Commentary on: Brazilian Butt Lift–Associated Mortality: The South Florida Experience

See the Original Article here.

It has been over 5 years since the Aesthetic Surgery Education and Research Foundation (ASERF) and concerned plastic surgeons, pathologists, and others serving on the Gluteal Fat Grafting Task Force first issued warnings about pulmonary fat embolisms associated with intramuscular fat grafting of the buttocks and published those findings in Aesthetic Surgery Journal.¹ Drs Pazmiño and Garcia’s recent article describing the South Florida experience over the last decade, with particular emphasis on the last 5 years after the widespread dissemination of warnings, reflects on the effective measures proposed by the Task Force to reduce mortality.²

The business practice of budget, high-volume South Florida clinics, where 92% of all deaths from fat grafting have occurred due to fat pulmonary embolisms, appears to contribute to the perception that Miami has become the epicenter of Brazilian butt lift (BBL)-associated mortality. Absolutely no one can effectively argue that the 14 deaths in these Miami clinics since the ASERF recommendations were issued and the 12 deaths since the 2019 “subcutaneous-only injection” rule was enacted by the Florida Medical Board are acceptable, or that any aesthetic procedure is worth this kind of loss of life. The dangers inherent to medical tourism typically associated with foreign low-cost and high-volume destinations clearly exist in this US microcosm described by the authors. The authors are careful to qualify that not a single BBL fat pulmonary embolism death in the area has ever been attributed to an American Board of Physician Specialties (ABPS)-certified surgeon working in a traditional accredited private practice or academic setting.

The plastic surgery societies have taken a rational position and have issued a recent statement supporting the Florida Medical Board emergency rulings that require the use of ultrasound to monitor the location of the tip of the cannula while fat is injected, and limit gluteal fat procedures to 3 per day per surgeon.³ They have also highlighted that operative assistants should not perform critical parts of the procedure. The most telling statistics from the South Florida experience are also the most terrifying: short surgical procedures lasting 90 minutes in facilities where a surgeon (or presumably assistants under their supervision) may perform as many as 12 BBL procedures in a day for as little as US$2900 each (including the anesthesia and facility charge) at presumably nonaccredited clinics commercially owned and operated.

There may be valid criticisms of the Florida Medical Board restrictions on the practice of BBL if looked at in a vacuum. Limiting a surgeon to 3 gluteal fat procedures a day presumably allows that same surgeon to perform additional procedures such as breast augmentation or liposuction without fat grafting. A patient in the type of Miami facility described by the authors, often referred to as “chop shops,” should feel equally unsafe having any medical procedure performed, not just BBLs. It is unlikely that a board-certified plastic surgeon could conceivably perform BBL procedures routinely in 90 minutes unless multiple assistants are involved.

The required use of ultrasound imaging to confirm that the surgeon is within a safe anatomic plane is also a sensible response. There is, however, a reasonable critique against the requirement that imaging need be continuous. Surgeons rely on both hands for proprioceptive control, which is lost when 1 hand is holding the ultrasound probe. There is a tendency for the 1-handed surgeon to bolus the fat being grafted under these circumstances into a pool of dead fat within the central zone where imaging is easiest and not as much laterally, a safer area to graft (Constantino Mendieta, MD, personal communication, August 19, 2022).

Perhaps the most obvious and effective solution to enhance the safety of the BBL procedure in South Florida would be to ban the type of business practices that have led to this catastrophe. Florida has no laws that prohibit the corporate practice of medicine as exist in many states. As a general rule, physicians and other healthcare providers in Florida may be employed by or contracted by corporations and other businesses owned and controlled by nonphysicians. A nonphysician, for example, may not own a medical practice in California.⁴ It is likely that most board-certified plastic surgeons would agree that physicians should not perform medical procedures outside the scope of their own specialties. If plastic surgery practices employing board-certified plastic surgeons were required to be owned and operated by practicing and board-certified plastic surgeons, it would be difficult to imagine how the self-policing and liability inherent to this structure would not significantly enhance patient safety. It would be redundant to state emphatically that no one other than a board-certified plastic surgeon (and certainly not an assistant) should perform a BBL (or any other plastic surgery procedure) in a facility owned by board-certified plastic surgeons.

As the tragedies in Miami have proven, a BBL, which is not an especially sophisticated procedure, can be dangerous when consistently performed inexpertly. In 1965, consumer advocate Ralph Nader published his landmark book Unsafe at Any Speed: The Designed-In Dangers of the American Automobile.⁵ This book was widely credited with the creation of the United States Department of Transportation in 1966 and the National Highway Traffic Safety Administration in 1970. Collectively and as a specialty, we should look at the current situation as an opportunity to improve patient safety and to self-regulate before restrictions or outright bans are imposed upon us by others.

Disclosures

Dr Mofid is the former chairman of the Aesthetic Surgery Education and Research Foundation (ASERF) Gluteal Fat Grafting Task Force.

Funding

The author received no financial support for the research, authorship, and publication of this article.

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