Our cultural obsession with butts has only increased over time. We can say it all started with Kim Kardashian, but before her we had J.Lo. Suddenly it seemed, we all wanted a bigger backside and gone were the days of the tiny, toned, Buns of Steel. We’re still very much in the era of the larger derrière, and thanks to the Brazilian Butt Lift, it’s an aesthetic shift we’ve been able to maintain over the last decade. However, just a few years ago, during the height of its popularity, the BBL became known as the surgical procedure with the highest mortality rate. There was even a multisociety plastic surgery task force created to examine how it was being performed. Today, BBLs continue to be highly sought after, but following an advisory warning, new injection recommendations and a viral social media trend, are we in a better, safer place? We investigate.
What is a BBL?
The first mention of the Brazilian Butt Lift came in 1964 when Brazilian plastic surgeon Ivo Pitanguy published a paper on buttock lift surgery. At that time, butt surgery involved excising unwanted skin and tissue to correct sagging, but it didn’t add volume to the butt. It was more than 20 years later when plastic surgeons began taking fat from other areas, and instead of disposing it, used it to augment other places on the body.
“Patients undergo harvesting of the fat from appropriate donor areas via liposuction—usually the abdomen and waist, and occasionally thighs,” explains Los Angeles plastic surgeon Ben Lee, MD. “The fat is then processed in a variety of ways to purify and concentrate it. These methods include centrifugation, closed system harvesting devices, and more commonly, passing the fatty aspirate through a strainer to remove the liquid component. The fat is then injected back into the buttock region in a subcutaneous plane.”
The Risks
As Louisville, KY plastic surgeon Chet Mays, MD explains, Brazilian Butt Lifts are considered risky because the anatomy of the butt is a danger zone. “Specifically, the large blood vessels of the gluteus muscle can be injured when the cannula penetrates the lumen of the vessel and the fat enters the venous system to return to the heart,” he says. “The fat then travels from the heart to the lungs, causing a fat embolus that can be deadly.”
In 2016, as rising incidents involving BBLs occurred, an advisory was issued to doctors and patients, and a Gluteal Fat Grafting Task Force was created by The Aesthetic Surgery Education and Research Foundation (ASERF). Leading surgeons from the American Society of Plastic Surgeons, The Aesthetic Society and the International Society of Aesthetic Plastic Surgeons were called to help investigate the fatalities and how the surgery was being performed. Through a worldwide survey, the group found 32 deaths from fat emboli between 2011 and 2016, with 25 of those occurring in the United States.
After the advisory was issued, there was a brief pause in the BBL’s acclaim, but a new wave of interest, including a viral trend, has placed the procedure back in the spotlight. “The BBL Effect” is a meme used to describe the post-surgical mannerisms of the average BBL patient, like not being able to sit down and dramatically protecting their new, rounder butt. “Social media has really helped perpetuate the ideal of fuller, more lifted buttocks, and it is a body type that will continue to increase in popularity for the foreseeable future,” says Dr. Lee.
Traveling for a New Butt
According to Santa Monica, CA plastic surgeon Steven Teitelbaum, MD, the most dangerous BBL cases typically come from environments where patient safety is often compromised, which can affect those who seek out a more affordable option far from home. “The bottom line is that while it is theoretically safe to do a BBL if the fat is placed only in front of the muscle, deaths are still occurring,” he says. “We know that many of the deaths in Florida have occurred at businessmen-owned discount clinics in strip malls—they’re a particular scourge there. I have heard secondhand reports of doctors not meeting patients until the morning of surgery and operating schedules that are so ‘busy,’ they need to rush through cases.”
Dr. Lee notes there are also difficulties posed when patients travel to and from their surgeon: “Sitting on your buttocks on the way home can affect results. Ideally, patients are best served by having the procedure done locally so that their surgeon can coach them through the recovery process.”
“This surgery requires close follow-up care because of the potential for complications,” adds Houston plastic surgeon German Newall, MD. “When traveling abroad, it can be difficult to follow up with your surgeon and you may have to spend more money fixing the problems later. Cheaper may be tempting, but your safety and health should come first.”
Dr. Mays agrees: “I often treat patients who have had issues arise from destination surgery and returned home with no follow-up. It ends up being more expensive to fix the problem than what the original surgery would have cost in a U.S. facility.”
The Safer Technique
In mid-2019, a joint task force made up of ASERF, the Aesthetic Society and ASPS shared recommendations for surgeons on how to perform fat transfer to the butt in a safer manner. These guidelines outlined the proper placement of fat in the superficial subcutaneous space—above the muscle—and not in the deeper muscles where large blood vessels exist. “Obviously, following the recommendation greatly improved the safety of the BBL,” says Dr. Lee.
“A safer BBL would be conducted by a surgeon who has the proper experience and training to do so, as well as an intimate understanding of correctly performing this type of procedure on your body,” adds Chicago plastic surgeon Michael Horn, MD.
La Jolla, CA plastic surgeon Robert Singer, MD, says that even with new guidelines, we’re not out of the woods yet. “There’s always a risk in any procedure. We’ve seen cases where the doctor said they injected above the muscle, and in fact it was later found that the injection went not only above the muscle, but behind the muscle. We don’t have an eye at the end of the cannula, so we can’t be 100-percent sure.”
Still, some surgeons prefer to skip the surgery altogether. “I don’t do many BBLs in my practice,” says Irvine, CA plastic surgeon Andrew Smith, MD. “I think the risks are not worth the outcomes.”
BBL Alternatives
The Injectable Lift
For patients who do not have the excess fat for liposuction and fat transfer, or those who prefer the nonsurgical route, longer-lasting fillers are a viable option. “One alternative to BBL is Sculptra, which is an injectable stimulator designed to build collagen and elastin,” says Dr. Mays. “It is injected off-label into the subcutaneous tissue of the buttocks, and two to three sessions of injections spread six weeks apart will give a nice volume increase for those who want a subtle boost without surgery.” However, Dr. Newall says it’s important to note that patients won’t get the same results from these injections as they would from a BBL procedure.
Body Sculpting
Sometimes a liposuction procedure alone can remove fat from the waist, lower back and abdominal area and reshape the body in a way that makes the butt look more prominent. “By removing the fat in the surrounding regions, many patients can have the appearance of fullness without actually having fat reinjected,” says Dr. Lee. “Some patients, however, have very little excess fat. For them, we suggest butt implants, which is a tried-and-true procedure that reliably adds volume.
Augmentation With Tissue
When his patients with too much skin laxity and not enough fat want to add volume to their derrière, Grand Rapids, MI plastic surgeon David Alfonso, MD says he uses a not-so-new technique that involves using the patient’s tissue, rather than fat, to enhance the butt. “Instead of excising the skin and throwing it away, we remove the outermost layer, keeping the skin attached to the blood supply, and kind of shift it down into the butt cheeks. It’s great for patients who are thin and have loose skin, but no fat to give.”
Muscle Stimulation
To give the butt a boost, noninvasive treatments like CoolTone and Emsculpt NEO help define and tighten the area by building muscle. “Emsculpt NEO builds up the gluteus muscle without having to do surgery,” says Dr. Horn. “In one 30-minute session, you are doing the equivalent of 20,000 squats, strengthening the gluteus muscle and giving a little more lift and fullness to the butt.” Dr. Horn advises doing four weekly sessions, followed by monthly maintenance for best results.
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