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Editorial

A Changing Paradigm: The Brazilian Butt Lift Is Neither Brazilian Nor a Lift—Why It Needs To Be Called Safe Subcutaneous Buttock Augmentation

Del Vecchio, Daniel A. M.D., M.B.A.; Rohrich, Rod J. M.D.

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Plastic and Reconstructive Surgery: January 2020 - Volume 145 - Issue 1 - p 281-283
doi: 10.1097/PRS.0000000000006369
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In 1996, the Learning Channel featured a Brooklyn board-certified plastic surgeon who liposuctioned fat from a patient and injected it into her gluteal region. The patient was from Brazil, and the segment was entitled, “Building the Brazilian Butt.” Herein lies the true and accurate origin of the term “Brazilian butt lift.”1

Contrary to urban legend,2 the Brazilian butt lift was not invented by Ivo Pitanguy. It is true that the legendary and prominent Professor Pitanguy devoted his entire life to plastic surgery and is the most well-known aesthetic surgeon in the history of our field. His contribution to the buttock dates back to 1964 (published in Plastic and Reconstructive Surgery), on how to treat “buttock sag.”3 Inspection of the original source document describes a dermolipectomy technique, not liposuction with fat transplantation.

If Pitanguy were alive today, he would likely be deeply concerned at how the media and the public have attached “Brazilian” to an intramuscular gluteal fat grafting operation that has serious technical flaws and is outright dangerous to perform. Such hyperbole and misinformation are typical of the Brazilian butt lift story and how the media perform “reality makeovers” of their own to appeal to what is popular and trendy.

If Brazilian butt lift is not Brazilian, neither is it a lift. It is a complete misnomer! There is no removal of skin and no lifting in the true sense of the word. Finally, its scope does not confine itself to the buttocks; rather, it is a reshaping of a confluence of aesthetic units—the lower back, the hip, the posterior thigh, and the gluteal region4—that affords expertise and good results in gluteal surgery. Not Brazilian, not a butt, not a lift.

Furthermore, in 1995, Mexico’s Guerrerosantos extrapolated from McGraw and Arnold5 that if muscle flaps had better blood flow than fascia flaps, fat transplanted into a muscle should have a better blood supply and therefore should have a better chance of survival. The work by Guerrerosantos et al. in rats, published in Aesthetic Plastic Surgery,6 suggested dismal fat survival when fat was placed into subcutaneous fat, whereas fat placed in muscle survived much better.

This experimental finding has never been proven in humans. No one has ever shown long-term volume maintenance of fat grafted to the lip, a recipient site rich in blood flow, whereas numerous clinical surgeons report successful large-volume maintenance when fat is placed into the recipient fat compartments of the breast and buttocks.7–9 The “muscle is better” fallacy is based on the confusion between blood flow and oxygen tension. Although blood flow may be better in a muscle, the oxygen tension in your subcutaneous fat is the same as the oxygen tension in your brain. Adipocyte survival is based on oxygen diffusion and gradients, and oxygen tension is the key determinant in fat survival, not blood flow.

Despite this, the scientific premise of Guerrerosantos et al. permeated through fat grafting. It became commonplace, indeed laudable for surgeons to graft in the gluteal muscle. Fast forward to 2019, and we find ourselves in a world where intramuscular gluteal fat grafting is condemned by many plastic surgical societies and some countries outlaw the Brazilian butt lift altogether.10,11

The Brazilian butt lift operation has a fatal trilogy: (1) it is based on a false story and urban myth; (2) it is incorrectly named; and (3) it is based on flawed science and an unawareness of dynamic anatomy. Therefore, this name must be removed from the new and updated literature emphasizing patient safety and outcomes with current science and technology.

What was responsible for the Brazilian butt lift’s rise to stardom may also serve as its downfall. In historic parallelism, the great Julius Caesar rose to power by means of the support of the Roman Senate, who eventually assassinated him. We in turn, will look to the media, in grand senatorial fashion, to perform the same “brutal” deed to Brazilian butt lift.

Recently, both on the podium and in print, we have proposed to indict dangerous aspects of gluteal surgery to modify and salvage the procedure, as opposed to banning the operation as a whole.12 Because of evidence-based collaboration,13–16 placing fat in the muscle has been successfully forbidden by our societal leaders and colleagues.

Safe subcutaneous buttock augmentation is a name that aptly describes the procedure without prejudice or panache. Safe subcutaneous buttock augmentation involves inserting fat in the subcutaneous position only, using techniques such as expansion vibration lipofilling,17 in a conscious manner so that every stroke of the cannula is felt by the nonoperating hand to stay subcutaneous, not unlike the maneuvers we use in liposuction. We therefore propose the name change from Brazilian butt lift to safe subcutaneous buttock augmentation.

