RESEARCH PROJECT

INTRODUCTION

“From silicone implants and fat transfers to bubble butts and a high mortality rate, we investigate whether the BBL is the most dangerous cosmetic surgery of all” (Gold, 2019a). Other than inside the cosmetic surgery industry, the procedure known as Brazilian Butt Lift (BBL) has vastly become one of the most scandalous surgeries partly due to its unusually high death rate (Gold, 2019b).

The Brazilian butt lift is an informal term for buttock fat grafting. It is an optional cosmetic procedure which requires the removal of fat from a particular area of the body by the use of liposuction and then relocating the fat by injecting it into the butt, which is aimed for a fuller and perkier result (Power, 2018a).

The BBL supports to surgically accomplish the method of altering the size, shape and contour of the buttocks, it is to benefit patients who want to achieve more of the time-honoured hourglass shape and body contouring that was only achievable by the use of restrictive undergarments and corsetry (Gold, 2019c).

With an increase of popularity over the last few years, the American Society for Aesthetic Plastic Surgery following a 26 per cent jump since 2016 up to 2017, which marking it the second most significant increased surgical procedure performed year over year (Power, 2018b).

BRAZILIAN BUTT LIFT

To perform a procedure such as a Brazilian Butt Lift, it requires a qualified plastic surgeon. To become a qualified surgeon, does require a large number of years. In Australia, plastic surgeons must start their training with the Royal Australasian College of Surgeons (RACS) in which they must specialise in the plastic and reconstructive surgery.

The course goes for 5-6 years, where due to training in plastic and reconstructive surgery it may involve in an added 2 years of general surgery which is followed by 4 years of specialised training in plastic surgery.

After the end of the surgical training time and also have accomplishing the RACS examinations, the surgeon can then go on to study with Fellows of the Royal Australasian College of Surgeons (FRACS), in typically will undertake a further 1-2 years of which semi-training is provided in their particular subspecialty of interest (Nguyen, 2017).

When undertaking such an intense treatment, the surgeon will firstly, locate where the fat donor sites are going to be. The most common areas for the fat to be harvest includes, but are not limited to, the abdomen, chest, lateral thorax, waist, hips, back, arms and thighs. Most of the patients recommend mostly the lower back, sacrum, waist and hips, in which these areas that is treated with liposuction, narrows the waist and mostly accentuates the curves.

Up next is the pre-surgical markings in which are preformed while the patient is in an upright position. Deep depressions or the areas that needs to be grafted are mostly drawn in red and the areas that are going to be liposuction are then marked in blue. This is usually the time the patient will now be put under general anaesthesia and the skin is getting prepared for a deep sterilisation.

Afterwards, a 20 gauge spinal needle that is joined to a Wells Johnson® infiltration pump is used to lightly insert the tumescent anaesthesia solution. A blade is then used to make small punctures in the areas marked up for liposuction. Finally then, a dulled infiltration cannula is attached to the infiltration pump that is used to infiltrate with majority of the tumescent solution into the deep and superficial fat layers up until the tissues have a apprehensive touch to them which is due to the increase of hydrostatic pressure.

Next up is 3 or 4 mm liposuction cannulas that are used to produce the fat after all the areas to be preserved. The fat is then stored into a sterile 3 L glass, and also a reusable sterile canister. Excess fluid and blood relaxes at the bottom of the canister and the fat micro-grafts will drift to the top of the canister through a continuous vibration table. The excess fluid is then poured out to separate just the fat grafts. The fat is formerly treated by an antibiotic solution.

Precisely before the fat is almost injected back into the patient, a 5 or 6 grams of platelet rich plasma (PRP) that is from the patient’s own blood is then assorted with the fat. A 4 mm infiltration cannula in which contains a single hole is then used to push the fat back into the patient’s buttocks. This fat infiltration technique which is best frequently used by the surgeons is known to be a superficial grafting technique that is above the muscle in a parallel plane toward the back plus far from the superior and inferior gluteal veins to dodge an injury.

Last of all, a pressure-controlled injection system also by Wells Johnson is then used in which switches off automatically if it senses any pressures that is higher than the central venous compression. The ideal infiltration system is a closed loop injection system that contains a pulsating table to help with the separation of the fat from the supernatant. One of the benefits to this system is that when related to previous methods of fat grafting it includes effectiveness, seamless micro-droplet size, more sterile and low pressure of injection (Cuzalina & Retana, 2018).

The most common ideal shape for a Brazilian Butt Lift is best described as an upside heart, making the sacrum the heart point. On top of the Brazilian butt lift treatment, the extra fat that has been removed can also benefit not even the shape of the body but it can also be inserted into lips, as a substitute for filler. The fat is managed much similar to dermal filler, however with a much slightly larger gauge cannula. Due to it being the persons own fat, the stem cells usually help restore the area, making the procedure permanent (Chan, 2019).

Fat grafting is becoming a popular technique compared to buttock enhancement in which patients who want to achieve a much fuller, well-formed appearance without using an implant and according to the American Society of Plastic Surgeons (ASPS) statistics, there was over 24,000 Brazilian Butt Lift procedures that were achieved in 2018, causing an increase of 19 precent over the previous year.

