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In April, we reported on the dangers of Brazilian butt lifts (BBLs), and what makes South Florida a hotspot for BBL-related deaths. In this report, we follow up on what has happened since plastic surgeons began raising concerns about the procedure's safety and Florida's medical board intervened.

Following a swath of deaths tied to gluteal fat graft procedures -- known as BBLs -- in Miami, plastic surgeons, physician groups, and Florida's medical board grappled with how to make the procedure safer. Now, Florida has a standards of care for the risky procedure, where fat is suctioned from a patient's midsection and reinjected into the upper buttocks.

"Our community feels very strongly about this," Pat Pazmiño, MD, a plastic surgeon and owner of Miami Aesthetic, told 番茄社区app. Pazmiño showing that BBL deaths were concentrated in South Florida, and is a director with the Florida Society of Plastic Surgeons, which helped recommend elements of the bill. "The last thing that we want is for plastic surgery to get a black eye, and more importantly, [we want] to protect all the patients that receive these procedures."

In recent years, patients who underwent BBLs have died of pulmonary fat embolism (PFE) -- where fat particles enter a blood vessel and block it -- at alarmingly high rates.

Concerned surgeons and other experts found that these PFEs were mostly happening when a surgeon deposited fat into the deeper gluteal muscle instead of the subcutaneous fat on its surface, injuring blood vessels or injecting straight into them. The procedure is often performed "blind," meaning the surgeon cannot see exactly where under the skin their cannula tip ends.

Florida's Board of Medicine in 2019 and 2022. Both were temporary measures, requiring injection only into the subcutaneous fat layer, the use of ultrasound guidance, and a limit of three gluteal fat grafting procedures per day. The Board had planned to implement permanent rules, but once the bill, HB 1471, passed .

In a first for plastic surgery, Pazmiño said, the bill mandates certain precautions when performing gluteal fat grafting. It went into effect on July 1. New clinics must have a health department inspection before being registered. Surgeons must meet patients in person at least a day before their scheduled procedure, and can't perform BBLs on more than one patient at a time. Physicians must also use ultrasound to guide their cannula when fat grafting, and they may not delegate fat extraction or grafting to other staff.

A state law simply packs more punch than a medical board's rule, Pazmiño said. "I think it raises awareness to everyone that it's not okay ... if you're a receptionist and the surgeon hands you the cannula. Now, you know very well that both of you are breaking the law."

The new law targets practices favored by clinics one surgeon referred to as "chop shops." These operations, many of them concentrated across one stretch of a main road in Miami, profited from speed and volume, scheduling many procedures per day and charging far less than average.

Mark Mofid, MD, who runs his own plastic and reconstructive surgery practice in San Diego, authored one of the BBL death rates. He told 番茄社区app he once spoke to a colleague working at one such clinic who told Mofid he did 10 to 12 BBLs a day, for around $3,000 to $3,500 each (the was $4,807).

"There's only a certain number of hours a day where you can do the procedure. So realistically, [the new law] probably does limit surgeons to some extent," Mofid said.

According to medical board disciplinary hearings and other reports, physicians at these clinics might not meet a patient until the day of the procedure, and had assistants or uncredentialed staff perform liposuction or other parts of the procedure unsupervised, maximizing the number of procedures performed as they moved between rooms.

Now, patients and doctors can develop the kind of relationship Pazmiño said is critical for patient safety. "Surgery is not the 2 hours that you spend in the operating room," he said. "It's all about making a relationship and a bond between the surgeon and the patient beforehand. Then, once that's established, the surgeon understands what the goals are to perform the surgery, and most importantly, to take care of the patient afterwards."

But while the legislation is an important step forward, Mofid said, it might just push the problem elsewhere.

"It certainly makes things safer in Florida, but it's not a national law," Mofid told 番茄社区app. "I think it's likely that now that Florida is becoming a more highly regulated state, that people are just going to move the business operations elsewhere."

Nowhere else in the U.S., however, had as many complications or deaths. "South Florida, up until now, had been the most dangerous place to receive a BBL," Pazmiño said. "And we hope that with the passage of this law educating surgeons and patients, that we have now elevated the standard of care, and we hope to be one of the safer places to perform the surgery."

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