Brazilian Butt Lift (BBL): A UK Institutional Experience

Future Directions for “Superficial Gluteal Lipofilling



Enhancing Safety in Buttock Augmentation: Our Experience and Future Commitments

We read the Special Topic article by Del Vecchio and Kenkel with great interest. This could not be timelier for the resumption of Brazilian butt lift (BBL) surgery in the United Kingdom. In 2018, the British Association of Aesthetic Plastic Surgeons (BAAPS) issued its guidance against performing BBL surgery in the United Kingdom. In 2020, the BAAPS BBL Task Force conducted a Delphi study to establish BBL research priorities in the United Kingdom. Subsequently, BAAPS conducted a survey of its members to establish current practice and perception around BBL surgery in the United Kingdom. These efforts paved the way for the recent publication of new guidelines in October 2022, supporting the safe resurgence of BBL surgery in the United Kingdom.

Our institution, too, wishes to contribute to this evolving landscape by sharing its experience with liposuction and fat transfer to the buttock/hip area for cosmetic contouring prior to 2018 when we halted all BBL-related work in line with BAAPS advice. Our aim is to shed light on this procedure, as there is a dearth of BBL data in the literature from the United Kingdom.

Between March 2015 and September 2018, we performed 24 BBLs, all on female patients. We termed this procedure "silhouette contouring" to emphasize the comprehensive approach, which included liposuction to the waist and/or thighs in addition to fat grafting to the buttocks and "hip dips." All surgeries were carried out by three surgeons, following strict preoperative protocols, including anesthetic clearance, ASA Grade 1 or 2, BMI <30 kg/m2, and standard photography.

While our intraoperative techniques slightly varied in terms of fat harvest and preparation, the common denominator was injecting fat above the muscle using 10-mL syringes. Fat donor sites encompassed the abdomen, flanks, thighs, knees, arms, and back, with an average fat aspirate of 1600 mL per patient and an average fat transfer of 265 mL per gluteal side. Postoperatively, patients wore compression garments for up to 6 weeks and received antibiotics for 7 days. Importantly, there were no major complications, no readmissions, and no mortalities.

It's worth noting that there is considerable international variation in the technical approach to this procedure, mirroring the diversity seen in fat grafting to the breast. However, this variation underscores that there may be no superior technique—what matters is the safe harvest and injection of fat. Key to safety, as confirmed by national and international authorities, is the practice of injecting fat above the muscle, thus averting the risk of fat embolism—a potentially catastrophic complication.

Our average injection volume per gluteal side was 265cc, possibly attributed to our patient group's lower BMIs and their preference for a modest, natural outcome. In line with Del Vecchio and Rohrich's recommendation, we concur that the term "BBL" is a misnomer and advocate for "safe subcutaneous buttock augmentation" as a more precise descriptor. Furthermore, we believe that sculpting the hips, flanks, and sometimes the thighs significantly contributes to the final augmented buttock result. Thus, we have chosen to move away from the term "BBL," referring to it as "silhouette contouring" to emphasize the holistic approach.

In summary, we share our limited but potentially significant experience of 24 BBL cases performed at our institution before the 2018 BAAPS advice halted such surgeries in the United Kingdom. We are committed to supporting future efforts to redefine the safety of this procedure, aligning with new international guidance. To this end, we plan to implement intraoperative ultrasound and will host a "safe BBL" course in the United Kingdom, featuring Dr. Del Vecchio as an international authority. Our goal is to offer local, safe solutions for our UK patients in line with the evolving standards of care.

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