A search for Brazilian Butt Lift (BBL) on any social media platform will yield thousands of before-and-after images, faja sales, operating room videos, recovery tips, and patients praising their plastic surgeon. With a little more digging however, you will also find women like Nelly Baptiste telling The New York Times, “When the pain came yesterday, I was like: I want my old body back” after undergoing a BBL in Miami. Or Helly Larson describing the first week after her Miami BBL as “absolute hell” to a Vox reporter.^1,2 You’ll also find the story of Sheila Powell, a woman who suffered a pneumothorax during her 2018 Miami BBL and whose 16-year-old daughter worried that in “just a blink of the eye, I could have lost my mom.”³

Autologous Fat Transfer Procedure

Gluteal autologous fat transfer procedures (AFT), popularly known as “Brazilian Butt Lifts” are gaining prominence in the aesthetic surgery community. A surgical technique to augment a patient’s backside, AFT involves abdominal liposuction followed by re-injection of the fat into the gluteal area. The procedure has soared in popularity as beauty standards have shifted and cosmetic surgery has become increasingly transparent on social media platforms, with reported cases in the United States increasing from 614 in 2002 to 61,387 by 2021, a nearly 10,000 percent increase.^2,4,5 The procedure costs thousands of dollars and requires significant post-operative care; in addition to typical post-surgical needs, patients often require aggressive lymphatic massage and have significant movement restrictions that include sleeping face down, avoiding sitting, and wearing constrictive corset-type garments called fajas.¹

The Rise of the Miami BBL

An entire industry has emerged around gluteal AFTs in Miami. Stand-alone cosmetic surgery centers offering the procedure, often at significantly “discounted” prices, can be spotted on nearly every block. Dedicated “Recovery Centers” have also sprouted up to meet the demand from patients who have traveled from out of state to take advantage of the competitive pricing in this area.

Unfortunately, the low prices come at a cost. Opportunistic physicians and entrepreneurs capitalized on the demand for these procedures by opening dedicated cosmetic surgery centers where physicians performed multiple gluteal AFT procedures per day, while providing little to no post-operative care or monitoring. These questionable practices led to a rash of bad outcomes. When seven South Florida gluteal AFT patients died tragically in one year alone, the Florida Board of Medicine issued an emergency regulation restricting fat injection to the subcutaneous space rather than injecting into muscle. Unfortunately, at least 13 deaths were subsequently reported in Miami-Dade County from 2019–2022, the three years immediately following the implementation of the subcutaneous injection regulation.⁶ The increasing mortality rate led to an additional emergency regulation in 2022 requiring the consenting physician to perform the critical steps of the case, limiting surgeons to three cases per day, and mandating continuous, recorded ultrasound guidance for gluteal AFT procedures.⁷ The impact of this latest set of regulations on the complication rate has yet to be reported.

Complications of Gluteal AFT

The pale, prone patient with multiple surgical drains and a constrictive faja has become a common site in the Jackson Memorial Hospital Emergency Department. Jackson Health System (JHS), the public hospital network in Miami-Dade County, has undertaken an internal review of these cases in response to the number of gluteal AFT patients being seen in our emergency department. Our experience at one of the country’s epicenters of gluteal AFT complications can prove instructive for emergency physicians nationwide who may encounter these patients after surgeries performed in their own cities or when patients return from medical tourism trips to Miami and other cosmetic surgery hubs.

Gluteal AFT complications are notoriously difficult to study as stand-alone cosmetic surgery centers have no reporting requirement. The data that are available come largely based on voluntary reporting, physician surveys, or autopsies. As a result, our current data on AFT complications likely underestimates the actual incidence. JHS’ chart review project, which identified 163 patients presenting to the ED with gluteal AFT complications in a 30-month period between 2020 and 2023, provides one of the most comprehensive and informative datasets on the breadth of AFT complications as they are currently being performed.