With saying that on the other hand, with its new popular status comes a series of increasing concern about the serious complications the can be resulted from the procedure. In 2018, the ASPS decided to join in with other plastic surgery specialty societies in which they issued an urgent warning, in regards to the alarming number of deaths that is correlated to gluteal fat augmentation.

It was stated that an advisory was issued to plastic surgeons that outlined the steps to confirm that the fat is only injected under the skin, rather than the muscle. “The study confirms that gluteal fat grafting is safe, only if the injections remain in the subcutaneous tissue,” according to Daniel Del Vecchio, MD. A plastic surgeon from Boston who has helped developed this new protocol (Wolters Kluwer Health, 2019).

LITERATURE REVIEW

The first study is in correlation to Daniel Del Vecchio belief. The aim of the study was to examine the deaths that have occurred due to gluteal lipoinjection which is the correct terminology for describing a Brazilian Butt Lift. The authors have stated, even though they believe that intramuscular gluteal lipoinjection has become one of the most frequently used surgical treatments when it comes to achieving improvement in the gluteal contour, nonetheless there are quite a small number of studies that have reported and analysed that the causes of secondary deaths are from this particular procedure.

In order to fulfil this method, they have conducted an analysis of secondary deaths from gluteal lipoinjection procedures that was achieved in Mexico and Colombia over the last 10 to 15 years. The study that was performed in Mexico was led through a survey of all members of the Mexican Association of Reconstructive, Plastic and Aesthetic Surgery. Whereas over in Colombia, the studies was based on an analysis of deaths and the autopsies documented by the National Institute of Legal Medicine and Forensic Sciences Regional Bogota.

The outcomes between the two studies showed that there were a total of 413 Mexican plastic surgeons that have reported around 64 deaths in relation to liposuction and with 13 deaths due to the Brazilian Butt Lift, 8 people out of the 13 had occurred while the surgery was taken place where the remaining 5 deaths all happened within the first 24 hour time frame.

As for Colombia, there were only 9 deaths that remained documented, 6 of those deaths were yet again happened during the BBL procedure and 3 of which followed immediately after the surgery. For the Colombian autopsy report, there were 7 cases which of macroscopic fat embolism and 2 cases with a microscopic embolism were reported, by means of abundant fatty tissue in the infiltrated gluteal muscles.

For this study, the end point being that the authors found that the intramuscular gluteal lipoinjection, does play a role with the death caused by gluteal blood vessel damage which allowed the macroscopic and microscopic fat embolism. As an overall conclusion, the Brazilian Butt Lift should be performed carefully and slowly, also trying to avoid injecting into the deep muscle planes (Cardenas, Bayter & et all, 2015).

For this next article, the authors believe that the Brazilian Butt Lift has upgraded considerable with their technique and with the overall results but they sense that people whom assume heath issues more particular fat embolism occurs due to injury of the veins superficial and to the gluteus muscles which is with that the reason fat must be stored within the muscle in order to accomplish the suitable result.

The purpose for this study is to clear up the theory simply by collecting the data in where BBL is achieved when under local anaesthesia, then report if there were any safety issues. On how they were going to prove the theory, the authors had all the patients who had experienced a Brazilian Butt Lift under the local anaesthesia through oral medications and the tumescent infiltration. They had also collected a bit of extra fat that was gathered by a closed-system liposuction, in which disconnected by gravity through injecting using a peristaltic pump and reticulating basket cannulas.

The biggest strong point was when the authors managed to get the results they were looking for. It seemed to appear that they managed to find 32 female patients roughly around 38 years of age with a body mass index of around 24.8 kg whom all endured 47 BBL surgeries while under local anaesthesia over the course of 52 months. With an average volume of fat that was injected was around 359 ml per buttock and with much luck there were no deaths and no complications.

As the article came to an end, it was then the authors decided that even though there have been recent fears in regards to enhancing the buttocks, due to death from fat embolism but in spite of the count-less theories that has been established, they believe that is untrue, it should not cause any harm to the patient unless the surgeon was not mindful of the mistaken cannula. With the authors recent discoveries, they recommend surgeries alike buttock fat grafting under local anaesthesia is safe and also an effective treatment that provides the safety of the patient and offers an outstanding result (Chia, Theodorou & et all, 2018).

Unlike the previous article and more similar with the first study, comes the third article. In their opinion, the death rate and the complications in Brazilian Butt Lifts are excessively great and with the recent debate amongst other surgeons in relation to the safety of where the fat is stored once in the gluteal area.

Due to added views, the fat can be placed within the gluteus muscle without an issue or the fat can only be restricted to only being placed in the subcutaneous area. That is why, for this study the authors purpose was to examine those assumption that when under an assured pressure, the fat that is injected within the gluteus muscle can essentially travel out from the muscle and into a much deeper plane which is holds dangerous neurovascular structures, in a sense of the process of the deep intramuscular relocation.

