Buttock augmentation by fat grafting, also commonly known as the Brazilian Butt Lift (BBL), is a surgical procedure during which fat is transferred from an area of the patient’s body to his or her buttocks to add volume and shape. BBL has been the “on-demand” surgical procedure over the past years, with a 12% global increase in just one year between 2016 and 2017¹.

The first alarm sounded in 2015 after a study conducted in Colombia and Mexico which analyzed cases of fatal fat embolisms following gluteal lipoinjection procedures². Further investigation discovered similar complications and deaths on an international scale, amounting to a startling mortality rate of one death out of 3000, the highest rate of all aesthetic procedures³. In response, an international task force of plastic surgeons released a formal call to action for patient safety in gluteal fat grating.

What are be the recommended approach for buttocks augmentation with fat graft? The IMCAS team reached out to a team of fat graft experts and plastic surgeons for their insight into safe practice.

UNDERSTANDING THE ANANTOMY BEHIND

Dr Sebastien Garson, plastic surgeon and president of the French Society of Aesthetic Plastic Surgery (SOFCEP) reiterates how crucial it is to understand that underneath the seemingly simple structure of the buttocks lies a complex network of arteries and nerves. The layers of the buttock that pertain to BBL procedures are namely the subcutaneous, deep fat layers, and muscle layer. According to Dr Garson, this latter layer is the region that interests us most because within the muscle and beneath it lies some deep structures that we do not want to touch - significant arteries, such as the superior and inferior gluteal perforators, the sciatic nerve and other large vessels.

But why are these structures, which are securely buried under layers of fat and muscle, still so susceptible during fat grafting? It’s the location in which these veins are situated, explains Dr Daniel Del Vecchio, plastic surgeon and expert in buttocks augmentation. The problem occurs when the fat is injected past the fascia of the gluteus maximus. In a recent study⁴ he suggested that when fat enters the muscle past the fascia, the fat migrates through to the sub-muscular danger zone where all the deep structures are found. And according to Dr Del Vecchio, here starts ticking the time bomb because the superior arterial vein (SGV) is a fragile vein that needs room to expand, for it expands four to five times its normal width; however, if fat migrates to these sub-muscular cavities and the SGV gets stretched, the fragile vein tears, opening itself up for a fat embolism.

TECHNIQUE TIPS AND TRICKS TO REMEMBER

With the danger zones and delicate areas to avoid during the procedure in mind, what are be the recommended approach for buttocks augmentation with fat graft? The first and foremost consensus between the three advising surgeons is choosing the adequate patient because the decision on whether or not to proceed with buttocks fat grafting should be based on the patient’s BMI. The patient must have sufficient autologous fat to harvest. If the patient is deemed fit for the fat graft treatment, there are a few preventative measures to follow to minimize risks. “Give antibiotic prophylaxis [and maintain] optimal clinical management during the perioperative period to avoid hypovolemia and hypothermia,” advised Dr Alexandra Conde Green, plastic surgeon at the University Hospital in Newark, “and follow up with prophylaxis for deep venous thromboembolism post-operation.”

Pr Katarina Andjelkov, professor and practicing plastic surgeon in Belgrade, explained that for her patients she performs a tumescent infiltration prior to the lipoaspiration. Once harvested, the fat is purified in a closed system in order to obtain uniform grafts, free of oil, free fatty acids and blood, as the presence of free fatty acids may favor the appearance of microscopic fat embolism. “My key tip here is to ensure that patients are hydrated adequately during the whole procedure.” she added.

The aforementioned anatomy for buttocks fat grafting indicates that the subcutaneous plane – the fatty layer between the skin and muscle – is considered the safe zone. First measure of precaution, according to Dr Conde Green, is using a blunt tip cannula with a diameter of 3mm or more so that it cannot accidently graze and perforate a vein. The tip of the cannula should always be pointing upward and in motion so as to avoid the muscle all together. This technique was further supported by Dr Andre Ferrao Vargas who shared his personal technique, “To transfer the fat to perform a BBL, my routine is to use 3.0 cannulas in the adipose tissue and utilize multiples tunnels. Maximum volume to each gluteal area should be around 300 to 400 cc to improve fat integration avoiding excessive pressure over the fat.” But both experts emphasize the importance of becoming familiar with the anatomy and acquiring experience with the procedure before any “personalized modifications”.

THE BOTTOM LINE FOR SUCCESS

The consulted physicians agree that BBL should be the method of treatment choice only if you feel comfortable with the procedure, and as mentioned above, only if the procedure suits the patient’s morphology. As it is the case with any surgical or even non-surgical procedure, the key to avoiding fatal mistakes is knowing the anatomy and evidence-based techniques for a safe and successful practice.

For an in-depth analysis of the anatomy and procedure of Buttocks augmentation from experts, watch Dr Garson’s dissection on a cadaver or Dr Del Vecchio’s lecture on IMCAS Academy!

References
1. ISAPS International Survey on Aesthetic/Cosmetic Procedures Performed in 2017. International Society of Aesthetic Plastic Surgery, 2017. https://www.isaps.org/wp-content/uploads/2018/10/ISAPS_2017_International_Study_Cosmetic_Procedures.pdf
2. Cárdenas-Camarena, L., et al. "Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong?” Plastic and Reconstructive Surgery 136.1(2015):58-66. https://www.ncbi.nlm.nih.gov/pubmed/26111314
3. Mills, D., Rubin, P.J. & Saltz, R. “Multi-Society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique.” ISAPS News 12.1:8-9. https://www.isaps.org/wp-content/uploads/2018/03/ISAPSNews_Vol12.1.pdf
4. Del Vecchio, D.A., et al. “Clinical Implications of Gluteal Fat Graft Migration: A Dynamic Anatomical Study.” Plastic and Reconstructive Surgery 142.5(2018):1180-1192. https://www.ncbi.nlm.nih.gov/pubmed/30102666