By Alexander Zuriarrain, MD

The growing trend of reversing the effects of gluteal augmentation with fat grafting prompted TikTok personality Roxanne Ramsey to suggest celebrities have the money to change the way they look should the cosmetic procedure—Brazilian Butt Lift, or BBL—“take an [undesirable] turn.” However, “girls are [otherwise] getting these bodies you just can’t reverse easily.”

So true—both on the patient cost front and in the surgical arena, where reducing the volume of a patient’s buttocks after a BBL can be equally, and sometimes even more, technically difficult than the original procedure and require a plastic surgeon who is proficient in the latest techniques. The goal is always to maintain the shapely contour of the backside while using various liposuction approaches to remove previously injected fat safely and return the patient’s buttocks to its more natural size.

So, what constitutes a well-shaped buttocks? In short, one that enhance a patient’s figure and has a V-shaped crease of the sacral triangle, a short infragluteal fold, supragluteal fossettes, and lateral depressions.

Recent Surge in BBL Demand

Thanks largely to social media, BBL procedures in the United States have surged recently as patients seek the same hourglass figures achieved by celebrities, often through cosmetic surgery and prominently highlighted in photos and videos. In a 2021 statistical analysis, The Aesthetic Society reported that the number of gluteal augmentation surgeries – both by fat grafting and implant insertion—jumped 37% between 2020 and 2021, from 44,725 procedures to 61,387.

Today’s ”gold-standard” BBL does not rely on implants, but, instead, involves removing and redistributing excess fat from the waist, stomach, or back of the patient; purifying it; and then injecting it into the buttocks and hips for better body contouring. Authors of a 2020 study published in the journal Seminars in Plastic Surgery agree, adding that “buttock augmentation by [autologous] fat grafting has a satisfaction rate of 97.1%. To create better harmony between the upper body, buttocks, and lower body is the goal of the surgery.

Unfortunately, the large number of patients requesting BBLs has prompted Stanford Medicine to speak out about the “huge increase in the number of non-board-certified plastic surgeons performing this [operation]. Gluteal augmentation surgery, including BBLs, are technically demanding procedures, which require appropriate training to be executed safely,” the article’s author states.

Are BBL Requests Losing Steam?

But the steep rise in BBL surgeries may be losing steam. A July article published in Yahoo News boldly proclaimed that the “BBL Era Is Ending,” citing patient concerns about potential risks involved in undergoing a BBL, decisions by celebrities to undergo BBL reversals, changing trends in fashion and body standards for women, and the growing tendency of women to “embrace their own beauty” and forego unrealistic body expectations.

Indeed, plastic surgeons are reporting increasing requests to undo BBLs performed elsewhere because patients’ buttocks have become more enlarged due to weight gain, patients are unhappy with the results of their original procedure, or they have simply grown older and are tired of the “look.” 

Reversing the procedure requires the surgeon to carefully apply different liposuction techniques, like tumescent or laser-assisted liposuction, to remove some of the injected fat while simultaneously ensuring the buttocks remains proportionate to the patient’s total figure. It’s a demanding operation requiring high technical surgical skills.

BBLs and BBL Reversals Safer Now

BBLs and BBL reversals have become much safer procedures since the 2018 release of a practice warning by the Multi-Society Task Force for Safety in Gluteal Fat Grafting, thanks to the introduction of new surgical techniques and technologically advanced tools. In their advisory, society members, representing board-certified plastic surgeons worldwide, cited an “unusually high mortality rate” for BBLs—estimated at one for every 3,000 procedures—higher than any other cosmetic surgery. The society blamed development of “fat embolisms due to fat entering the venous circulation associated with injury to the gluteal veins.”

Most notable in the overall improvement in BBL outcomes have been the introduction of wireless ultrasound and the use of platelet-rich plasma (PRP) in the fat-injection process. 

In an ultrasound-guided BBL, physicians use a wireless ultrasound probe placed on the buttocks to locate the tissue layer where the grafted fat is to be introduced. The probe allows monitoring in real time, making the entire procedure far safer and more precise than former techniques. The ultrasound images are projected wirelessly on a screen so that the surgical team can closely follow the procedure.

Ultrasound-assisted gluteal fat grafting is dependable, ensures the best possible aesthetic outcomes, avoids injury to the deep vessels, and decreases the risks of major complications such as the development of fat embolisms. In fact, earlier this year, the Florida Board of Medicine approved an emergency order requiring surgeons to use ultrasound for BBLs to “avoid injecting fat into muscle,” thereby reducing the risk that potentially fatal fat embolisms might develop.

Meanwhile, the addition to the process of plasma-rich platelets, harvested from a patient’s own blood, helps ensure the body “takes” more of the injected fat. The higher percentage of fat the body accepts, the better and longer lasting the outcome of a BBL procedure.

Proper Patient Selection Is Key

As plastic surgeons, we have the responsibility to select the appropriate candidates for a BBL and fully inform them of what to expect now and in 10 years should they go forward with the procedure. A potential patient should be mentally healthy, a non-smoker, and committed to maintaining a stable weight through an ongoing healthy lifestyle regimen. The individual also must be psychologically prepared for the rigors of recovery and any physical changes that can occur due to aging.

Proper patient selection and use of the best techniques available can improve overall patient safety and satisfaction and hopefully limit the number of those seeking BBL reversals. 

Alexander Zuriarrain, MD, FACS, is a board-certified plastic surgeon and owner of Zuri Plastic Surgeryin Miami. Listen to a podcast PSP did with him here.