The original survey about the safety of buttock fat augmentation (Brazilian butt lift) was a result of the Aesthetic Surgery Education and Research Foundation’s (ASERF) formation of a gluteal task force in 2015 to study the mortality and complication rate of gluteal fat transfer following anecdotal and media reports of fatalities. The procedure was one of the fastest growing aesthetic procedures in the United States according to The Aesthetic Society (formerly known as the American Society for Aesthetic Plastic Surgery [ASAPS]) with 26,774 performed in 2018, which was a 61% increase since 2014.1 An anonymous web-based survey was sent in 2016 to ASAPS and International Society of Plastic Surgery (ISAPS) members, and 692 members responded. The results were published in the Aesthetic Surgery Journal in 2017.2 Following the report of the survey, there was an intense educational campaign by ASERF, ASAPS, ISAPS, the American Society of Plastic Surgeons, and the International Federation for Post-Therapeutics and Science to educate members and the public of the recommendations from the task force: Avoid injecting into muscle at all Use ≥4.1-mm-diameter single-hole injection nonflexible cannula Avoid downward angulation of the cannula Position patient and place incisions to create a path that will avoid muscle injections Maintain constant 3-dimensional awareness of the cannula tip Only inject when cannula is in motion Consider pulmonary fat embolism (PFE) in unstable intra- and postoperative patients Review gluteal vascular anatomy Include the risk of fat embolism and surgical alternatives in the informed consent3 Subsequent anatomic studies confirmed the recommendations of the task force and showed the unique anatomy of the buttock region with prominent vessels, especially medially and inferiorly, making the risk of disastrous results from fat injections in the buttock very different from fat injections in the breasts or elsewhere.4-9 The reported fatality rate in the 2017 article of Brazilian butt lift was 1:2250 to 1:6214, which included data from The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and was multiple times higher than the mortality rate of any other aesthetic procedure. This compared with the overall risk in an aesthetic procedure of 1:58,810.10 Fatalities in this procedure were generally from macro-fat embolism, which had never been reported in any other aesthetic procedure and differs from the microscopic fat embolism that occurs in liposuction alone and in many other surgical procedures.11,12 Macro-fat embolism mortality is almost 100%.13-15 Since that time, Brazilian butt lifts increased from 2016 to 2017 by 25% and further increased 19% from 2017 to 2018 (American Society of Plastic Surgeons), which are the latest figures available. However, the ISAPS reported 346,432 buttock augmentations with either fat transfer or implants were performed worldwide in 2018 according to their latest statistics, which represented a −7.5% decrease from the 372,496 in 2017.16. The authors report the results of a second anonymous web-based survey that was sent in May 2019 and a reminder in June to 5048 ASAPS and ISAPS members to gauge awareness of the 2017 ASERF Gluteal Task Force recommendations.17 It included the previous questions from 2017 as well as additional questions about awareness of 2017 recommendations and subsequent changes in surgical techniques. There was a 11.3% response rate compared with 14.3% in 2017. In the newer survey, there were more physicians from Mexico and Central America and fewer from South America. It appears the educational campaigns and research findings yielded a significant effect, because 94% of the respondents were aware of the recommendations and generally have followed them, which resulted in a significant decrease in PFE and a safer procedure: In the 2 years following the publication recommendations, incidence of PFE was 1:2492 compared with 1:1030 reported in 2017. Mortality rate decreased from 1:3448 in 2017 to 1:14,952 in 2019. Only 0.8% of surgeons reported injecting into the deep muscle compared with 13.1% in 2017. 29.8% reported employing cannulas greater than 4.1 mm compared with 4.1% in 2017. Only 4% of respondents reported angling the canula down compared with 27.2% in 2017. Key aspects of improving safety: 86% of those who previously injected into the muscle switched to the subcutaneous plane and 93% have switched their canula tips from downward to angling them parallel or upwards. Of note, significantly fewer surgeons reported performing gluteal fat grafting than in 2017: 79.7% vs 88.4%. The main reason for the decrease was surgical risk. Although the survey showed gluteal fat grafting is becoming safer, it showed only the data from the limited number of fully trained ASAPS and ISAPS members who responded. It did not show the complication and fatality rate from those who did not respond and the multitude of inappropriate providers and inadequately trained surgeons performing the procedures in unaccredited or unlicensed facilities around the world, which may be significantly greater. One area of concern is the statement that the fatality rate of 1:14,952 was better than the reported fatality rate of 1:13,193 from performing an abdominoplasty in an AAAASF facility,18 indicating that it was a safer procedure than an abdominoplasty. The patients undergoing buttock fat injections are generally younger female patients, often with young children, whereas abdominoplasties are performed in all age groups with different risk factors. More importantly, the data are not equivalent. AAAASF requires a mandated reporting of all cases and problems. That is not the case in this electively completed survey. The actual total number of buttock fat augmentations performed is unknown, and there is no mandatory reporting of complications, so this comparison creates a false impression. Unfortunately, any fatality is a disaster, especially in an elective procedure. The most important priority should always be patient safety, which can be improved further by requiring only board-certified plastic surgeons in accredited or licensed surgical facilities to perform the procedures, including an anesthesiologist aware of the potential risks, and maintaining a transfer agreement with a local hospital if the procedure is performed in an ambulatory surgical facility. Even that will not bring the complication rate to zero. It has improved with anatomical research, but further research is needed to make the procedure safer. The authors point out significant room for improvement still exists through continuous research and education, and ideally a registry would be established .19 The key problems with a registry are administration and especially compliance. This possibly could be accomplished in the future through the ASAPS and ASERF sophisticated data extraction program Aesthetic Neural Network. I commend the authors for publishing updated data that show the procedure seems to be becoming safer. The main question that every surgeon still has to answer for himself/herself is if it is safe enough to proceed with the procedure. It will be interesting to see in the future, as the safety of the procedure improves with further refining of techniques and better instrumentation, how many of the surgeons who have stopped performing the procedure will start offering it to patients again.14,20 The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.
No takes yet. Share an insight, caveat, or question.
Robert D. Singer (2020) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: