New Data Show Board-Certified Cosmetic Surgeons Safely Performing Brazilian Butt Lift Surgery

New research results were recently unveiled at the May 2023 meeting of the World Association of Gluteal Surgeons (WAGS), which illustrate the enhanced safety of Brazilian butt lifts (BBLs) performed by cosmetic surgeons certified by the American Board of Cosmetic Surgery (ABCS). These data reveal zero fatalities during more than 12 000 conse­ cutive cases performed by ABCS diplomats, which were performed subsequent to the Florida Board of Medicine’s emergency rule which prohibited dangerous intramuscular fat injection. Ninety­eight percent of the ABCS surgeons (sur­ geons who practice both in Florida and in other states which have not enacted prohibitions against intramuscular injection) polled reported injecting only in the subcutaneous plane. This finding contrasts with a 2023 article published in the Aesthetic Journal which revealed that 10 out of 11 BBL deaths in the state of Florida occurred at the hands of plastic surgeons certi­ fied by the American Board of Plastic Surgery and that the other surgeon with a death in Florida during this timeframe was certified in neither cosmetic nor plastic surgery.1 Continuing demand for the BBL has propelled it to become the cosmetic procedure with the fastest growth in recent years. In 2021, the American Society of Plastic Surgeons reported 61 000 BBLs performed. However, experts believe that the actual number could be twice as high given that other surgeons also perform BBLs. It is estimated that Americans spent between $250 million and $750 million US dollars on BBLs annually. Despite its soaring popularity, BBL has not been without its controversies, particularly concerning the risks associated with the procedure. One of the most significant concerns has been cases of mortality resulting from pulmonary fat embolism. The reported mortality ranges from 1 in 3000 to 1 in 20 000.2 There was a decrease in deaths between 2018 and 2020, but a staggering 400% surge in BBL­related deaths in South Florida in 2021 raised alarm bells within the medical community. This was particularly true of the Florida Board of Medicine, which led the country in BBL safety by prohib­ iting intramuscular fat injection and requiring that surgeons employ intraoperative ultrasound, the current gold standard in safety for this procedure. At a recent WAGS meeting held in Miami, Dr. Angelo Cuzalina presented a groundbreaking study concerning the safety of BBL procedures.1 This study stands out as it is the first two­stage prospective analysis spanning 6 years, exam­ ining the safety record of BBL surgery, specifically when performed by fellowship­trained, board­certified cosmetic surgeons under the ABCS. In the first stage of the study, conducted in 2019, diplo­ mates of the ABCS were surveyed via email questionnaires. A total of 393 surveys were distributed, with a response rate of 23% as 93 respondents participated. Among them, 63% (or 64 out of 93) reported having performed BBLs, with a total of 22 800 BBLs carried out between 2016 and 2018. A significant 39% admitted to injecting fat into the gluteal muscle. There were two fatal and one nonfatal cases of pulmonary fat embolism recorded, with the fatalities attrib­ uted to intramuscular fat injections. This brought the BBL mortality rate to 1 in 11 400. Between 2018 and 2020, organized cosmetic surgery and aesthetic plastic surgery societies endorsed the injection of fat exclusively into the subcutaneous plane as a precautionary measure to prevent pulmonary fat embolism.3­5 The second stage of this study entailed another survey of the same ABCS cohort in 2022. This time, 156 respondents participated out of the 393 surveys sent, yielding a response rate of 40%. Among the respondents, 85 (or 59%) performed BBLs. From 2019 to 2021, 12 172 BBLs were performed without a single case of fatality or pulmonary fat embolism. A staggering 98% of the surgeons reported injecting fat sub­ cutaneously, while only three confirmed injecting it into the muscle. Taking into account the additional BBL procedures con­ ducted during the second stage of the study, the total number of BBLs conducted by the survey respondents over the entire 1186181 ACSXXX10.1177/07488068231186181The American Journal of Cosmetic SurgeryHah letter2023