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P. Pazmino
2. Deep space fat grafting to the central domes, supragluteal area, and outer hips at
a high point of greatest hip projection.
3. Anticipate for additional adhesion release in both spaces along the outer hip
before and after fat grafting for smooth graft distribution.
4. Supercial space fat grafting to correct supercial concavities at the outer hips.
5. To more reliably achieve the patient’s desired waist to hip ratio, extract as much
fat as possible throughout the waist and anks, rather than rely on the survival of
fat graft in the outer hips.
5.6.10 Result
The patient received an ultrasound guided gluteal fat grafting, a Brazilian Butt Lift
with fat grafting under real time intraoperative ultrasound visualization. The patient
received fat separation without suction and fat extraction under suction of the abdomen, waist, anks, lower back, and sacral areas. Care was taken to empty the waist
and anks and the suprasacral triangle concavity. She then received 1000 cc of fat
graft per side. 700cc of fat graft was placed in the deep subcutaneous space (above the
deep gluteal fascia and below the supercial gluteal fascia) for the creation of gluteal
volume, central dome projection, and supragluteal contour. Release of adhesions
throughout the deep and supercial gluteal spaces at the outer hips was performed,
taking care to leave the supercial gluteal fascia intact. She then received 300cc of fat
graft to the supercial subcutaneous space (above the supercial gluteal fascia and
below the skin) at the outer hips, bilaterally. Further adhesion separation was performed after fat grafting to ensure even distribution of the fat graft in both spaces. The
patient is shown with a 9month result and is satised with the result (Fig.5.16).
Fig. 5.16 Case 2: Ultrasound Guided Fat Grafting Plan. Left: Preoperatively gluteal fat grafting
was planned to the deep subcutaneous spaces (Green) to increase projection and add volume. Fat
grafting to the supercial subcutaneous spaces (Yellow) would supplement the deep volume and
correct supercial irregularities. Center: Preop. Right: Post-operative result at 9months
5 Real Time Intraoperative Ultrasound Guidance Can Make Any Gluteal Fat Grafting…
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5.7 Conclusion
Gluteal fat grafting is a powerful body contouring technique that can create impressive results not obtainable with implants or liposuction alone. This procedure is very
technique dependent and because of the too frequent fatal complications, it has been
recommended that surgeons avoid intramuscular injection and only fat graft in the
subcutaneous space above the deep gluteal fascia. The subcutaneous space, however, is a thin curving dome that ranges in thickness from 1cm at the outer hips to
3–4cm at the central gluteal dome. This creates a difcult target for gluteal surgeons who do not use intraoperative imaging. Real time intraoperative ultrasound
guided fat grafting allows the surgeon to consistently avoid an intramuscular injection and manipulate the subcutaneous spaces above and below the supercial gluteal fascia to precisely control fat graft volume and distribution, create projection,
and correct supercial irregularities. The surgeon can also create ultrasound video
of the entire procedure to document that they remained above the deep gluteal fascia
at all times and analyze how their fat graft placement affected their ultimate clinical
results. None of this is possible without ultrasound. Surgeons do not need to change
their preferred fat grafting technique. Intraoperative ultrasound can conrm the cannula position at all times, making any fat grafting technique safe and accurate. Real
time intraoperative ultrasound is now an affordable tool that can work with any fat
grafting system that can not only make gluteal fat grafting more accurate and powerful, but safer, as well.
References
1. Roberts T.Augmentation of the buttocks by micro fat grafting. Aesthet Surg J. 2001;21:311–9.
2. Mendieta C, Stuzin JM.Gluteal augmentation and enhancement of the female Silhouette:
analysis and technique. Plast Reconstr Surg. 2018;141:306–11.
3. Mod MM, Teitelbaum S, Suissa D, Ramirez-Montañana A, Astarita DC, Mendieta C, Singer
R.Report on mortality from gluteal fat grafting: recommendations from the ASERF task force.
Aesthet Surg J. 2017;37:796–806.
4. Wall S Jr, Del Vecchio D.Commentary on: Report on mortality from gluteal fat grafting: recommendations from the ASERF task force. Aesthet Surg J. 2017;37:807–10.
