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Table 6.3 Adjusted BBL mortality for outlier data
Reference to removing outlier data was made in the manuscript; however, the calculations do not
support removal of such outliers. The corrected adjustments support a mortality rate from the survey data of 1:11,000–1:13,000 cases
D. Del Vecchio
A surgeon from Central America reported performing ten lifetime BBLs, nine of
which resulted in fatal pulmonary fat embolism for a 90% career mortality rate; a
surgeon from the USA reported ten career BBL deaths from pulmonary fat embolism; and another USA surgeon performed 7 lifetime BBLs and had three deaths for
a 43% lifetime mortality rate.
Correcting for these presumed outliers, the intraoperative macroscopic pulmonary fat embolism mortality rate from the authors’ survey data is approximately
1:12,000, (Table6.3):
6.2 Methodology 2: USA Autopsy Data
The authors collected national autopsy data on intraoperative deaths related to pulmonary fat embolism for a time period 2011–2015. The authors added three- quarters
of the year 2016, thereby “including three deaths in 2016.” They collected 25 deaths
that were consistent with intraoperative macroscopic pulmonary fat embolism. The
authors sought to derive their denominator, the total number of BBLs performed in
the USA, from ASAPS procedural statistics. They used 65,068, citing the 5-year
ASAPS procedural statistics for BBL from 2011 to 2015 and assuming “a margin of
error of 30%.”
The autopsy data numerator of a 5.75-year period fails to match the time period
of the reported number of procedures—a 5-year period. This statistical treatment
upwardly biases the mortality rate. In addition, ASAPS procedural statistics do not
capture all the BBL procedures performed in the USA by “non-core” practitioners.
The authors adjusted this 5-year denominator of 65,068, to “roughly 100,000,”
stating:
“Based upon the impression of Task Force members in their own communities, it was esti-
mated that an additional 25% of cases were performed by noncore physicians not accounted
for in ASAPS procedural statistics.”
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In January 2020, the World Association of Gluteal Surgeons (“WAGS”) presented their data, demonstrating 13,122 BBL cases performed in 2018 by their
“non-core” membership [51]. This data excluded WAGS BBL cases performed by
ASPS or ASAPS members. In 2018, ASAPS statistics reported 25,168 BBL cases.
WAGs cases alone therefore constitute an additional 52% increase over ASAPS
numbers. This contrasts with the authors’ published assumption that only 25% additional BBLs are performed by “non-core” physicians. Further, it does not include
practitioners who are neither ASAPS nor WAGS members, making this 52%
increase potentially much higher.
The additional percentage of BBLs that are performed by “non-core” physicians
is frankly unknown. At a minimum we know the author’s 25% assumption is underestimated. We do know it is greater than 52%.
The denominator assumptions “Margin of Error” and “Percent Non-Core performing BBL” in Methodology 2 carry extremely powerful mathematical weight.
One of them, “Percent Non-Core performing BBL” is known to be inaccurate, while
the other, “Margin of Error” is by denition inaccurate. Therefore, the accuracy of
the denominator in Methodology 2 is called into question.
A table pivoting these two assumptions was employed, to better appreciate the
possible range of mortality rates given different margins of error and different “noncore” BBL contribution, as seen in Tables 6.4 and 6.5:
Table 6.4 Pivoting the assumptions of “Margin of Error” and “Percent Non-Core” to demonstrate
the mathematical power of these levers on true denominator calculations in Methodology 2
The true denominator for BBLs performed in the USA during this time period ranges from 128,000
to over 220,000
Table 6.5 Pivoting the assumptions of “Margin of Error” and “Percent Non-Core” to demonstrate
the power of these assumptions on BBL mortality calculations in Methodology 2
The true mortality for BBLs performed in the USA from this methodology ranges from 1:6000 to
1:10,000
96
D. Del Vecchio
6.3 Methodology 3: AAAASF Mortality Data
The Authors obtained AAAASF mortality data from 2014 to 2015, [3] stating there
were four macroscopic pulmonary fat embolism mortalities from BBL in this time
period. They derived a denominator from 2014 to 2015 ASAPS BBL statistics, and
took 25% of these to generate a denominator of 9407, citing an assumption that:
“It is estimated that 25% of all aesthetic procedures are performed in AAAASF facilities by
core physicians that make up ASAPS procedural statistics.”
