All in the wrist: Improving safety for the Brazilian butt lift
New risk-reducing guidelines are revamping the BBL into a safer and more predictable procedure

You'd be hard-pressed to find a procedure in plastic surgery that has been under more surveillance than the Brazilian butt lift (BBL), which transfers excess fat into the butt and hips for a fuller silhouette.

The incredibly popular procedure has been under a medical microscope for years – and for good reason. According to New York-based plastic surgeon Christopher Funderburk, MD, the early BBL years had a fatality rate that was "way too high of a number to be acceptable for any cosmetic procedure."

Yet, after years of rigorous research, technique refinement and just plain dogged determination on behalf of leading plastic surgeons to develop safer protocols, new BBL guidelines have been established within the medical community and are being rolled out across the country to strengthen the procedure's safety profile. And the truth is, when performed by an experienced board-certified plastic surgeon, the risk of BBL complications drops dramatically.

Ahead, five board-certified plastic surgeons and ASPS Member Surgeons who regularly perform BBLs explain the latest safety measures, surgical techniques and tech innovations that are reshaping how surgeons and patients alike view the procedure.

Formation of the BBL task force

More formally referred to as the Task Force for Safety in Gluteal Fat Grafting, this board was established in 2018 by ASPS with the goal of investigating the dangers of BBLs and creating new safety strategies.

"This is a procedure that's relatively new," explains the president-elect of ASPS, Steven Williams, MD, alluding to the fact that with any new procedure, there will likely be growing pains. "As part of our review, the task force discovered that there was a relatively high incidence of complications, the most serious of which included fat embolism."

Miami-based plastic surgeon, Adam J. Rubinstein, MD, says that fat embolism occurs when fat gets into the bloodstream and blocks circulation. "It turned out that all of these complications seem to be related to fat grafting in and around the muscle," he said. "The reason for that is, in the buttocks, there are really large veins in and deep to the muscles and if you're intentionally trying to get fat deep down into the muscle, that's a dangerous place to be because that's where all these big veins are. And if you tear the veins while you're injecting fat, the fat can get sucked up into a vein and then it's traveling towards your lungs."

This sets off a waterfall of dangerous events within the body that Rubinstein says can be hard to survive. "When there's a mortality based on a complication of BBL, the task force surgeons will fly in and participate in the postmortem examination – they're present during the autopsy," said Rubinstein. "They look for specific causes of death, specific things that may have gone awry during surgery, and that has helped shape policy."

Based on these findings, the task force released an advisory filled with a series of safety measures and surgical recommendations, including the use of rigid large-diameter cannulas, injecting the fat slowly and at a specific, slanted angle.

"Recent survey data has suggested that many, many surgeons are changing their technique based on the recommendations of the task force and that the mortality rate is approximately that of the tummy tuck, one in about 15,000," said Pittsburgh-based plastic surgeon and ASPS immediate-Past President, J. Peter Rubin, MD.

Evolving techniques

One of the key takeaways from the task force's advisory is that fat should only be placed in the subcutaneous space, which is the area between the skin and the muscle.

"To my knowledge, when they've gone through the autopsy and they've looked at causes of death in these terrible tragedies of people who've died in these operations, I don't believe that there's ever been a mortality case where the fat was completely injected in the subcutaneous space," said Rubinstein. "It's very well established that if you stay in the right area – the space above the muscle – that is the key to making this a safe operation."

Jerry Chidester, MD, a plastic surgeon in Utah who performs about five BBL procedures a month, agrees that BBL surgery is trending in a positive direction. "As we've become more aware of the complications, we've found ways to better prevent them from happening," he said. "A lot of things have changed in terms of actual surgical technique, from the way we position patients on the table to the way we insert the cannula that we inject the fat with, surgeons are doing things very differently now."

Adoption of ultrasound technology

In the summer of 2019, the Florida Board of Medicine ruled that any doctor who injected fat into the muscle could lose their medical license. Fast forward to June 2022, when the Board issued another emergency order requiring the use of ultrasound during BBL surgeries to avoid injecting fat into the muscle and reduce the risk of fat embolisms.

Their theory was that the ultrasound would provide "real-time imagery during surgery to see where the fat is being placed and making sure it is in the correct space, away from the muscle," said Chidester.

Along with the ultrasound guidance requirement, Florida instituted another emergency rule limiting the number of BBLs doctors are permitted to perform each day to three, citing surgeon fatigue.

"As plastic surgeons, we want to avoid bad events to begin with, so I encourage people to get trained and use ultrasound," said Williams. "I think it's an important tool, even in my practice where I haven't had one of these horrible and unfortunate complications in the past, I've tried to increase safety by adding it as a tool that I use regularly. Everything you can do to minimize complications makes sense."

The future of BBL safety

As education and innovation continue and improve, surgeons expect that BBL procedures will become even safer with new technology and surgical instruments. The most hotly anticipated tool that surgeons are talking about is a smart-sensing cannula that signals to surgeons when it is placed too deeply or too closely to the muscle.

The use of ultrasound is strongly encouraged by medical organizations, including ASPS, along with other medical governing bodies and state governments, all of which recognize its value in providing surgeons with real-time imaging of their cannula placement. Ultrasound can be especially helpful in the development and training of young surgeons to help them gain a precise understanding of safe BBL techniques.

"The tides are definitely turning for BBLs," said Funderburk. "A number of plastic surgeons have dedicated just an exceptional amount of time and effort in developing much safer and more standardized ways to perform a BBL, and that research and education are ongoing. I don't see it changing."

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.