Body Contouring

Aesthetic Surgery Journal

Augmented Safety Profile of 2024, Vol 44(4) NP263–NP270

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© The Author(s) 2023. Published by
Oxford University Press on behalf of The
Ultrasound-Guided Gluteal Fat Transfer: Aesthetic Society. All rights reserved.
For permissions, please e-mail:
Retrospective Study With 1815 Patients journals.permissions@oup.com
https://doi.org/10.1093/asj/sjad377
www.aestheticsurgeryjournal.com

Natalia Vidal-Laureano, MD; Carlos T. Huerta; Eduardo A. Perez, MD;

and Steven Alexander Earle, MD, FACS

Abstract
Background: Gluteal augmentation with autologous fat transfer is one of the fastest growing aesthetic surgical procedures
worldwide over the past decade. However, this procedure can be associated with high mortality from fatal pulmonary fat
embolism events caused by intramuscular injection of fat. Ultrasound-guided fat grafting allows visualization of the transfer
in the subcutaneous space, avoiding intramuscular injection.
Objectives: The aim of this study was to assess the safety and efficacy of gluteal fat grafting performed with ultrasound-
guided cannulation.
Methods: A retrospective chart review of all patients undergoing ultrasound-guided gluteal fat grafting at the authors’ cen­
ter between 2019 and 2022 was performed. All cases were performed by board-certified and board-eligible plastic sur­
geons under general anesthesia in ASA Class I or II patients. Fat was only transferred to the subcutaneous plane when
over the gluteal muscle. Patients underwent postoperative follow-up from a minimum of 3 months up to 2 years. Results
were analyzed with standard statistical tests.
Results: The study encompassed 1815 female patients with a median age of 34 years. Controlled medical comorbidities were
present in 14%, with the most frequent being hypothyroidism (0.7%), polycystic ovarian syndrome (0.7%), anxiety (0.6%), and
asthma (0.6%). Postoperative complications occurred in 4% of the total cohort, with the most common being seroma (1.2%), local
skin ischemia (1.2%), and surgical site infection (0.8%). There were no macroscopic fat emboli complications or mortalities.
Conclusions: These data suggest that direct visualization of anatomic plane injection through ultrasound guidance is as­
sociated with a low rate of complications. Ultrasound guidance is an efficacious adjunct to gluteal fat grafting and is asso­
ciated with an improved safety profile that should be considered by every surgeon performing this procedure.

Level of Evidence: 3
3

Editorial Decision date: December 8, 2023; online publish-ahead-of-print December 20, 2023.

Gluteal contouring and augmentation with fat grafting is not a

Drs Vidal-Laureano and Earle are plastic surgeons in private practice
new procedure, having now been performed for over 4 de­ in Miami, FL, USA. Drs Huerta and Perez are general surgeons,
cades,1 but has become very popular in the last decade. It is Department of Surgery, University of Miami Miller School of Medicine,
one of the fastest-growing procedures worldwide as docu­ Miami, FL, USA.
mented by the International Society of Aesthetic Plastic
Corresponding Author:
Surgery 2021, with a 34.1% growth between 2020 and 2021.2 Dr Natalia Vidal-Laureano, 7265 SW 93rd Avenue, Suite 201, Miami,
A similar increase was found by The Aesthetic Society, which FL 33173, USA.
reported a 37% increase in buttock augmentations (fat grafting E-mail: drvidal@pureplasticsurgery.com
NP264 Aesthetic Surgery Journal 44(4)

and implants) from 2020 to 2021.3 But with the increase in pop­ surgeons following them, we kept on seeing fat embolism
ularity, we have unfortunately also seen an increase in cata­ cases.6 Therefore, tactile feedback alone is not enough to
strophic complications. Mortalities from gluteal fat grafting avoid intramuscular injection of fat in the gluteal region.16
were first reported in 2015 from Mexico and Colombia, with The use of ultrasound to guide fat transfer has been de­
22 deaths in the previous 10 and 15 years, respectively.4 scribed by Pazmiño.17,18 This method, which involves injecting
These cases were reviewed, and it was found that all showed the fat in a static manner using real-time ultrasound guidance,

