Liposuction, a perennially popular procedure, removes a variable amount of fat from places where patients desire less bulging and smoother curves. This fat is usually discarded, however, it can also be injected into other areas of the body as a graft to provide permanent volume enhancement where this is needed or desired. Fat provides multiple benefits including smoothing out contour depressions, softening hard features, and fat has been shown to even benefit the overlying skin. This is poorly understood and may be due to the influence of stem cells in the fat.

Fat injections into the buttocks to make them more full have been done since they were pioneered by Dr. Ivo Pitanguy, a legendary Brazilian plastic surgeon in the 1960’s. Interest in this exploded in the past few years largely due to the influence of such gluteal luminaries as Kim Kardashian, CardiB, Jennifer Lopez, and Nicki Minaj who are known for, among other things, their full, curvaceous buttocks. The number of young women seeking this currently fashionable enhancement has skyrocketed with the numbers doubling over the past decade or so. With this has been a complementary rise in the number of practitioners performing this surgery, both plastic surgeons and physicians of almost every specialty, even non-surgical ones. There is no special requirement to perform a BBL beyond a medical license and the will to do it. Even the license is sometimes optional as some BBL “surgeons” are not surgeons at all, but rather mid-levels such as nurse practitioners and physician’s assistants. That this is so in our litigious age is astounding, and frightening.

Sometimes unbelievable quantities of fat are injected in a single BBL procedure, up to several liters at one time. To obtain this much fat, many patients are left with an abnormally narrow mid-torso, sometimes referred to as a “snatched waist”. This can lend a bizarre, almost cartoonish look with a tiny waist and a huge derriere to young women. Among many unanswered questions about the BBL is this one. How will these women appear in middle age, when the skin looses elasticity and gravity has exerted it effect?

It is not surprising that, with the rise in demand and often minimally trained physicians performing the BBL, there has been an increase in reported complications. Cosmetic complications include irregular contours, poor placement of the fat, over or under-correction, and results that do not last because of the failure of large amounts of grafted fat to survive over the long term. These pale in the face of the ultimate risk: death.

In addition to being the most rapidly growing procedure in cosmetic surgery, the BBL is now the most dangerous. The death rate was so high in South Florida, the acknowledged epicenter of the BBL craze, that the state stepped in with an emergency rule in 2019 with limitations on how much fat could be injected at one time and where it could be injected (only into the fat, not into the muscle.

The anatomy of the buttocks is such that it is very easy to deliberately or accidentally inject fat into the gluteal muscles. These large, powerful muscles have large veins. If fat is injected directly into one of these, it has an unimpeded, straight shot to the lungs, a condition called fat embolism. A patient with a significant fat embolism can literally drop dead in seconds. Despite the above ruling, death rates did not drop, and actually increased with eight reported deaths in 2021 such that the Florida Board of Medicine stepped in again and issued an emergency ruling on June 14 to require that all BBL procedures be videotaped as part of the patient’s medical record. The ruling also required that ultrasound guidance be used to insure that the fat is placed only within the fat layer of the buttocks (It doesn’t take genius to anticipate a run on the purchase of ultrasound machines in the immediate future). The ruling also limits surgeons to performing no more than 3 of these in a single day. Apparently some surgeons were doing a half dozen or more, leading to fatigue and increased potential for complications.

The ruling provides some protection for young women but only temporarily, as it expires on September 12 and may not be renewed. Given the fickleness of women’s fashions and the short life of any fad, one has to wonder how soon the BBL will be tossed on the trash heap of cosmetic surgery fads and current demand for the BBL will end. More to the point, how many dead and disfigured young women will it leave in its wake?

Richard T. Bosshardt, MD, FACS

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