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O. Garcia Jr and P. Pazmiño
teal musculature. These techniques of “intramuscular
grafting” allowed for large-volume fat transfers to be
injected into a well-perfused recipient site, theoretically
resulting in a higher percentage survival of the grafted fat.
Surgeons with expertise in gluteal contouring surgery
developed techniques for intramuscular fat grafting [8–10]
and delineated what were thought to be “safe areas” for fat
grafting within the gluteal musculature [11]. Since then,
detailed MRI venography studies of the gluteal venous system suggest that there really is no “safe zone” for fat grafting in the intramuscular or submuscular plane [12].
Brazilian Butt Lift Surgery was the fastest-growing aesthetic surgical procedure between the decade 2010 and
2020 [6]. Unfortunately, with the increase in cases, came an
unprecedented increase in the mortality associated with the
procedure.
In 2015, Cárdenas-Camarena etal. reviewed the experience of plastic surgeons in Mexico and Colombia over the
past 10 and 15years, respectively, and identied 13 pulmonary fat emboli (PFE) deaths in Mexico and 9 PFE deaths in
Colombia after gluteal fat grafting [13]. After analyzing the
autopsy ndings, they found that all the deaths were associated with intramuscular fat grafting. For the rst time, the
danger of grafting fat into the gluteal muscles was recognized, and these authors recommended avoiding fat graft
injections into the deep gluteal muscle.
In July 2016, the ASERF Gluteal fat grafting survey was
sent to all active members of the Aesthetic Society and the
International Society for Aesthetic Plastic Surgery (4843
questionnaires). A total of 692 surgeons responded (14.3%)
to 198,857 cases. The survey placed the mortality associated
with BBL surgery somewhere between 1/2351 and 1/6241
[14]. The Aesthetic Surgery Education and Research
Foundation (ASERF) created the Gluteal Fat Grafting Task
Force to study the factors involved in the high mortality rate
associated with BBL surgery. Under the direction of Peter
Rubin MD, the Intersociety Gluteal Fat Grafting Task Force
began a series of cadaver studies to identify the surgical techniques and anatomic factors that contributed to the unacceptably high BBL mortality rate.
The Task Force convened in Miami in 2017 to create an
appropriate anatomic model to determine safe BBL techniques. Both authors served as consultants to the Task Force
and participated in all the cadaver studies. The central
hypothesis for the study was that “safe approaches for gluteal fat grafting could be delineated by modeling the operation in cadavers.” Once the model was validated, two separate
sessions were scheduled with invited surgeons (Fig.15.1a, b)
who performed their typical BBL techniques under video
uoroscopic monitoring and used color-coded fat to examine
their graft dispersion. Following completion of the grafting
sessions, the buttocks were anatomically dissected, and the
colored fat dispersion was documented with high-resolution
photography. (Fig.15.2a, b).
The authors wish to extend their gratitude to all the invited
surgeons who traveled nationally and internationally to participate in the gluteal fat grafting study. Dr. Rubin ran a very
tight schedule, and the sessions were long and intense. Their
participation resulted in signicant contributions to our
understanding of gluteal fat grafting and the events that could
result in pulmonary fat emboli, associated with the procedure. All invited surgeons, who planned to fat graft only into
the subcutaneous space, were able to do so, even when
injecting large volumes (>1000 mL) into each buttock
(Fig.15.3a, b). The three most important safety recommendations derived from these cadaver studies were: (1) Fat
grafting only into the subcutaneous space, (2) Not injecting
at a downward angle, (3) Using a stiff injection cannula
(>4mm) [15].
ASERF repeated the gluteal fat grafting survey online in
May 2019. This time, 5048 invitations were sent, and 572
responses (11.3%) were received from plastic surgeons
reporting on 29,843 cases. This survey calculated the 2019
BBL mortality rate to be 1/14,921, which, if accurate, would
have surpassed the safety prole of abdominoplasty
(1/13,193 at the time of the survey) [16].
By this time, it had become increasingly clear that the
mortality from BBL was intimately related to pulmonary
fat emboli (PFE) [17, 18], and the physiologic and clinical
differences between macro fat emboli and micro fat emboli
syndrome were well described in the literature [19, 20].
