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The JetBlue terminal at Miami International Airport resembles more of a Miami plastic surgeon’s waiting room than it does a departure gate at a major airport. At 2:38 pm on a Tuesday in November, women of all ages, shapes, sizes, and races slouch in the wheelchairs (which are in a processional formation), wearing loose coordinating sweatsuit sets, fuzzy Ugg slingback sandals and a whole lot of compression garments. Some are so fresh from their recent Brazilian Butt Lift (BBL), often combined with additional procedures, that they are discretely trying to hide their drains and nonchalantly readjusting their post-recovery donut-shaped pillow. Even the billboards lining I-95, Miami’s major highway, prompt images of a rounder, shapelier, bigger butt with ‘deal-of-the-day’ esque marketing messages, the kind of mega markdowns that we all know are too good to be true.
Miami is the BBL capital of America—and the destination for women from all four corners of the globe to flock to for the curves they crave. That’s just what 30-year-old Safiya did. After losing weight, Safiya wanted to address a few things about her new body.
“I was always top-heavy, and if you were to cut me in half, my bottom is not equal with my top,” she says. Despite working out like crazy, she wasn’t getting her desired results. “At first, I thought, I’ll get liposuction, but then I thought to myself, what are they doing to do with all that fat? So, I decided to put it in my ass,” she continues. That same thinking is what had plastic surgeons realizing that discarded fat (from liposuction) could be injected back into the patient’s body and survive, says Dr. David Shafer, a board-certified plastic surgeon in New York City.
Three years ago, Safiya, a New Jersey native, booked a ticket to Miami for a BBL (following a previous face-to-face in-office consultation) with Dr. Robert Kagan. He was the only plastic surgeon she consulted with and chose him based on his qualifications. “I did a lot of research and liked his before-and-after images, which were very natural looking, and that’s what I wanted,” she says.
Because a BBL is a highly skilled procedure that requires attention to detail and a ton of experience, you can’t pick your doctor from TikTok or Instagram alone, and not just anyone will do. “If you go back and see (on social media) that a surgeon has consistent results and professionally showcases their work and focuses on the patient, that’s the mark of a good surgeon,” says Dr. Ashkan Ghavami, a board-certified plastic surgeon in Los Angeles.
The Backstory on the BBL
The advent of the BBL is credited to one of the most well-known plastic surgery visionaries, Dr. Ivo Pitanguy, a Brazilian surgeon. Initially, butt lift surgeries removed excess skin and tissue to reduce sagging. According to Dr. Alex Earle, a board-certified plastic surgeon in Miami who has performed more than 2,000 ultrasound-guided BBLs, Dr. Pitanguy advocated for only a modest amount of fat transfer. Yet, surgeons became more aggressive over the years, reallocating much more significant amounts of fat into various planes of the buttocks, which led to the labeling of the surgery as dangerous and even lethal.
In simple terms, the Brazilian Butt Lift removes fat from where it’s unwanted and puts it where you do want it. The two-step surgery (done all at once while under anesthesia) includes liposuction first to remove excess fat from the stomach, thighs and/or love handles. Next, the donor fat is purified to create a pure-fat concentrate and then transplanted via injections into the buttocks. The procedure is entirely customizable, so patients can choose to go as small or as large as they desire (safely and within reason) as long as they have a “healthy” BMI (body mass index) and enough fat to harvest. A bigger butt calls for more fat, whereas a subtle increase in size uses less.
For Safiya, her high BMI instantly took many doctors off her list. “There were only a few doctors that I liked that do surgery on people in my range,” she says. “I had to lose about 12 pounds before the surgery to fall into the exact BMI range of where I needed to be.” Losing weight before surgery isn’t out of the norm, and neither is gaining it if need be. Some surgeons put their patients on high-fat diets to gain five or 10 pounds of much-needed fat for a successful result.
The amount of fat on the body determines how much fat your plastic surgeon can safely remove. BMI varies from person to person since height and weight factor into it. “Elevated BMIs, over 30, have been associated with increased risk for surgical complications during the surgery and with healing afterward,” says Dr. Matthew R. Schulman, a board-certified plastic surgeon in New York City who performed his first BBL in 2007. For this reason, any reputable plastic surgeon will pay ample attention to your BMI and correctly calculate it in advance of the procedure.
