The Brazilian Butt Lift or buttock augmentation by autologous fat injection is one of the fastest growing cosmetic operations in this country and around the world. Basically it involves removing fat from one area of the body with liposuction, and injecting it into another area of the body.
I have been a slow adopter of this operation, or more accurately a non-adopter. Recently, a possible and potentially fatal complication has been receiving much attention: death from fat embolism.
Let me explain.
In order to have the fat survive as a graft (like a skin graft), the fat must be injected into an area with an excellent blood supply. In the buttock area this is the gluteal musculature, and more specifically the deep gluteal musculature. So this has become the preferred area for the fat to be injected.
However, there are very large veins in this area. These carry the blood from these muscles directly back to the heart. The problem is that if fat is injected into one of these veins it can flow directly into the heart and cause it to stop or fail. If this happens, it is nearly impossible to get the heart started again and can cause sudden death. Deaths can also occur within the first 24 hours. Alternatively, the injected can get into the blood vessels to the lungs and cause portions of the lungs to die.
It is possible that injecting the fat into the subcutaneous fat might avoid this problem, but this is not the preferred area in terms of graft (fat) survival, and the final cosmetic result. It might also be possible to inject the fat into superficial muscle, but studies of these veins show that they can be in this area as well as the deeper musculature.
Our societies are advising us to reconsider this procedure.
Recently, the International Society of Aesthetic Plastic Surgeons (ISAPS), and the American Society of Aesthetic Plastic Surgeons (ASAPS) polled their members about this problem. Now understand that this data comes exclusively from Board-certified plastic surgeons both here and in other countries who operate in fully-accredited facilities.
It is very possible that this phenomenon occurs in as many as 1 out of every 1,575 to 2,950 cases. To put this in perspective, in accredited outpatient centers the rate of fatal complications from cosmetic operations is 1 in 55,000 cases.
Obviously this is a huge concern for all plastic surgeons and their patients. This has prompted ASAPS to recommend to its members to reconsider injection of fat into the deep musculature of the buttock. While this data is not rock solid since it comes from voluntary physician reporting and has not been scientifically validated, it is quite troubling. It is possible that these number are overstating the risks. It is equally possible, and — indeed – probable, that the risks could be even higher.
Should we be doing fat injection into the buttock at all?
Certainly this question must be crossing the minds of all plastic surgeons who do this operation. It must also be quickly pointed out that this is by no means a blanket condemnation of all fat grafting. Fat grafting can be done safely in many areas of the body (such as the face and the breast) with good results.
The reason for this is both the volume of fat injected and the size of the blood vessels. For instance, when fat is injected into one buttock the volume can be in the range of 120 cc to 300 cc. However, when injecting fat into the face, usually less than 4 cc to 6 cc are injected into one side of the face and these injections are not done in the vicinity of large veins.
Where the Brazilian Butt Lift will end up is unknown at the present time. Caution is advised to patients considering this, and plastic surgeons performing this. It would be great if this worked well without serious complications as many of us are not thrilled with the alternative: buttock implants. From my perspective I do neither and have no plans to change this.
Perhaps the best way to increase buttock volume is by increasing the volume of the musculature via exercise (ie:squats). But if this is not a good solution for you, please be careful in considering other options.
David B. Reath, MD