Increasing Mortality with Gluteal Fat Grafting in South Florida: Are Local Plastic Surgeons Ready and Willing to Change Their Practice to Promote Safety?

Goals/Purpose: Gluteal fat grafting, or the “Brazilian Butt Lift” (BBL), has become the deadliest cosmetic procedure in the United States with pulmonary fat emboli (PFE) being the cause of mortality in the majority of these cases. Since the advisory that mandated subcutaneous only injections for BBL procedures in 2019, 14 deaths from PFE have been reported in South Florida, which is more fatalities than before the subcutaneous injection mandate.^1,2 In response to this increase in PFE related death, the Florida Board of Medicine (FBoM) put into effect an emergency ruling requiring real-time ultrasound-guided cannula visualization and restricted the number of BBL procedures to three per day. These recommendations were recently published by the Aesthetic Surgery Journal in August of 2022.¹ Florida’s emergency ruling has since expired, generating discussions over permanent regulations. The purpose of this study is to evaluate if South Florida Plastic Surgeons are in favor of these recent regulations and whether they continue to follow recommended risk reducing practices in the absence of formal mandates.

Methods/Technique: An anonymous survey was emailed to 252 local board certified and board eligible plastic surgeons in South Florida with a 16% (n=40) response rate. Plastic surgeons were asked if they agree with the ruling that required ultrasound-guidance for BBL procedures and limit the number of BBL procedures to three or less per day. If not in favor of these recent regulations, respondents were asked to explain their reasoning. Additional questions asked about current practices including the use of real-time ultrasound and the average number of BBL procedures performed in a one-month time span.

Results/Complications: Fifty-three percent (n=20) of respondents no longer use ultrasound guidance for BBL procedures, with the most common rationales being that it is unnecessary in the hands of a surgeon highly experienced in BBL procedures and that the use of ultrasound adds too much difficulty (n=9). Conversely, 62% (n=24) of the local plastic surgeons agree that ultrasound guidance should be required. Majority of survey respondents believe there is inadequate access to education and training for the use of ultrasound during BBL procedures (n=22; 56%). Eighty percent (n=32) of surveyed plastic surgeons agree with the ruling to limit the number of BBL procedures performed to three or less in a single day. Perspectives from those who disagreed with limiting the daily number most frequently claimed that surgeons should not be limited by law to a certain number of procedures but rather the limitation should be self-imposed by the operating surgeon (n=3). Other rationales included no published data pertaining to physician fatigue from multiple BBL procedures, and arguments towards overall case volume being more pertinent. Seven respondents (18%) perform 15 or more BBL procedures per month (range 0–80).

Conclusion: As BBL related deaths continue to rise in South Florida, it is imperative to determine how we can make this procedure safer for patients. Following the expiration of the emergency order in Florida, this study suggests that the majority of local board-certified or board eligible plastic surgeon are no longer using ultrasound for BBL procedures, which may be partially related to insufficient access to education and training. Other reasons cited by respondents include that sufficient surgeon experience with BBL procedures makes the use of ultrasound unnecessary and that the greater problem exists in high-volume budget clinics where most BBL deaths occur. In addition, most survey respondents agreed that fatigue may play a large role in BBL related mortality. An important point brought to our attention suggested that by placing a limit on the number of BBL procedures only, this does not address fatigue from other surgeries performed by the surgeon in the same day. Our study focused on board-certified and board eligible plastic surgeons and did not account for the majority of plastic surgeons employed at these high-volume budget clinics where most fatalities occur. Findings of this study support continued efforts being made to educate patients on seeking board-certified plastic surgeons with adequate experience performing these procedures, along with further discussions on risk reducing practices.

1. Del Vecchio D, Kenkel JM. Practice Advisory on Gluteal Fat Grafting. Aesthet Surg J. 2022 Aug 24;42(9):1019-1029.

2. Pat Pazmiño, MD, Onelio Garcia, Jr., MD, Brazilian Butt Lift–Associated Mortality: The South Florida Experience, Aesthetic Surgery Journal, 2022; sjac224