Micro fat emboli syndrome carries reported mortality in
the 10–30% range. A delay in treatment of the syndrome is
associated with a 35% mortality [21], which may be a frequent occurrence in the plastic surgery population undergoing outpatient surgery. Macro pulmonary fat emboli
following BBL surgery, however, is almost always a fatal
event. A 2018 publication involving 16 BBL deaths found
that 50% of the patients died on the operating table while
the other 50% died within 3h of the surgery [22]. Since
that report, there have been three reported cases of survival
following macro fat emboli associated with BBL surgery
(two patients with pulmonary macro fat emboli and the
other with a cerebral fat embolism, in a patient with a patent foramen ovale [23, 24]. The most important commonalities among these survival cases were extremely rapid
access to intensive care at a tertiary care facility with inhouse specialists and the availability of extracorporeal
15 Gluteal Fat Grafting: Technology, Techniques, andSafety
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Fig. 15.1 (a) Session 1
Principal Investigator: J Peter
Rubin, Co-Chair Gluteal Fat
Grafting Task Force: Dan Mills
Invited injectors: Ricardo
Rodriguez (USA), Tino Mendieta
(USA) and Arturo Ramirez
Montanana (Mexico)
Consultants to Gluteal Fat
Grafting Task Force: Pat
Pazmino, Onelio Garcia Jr
Resident Assistants: David Turer,
David Gerth
Observers: James Fernau, Roger
Khouri, Richard D’Amico
(b) Session 2
Principal Investigator: J Peter
Rubin
Invited injectors: Dan Del
Vecchio (USA), Ash Ghavani
(USA, Raul Gonzalez (Brazil),
and Tino Mendieta (USA)
Consultants to the Gluteal Fat
Grafting Task Force: Pat
Pazmino, Onelio Garcia Jr
Resident Assistants: David Turer,
David Gerth
Observers: James Fernau, Roger
Khouri, Richard D’Amico,
Ricardo Rodriguez
a
b
membrane oxygenation (ECMO) devices. Despite the
heroic, life- saving measures, all three surviving patients
suffered varying degrees of associated serious sequelae
from their fat emboli episode. Since the majority of BBL
surgeries take place at outpatient surgery centers and
ofce-based surgical facilities, it appears highly unlikely
that these conditions, necessary for the slimmest chance at
survival, will present themselves even rarely. Currently, it
is fair to say that the large amounts of fat seen in the heart,
lungs, and major vessels during the autopsies of BBLAssociated Fat Emboli deaths are incompatible with life
(Fig.15.4a–c).
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O. Garcia Jr and P. Pazmiño
ab
Fig. 15.2 (a) Color-coded fat prepared for injection. (b) Color-coded fat was injected into tissues. Note the lack of dye bleed into surrounding
tissues which allowed for accurate assessment of the fat dispersion
Fig. 15.3 (a) All invited injectors stayed in the subcutaneous plane, even when injecting large volumes (>1000mL/buttock). (b) Note that all
color-coded fat is supercial to the muscle fascia
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a
b
c
Fig. 15.4 (a) Shows fat exciting cut portion of the vena cava. (b) Displays gross globular fat within the right atrium. (c) Fat graft within pulmonary
artery
15.2 The High BBL Mortality Rate inSouth
Florida
A total of 29 BBL-associated deaths were recorded in Florida
between January 2010 and April 2022. In the time frame
between 2010 and 2016, an average of one BBL-associated
death per year was recorded. Between 2017 and 2018, 8
deaths were recorded, which raised alarms and prompted the
FL BOM to convene a special session to discuss BBL surgery and associated mortality.
In April 2019, the Florida Board of Medicine (FL BOM)
held a special session to discuss the high mortality rate of
BBL surgery in the state. One of the authors (OG) appeared
before the FL BOM on behalf of the Florida Society of
Plastic Surgeons (FSPS), and the results of the latest ASERF
survey along with recommendations from the Task Force,
were shared with the board members. The FL BOM drafted
the Florida BBL surgery Rule, which prohibits surgeons
from injecting fat grafts into the gluteal muscles or the submuscular space. In addition, the ruling notes that physicians
who inject fat grafts into the gluteal muscle during BBL
procedures are subject to disciplinary action, including the
potential loss of their medical licenses. Fat graft injection,
strictly restricted to the subcutaneous space, was considered
the standard of care for BBL surgery in 2019 by the FL
BOM [25].
It was both unfortunate and unexpected that neither the
FL BOM rule nor the ASERF recommendations were able to
improve BBL-associated mortality in Florida. The fact is that
the years following the safety recommendations and the
BOM rules have been the deadliest so far. There have been
14 deaths recorded in Florida since the ASERF guidelines
and 12 deaths since the FL BOM “subcutaneous injection
only” rule was enacted. The worst by year by far was 2021
when a total of six BBL PFE deaths and two nonfatal BBL
PFE cases were recorded in South Florida alone (Fig.15.5).
