From real-time cannula tracking to video documentation, Dr. S. Alexander Earle explains how ultrasound is changing the way BBLs are performed.
As ultrasound-guided gluteal fat grafting gains traction across the specialty, many plastic surgeons are asking whether the technology represents an incremental improvement or a fundamental shift in how Brazilian butt lifts should be performed. Florida became the first state to mandate ultrasound guidance during BBL procedures, a move that followed years of scrutiny surrounding patient safety and fat placement techniques. Supporters argue that real-time visualization provides a level of certainty that traditional tactile feedback alone cannot match.
In this interview with Plastic Surgery Practice, S. Alexander Earle, MD, FACS, a double-board certified plastic surgeon and founder of Pure Plastic Surgery, who was an early adopter of ultrasound-guided BBLs, discusses why he incorporated the technology into his practice, how it has changed surgical decision-making, the realities of adoption and training, and why he believes ultrasound guidance is on track to become the standard of care for gluteal fat grafting.
Plastic Surgery Practice: You were an early adopter of ultrasound-guided gluteal fat grafting. What convinced you to incorporate ultrasound into your practice, and how has it changed your operative technique over time?
S Alexander Earle, MD, FACS: For me it came down to patient safety because when I looked at the BBL procedure years ago, I understood where the risk was. The danger comes from placing fat too deep, and I never liked the idea of relying entirely on feel when technology existed that could let me actually see where I was. I remember thinking, “There has to be a better way to do this.”
Once I started using ultrasound, I never looked back. It changed the procedure from something that was largely based on experience and tactile feedback to something where I could visualize exactly where the cannula was and where the fat was going. That level of real-time information is incredibly valuable.
PSP: For surgeons who have not yet adopted ultrasound guidance, what does the technology allow you to visualize in real time that cannot be reliably confirmed through traditional tactile techniques alone?
Earle: The biggest difference is that you can actually see the tissue planes underneath the skin. Before ultrasound, surgeons were relying on feel, experience, and judgment. Those things still matter, but they’re indirect. With ultrasound, I can see the cannula as I’m working and confirm that I’m staying in the subcutaneous plane where the fat should be placed. It’s the difference between thinking you’re in the right place and knowing you’re in the right place.
PSP: Florida became the first state to mandate ultrasound-guided BBLs. Do you view that requirement as a regulatory response to a patient safety issue, or as an acknowledgment of where the specialty was already heading?
Earle: I think it was both because the law was clearly a response to safety concerns and the complications that brought a lot of attention to BBL procedures. But at the same time, many surgeons had already started moving in this direction because the benefits were becoming pretty clear.
Florida just happened to be the first state to put it into law. In many ways, the specialty was already heading there.
PSP: How significant is the learning curve for surgeons transitioning to ultrasound-guided fat grafting, and what training or educational resources do you believe are necessary to ensure consistent adoption?
Earle: Honestly, I think people sometimes make the learning curve sound bigger than it is. Like any new skill, you need training and practice. You have to learn how to interpret what you’re seeing on the screen and correlate that with what you’re doing surgically. But this isn’t years of retraining. Most surgeons can become comfortable with it fairly quickly.
I’ve taught courses on ultrasound-guided BBLs, and once surgeons get hands-on experience, they usually realize it’s much more straightforward than they expected.
PSP: Has the use of ultrasound changed discussions around documentation, quality assurance, or risk management in your practice? If so, how?
Earle: Absolutely. One of the benefits that doesn’t get talked about enough is documentation. Ultrasound gives you visual confirmation of what you’re doing during the procedure. In Florida, video documentation is now part of the process, and I think that’s a good thing. From a quality and risk management standpoint, having that additional level of transparency benefits everyone. It creates accountability and helps reinforce best practices.
PSP: As safety protocols have evolved—from subcutaneous-only injection recommendations to ultrasound guidance—what lessons has the specialty learned about reducing risk in gluteal fat grafting?
Earle: I think the biggest lesson is that assumptions aren’t enough, for example, years ago surgeons believed they were staying in the correct plane, but studies showed that wasn’t always the case. That’s what led to the push for subcutaneous-only fat placement and eventually ultrasound guidance. The more we’ve learned, the more we’ve realized that safety improves when you can verify what you’re doing rather than relying solely on feel. Ultrasound gave us a way to do that.
PSP: When you speak with colleagues about ultrasound-guided BBLs, what concerns or barriers to adoption do you hear most often, and how do you address them?
Earle: Most of the time it’s not really about cost or time. The ultrasound machines are relatively inexpensive compared to a lot of the technology we use in plastic surgery, and once you’re comfortable with it, it doesn’t add much time to the procedure. What I see more often is inertia. People get comfortable with the way they’ve always done things.
Occasionally you’ll also hear someone say they don’t need it because they’re experienced. My response is always the same: experience is valuable, but if there’s a tool that gives you more information and can potentially make the procedure safer, why wouldn’t you use it?
PSP: Looking ahead, do you believe ultrasound guidance will become the standard of care for gluteal fat grafting nationwide? What factors will determine whether adoption accelerates across the specialty?
Earle: Yes, I do and I think we’re already moving in that direction. Florida took the first step, but I don’t think this conversation stops there. As more data becomes available and more surgeons adopt the technology, it becomes harder to argue against it.
I also think patients will play a role. Once patients understand that some surgeons use ultrasound and others don’t, they’re going to start asking questions. When enough patients start asking for something, the industry tends to respond.At the end of the day, this isn’t about technology for technology’s sake. It’s about using a tool that allows surgeons to perform the procedure with more information and, ultimately, with a greater margin of safety. PSP
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