Current Knowledge and Future Perspectives of Buttock Augmentation: A Bibliometric Analysis from 1999 to 2021

Publications were downloaded from the Web of Science Core Collection (WOSCC) database using the following search terms: TS = (gluteoplasty) OR (gluteal myoplasty) OR (buttock myoplasty) OR (gluteal augmentation) OR (buttock augmentation) OR (gluteal implant) OR (buttock implant) OR (gluteal lipoaugmentation) OR (buttock lipoaugmentation) OR (buttock fat grafting) OR (gluteal fat grafting). On July 15, 2022, the database was searched, and the publications included in the analysis comprised only original research articles and reviews published in English. The search indicated that the first article on buttock augmentation in WOSCC was published in 1999. Hence, we used 1999 as the starting point of the search year and 2021 as the end point of the search year and analysed all publications.

Two researchers independently selected and collected the literature and cross-checked references, and any conflicts were resolved by the senior researcher after reading the full text for inclusion in the study. Study data included: country/region, institution, author, journal, keywords, number of annual publications, and number of publications by the authors. The data were downloaded in plain text format. The h-index is a new method for assessing academic achievement. The h-index can precisely reflect one’s academic achievement. The “impact factor (IF)” of the journals and “Quartile” in the category were also obtained and utilized to estimate the scientific impact of the country/region. The obtained data are presented in tables and figures using Microsoft Excel 2016.

VOSviewer (1.6.18), a free JAVA-based software, was developed in 2009 by Van Eck and Waltman of The Centre for Science and Technology Studies (CWTS), Leiden University, The Netherlands. Compared to other bibliometric software, the best application of VOSviewer is its graphical presentation capability, adaptability for large-scale data, and versatility in adapting to multiple databases with varied formats of source data [6, 7]. The core concept of VOSviewer software design is “co-occurrence clustering”, which means that two things appearing at the same time are related to each other; there are multiple types of such related relationships with different strengths and directions; clustering is based on measures of relationship strengths, and directions allow for the identification of different types of groups. Circles and labels form an element, and the size of the element depends on the size of the node, the strength of the link, the number of citations, etc. The colour of the element represents the cluster it belongs to, different clusters are represented by different colours, and each cluster can be seen through this view. Total link strength (TLS) indicates the degree of cooperation between an item and other items, and its value is proportional to the level of cooperation.

The publications were distributed in 55 countries/regions. Figure 2 depicts the annual growth trend of buttock augmentation publications of the top 10 countries/regions. The top 10 countries/regions with the most publications are shown in Fig. 3, with the USA producing the highest number of buttock augmentation publications than any other country. Table 1 displays the extensive data about the top 10 countries/regions with the most publications. The USA had the highest number of relevant publications (208, 42.28%), followed by Germany (41, 8.33%), Brazil (39, 7.93%), England (28, 5.69%), and Mexico (23, 4.67%). Figure 4 depicts the network visualization map of countries/regions involved in buttock augmentation research, with the size of the circular nodes representing the number of publications published by the corresponding countries and the connecting lines between the nodes representing the collaboration relationship between countries/regions. The USA has the most number of publications (208), the most collaborating countries (19), TLS (713), and total citations (4015), suggesting that the USA is a major contributor to buttocks research and has a high academic reputation. The USA has far more publications in this field than any other country, five times more than Germany (the second highest number of publications). Moreover, Italy has the highest number of citations per publication (CPP: 29.94).

All publications were distributed among 778 institutions. The top 10 institutions with the most publications are listed in Table 2. The leading institution was New York University (60 publications, 12.20%), followed by Louisiana State University (50 publications, 10.16%), University Estado Rio De Janeiro (40 publications, 8.13%), Rutgers New Jersey Medical School (35 publications, 7.11%), and Ohio State University (35 publications, 7.11%). Most of the 10 institutions with the highest output of buttock augmentation-related publications were from the USA, indicating the strong academic influence of the USA in this field. Louisiana State University (USA) had the highest number of citations per publication (9.14), indicating that this institution publishes a large number of high-quality publications and is a major contributor to the development of the field.

