high risk populations. [ 47 ] [ 48 ]


In 2020, the  World Health Organization  (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. [ 49 ]


Human papillomavirus  (HPV) is the most commonly transmitted  sexually transmitted infection , affecting both men and women. While most infections are  asymptomatic  and are cleared by the  immune system , some types of the virus cause  genital warts , and other types, if untreated, cause various forms of cancer, including  cervical cancer  and  penile cancer . Genital warts and cervical cancer are the two most common problems resulting from HPV. [ 52 ]


Circumcision is associated with a reduced  prevalence  of  oncogenic  types of HPV infection, meaning that a randomly selected circumcised man is less likely to be found infected with cancer-causing types of HPV than an uncircumcised man. [ 53 ] [ 54 ]  It also decreases the likelihood of multiple infections. [ 7 ]  As of 2012 [update] , there was no strong evidence that it reduces the rate of new HPV infection, [ 8 ] [ 7 ] [ 55 ]  but the procedure is associated with increased  clearance  of the virus by the body, [ 8 ] [ 7 ]  which can account for the finding of reduced prevalence. [ 7 ]


Although genital warts are caused by a type of HPV, there is no  statistically significant relationship  between being circumcised and the presence of genital warts. [ 8 ] [ 54 ] [ 55 ]


Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have, generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of  syphilis ,  chancroid , and possibly genital  herpes . [ 56 ]  A 2010 review found that circumcision reduced the incidence of  HSV -2 (herpes simplex virus, type 2) infections by 28%. [ 57 ]  The researchers found mixed results for protection against  trichomonas vaginalis  and  chlamydia trachomatis , and no evidence of protection against  gonorrhea  or syphilis. [ 57 ]  It may also possibly protect against syphilis in MSM. [ 58 ]


Phimosis is the inability to retract the foreskin over the glans penis. [ 59 ]  At birth, the foreskin cannot be retracted due to  adhesions  between the foreskin and glans, and this is considered normal (physiological phimosis). [ 59 ]  Over time the foreskin naturally separates from the glans, and a majority of boys are able to retract the foreskin by age three. [ 59 ]  Less than one percent are still having problems at age 18. [ 59 ]  If the inability to do so becomes problematic (pathological phimosis) circumcision is a treatment option. [ 3 ] [ 60 ]  This pathological phimosis may be due to scarring from the skin disease  balanitis xerotica obliterans  (BXO), repeated episodes of  balanoposthitis  or forced retraction of the foreskin. [ 61 ]   Steroid  creams are also a reasonable option and may prevent the need for surgery including in those with mild BXO. [ 61 ] [ 62 ]  The procedure may also be used to prevent the development of phimosis. [ 4 ]  Phimosis is also a complication that can result from circumcision. [ 63 ]


An inflammation of the glans penis and foreskin is called balanoposthitis, and the condition affecting the glans alone is called  balanitis . [ 64 ] [ 65 ]  Most cases of these conditions occur in uncircumcised males, [ 66 ]  affecting 4–11% of that group. [ 59 ]  The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially  Candida albicans , are the most common penile infection and are rarely identified in samples taken from circumcised males. [ 66 ]  Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. [ 64 ] [ 65 ]  Circumcision is a treatment option for refractory or recurrent balanoposthitis, but in the twenty-first century the availability of the other treatments has made it less necessary. [ 64 ] [ 65 ]


A UTI affects parts of the  urinary system  including the  urethra ,  bladder , and  kidneys . There is about a one percent risk of UTIs in boys under two years of age, and the majority of incidents occur in the first year of life. There is good but not  ideal evidence  that circumcision of babies reduces the incidence of UTIs in boys under two years of age, and there is fair evidence that the reduction in incidence is by a factor of 3–10 times (100 circumcisions prevents one UTI). [ 1 ] [ 67 ] [ conflicted source ] [ 68 ]  Circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects, [ 1 ]  and may be used to treat recurrent UTIs. [ 3 ]


There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the  urinary meatus ) hosts more urinary system disease-causing bacteria in uncircumcised boys than in circumcised boys, especially in those under six months of age. As these bacteria are a risk factor for UTIs, circumcision may reduce the risk of UTIs through a decrease in the bacterial population. [ 1 ] [ 68 ]


Not being circumcised is the primary  risk factor  for  penile cancer . [ 69 ] [ 70 ]  Pre-adolescent circumcision has a strong protective effect against penile cancer in later life. [ 14 ]  Penile cancer is a rare disease in the  developed world  but much more prevalent in the  developing world . [ 14 ]  The penile tissue removed during circumcision is a potential origin for penile cancer. [ 71 ]  Risk-benefit considerations around the use of circumcision as a cancer-preventive measure are a source of debate. [ 69 ]


