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In surgical circles, the Brazilian butt lift (BBL) is known as the deadliest aesthetic procedure ever performed, and despite several calls to improve outcomes, recent data suggest mortality is only getting worse -- especially in South Florida.

Sunny, image-conscious Miami is home to a substantial proportion of the country's high-volume, low-cost clinics where U.S. patients flock for the procedure. Despite widely publicized deaths and changes in rules about performing the procedure in Florida, researchers say it's still causing harm.

"You have people from all over the United States coming to Florida, and they have these complications, and unfortunately, they either have to receive hospital care or they perish," Pat Pazmiño, MD, a plastic surgeon and owner of Miami Aesthetic, told 番茄社区app. "And it's affecting the whole country."

Pazmiño and colleagues of the factors that make South Florida a particularly dangerous place for the BBL, which is also known as gluteal fat grafting. They analyzed 25 BBL deaths resulting from pulmonary fat embolism (PFE), where fat globules travel through the bloodstream and cut off circulation. Blocked pulmonary vessels can lead to respiratory failure and death.

They found most of the deaths occurred after plastic surgery associations tried to make the procedure safer.

'The Most Dangerous Aesthetic Procedure Ever Performed'

The Brazilian butt lift became popular over the past 2 decades, with procedures surging more than 800% over the last decade alone, from in 2011 to in 2021, according to data from the American Society for Aesthetic Plastic Surgery.

Whereas in the '90s, women prized big breasts and a thin silhouette, now wider hips and a fuller buttocks are the ideal, plastic surgeons told 番茄社区app.

"Forty years ago, it may have been Kate Moss or Pamela Anderson," M. Mark Mofid, MD, associate clinical professor of plastic surgery at the University of California San Diego, told 番茄社区app. "Now it's Jennifer Lopez and it's Kim Kardashian, and they look very different from the America that existed forty years ago."

During a BBL, a surgeon uses liposuction to remove fat from the abdomen, flanks, or back of an anesthetized patient. The surgeon then uses a syringe attached to a cannula to reinject or "graft" the reserved fat into the buttocks. The cannula is inserted repeatedly deep under the skin, fanning out from a few small incision points to distribute the fat across different areas.

It's known as a "blind" procedure, and surgeons can inadvertently injure the large vessels in the muscle or even inject fat directly into those vessels if the cannula goes too deep. The fat can travel via the bloodstream to the heart and lungs, and deaths from such a pulmonary fat embolism can occur within hours of the procedure, or even on the operating table.

Sometimes, this has happened when a patient was turned from a prone to a supine position on the operating table, putting pressure on the lower buttocks, according to Pazmiño's analysis.

It wasn't until recently that plastic surgeons realized some BBL procedures were going very wrong. Mofid started performing BBLs at a time when only two other surgeons in the country were doing them. But as their popularity grew, he became alarmed by reports of BBL-related deaths in journals and conferences.

Given those concerns, Mofid and a group of surgeons formed the Aesthetic Surgery Education and Research Foundation (ASERF). In 2017, they published one of the quantifying BBL deaths.

"What we found was just absolutely jaw-dropping and shocking," Mofid said. "We had determined that this was likely one of the most dangerous operations in the world, and certainly the most dangerous aesthetic procedure ever performed."

Of 692 plastic surgeons surveyed, 3% said they had had at least one PFE death, and 7% reported at least one PFE from gluteal fat grafting. Mofid and colleagues estimated the mortality rate for BBLs to be between one in 2,351 to one in 6,241. By comparison, cosmetic breast surgery has an of one in 72,000.

Arthur Perry, MD, a plastic surgeon at Lenox Hill Hospital in New York, said any death from an aesthetic procedure is alarming. "One death in a plastic surgeon's office and you pretty much want to retire from medicine," he said. "It's terrible."

"Remember, no one ever died of a skinny buttocks," Perry told 番茄社区app.

"It's not like you're [in] pulmonary failure, heart failure, or something like that, and we need to operate because you're going to die," he said. "The risk-benefit ratio has to be better in cosmetic surgery."

While the surgical literature shows that the vast majority of deaths from BBLs occur when a patient suffers a PFE, these events are hard to quantify because of different reporting standards for various state medical examiners. BBL complications are even harder to track, because of limited follow-up by clinics that perform them and few state reporting requirements.

Deaths Worse After Warnings

As Mofid and colleagues published their paper in 2017, the Miami-Dade County Medical Examiner had determined that PFE was indeed the cause of death for five patients who had died in South Florida that year.

The leaders of ASERF assembled a task force. They had plastic surgeons perform BBLs as they usually would on cadavers with color-coded fat, and then dissected them.

Based on the results, the task force issued that was widely distributed to members of plastic surgery societies. To avoid injuring blood vessels and risking PFEs, they warned, surgeons should only inject into the subcutaneous fat, and not inject at a downward angle. They should also use a stiff cannula instead of one that could bend and accidentally inject deeper.

A of plastic surgeons in 2019 revealed that the warning, and a wider public education campaign, had worked -- the BBL mortality rate appeared to have dropped to 1 in 14,952.