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evidence of intramuscular fat being present. Consequently, it has been shown to yield safe results. Recently the Florida
was recommended to avoid injection into the deep gluteal Department of Health instituted a law mandating all surgeons
muscle. to use ultrasound imaging when performing fat transfer.19
The popularity of the procedure continued to grow and This has been supported by the American Society of Plastic
with it the number of fatal cases, leading to a survey by Surgeons and The Aesthetic Society. In our busy center,
the Aesthetic Surgery Education and Research Foundation ultrasound-guided gluteal fat transfer has been performed
sent to all active members of the American Society of since 2019. The aim of the current study was to assess
Aesthetic Plastic Surgery and the International Society of the safety and efficacy of gluteal fat grafting utilizing
Aesthetic Plastic Surgery in 2017 to document the incidence ultrasound-guided cannulation.
of fatal and nonfatal pulmonary fat embolism and mortality
rate. The survey found an annual mortality rate of 1:3448.5
During this same year, 2017, South Florida saw the high­ METHODS
est number of Brazilian butt lift deaths, 5, in the United
States up to that date.6 This contributed to the creation of A retrospective chart review of all patients undergoing
an international intersociety work group called the ultrasound-guided gluteal fat grafting at our center between
Gluteal Fat Grafting Task Force, led by Dr Peter Rubin, September 2019 and September 2022 was performed. No
MD. The goal was “to create an appropriate anatomic mod­ cases of liposuction and fat transfer to buttocks performed
el to study the pathophysiology behind these deaths, iden­ during this period were excluded from the data analysis.
tify contributing anatomic factors and determine safer fat IRB approval was not obtained as this study qualified for ex­
graft injection techniques.”7 After performing cadaver stud­ emption. Medical charts were accessed to obtain the infor­
ies a consensus was reached, and in 2018 the Task Force mation required, but patient identifiers were not linked to
made the following recommendations: fat graft should be the research data set. Written consent was obtained, by
injected in the subcutaneous space; intergluteal access is which the patients agreed to the use and analysis of their
preferable to avoid deep angulation; instruments should of­ data. Declaration of Helsinki guidelines were used to guide
fer control of the cannula and therefore a rigid cannula this study. All cases were performed by board-certified and
should be used to avoid inadvertent bending and Luer con­ board-eligible plastic surgeons (American Board of Plastic
nections should be avoided as well; and injection should Surgery) under general anesthesia in American Society of
only be done while the cannula is in motion.7 Anesthesiology (ASA) Class I or II patients. Fat was only
As a response to the increased mortality rates of this pro­ transferred to the subcutaneous plane when over the glute­
cedure, especially in South Florida, the Florida Board of al muscle. Patients underwent postoperative follow-up from
Medicine conducted a special meeting in 2019. The result a minimum of 3 months up to 2 years.
was an emergent rule that prohibited injection of fat deep We retrieved demographic and clinical data including
to the superficial gluteal fascia, intramuscularly or submuscu­ age, gender, comorbidities, BMI, volume of tumescence flu­
larly.8 Unfortunately, this did not slow down the alarming mor­ id infiltrated, total lipoaspirate, volume of fat injected, and
tality rate we were experiencing in South Florida. In fact, the operative time. Complications, including seroma, local skin
deadliest year on record for Brazilian butt lift mortality in ischemia, surgical site infection, fat necrosis, dehydration,
South Florida was 2021, in which there were 6 fatalities.6 hematoma, and macroscopic fat embolism, were reviewed.
Traditionally, fat transfer is done blindly with the correct lo­ In addition, any other complications seen were included in a
cation being identified based solely on experience and feel. separate column as “miscellaneous.” Results were analyzed
Ultrasound guidance allows the surgeon to be able to see with standard statistical tests.
the cannula in real time. It has been shown with ultrasound
there are consistently 5 layers in the gluteal subcutaneous
Procedure
anatomy (skin, superficial fat, superficial fascia, deep fat,
deep fascia), independent of age, sex, or BMI.9 Other tech­ All patients were treated in our Joint Commission on
niques to avoid intramuscular fat injection, such as angle on Accreditation of Healthcare Organizations–certified office-
injection, cannula thickness, access incision, among based surgery facility by board-certified and board-eligible
others,10-15 have been proposed to decrease this risk. But un­ plastic surgeons. All procedures were performed under ge­
fortunately, even after all these recommendations, and neral anesthesia. Procedure was started with the patient in
Vidal-Laureano et al NP265

manner or static in boluses using a 60-mL syringe while ob­

serving it with ultrasound (as shown in the Video, available
online at www.aestheticsurgeryjournal.com). The final vol­
ume injected was determined by skin elasticity and final
aesthetic shape. Patients were placed in a compression
garment and discharged home. Follow-ups were done at

