Three findings changed the operation, a worldwide survey of surgeons, dissection studies on cadavers and a review of deaths in the region with the most of them.
What does the evidence behind these rules show?
Questions to ask any clinic
In which layer do you inject the fat, and how do you confirm it? Do you use ultrasound during grafting? What cannula size do you use? How many BBLs does the surgeon perform in a day, and how long does each take? Who gives the anesthetic? A clinic that cannot answer clearly, or that promises very large volumes in a short operation, is the kind of clinic where the deaths occurred.
Based on this survey, fat injections into the deep muscle, using cannulae smaller than 4 mm, and pointing the injection cannula downwards should be avoided.
ASERF Task Force report, Aesthetic Surgery Journal, 2017
Why fat in the muscle travels deeper
Surgeons once injected fat into the upper part of the gluteal muscle, believing it survived better there and allowed more volume. A dissection study on cadavers tested what happens next. Every time fat was injected into the muscle, some of it migrated through the muscle into the deep space beneath, where the large gluteal veins run. When fat was placed above the muscle, none reached the deep space.
The finding explains why injecting only superficially in the muscle was still dangerous, since pressure pushes the fat along the muscle fibers toward the veins. The authors called intramuscular injection an inexact and risky technique and recommended abandoning it.
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Fat retention with subcutaneous-only grafting, 50 women
| Ultrasound measurement |
Change in fat thickness |
| Immediately after surgery |
56.5 percent thicker than before |
| At 12 months, compared with immediately after |
18.2 percent lost |
| Conclusion |
Retention similar to earlier reports of intramuscular injection |
The intramuscular insertion of fat, which up to this point has been considered reasonable to perform in the superficial muscle and even recommended in the literature, is now deemed to be an inexact and risky surgical technique.
Cadaver dissection study, Plastic and Reconstructive Surgery, 2018
How much fat stays
For years surgeons worried that fat placed only above the muscle would melt away, and that the safer layer would cost patients the result they had paid for and traveled for. A prospective study measured it by ultrasound in 50 women. Fat thickness in the buttocks rose by 56.5 percent after surgery and fell back by 18.2 percent over the following year, a retention similar to earlier reports of intramuscular injection. The safer plane keeps the result.
- Part of the transferred fat is reabsorbed in the first three to six months, and surgeons slightly overfill to allow for it.
- The final shape shows at six months to a year, once swelling has gone and the surviving fat has settled into its new blood supply.
- Transferred fat behaves like fat elsewhere and changes with weight gain or loss.
- A second session can add volume once the first has settled.
Recovery
Protecting the grafted fat from pressure is the main task of the first weeks. Surgeons advise no direct sitting on the buttocks for two to three weeks, sleeping face down or on the side, and using a cushion under the thighs when sitting is unavoidable.
Subcutaneous-only gluteal fat augmentation is shown to be as effective as previous studies reporting intramuscular fat injection with regard to long-term fat retention in the buttocks.
Prospective ultrasound study, Plastic and Reconstructive Surgery, 2019
The weeks after surgery
A compression garment is worn day and night over the liposuction areas for four to six weeks, shaped to avoid pressing on the buttocks. Walking starts the same day, since the risk of clots is raised by the long operation and the restrictions on sitting. Bruising and swelling around the waist are expected, and the buttocks may feel firm and sore.
Desk work done standing or lying resumes after one to two weeks, driving after three, and exercise after six. Lumps in the grafted fat, fat necrosis, fluid collections, infection, asymmetry and loss of volume are the commoner complications that a touch-up or time resolves.
Warning signs
Sudden breathlessness, chest pain, confusion, a rapid pulse or a red rash across the chest in the first days, and later a painful swollen calf, fever or spreading redness, need emergency care at once, and a patient already home should mention the fat grafting to the emergency team, since that single fact changes which scans they order and how fast.
The working environment at the clinics, and the short surgical times for these cases, may be the most important contributors to the BBL mortality in South Florida.
Review of 25 deaths, Aesthetic Surgery Journal, 2023
- Photographs from the front, back and both sides, standing, following the guide we send.
- Height and weight.
- Recent weight change and the look you have in mind, with example pictures if you wish.
- Medical history, medicines including hormonal contraception, and any clot in you or your family.
Days, cost and the trip
Plan ten to fourteen days in Istanbul.
Sitting is the problem.
The long flight home is the hardest part of a BBL recovery, since it combines hours of sitting with a raised clot risk. Waiting until the second week, sitting on a cushion that lifts the buttocks, walking every hour and taking blood-thinning injections if the surgeon advises them make it safer.
Price depends on the areas of liposuction, the operating time, the ultrasound guidance, the anesthesia, the hospital night and the garment. A safe BBL costs more than the lowest prices advertised, because time and control are what make it safe. Your own figure follows the free review of your photographs.
Your coordinator is the person you write to on WhatsApp from the start. The invitation letter for your visa arrives ten days before you fly, a driver meets you at the airport, and a hotel near the hospital holds a room for you and a companion. The team speaks seven languages, and interpreters handle the rest. Halal, vegetarian and diabetic meals are available, patients may use the prayer room, and a female doctor joins your care on request when the schedule permits. Back home, the surgeon follows your photographs at two weeks, six weeks, three months and six months, and advises on sitting, the garment and when to return to training, and because the final volume only shows once the reabsorbed fat has gone, the six-month photographs are the ones that decide whether a second, smaller session would help, a decision that should never be made in the swollen first weeks, when the buttocks look larger than they will stay and patients understandably judge the result too early.
Brazilian butt lift FAQ
Is a Brazilian butt lift safe when it is done in the layer above the muscle?
The risk depends on where the fat is placed. Almost all deaths followed injection into or under the muscle. Grafting only above the muscle, confirmed by ultrasound, is the current safety standard.
How much fat survives after a BBL?
In an ultrasound study of 50 women, fat thickness rose by 56.5 percent after surgery and fell by 18.2 percent over the first year.
When can I sit after a BBL?
Surgeons advise no direct sitting for two to three weeks, using a cushion under the thighs when necessary.
When can I fly home after a BBL?
After ten to fourteen days, sitting on a cushion, walking every hour and using blood thinners if advised.
Why are some BBLs so cheap?
Low prices often mean short operations and high patient numbers. A review of 25 deaths found 92 percent occurred in high-volume, budget clinics with operations of about 90 minutes.
Can my family come with me?
Yes. A companion stays with you at the hotel we arrange.
References
- Mofid MM, Teitelbaum S, Suissa D, et al. Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force. Aesthetic Surgery Journal. 2017;37(7):796-806.
- Del Vecchio DA, Villanueva NL, Mohan R, et al. Clinical Implications of Gluteal Fat Graft Migration: A Dynamic Anatomical Study. Plastic and Reconstructive Surgery. 2018;142(5):1180-1192.
- Cansancao AL, Condé-Green A, Vidigal RA, Rodriguez RL, D'Amico RA. Real-Time Ultrasound-Assisted Gluteal Fat Grafting. Plastic and Reconstructive Surgery. 2018;142(2):372-376.
- Cansancao AL, Condé-Green A, David JA, Vidigal RA. Subcutaneous-Only Gluteal Fat Grafting: A Prospective Study of the Long-Term Results with Ultrasound Analysis. Plastic and Reconstructive Surgery. 2019;143(2):447-451.
- Pazmiño P, Garcia O. Brazilian Butt Lift-Associated Mortality: The South Florida Experience. Aesthetic Surgery Journal. 2023;43(2):162-178.
