The American Society of Plastic Surgeons (ASPS) has been warning about the alarming complication rates from the Brazilian butt lift (BBL) surgery.

Last Updated: 12 February 2020

BBL Surgery

By Inessa Shlifer, PA-C, DFAAPA

Inessa Shlifer, PA-C, DFAAPA

Inessa Shlifer, PA-C, DFAAPA

Inessa Shlifer has been plastic surgery PA for over twenty four years with a clinical focus on plastic and reconstructive surgery. She is the past president of the Association of Plastic Surgery PA’s and published author of several works on plastic surgery. She practices in New York City.

Brazilian Butt Lift Controversy

The American Society of Plastic Surgeons (ASPS) has been warning for a while about the alarming complications and death rates due to the so-called Brazilian butt lift (BBL).

The surgical procedure consists of liposuction of various areas of the body and then injection of collected fat into buttock and sometimes hips. The procedure may seem simple, which sparks interest among surgeons and medical providers from other fields of medicine wanting to perform it. 

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BBL Surgery Safety

As with many things in life, it may look safe on paper, but not so in the operating room. We all know the anatomy of the human body and its main blood supply to gluteus medius and maximus muscles that create the shape of the buttock. A successful procedure has to give the patient not only a pleasing aesthetic result, but be performed safely and without complications, particularly fat embolism. 

Experience is everything and surgeons that do most of the BBL surgeries tend to deliver safe outcomes with the best results. BBL surgery is especially dependent on experience because certain parts of it are done “blind.” When we perform liposuction, we have to rely heavily on what we feel, since seeing is difficult.

The same applies to the fat injection; we choose the injection site and depth level carefully. The rest is up to being able to feel how deep we need to go in order to make it safe and produce the best result. 

Often, patients walk through the door and say, “I want to have a big butt. Make it as big as you can. Give me the ‘Kardashian look.’” In order to do that, the surgeon not only has to harvest a considerable amount of fat, but also inject it back to the buttock. In many cases, the buttock tissue can only safely accommodate a particular amount when properly injected.

The primary goal is to inject it safely and to ensure healing of transferred fat. The secondary goal is to provide a natural and even shape to the buttock. 

Controversial BBL surgery

BBL Surgery in the Literature

In February of 2019, the Aesthetic Surgery Journal presented an interesting article in which the authors performed an anatomical study in cadavers on gluteal augmentation (GA) safety. They presented four groups each utilizing different injection techniques. 


Infiltration Location



Upper medial intergluteal sulcus

−30°  / −10°  / 0°


middle lower gluteal sulcus

−30°  / 0° /  +15°


peritrochanteric (PT) access at the level of the femur head

0° and +10° and in the middle of the buttock at the level of the posterior superior iliac crest at −30° toward the trochanter (lateral direction)


Upper medial intergluteal sulcus

−10°  / 0°

The safest was performing the procedure with −10 degrees of angulation using the upper medial intergluteal sulcus as an entry point. The remainder of the groups had the experimental dye injected into major vessels, suggesting that those techniques were less safe than those used in groups three and four.  

ASPS Guidelines & Safety Warnings

The ASPS developed safety guidelines for fat transfer procedure more than 10 years ago. So why do BBL surgery morbidity and mortality rates remain at alarming levels? Why has fat transfer become deadliest surgery?

In 2018, the ASPS task force found that the death rate from BBL surgery was 1 in 3,000. And these operations were performed by board-certified plastic surgeons. Astonishing number of deadly complications. Many surgeons refuse to offer BBL to their patients for that reason. Hippocratic oath promises to “do no harm” and they literally practice it to keep their patients safe. 

I attended a New York Regional Society of Plastic Surgery (NYRSPS) conference on October 26th, 2019. One of the hot topics was Brazilian butt lift. Many questions were raised by the audience of plastic surgeons and other clinicians.

Should we ban this procedure all together just like the United Kingdom did? Should we create centers where experienced plastic surgeons teach proper and safe techniques? 

Can BBL Surgery be Performed Safely?

There is no single answer to it. I can only speak from our own experience. In our office we perform at least one Brazilian Butt Lift a week. Often we combine it with Buttock Augmentation.

We developed a system to make sure the surgery goes safe and with good results. We carefully select appropriate patients, ensuring they will benefit from surgery. If the patient is thin, we suggest buttock implants alone to give them guaranteed augmentation. We don’t offer liposuction to them, since it may only leave them over-suctioned with limited fat augmentation.

Also, they may be at bigger risk to get into muscle and possible vessel occlusions-creating a good condition for fat embolism. 

Once we decide to go ahead with fat injections we don’t over inject them. During injections we pay close attention to where fat is being deposited. We use small amounts, medium to large bore cannula and move it constantly during injection.

We don’t pass muscle fascia and inject only subcutaneous, deep fat layer above muscle. Most of the fat is placed into superior, medial and lateral parts of buttock. We don’t deposit any fat into the lower third of the buttock. It is considered to be a danger zone where large vessels run and where injected fat can become an embolus.

This is of special danger because fat, injected in relatively large amounts, has no “antidote” to it, like thrombotic emboli. Once it’s in the vessel, it’s unstoppable and potentially fatal. 

The question is: can it be done safely? The answer is: yes. 

Surgical CME

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Perioperative Management – Johns Hopkins Clinical Update

Board Vitals Surgery CME – More than 1,000 board-style questions & explanations worth 60 category 1 CME credits and 60 MOC points simultaneously.


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