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24 hours, 1 week, 6 weeks, 3 months, and 2 years.

RESULTS
The study period covered 1815 female patients with a
median age of 34 years (range, 18-58 years). Controlled
medical comorbidities were present in 14%, with the
most frequent being hypothyroidism (0.7%), polycystic
ovarian syndrome (0.7%), anxiety (0.6%), and asthma
(0.6%). BMI ranged from 22.2 to 34.6 kg/m2, with an aver­
age of 28.3 kg/m2. The mean total volume infiltrated was
4600 mL (range, 3500-5800 mL), and the mean total lip­
oaspirate volume was 4300 mL (range, 3100-4900 mL).
The mean volume of fat transferred to the buttocks and
hip region was 720 mL (range, 540-1200 mL), and the
mean operative time it took surgeons to transfer the fat
(injecting time) was 28 minutes (range, 20-39 minutes);
this included the usage of ultrasound during the transfer
which was not documented separately. Postoperative com­
plications occurred in 4% of the total cohort, with the most
common being seroma (1.2%), local skin ischemia (1.2%),
and surgical site infection (0.8%; Table 1). There were no
macroscopic fat emboli complications or mortalities.

Figure 1. Equipment used: 60-mL syringes with Toomey-type DISCUSSION

tip, blunt-tip 5-mm single-hole infiltrating cannulas, sterile bowl
for fat placement, 2800-mL glass collection bottle, and sterile Macroscopic fat embolism has been a catastrophic complica­
bag and gel for ultrasound. tion we started seeing as gluteal fat grafting became more
popular. There were 25 fatal cases of macroscopic fat embo­
the supine position. Liposuction to the anterior torso was lism in South Florida between January 2010 and April 2022,6
performed first. A super-wet technique was used with tu­ a rate that has triggered various legislative measures to reg­
mescence fluid prepared with 2 mg of epinephrine in 1 liter ulate and make this procedure safer.19 A comprehensive re­
of 0.9% normal saline. Power-assisted liposuction was per­ view of these cases, the South Florida experience, and the
formed with a 4-mm basket cannula. At completion of lipo­ pathophysiology of this complication has been recently pub­
suction, a 10fr Jackson-Pratt drain was left in the lower lished.6 The authors of this thorough review concluded that
abdomen and incisions were closed. The patient was intramuscular fat injection was responsible for macroscopic
then placed in a prone, flexed position. Liposuction to the fat embolism. Intramuscular injection was previously en­
posterior trunk was performed in a similar manner. Fat couraged to promote a well-vascularized bed for the fat
was prepared by the decantation method and transferred transferred, to ensure fat viability,20 and to increase the vol­
to 60-mL syringes for injection. Figure 1 shows the equip­ ume injected.21 Multiple studies have reported the dangers
ment used. Incisions for gluteal fat transfer were made in of this technique and the importance of performing only sub­
the midline intergluteal crease and bilateral inferior gluteal cutaneous fat transfer.4-7,9-12,14,15,22-27 This has also been rec­
folds. A portable ultrasound (Clarius L15 HD3) was used in ommended by the last published “Practice Advisory on
all patients to assess the gluteal layers in real time, as Gluteal Fat Grafting” in 2022.28 In the South Florida experi­
shown in Figure 2, and for the fat transfer portion over ence, in every case reviewed autopsy dissection revealed
the gluteal muscle. A 5-mm blunt-tip, single-hole cannula evidence of fat in the gluteal muscle.6 It is also important to
was used for injection. Fat was injected in a retrograde mention that the extent of fat in this compartment did not
NP266 Aesthetic Surgery Journal 44(4)

A B

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Figure 2. Ultrasound view of gluteal anatomy with layers labeled (dermis, superficial subcutaneous space, superficial gluteal
fascia, deep subcutaneous space, deep gluteal fascia, and gluteal muscle) with (A) and without (B) the infiltrating cannula.

