Objective To analyze the clinical effect of autologous fat grafting combined with abdominal and flank liposuction in gluteal shaping. Methods A total of 80 female patients with flat buttocks and localized fat accumulation in the waist and abdomen admitted to Chinese Doctor's Union Plastic and Beauty Hospital from January 2024 to December 2025 were selected as the research subjects. According to the random number table method, they were divided into the control group and the observation group, with 40 patients in each group. The control group received abdominal and flank liposuction, and the observation group received autologous fat grafting on the basis of the control group. The morphological indicators, overall aesthetic improvement, satisfaction and complication rate were compared between the two groups. Results At 6 months after operation, the hip circumference of the observation group was larger than that of the control group, the increment of hip circumference and improvement rate of waist-to-hip ratio (WHR) were higher than those in the control group, and the WHR was lower than that in the control group (P <0.05). There was no significant difference in waist circumference between the two groups (P >0.05). At 6 months after operation, the GAIS score of the observation group was higher than that of the control group (P <0.05). The satisfaction rate in the observation group (92.50%) was higher than that in the control group (75.00%) (P <0.05). There was no significant difference in the incidence of complications between the two groups (P >0.05). Conclusion For female patients with flat buttocks and localized fat accumulation in the waist and abdomen, autologous fat grafting combined with abdominal and flank liposuction can achieve comparable waist volume reduction, further increase gluteal volume, optimize WHR and overall aesthetic evaluation, and improve patient satisfaction, with acceptable safety.