How do doctors know without ultrasound where to inject the fat safely?

Dear charityb09,
with years of training and excellent anatomy knowledge, it is possible to perform BBL safely without need for an ultrasound. If you are considering a surgery, I would suggest you to consult a board-certified plastic surgeon. Only after a thorough examination you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

There has been a lot of news coverage about unsafe BBL procedures. Going to a fully trained plastic surgeon is probably the most important thing to ensure safety. Moreover, injecting the fat into the fatty layer between the butt (gluteal) muscles and the skin. There is a strong tissue layer over the muscle that is possible to feel and avoid when doing the procedure safely. I also used a curved cannula that is always pointing up to avoid injecting down into the muscle. As always, be sure to research who performs your surgery to ensure the best likelihood of a positive result.

Larger cannulae and more superficial injection into the fat and under the skin are recommended. The vessel diameter of the vessels feeding the gluteal skin are much smaller than the 4+ mm, blunt, remote single hole cannula I use for injection. Thus, the fat cannot gain entrance into the vessels and no fat embolus can occur. By injecting under the skin, the tip of the cannula can be visualized at all times. Injecting into any portion of the muscle may cause the fat emboli to get into the venous system and result in emboli and death.

Hello darling,

Experience can help you put the fat in the right place. Ive been doing BBL per years and all my patients loved their results. No complications, no cons post-op.

Please make sure you go on consultation with a board-certified plastic surgeon.

Hope this helps and best of lucks.

Dr. Luis Mejia.

I will start by saying that you cannot be 100% certain of the injection location, but experience does help guide you as to where it is safe to inject. The reason an US is not used more often is the following: 1) COST - using an US would slow things down leading to more operating room/anesthesia time which leads to more money spent by the patient 2) Longer OR time and more work by having to use the US will also likely lead to increased surgeon fees as the surgery takes longer. In my practice I do a large number of BBLs and have never had a fat embolus/death. I follow all the safety guidelines and DO NOT rush. The average cost of a BBL in my hands is ~ $10,000. I find routinely that patients travel to Florida/Austin where the BBL is offered for thousands of dollars less. At these cheaper locations, the BBL is rushed and tends to be much more dangerous (high death numbers). The thing is a lot of patients would rather compromise safety for lower cost.

Ultrasound guidance can be useful tool for fat placement in the correct plane. However, with experience and feel, which is the art and essence of plastic surgery, you “know” where your cannula is. You can feel it. This is partly influenced by the access incisions are used, by the angle of the cannula placement etc. These are all technical pearls. If a practitioner is not confident of their placement and use of the cannula during fat grafting then ultrasound may be a beneficial addendum. People get into trouble with fat embolism largely due to the pursuit of over accentuated and pornographic results (which typically come from submuscular placement ) in the context of a practice which is performing for too many surgeries in a given day. It’s usually a product of haste and misguided aesthetic goals on the part of both the patient and the practitioner.

Most plastic surgeons do not use ultrasound guidance for fat transfer for the same reason they don’t use ultrasound guidance for liposuction or other blind procedures.

For example, how do plastic surgeons know they’re not doing liposuction inside the abdomen, are going through the diaphragm, or are in muscle, the chest, the lungs, the heart or major vascular structures?

We use skill, our experience, knowledge of human anatomy and judgment.

Still, all of the above structures have been penetrated during liposuction and fat transfer procedures including delivering fatal outcomes.

Doing entire body contouring procedures under direct visualization with ultra sound distracts the surgeon from the task at hand, slows down the procedure dramatically and increased cost.

With The BBL procedure the concern is to not graft fat in the vicinity of the gluteal vein. This vein sits at the bottom of the gluteus muscle which is a fairly thick muscle in the pelvic region.

It’s possible that summer fat make it grafted at the very superficial surface of the gluteus muscle. This theoretically can post some risk asking any fat transfer or any liposuction procedure.

It’s possible that summer fat may get grafted at the very superficial surface of the gluteus muscle. This theoretically can pose some risk asking any fat transfer or any liposuction procedure.

The difference between a theoretical risk and a real risk is what we call clinical experience and intuition.

We know where the maximum danger zone is. It’s deep and the more surgeons stay superficial the more they’ll be staying away from the danger zone.

Those who stay very superficial will by definition limit results to some degree. Fat transfer requires lots of host tissue in order for high-volume graft to be successful.

Historically grafting into the gluteus muscle was considered the standard of care because muscle serves as an excellent source of host tissue for successful fat transfer.

In the end it is a balancing act that requires education, skill, experience and a conscious ethical approach.

Those who are highly risk-averse should probably not have cosmetic surgery.

High risk procedures should be done only when the reward justifies the risk.

Risk reduction should be done whenever possible and done in accordance with balancing outcomes based on a realistic and honest risk benefit ratio that should be openly discussed with the patient.

There may be plastic surgeons who are using ultrasound to visualize fat transfer procedures. Personally I would want my surgeon looking at my body rather than an ultrasound monitor while operating on me.

Best,

Mats Hagstrom MD
linea nova body contouring