The Brazilian Butt Lift (BBL) has surged in popularity as a cosmetic procedure designed to enhance the shape, size, and projection of the buttocks. It involves using liposuction to remove fat from areas like the abdomen, thighs, or lower back, and then injecting this purified fat into the buttocks to create fuller, rounder curves. While BBL surgery can offer a dual benefit of slimming down areas of excess fat and enhancing the buttocks, it's crucial to understand the potential risks associated with the procedure.
What is BBL Surgery?
BBL surgery, or Brazilian Butt Lift, is a cosmetic procedure that can enhance the shape, size, and projection of your buttocks using your own body fat. Instead of using artificial implants, BBL involves fat transfer, removing fat from areas where it’s unwanted (like the abdomen, thighs, or lower back) and injecting it into the buttocks to create fuller, rounder curves. This dual-benefit approach not only improves the appearance of your buttocks but also slims down areas of excess fat, helping you achieve a more balanced figure. The result is a natural-looking enhancement that reflects your own body’s aesthetic potential.
How BBL Procedures are Performed
The procedure begins with liposuction using the advanced VASER system, which gently loosens fat from the donor areas while preserving its viability. This allows Dr. Marosan to precisely sculpt your body while harvesting high-quality fat for transfer. Once the fat is collected, it’s carefully purified to remove excess fluids and damaged cells. The surgeon then meticulously injects the healthy fat into different layers of the buttocks, primarily focusing on the upper portion to create a lifted, youthful shape. The expertise in body contouring ensures that the transferred fat is placed symmetrically for smooth, natural-looking results.
Liposuction Techniques Used in BBL
Liposuction is a type of surgery. It uses suction to remove fat from specific areas of the body, such as the stomach, hips, thighs, buttocks, arms or neck. Liposuction also shapes these areas. That process is called contouring. Liposuction isn’t considered an overall weight-loss method or a weight-loss alternative. Liposuction removes fat from areas of the body that don't respond to diet and exercise. When you gain weight, fat cells get bigger. Liposuction lowers the number of fat cells in a specific area. The amount of fat removed depends on what the area looks like and the volume of fat. After liposuction, the skin molds itself to the new shapes of the treated areas. If you have good skin tone and elasticity, the skin usually looks smooth. Liposuction doesn't help with dimpled skin from cellulite or other differences in the surface of the skin. To have liposuction, you must be in good health without conditions that could make surgery more difficult.
Several liposuction techniques may be employed during a BBL, including:
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Suction-assisted liposuction: The surgeon injects a mixture of salt water and two medicines into the area that's being treated. The salt water aids fat removal and one medicine relieves pain. The surgeon then makes small cuts into the skin and inserts a thin tube under the skin.
Ultrasound-assisted liposuction (UAL): During UAL, the surgeon inserts a metal rod that puts a certain kind of energy under the skin. This energy opens the fat-cell walls and breaks down the fat for easier removal.
Laser-assisted liposuction (LAL): During LAL, the surgeon puts a laser fiber through a small cut in the skin and breaks down fat deposits.
Power-assisted liposuction (PAL): This type of liposuction uses a thin tube that moves back and forth quickly. The vibration allows the surgeon to pull out tough fat more easily and faster. PAL may sometimes cause less pain and swelling and allows the surgeon to remove fat more accurately.
During the procedure, some liposuction procedures use medicines to numb a specific area of the body. These medicines are called local or regional anesthetics. If you are given local or regional medicine, you also may be given a medicine, usually through an IV injection, to help you stay calm and relaxed. Other procedures may use medicines called general anesthetics. The surgical team watches your heart rate, blood pressure and blood oxygen level during the procedure. If you are given local anesthesia and feel pain during the procedure, tell your surgeon. If you've had general anesthesia, you'll wake up in a recovery room. You'll typically spend at least a few hours in the hospital or clinic so that your medical team can watch your recovery.
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Post-Operative Expectations and Recovery
Expect some pain, swelling and bruising after the procedure. After the procedure, the surgeon may leave your incisions open or put in temporary drains to help fluid drain out of your body. Most people need to wear tight garments after surgery to help reduce swelling. You may need to wait a few days before going back to work. During this time, expect some differences in shape as the remaining fat settles into position.
Recovery after a BBL is essential to ensuring your fat grafts take hold and your results last. Right after surgery, you’ll be placed in a compression garment to help reduce swelling and support the new contours of your body. Most patients feel sore and swollen for the first few days, especially in both the liposuctioned areas and the buttocks. One of the most important recovery rules is avoiding direct pressure on your buttocks for at least two to three weeks. This helps protect the transferred fat cells so they can successfully integrate with your existing tissue. You’ll need to sleep on your stomach or sides and use a special BBL pillow when sitting to avoid compromising your results. Following these instructions closely will help you heal smoothly and maximize the long-term benefits of your surgery.