This assumption is referenced in their paper (Ref. [15] form the paper):
“Email communication from President, The American Association for the Accreditation of
Ambulatory Surgical Facilities (AAAASF) to M.Mark Mod, MD September 22, 2016.”
Based on a derived denominator of 9407 AAAASF BBL cases, four determined
deaths resulted in a 1:2351 mortality rate for BBL in AAAASF facilities.
AAAASF mortality data for all pulmonary embolus cases was available and was
independently obtained from 2013 to 2017, as depicted in Table 6.6 [52]. The
ASAPS procedural data was also examined. For 2014–2015, there were 39,629
BBL cases reported by ASAPS, making 25% of these cases 9907 cases as opposed
to the authors’ stated 9407 cases. It is unclear why the authors elected to use only
2014–2015 data when 2013–2016 data was available to them at the time of the
manuscript’s acceptance. Independent examination of AAASF deaths from 2014 to
2015 demonstrated three cases attributed to intraoperative macroscopic pulmonary
fat embolism as opposed to four cases.
Examining AAAASF mortality data over a 4-year period from 2013 to 2016,
there were a total of four deaths due to intraoperative pulmonary fat embolism.
AAAASF was asked to corroborate the number of BBLs used by the authors of the
paper that states a 1:3000 mortality rate for BBL [3], and to validate this 25%
assumption that “25% of all aesthetic procedures are performed in AAAASF facilities by core physicians that make up ASAPS procedural statistics.” AAAASF was
unable to corroborate or reproduce the percentage of cases performed in AAAASF
facilities by core physicians that make up ASAPS procedural statistics [53], as cited
in the paper that states a 1:3000 mortality rate for BBL [3].
Table 6.6 Review of BBL mortality 2013–2016
Source: AAAASF. For 2014–2015 there were only three deaths from pulmonary fat embolism
associated with BBL, validated by independent observers. When compared to abdominoplasty
there were twice as many deaths from abdominoplasty in AAAASF facilities over this time period
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Because the same ASAPS BBL statistics were used in Methodology 3 to derive
the denominator, this denominator calculation is also subject to the same margin of
error already referenced in Methodology 2. Because these assumptions carry powerful weight, and because the published estimate of 25% ASAPS BBLs done at
AAASF facilities could not be corroborated by AAAASF, the accuracy of the
denominator calculations in Methodology 3 is called into question. A table pivoting
these two assumptions was employed, using the AAAASF data from 2011 to 2016,
to better appreciate the possible range of mortality rates given different margins of
error and different % ASAPS BBLS done by core physicians at AAAASF facilities,
as depicted in Table6.7:
The adjusted analysis of all three methodologies is summarized in
Table6.8 below:
Table 6.7 Pivoting the assumptions of “Margin of Error” and “Percent ASAPS BBLs performed
at AAAASF Facilities” to demonstrate the power of these assumptions on BBL mortality
calculations in Methodology 3
The true range of mortality for BBLs performed in AAAASF facilities from this methodology
ranges from 1:5700 to 1:16,300, assuming Margin of Error Scenarios between 25% and 55%, with
an average mortality of 1:10,500
Table 6.8 Summary of published mortality rates from the 2017 ASJ paper vs. corrected mortality
rates employing the above analyses
The mortality from the corrected analysis averages 1:12,000, which is more in line with other
published survey data on BBL mortality
98
D. Del Vecchio
6.4 Summary andConclusion
The paper that states a 1:3000 mortality rate for BBL [3] is highly cited and important because BBL is a relatively new and innovative technique in plastic surgery. Its
message that BBL is a dangerous procedure when performed incorrectly is without
challenge. However, regarding its published mortality rates there is evidence in its
statistical analysis, which may represent data errors. Given the benet of time, purposeful research by multiple surgeon authors since its publication, and future safety
benets afforded by the adoption of ultrasound, we are now poised with a better lens
to view a more accurate safety prole for BBL surgery, including its place among
other commonly performed aesthetic surgeries.
