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C. Khorsandi
things they are not interested in. Thus we can deduce that in these geographically
isolated communities, some underlying drive collectively brought artists to sculpt
what they believed to be important.
Further evidence in the archaeological record exists for the fascination of the
female buttocks. Nefertiti, the Egyptian Queen of fourteenth century BC was considered to be one of the most beautiful woman of her time. Her name literally translates to: “a beautiful woman has come.” The notion of this idea has resonated
throughout history to the present so much so that the famous bust of her face was
adopted by the American Society of Aesthetic Plastic Surgery to be the symbol of
their group. While many may associate the image of Nefertiti with her face alone, a
statue unearthed, which now stands in the Louvre, shows that Nefertiti possessed a
round, projected buttocks. A tribute yet again to that which is considered desirable.
If we were to travel back in time to visit our hominid ancestors prior to bipedal
ambulation, we would see that in the process of walking on all four limbs results in
the buttocks and the genitalia being prominently displayed from behind. In order for
a species to survive, procreation is an imperative drive, and this instinct needs no
instruction, as we see throughout all of nature. From a complex interplay of olfactory, visual, tactile, and other sensory cues, males will invariably seek a place to
give action to their procreative drive, whether real or in some cases an imitation
of such.
Take for instance the spider orchid, this remarkable ower has evolved to not
only look like a female wasp, but to also secrete a pheromone that mimics a solitary
female wasp. The effect it has is to lure naive males to the ower in an attempt to
mate with it. The result is a fooled wasp but a potentially pollinated ower. This
remarkable example of natural mimicry can be seen in many parts of nature, but to
narrow our focus a bit, let us refer to the idea of the female human breast.
I have been asked to present this concept at several meetings around the world
and during this lecture I play a game with my audience. To illustrate that we as
humans are susceptible to biologic mimicry, I show a series of photos with the
majority of the image obscured, except for two areas of esh pressed up against
each other. I poll the audience as to whether they believe this is a picture of a buttocks or a pair of breasts. As they respond to the revealed images alternating from a
buttocks to breast, the certainty of the audience begins to diminish as to what’s
behind the rest of the picture. In my last slide I show an obscured close-up image of
my index nger closed in a tight st, and showing the middle and proximal phalanges pressed up against each other. When I reveal to the audience that this is neither
a buttocks nor a breast, but my own hand, made to look like a buttocks, the room
generally erupts into laughter, a sure sign a new information is being assimilated.
So what, you may ask, does breast aesthetics and mimicry have to do with gluteal
aesthetics? Evidence suggests that a relative enlargement of the female breast size
compared to other primates occurred around the time when our ancestors began
walking upright. During this period, the female genitalia became hidden between
the legs and oriented downward as bipedal ambulation led to far more face-to-face
interactions. While the lactiferous tissue of the breast serves a logical function for
rearing young, the fatty tissue of the breast can range in proportion from a small
2 The Buttocks: Anthropologic andCultural Evolution
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33
percentage to greater than half the volume of the breast and this serves no functional
purpose. When viewed from the front, however, a remarkable natural mimicry of the
gluteal area can be evident, especially when presented as cleavage with the rest of
the breast obscured in clothing.
In one of our close primate relatives, the bonobo, female breasts sometimes
approximate the shape and appearance of human female breasts. Bonobos can walk
upright for short distances, and are considered to be extremely social creatures.
Bonobos live in highly sexualized communities, where not only is face-to-face copulation common, but the act of copulation is also frequently used to solve disputes,
form bonds, and socialize. Perhaps the bonobo is subjected to the dual stimulations
of seeing the genitalia, when walking on all fours, and also being subjected to seeing the breasts when face to face. One can only speculate.
For humans, the female breast has been deemed a sexualized organ and its display in public considered to be taboo in most societies throughout history. Even to
this day the breast is considered to be provocative, and best left covered in most
common activities. But why? The female breast is not a true sexual organ, you cannot procreate with a breast, and surprisingly there are very few instances in which a
bare male chest is considered to be taboo. Yet the female breast is undeniably triggering for most individuals, and this is may be due to its form and natural mimicry
of the buttocks, the area between which procreation is done.
It serves a female wishing to attract the attention of males, much like the spider
orchid, to make a display of exaggerating things, and one way in which modern
humans have accomplished this is through their clothing. Today as it was for much
of modern human history, clothing is much more than a protection from the elements, as it often serves as decoration. Since we reasonably can attribute the physical enhancement of the body through plastic surgery to the last 100years, we must
wonder how our ancestors made a show of things, so to speak. I propose that If you
want to know about a society, study the way in which it dresses.