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O. Garcia Jr and P. Pazmiño
Fig. 15.5 There have been 29 FPE BBL-related deaths in South
Florida from 2010 to 2022
Fourteen of the deaths have occurred since the ASERF guidelines
Twelve deaths have occurred since the ASERF 2019 survey that
depicted a better mortality rate than abdominoplasty and the FL BOM
BBL mandate
2021 was the deadliest year so far, with at least eight deaths conrmed
15.3 Lessons Learned intheMiami Morgue
In an effort to understand the factors associated with BBL
mortality in South Florida, the authors developed a relationship with the Miami-Dade County Medical Examiner’s
Ofce. The Chief Medical Examiner was Dr. Emma Lew,
and by 2017, she had become the foremost authority on
BBL-associated fat emboli deaths, having performed more
autopsies on these patients than any of her peers. She developed a special interest in these cases and was invited to the
Gluteal Task Force cadaver injection sessions so that she
could witness the mechanism of injury resulting in the fat
embolus during BBL procedures. She, in turn, invited the
authors to observe the gluteal dissections at the Miami-Dade
Medical Examiner’s Ofce.
In 2021, two FPE after BBL patients survived, but these are not included
in this data set
It is important to note that there have been more post-BBL deaths in
South Florida (due to anemia and hypovolemic shock, DVT, sepsis, cardiac arrest, intra-abdominal organ damage, etc.), but that the focus of
this paper is only FPE-associated BBL deaths
Once the Medical Examiner team determined the cause of
death, a detailed gluteal dissection was performed to determine if there was any evidence of vascular injury, particularly
to the gluteal veins, and to note the dispersion and location of
the fat grafts. The authors were present in 11 of the autopsies
(22 hemi-buttocks were dissected). The anatomic commonalities noted in these cases are the result of their observations
during the post-mortem gluteal dissections.
Fat grafting into the muscle during BBL surgery always
resulted in fat grafts under the deep gluteal fascia and also
below the muscle belly of the gluteus maximus. Del Vecchio
et al. described in dynamic cadaveric studies that fat graft
placed under the deep gluteal fascia could migrate through
the muscle belly of the gluteus maximus and reach the intramuscular vessels or the submuscular vascular plexus [26, 27].
ab
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Another common nding in the post-mortem gluteal
dissections was the presence of free fat graft around the gluteal vessels (Fig.15.6). Typically, the grafts appeared as intramuscular strings of fat throughout the muscle, at multiple
Fig. 15.6 Fat grafts in proximity to the Gluteal Veins
sites and depths, suggesting multiple passes of the cannula
through the muscle and the injection of fat graft as the cannula is withdrawn (Fig.15.7a, b). These ndings are not consistent with intramuscular fat being the result of one or two
inadvertent passes of the cannula, or subcutaneous fat graft
spilling into the muscle. The ndings suggest that either the
surgeon had intentionally performed an intramuscular gluteal
fat graft or that the surgeon was not aware of the precise location of the cannula tip at the time of fat graft injection.
Another commonality relates to the location where the
surgical procedure was performed. Out of the 29 BBLassociated deaths (2010–2022), 25 surgeries (86.2%) were
performed at the low-budget, high-volume clinics that have
become commonplace in South Florida. Two of the deaths
were attributed to an outlier American Board of Plastic
Surgery (ABPS) surgeon who has had three deaths from
body contouring procedures (2 BBL-associated), plus
numerous other serious complications also from body contouring procedures (Table15.1).
