In the last several years, and particularly with the proliferation of plastic surgery imagery and the impact of social media influencers, gluteal shaping has become a topic of great interest to consumers, and procedures for gluteal enhancement have become all the buzz.
There are whole Instagram communities dedicated to reviewing and critiquing the credentials, techniques and surgical results (as well as complications) of gluteal augmentation with fat grafting – the so-called “Brazilian Butt Lift.”
In the wake of several highly publicized tragic complications of this procedure, particularly in high volume centers in Miami (a city increasingly synonymous with the BBL thanks to many social media-savvy surgeons and clinics), the American Society for Aesthetic Plastic Surgery issued a whitepaper in 2018 with guidelines on how to perform the operation and optimize patient safety.
Of particular focus was addressing the risk of fat embolism. A taskforce was also convened to study, in cadaver models, different injection techniques and concluded that injection above the gluteal muscle plane (not into or below it), using large bore (4 mm or larger) blunt cannulae, and paying particular attention to certain anatomic danger zones, should be implemented for best practices.
For all the negative press, however, Miami-style BBL surgery has its technical merits and has taught me a lot about body contouring and the feminine silhouette. Here are some key lessons every surgeon should know before performing BBLs:
Know your facts
First, understand that the term “Brazilian Butt Lift” is largely a misnomer. The Brazilian Butt Lift is neither Brazilian, nor a lift. It is primarily an operation to improve the circumference of the trunk at the waist and to restore curvature to an often ill-defined body silhouette. This often takes the form of removing excess rolls from the flank areas and lower back, and redistributing it to the upper and outer gluteal region to create a fuller and rounder buttock.
Lifting may be an additional benefit in certain patients with good gluteal skin and muscle tone, but the surgeon should be careful to advise patients that this operation does not remove loose skin from the gluteal region to actually lift up ptotic tissues.
Consultation is key
Good results start with a careful consultation that includes assessment of the patient’s hip to waist ratio (this can be quantified or placed into “tiers” of body frame types, to help guide the conversation with the patient); degree of abdominal skin laxity and stretch marks; presence or absence of hernias; extent of gluteal projection; amount of lateral hip/gluteal border roundness; presence of any obvious flat zones in the buttock (particularly laterally); and takeoff point of the upper gluteal border (as this can determine how “tall” the buttocks will ultimately look).
Patients with severe skin excess in the abdomen, very ptotic buttocks, severe gluteal muscular atrophy, and/or multiple lateral back/bra rolls, may need special counseling to set realistic expectations.
Setting limits
I find that patients with a BMI ranging from 25 to 29 tend to get the most predictably pleasing final results, in that they have enough fat to demonstrably improve the waistline and lower back, and to use for transfer, while not being overweight enough to anticipate persistence of a round abdomen or severely overhanging lower abdominal pannus (the “apron”).
Much attention is paid to patient selection in the upper BMI ranges, with many surgeons setting upper bounds (mine is around 31) for patient candidacy.
Conversely, those with very low BMI’s may have relatively inadequate fat for transferring more than a few hundred ccs of fat, but may still enjoy some improvement in shaping if the donor site fat is concentrated in the flanks. I do advise these skinny patients to consider weight gain pre-op, with the anticipation being that fat accumulation in “hard-to-lose” areas, which may possess higher concentrations of lipase inhibitors, may allow us to achieve a greater degree of gluteal shaping, and that the patient should not look at the number on the scale with fear, since we will be redistributing much of the gained fat to the desired gluteal region.
Understand what buttock shape your patient finds attractive, but put it into the context of the patient’s pre-op anatomy and amount of gluteal fullness. Some patients have wildly unrealistic expectations and may be best served without surgery; others need to be reeducated about what the procedure can accomplish; the rest may simply need the location of grafting to be tailored based on whether they want “more hip,” “a Kardashian shelf,” an “inverted heart,” or other specific popular gluteal shape.
Pre-op planning
Preop planning includes basic laboratory profiles in most patients, and an assessment of Caprini risk score for DVT prophylaxis. Patients on oral contraceptives may be well served by going off their medication for a cycle – though this is not necessarily evidence-based – as an empiric step to reducing DVT risk. Early ambulation post-operatively and the placement of sequential compression devices prior to the onset of anesthesia are critical. Patients receive an IV antibiotic dose within 30 minutes of incision, with Foley catheters placed in patients where surgery is expected to exceed three hours.
The preop marking includes defining the upper buttock border – or deciding where it belongs in the patient with ill-defined anatomy in the lower back – as well as marking areas for specific injection focus for posterior or lateral projection. The midline is marked from the upper back to the gluteal cleft, and back creases are marked, with the lateral flank area marked obliquely and connecting to the anterior extension of the love handle, which is marked from the abdominal side. I mark the costal margin, iliac crests, linea semilunaris and linea alba in all patients, to give me basic landmarks. The abdomen is marked roughly into a superior portion up to the rib rolls, an inferior portion from belly button to pubis and the flanks extending to the lateral breast roll region, with any folds or indentations clearly marked.