Here’s what to keep in mind during the aftercare period:
- Wear your compression garment as directed to control swelling and support healing.
- Avoid sitting directly on your buttocks for at least 2-3 weeks. Use a BBL pillow when you need to sit down.
- Sleep on your stomach or sides to reduce pressure on the newly grafted fat.
- Walk lightly and frequently to promote circulation and prevent blood clots.
- Stay hydrated and eat nutrient-rich foods to support tissue repair.
- Avoid strenuous activities for about 4-6 weeks, or as advised by your surgeon.
- Attend all follow-up visits to monitor your healing progress and results.
After liposuction, swelling typically goes away within a few weeks. By this time, the treated area should look less bulky. Skin loses some firmness as people age, but liposuction results usually last a long time if you maintain your weight. If you gain weight after liposuction, your fat levels may change.
Potential Risks and Complications of BBL Surgery
Like any surgery, BBL carries risks, and understanding them is an essential part of making an informed decision. The most serious complication is fat embolism, during which fat enters the bloodstream and blocks vital vessels, which can be life-threatening if not managed. This is why it’s critical to choose a board-certified plastic surgeon who uses safe, proven techniques. Other potential complications include infection, fat necrosis (where some fat cells don’t survive), asymmetry, contour irregularities, and prolonged swelling. While many of these issues can be prevented or minimized through careful surgical planning and postoperative care, it’s important to be aware of them and follow safety protocols.
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Specific Risks to Consider
- Fat embolism: This is the most serious risk associated with BBL surgery, occurring when fat is injected too deeply or near major blood vessels, allowing it to enter the bloodstream and potentially block vital vessels.
- Infection: Infection can occur at incision or injection sites, requiring antibiotic treatment and potentially further procedures. BBL procedures can lead to soft tissue infections, often in the bilateral gluteal soft tissues. Inadequate sterilization during the initial cosmetic surgical procedure may lead to initial bilateral gluteal lesions and multiple soft tissue defects. Complicated postoperative infections are common after BBL.
- Fat necrosis: This occurs when some of the transferred fat cells don't survive due to insufficient blood supply, leading to lumps or uneven texture in the buttocks.
- Asymmetry: Uneven fat absorption can result in asymmetry, where one buttock appears larger or differently shaped than the other.
- Contour irregularities: The skin may appear bumpy, wavy or withered due to uneven fat removal, poor skin elasticity and scarring.
- Prolonged swelling or bruising: Swelling and bruising are common after surgery, but in some cases, they can be prolonged and require additional management.
- Seroma: Temporary pockets of fluid, called seromas, can form under the skin.
- Changes in skin sensation or numbness: You may feel temporary or permanent numbness in the treated areas.
- Kidney and heart problems: When large volumes of liposuction are performed, fluid shifts.
- Lidocaine toxicity: Lidocaine is a medicine that is used to help manage pain. It's often given with fluids injected during liposuction.
Addressing the High Mortality Rate
By 2017, the risk of death from pulmonary fat (PFE) was identified, earning the BBL the highest mortality rate of any aesthetic surgical procedure. Brazilian Butt Lift procedures historically carried concerning mortality rates as high as 1 in 3,000 procedures, though improved techniques have reduced this to approximately 1 in 14,900.
Dr. R.C. O’Neill’s research emphasizes that much of the safety discussion surrounding BBL focuses on these life-threatening complications, particularly when fat is injected into deeper tissues. The critical safety improvement came from technique modifications avoiding intramuscular injection, keeping fat grafts in subcutaneous planes where large vessels are less prevalent.
The "Subcutaneous-Only" Technique
In 2018, ASERF compiled the information acquired from these cadaver studies to publish a set of 10 guidelines that emphasized the subcutaneous-only injection technique with recommendations that focused on cannula awareness during fat grafting: using a stiff cannula (>4 mm), avoiding a Luer-Lock interface to prevent inadvertent cannula misguidance, preferring intergluteal (sacral) incisions, and continuous tactile awareness of the cannula tip.
In April 2019, the Florida Board of Medicine (FL BoM) held a special session to discuss the high mortality rate of BBL surgery in the state. During this meeting, the FL BoM affirmed that the standard of care for gluteal fat grafting in 2019 was a “subcutaneous-only injection” technique and then drafted the June 2019 emergency rule which mandated gluteal fat grafting to the subcutaneous space (above the deep gluteal fascia).