To test this hypothesis, the authors performed an overall 8 dissection of the human corpse. 4 of which had hemi buttocks were chosen for intramuscular fat injection. They also studied the rhythms of subfacial fat migration in which was weighed into 3 of the hemibuttocks using direct visual inspection, and 1 of them by endoscopic evaluation. On top of that, another 4 hemibuttocks were chosen for subcutaneous or suprafascial fat injection.

The end result, for this study was that the authors found that alternative fat was in fact travelling through the muscle and into the deep submuscular area per intramuscular injection. As for the injections, there was actually no extra fat created during the dissection of the intramuscular space.

An overall conclusion, the insertion of intramuscular fat, was basically up to this point been considered practical to achieve in the superficial muscle and has studies proving the theory, but nowadays is believed to be inaccurate technique, not to mention an extremely dangerous surgery. The authors believe with their technique, due to the travelling nature of the fat injected and must be avoided as additional use with the fat transplantation into the gluteal area (Del Vecchio, Villanueva & et all, 2018).

This last article acknowledges Brazilian Butt Lift has most definitely increased in popularity worldwide, but do provide a series of complications. The authors state it was in fact, Brazilian plastic surgeons that have been performing this technique roughly 30 years, give or take and with each year more often than previous. For that reason, the authors concluded a study amongst board-certified plastic surgeons, whom are members of the Brazilian Society of Plastic Surgery, in which to assess their techniques, recognize what their preferences are, they are also aiming to examine any complications and outcomes of the surgery.

The type of method the authors decided to go with was an anonymous web-based survey made of 16 questions which was sent to roughly 5655 members of the Brazilian Society of Plastic Surgery in July, 2017. They also included an additional survey which contained further statistics about the major complications.

Over the course of the study, a total of 853 answers were analysed and with one of the highest proportions of responses in different categories where: fat decantation for processing, injection with a 3-mm cannula, the use of superior incisions, subcutaneous fat grafting only and lastly with a volume of 200- 399 ml of fat each gluteal.

As most of the surgeons, had undergone actual training in order to perform the procedure whilst in residency, majority of the basic complications was due to contour indiscretions. It was estimated that the death rate an average 1 in 20, there was 117 cases and with an amount of nonfatal fat embolism being every 1 in 9530. Total being that the death was more 16 times greater than fat that was injected intramuscular.

The total decision of the study was even though based on the surveys, the authors do acclaim when surgeries such a Brazlian Butt Lifts, the fat being injected should only be internally, meaning superior incisions and the use of cannulas should be 3-mm or more. The authors discover that acknowledging these approvals, the BBL should remain harmless as any surgeries should be, they have also stated with further research in order to create a course of action will increase an overall safety, is most necessary (Cansancao, Condé-Green & et all, 2019).

CONCLUSION

A Brazilian Butt Lift, is the term used for buttock fat grafting, it is a cosmetic surgery in which requires the removal of fat from a certain area of the body by liposuction, most commonly being the abdomen area and then placing the injected fat into the gluteal area, which alternates the size, shape and contour the area.

To perform such treatment, requires years of study and training due to, as like any surgery BBL does come with its fair share of complications. Even though the treatment is easily increasing over the years, it has been known to cause death in the patients if not performed accurately.

To prove that theory the first study aim was to examine the deaths that have occurred due to Brazilian Butt Lift and in conclusion the authors found that placing the fat under the muscle does lead up to deaths which is caused by gluteal blood vessel damage which allowed the macroscopic and microscopic fat embolism. They said BBL should be performed carefully and slowly, also trying to avoid injecting into the deep muscle planes.

For the second study they wanted to clear up the theory, that people whom assume heath issues occurs due to injury of the veins superficial and to the gluteus muscles, by simply collecting the data in where BBL is achieved when under local anaesthesia, then report if there were any safety issues. In conclusion to the theory the authors discovered Brazilian Butt Lifts under local anaesthesia is safe and also an effective treatment that provides the safety of the patient and offers an outstanding result.

The third study purpose, was to examine those assumption that when under an assured pressure, the fat that is injected within the gluteus muscle can essentially travel out from the muscle and into a much deeper plane and as an end result found that insertion of intramuscular fat is believed to be inaccurate technique and dangerous.

And lastly for the last study, their aim was to examine board-certified plastic surgeons, whom are members of the Brazilian Society of Plastic Surgery and evaluate their techniques, recognize what their preferences are, they are also aiming to examine any complications and outcomes of the surgery. As a result, the surgeons decided that even though the study is based on surveys, they do approve of the fat being injected with cannulas that should be 3-mm or more, and if continue to use the 3-mm cannulas, treatments such as BBL will remain an overall success

One thing they all have in common is that the reason there is so many deaths is because of the lack of capabilities from the surgeon. They all agree when it comes to successful outcomes, using the right tools is a must. 2 of the articles both suggest using a 3mm cannula reduces the risk of complications, and the other 2 suggest inserting fat over the muscle will help, reduce the risk of deaths. All articles did however have no limitation as all 4 studies proved the theory they were trying to accomplish.

REFERENCES

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• Wolters Kluwer Health, (2019) study proposes new standards for safely performing ‘brazilian butt lift’. MedicalXpress