The procedure
I rarely combine BBL with other procedures, except in relatively low BMI patients who may have limited fat (and therefore will have a shorter BBL component to their combined surgery OR time). In most cases, where BBL is being done alone, the patient is first positioned and liposuctioned in supine position and then flipped for the posterior liposuction and fat grafting. Some surgeons prefer lateral decubitus positioning, but I have found that in surgicenters where BBL is not the predominant procedure, the added time for multiple repositionings can be prohibitive.
I usually access the abdomen through two low-lateral (above the inguinal area near the iliac crest) incisions and one on the upper belly button margin. In wider patients, an additional midline incision may be placed above the pubis for greater access. On the back, I use incisions on either upper gluteal curve, one at the apex of the midline gluteal cleft, and one or two in the upper / mid-back depending on the distribution of rolls. Axillary / batwing areas are most easily accessed from incisions close to the upper border of the roll, in order to work around the lateral chest wall easily. I use a standard Klein tumescent formula and rarely infuse more than 5 L of tumescence in even the largest patients, with 3.5 – 4 L being typical.
Great care should be paid in the abdomen to horizontal suctioning technique and avoidance of deep passage of cannulae near the rib cage or lower pelvic regions. Patients with prior liposuction, abdominoplasty, C-sections or large laparotomy incisions are at increased risk for abdominal wall violation and informed consent must include educating patients about the uncommon, but real, risk of abdominal injury.
The real key to this procedure is aggressive suctioning around the waist from both the front and back, and debulking the lower back continuation of the flank fat. Suctioning the lower back in a “thong” pattern and getting the waist sufficiently thinned out can provide enough improvement that even if fat acceptance in the buttocks is modest, the shape improvement is obvious and lasting.
Preparing the fat
I prepare fat with some antibiotic (case reports of infected fat necrosis and micro abscesses have encouraged me to try to further optimize the antisepsis of the fat aspirate) and allow decanting with gravity and a strainer, to remove fibro-adipose strands and allow a sufficiently concentrated, but not too dry fat supernatant to be easily injected, by hand, in 60 cc syringes (50 cc at a time for easy math), using a 4 mm blunt cannula.
Some surgeons have had success and increased operative efficiency by injecting using mechanical assistance, such as running the power-assisted lipo (PAL) system in reverse, but I have found I have more tactile feedback injecting with a syringe manually. It may take longer, but in my hands, it feels safer at this time.
Injection is strictly above the muscle until either the fat runs out or the skin is very taut at a point of desired projection, whichever comes first. For me, that means thinner patients may only have 300 – 400 ccs available per side, while heavier patients may receive 1100 – 1400 ccs per side, with my average patient receiving 800 – 900 ccs per side.
Having observed at least a dozen of my colleagues in the OR performing this procedure in high volume over the years, I do believe that subcutaneous injection may have slight limitations on the amount of super-round over projection (the “bubble” or “shelf” some patients seek) that the surgeon can achieve, but I believe the trade-off for patient safety is worth it. If a patient wants a super extreme result, I may not be the right surgeon for them.
Post-procedure
I use a drain in the abdomen in most patients to help minimize seroma risk and to at least partly control the fluid drainage. Post-op recovery can be messy as post-lipo fluid is expected to leak from the small incisions for a couple of days.
Aftercare also includes shaping garments (most patients should buy two in the beginning to allow for laundering and expect to downsize garments around six weeks post-op when swelling is starting to significantly resolve. I tell patients to do their best to stay off the point of maximal projection except to use the bathroom or eat for the first ten to fourteen days.
At the end of the day, a surgeon entering the world of BBL should be prepared for a variety of challenges, including the fact that this operation can simply be tiring when done multiple times a week.
Learn more about Dr. Sayed’s Brazilian Butt Lift techniques in person during A Glimpse into the Future of Plastic Surgery session at The Aesthetic Show 2019. Click here to learn more.
About the author
Tim Sayed, M.D., M.B.A., F.A.C.S.
Dr. Sayed is a Harvard-trained, double board certified plastic surgeon with over 13 years of experience. Dr. Sayed specializes in a range of cosmetic surgeries including: breast augmentation, rhinoplasty, facelift, tummy tuck, liposuction and body contouring.
His boutique style practice focuses on safely achieving beautiful and natural looking results while providing an amazing patient experience. A perfectionist by nature, Dr. Sayed continues to push himself and his craft by staying up to date on the latest plastic surgery technologies to provide his patients with state-of-the-art techniques and amazing results. His ability to blend technology and technique and his personalized service is what keeps his patients coming back, and it’s what Dr. Sayed calls Aesthetics Done Right™.