Around the turn of the nineteenth century a phenomenon began, in which women’s dresses were made to enhance the appearance of the female form, by the use of
various materials and styles. It started out rather tamely in 1811 with the regency
dress. This garment used tufted material on the back of the dress to create a wider
backside than the relatively at embroidered front. As we progress through the
1800s we see a continued exaggeration of this theme. In the 1830s dresses used
gored panels to narrow the waist and pleated rows of fabric to widen the hips. In the
early Victorian era of the 1840s dresses began to compound the fabric with paddings
on the hips and back side with more pleated fabric. The exaggeration continued into
the 1850s with ever more fabric, creating dresses with the lower half three to four
times the diameter of the waist. The limits of fabric only techniques were reached in
the 1860s when metal ttings such as the elliptical loop were added to support even
more fabric. The 1870s and 1880s saw the advent of the bustle, a remarkable dress
in which the width was tamed and the posterior projection was made round and
highly exaggerated.
In the famous painting “A Sunday Afternoon on the Island of La Grande Jatte”
by George Seurat, a scene depicting the bourgeoise of Paris enjoying a sunny day is
34
C. Khorsandi
highlighted by a female in the foreground wearing a typical bustle. She is accompanied by a well-dressed man holding a cigar and with a cane tucked upright under his
arm. Art historians have suggested that this woman is a courtesan, a prostitute associated with the upper class, and the image of the young girl in the center of the
painting, dressed in a simple white dress, staring out at the viewer, is the criticism
of this society and its sexualized dress. Some may beg to differ, but it is likely Seurat
was drawing attention to the concepts that higher society seemed to overlook in the
name of fashion.
But what sparked this trend in clothing styles and textile enhancements of the
female form? Around the time of the regency dress in 1815, Napoleon was defeated
at Waterloo, and the control of Africa goes to England, and the Dutch. With this, the
colonization of Africa begins. Through the exploration of Africa, Europeans came
into contact with societies that had been isolated from them for many thousands of
years. One particular group of individuals in the southern part of Africa displayed a
phenotypic variance that sparked the interest of these colonial Europeans.
The Khoi-san, Bantu, and Hottentot peoples of southern Africa have an inherited
characteristic called Steatopygia. Considered a sign of beauty in these cultures, the
typical features are a relatively large collection of adipose in the buttocks and hips,
extending sometimes to the knees. For early explorers these people’s appearance
differed from what they had been accustomed to. As many atrocities occurred during the colonial period in Africa, several of the women were forcibly taken from
these tribes to Europe, to be part of traveling shows as entertainment. One woman
in particular, Sarah Baartman, became a sensation, engendering many writings and
recreations of her image in throughout Europe. It is precisely this exposure, at this
time in history, which likely led to the change in woman’s fashion across the continent. European woman and men fascinated with the sexualized nature of the
Steatopygic body sought to recreate the look with needle, thread, and, later, the
metal frame.
Just as exposure to the Steatopygic people led to a change in the concepts of
fashion in the 1800s, a corollary to this has occurred in more modern times. Over
the past decade we have seen a surge in procedures aimed at enhancing, augmenting, and restoring the youthfulness to the aged buttocks. But why did this trend take
so long to form, and where did the impetus for such a change come from? We once
again must look at the cross-cultural pollination of ideas to grasp its roots.
In South America and particularly in Brazil where the festival of Carnivale is
celebrated with bombastic air, we see that the notion of a large rounded buttocks is
not only cherished but in some ways held to be central to the desirable traits of the
female form. Woman of all ages, are seen dressed in attire that leaves the buttocks
exposed and there are even beauty contests for the most beautiful buttocks. We see
this notion predate the rise in gluteal enhancement procedures and it may have
something to do with the ethnic makeup of the Brazil.
Looking to the makeup of which peoples settled in South America, we see that it
is comprised of a very ethnically diverse population of Native American, Caucasian,
African, and Asian. Nearly one half of the population is of mixed or African ancestry, but not just any African ancestry. From 1518 to 1850 nearly 11 million African
2 The Buttocks: Anthropologic andCultural Evolution
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35
people were stolen from their homes and brought to the new world. An analysis of
the slave trading routes shows that the majority of those who were brought to South
America originated from the southern part of Africa, from the areas in which
Steatopygia was endemic. In contrast the slaves brought to North America generally
were taken from the northern and western parts of Africa. A difference that led to
the traits of Steatopygia becoming part of the genetic tapestry of South American life.
