Cover Story | February 2014 Plastic Surgery Practice

On the Mark

M. Mark Mofid, MD, gets behind gluteal augmentation MarkMofidMD 007

By Denise Mann

The headlines are bold, brash, and alarming:

Fake Doctor Used “Fix-A-Flat” for Woman’s Butt Lift

Woman Loses Limbs After Botched Butt Implant

And who could ever forget the YouTube video sensation where a woman literally flipped her oversized butt implant for the camera?

Gluteal augmentation—whether with implants, fat, or other substances—is rarely in the news for anything good. For these reasons, San Diego-based plastic surgeon M. Mark Mofid, MD, knows what he is up against when he discusses the anthropologic origins and safety profile of buttock augmentation. It’s an uphill battle, but Mofid is helping to alter the perception of his peers with some meticulous research and innovations that he pioneered.

Of course, there’s more to the Harvard and Johns Hopkins-trained surgeon’s aesthetic practice than just gluteal augmentation. However, his approach to perfecting this particular procedure helps illustrate his surgical skill and proclivity as well as his outside-the-box way of thinking.

Mofid is contemplative, conservative, and confident in his approach to buttock augmentation with implants.

“I place only intramuscular implants, and I never overdo it even if patients try to push for larger implants,” he tells Plastic Surgery Practice.

And push for them, they do. Some even beg. “Many patients believe that it will add to their fame and notoriety if they go larger.” In reality, this only increases the risk of complications, he says.

There is no line in the sand with Mofid. He won’t go bigger than 330 cc, and subfascial placement is out of the question. “Large implants have higher rates of palpability, incisional separation, and malposition,” he says. “Gravity will eventually move these implants to an inferior position where the implant hangs over the butt fold,” he says.

That’s not to say implants are the go-to procedure for anyone who seeks bigger buttocks. Fat grafting is an easier surgery with a shorter recovery time, but there are limits to what you can do with fat alone.

FROM DIY TO DESIGNER BUTTOCK IMPLANTS

When he first began performing buttock augmentation with implants around 8 years ago, Mofid was frustrated with what the off-the-shelf solid silicone implants could offer a deficient derriere. The bottom line at the time was that available implants were just too large for intramuscular placement. “For a number of years, I carved every one down before surgery, which was time-consuming,” he recalls.

So what did he do? Mofid designed a Low Profile Round Gluteal Implant for Implantech that solves two of his most vexing problems. It provided a more tapered profile and shape to ease intramuscular positioning and an improved base width-to-volume ratio for a more proportional outcome. They just don’t look fake, and after performing countless procedures and revision butt augmentation surgeries, he has a keen eye for what does. (Mofid does not receive any royalties from Implantech.)

By his own (and objective) accounts, Mofid learned his butt augmentation technique from the best: Raul Gonzalez, MD, a plastic surgeon in Ribeirao Preto, Brazil, who began performing buttock surgery in 1984 and has the largest case series in the world. Really, where better than Brazil to learn about buttock augmentation?

Brazil is always ahead of the curve when it comes to body contouring surgery, and Gonzalez predicts that the buttock implant craze is just beginning its ascent in America.

“The first step is to believe that buttocks implants, when well done, have an amazing low rate of complications and wonderful results,” he says.

In Brazil, a significant number of surgeons are now well-trained in buttock augmentation, which has increased demand. In 2012, buttock implants surgery in Brazil increased more than 300%—and more than 20,000 patients were operated on, he says.

“The demand for this procedure in America is not so big because the supply is tiny, but [increase] the supply of well-prepared surgeons and surely the market will grow as never imagined,” Gonzalez says.

THE PLAYBOY PARADIGM

Mofid, along with a select few other surgeons in the US, will likely lead the charge here. Right now, the numbers do not compare to those in Brazil. The American Society of Plastic Surgeons reports that there were just 858 buttock implant procedures performed in 2012, which is down 25% since 2011.

Changes in technique may help increase the operation’s popularity, Mofid says.

“From the time we were trained until a few years ago, we weren’t really paying full attention to the aesthetics of what we were doing,” he says. “For example, when performing an abdominoplasty as part of a mommy makeover, we were not really doing the woman a favor unless we recreated the silhouette that existed before pregnancy and kids.”

The question then becomes, how do you recreate the silhouette, and do so consistently with reliable results? To answer this, he conducted a study comparing the waist-to-hip ratio and weight of all Playboy magazine centerfolds from 1953 onward, and found that there is a well-preserved waist-to-hip ratio of 0.68. This was the same across all Centerfolds regardless of body mass indexes.

“Similar to the Fibonacci sequence or golden ratio, I consider this to be an aesthetic ideal,” he says. This finding most likely has sociocultural routes, he adds. “Women with narrow waists and wide hips are more fertile, and primates engage in front and back intercourse, so the buttock is a pathway for females to show males they are interested,” he says. Male attraction to the buttocks may be a vestigial instinct, he says.

INNOVATIONS ABOUND

He takes the same thoughtful and analytic approach to all of the procedures that he performs.

Take blepharoplasty, for example. “The way I was trained over a decade ago was to aggressively excise tissue and fat,” he recalls.

But that was then.

Now it is rare to remove nearly as much skin, muscle, and fat in lower blepharoplasty. “We are respecting fat in eyelid surgery and doing more repositioning and providing more support.” He often addresses the lower eyelid transorally. “When I do midface endoscopic surgery, it is very easy to reposition lower eyelid fat. We zip the septum open and reposition undereye fat with great results.” Mofid was the first to publish on this novel technique in Aesthetic Plastic Surgery.

He thinks about things from all different angles, and doesn’t accept something just because it is widely favored. Though he was among the first to present and publish on revisionary cosmetic breast surgery using acellular dermal matrix products, now he’s thinking differently about breast procedures and moving away from biologics due to the advent of non-tissue-based resorbable synthetic meshes or bioinductables, such as Allergan’s Seri scaffold, Novus Scientific’s Tigr Mesh, and Bard Davol’s Phasix Mesh. “The techniques in breast reconstruction and revisionary breast surgery have evolved far more rapidly than the products to support them.

“Acellular dermal matrix, xenografts, allografts, and the like have higher rates of seroma and infection in most studies and are non-standardized in terms of thickness and revascularization,” he says. So far, there does not seem to be an increased risk of seroma with these new bioinductable meshes.

“The biologics are also more expensive to manufacture and need to be tracked. Some need to be kept refrigerated,” he says. By contrast, the resorbable synthetic meshes can be used for breast reconstruction and abdominal wall reinforcement after pedicle and free transverse rectus abdominus myocutaneous (TRAM) flaps, deep inferior epigastric perforators (DIEP) flaps, and for hernia repair. “They also have a role revisionary cosmetic breast surgery and to reinforce periareolar mastopexies.”

Mofid has recently developed a procedure and training video using the new Seri scaffold that prevents nipple areola complex dilatation after circumareolar mastopexies. “These ‘bioinductive’ meshes use the host to repopulate the scaffold and replace it with tissue of fascia-like strength and ultimately degrade and disappear. What could be better than that!” If there is something, count on Mofid to find it.

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at dmann@allied360.com.

Original citation for this article: Mann, D. On the mark: M. Mark Mofid, MD, gets behind gluteal augmentation, Plastic Surgery Practice. 2014; February: 12-17