The Florida Board of Medicine also introduced a "subcutaneous-only injection" in 2019, alerting every physician in the state not to inject into the deep gluteal muscle fascia. If they did, they could face .

"One would assume that because of all these advances, BBL-related deaths would have decreased since 2019," Pazmiño and co-authors wrote in their recent study. "Unfortunately, in South Florida, the opposite happened."

From 2019 to 2022, there have been 12 deaths due to PFE following BBL in South Florida, according to Pazmiño and colleagues. Eight PFEs occurred in 2021 alone -- 6 of them were deaths.

Importantly, of the 25 BBL-related PFE deaths in South Florida from 2010 to 2022, the vast majority (23) were performed at what Pazmiño's study calls "high-volume budget clinics."

Budget Clinic Cluster

Pazmiño and colleagues mapped out the 25 deaths, revealing clusters of clinics, with the greatest concentration along 8th Street near the neighborhoods of Westchester and West Gables.

"Low-budget, high-volume" clinics lean heavily on social media and advertise BBLs for as little as $2,900, according to the paper. From a quick Google search, it's easy that offers a special payment plan of $27 per month for the procedure, and even a medical credit company to attract patients who might otherwise not be able to afford it.

Plastic surgeons 番茄社区app spoke with and Board of Medicine records where three BBL surgeons with PFE deaths were disciplined revealed the dangerous practices fueling them. The clinics were hiring contract physicians who rotated in and out of various clinics, performing as many as eight to 10 BBLs a day, according to Pazmiño's paper.

Experienced surgeons say this is not possible to do safely. Both Pazmiño and Mofid said it takes them 2.5 hours to do one BBL, and they schedule at most three in a day. "After 10 years, that's how efficient I've become," Pazmiño said.

Mofid said that at a Miami clinic his colleague has since left, the colleague had confided that he'd been performing an average of 11 BBLs a day.

"The only way you can do that is just blatant disregard for a patient," Mofid said. "I don't know how you could do that."

One surgeon, John Sampson, MD, who was banned from performing BBLs by the medical board, told the board his patient death happened -- at 8:31 p.m. , Sergio Alvarez, MD, said he barely remembered the patient he'd killed, according to a .

"It doesn't take a mathematical genius to figure out that they're doing something very wrong," Mofid said.

A 2021 investigation found that surgeons at one clinic were running multiple BBLs at the same time, rotating between rooms.

"What's happening in these clinics is that the board-certified surgeon is not doing the whole procedure, so they're letting non-doctors do the liposuction in the background," Pazmiño said.

Mofid said that while he can't prove it, "that's the only way that you can do it -- is by having someone who's not a physician do the case."

What surprised Pazmiño was that 69% of the surgeons behind the 25 deaths were board certified by the American Board of Plastic Surgery. Even though patients have learned to search for practices with board-certified surgeons, he said, the credential is not enough.

"We want to emphasize that board certification alone has not protected these patients," Pazmiño said.

Pazmiño said it would seem ridiculous, "If I told you, 'oh my gosh, yesterday I did the most beautiful shaped-breast [implant] in the parking lot, can you believe I had a problem afterwards?' And then you will say 'well, my God, you did it in the parking lot' and I would say, 'But I'm board certified!'"

He said, "Board certified is not enough."

Can BBLs Be Safer?

Florida's medical board, alarmed by the continuing deaths, passed a second, temporary in 2022. Surgeons would only be allowed to perform three BBLs per day and require ultrasound guidance to help limit their grafting placement to the subcutaneous space only.

The board recently proposed a more that would limit surgeons to five BBLs a day.

Surgeons who want to keep patients safe -- and uphold the field's reputation -- say they're not sure what the solution is.

"They told us to inject only into the fat, and the deaths continue. They told us to use ultrasound, and the deaths continue," said Perry, who has reviewed autopsies related to BBL PFE deaths and does not perform the procedure.

He's opening up a new practice in Manhattan, and will not allow BBLs there. "I feel it's just a procedure that at this point in time is too dangerous to do."

Pazmiño, who teaches the procedure, insisted that keeping grafts within the subcutaneous fat is safe.

Initially, Mofid agreed, but he's not so sure anymore. Less than a month ago, a doctor who used to do autopsies in Los Angeles County reached out to Mofid about four or five BBL patients he'd learned of who had died with microscopic fat in the lungs after fat grafting, instead of the larger pieces of fat they'd come to associate with PFE after BBL.

"Now, after talking to [the colleague], it's hard for me to absolutely state with 100% confidence that this was a completely safe operation, if it's done correctly," Mofid said.

He thinks enacting a law that prohibits non-board-certified plastic surgeons from running medical group practices would go a long way in protecting patients.

"The likelihood that enacting that legislation would save lives is very high," he said. "And I think that there would probably be zero mortalities in the state of Florida."

Stricter control of the procedure and more rigorous studies are also needed, Perry said. "I'm not wild about someone telling me how to operate," he said. "But I understand. I mean, this is an epidemic. There are hundreds and hundreds of deaths."

"I think there's no question," he added, "that this procedure should not be done in the United States."

Correction: Pazmiño's affiliations have been corrected. The number of deaths from PFE in 2021 in South Florida has also been corrected.

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