As these peoples ourished and thrived in relative isolation, a new wave of immigration from South America to the United States in the early 1990s, particularly to
South Florida, led to Americans coming into contact with South Americans and
their aesthetic values. The introduction of the thong bikini and the generously sized
buttocks no doubt left an impression of tourists to the beaches of Miami, in much
the same way that the Europeans of the 1800s were fascinated with the peoples of
Africa. This in turn spurred demand for procedures that would allow those who
were less endowed to seek a physical change.
In South America many surgeons were already performing buttocks augmentation with silicone implants and to a lesser degree, fat transfer. However, it wasn’t
until more recently that the term Brazilian Butt Lift was coined by an American
surgeon looking to capitalize on the trend. From there we see a complex interplay
of many factors leading to the rise of demand.
For one, pop cultural milestones opened the door to openly and publicly considering the buttocks as an object of desire. In 1992, the Hip Hop Artist known as Sir
Mix A Lot released a song extolling his love of woman’s butts. The chorus of “I like
big butts, and I cannot Lie,” led the song to receive the Grammy Award for Best Solo
Performance, and 2.9 million copies being sold, the second best-selling song of the
year. This tongue-in-cheek song begins with two Caucasian women disparaging a
woman who has a curvy body with a large buttocks. It drew a stark contrast between
cultural lines in America, and seeded the idea that there was something wrong with
those who did not appreciate the beauty of the buttocks.
At around the same time we see the inuence of the Hip Hop industry and the
Black community as a whole softening the cultural divisions present for much of
American history. Public opinion of interracial marriage crosses a milestone in 1994
with more Americans approving of interracial marriage than disapproving of it.
Interracial marriage itself increases on larger scale in the ensuing years and with it
diversity of aesthetic concepts.
Humans like our bonobo cousins are extraordinarily social creatures and as such
we often take our cues from others in how to act, dress, and look. In the 2000s we
begin to see the wholesale change in attitudes toward a more Steatopygic form.
Celebrities such as Jennifer Lopez and Kim Kardashian become as much known for
their buttocks as anything else. Reality TV catapults us toward the idea of watching
other people in their daily life, followed by the advent of social media and mobile
technology delivering these cues directly into our daily life and at the press of a button. The rapidity of this change cannot be understated. Today my ofce is awash
with individuals who have made an entire career of using the appearance of the buttocks to make money. I no longer have patients bringing in pictures of celebrities to
emulate. Instead they tap on their phones and pull up a collection of images of
36
C. Khorsandi
seemingly unknown woman from social media whose buttocks they wish to have. It
is easy to understand why.
Social media has provided social pressure. On a typical platform, individuals
who post alluring images of themselves are instantly rewarded with positive feedback in the form of “likes.” Comments take the form of patronage to these image
and, occasionally, a negative comment is placed by a disagreeable person, which is
often rapidly deleted. By contrast, posts from a provocateur that talk about ideas and
speak of the mundane often get little response. Thus a cycle of behavior and drive
has become xed. While mainstream social media platforms do not allow for nudity
or sexual content, a rise of private web services linked to social media have provided
a means for individuals to monetize their appearance from the comfort of their own
home. These services charge a fee to view content and they have seen a tenfold rise
in creators over the Covid-19 pandemic, hoping to cash in on their looks. One site,
in particular, at the time of this writing called OnlyFans.com has over one million
content creators, and over 50 million subscribers. This social pressure along with
nancial incentive is driving more and more patients to their plastic surgeon, hoping
to stand out from the crowd.
The question that is often asked regarding gluteal augmentation is: “How long
this trend will last.” However the question is awed in assuming that the desire to
augment the buttocks is merely a trend, one that will see beauty ideals swing in the
opposite direction, to smaller, less rotund, less buoyant buttocks. It is unlikely that
we will ever see the demand for gluteal augmentation change. As we have seen
throughout history, the biological drives and underlying functional imperative will
keep us grounded in the notion that a shapely buttocks is a desirable trait. The
degree of augmentation and restoration will invariably differ between individuals
and cultures, but the fundamental principle will always remain the same.
Chapter 3
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Artistic Anatomy oftheGluteal
andLumbosacral Area
StefanDanilla
The female gluteal area has been a cardinal beauty zone of attraction since the
beginning of civilization and artists have focused on gluteal anatomy for more than
2000years (Fig.3.1).