To ensure safe and aesthetically effective execution of safe subcutaneous buttock augmentation, we also propose training courses similar to what we have done when we introduced other new technology in lasers and in ultrasound-assisted liposuction. These courses should be taught by the true experts in this area and by those board-certified plastic surgeons who have mastered the safety and efficacy of this technique. If even one more patient dies at the hands of a board-certified plastic surgeon member of the American Society of Plastic Surgeons, the American Society for Aesthetic Plastic Surgery, or the International Society of Aesthetic Plastic Surgery, we have all failed in our duty to continue to protect patients.

After all, we are all physicians first and foremost before we are plastic surgeons. We all have taken the Hippocratic Oath: “First do no harm.” We must always put patient safety and public health first as we always have done in the past when new techniques and technology have been introduced to us. In the final analysis, plastic surgery has always had its roots in innovation, but today we must also be rooted in advancing patient safety and outcomes. We must methodically teach these new techniques and technology not only in our residency programs but to all board-certified plastic surgeons performing this procedure going forward. The time is now to do so with structured hands-on educational courses by those who have advocated safety in this procedure. Safe subcutaneous buttock augmentation—it is long overdue to give this new safe technique the correct name as we begin this uniform training process for all in plastic surgery. This could represent the new model for how plastic surgery innovations are brought forward into the clinical arena for maximal patient safety and outcomes.

For safety is not a gadget but a state of mind.

—Eleanor Everet

REFERENCES

1. History of the Brazilian butt lift in Brooklyn: Dr. Leonard Grossman. Available at: https://www.youtube.com/watch?v=mY6xpzoF4EU.
2. Zuckerman Plastic Surgery. History of the Brazilian butt lift (BBL). Available at: https://www.zuckermanplasticsurgery.com/history-brazilian-butt-lift/.
3. Pitanguy I. Trochanteric hypertrophy. Plast Reconstr Surg. 1964;34:280–286.
4. Centeno RF. Gluteal aesthetic unit classification: A tool to improve outcomes in body contouring. Aesthet Surg J. 2006;26:200–208.
5. McCraw JB, Arnold PG. McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps. 1987.Norfolk, Va: Hampton Press Publishing Company.
6. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P. Long-term survival of free fat grafts in muscle: An experimental study in rats. Aesthetic Plast Surg. 1996;20:403–408.
7. Petit JY, Lohsiriwat V, Clough KB, et al. The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: A multicenter study. Milan-Paris-Lyon experience of 646 lipofilling procedures. Plast Reconstr Surg. 2011;128:341–346.
8. Khouri RK Jr, Khouri RK. Current clinical applications of fat grafting. Plast Reconstr Surg. 2017;140:466e–486e.
9. Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous fat transplantation: A clinical radiographic study. Plast Reconstr Surg. 2011;127:2441–2450.
10. American Society of Plastic Surgeons. Plastic surgery societies issue urgent warning about the risks associated with Brazilian butt lifts. Available at: https://www.plasticsurgery.org/news/press-releases/plastic-surgery-societies-issue-urgent-warning-about-the-risks-associated-with-brazilian-butt-lifts.
11. British Association of Aesthetic Plastic Surgeons. The bottom line: Popularity of risky buttock enhancement procedures leading to costliest emergency complications. British surgeons warned not to perform procedure until more data is collected. Available at: https://baaps.org.uk/about/news/1630/the_bottom_line.
12. Del Vecchio D. Common sense for the common good: Staying subcutaneous during fat transplantation to the gluteal region. Plast Reconstr Surg. 2018;142:286–288.
13. Villanueva NL, Del Vecchio DA, Afrooz PN, Carboy JA, Rohrich RJ. Staying safe during gluteal fat transplantation. Plast Reconstr Surg. 2018;141:79–86.
14. Turer DM, Rubin JP. Commentary on: Safe gluteal fat graft avoiding a vascular or nervous injury: An anatomical study in cadavers. Aesthet Surg J. 2019;39:185–186.
15. Del Vecchio DA, Villanueva NL, Mohan R, et al. Clinical implications of gluteal fat graft migration: A dynamic anatomical study. Plast Reconstr Surg. 2018;142:1180–1192.
16. Wall S Jr, Delvecchio D, Teitelbaum S, et al. Subcutaneous migration: A dynamic anatomical study of gluteal fat grafting. Plast Reconstr Surg. 2019;143:1343–1351.
17. DelVecchio DA, Wall SJ. Expansion vibration lipofilling: A new technique in large volume fat transplantation. Plast Reconstr Surg. 2018;141:639e–649e.
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