“[We consider] BMI, with other factors, such as overall health and the specific location where people are storing their extra fat,” he adds. “We know that excess fat in the abdomen and center of the body is riskier than excess fat in the lower body and legs. So, a person with a slightly elevated BMI who has a thin abdomen but large legs may be acceptable for surgery.”
The New BBL Rules
When the BBL first became popular, surgeons injected fat deep into the gluteal muscles, which, unfortunately, has a high incidence of vessel injury with fat embolism. When fat is accidentally inserted, placed, or injected into a vessel and travels to the heart, brain, or lungs leading to complications or death. However, due to growing demand, Dr. Constantino Mendieta, a board-certified plastic surgeon in Miami who literally wrote the book on buttock plastic surgery, The Art of Gluteal Sculpting, says the BBL back-alley business has caused unlicensed individuals to offer “butt enhancement” treatments at a significantly discounted price.
“Patients don’t know what they are being injected with, which can cause serious complications and possibly even lead to death,” he says. “Stories like these have created fear around this procedure.” As backroom botched butt jobs became front-page headlines and the number of complications and deaths rose due, the plastic surgery community collectively continued to focus on evolving the procedure to make it safer and more predictable.
Of course, these ill-fated incidents affect the total number of complications and the mortality rate associated with the procedure. Dr. Schulman says that many of these deaths occurred in specific geographic locations and with providers who should not be doing these procedures in the way they are. Like anything in aesthetics, experience is paramount to avoid risks. “There is a rise in the number of surgical clinics that crank out BBLs all day long, often for a low fee, which is a recipe for disaster and can place patients at risk,” he adds.
Even with new surgical recommendations and guidelines in place (more on that in a minute), there is still plenty of misinformation circulating about BBLs. One of the biggest whistles to blow is that it’s dangerous and deadly — perhaps the most fatal surgery. “At one time, BBLs did have a high incidence of severe complication and death, but that is not the case currently,” Dr. Earle says.
When a highly trained and experienced plastic surgeon performs the procedure, butt augmentation with fat is deemed safe. That’s why, no matter what, it’s essential to make sure your surgeon is a board-certified plastic surgeon. On the flip side, opting for an inexperienced, unqualified doctor to execute the surgery can easily cause fat to enter the venous system and flow back into the heart and lungs, causing a potentially fatal fat embolus.
Red flags that should have you walking away no matter what include: surgery with a non-board certified doctor (this means the doctor does not hold the proper education, training and credentials to perform the said procedure), procedures done in unaccredited facilities (Dr. Shafer says to make sure the procedure is performed in an accredited surgical facility by the American Association for Accreditation of Ambulatory Surgery Facilities and that a board-certified plastic surgeon performs the anesthesia) and surgeons with little to no experience or a track record for complications, poor results, or, unfortunately, death. Plus, surgery centers that operate on high-volume and low costs are not known for prioritizing patient safety.
“Everyone loves to say that the “death rate for a BBL is 1 in 3,000″, which was based on a poorly conducted survey from five years ago,” Dr. Schulman says. “The study was flawed, and the data was simply inaccurate.” More recent data shows that a more precise death rate is 1 in 15,000 patients, and when you consider that it’s 1 in 14,000 for a tummy tuck, it’s not a hard number to swallow. “When an experienced board-certified plastic surgeon using modern techniques does a Brazilian Butt, it is safer than a tummy tuck,” he says.
Plastic surgeons are performing BBLs today more judiciously than ever before. However, after the number of adverse incidents continued to rise incessantly, the American Society of Plastic Surgeon’s Aesthetic Surgery Education and Research Foundation (ASERF) stepped in to assemble the specialized Gluteal Fat Grafting Task Force. A strict advisory was put into place. The goal of both initiatives was to determine why patients were continually dying from BBLs while also instituting new guidelines on the right way to transplant fat.
“In 2017 and before, it was encouraged to place the fat deep into the gluteal muscle,” Dr. Earle says. “At that time, we didn’t know about the dangers; we just knew that we could get more dramatic results this way, and it was easier to get the shape into or beneath the muscle.” But injecting fat at that level poses a real threat since, as he says, there are critical large arteries and veins there. “If you injure one of them and fat gets into it, there will be a fat embolus, which can lead to poor outcomes, respiratory failure, and even death.”
