Dr. Dirk Lazarus

Plastic, Reconstructive & Cosmetic Surgeon

MBChB (UCT), FCS (SA) Plast & Recon Surg

Butt Augmentation

Butt augmentation or the Brazilian butt lift (BBL) is a procedure to enhance the shape and size of the butt. The procedure entails a liposuction to harvest fat which is then treated and injected into the butt as a fat graft. Liposuction on its own sometimes provides sufficient butt improvement without the need for grafting. Removal of fat from above (love handles, lower back) and below (saddlebags, thighs) can enhance relative butt projection. For even more butt projection, the fat is injected into the buttocks, but this does carry risks – see below.

The alternative is Butt implants (which I do not offer in my practice). Because you sit on them, butt implants are less successful than breast implants.

BBL is performed with liposuction as day case surgery in my own facility, Tranquillity Clinic. The details of the anaesthesia, surgery, complications and recovery are as for liposuction. When doing a liposuction for fat grafting I harvest the fat with syringes. This is more gentle on the fat and allows the fat to be collected. Fat harvest is done from the usual liposuction areas and once collected the fat is treated (the tumescent or wetting fluid removed by gravitation or centrifuge) and transferred to smaller syringes for injection into the butt. Injection of the fat is done through 3 or 4 small (<5 mm) incisions per side. These usually heal with inconspicous scarring. The average volume of fat injected per side is around 300 to 400 ml. The volume provides augmentation (enhancement) and some degree of lift. Recovery and complications are as for liposuction with the additional factor that your butt will be tender, bruised and sore. It will be difficult to sit.


Multiple syringes of fat ready for injection

The fat is transferred as a large volume fat graft. For it to survive it needs to acquire a blood supply, a process called vascularisation which takes a few weeks to months. In the interim, the fat lives by a process of diffusion (diffusion of nutrients to and waste products from the fat cells), but this is sub-optimal and some of the fat cells will die. It is unknown how much of the fat will survive, perhaps around half to three quarters, and there is therefore some unpredictability about the procedure. In fact it will appear that a lot of the fat is lost and then usually it sort of fills up again to some extent as the grafted fat becomes vascularised. Nevertheless, in this early period, hard areas may occur and these can also form cysts or collections of fluid due to fat necrosis (fat cells dying due to insufficient nutrition). Later complications include asymmetry, irregularity or inadequate correction. Nevertheless butt fat grafting combined with liposuction can give satisfactory results.

Download Sunday Times Article, 22 January 2017 (.PDF)

Multi-Society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique
1 Feb 2018
Dear Colleagues,
An Inter-Society Gluteal Fat Grafting Task Force** has analyzed deaths from gluteal fat injection (“Brazilian Butt Lift” or “BBL”) and offers the following advisory statement:
The death rate of approximately 1/3000 is the highest for any aesthetic procedure. In 2017, there were three deaths in the state of Florida alone. Every surgeon performing BBLs should immediately reevaluate his or her technique.
Some patients have died when their surgeon said they had injected into the subcutaneous fat layer, but all autopsies of deceased BBL patients have had these findings in common: 1) fat in the gluteal muscles; 2) fat beneath the muscles; 3) damage to the superior or inferior gluteal vein; 4) massive fat emboli in the heart and/or lungs. No post mortem has yet shown a case of death with fat only in the subcutaneous space; this means that surgeons have injected more deeply than they had intended. The mechanism of death is presumed to be high pressure extravascular grafted fat entering the circulation via tears in the large gluteal veins with subsequent embolization to the heart and lungs.
The task force, therefore, offers these suggestions*:
1) Stay as far away from the gluteal veins and sciatic nerve as possible. Fat should only be grafted into the superficial planes, with the subcutaneous space considered safest. If the aesthetic goal requires more fat than can be placed in the subcutaneous layer the surgeon should consider staging the procedure rather than injecting deep.
2) Concentrate on the position of the cannula tip throughout every stroke to assure there is no unintended deeper pass, particularly in the medial half of the buttock overlying the critical structures.
3) Use access incisions that best allow a superficial trajectory for each part of the buttock; avoid deep angulation of the cannula; and palpate externally with the non-dominant hand to assure the cannula tip remains superficial.
4) Use instrumentation that offers control of the cannula; avoid bendable cannulas and mobile luer connections. Vibrating injection cannulas may provide additional tactile feedback.
5) Injection should only be done while the cannula is in motion in order to avoid high pressure bolus injections.​​​​​​​
6) The risk of death should be discussed with every prospective BBL patient.​​​​​​​
7) These are links to three helpful articles:
Research projects overseen by the task force and funded by The Plastic Surgery Foundation (PSF), Aesthetic Surgery Education and Research Foundation (ASERF) and International Society of Aesthetic Plastic Surgery (ISAPS) are underway. They will correlate deep and topographical anatomy, define danger zones, and try to understand the mechanism of embolization. The ability to safely perform this procedure in the future is dependent upon this research.
Members of the task force have also assisted coroners during autopsies, and this has provided invaluable safety information. If you become aware of a fatality, immediately contact the task force co-chairs care of Keith Hume, executive director of The PSF, at khume@plasticsurgery.org.
Your societies will keep you updated with all developments.
Dan Mills, MD
Gluteal Fat Grafting Task Force co-chair
J. Peter Rubin, MD
Gluteal Fat Grafting Task Force co-chair
Renato Saltz, MD
Gluteal Fat Grafting Task Force co-chair
* The information in this Advisory Statement while setting forth the strong recommendations of the Task Force, should not be considered inclusive of all methods of properly performing buttock augmentation with fat transfer or as a statement of the standard of care or as a mandate to strictly follow the recommendations of the Task Force.
This Advisory Statement is not intended to substitute for the independent professional judgment of the treating plastic surgeon nor for the individual variation among patients.
The Members of the Multi-Society Task Force and the participating societies assume no responsibility or liability for injury arising out of any use of the information contained in this Advisory Statement.
** The Inter-Society Gluteal Fat Grafting Task Force represents leading clinical plastic surgery societies, including the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), and the International Society of Aesthetic Plastic Surgeons (ISAPS). Additionally, two scientific societies, the International Society of Plastic & Regenerative Surgeons (ISPRES) and the International Federation for Adipose Therapeutics and Science (IFATS) are represented and provide scientific support. The efforts of the Task Force build upon a foundation of important work by the Aesthetic Surgery Education and Research Foundation (ASERF), the American Society of Plastic Surgeons (ASPS) Regenerative Medicine Committee, and the International Society of Aesthetic Plastic Surgery (ISAPS) Patient Safety Committee. The Task Force is an unprecedented collaborative effort to address a major patient safety concern, investigate factors that lead to increased risk with gluteal fat grafting, perform scientific studies to improve safety, and educate plastic surgeons.

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We have met before – about 10 years ago – I was kicked in the face by my horse and you performed the surgery (rather brilliantly). Now I am interested in something else…

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