Is it possible for a surgeon to accidentally puncture muscle during BBL if patient is only under local anesthesia?

I have first-hand experience doing awake BBL with fat subcutaneously and intramuscularly.The gluteus muscle doesn’t really have a developed  facia on the main part of the muscle. It’s very different than the fascia of the rectus muscle.  For many years plastic surgeons purposely grafted in the gluteus muscle. Fat take or fat survival is better in the muscle and it serves as an excellent source of host  tissue for aesthetically successful BBL outcomes.When  data was released associating fat emboli with deep gluteal fat grafting most plastic surgeons myself included adjusted our technique avoiding grafting directly into the muscle.The sensation patients feel when the cannula both tumescent solution and grafting enters the gluteal muscle Is muscle spasm or contraction of the muscles. It’s only uncomfortable if the muscle has not been properly anesthetized with tumescent solution.  If the patient has been properly numbed they will not sense the cannula entering the muscle. there may be muscle twitching on occasion.Unless plastic surgeons use some type of radiologic visualization there’s no way to know if the cannula is penetrating part of the gluteus muscle other than clinical intuition.  obviously if the cannula  is just below the skin it’s highly unlikely it’s going through deep structures.The gluteal vein is deep to the muscle and generally not even close to where fat is grafted using safe techniques.I’m a big advocate of doing body contouring with patients awake.The primary reason is that at least in my experience the results are superior but there are other advantages which include patient safety as well.So to answer your question, pain is not a good indicator to differentiate whether the surgeon is grafting into the gluteus muscle or not.In reality this is not such a black and white procedure that people make it out to be in regards to grafting in the muscle or not.  My best guess is that many plastic surgeons still graft through superficial muscle when attempting dramatic results whether they are aware of it or not. There  is real evidence to back this up. We don’t have enough evidence to differentiate variables in regards to safety.We know from autopsy results the patients who had fat emboli had some association with fat found in the gluteus muscles.The American society of plastic surgeons have come out with guidelines recommending not grafting in the muscle, using large diameter blunt graft and cannula‘s and a few other suggestions.The reality is we don’t have a good scientific knowledge but there have been enough complications and all plastic surgeons take this seriously and I would venture to say the great majority have adjusted their  technique.Personally I believe that judicious use epinephrine containing tumescent solution is one of the greatest safety barriers surgeons can use to prevent this and other complications.  The vasoconstrictive properties of epinephrine greatly reduces vascular injury.There is no scientific evidence to back this up in regards to fat emboli but clinically all plastic surgeons know the power of vasoconstriction using epinephrine.Much of the alarm that caused the inquiries into the fatalities in regards to fat emboli from the BBL procedure came from a small number of providers who are not plastic surgeons.   In particular two rouge providers had many of the fatalities included in the reporting statistics. One single provider had four fatalities fat emboli with the bbl procedure.  It seems hard to imagine any human being to continue to do the same procedure without changing after having a single fatality. In this case it took for young women dying before authorities finally took this rogue players medical license away. Was it the provider or the procedure or both? Is it possible that this one provider who felt entitled to do cosmetic surgery without any proper training may have simply been using bad technique all around putting patients at great risk for all kinds of complications including fat emboli?These isolated complications were not only  ones reported from a handful of clinics in Miami.  BBL related fat emboli been reported around the world and there is definitely a correlation with the procedure and an increased risk of fat embolism.  Prior to the BBL procedure fat emboli most commonly associated with long bone and pelvic fractures.If done by a trained provider(experienced board-certified plastic surgeon) using good common sense the proper surgical technique is the chance of a fat embolism really 1:  3000?We don’t know but most of us aren’t going to gamble and will compromise Aesthetic outcome  to maintain a better safety profile.There is no question that when plastic surgeons purposely avoid grafting fat in the gluteus muscle the potential results from the procedure is going to be less.grafting into the gluteus muscle was considered something appropriate with reports documenting better outcomes. I’ve been a board-certified plastic surgeon for over 20 years. The last decade has been devoted exclusively to Liposuction and fat transfer procedures. I have an extensive amount of experience with these procedures.   In my opinion things are not clear-cut and there are numerous variables surgeons need to take into consideration.Fat emboli is only one of many things to be concerned about with this procedure.For those who are highly risk-averse it is always safer to not have cosmetic surgery.The same can be said for many of life‘s activities.As much as you want your fears to be alleviated they are too many unknowns for anyone to give you guarantees or promises that  nothing will go wrong.Chance of having high patient satisfaction with the greatest degree of certainty and safely will always come from being in the hands of the most talented provider.I spent 10 years doing general plastic surgery before focusing my career exclusively and liposuction and fat transfer.My personal experience has been that both Liposuction and fat transfer are some of the safest procedures we perform. Complication rates are exceedingly low. I would venture to say far lower than average plastic surgery procedures such as tummy tucks or breast reductions.  At least that has been my experience. To date I have completed over 7000 Liposuction cases. About 25% of the work I  do include fat transfer.Of those cases I can still count my real complications on one hand and all of the patients did fine after intervention was appropriately taken.   When I compare that to procedures like breast reductions that have a documented complication rate around 20% body contouring with liposuction and fat transfer seems like a very straightforward and safe procedure.The selection of choosing an experienced skilled board-certified plastic surgeon is by far the most important decision. While  I prefer local anesthesia with mild sedation  the form of anesthesia is not all that important in comparison to the skill of the provider. In reality there’s no way for patients to actually know if fat was or will grafted in their muscle or not.  There  been numerous cases of plastic surgeons documenting not grafting fat in the gluteus muscle with MRI findings showing grafted fat in the muscle. No question that a surgeon who is safety oriented and makes an purposely stays superficial will minimize the chance of fat going in the gluteus muscle and will certainly be much less likely to graft deep where the veins are.  There’s a big difference clinically, radiologically and risk related  from the surgeon encroaching on the superficial aspects of the gluteus muscle compared to grafting deep in the muscle which once upon a time was considered ideal technique.I suggest having multiple In person consultations with experienced local board-certified plastic surgeons who have extensive experience with this procedure. Discuss your concerns and talk to the plastic surgeon about their approach and philosophy when it comes to this procedure.Confirming that you’re a good candidate then decide for yourself if this is a good procedure for you.In the end everybody wants the same thing.Safety and excellent aesthetic outcomes.Best, Mats Hagstrom MD