Fig. 15.7 (a) Numerous cannula tunnels within the muscle are laden with fat grafts. (b) Close-up image of gross pathology specimen of gluteus
maximus muscle, displaying the fat grafts within the multiple injection cannula tracts
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Table 15.1 Demographics of South Florida BBL FPE fatalities
Surg date Age (decade) BMI ABPS surgeon Budget clinic Cause of death
2010.12 30–p40 24.4 No Yes FPE
2011.06 30–40 29.3 No Ye s FPE
2012.03 30–40 23.4 Yes Yes FPE
2013.07 50–60 31.1 No Ye s FPE
2015.07 50–60 32.2 Yes Yes FPE
2016.05 20–30 27.8 No Ye s FPE
2017.03 30–40 29.8 Yes Yes FPEX
2017.03 20–30 25.5 BE Ye s FPE
2017.04 30–40 22.8 BE Ye s FPE
2017.06 30–40 30 No Yes FPE
2017.12 40–50 30.4 No Ye s FPE
2018.06 30–40 29.1 Yes Yes FPE
2018.09 50–60 34.3 Yes No FPE
2019.05 20–30 30.2 Yes Yes FPE
2019.08 20–30 27.33 Yes No FPE
2020.09 40–50 28.2 Yes Yes FPE
2021.01 30–40 27.42 Yes Yes FPE
2021.01 20–30 30 Ye s Yes FPE
2021.03 40–50 42 No Yes FPE
2021.05 30–40 36.9 Yes Yes FPE
2021.06 30–40 36 Ye s Yes FPE
2021.06 40–50 37.8 Yes Yes FPE
2022.02 30–40 30 Ye s Yes FPE
2022.04 40–50 42 Ye s Yes FPE
AV G 37 31.0
FPE Deaths: 25
ABPS: 17 17/25=(68%)
Deaths in budget clinics/total 23/25=(92%)
O. Garcia Jr and P. Pazmiño
15.4 Optimizing Safety inBBL
Despite the potential dangers associated with this surgery,
both authors agree that plastic surgeons must not abandon
this operation. Gluteal fat grafting is a powerful tool that can
augment tissue, correct deformities, and create impressive
results that cannot be produced any other way. High patient
demand for this procedure will continue. If board-certied
plastic surgeons stop performing this procedure, interested
patients will simply go to the non-board-certied, non-core
practitioners who do not have training in this procedure [28].
As researchers and patient advocates, plastic surgeons must
study this technique and determine how gluteal fat grafting
can be performed safely and consistently.
Ideally, surgeons should have a consistent and reliable
way to always conrm the position of their cannula tip during gluteal fat grafting. Furthermore, surgeons should have a
reproducible method to prove that they only injected fat subcutaneously and to document that they never injected fat into
the gluteal musculature. Keeping an ultrasound video record-
ing of the surgery serves as important medicolegal protection
for the surgeon by providing irrefutable proof that all the fat
grafting was performed only into the subcutaneous space. In
the last 3years, ultrasound equipment has become portable,
wireless, and affordable, opening the door for its use in the
sterile eld of the surgical suite. Ultrasound-visualization
can be used with any cannula style or injection system [29].
Real-time intraoperative ultrasound visualization can help
the surgeon perform fat harvesting and accurate fat grafting
into the unique spaces of the subcutaneous region. This will
not only make for a safer surgeon, but a better surgeon—a
surgeon who can manipulate subcutaneous anatomy not
appreciable without ultrasound.
15.5 Intraoperative Ultrasound Systems
Real-time intraoperative ultrasound can be used with any
cannula or liposuction/fat grafting system. However, when a
syringe fat grafting system is used, both of the surgeon’s
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Fig. 15.8 (a) The Clarius L7
is a 4–13MHz highfrequency linear, portable,
waterproof, wireless
ultrasound probe that can
stream a high-resolution
ultrasound video to Apple OS
or Android phones or tablets.
(b) The Buttery iQ+ is a
1–10MHz wired ultrasound
probe that connects with a
cable to Apple iPhones or
iPad tablets
a b
hands are occupied. One hand must hold the syringe while
the other pushes the plunger to inject the fat. In this scenario,
the surgical assistant or scrub tech often controls the sterile
ultrasound probe, making coordination with the injecting
surgeon difcult. To allow the surgeon to control the fat
grafting system and the ultrasound probe simultaneously, a
power-assisted liposuction system (PAL, MicroAire
Charlottesville, VA) is used in conjunction with a peristaltic
pump for controlled propulsion of the fat graft. In this manner, the surgeon can inject fat via expansion vibration lipolling [30] with one hand and control the ultrasound probe
with the other hand.
One of the authors (PP) has used nine different ultrasound systems during gluteal fat grafting procedures over
the past 10years. Currently, the two most common inexpensive and portable ultrasound systems for real-time
intraoperative ultrasound are available: the Clarius ultrasound (Clarius, $3400) or the Buttery iQ+ (Buttery,
$2399 with $199 annual subscription) (Fig.15.8a, b). The
Clarius L7 is a 4–13MHz high-frequency linear, portable,
waterproof, wireless ultrasound probe (maximum depth
of 11 cm) that can be placed entirely in a sterile probe
cover and can stream a high- resolution ultrasound video
to Apple OS or Android phones or tablets. The Buttery
iQ+ is a 1–10 MHz wired ultrasound probe (maximum
depth 30cm) that connects with a cable to Apple iPhones
or iPad tablets. Both the Clarius and Buttery systems
will upload their data to the cloud so that ultrasound still
images and video can be accessed on a computer or added
to a patient chart.