Usually, anatomy is taught in medical school and surgery residency by layers of
tissue, blood supply, and innervation but without emphasizing the tridimensionality
of the structures (Fig.3.2).
The gluteal area does not correspond to a single structure but several structures
that involve bones, muscle, subcutaneous fat, and skin.
Cuenca-Guerra, Mendieta, and De la Peña have contributed to the understanding
of the esthetic traits in a beautiful buttocks, that summarized are:
• Four main determinants of the gluteal esthetics are:
– Bony structure: the pelvis shape greatly inuences the perception of beauty.
There are four shapes A, V, circular, and square pelvis. “A” shape and circular
shape are the most esthetic ones.
– Gluteus maximus muscle: the greater the development of the mass of the glu-
teus maximus and
– Subcutaneous fat compartment
– Skin.
The anatomical structures surrounding the gluteal region also are important for
the correct esthetic proportions of the buttocks: the waist, lower back, sacral area,
and thighs must be treated in order to achieve a natural harmonic result. For example, a big buttocks with thin thighs created by fat graft buttocks alone are called ant
deformity, because of the unnatural appearance that it gives to the patient.
S. Danilla (*)
Plastic Surgery Unit, Surgery Department, University of Chile, Santiago, Chile
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_3
37
38
Fig. 3.1 Aphrodite
Kallipygos or Callipygian
Venus
S. Danilla
In Fig.3.3 a picture of a model with esthetical ideal buttocks without cosmetic
surgery can be seen. Clearly an A shape pelvic framework with adequate proportional and symmetric development of all muscles in the back, gluteal region, and
thigs, thin and even fat pad distribution, and turgid elastic skin.
3 Artistic Anatomy oftheGluteal andLumbosacral Area
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Fig. 3.2 Traditional
anatomical drawing
Fig. 3.3 Fitness woman
without surgeries
39
In order to clearly understand the supercial tridimensionality of the posterior
female body, it is useful to study from an artistic approach, from lines of rst dimension, to shapes in second dimension to the volume of the tridimensional approach
that plastic surgery requires.
In the sketch, the silhouette of a woman with a beautiful body is drawn, with
adequate proportions of waist and hip, buttocks and thighs is evident (Fig.3.4a).
40
ab
cd
S. Danilla
Fig. 3.4 (a) Silhouette of tness woman. (b) Sketch marks of muscular groups. (c) Muscular
volume of tness woman. (d) Actual picture of tness woman
3 Artistic Anatomy oftheGluteal andLumbosacral Area
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41
Adding some lines between major muscle groups add denition and sensation of
depth in the gure: posterior belly of the deltoid, midline from interscapular line to
L4–5 is drawn, the lateral border of the paravertebral muscles, the posterior superior
iliac spine (dimples of Venus), and insertion of the gluteus major in the inferolateral
border of the sacrum and iliac crests (Fig.3.4b).
An adequate blending of the major lines, valleys and the muscle group between
them, hills, creates tridimensionality, the surgeon can create or accentuate the anatomy by carving the subcutaneous fat or adding volume by fat grafting or implants
(Fig.3.4c).
Applying those concepts to a real patient can improve the results of the surgery
(Fig.3.4d).
Liposuction of the supercial fat in posterior belly of the deltoid, midline, insertion of the gluteus major muscle in the sacrum, posterior iliac spine, and iliac crest
is marked in green (Fig.3.5a).
Deep fat of the posterior arm and anks must be removed to reveal anatomy of
the underlying muscles (Fig.3.5b).
Preserving the fat over the paravertebral muscles can contribute to enhance the
muscular appearance of the lower and middle back. The buttock area can be
improved by adding volume through implants or fat grafting according to the surgeon’s preferences and patient result desire (Fig.3.5c).
The lateral aspect of the buttock can vary depending on the muscularity of the
patient and ethnic differences. In a woman with hip muscle hypertrophy and lean
subcutaneous fat in the hips, a lateral depression can be noticed (Fig.3.6).
The lateral depression is created by the bulkiness of the gluteus major muscle,
gluteus medius, tensor of fascia lata, and the depression of the iliotibial tract
(Fig.3.7).
abc
Fig. 3.5 (a) Negative zones (supercial liposuction). (b) Debulking areas (deep liposuction). (c)
Positive areas of fat grafting or implants
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