Recently, Brazilian Butt Lifts have been back in the news, this time for the wrong reasons.The Aesthetic Surgery Education and Research Foundation (ASERF) recently formed a Gluteal Fat Grafting Task Force to investigate risks associated with high volume fat grafting to the buttocks. The risk about which they were most concerned was fat embolism, in which fat can enter the bloodstream and travel to the lungs, resulting in sudden death during surgery or shortly thereafter. The task force sent out surveys to surgeons throughout the world; respondents reported 17,519 surgeries with 5 fatal fat embolisms (1/3448). The techniques being utilized during cases which led to fatality were not revealed nor was the relative experience to the injectors. Obviously, techniques being utilized during Brazilian Butt Lift matter as does the experience of the surgeons doing the injection. I have performed hundreds of Brazilian Butt Lifts and have honed techniques designed to optimize safety and cosmetic results for Brazilian Butt Lift patients.
One of the thoughts recently advanced by the ASERF task force is that plastic surgeons should avoid injecting fat within the gluteus maximus muscle or deep to the muscle, as these anatomic planes are richer in large blood vessels and inadvertent fat injection could be more likely to happen in these locations. The task force was quick to point out that it had no data to support this assertion. Although I am not cavalier about injecting fat in deeper anatomic planes, I cannot achieve the same cosmetic results without injecting fat into the plane deep to the gluteus maximus muscle. In my hands, deep injection is necessary to achieve significant anteroposterior projection of the buttocks; think of fat in this plane as the foundation on which a house is built. Intravascular lipoinjection is possible in any anatomic plane. Although it makes sense that vascular injury would more prevalent in the plane deep to the gluteus maximus because of the presence of large vessels, anecdotal reports exist of large volume subcutaneous injections (injections in the plane underneath the skin and superficial to the gluteus maximus muscle) also leading to fat emboli, which is not surprising as the subcutaneous plane also has a relatively rich supply of blood vessels. As is true in all operations, surgeons must be mindful of safe technique when injecting into deep anatomic planes. To me, safe practices include using large bore, blunt (i.e. not sharp) injection instruments to prevent inadvertent trauma to large vessels, ensuring that injections are performed under low pressure, and largely avoiding the inner half of the plane deep to the gluteus maximus, in which virtually all of the large named blood vessels supplying the buttock exist.
Most, if not all, of the reported deaths from Brazilian Butt Lift are though to be the result of syringe based injection of fat; in this technique, surgeons use their hands to push fat into the buttock. This technique not only is more time consuming and fatiguing, but the potential for higher pressure fat injection exists using this older method. As I have mentioned above, low pressure injection is vital to promoting safety and, to that end, I have switched to a closed, automated system with a built in pressure monitor. The rationale behind this is that injections with pressure of less than 10-12 mmHg will be at lower pressure than large peripheral veins and, as such, should not allow fat to be introduced into these large veins. For injections utilizing syringes and cannulas, it’s imperative that the injector utilize slow injections without significant resistance; surgeon experience is vital to ensure that a safe technique is being utilized. For injectors like me, who use a closed, automated system, having a built-in pressure monitor will insure that only low pressure injections occur, thereby preventing inadvertent injection of fat into blood vessels.
It’s important that all patients do their research before having a Brazilian Butt Lift. Full knowledge of the risks and complications is important, just as with any other operation. That being said, in order to avoid unnecessary fear and anxiety, patients should seek out a highly trained and highly experienced plastic surgeon to perform their Brazilian Butt Lift.