The most concerning complication of AFT is the pulmonary fat embolism (PFE). Classically associated with long bone fractures, a PFE may also occur when fat is injected or absorbed into a blood vessel during the reinjection phase of an AFT procedure. It even has been suggested that moving the patient into a supine position post-operatively can put enough pressure on newly deposited adipose tissue to shift it into the bloodstream.⁶ Theoretically, ultrasound guidance should decrease this risk, which formed the basis for the 2022 Florida Medical Board regulation. PFEs from gluteal AFT are rare (occurring in an estimated 1:1,030 procedures) but life threatening, with mortality rates as high as 50 percent.^8,9 This statistic represents the highest mortality rate of any aesthetic procedure.⁹

PFE is only definitively diagnosed on autopsy and a high clinical suspicion must be maintained in high-risk patients. The term PFE is often used broadly to encompass two distinct clinical entities: microscopic and macroscopic fat embolism. Macroscopic fat embolism is thought to cause mortality through mechanical obstruction of large vessels. This should be suspected in patients with intraoperative cardiac arrest or shock. Microscopic fat embolism, on the other hand, causes morbidity and mortality through a systemic inflammatory response within 24 hours of the procedure, also known as “fat embolization syndrome.” While both conditions rely on supportive care as the mainstay of treatment, plastic surgery literature suggests better outcomes with microscopic fat embolism.¹⁰

It is difficult to say exactly how many of the 163 patients at JHS suffered a PFE without autopsy reports. However, only one case—a patient who decompensated during her procedure and suffered a stroke but ultimately survived to hospital discharge—was presumed to be attributable to PFE.

Instead, the overwhelming majority of post-AFT patients at JHS presented secondary to bleeding, pain, and syncope. Emergency physicians are very familiar with the workup and treatment of these conditions , however EPs must not underestimate the severity of these concerns in a purportedly “minimally invasive” procedure. For example, in our system, 37 percent of patients presenting after gluteal AFT procedures required transfusion, an average of 1.7 units per patient. Nearly half of all post-AFT patients presenting to our emergency departments required admission and six percent required ICU admission. Other complications seen in our cohort included sepsis, hemorrhagic shock, electrolyte derangements, bowel perforation, hematomas, abscess formation, and cardiac arrest.

Communities like South Florida are scrambling to regulate gluteal AFT procedures, but in the meantime, the care of patients like Ms. Baptiste, Ms. Larson, and Ms. Powell will continue to fall to emergency physicians. Pain and bleeding need to be taken seriously in these patients, and for those who present in critical condition, fat embolism must be considered. Familiarity with post-op restrictions for gluteal AFT patients will also improve their care in the emergency department. Until these procedures are regulated in a way that makes them safe for patients, emergency physicians must be ready and equipped to care for them

Dr. Lee is a PGY2 emergency medicine resident at Jackson Memorial Hospital with an interest in critical care disparities and public policy.

Dr. Pyle is an attending physician and ultrasound director at Jackson Memorial Hospital with an interest in medical education, ultrasound and critical care.

References

1. Garcia SE. Butt Lifts Are Booming. Healing Is No Joke. The New York Times. Published May 11, 2022. Accessed March 6, 2024.
2. The BBL effect: How the Brazilian butt lift went mainstream. Vox. Accessed February 19, 2024.
3. The Price of Perfection: The dangers of Brazilian butt lifts. Al Jazeera. Accessed March 6, 2024.
4. Cosmetic Surgery National Data Bank: 2002 Statistics. The American Society for Aesthetic Plastic Surgery.
5. Aesthetic Plastic Surgery National Databank Statistics 2020–2021. Aesthet Surg J. 2022;42(Supplement_1):1-18.
6. Pazmiño P, Garcia O Jr. Brazilian Butt Lift–Associated Mortality: The South Florida Experience. Aesthet Surg J. Published online August 11, 2022:sjac224.
7. Garcia O, Pazmiño P. BBL Mortality in South Florida: An Update From Ground Zero. Aesthet Surg J. 2022;43(3):NP223-NP224.
8. Che D hui, Xiao Z bo. Gluteal Augmentation with Fat Grafting: Literature Review. Aesthetic Plast Surg. 2021;45(4):1633-1641.
9. Mofid MM, Teitelbaum S, Suissa D, et al. Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force. Aesthet Surg J.2017;37(7):796-806.
10. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H, Cuenca-Pardo J. Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong? Plast Reconstr Surg. 2015;136(1):58-66.