The visualization of the network of collaborating institutions based on the number of citations is depicted in Fig. 5, with a minimum unit of measurement of five for each institution’s publications and a total of 14 nodes, with the lines between the nodes representing collaborative relationships, divided into four clusters. Figure 5 shows that the leading institutions collaborating with New York University are Louisiana State University, Rutgers New Jersey Medical School, University of Texas Southwestern Medical Center, Dallas, University of Sao Paulo, and University of California San Diego.

A total of 2058 authors have published articles on the augmentation of the buttocks. The top 10 authors with the most publications and co-cited authors are listed in Table 3. Cardenas-Camarena (9 publications, 1.83%) published the most papers, followed by Aboudib JH (7 publications, 1.42%) and Serra F (6 publications, 1.22%). The top three co-cited authors were Cardenas-Camarena (158 citations, TLS: 1993), Gonzalez R (118 citations, TLS: 1398), and Mofid MM (158 citations, TLS: 821). Cardenas-Camarena is the most published and co-cited author in buttock augmentation-related publications, indicating his high academic achievement in this field. Figure 6 depicts the network visualization of co-cited authors, using a minimum co-citation count of 20 as the unit of measurement. A total of 56 authors satisfied the condition, and the analysis results showed four clusters, with the largest nodes representing the most co-cited, namely Coleman SR (cluster 1, red areas, 16 items), Gonzalez R (cluster 2, green areas, 16 items), Cardenas-Camarena (cluster 3, blue areas, 15 items), and Allen RJ (cluster 4, yellow areas, 8 items).

A total of 206 journals published on buttock augmentation. Tables 4 and 5 show the top 10 most published and most co-cited articles on buttock augmentation. Plastic and Reconstructive Surgery (66 publications, 13.41%) published the most publications in this field, followed by Aesthetic Surgery Journal (38 publications, 7.72%) and Aesthetic Plastic Surgery (38 publications, 7.72%). The top three most co-cited journals were Plastic and Reconstructive Surgery (2200 citations, TLS: 39,999), Aesthetic Plastic Surgery (831 citations, TLS: 16,880), and Aesthetic Surgery Journal (716 citations, TLS: 15,868). Plastic and Reconstructive Surgery is the most productive and co-cited journal in this field, indicating that this journal can serve as a quality information resource for researchers studying the augmentation of buttocks. The network visualization of co-cited journals is shown in Fig. 7.

A visual network map of co-cited references in this field with 30 nodes, three different coloured clusters, and 2783 links is depicted in Fig. 8. The size of the nodes indicates the number of citations of the publication. Table 6 summarizes the top 10 most co-cited articles based on the title, author, journal, impact factor, number of citations, year of publication, and Quartile in category. According to the top 10 most co-cited references, the article “Intramuscular gluteal implants” published in Aesthetic Plastic Surgery (IF: 2.708), was the most co-cited article. The article is authored by Vergara R et al. and co-cited 46 times. The next most co-cited articles were “Gonzalez et al., 2004, Aesthet Plast Surg”, “Mofid et al. “Cardenas-Camarena et al., 2015, Plast Reconstr Sur”, and “Gonzalezulloa et al., 1991, Aesthet Plast Surg”. More than half of the articles were published in Q1 (Quartile in category). There are three clusters, and an evaluation of the leading publications in each cluster reveals that they correspond to three research hotspots: experience and technology of buttock augmentation (Cluster 1, red area), autologous fat buttock augmentation and its safety (Cluster 2, green area), and buttock aesthetics study (Cluster 3, blue area) (Fig. 8).

A total of 2252 keywords were mentioned in 492 publications. The annual keywords publication output of the buttock augmentation research is depicted in Fig. 9. The analysis was performed using 135 keywords (used at least five times). Figure 10 demonstrates the network analysis map of keywords co-occurrence, with 135 items and eight clusters. Each item is represented by a node, and the node’s size indicates the frequency of the corresponding keyword in the field. The larger the node, the more relevant research around the keyword. The thicker the line between the two nodes, the greater the frequency of these two keywords in the subject area, and the greater the relationship between the two keywords. The keyword analysis can quickly identify the research hotspots in the field. Obvious keywords can help researchers and non-researchers quickly identify hot topics in literature research.