Penile cancer development can be detected in the carcinoma  in situ  (CIS) cancerous precursor stage and at the more advanced invasive squamous cell carcinoma stage. [ 1 ]   There is an association between adult circumcision and an increased risk of invasive penile cancer; this is believed to be from men being circumcised as a treatment for penile cancer or a condition that is a precursor to cancer rather than a consequence of circumcision itself. [ 72 ]  Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally. [ 59 ]


Important risk factors for penile cancer include phimosis and HPV infection, both of which are mitigated by circumcision. [ 72 ]  The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis are equally likely to have penile cancer as circumcised men. [ 1 ] [ 72 ]  Circumcision is also associated with a reduced prevalence of cancer-causing types of HPV in men [ 7 ]  and a reduced risk of cervical cancer (which is caused by a type of HPV) in female partners of men. [ 4 ]


There is some evidence that circumcision is associated with reduced risk of  prostate cancer . [ 73 ]


A 2017 systematic review found consistent evidence that male circumcision prior to heterosexual contact was associated with a decreased risk of cervical cancer,  cervical dysplasia , HSV-2, chlamydia, and syphilis among women. The evidence was less consistent in regards to the potential association of circumcision with women's risk of HPV and HIV. [ 74 ]


The accumulated data show circumcision does not have an adverse physiological effect on sexual pleasure, function, desire, or fertility. [ 75 ] [ 76 ]  There is some evidence that circumcision has no effect on  pain with intercourse ,  premature ejaculation ,  intravaginal ejaculation latency time ,  erectile dysfunction  or difficulties with  orgasm . [ 77 ]


According to a 2014 review, the effect of circumcision on sexual partners' experiences is unclear as this has not been well studied. [ 78 ]   According to a policy statement from the  Canadian Paediatric Society  that was reaffirmed in 2021, [ 79 ]  "medical studies do not support circumcision as having an impact on sexual function or satisfaction for partners of circumcised individuals". [ 76 ]


There are popular misconceptions that circumcision benefits or adversely impacts the sexual pleasure of the circumcised person. [ 76 ]


The most common acute  complications  are bleeding, infection and the removal of either too much or too little foreskin. [ 1 ] [ 80 ]  These complications occur in approximately 0.13% of procedures, with bleeding being the most common acute complication in the United States. [ 80 ]  Minor complications are reported to occur in three percent of procedures. [ 45 ]  Severe complications are rare. [ 63 ]  A specific complication rate is difficult to determine due to scant data on complications and inconsistencies in their classification. [ 1 ]  Complication rates are greater when the procedure is performed by an inexperienced operator, in unsterile conditions, or when the child is at an older age. [ 15 ]  Significant acute complications happen rarely, [ 1 ] [ 15 ]  occurring in about 1 in 500 newborn procedures in the United States. [ 1 ]  Severe to catastrophic complications, including death, are so rare that they are reported only as individual case reports. [ 1 ] [ 46 ]  Where a Plastibell device is used, the most common complication is the retention of the device occurring in around 3.5% of procedures. [ 16 ]  Other possible complications include  buried penis ,  chordee , phimosis,  skin bridges , urethral fistulas, and  meatal stenosis . [ 46 ]  These complications may be partly avoided with proper technique, and are often treatable without requiring surgical revision. [ 46 ]  The most common long-term complication is meatal stenosis, this is almost exclusively seen in circumcised children, it is thought to be caused by ammonia producing bacteria coming into contact with the meatus in circumcised infants. [ 16 ]  It can be treated by  meatotomy . [ 16 ]


Effective pain management should be used during the procedure. [ 1 ]  Inadequate pain relief may carry the risks of heightened pain response for newborns. [ 39 ]  Newborns that experience pain due to being circumcised have different responses to vaccines given afterwards, with higher pain scores observed. [ 81 ]  For adult men who have been circumcised, there is a risk that the  circumcision scar  may be tender. [ 82 ]  There is no good evidence that circumcision affects cognitive abilities. [ 83 ]


Circumcision is the oldest known surgical procedure. [ 84 ]  Depictions of circumcised penises are found in  Paleolithic art , [ 85 ]  predating the earliest signs of  trepanation . [ 84 ] [ 86 ]


The history of the migration and evolution of circumcision is known mainly from the cultures of two regions. In the lands south and east of the Mediterranean, starting with Central Sahara, Sudan and Ethiopia, the procedure was practiced by the  ancient Egyptians  and the  Semites , and then by the Jews and Muslims. In Oceania, circumcision is practiced by the  Australian Aboriginals  and  Polynesians . [ 87 ]  There is also evidence that circumcision was practiced among the  Aztec  and  Mayan  civilizations in the Americas, [ 2 ]  but little is known about that history. [ 27 ] [ 28 ]


It has been speculated that circumcision originated as a substitute for  castration  of defeated enemies or as a  religious sacrifice . [ 28 ]  In many traditions, it acts as a  rite of passage  marking a boy's entrance into  adulthood . [ 28 ]


