May 16, 2019A new anatomic study highlights critical technical issues to ensure safe performance of the increasingly popular "Brazilian butt lift" – a procedure using the patient's own fat to augment and improve the appearance of the buttocks. The study appears in the May issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

"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 Boston plastic surgeon who developed the protocol and is a leading  global expert in this area. A video commentary by coauthor Rod J. Rohrich, MD, of Dallas Plastic Surgery Institute strongly emphasizes the need to avoid any fat injection into the gluteal muscle itself in order to prevent serious complications.

New Evidence on Safe Injection Technique for Gluteal  Fat Grafting

Fat grafting has become a popular technique of buttock enhancement for patients who want a fuller, shapelier appearance, without the use of implants. In this procedure, fat obtained by liposuction from one part of the body (such as the abdomen) is processed and injected to enhance the gluteal area. According to ASPS statistics, more than 24,000 buttock augmentation with fat grafting procedures were performed in 2018 – an increase of 19 percent over the previous year.

However, there is growing concern about serious complications resulting from this procedure. A 2015 paper in Plastic and Reconstructive Surgery reported a series of 22 deaths in patients undergoing gluteal fat injection in Colombia and Mexico. The deaths were caused by pulmonary embolisms: collections of fat blocking the arteries in the lungs.

In 2018, the ASPS joined with other plastic surgery specialty societies in issuing an urgent warning regarding the "alarming" number of deaths related to gluteal fat augmentation. An advisory issued to plastic surgeons (PDF link) outlined steps to ensure that fat is injected only under the skin – never into the muscle.

To build the evidence base for this recommendation, Drs. Del Vecchio and Rohrich and colleagues performed a cadaver study to evaluate patterns of fat spread in the gluteal area after injection. Four approaches were evaluated, simulating injection techniques that might be used by plastic surgeons performing gluteal fat grafting.

In three of the four injection techniques, the spread of the simulated fat was mainly limited to the subcutaneous area, immediately beneath the skin. Even when small perforations were made in the fascia – the connective tissue layer separating the muscle from the subcutaneous space – there was little or no spread of the simulated fat into the muscle itself.

Even with multiple perforations and high injection pressures, the muscle fascia prevented the simulated fat from crossing into the muscle. The researchers discuss the process of "subcutaneous migration" that keeps injected fat from spreading into or under the gluteal muscle, if injected into the subcutaneous "safe zone."

The findings were different in the fourth scenario, where multiple punctures were made in the gluteal muscle. In this situation, large amounts of proxy fat were found under the muscle – demonstrating that "deep intramuscular migration" had occurred. Once fat has migrated into the submuscular space, damage to the veins in that area could allow fat cells to enter the circulation, with a potential risk of pulmonary embolism.

The experimental study provides an important piece of evidence supporting previous recommendations to ensure the safety of the Brazilian butt lift. The researchers conclude: "These persuasive findings are profound enough to propose a new standard of care: no subfascial or intramuscular injection should be performed, and all injections should be done exclusively into the subcutaneous tissue."

In his video commentary, Dr. Rohrich adds: "If you are considering buttock augmentation procedures, please do so safely. Start today by finding a board-certified plastic surgeon and an accredited facility in your area; bring in a copy of the safety advisory…and discuss the safest way to achieve the results you want."

Click here to read "Subcutaneous Migration: A Dynamic Anatomical Study of Gluteal Fat Grafting"

DOI: 10.1097/PRS.0000000000005521

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Dr. Rohrich is Editor-in-Chief of Plastic and Reconstructive Surgery.

Plastic and Reconstructive Surgery® is published in the Lippincott portfolio by Wolters Kluwer.

About Plastic and Reconstructive Surgery

For more than 70 years, Plastic and Reconstructive Surgery® ( has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. The official journal of the American Society of Plastic Surgeons, Plastic and Reconstructive Surgery® brings subscribers up-to-the-minute reports on the latest techniques and follow-up for all areas of plastic and reconstructive surgery, including breast reconstruction, experimental studies, maxillofacial reconstruction, hand and microsurgery, burn repair and cosmetic surgery, as well as news on medico-legal issues.

 About ASPS

The American Society of Plastic Surgeons is the largest organization of board-certified plastic surgeons in the world. Representing more than 7,000 physician members, the society is recognized as a leading authority and information source on cosmetic and reconstructive plastic surgery. ASPS comprises more than 94 percent of all board-certified plastic surgeons in the United States. Founded in 1931, the society represents physicians certified by The American Board of Plastic Surgery or The Royal College of Physicians and Surgeons of Canada.

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Journal Link: Plastic and Reconstructive Surgery