Table 1. Postoperative Complications Among Patients

Undergoing Ultrasound-Guided Gluteal Fat Grafting
Procedures From 2019 to 2022

Characteristic n (%)

Any complication 72 (4)

Seroma 21 (1.2)

Local skin ischemia 22 (1.2)

Surgical site infection 14 (0.8)

Fat necrosis 6 (0.3)

Video. Watch now at http://academic.oup.com/asj/
Miscellaneousa 6 (0.3)
articlelookup/doi/10.1093/asj/sjad377
Dehydration 2 (0.1)

Hematoma 2 (0.1) complete cut or direct cannulation of the gluteal veins is

not necessary for macroscopic fat embolism to occur
Macroscopic fat embolism 0 (0)
due to the constant negative pressure that the gluteal ve­
Mortality 0 (0) nous system maintains. This makes it paramount to di­
rectly visualize the placement of fat in the subcutaneous
a
Arrhythmia, thrombophlebitis, allergy to antibiotics.
space.
Fat grafting has long been performed “blind,” guided pri­
correlate with inadvertent intramuscular fat injections. It is be­ marily by the surgeons’ tactile feel and anatomic knowl­
lieved this was the result of intentional intramuscular fat graft­ edge. Experienced surgeons who have performed
ing or the result of the surgeon not being aware of their numerous fat grafting procedures vouch for experience
cannula position at the time of injection. as the most important component for knowledge of the
Differentiating between macroscopic and microscopic cannula tip position and avoidance of intramuscular injec­
fat embolism has been very important in understanding tion. Unfortunately, there are several cases of macroscopic
the pathophysiology of this condition. A thorough review fat embolism with experienced surgeons documenting
of both pathological entities by Cardenas-Camarena only subcutaneous injection and with evidence of fat in
et al revealed the importance of prevention and the dan­ the muscular plane after postmortem examination.6 This
gers of muscular fat injection leading to fat embolism, car­ tells us that experience and anatomic knowledge are not
diovascular collapse, and death.22 They also found that a enough to avoid this complication.
Vidal-Laureano et al NP267

A B A B

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C D C D

E F E F

Figure 3. A 23-year-old female patient who is 6 months Figure 4. A 34-year-old female patient who is 2 years
postoperative liposuction and ultrasound-guided fat transfer postoperative liposuction and ultrasound-guided fat transfer to
to buttocks and hips. She had a BMI of 26.1 kg/m2 and the total buttocks and hips. She had a BMI of 29.5 kg/m2 and the total fat
fat transferred was 720 mL. (A) Preoperative anterior view, transferred was 780 mL. (A) Preoperative anterior view,
(B) postoperative anterior view, (C) preoperative posterior (B) postoperative anterior view, (C) preoperative posterior view,
view, (D) postoperative posterior view, (E) preoperative lateral (D) postoperative posterior view, (E) preoperative lateral view, and
view, and (F) postoperative lateral view. (F) postoperative lateral view).

The use of ultrasound in plastic surgery has become has diversified starting from microsurgery and lymphede­
more popular in the last few decades. Its benefits include ma surgery to identify small vessels and avoid unnecessary
the fact that it is noninvasive, poses no radiation risk, is donor sites, to breast procedures for identification of post­
painless, has a patient-friendly technique, and a short operative complications, such as hematoma and seromas,
learning curve, making it more accessible and usable for and even capsular contracture. The use of ultrasound to
practitioners.29 Interest in plastic surgeon–led ultrasound guide fat transfer was studied by D’Amico and co-workers
NP268 Aesthetic Surgery Journal 44(4)

