No procedure in plastic surgery has been more scrutinized and defamed in recent history than the Brazilian butt lift (BBL), which transfers fat from areas of excess into the butt and hips, for a fuller, shapelier look. Following a spate of highly publicized deaths, the procedure has been relentlessly studied, dissected, and refined over the past several years by BBL leaders—many of whom believe the procedure has now, at last, righted its reputation.
Aiming to further enhance the procedure’s safety profile, new BBL guidelines were recently announced at the 2022 meeting of The Aesthetic Society (coinciding with their publication in the Aesthetic Surgery Journal). Per the latest recommendations, plastic surgeons should routinely use ultrasound guidance when placing and navigating the cannula during fat injection to ensure they’re in a safe plane, and they should perform no more than three BBLs per day, to minimize fatigue-related mistakes.
The guidelines are based on findings gathered by the Working Group on BBL Patient Safety, which was assembled by The Aesthetic Society in 2021, to protect patient welfare. According to the group’s first advisory, “the majority of BBL deaths [in Florida] occur at the end of the week. Such a non-normalized distribution most likely represents the result of fatigue and/or distraction, which has been linked to surgical mortality in multiple published communications. In addition, mortality is likely due to uncertainty or lack of documentation as to the correct plane of fat injection.” (Injecting into or below the muscle can cause fatal complications.)
Before we explore the full scope of the BBL’s safety shift, let’s catch you up on the problems that have been plaguing the procedure for the past few years and explain why the BBL surgery death rate is a hot topic.
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BBL dangers and risks revealed and researched
In 2015, a PRS study entitled Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong?, led by Dr. Lázaro Cárdenas-Camarena, a board-certified plastic surgeon in Zapopan, Mexico, captured the attention of plastic surgeons worldwide. “That was the alarm bell—he warned everyone that there was something going on,” says Dr. Simeon Wall Jr., a board-certified plastic surgeon in Shreveport, Louisiana. Dr. Cárdenas-Camarena and his coauthors analyzed a series of deaths resulting from BBLs performed by legitimate plastic surgeons in Mexico and Colombia over spans of 10 and 15 years, respectively. In all cases, fat was injected into the gluteal muscles and the patients died of pulmonary fat embolism (PFE).
“Two things have to happen for a pulmonary fat embolism to occur,” explains Dr. Pat Pazmiño, a board-certified plastic surgeon in Miami. “A vein in [or below] the gluteus maximus muscle has to be injured, and fat has to enter that vein. Once it does, it can travel throughout the body and end up in the lungs, with a tragic consequence”—death from respiratory and heart failure.
In 2016, the Aesthetic Surgery Education and Research Foundation (ASERF) assembled the Gluteal Fat Grafting Task Force—tapping doctors from leading plastic surgery organizations such as The Aesthetic Society, the American Society of Plastic Surgeons (ASPS), and the International Society of Aesthetic Plastic Surgeons (ISAPS)—to investigate BBL dangers and offer safety strategies.
The task force conducted an anonymous survey of 4,843 plastic surgeons worldwide; 692 surgeons responded. A paper published in the Aesthetic Surgery Journal in 2017 heralded their findings: 32 deaths from fat emboli, including 25 deaths in the United States between 2011 and 2016.
Related: The Brazilian Butt Lift Consultation Checklist
How many people die from BBL procedures?
Surgeons who reported injecting fat into the muscle “experienced a 403% increase in the risk of pooled fatal and nonfatal PFEs.” The task force calculated the BBL death rate to fall between 1 in 6,214 and 1 in 2,351 cosmetic surgery patients—a range that’s since been averaged out to the oft-quoted BBL mortality rate of 1 in 3,000.
While some plastic surgeons have been quick to point out the survey’s limitations, its key takeaway has been widely accepted: fat should be placed only in the subcutaneous space above the gluteal muscles, and it should never cross the fascia covering the muscles in a safe BBL. (Subsequent studies—here and here—have shown how fat injected beneath the fascia can migrate through the muscle under pressure, raising the risk of PFE.) “If you stay subcutaneous, your chance of getting fat into the deep vessels is zero—you should never have a PFE,” says Dr. Wall.
The report recommended additional safety measures as well, such as using rigid large-diameter cannulas (tubes used to place fat), injecting slowly with the cannula in motion, and—of critical importance—being acutely aware of the location of the cannula’s tip throughout surgery: “It’s about seeing the cannula tip right underneath the skin—that’s how you know you’re in a safe plane,” explains Dr. Constantino Mendieta, a board-certified plastic surgeon in Miami.
In the past few years, BBL thought leaders have conducted pivotal safety studies and attended autopsies of patients lost to PFE to gain a clearer understanding of gluteal anatomy and danger zones, so BBL risk can be reduced. “We’ve observed seven autopsies under the Miami medical examiner, and we’ve taken those findings into the cadaver labs, where we’ve replicated BBLs under fluoroscopic imaging using different injection techniques, cannulas, and styles of injection,” says Dr. Pazmiño. These studies confirmed that “the best way to avoid a tragic result is to stay away from the gluteal muscles and vessels,” he says.
Another key revelation: “There is no one perfect way to do a BBL—many techniques can give a good result,” he says. Plastic surgeons are actually split on this issue, with some favoring standard cannula injection and others believing that powered cannulas—in particular, following a technique pioneered by Drs. Del Vecchio and Wall called expansion vibration lipofilling, or EVL—offer superior precision, efficacy, and safety.
BBL safety—where are we now?