Today, the transfer portion of the procedure is about placing fat only in the superficial plane between the muscle and skin and using a single hole blunt-tipped cannula (larger than 4mm) to extract the fat, Dr. Earle explains. “Plastic surgeons can also use ultrasound imaging technology to turn a ‘blind’ procedure to one where we can see the tip of the cannula and make sure that it is in the appropriate plane.” However, despite the new recommendations, which result in fewer complications and mortality rates, there’s always the risk for a surgeon not to follow these set rules and inject fat above the muscle or still deep within it, which will lead to unfavorable outcomes.
Some Opt for Two BBLs
BBLs may have garnered a bad rap in the past. Still, many patients are happy and extremely satisfied with the procedure itself and the results — some even choose a follow-up procedure to refine their results further.
At first, Safiya says the procedure gave her everything she wanted. Of course, there was the typical swelling and bruising during the healing process, which she says wasn’t nearly as painful as expected. She recalls feeling “a lot better and getting back to normal” after week two of the recovery, which requires sleeping on the stomach and wearing a foam board stuffed inside a compression garment 24-7. “There were a lot of everyday things — something as simple as peeing on the toilet, which was a scenario in and of itself—that I couldn’t do. My mother had to shower me because I didn’t have the strength to do it myself,” she says. “But I was really prepared for what was to come and made sure I did everything in advance.” Her pre-surgery checklist included pre-filling all her medications, meal prepping and following everything her surgeon told her to do.
The one area where she admits to not following the assignment is with lymphatic drainage massages. “I didn’t do it every other day,” she says. “I got a few free ones from my surgeon, but since I was recovering a few hours away from his Miami office, it was too far away for me to go.” When she flew back home a few weeks later, she began to see lumpiness on her abdomen, which turned out to be fibroids. Thirty lymphatic drainage massages got rid of the lumping. Safiya’s two most significant pieces of advice are to budget for all the necessary healing supplies because “it adds up and is expensive” and to have a trustworthy, reliable person to help take care of you.
Now, she’s at the three-year mark with two invisible scars on her hips and contemplating a second BBL to address minor asymmetry issues. She says no one else notices it, but it bothers her. “If you’re focusing on my butt, you can see that one butt cheek is larger than the other,” she says. “One year after my BBL, I started to become aware that one cheek was bigger than the other. I’m a boyfriend jeans kind of girl. So when I started wearing skinny jeans, fitted clothes, and lighter washes more, I saw it.” She says her backside, “may not be perfect and flawless but wanting a second procedure is partly because of my perfectionism with my body.” While she’s still on the hunt for a surgeon, Safiya says she’s in no rush but will eventually address the issue.
There is always the potential for asymmetrical results post-treatment, and like how our eyebrows aren’t identical, neither are the butt cheeks (same with the breasts). The goal of any procedure is to try and achieve as symmetrical a result as possible so that each cheek resembles the other and one is not noticeable larger, higher, or rounder than the other. “I always tell my patients that the left and right side of their body are not twins but sisters,” Dr. Mendietta says. “It is always my goal to make the butt cheeks look as similar as possible during surgery, but I am always transparent with this during the initial consultation.”
The Fat Doesn’t Stay Forever
Regardless of how little or much fat your surgeon injects into the butt, all of it won’t stay indefinitely. On average, 30 to 50 percent of the added fat survives. “In some patients, there is more fat that survives on one side versus the other because fat survival rates are unpredictable,” Dr. Earle says. One way to ensure a higher retention rate is to avoid sitting on the buttocks in the first few weeks post-procedure. Any pressure or stress on the area can cause the newly transplanted fat not to survive, hence the reason for post-op donuts for sitting and avoiding laying on the back (plastic surgeons always advise stomach sleeping).
Over the years, the overall concept of the procedure has not changed, but aesthetics, process and technology have. “We have many technologies that help to remove the fat and then reinject it in a manner that is less traumatic and ensures a higher percentage of fat cells that survive the process,” Dr. Schulman says. However, once the fat fully settles into its new home, it will last forever and will even change as your body changes with aging.
Some patients end up a little bigger than anticipated at first, but that’s just because of initial swelling. As some transplanted fat resorbs, the butt will take on its final shape. If a striking contrast butt that sits high is what you’re after, you may require more than one procedure to achieve those results. Significant weight loss or gain will also cause the results to fluctuate since weight gain causes fat cells to swell, and weight loss causes them to decrease in size.