5. Saylan Z.Liposhifting instead of lipolling: treatment of postlipoplasty irregularities. Aesthet
Surg J. 2001;21:137–41.
6. Abboud MH, Dibo SA, Abboud NM.Power-assisted liposuction and lipolling: techniques
and experience in large-volume fat grafting. Aesthet Surg J. 2019;40(2):180–90. https://doi.
org/10.1093/asj/sjz019.
7. Wall SH, Lee MR. Separation, aspiration, and fat equalization. Plast Reconstr Surg.
2016;138:1192–201.
8. Condé-Green A, Kotamarti V, Nini KT, Wey PD, Ahuja NK, Granick MS, Lee ES.Fat grafting for gluteal augmentation: a systematic review of the literature and meta-analysis. Plast
Reconstr Surg. 2016;138:437e–46e.
9. Villanueva NL, Del Vecchio DA, Afrooz PN, Carboy JA, Rohrich RJ. Staying safe during
gluteal fat transplantation. Plast Reconstr Surg. 2018;141:79–86.
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10. Villanueva NL, Del Vecchio DA, Afrooz PN, Rohrich RJ.Reply: Staying safe during gluteal
fat transplantation. Plast Reconstr Surg. 2018;142:594e–5e.
11. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H, Cuenca-Pardo J.Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg. 2015;136:58–66.
12. Rapkiewicz AV, Kenerson K, Hutchins KD, Garavan F, Lew EO, Shuman MJ.Fatal complications of aesthetic techniques: the gluteal region. J Forensic Sci. 2018;63:1406–12.
13. Multi-Society Task Force for Safety in Gluteal Fat Grafting (ASAPS, ASPS, ISAPS, IFATS,
ISPRES). Urgent warning to surgeons performing fat grafting to the buttocks (Brazilian Butt
Lift or ‘BBL’). Isaps News. 2018;12:8.
14. E.Lew, Personal communication on statistics on mortality after fat grafting and liposuction in
Miami Dade County (2019)
15. Cansancao AL, Condé-Green A, Vidigal RA, Rodriguez RL, D’Amico RA. Real-time
ultrasound- assisted gluteal fat grafting. Plast Reconstr Surg. 2018;142:372–6.
16. Mendieta C. The art of gluteal sculpting. New York: Thieme Medical Publishers;
2011. https://books.google.com/books/about/The_Art_of_Gluteal_Sculpting.
html?hl=&id=2ZUdvgAACAAJ
17. Shermak M.Body contouring. New York: McGraw Hill Professional; 2010. https://market.
android.com/details?id=book-LmUWgPpOBAwC
18. Stecco C, Hammer W, Vleeming A, De Caro R.Subcutaneous tissue and supercial fascia. In:
Functional atlas of the human fascial system. Amsterdam: Elsevier; 2015. p.21–49.
19. Del Vecchio D, Wall S Jr. Expansion vibration lipolling: a new technique in large-volume fat
transplantation. Plast Reconstr Surg. 2018;141:639e–49e.
P. Pazmino
Chapter 6
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Safety Comparison ofAbdominoplasty
andBrazilian Butt Lift: How Dangerous Is
BBL?
DanielDel Vecchio
Abdominoplasty and Brazilian Butt Lift (BBL) are two popular operations in body
contouring surgery. Abdominoplasty demonstrates stable but low growth rates in the
USA and the UK; however, BBL rates in the USA and UK demonstrate high procedural growth. BBL is also in a state of technical ux. Recently, plastic surgeons in
leadership positions have discussed banning BBL in the USA due to perceived high
mortality rates [1]. In some countries the operation is effectively banned altogether [2].
The central rationale for banning BBL or for labeling is as “the most dangerous
cosmetic surgery procedure” stems from a compelling publication from the USA
showing a 1:3000 mortality rate [3]. Additional evidence presented by proponents
of a ban on BBL includes articles in the lay press depicting patients who have died
from BBL surgery.
Over the past 5–7 years, new techniques of large volume fat grafting have
emerged. Expansion Vibration Lipolling (“EVL”) combined with Safe
Subcutaneous Buttock Augmentation (SSBA) has been described and has been published in the plastic surgery literature. With proper execution of subcutaneous fat
grafting to the gluteal region, the anatomical barrier afforded by the muscular fascia
of the gluteus maximus muscle eliminates the theoretical risk of pulmonary fat
embolism. As long as the surgeon stays subcutaneous with their cannula there is no
anatomic possibility of fat entering into the intramuscular or submuscular gluteal
vessels.
