Why One of the Hottest Plastic Surgery Procedures Is Also the Deadliest

Why One of the Hottest Plastic Surgery Procedures Is Also the Deadliest featured image
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If you’re even a casual consumer of those provocative, live-from-the-OR plastic surgery videos on social media, you’ve no doubt seen the Brazilian butt lift in action: the bare bum (obligatory fabric strip hiding its not-suitable-for-IG crack), the splay of syringes full of peach-hued fat, the steely cannula mesmerizing audiences with every jab. These snippets, their sheer volume online, make the booty-enhancing surgery seem routine, utterly no big deal, totally obscuring the fact that this is literally the most dangerous cosmetic procedure, with a mortality rate roughly 20 times higher than any other.

For those unfamiliar, Brazilian butt lift (BBL) is the exotic-sounding colloquialism for gluteal fat grafting, an elective aesthetic procedure that involves removing fat from one part of the body (via liposuction) and transplanting it (via injection) into the butt for a fuller, perkier effect. Its popularity has swelled over the last few years, with the American Society for Aesthetic Plastic Surgery (ASAPS) tracking a 26-percent jump from 2016 to 2017, making it the surgical procedure that saw the second most significant increase performed year over year. According to RealSelf, U.S. visitors to its site have researched the Brazilian butt lift more than 3.8 million times in the last 12 months. In short, “the butt is the new breast,” says Boston plastic surgeon Daniel Del Vecchio, MD.

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Recent Fatalities Prompt Worldwide Warning

But as demand for the BBL has grown, so too has its death toll. Earlier this month, in the wake of recent casualties in Miami and Los Angeles, the Multi-Society Task Force for Safety in Gluteal Fat Grafting—comprising doctors from five global plastic surgery societies assembled expressly to investigate BBL complications and sponsor research on safety guidelines—sent an unprecedented warning to plastic surgeons worldwide. “You don’t see an alarm put out by these organizations unless there’s a significant concern about safety,” says La Jolla, CA plastic surgeon Robert Singer, MD. What people need to understand, he adds, is that “even in the best hands, complications occur at a higher rate [with the BBL] than with any other cosmetic surgery.”

Interestingly, “while this procedure has been done for decades, it wasn’t recognized as risky until recently,” says Pittsburgh plastic surgeon J. Peter Rubin, MD, a co-chair of the task force. The wake-up call for some surgeons came in 2015 in the form of a study titled “Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong?”, which analyzed 19 BBL-related deaths in Colombia and Mexico over a 15-year period. “I looked at that paper, and said, Jesus, this is serious,” recalls Dr. Del Vecchio, who performs upwards of a dozen BBLs each week. Graver still, he says, was learning that some of the doctors involved were, in fact, highly trained and well-respected. “Our initial impulse [upon hearing of BBL fatalities] is to say: These guys are quacks, they’re not board-certified, they’re working in strip malls, they’re not real plastic surgeons, but that’s not always true,” he adds.

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What followed was an exhaustive survey conducted by the task force of the Aesthetic Surgery Education and Research Foundation (ASERF), which calculated the BBL death rate to be between one in 2,350 cases and one in 6,241 cases, depending on the data source. (One in 3,000 is the most widely accepted figure “based on known numbers of fatalities and overall case volume estimates,” Dr. Rubin says.) The 2017 report also noted at least 25 fatalities in the U.S. in the preceding five years.

Fatal Flaw: How a BBL Can Turn Deadly

The cause of death across the board: fat emboli—globules of fat that inadvertently enter the gluteal veins and swiftly make their way up to the heart and lungs, causing patients to arrest and die “usually in the operating room during the procedure or in the recovery room shortly after,” says Santa Monica, CA plastic surgeon Steven Teitelbaum, MD, who helped write the urgent advisory. These emboli are “unique to the buttock area,” notes Dr. Singer, as “fat injections in the breast, face and thighs don’t produce this same phenomenon.” The gluteal veins’ distinctive anatomy makes them especially “nasty,” explains Dr. Del Vecchio: “They’re very big and very thin, and only one branch away from the vena cava, which is the major vein in the body running from the pelvis to the heart. If a surgeon nicks one of these gluteal veins, it’ll act like a siphon, sucking in fat around it,” and ultimately fleeting it up to the heart. However, because these veins reside, predictably, below the gluteal muscle, “the risk can be easily managed: If you don’t put fat in the muscle, you can’t kill anyone,” says Dr. Del Vecchio, who is a vocal proponent of injecting fat only into the subcutaneous tissue, or the fat layer just below the skin and high atop the muscle.

On the heels of the task force study, a number of plastic surgeons published papers exploring the complex anatomy of the buttock, the nuances of the BBL, and the precise techniques and tools needed for a safe, predictable outcome (namely: large, inflexible cannulas for maximum control, and an unwavering GPS-like awareness of the cannula tip’s location throughout surgery). But, “there was still some vagueness [concerning proper fat placement] because there are, indeed, excellent surgeons who favor going into the muscle, who say they can do it safely, so the task force was initially reluctant to flat out condemn it,” says Dr. Teitelbaum. But this month’s safety advisory aimed to eliminate any lingering ambiguity, unequivocally declaring: “Fat should never be placed in the muscle. Fat should only be placed in the subcutaneous tissue.” And underscored its directive with: “In every patient who has died, at autopsy, fat was seen within the gluteal muscle. In no case has fat been found only in the subcutaneous plane.”

Fat Placement: A Sticking Point Among Surgeons

Cut and dry. Yet, plenty of board-certified plastic surgeons believe they can get a better (bigger, rounder) result by injecting fat into or below the muscle rather than into the superficial tissue alone. “I think most surgeons who have performed this procedure safely and successfully over the past decade or more inject fat into multiple planes, including the subcutaneous and the muscle,” says Miami plastic surgeon Sean Simon, MD, who has done thousands of BBLs in the last 10 years, and calls it “one of the safest procedures, with the least amount of problems, when done right.”

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Dr. Del Vecchio, on the other hand, maintains “there is absolutely no advantage” to placing fat in the muscle, as it “doesn’t actually stay there”—a point he proves in a study pending publication in the journal Plastic and Reconstructive Surgery. “When you inject fat just under the [outermost] membrane of the muscle,” he explains, “it literally pushes right through the fibers, and tracks under the muscle, into the area where these vessels live.”

The bottom line? As with most cosmetic controversies, more research is needed. And safety-elevating trials are currently underway: “The task force is bringing together leading experts in gluteal fat grafting to study every aspect of the procedure in an anatomy lab with imaging equipment not readily available in the operating rooms where these surgeries typically take place,” says Dr. Rubin. The task force expects to release updated practice recommendations this fall. “Because of the current data, there’s a discussion among plastic surgeons as to whether BBLs should even be performed at this time,” adds Dr. Singer.

For now, and above all else, trust only board-certified plastic surgeons to perform this procedure at accredited and licensed facilities or hospitals. Searching for surgeons on task force–affiliated society websites (like ASPS or ASAPS) can help ensure your doc is up-to-date on the latest safety guidelines. You, too, should stay informed on the issue, and when consulting with doctors, don’t hesitate to question their approach. It’s your ass on the line, after all.

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