According to Fig. 10, the most frequently used keywords are “augmentation”, “complications”, “gluteoplasty “, “liposuction”, “gluteal augmentation”, “buttocks “, “implants”, “surgery”, “experience”, “experience “management”, “outcomes”, “efficiency”, “safety “. The different colour clusters correspond to different themes of the study. Different colour clusters are connected by lines to indicate their cross-correlation. According to Fig. 10, there are 8 related themes by colour, and “gluteoplasty” is the largest theme (Cluster 1, 49 occurrences ,TLS:229), containing 24 items, followed by “ implants” (Cluster 2, 35 occurrences ,TLS:107), “reconstruction” (Cluster 3, 18 occurrences ,TLS:31), and “efficacy” (Cluster 4, 23 occurrences ,TLS:92), “complications” (Cluster 5, 52 occurrences ,TLS:213), and “ outcomes” (Cluster 6, 24 occurrences ,TLS:74), “ augmentation” (Cluster 7, 61 occurrences , TLS:219), “ experience” (Cluster 8, 28 occurrences ,TLS:135).

Figure 11 depicts the timing analysis of keywords co-occurrence of buttock augmentation research. The marks in the lower right corner of the figure indicate that we can judge the hotness of keywords in different periods based on their colour, and the nodes close to yellow indicate the hot keywords with high frequency in recent years, further indicating the development direction of research trends in this field. According to the time-series map, the research trends of buttock augmentation are focused on silicon implant, safety, satisfaction, and autologous fat grafting.

According to the analysis of the co-cited reference network shown in Fig. 8, there are currently three research hotspots in this field: experience and technology of buttock augmentation (Cluster 1, red area), autologous fat buttock augmentation and its safety (Cluster 2, green area), and buttock aesthetics study (Cluster 3, blue area).

“Experience and technology of buttock augmentation” (Cluster 1) has the largest number of publications, with articles describing surgical techniques and sharing experiences in buttock augmentation. In the second most co-cited article, Gonzalez et al. [10] presented the “XYZ technique”, which is worth promoting since it allows for safe intragluteal muscle separation based on anatomical localization points, allowing for a perfect implant space and avoiding complications. In the fifth most co-cited article, González-Ulloa et al. [11] presented a follow-up study of patients who underwent gluteomyoplasty ten years ago, including patients with unilateral gluteus atrophy and bilateral improvement of gluteal shape, and discovered that all patients maintained good gluteal shape ten years after surgery, with the satisfaction of both patients and physicians. Furthermore, Serra et al. [12] detailed the fundamentals of gluteal anatomy and gluteal augmentation techniques to help plastic surgeons perform gluteal augmentation by identifying anatomical reference points.

“Autologous fat grafting for buttock augmentation and its safety” (Cluster 2) has shown that fat grafting to fill the buttocks, in addition to buttock augmentation with implants, is a popular procedure. Toledo et al. [13] described a thirty-year experience in Brazil with buttock augmentation by fat grafting by removing the arm, back, waist, and abdominal fat. The fat was processed, centrifuged, and injected for transplantation into the buttocks with good therapeutic effectiveness. Roberts et al. [14] used autologous microfat grafting to address the external part of the buttocks and external thighs that could not be improved by implants. This method achieved excellent outcomes. The articles with the third and fourth highest number of co-cited articles reported analysis of fat injections in the gluteal region that resulted in death, with all patients dying due to fat embolism. It also suggested that fat injections should be administered slowly, in small amounts, repeatedly, and in multiple planes, avoiding injections into the deep muscle planes of the gluteus maximus [8, 15].