Factors Contributing to Complications
The anatomic findings of the gluteal dissections from 11 post-BBL surgery autopsies (22 hemibuttocks) were assessed for commonalities. All BBL PFE cases had fat grafts injected into the gluteal musculature in multiple different levels. Another commonality involved the location where the surgery took place, with the great majority of patients (92%) undergoing surgery at high-volume, budget clinics located in South Florida.
The postmortem results confirmed a 2-factor hypothesis for this fatal complication: fat must be injected into the gluteal muscles and a gluteal vein injury must be present.
Comparing BBL to Buttock Implants
When considering buttock augmentation in Orange County, patients face a critical decision between two primary surgical options, each carrying distinct safety profiles and long-term outcomes.
Butt implants involve the surgical placement of solid silicone prosthetics into the gluteal region to create permanent volume enhancement. The surgeon creates a pocket either within the gluteus maximus muscle or above it, positioning the implant to achieve the desired projection and shape. The surgical technique requires precise dissection and pocket creation to minimize complications such as displacement or rotation. Modern implants come in various shapes and sizes, allowing customization based on individual anatomy and aesthetic goals.
The most significant safety distinction between these procedures lies in their potential for life-threatening complications. Butt implants present a fundamentally different safety profile with no reported risk of fat embolism, as the procedure involves solid prosthetic placement rather than injection of liquid material. The absence of fat embolism risk with implants represents a significant safety advantage for patients prioritizing mortality risk reduction.
Statistical analysis reveals a seemingly paradoxical finding: buttock implants show a 21.6% overall complication rate compared to BBL’s 9.9% rate. However, these numbers require careful interpretation, as the types and severity of complications differ significantly between procedures. The higher complication rate for implants primarily reflects manageable issues rather than life-threatening events.
How to Minimize BBL Risks
- Choose a board-certified plastic surgeon: Selecting a qualified and experienced surgeon is crucial for minimizing risks. Verify board certification by the American Board of Plastic Surgery and ask about their experience with BBL procedures, including annual procedure volumes and complication rates.
- Ensure the surgeon uses safe techniques: The surgeon should be using the "subcutaneous-only" injection technique to avoid injecting fat into the muscle, which carries a higher risk of fat embolism.
- Surgical Facility Accreditation: Verify that the surgical facility maintains accreditation from recognized organizations such as AAAASF or Joint Commission. Orange County regulations require specific safety equipment and protocols for surgical centers - confirm compliance with these standards.
- Discuss your medical history: Be transparent with your surgeon about your medical history, including any pre-existing conditions, allergies, and medications you are taking.
- Follow pre- and post-operative instructions: Adhere to all instructions provided by your surgeon, including stopping smoking, avoiding blood thinners, and following the recommended recovery protocol.
- Maintain a stable weight: Significant weight fluctuations after the procedure can affect the results.
- Anesthesia providers’ qualifications: Inquire about anesthesia providers’ qualifications and experience with buttock augmentation procedures.
- Infection prevention protocols: Understanding the facility’s infection prevention protocols and post-operative monitoring procedures provides insight into their commitment to patient safety.
Preparing for a BBL
Before the procedure, discuss with your surgeon what to expect from the surgery. Your surgeon will review your medical history and ask about any medical conditions you may have. Your surgeon will recommend that you stop taking certain medicines, such as blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs), at least a week before surgery. If only a small amount of fat is to be removed, the surgery may be done in a clinic or medical office. If a large amount of fat will be removed or if you have other procedures done at the same time, the surgery may take place in a hospital. Before your liposuction procedure, the surgeon may mark circles and lines on the areas of your body to be treated.
Before a Brazilian butt lift procedure, your healthcare provider will assess many factors, including your mental health and any social conditions. Your healthcare provider may ask you the following questions:
- Why do you want a Brazilian butt lift?
- What are your expectations?
- Do you think a lot about imagined or very small defects with your body?
- Is a spouse, partner or friend encouraging you to get a Brazilian butt lift?
- Are you aware of the risks involved in a Brazilian butt lift procedure, including fat embolisms?
Your healthcare provider will evaluate your general health, including any preexisting health conditions or risk factors. Talk to your healthcare provider about any allergies you have. Tell them about any prescription or over-the-counter (OTC) medications that you’re taking, including herbal supplements.
Your physical health and the shape of your body are also important. Your healthcare provider will examine the following regions to determine the best place(s) to perform the fat harvesting via liposuction:
- Lower back region.
- Hips.
- Inner thighs.
- Outer thighs.
- The space between your tailbone, sacrum and rectum (presacral triangle).