That being said, the recent knowledge that fat placed under the fascia is dangerous, while fat limited to the subcutaneous space is safe, falls short of satisfying the
procedure as safe because it is not 100% certain that the operator’s cannula is not
below the muscular fascia. It was not until the introduction of ultrasound-guided
BBL that this operation can truly be deemed a safe procedure for the masses.
D. Del Vecchio (*)
Boston, MA, USA
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_6
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D. Del Vecchio
The fundamental question remains, in the present time before ultrasound is 100%
adopted by BBL clinicians, what is the real present mortality rate for BBL? This
chapter objectively reviews the true mortality data from published abdominoplasty
communications and compares them to what literature is currently available regarding mortality on BBL, to make a logical comparison of the accurate risks of each
procedure. Hopefully by the time this chapter is in print, we may rephrase the narrative to, “prior to ultrasound, what was the true mortality of BBL?”
In order to determine an accurate mortality for abdominoplasty, literature
searches were performed using Google and Ovid databases in the eld of plastic and
reconstructive surgery. English-language scientic publications about abdominoplasty and its complications were analyzed using PubMed.gov. Abdominoplasty
papers that queried survey study mortality rates were searched, and abdominoplasty
publications that contained true clinical series data on mortality rates were identied. Appropriate terms were used to search for abdominoplasty complications. A
similar literature search was applied for BBL.
Surprisingly, there are not many publications that speak directly of the mortality
rate of abdominoplasty, nor is its mortality well-known among plastic surgeons.
Table6.1 depicts the search results on the publications that are the most clinically
relevant or explicitly mention or include data on mortality rates for either abdominoplasty or for BBL.
Mortality rates for abdominoplasty from published survey studies and from clinical series ranged from 1:2400 to 1:13,000. No clinically relevant papers exist on
BBL mortality that involve a retrospective, prospective, or registry series of cases.
We are only left with retrospective survey studies, which demonstrate in Table6.1
that the mortality for BBL surgery ranges from 1:3000 to 1:20,000 with an average
mortality of 1:12,700.
There have been many publications on abdominoplasty surgery that focus on a
wide variety of patient safety topics [4–13]. The publications on abdominoplasty
mortality depicted in Table6.1 suggest the mortality for abdominoplasty has trended
downward over time. This is consistent with many innovations and/or techniques in
Table 6.1 Mortality rates for abdominoplasty from published survey studies and from clinical
series ranged from 1:2400 to 1:13,000
No clinically relevant papers exist on BBL mortality that involve a retrospective, prospective, or
registry series of cases. As depicted in Table6.1, the mortality for BBL surgery from survey studies
ranged from 1:3000 to 1:20,000 with an average mortality of 1:12,700
200000
180000
160000
140000
120000
100000
UK USA
Annual Abdominoplasty Cases 2009-2018
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plastic surgery, where procedural advances, better instrumentation, and proper surgical education have led to better patient safety and better outcomes [14, 15].
Most clinical series papers on abdominoplasty safety have focused on local
(wounds, seromas) complications, systemic complications [16–20], and on DVT
prophylaxis [21]. With one exception, [22] no publication on abdominoplasty has
ever directly focused on mortality as the central theme of its communication. Some
large clinical series containing valuable mortality statistics appear to be overshadowed by the authors’ preferred topic such as liposuction or complications of deep
vein thrombosis [23]; some abdominoplasty mortality rates were not even mentioned in publications on abdominoplasty and required calculation from the paper’s
raw data [24].
Mortality rates for abdominoplasty are not insignicant. Despite this fact, the
procedural mortality for abdominoplasty has been tolerated over the past 20years
by organized plastic surgery both in the USA and the UK.While abdominoplasty
procedures performed in the UK averaged 3000 over the past 10years, [25] those in
the USA averaged 156,000 [26] (Fig.6.1).
In 2018 there were 157,492 USA abdominoplasties. Applying known mortality
rates, one would have expected 12 abdominoplasty deaths in 2018, yet few media
deaths are mentioned [28, 29].
