by Dr. Kenneth Hughes, MD, Board Certified Plastic Surgeon
Harvard University, Harvard Medical School (Beth Israel Deaconess)

Many surgeons, including board certified plastic surgeons, are continuing to inject into the muscular regions to help augment results of the buttocks. There is no question that larger, more projected buttocks can be achieved with intramuscular injections, but at what cost? The risk with injection into the muscle is the risk of introducing a fat embolus into the circulation. It is also important to realize that avoidance of the vascular pedicle or avoidance of deep injection of the muscle does not eliminate the risk. The safest route is to inject the fat under the skin. This method will limit the overall result to be sure. In addition, fat necrosis and infection can be more common as the amount of fat that is capable of surviving in this plane is much less. Certainly, intrinsic tissue dynamics will allow one patient to realize much more improvement than another. If the elasticity of the tissue is great, the expansion possible is great.

When injecting only under the skin, placement of the fat is paramount to avoid lakes of fat tissue that will not have access to blood supply and will generate a higher likelihood of fat necrosis. In addition, fatty lakes serve as a very efficient culture medium for bacteria and other microorganisms which can lead to infection.

Injection into as many different superficial locations as possible will reduce the risk for fat necrosis and infection to the extent possible.
Many purported experts on the subject have suggested that larger volume injections have a greater risk for the complication of fat embolus. This also applies to larger volumes generating more risk for fat necrosis and infection.

So in the end we have some diametrically opposed considerations. One can be conservative and inject very little into the subcutaneous plane and report the procedure as very safe. However, that will likely result in several revisions to achieve a patient’s goal. Each of those revision surgeries will involve additional risk with each anesthetic component and the scar tissue generated by previous surgery will provide for a more difficult tissue plane for removal and injection. This undoubtedly will increase the risk for perforation, contour deformities. This also adds to the recovery of the patients and the cost.

So then how does a plastic surgeon manage all of these considerations? As an individual who performs hundreds of these procedures each year and who has performed between 4,000 and 5,000 Brazilian butt lifts I have seen the gamut of patient phenotypes, surgical outcomes, and patient expectations. Given that about 80% of my patients have had previous surgery, I am confronted with seemingly only the most difficult cases due to existing scar tissue, deformity, etc. These patients do in fact have a greater risk for complications and I utilize every measure possible to combat those risks. Although I switched my technique to under the skin injection over 3 years ago and have had no fat emboli during that period (around 1500 BBLs) I am not completely convinced that this complication can be entirely avoided. I do think that the numbers reported are under-reported particularly with regard to pulmonary emboli due to reluctance of surgeons to report and many cosmetic surgeons who were not queried about complications by the American Board of Plastic Surgery. Though the risk of fat emboli is reported at between 1:1000 and 1:1500, this number can really only be higher.

It is foolish to believe that so many excellent surgeons in the US, who are board certified in plastic surgery, would not be doing everything possible to reduce the risk of complications. These are the most well-trained individuals that are frequently at the top of medical school classes due to the integrated plastic surgery residency being the most competitive by a great deal over other sub-specialities such as dermatology, neurosurgery, and orthopedic surgery.

It would also be foolish to believe that we completely understand how fat emboli develop. It is simple to say that a vessel is cannulated by a cannula and fat is injected into that larger vessel. however, when you consider that many of these cannula are large blunt cannula with the hole being farther from the tip, it becomes very difficult to intuit a mechanism by which this occurs. In addition, we have reports in the literature of this occurring in other cases including liposuction. How does a liposuction cannula that is applying suction to an area cause a retrograde entry of fat into a vessel at the time of liposuction? It simply defies logic.

Although, Dr. Hughes has adopted the safest technique for the Braizlina Butt Lift to avoid fat emboli death, no one can say what the true risk is with any one technique. The surgeons who have performed less than a 1000 BBLs in their career, which is over 90% of the surgeons performing the procedure, have likely not had the number of cases to determine if their technique is safe or not. Therefore, it is imperative to evaluate technique among only the most experienced Brazilian Butt Lift practitioners.

Only by evaluating technique among the most experienced and elite practitioners will we as a community truly gain insight into the best possible methods for reduction of fat emboli in death rate in this procedure. Pontification from the sidelines or theoretical insight from non-practitioners will not be productive. There are only a handful of surgeons who have performed several thousand BBLs and it would be helpful that those individuals compare technique and statistics on this procedure.

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