15.6 Gluteal Anatomy andUltrasound
The pelvic bony framework, gluteal muscles, gluteal fat,
and skin have been well described in our literature [31, 32].
Ultrasound can help us accurately delineate and manipulate
the subcutaneous zone. Cadaver dissections have unequivocally identied two well-dened gluteal fasciae (Fig.15.9).
The external surface of the gluteus maximus muscle is covered with a fascial plane (the deep gluteal fascia). The
Multi- Society Task Force has recommended surgeons never
fat graft beneath this deep gluteal fascia [15]. However,
there also exists a second fascial layer (the supercial gluteal fascia) within the subcutaneous zone above the deep
gluteal fascia and below the dermis. The supercial gluteal
fascia is thick, irregular, impregnated with fat, and can only
be appreciated in an open dissection or with ultrasound
visualization.
The supercial gluteal fascia is analogous to Scarpa’s
fascia in the anterior abdomen and divides the subcutaneous zone into two subcutaneous spaces: the supercial sub-
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O. Garcia Jr and P. Pazmiño
Fig. 15.9 Well-delineated supercial and deep gluteal fasciae
cutaneous space (between the dermis and the supercial
gluteal fascia) and the deep subcutaneous space (between
the supercial gluteal fascia and the deep gluteal fascia)
[33] (Fig.15.10). More important clinically, if the supercial gluteal fascia remains intact, it can retain the fat graft
that is specically injected above or below it, like the casing of a sausage. Fat graft injected into the deep subcutaneous space (above the deep gluteal fascia and below the
supercial gluteal fascia) can create excellent volume and
central dome projection, similar to a subfascial implant. Fat
graft precisely injected into the supercial subcutaneous
space (above the supercial gluteal fascia and below the
skin) can correct supercial contour deformities and
depressions. The consistent accurate injection of the fat
graft into either the supercial or deep subcutaneous spaces
can only be performed with real-time intraoperative ultrasound visualization.
It is also important to remember that the entire subcutaneous zone (including both the supercial and deep gluteal
spaces) ranges in thickness from 1cm (outer hips) to 3–4cm
(central gluteal dome). This thickness may also vary signicantly between patients. This means that gluteal surgeons
must graft in a thin space under a curving dome of varying
thickness. This small variable target may account for the
inadvertent deep intramuscular injections by well- intentioned
surgeons performing gluteal fat grafting without ultrasound
visualization.
A surgeon can use real-time intraoperative ultrasound to
not only avoid an intramuscular fat graft injection but to
accurately target fat graft into the supercial or deep subcutaneous spaces. Neither of these techniques are possible
without ultrasound. Real-time intraoperative ultrasound during a Brazilian Butt Lift can not only make fat grafting safer
but much more powerful and accurate as well.
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Fig. 15.10 The supercial (yellow) and the deep (green) gluteal subcutaneous spaces, divided by the supercial gluteal fascia
15.7 Real-Time Intraoperative Ultrasound
Setup
Once the liposuction has been completed and the harvested
fat collected, surgeons can add real-time intraoperative ultrasound visualization to their preferred fat graft injection technique. The following technique will be described using the
EVL injection technique with the peristaltic pump for fat
graft propulsion.
An Android or iOS tablet is mounted on an IV pole facing
the gluteal area and the surgeon. The portable wireless ultrasound probe and a Bluetooth computer mouse are placed into
a sterile probe cover (6″×48″ Soft Flex Probe Cover REF
20-PC648 Advance Medical Designs Marietta, GA) and
brought onto the eld. The ultrasound probe is placed on the
skin over the rst treatment area (central mound), and the
sterile computer mouse is used to adjust the ultrasound
probe’s depth of eld, gain, mode, and contrast. Then,
recording of the ultrasound-guided fat grafting procedure
begins.
The surgeon will hold the MicroAire handle and cannula
with one hand and the ultrasound probe with the other to
visualize the cannula tip and control the propulsion of the
aqueous fat graft with a foot pedal. The order of gluteal fat
grafting begins centrally to establish projection over the
central gluteal dome, then laterally to the hips, and nally,
into the supragluteal and medial gluteal regions. The cannula is inserted through the supragluteal or intergluteal
incisions and advanced into the treatment zone until it is
visualized by the ultrasound. To create signicant central
dome projection, the cannula tip is placed with ultrasound
guidance in the deep subcutaneous space (under the supercial gluteal fascia and above the deep gluteal fascia), and
fat graft is precisely injected. The cannula tip is always
visualized, and care is taken never to place the cannula tip
below the deep gluteal fascia, as this would result in an
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