Despite death risks, the BBL has retained popularity. How can doctors make this infamous procedure safer

The Brazilian Butt Lift (BBL) is one of the most popular—and deadly—cosmetic procedures of the 2000s. Despite measures to reverse trends, it continues to rise in fatality and fame.

First pioneered in the 1960s, the BBL is a cosmetic fat grafting procedure in which a surgeon takes fat from one area of a person’s body (often the abdomen) and puts it in the buttocks region. The outcome: a snatched waist and plump rear end. Or death.

While exact figures vary, some reports say that BBL-associated mortalities could be as high as 1 in 3,000 procedures, making it the deadliest cosmetic surgery.^[]

And according to a 2023 article published in the Aesthetic Surgery Journal, BBL-associated mortality numbers have risen since 2019.^[] (However, others disagree. Some surveys suggest recent death rates have decreased to about 1 in 14,000, making the BBL less dangerous than abdominoplasties.)^[]  

Reducing BBL risks 

As reflected by their high demand, reversing death trends isn’t as simple as convincing people not to get the procedure. Instead, harm reduction involves educating patients on the existing risks and helping them connect with a doctor who operates with the best practices. So what are they?

BBL fat placement: a life or death decision

In 2017, it was identified that BBL mortalities could occur from pulmonary fat embolisms (PFE) from the surgery. PFEs can happen when fat is placed in or under the butt muscles; it can travel up veins and into the pulmonary circulation, causing (sometimes instantaneous) death.^[]

“When you look at most patients, they actually have like a small or some people have a large incision all the way at the bottom of their buttocks,” says Dr. Leonard Grossman, surgical director at NYC Plastic Surgery PC. “The first thing you encounter when you stick an instrument in there is a gluteal vein that has a consistency a little stiffer than toilet paper.”

“When you puncture that blood vessel, it could cause bleeding,” he adds. “And if you inject fat into it, it can go straight to the heart.”

To mitigate risks, surgeons only inject fat “from a tiny incision in between both buttocks and the small of the back, overlying the bone,” Grossman adds. He also stresses holding the cannula (from which the fat is injected) parallel to the ground for accuracy.

Grossman suggests that risks may still exist if the fat is placed in the lower subcutaneous areas (beneath the butt) instead of higher areas (above the butt). He says he has been using this method since 1995 and has never lost a patient due to a BBL.

To ensure safety going into a procedure, Grossman recommends patients ask their surgeon point blank, “Where do you place the fat?” If they answer in or below the muscle, it’s time to explore other options, he says.

Setting maximums and temperature recommendations

Florida also more recently issued rules that limit the number of BBLs that a surgeon can perform to three a day maximum and require surgeons to use an ultrasound to monitor the placement of the fat cannula during the injection.^[]

Setting a limit on the number of BBLs one can perform is important so that surgeons can be at top-notch mental focus and physical strength, says Grossman.

Another topic for concern is the temperature of the operating room, as many ORs hover in 50 or 60-degree ranges, which he deems unsafe for the BBL procedure, he adds.

ORs tend to be kept warm for the surgeon's comfort, which is not always conducive to patient safety. 

Cold temperatures combined with sedatives and other fluids involved in the fat transfer process can create a recipe for hypothermia, furthering risks of health complications post-surgery, or mortality, he adds.

“When you do procedures such as fat grafting, there's almost so much water in the area, the patient is literally bathing in it,” Grossman says. “If the patient is exposed to such cold for a prolonged period of time, it increases their chances of going into a cold shock.”

Warmer temperatures may also aid in preserving fat during the transfer process, according to studies.^[]

Despite their past and current risks, BBLs shouldn’t have to be deadly, Grossman adds. He encourages doctors to follow best practices when operating on a patient and patients to ask as many questions as they need before choosing a surgeon they are comfortable with.

“The BBL and fat grafting in general, is a wonderful procedure,” Grossman says. “I think it should be safe.”