The “Buttock Aesthetics Study” (Cluster 3) demonstrated that plastic surgeons and beauty enthusiasts are exploring the aesthetics of the buttocks. A full and well-rounded buttock is a defining trait and one of the secondary sexual characteristics of women. In 1993, Singh et al. [16] conducted an in-depth study on female body aesthetics and concluded that a waist-to-hip ratio of 0.7 was a widely accepted aesthetic criterion. According to body surface markings, Cuenca-Cuerra et al. [17] proposed a set of aesthetic criteria where the greater trochanter of the femur was labelled A, the most prominent point of the pubic mound was labelled B, the most prominent point of the buttocks was labelled C, and the anterior superior iliac spine was labelled D. The study also concluded that the ideal buttock form is AC:AB equals 2:1. Subsequently, Cuenca-Cuerra and Lugo-Beltran [18] concluded that a ideal buttock should have four “depressions”: the lateral depression, the short inferior gluteal fold, the superior gluteal fossa, and the V-shaped groove at the sacral triangle. Mendieta CG et al. [19] proposed a more comprehensive aesthetic assessment system and classified buttock morphology into four types: A, V, circular, and square.

According to the keyword timing (Fig. 11), the research trends include the following: silicone implant, safety, satisfaction, and autologous fat grafting.

In North America, the law forbade silicone implants for buttock augmentation, and hence, only elastic implants were used. However, patients often complained of discomfort because the implants were too hard [20]. Although breast implants can also produce better buttock augmentation outcomes, their capsule membranes have shown to be weak and prone to rupture and leakage [21, 22]. Nowadays, with a full range of buttock implants, including circular and anatomical shapes, glossy and frosted surfaces, silicone rubber, and silicone gel, the development of buttock augmentation surgery has been as complete as that of breast implants [23, 24]. It is expected that further research will be conducted in support of silicone buttock implants in the future.

Safety is a priority concern for patients seeking beautiful buttocks simultaneously. Cárdenas-Camarena et al. [8] analysed and reported the causes of death due to buttock fat injections performed in Mexico and Colombia. A total of 13 of the 64 deaths related to liposuction reported in Mexico were caused by buttock fat injections, while nine deaths in Colombia were caused by fat embolism. Mofid et al. [15] also reported on the mortality of buttock fat grafting and detailed some techniques to improve the safety of the procedure. Furthermore, complications of buttock augmentation surgery are also within the scope of safety examination. Incisional dehiscence is the most common complication following buttock augmentation with implants. In the published literature, Sinno et al. [25] collected 2375 cases of buttock augmentation, with a 9.6% incidence of postoperative incisional dehiscence. Another study has shown incidences of incisional dehiscence up to 30% after buttock augmentation with implants [26]. Cárdenas-Camarena et al. [27] showed a 4.4% probability of seroma after buttock augmentation. The rate of infection after buttock augmentation with implants was 3.2% [28]. The overall incidence of implant displacement, ectopic position, rotation, or buttock asymmetry was about 2.3% [24]. The incidence of contracture of the buttock implant envelope was 3.5% [29]. Condé-Green et al. [30] performed a meta-analysis of postoperative complications in 4084 patients who underwent autologous lipofilling of the buttocks. The incidence of each complication was seroma (2.40%), rash (1.30%), pain (0.76%), morphological abnormalities (0.64%), and fat necrosis (0.56%), in that order.

Satisfaction, the ultimate criterion for evaluating the outcome of buttock augmentation, is closely related to safety, complications, and postoperative experience of the procedure. With the increasing number of buttock augmentation procedures, there is an urgent need to explore a standardized method for measuring patient satisfaction.

First reported in 1990 by Chajchir without a detailed description of the case, autologous fat grafting for buttock augmentation is an evolving field [31]. Subsequently, the use of autologous fat grafting for buttock augmentation has been reported successively [32, 33]. Currently, for patients with lateral thigh depressions that cannot be covered by implants, autologous fat grafting of the buttocks has become the predominant buttock augmentation approach. Its most significant advantage is that the entire buttock can be finely shaped by liposuction and fat injection, with few complications and minimal surgical scarring [34]. According to the American Society for Aesthetic Plastic Surgery 2018 data, 94% of buttock augmentation procedures are autologous fat-filled buttock augmentation, and only 6% are implants [35].

The study assessed the current status of buttock augmentation research, research hotspots, and research trends through bibliometric analysis. However, there are some limitations in the study; the analysis of this study retrieved content only from the English language publications in the WOSCC database, causing language bias; this study has omitted publications that are not included in the WOSCC database. Furthermore, with the increased number of publications related to buttock augmentation in recent years, some newly published high-quality publications have low citation frequency and are easily missed.