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Plastic Surgery Safety in 2018

Brazilian Buttlift with Dr. Kenneth Hughes

In 2018, According to the American Society for Aesthetic Plastic Surgery (ASAPS/The Aesthetic Society), deaths and serious complications associated with the Brazilian Butt Lift procedure have resulted in an MultiSociety Gluteal Fat Grafting Task Force. The Task Force is examining the causes behind complications and deaths to try to prevent them from occurring through a variety of physician and patient safety education measures, including research.

ASAPS, the American Society of Plastic Surgeons, the International Society of Aesthetic Plastic Surgery, the International Society of Plastic and Regenerative Surgeons and the International Federation for Adipose Therapeutics and Science have all recognized that the death rate for BBL (approximately 1/3,000 or higher) is the highest for any aesthetic procedure. This is believed to be due to injection of the fat into the gluteal muscles, wherein larger blood vessels can be traumatized and the fat can enter the bloodstream.

The procedure was taught in residency programs throughout this country and other countries for several decades. For several decades, the procedure was performed by injecting fat into the muscle due to its better blood supply. After all, the goal of the procedure is to have as much fat live as possible to make a noticeable contribution to buttock size, volume, shape, and projection.

It was not until very recently with the performing of tens of thousands of buttock lifts that the issue of the fat embolus became statistically realized.

The most important aspect of the procedure is now to prevent the occurrence of fat embolus. Though it has never been considered malpractice or negligence, many surgeons who perform this procedure are doing everything possible to prevent this complication from occurring.

Since 2015, Dr. Hughes has been performing the fat transfer under the skin to avoid the complication of fat embolus. During this period of time he has performed about 1500 BBLs without a fat embolus of any kind, both fatal and nonfatal.

Plastic Surgery Societies have suggested various measures to improve the safety of the procedure recently.

  1. No injection into the muscle. For over 3 years, Dr. Hughes has injected beneath the skin long before the task force recognized the problem
  2. Fat should only be grafted into the superficial planes with the subcutaneous space considered safest
  3. Use a large, blunt, single hole injection cannula and instrumentation that offers control
  4. Avoid downward angulation of the cannula
  5. Position patient and place incisions to create a path that will avoid deep muscle injections
  6. Maintain constant three-dimensional awareness of the cannula tip
  7. Include risk of fat embolism and surgical alternatives in the informed consent process

The most important point rather to this discussion is to keep the tip of the cannula away from larger vessels. This can only be assured by injected under the skin so that the tip can be visualized at all times. This is Dr. Hughes’s method of performing the procedure. This can be viewed on youtube as well.

Additional research is being conducted in the form of more anatomic studies, dye studies are being performed. In addition, the autopsy results are being catalogued for all of the deaths that have occurred throughout the world. Once those results are finalized, a comprehensive set of guidelines should be forthcoming.

In the interim, Dr. Hughes is performing the procedure only by injecting fat under the skin to avoid any of the larger vessels. The vessel diameter of the vessels feeding the gluteal skin are much smaller than the 4+ mm, blunt, remote single hole cannula Dr. Hughes uses for injection. Thus, the fat cannot gain entrance into the vessels and no fat embolus can occur.

Fat embolus has long been known to a complication of many orthopedic procedures and also traumas of many kinds as well as liposuction procedures. The manner in which fat embolus has occurred in liposuction is a subject of speculation as intuitively it makes little sense how this could occur. However, there are only a few reported cases during liposuction despite hundreds of thousands of liposuction procedures being performed in the US alone each year.

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