“Remember, the fat is still alive and can change over time, so if the patient loses weight, then the fat cells will shrink,” Dr. Shafer says. “And if the patient gains weight, the fat will grow.”
Bigger Isn’t Always Better
One of the advantages of a BBL is that your surgeon can customize it precisely to what you want. Some patients desire a barely noticeable increase in size and shape, whereas others wish for a dramatically larger butt. During the pre-op planning phase, both patient and surgeon should be on the same page regarding size, roundness and realistic achievability. It is also the surgeon’s responsibility to let a patient know what is practical and doable and never deliver unrealistic expectations. For example, the amount of fat transferred to the butt as well as skin laxity both influence the final results.
Having performed more than 5,000 BBLs, Dr. Schulman says there is always a variety in what each patient wants. “I find that whether the butt looks “fake” or “natural,” it is less about the volume of fat and more about the shape. You can have a huge butt that looks like you naturally have it,” he says.
And that’s where exemplary technique comes in. The power of the BBL is that plastic surgeons can tailor the surgery to match each patient’s unique body type and preference — it is akin to molding a sculpture. For example, to create a natural-looking butt, Dr. Schulman emphasizes that the shaping portion of the surgery needs to blend the butt and hips into the thighs, with the butt displaying a smooth curve between the back and butt. “This is more of an ‘upside-down-heart’ shape that patients desire,” he says. For a more prominent look, your surgeon will need to fashion the butt into a rounder shape at the hips and augment it so that the upper portion of the butt is like a top-shelf.
Some surgeons even started to put their own spin on the BBL. For example, Dr. Ghavami’s SCurve technique (the ‘S’ also stands for safety) balances the entire body with a bit of a subtle yet natural curve that he can exaggerate depending on a woman’s body and size. “You should always look like you haven’t had surgery, and the body should have the shape of a 360-silhouette,” Dr. Ghavami says. Surgeons that take a more holistic approach to contour the body from a 360° approach are not overinflating the butt, he adds, which is why the result is that much more natural-looking.
So, how do you know how big is big enough and if you will end up with a butt that doesn’t suit your body? “Too big is anything that does not ‘flow’ with the patient’s frame,” Dr. Earle says. “For example, buttocks or hips that the patient’s thighs do not support will lead to the so-called ‘ant booty’ or ‘diaper booty.’ Also, just because you want a specific size or shape doesn’t necessarily mean it’s the right fit for your body, or that’s even possible with your anatomy.
Going large with any body sculpting procedure can distort the body’s overall balance and symmetry. As Dr. Ghavami says, the idea is always to create a natural curve and “keep them guessing” since most women he treats are now coming in wanting more natural-looking results. However, geography still dictates the current trends.
In certain parts of the country, women still request that their newly plumped-up butt flies under the radar, yet others beg their surgeons for a noticeably amplified look. “Recently, I was at a Kanye and Drake concert in Miami, and everything is big there, kind of like the ’90s where we used to see huge breast augmentations in patients,” Dr. Ghavami says. “There’s always an early phase where surgeons and patients do too much or want too much, and then there’s the secondary, evolved phase where things balance out and look natural. Since day one, I have always believed in a more natural silhouette.”
“Women desiring more of a Kim Kardashian-type butt will need much more fat injected into their buttocks and hips than compared to an individual wanting a more subdued appearance,” Dr. Mendietta says. Yet, depending on what state you have surgery dictates how much fat can be removed, ultimately affecting the result. “In Florida, the law requires that no more than four liters of fat be removed during liposuction if we are not performing another procedure (that includes cutting) at the same time,” he says.
For example, a patient who elects to do a breast augmentation with a BBL cannot have more than one liter of fat surgically removed. “If a patient has plenty of fat to be removed and is hoping to achieve a significant appearance, electing only to do the BBL and coming back in the future for the other procedure may make the most sense for maximum fat removal,” he adds.
It’s not just the look of a too-big butt that deters some patients who want a BBL from getting one. Going too radical in size puts additional pressure on the fat cells, which Dr. Schulman says results in a high percentage of fat cell loss. The augmented rear end will age and not always for the better. That sizeable, now-heavy butt will eventually begin to droop as the body ages due to a lack of support. So, while your butt may look juicy, perky, and round at 30, chances are it won’t look nearly the same as you enter your 60s. Consider that as food for thought.