The Australasian Society of Aesthetic Plastic Surgeons (ASAPS) has supported the formation of a Patient Safety Task Force to investigate the risks and improve the patient safety of the increasingly popular procedure of Brazilian Butt Lift (BBL) in Australia.
The increase in the number of complications following BBL has been the focus of the leading professional Plastic Surgery Societies of the world.
BBL is the colloquial term for buttock fat grafting, an elective cosmetic 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 increased over the last few years, with the American Society for Aesthetic Plastic Surgery tracking a 26 per cent jump from 2016 to 2017, making it the surgical procedure that saw the second most significant increase performed year over year.
“In short, the butt is becoming the new breast,” Dr Tim Papadopoulos, Specialist Plastic Surgeon and past President of ASAPS said.
The Buttock Fat Grafting Task Force
Dr Papadopoulos confirmed that five of the world’s preeminent Plastic and Cosmetic Surgery-related organisations had banded together to form an Inter-Society Buttock Fat Grafting Task Force to research complications and deaths associated with BBL.
“The American Society of Aesthetic Plastic Surgery, the American Society of Plastic Surgeons, the International Society of Aesthetic Plastic Surgery (ISAPS), the International Society of Plastic and Regenerative Surgeons and the International Federation for Adipose Therapeutics and Science recognised that the high death rate for BBL, and took action in order to prevent further tragedies from occurring.
“The Task Force is concerned with the high mortality rate of this operation and is aggressively investigating ways to make this procedure safer. This new warning emphasises the continued risk with this procedure. Patient safety is the highest priority for plastic surgeons, and this multi-society task force is an essential and unprecedented collaboration.
“The procedure has resulted in an alarming rate of mortality, estimated to be as high as 1:3,000.
“This rate of death is far higher than any other cosmetic surgery. Whilst we haven’t had any deaths from BBL in Australasia, this may be due to the cultural and ethnic differences and perceptions of beauty regarding the derriere.
“Although social media has had a huge influence in promoting BBL, especially with celebrities like Kim Kardashian and Jennifer Lopez, the volumes of buttock fat transfer overseas don’t necessarily translate to what’s going on here in Australia. In the USA, the African-American and Hispanic populations have generally dictated their beauty norms which promote larger backsides and smaller breasts, so volumes of 1,500cc per buttock can be the norm. This is not the case in Australia where women generally prefer larger breasts and smaller backsides. Hence, the amounts of fat transferred to the buttocks are much more conservative, usually, in the range of 300-400cc (the size of a can of Coca-Cola) and most plastic surgeons in Australia inject in the subcutaneous plane only. Generally, fat grafting to the buttock is all about giving shape, whereas, implants are used to give a projection,” Dr Papadopoulos said.
The Task Force will examine the causes behind complications and deaths to try to prevent them from occurring through a variety of doctor and patient safety education measures, including new research.
The research to be conducted is from anatomic studies on cadavers, using injectable dye studies with ultrasound and fibre optic equipment, cannula testing, injection depth testing and specific site injection testing.
“Once the results are finalised, a comprehensive set of guidelines for the procedure will be submitted for publication in major clinical journals,” Dr Papadopoulos said.
BBL Surgery Complications
Dr Papadopoulos explains that complications from the surgery are likely a result of numerous factors, including the technically challenging nature of the surgery and that the rise in interest has caused more non-FRACS qualified and non-plastic surgeons to perform the operation.
“Patient safety is always our top concern, so we encourage all surgeons and potential patients to talk in-depth about the significant risks associated with buttock fat grafting before considering a BBL.
“Interestingly, while this procedure has been performed for decades, it wasn’t recognised as risky until recently,” Dr Papadopoulos said.
The alarm bells started to ring for some surgeons in 2015 in the form of a study titled ‘Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong?’, which analysed 19 BBL-related deaths in Colombia and Mexico over a 15-year period. This study was followed by 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 1:2,350 cases and 1:6,241 cases, depending on the data source. (1:3,000 is the most widely accepted figure based on known numbers of fatalities and overall case volume estimates). The 2017 report also noted at least 25 deaths in the U.S. in the preceding five years.
Cause of Death
“The cause of death is 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 usually die in the operating room during the procedure or in the recovery room shortly after.
“These emboli are unique to the buttock area, as fat injections in the breast, face and thighs don’t produce this same phenomenon. The gluteal veins’ distinctive anatomy makes them especially vulnerable because they’re big and thin, and only one tributary away from the inferior 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 or they tear because of traction from the pooling of fat beneath the muscle, it’ll act like a siphon, sucking in fat around it, and ultimately sending fat up into the heart, causing a electromechanical dissociation where there is an ECG trace but no palpable pulse.
“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 get fat emboli and subsequently cause a fatality,” Dr Papadopoulos said.
Dr Papadopoulos is a vocal proponent of injecting fat only into the subcutaneous tissue (the fat layer just below the skin and on top the muscle).
“There is absolutely no advantage in my opinion to placing fat in the muscle, as it doesn’t stay there. When you inject fat just under the outermost membrane of the muscle, it pushes right through the fibres, and tracks under the muscle, into the area where these gluteal veins live,” Dr Papadopoulos said.
Guidelines & Recommendations
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 maintenance of 3D awareness of the cannula tip’s location throughout surgery). The 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.”
Dr Papadopoulos said these guidelines should be adhered to by anyone performing the BBL to curtail complications as much as is possible.
“Any patients interested in the procedure should research and trust only FRACS-qualified Specialist Plastic Surgeons to perform this procedure at accredited and licensed facilities or hospitals. You should ask to see before-and-after photos and ask for patient references. You, too, should stay informed on the issue, and when consulting with doctors, don’t hesitate to question their approach. To find a suitable surgeon, search through the Australasian Society of Aesthetic Plastic Surgeons Member Database.
“After all, it’s your ass on the line,” Dr Papadopoulos said.
Media contact: Julia Power, National PR and Marketing Manager, 0414 276 990