Plastic surgeons often chalk the BBL’s struggles up to growing pains. “Most procedures, when they first come out, have a little bit of a bell curve, where people do really well, and then because the masses are starting to do it, complications go up,” explains Dr. Mendieta. He adds that when abdominoplasty first became popular, it too had a 1 in 3,000 mortality rate. And, for a time, liposuction’s death rate hovered around 1 in 5,000. But with intensive research comes a firmer grasp on anatomy plus enhancements in buttock lift technique—ultimately leading to a healthier safety profile. “The BBL has been going through the same unfortunate learning curve,” Dr. Mendieta says, “but it’s starting to get a lot safer.”
In the summer of 2019, the Florida Board of Medicine “issued the first rule in the nation to regulate the BBL, stating that any doctor who injects into the muscle can lose their medical license,” says Dr. Pazmiño. It’s been a “serious wake-up call” to surgeons in Florida—a state responsible for 60% to 70% of all BBLs performed in the U.S., per Dr. Mendieta’s estimate.
Dr. Herluf Lund, a board-certified plastic surgeon in St. Louis, Missouri, and past president of The Aesthetic Society, agrees that the BBL is trending in a positive direction. Whenever there’s a death, he explains, the task force sends a team of doctors to oversee the autopsy. “Just a few years ago, we were flying doctors back and forth across the country every couple of weeks,” he says. “But we haven’t had to fly anybody recently.”
In more measurable data, a study published in PRS in 2019—the results of a survey sent to 5,655 board-certified plastic surgeons in Brazil—estimated the BBL mortality rate to be around 1 in 20,117, noting that “the risk of death was 16 times greater when fat was injected intramuscularly.”
Lending further support to BBL safety, ASERF repeated its 2017 global survey of board-certified plastic surgeons who are members of ASAPS and ISAPS. “Since we dropped that bomb back in 2017, saying there’s something going on with this procedure, we’ve been working to educate surgeons in hopes of improving the BBL mortality rate,” says Dr. Luis Rios Jr., a board-certified plastic surgeon in Edinburg, Texas, and president of ASERF. “We felt it was our responsibility to follow up and see if we’d made an impact—and, it turns out, we have.”
The survey, published in the Aesthetic Surgery Journal in 2020, found the BBL mortality rate has dropped to 1 in 14,952, “which puts the BBL at a better safety profile than tummy tucks, which have a mortality rate of 1 in 13,147,” says Miami board-certified plastic surgeon Dr. Onelio Garcia, who was involved with the BBL autopsies. (For the record, this revised mortality rate pertains only to BBLs performed by board-certified plastic surgeons. These stats don’t reflect the number of “cosmetic surgeons” and other types of providers who are performing BBLs despite not being board-certified in plastic surgery.)
The majority of board-certified plastic surgeons have heeded industry warnings and abandoned intramuscular injections, ASERF data reveals. According to Dr. Rios, 94% of physicians surveyed in the most recent poll were aware of the surgical guidelines issued by the task force in 2017—avoiding the muscle being chief among them. Only 0.8% of surgeons in the current survey reported injecting in deep muscle, compared with 13.1% in 2017, prior to the task force alert. A significant number of surgeons also altered their technique in accordance with task force recommendations, changing their angle of injection to avoid the muscle and increasing cannula size as an added precaution, says Dr. Rios.
Still, there are surgeons here and abroad who claim to get bigger, better results by grafting fat into the muscle—a fallacy debunked in this new study comparing long-term results of subcutaneous-only gluteal fat grafting to intramuscular injections.
The future of BBL safety
On the horizon, experts say, are next-generation instruments aiming to make BBL surgery even safer and more efficient. Currently in the works is a smart-sensing cannula that alerts surgeons when they’re nearing muscle. As previously mentioned, the role of ultrasound is also being widely encouraged. “Powerful and portable, it shows me where the tip of my cannula is at all times,” says Dr. Pazmiño, an early proponent of the technology. While some surgeons argue it’s better to feel the cannula tip—palpating the area with their free hand (the one not guiding the cannula)—than to see it, all acknowledge the value ultrasound holds, particularly to young surgeons who are just learning proper BBL technique and anatomy.
“If you can avoid where the sharks swim, there’s less of a chance of something bad happening,” says Dr. Mendieta, who believes that standardized training is the surest way to increase BBL safety in the future. “We need to know where the danger zones are and be vigilant about staying in the subcutaneous level. But simply saying ‘stay subcutaneous’ isn’t enough—we have to educate surgeons on how to do that.”
Dr. Mendieta has discovered an anatomically based “safety line” that helps him pinpoint upon physical examination where the gluteal vessels live. “You can draw a huge circle around that spot and know that’s your danger zone,” he says—a teachable insight he hopes to share with other BBL surgeons.
So, is BBL surgery dangerous? Bottom line: All surgeries have their risks, and while BBLs can be dangerous, they’re getting safer, especially when they’re executed by highly trained and well-informed board-certified plastic surgeons. Studies like those outlined above are elucidating “the tools and guidelines needed to remain in the subcutaneous plane when injecting fat in the buttocks—and this has been a game-changer for the procedure,” says Dr. Alexandra Condé-Green, a board-certified plastic surgeon in Delray Beach, Florida. “And with an increased awareness of the complications that have happened around the world in [recent] years, patients are now more inclined to question their plastic surgeons and make better choices.”
For more actionable advice on navigating the risks of BBL surgery—from finding and interviewing board-certified experts to managing expectations and recovery—check out our 7-Step Guide to a Safe and Successful BBL, created in partnership between RealSelf and The Aesthetic Society (The American Society for Aesthetic Plastic Surgery).