Articles in the lay press have never been used as evidence by plastic surgeons to
indict the safety of abdominoplasty. Such content on BBL deaths has and is used by
80000
60000
40000
20000
0
2009 2010 2011 2012 2013
Fig. 6.1 Abdominoplasty Trends, UK, USA, 2009–2018. Overall, this is a stable/at growth rate
procedure in both countries, amenable to statistical sampling and extrapolation. Negative US
growth in 2016–2017 likely reects general economic conditions [27] rather than decreased adoption of the surgical technique per se
2014 2015 2016 2017 2018
90
D. Del Vecchio
leaders in organized plastic surgery to condemn BBL [30]. There has never been a
mention of banning the abdominoplasty operation, despite published survey studies
reporting as high as a 1:3000 mortality.
The initial alarm bell on BBL mortality was sounded in 2015 by a publication
showing massive pulmonary fat embolism as a cause for BBL mortality [31]. In
June 2016, ASAPS members convened a “Gluteal Task Force” and formulated a
membership survey study regarding BBL mortality. A mortality rate of 1:3000 was
published, which is the statistic often quoted by international regulators, plastic
surgery leaders, celebrity surgeons, and the media.
After the death of a British national who underwent BBL in Turkey, a UK coroner argued in favor of a “moratorium on BBLs” in the UK in view of “mortality and
morbidity risks” [32] (Fig.6.2).
In June 2019, a public letter signed by individuals from the Multi-Society Gluteal
Fat Grafting Task Force Advisory stated that the mortality of the BBL procedure to
be “the highest known for any cosmetic procedure” [33]. A Board-Certied Plastic
Surgeon’s existing web page states the BBL procedure as having the “highest incidence of death” [34]. A Hufngton Post Article on BBL Safety contained a headline
quote by a Board-Certied Plastic Surgeon, stating,
“It’s really unacceptable what’s going on…Its outrageous” [35].
The impact and implications of a peer-review published 1:3000 BBL mortality
rate are far-reaching [3]. In an editorial commentary, written by the publishing
Journal’s editor, the question was raised:
“So why do we, as plastic surgeons dedicated to the health and safety of our patients, not
decide that the high level of risk associated with this particular procedure warrants restrict-
ing or no longer offering it to our patients?” [36]
The published 1:3000 BBL mortality rate [3] stimulated a urry of clinical and
basic science research, which is summarized below. Some of the research ndings
stem from independent research which demonstrated several key points:
1. There is a large free space under the gluteus maximus muscle; there is no fascia
on the deep surface of this muscle.
2. Fat placed just under the fascia of the gluteus maximus muscle migrates through
the gluteus muscle, entering the deep submuscular space, potentially injuring
vessels and entering the sciatic foramen [37].
3. When fat is placed completely in the subcutaneous space, the gluteus fascia acts
as an effective barrier to deep migration; fat will not traverse to the submuscular
space even up to pressures of 200mmHg [38].
4. When surgeons are trained in SSBA [39] using EVL [40], in zero out of 60 but-
tocks there was inadvertent placement of fat beneath the gluteal fascia, evaluated
at 2weeks postoperatively by MRI.This suggests that, as in liposuction, surgeons can be properly trained to stay subcutaneous during fat grafting and can
prevent inadvertent subfascial insertion of fat [41].
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Fig. 6.2 19 December 2019 Letter from Coroner’s Ofce, County of Yorkshire, England, UK,
regarding BBL Inquest, quoting declaration of a “moratorium on BBLs” in the UK in view of
“risks considerably greater than any other cosmetic procedure”
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D. Del Vecchio
The above ndings on the safety of BBL were presented to the Executive Council
of the British Association of Aesthetic Plastic Surgery (BAAPS) in November 2018
[42]. In October 2018, BAAPS recommended a halt on BBL, recommending it not
be performed by its membership [43]. In February 2020, some UK malpractice
underwriters attached BBL exclusions to their policies.
Cited as factors to support the BAAPS decision to recommend a
“moratorium” against BBL were
1. A 1:3000 mortality [44]
2. Reports of UK nationals who died from BBL overseas [45]
Except for the above, there exists no scientic evidence for the justication for
this effective UK moratorium on BBL.In 2013, a UK-published report on cosmetic
surgery discussed gluteal fat grafting but there is little else to go by [46].
