A new advisory suggests “new and important guidelines” for plastic surgeons performing gluteal fat grafting, or what is commonly referred to as “Brazilian butt lift” surgery.
The use of ultrasound during the fat-injecting portion of BBL surgery, and the limiting of providers to doing no more than 3 BBL surgeries per day are cited as the “most compelling” and important of the new guidelines.
Practice Advisory on Gluteal Fat Grafting was published, ahead of print, on April 11 in Aesthetic Surgery Journal, the peer-reviewed journal of The Aesthetic Society.
Its authors are board-certified plastic surgeons Daniel Del Vecchio, M.D. and Jeffrey M. Kenkel, MD, FACS.
The purpose of the recommendations, which number 10 in all, are twofold:
- To ensure surgeons safely inject fat into the right layers of the buttocks, and
- To eliminate surgeon fatigue and distraction–which can lead to inadvertent but lethal violations of (1).
If fat is improperly injected too deeply into the buttocks, it can cause a pulmonary fat embolism, which the authors note is the #1 cause of death during the popular procedure.
The author’s research focuses on Florida, but their recommendations are suggested for use by all surgeons.
“Practice advisories are developed to assist physicians in clinical decision making and represent strategies for improved patient management….
“The purpose of the present advisory is to employ a combination of scientific evidence, empirical data, and common sense to provide a set of updated guidelines for practitioners performing BBL, or gluteal augmentation with fat grafting.”Daniel Del Vecchio, MD, Jeffrey M Kenkel, MD, FACS, Practice Advisory on Gluteal Fat Grafting, Aesthetic Surgery Journal, 2022;, sjac082, https://doi.org/10.1093/asj/sjac082
Florida has 7% of the U.S. population but accounted for 28% of U.S. BBL deaths between 2011-2016 according to the authors.
One death the advisory makes mention of occurred June 16, 2021, the day a south Florida plastic surgeon began his first surgery at 6:32 am.
At approximately 8:21 pm, his seventh patient of the day perished.
Her death was one of 12 BBL fatalities that occurred in the state in 24 months.
Fifty-eight percent of these deaths were “clustered toward the end of the week,” and all deaths at the start of the week “occurred on Monday, the first day after the weekend.”
Drawing on US highway fatality statistics, and legal limits set in place to curb truck driver fatigue, the authors suggest similar limitations for surgeons performing gluteal fat grafting.
In a live presentation for providers held June 9, Advisory author Del Vecchio notes that the recommendations are not considered to be the new standard of care, but are opinions based on putting safety first.
Practice Advisory on Gluteal Fat Grafting
“But clearly, the most important recommendations in the guidelines—and the ones that I think carry the most weight in terms of reducing mortality—are going to be the use of ultrasound to show that the tip of the cannula is above the gluteal fascia at all times during injection, and then putting some limitations on fatigue and distraction.
“And coming up with three cases a day just seemed like a reasonable number of cases for a surgeon to do in a nine to 10-hour surgical day.
“Again, I bring you back to the Ron Iverson and Dennis Lynch paper, which was written 20 years ago during a time when liposuction mortality was about one in 5,000…
“And this paper is still quoted on a daily basis. This paper has stood the test of time and it wasn’t based on a single iota of scientific evidence. It was based on experience, common sense and a focus, above all, on patient safety.
“So I think we have to think about these recommendations as guidelines. We clearly state that it’s not considered to be the standard of care, but it is an opinion based on putting safety first.”
Dr. Dan Del Vecchio, June 9, 2022
[“Standard of care is an essential concept in determining whether a person was negligent and potentially liable for a tort. If a person breaches the standard that applies to them and their actions cause harm to another person, they will be liable for negligence.” – Cornell Law School, Legal Information Institute]
“A total of 3 BBL procedures is a reasonable limit of total procedures per day,” the authors write in a summary table of recommendations for which they provide a detailed breakdown of the math involved.
While many of the advisory’s 10 recommendations are technical in nature, some are points that patients may be able to use to spot red flags in online reviews of providers.
From the same table of recommendations, the authors summarize:
- “Ultrasound-guided BBL should be learned and incorporated into every gluteal fat-grafting procedure; static injection technique is recommended”
- “Factors that cause distraction must be minimized during fat transplantation” [Music, videos, social media, visitors, and room traffic are among the specific distractions mentioned throughout.]
- “A ‘single-surgeon’ approach, where one [surgeon] performs the entire surgery, is recommended.”
In light of the death of patients in its state, the Florida Board of Medicine approved an Emergency Rule, June 3rd, that requires the use of ultrasound during Brazilian butt lifts and limits providers to performing no more than three of the procedures in any one day.
Critics have argued that using ultrasound requires a second surgeon to be present and adds time to the operation, but a live presentation for providers that aired on June 9 shows a single surgeon operating with a handheld ultrasound device.
The advisory suggests that the “single surgeon” BBL technique shown can produce superior aesthetic results despite using smaller volumes of fat, and while providing certainty that the fat has been placed in the correct, non lethal, layers of the buttocks.