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news/boob- job- tummy- tuck- surgery- 16893394. Accessed 27 Dec 2019.
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of Plastic Surgeons’ Annual Meeting, NewYork City, October, 2019.
31. Cárdenas-Camarena L, Bayter J, Aguirre-Serrano H, Cuenca-Pardo J.Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg. 2015;136(1):58–66.
32. Inquest Letter, from Senior Coroner, Yorkshire County, England, dated 19 December, 2019.
33. Thorne C, Matarasso A, Richter D, Coleman S, Magalon G.Multi-Society Gluteal Fat Grafting
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35. Bruccerelli J.Brazilian butt lifts are resulting in an alarmingly high mortality rate. Hufngton
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4b0530743c77cf6. Assessed 23 Jan 2020.
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37. Del Vecchio D, Villanueva N, Mohan R, Johnson B, Wan D, Venkataram A, Rohrich R.Clinical
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40. Delvecchio D, Wall S Jr. Expansion vibration lipolling: a new technique in large-volume fat
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41. Delvecchio D, Wall, S, etal. Dening the role of safety training in safe subcutaneous buttock
augmentation (“SSBA”)—a clinical radiological study. Submitted for publication.
42. Large Volume Fat to the Gluteal Region-BBL: problems, and patient safety and public health
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43. BAAPS The Bottom Line. Popularity of risky buttock enhancement procedures gtrLeading
to costliest emergency complications. In: British Surgeons warned not to perform procedure
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44. Harris P.In discussion of: “This House Shall Ban BBL”, Presented at the British Association
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48. Perry A.Should we perform BBL? ASPS presidential panel, ASPS annual meeting, San Diego,
CA, September 21, 2019.
49. Rohrich R, Glasberg S.Brazilian butt lift: status quo or status no? In: Debate presentation at
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50. ASERF Gluteal Task Force Survey, 2016. Raw data. American Society of Aesthetic Plastic
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51. Angullo F.Report on the frequency of BBL surgery amongst WAGS Membership. In: Presented
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D. Del Vecchio
Chapter 7
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Safety inGluteal Fat Inltration
LazaroCardenas-Camarena
7.1 Introduction
Buttock contouring surgery through the implementation of fat injection has produced an important change in the way that a buttock can be improved. Currently,
buttocks fat inltration is one of the most performed surgical procedures worldwide
to achieve changes in body contour. It has been one of the procedures that has
increased the most over the last few years [1], with an increase from 59,372 gluteal
augmentation procedures in 2010 to 335,637in 2018 [1]. This implies an increase
of about 600%, constituting the esthetic surgical procedure that has increased the
most in percentage in the last 10years. In Mexico, more than 90% of plastic surgeons perform buttocks fat inltration at the same time as liposuction, which means
that this surgery should be considered as a concomitant procedure when doing liposuction. Fat injection into the buttocks has evolved rapidly since its inception due to
the progress that liposuction suffered, which has allowed to improve the processes
of obtaining fat, fat preparation, and nally fat inltration into the buttock [2–11].
7.2 Complications
We have been doing buttock contour through fat injection since 1995 with excellent
results [3], but we have also pointed out the unfavorable implications that this procedure can have [3, 11, 12]. Unfortunately, just as there are many advantages of
using fat to improve the buttock, there are also undesirable eventualities secondary
to the procedure. Thus, the inltration of fat into the buttocks has conditioned the
L. Cardenas-Camarena (*)
Department of Plastic Surgery, Institution Innovare, Zapopan, Jalisco, Mexico
e-mail: drlazaro@drlazarocardenas.com
© 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_7
101
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L. Cardenas-Camarena
appearance of several complications that rarely existed in body contouring procedures, and many of them are particular to this surgical procedure [3, 11, 12].