In the USA, discussions about banning BBL surfaced. In September 2019, a
panel was organized titled, “Should we Perform BBL?” During this ASPS
Presidential Panel debate, the only piece of scientic data that was used by proponents of banning BBL was the 2017 paper that stated a 1:3000 mortality rate for
BBL [3]. Besides a publication in a tabloid publication showcasing an American
surgeon who stated “I don’t do BBLs, they are deadly” [47], there was no other
presented data, scientic or nonscientic, which supported an argument for banning
BBL [48]. On Oct 26, 2019, another debate in NewYork City raised the question of
banning BBL in the USA [49].
The paper that states a 1:3000 mortality rate for BBL [3] made a signicant
impact. Apart from its credible conclusion that the BBL safety problem was real,
and apart from the fact that it stimulated much needed research to better understand
the BBL problem, its noticeably high mortality rate compared to other published
survey studies serves as the sole scientic basis for commentary regarding banning
BBL in lay press, media articles, academic presentations, publications, and in governmental proceedings. Because of this, and because it was quoted as the driving
evidence to support banning BBL in the UK, a closer look at its methodology was
undertaken.
We carefully reviewed the materials and methods of the paper and fact-checked
all the source data supporting the paper’s conclusions. The paper that states a 1:3000
mortality rate for BBL [3] presented three methodologies to determine the mortality
rate from BBL surgery [3]:
1. ASAPS Member Survey on BBL Mortality
2. US Autopsy Data over a Time Period of 5¾Years
3. BBL PFE deaths from AAAASF Facilities, 2014–2015
We proceeded with a four-point analysis
1. An examination of the paper’s statistical survey data was performed [50].
2. Reassessment of ASAPS’ BBL Procedural Statistics, 2011–2016 was performed.
The statistical methods in which the authors treated data in the autopsy method-
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ology were analyzed. The validity of the authors’ assumptions regarding incremental “noncore physicians” performing BBL in the autopsy methodology
was tested.
3. Assessment regarding AAAASF deaths from pulmonary fat embolism in con-
junction with BBL surgery from 2014 to 2015 was undertaken. The data used in
the paper was also fact-checked by independently requesting and obtaining BBL
mortality from AAAASF for the 4years of available data: 2013–2016.
4. The validity of the authors’ assumptions regarding translating ASAPS proce-
dural statistics to AAAASF BBLs to derive a denominator was examined.
6.1 Methodology 1: ASAPS Survey Raw Data [50]
The authors recommended avoiding fat injection into the “deep muscle,” with the
implication that the supercial muscle was permissible. Of note:
1. There is no “supercial” or “deep” muscular plane of the gluteus maximus mus-
cle, nor has any surgeon ever described how to determine how one remains in the
supercial or deep gluteus muscle.
2. Recent published work on Deep Intramuscular Migration [37] proves that fat
placed beneath the fascia migrates deep below the muscles, negating the authors’
recommendation that supercial muscle injection (below the fascia) is safe and
permissible.
The authors compiled deaths from intraoperative macroscopic pulmonary fat
embolism reported by surgeons from their survey data and used the number of
BBLs performed from the survey data as their denominator. The authors stated the
total number of BBLs was 198,857 and the total deaths totaled 32. Examination of
the authors’ raw data reveals the total number of BBLs was 178,867 and the total
deaths totaled 37. There is a discrepancy between the published data and the survey
data regarding the denominator, the number of BBLs performed.
The authors stated,
“The Task Force elected to exclude two surgeons whose unusually high outlier responses
were most likely due to an erroneous entry while completing the survey.”
Examination of the authors’ raw survey data reveals three survey entries that
could constitute outliers (Table6.2):
Table 6.2 Outlier analysis of the Mod-Teitlebaum Survey Data
A surgeon from Central America reported performing ten lifetime BBLs, nine of which resulted in
fatal pulmonary fat embolism for a 90% mortality rate; a surgeon from the USA who reported ten
career BBL deaths from pulmonary fat embolism; and another USA surgeon who performed seven
lifetime BBLs and had three deaths for a 43% mortality rate
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