At  Oued Djerat , in  Algeria , engraved rock art with masked bowmen, which feature male circumcision and may be a scene involving ritual, have been dated to earlier than 6000 BP amid the  Bubaline Period ; [ 88 ]  more specifically, while possibly dating much earlier than 10,000 BP, rock art walls from the Bubaline Period have been dated between 9200 BP and 5500 BP. [ 89 ]  The cultural practice of circumcision may have spread from the Central  Sahara , toward the south in  Sub-Saharan Africa  and toward the east in the region of the  Nile . [ 88 ]  Based on  engraved  evidence found on walls and evidence from  mummies , circumcision has been dated to at least as early as 6000 BCE in  ancient Egypt . [ 90 ]  Some  ancient Egyptian mummies , which have been dated as early as 4000 BCE, show evidence of circumcision. [ 87 ] : 2–3  [ 91 ]


Evidence suggests that circumcision was practiced in the Middle East by the fourth millennium BCE, when the  Sumerians  and the Semites moved into the area that is modern-day Iraq from the North and West. [ 27 ]   The earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankh-Mahor at  Saqqara , dating to about 2400–2300 BCE. Circumcision was possibly done by the Egyptians for hygienic reasons, but also was part of their obsession with purity and was associated with spiritual and intellectual development.  No well-accepted theory explains the significance of circumcision to the Egyptians, but it appears to have been endowed with great honor and importance as a  rite of passage , performed in a public ceremony emphasizing the continuation of family generations and fertility.  It may have been a mark of distinction for the elite:  the Egyptian  Book of the Dead  describes the sun god  Ra  as having circumcised himself. [ 28 ] [ 87 ]


Circumcision is prominent in the  Hebrew Bible . [ 92 ]  In addition to proposing that circumcision was adopted by the Israelites purely as a religious mandate, scholars have suggested that Judaism's patriarchs and their followers adopted circumcision to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice. [ 27 ] [ 87 ] [ 93 ]


Historical campaigns of  ethnic, cultural, and religious persecution  frequently included bans on circumcision as a means of  forceful assimilation, conversion, and ethnocide . [ 94 ]   Alexander the Great  conquered the Middle East in the fourth century BCE, and in the following centuries ancient Greek cultures and values came to the Middle East. The Greeks abhorred circumcision, making life for circumcised Jews living among the Greeks and later the Romans very difficult. [ 94 ]   Restrictions on the Jewish practice  by European governments have occurred several times in world history, including the  Seleucid Empire  under  Antiochus IV  and the  Roman Empire  under  Hadrian , where it was used as a means of  forceful assimilation and conversion . [ 94 ]  Antiochus IV's restriction on Jewish circumcision was a major factor in the  Maccabean Revolt . [ 94 ]   Hadrian 's prohibition has also been considered by some to have been a contributing cause of the  Bar Kokhba revolt . [ 94 ]  According to Silverman (2006), these restrictions were part of a "broad campaign" by the Romans to "civilize" the Jewish people, viewing the practice as repulsive and analogous to  castration . [ 94 ]  His successor,  Antoninus Pius , altered the edict to permit  Brit Milah . [ 94 ]  During this period in history, Jewish circumcision called for the removal of only a part of the prepuce, and  Hellenized  Jews often attempted to look uncircumcised by stretching the extant parts of their foreskins. This was considered by the Jewish leaders to be a serious problem, and during the second century CE they changed the requirements of Jewish circumcision to call for the complete removal of the foreskin, [ 95 ]  emphasizing the Jewish view of circumcision as intended to be not just the fulfillment of a Biblical commandment but also an essential and permanent mark of membership in a people. [ 87 ] [ 93 ]


A narrative in the Christian  Gospel of Luke  makes a brief mention of the  circumcision of Jesus , but physical circumcision is not part of the received teachings of Jesus.  Circumcision has  played an important role  in  Christian history  and  theology .  Paul the Apostle  reinterpreted circumcision as a spiritual concept, arguing literal circumcision to be unnecessary for Gentile converts to Christianity. The teaching that circumcision was unnecessary for membership in a divine covenant was instrumental to the separation of Christianity from Judaism. [ 96 ] [ 97 ]  While the circumcision of Jesus is celebrated as  a feast day  in the  liturgical calendar  of many  Christian denominations . [ 97 ]


Although it is not explicitly mentioned in the  Quran  (early seventh century CE), circumcision is considered essential to Islam, and it is nearly universally performed among Muslims.  The practice of circumcision spread across the Middle East, North Africa, and Southern Europe with Islam. [ 98 ]


Genghis Khan  and the following Yuan Emperors in China forbade Islamic practices such as  halal  butchering and circumcision. [ 99 ] [ 100 ]