Therefore, the analysis of the complications secondary to buttocks fat inltration is
one of the knowledge that we must know in an exhaustive way when we are going
to perform this surgery. And even more when the incidence of the combination of
liposuction and buttocks fat inltration is greater than 90%.
When we talk about complications secondary to buttocks fat inltration, we can
classify them into two groups: general complications and specic complications.
These complications, whether general or specic, can be mild, moderate, or severe.
General complications are all those that are common to any surgical procedure and
that occur without any specic relationship to fat inltration. This classication of
complications is shown in Table 7.1. Mild or moderate general complications
include but are not limited to medical or surgical stress gastritis, urinary retention,
anesthetic reactions, phlebitis, etc. While among the severe general complications
are bleeding, allergic reactions, sepsis, transoperative arrhythmias, respiratory complications, septic phlebitis, acute myocardial infarction, etc. Specic mild or moderate complications are eventualities that can be solved in a satisfactory way without
causing great sequels. These may be related to liposuction itself. Some of these
complications may be related to scarrings, such as a hypertrophic or keloid scar, or
some collection of seroma or bleeding in the area of the surgery. However, the most
important complications on which we must take special care are those classied as
severe specic complications, since these complications can signicantly compromise the outcome of the surgery or even the life of the patient.
Table 7.1 Classication of the different complications secondary to gluteal fat injection
Complications
Mild andmoderate
Stress gastritis,
urinaryretention,
anestheticreactions,
phlebitis
General
Bleeding, allergic
reactions,sepsis,
complications,septic
Severe
transoperative
arrhythmias,
respiratory
phlebitis, acute
myocardial
infarction
Mild andmoderate
Seroma,
hypertrophicscar,
keloid scar,
hematoma
Specific
FatNec rosis Infection
GRAM +and GRAM-
bacteria
Severe
SciaticNerve Injury Fatinblood stream
Mycobacteria
MIFE MAFE
Severe specic complications are the most important and we must take special care to avoid and
treat them
7 Safety inGluteal Fat Inltration
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103
7.3 Specic Severe Complications
Specic severe complications secondary to buttocks fat inltration that can alter the
result of the surgery and the integrity of the patient are 5. We must know these complications, knowing them we will be able to treat them in an adequate way, but
above all we will have the adequate knowledge to know how to act and be able to
prevent them.
7.3.1 Fat Necrosis
Fat necrosis is an eventuality secondary to a process of lack of integration and survival of the fat injected into the buttock. This process is common if the amount of
inltrated fat is greater than the irrigation it can receive according to the inltrated
area [12]. Normally, a small or moderate fat necrosis can either be self-controlled by
the body, absorbed without contingencies, or form a fat cyst (Fig.7.1). However,
when the fat necrosis is greater, it can produce very severe irritation in the adjacent
tissues or an infection of the operated area. In the presence of any of the two eventualities, immediate action must be taken to prevent the process from continuing and
advancing thus conditioning a worsening of the clinical picture with infection of the
necrotic fat. In the presence of an area of hyperemia, which is painful, hard, initially
diffuse and later localized and uctuating, and which appears 5–7days after the
procedure, it is necessary to think about this eventuality. The initial treatment in
mild cases is antibiotic management and the use of warm compresses. Initially with
a broad-spectrum antibiotic. However, if there is already uctuation in the affected
area, with the evident presence of some liquid collection, it should be drained and
sent to study for determination of the causal microorganism and antibiogram to
select the proper antibiotic (Fig.7.2). This eventuality will usually involve a double
Fig. 7.1 Patient 7 days
after surgery. Gluteal
irritation secondary to fat
necrosis
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