A B A B

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C D C D

E F E F

Figure 5. A 33-year-old female patient who is 8 months Figure 6. A 21-year-old female patient who is 6 months
postoperative liposuction and ultrasound-guided fat transfer postoperative liposuction and ultrasound-guided fat transfer
to buttocks and hips. She had a BMI of 26.1 kg/m2 and the total to buttocks and hips. She had a BMI of 27.4 kg/m2 and the total
fat transferred was 840 mL. (A) Preoperative anterior view, fat transferred was 900 mL. (A) Preoperative anterior view, (B)
(B) postoperative anterior view, (C) preoperative posterior postoperative anterior view, (C) preoperative posterior view,
view, (D) postoperative posterior view, (E) preoperative lateral (D) postoperative posterior view, (E) preoperative lateral view,
view, and (F) postoperative lateral view. and (F) postoperative lateral view.

in 15 patients, showing its efficacy and reliability.30 They both surgeons use a surgeon-held technique (Video).
mention as limitations the cost of ultrasound and the With the nondominant hand, the probe is held, and the
need for an assistant to hold the probe. In our practice, dominant hand is used for injecting. The probe may be
Vidal-Laureano et al NP269

put down for 2-hand proprioception when inserting the ultrasound device is affordable and does not add significant
cannula, and then the probe is placed to confirm subcuta­ additional time to the procedure. It is also an essential tool
neous cannula placement before and during the injection. for training new surgeons on this procedure safely.
The learning curve associated with ultrasound use is not Ultrasound guidance is an efficacious adjunct to gluteal
steep. Proper knowledge of the anatomy of the gluteal region fat grafting and is associated with an improved safety profile
is most important. In our practice, the senior surgeon has that should be considered by every surgeon performing this

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been utilizing ultrasound for all his gluteal fat transfer proce­ procedure.
dures since 2019. The junior surgeon joined this practice after
training in 2021 and was proctored by the senior surgeon for Supplemental Material
approximately 20 cases, after which, based on observation
This article contains supplemental material located online
by the senior surgeon, he was deemed safe to proceed with­
at www.aestheticsurgeryjournal.com.
out supervision. In our experience, ultrasound is extremely
useful for teaching the procedure and ensuring patient safety.
Regarding surgical time, it is a concern of most surgeons Disclosures
that the use of real-time ultrasound will increase their opera­ The authors declared no potential conflicts of interest with re­
tive time. As mentioned before, the learning curve is not steep spect to the research, authorship, and publication of this article.
and even in the first few cases, operative time only increased
by 10 to 15 minutes. As surgeons become more familiar with Funding
the device and identification of the cannula, the extra time The authors received no financial support for the research,
may come down to approximately 5 minutes. Due to the ret­ authorship, and publication of this article.
rospective nature of this study, there are no data on the
amount of time it took the surgeons to use the ultrasound.
What is documented in the charts is the time of fat transfer, REFERENCES
which was an average of 28 minutes. The use of ultrasound
is only necessary while injecting over the gluteal muscle. 1. Toledo LS. Gluteal augmentation with fat grafting: the Brazilian
buttock technique: 30 years’ experience. Clin Plast Surg.
Another important aspect to discuss is the maintenance
2015;42(2):253-261. doi: 10.1016/j.cps.2014.12.004
and even improvement of results. By using real-time ultra­
2. International Society of Aesthetic Plastic Surgery (ISAPS)
sound, not only can you ensure fat grafting only in the subcu­ International survey on aesthetic/cosmetic procedures
taneous space, but you can selectively inject in the deep or performed in 2021. Accessed November 13, 2023. https://
the superficial subcutaneous spaces. The authors have ob­ www.isaps.org/media/vdpdanke/isaps-global-survey_2021.
served differences in the projection and shape while injecting pdf
in the different planes (Figures 3-6). The deep subcutane­ 3. Aesthetic plastic surgery national databank statistics
ous space allows for more projection and volumetric ex­ 2020-2021. Aesthet Surg J. 2022;42(Suppl 1):1-18. doi: 10.
pansion, while the superficial subcutaneous space allows 1093/asj/sjac116
for more subtle correction of flat areas and indentations. 4. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H,
This experience is shared by Pazmiño and Del Vecchio Cuenca-Pardo J. Deaths caused by gluteal lipoinjection:
what are we doing wrong? Plast Reconstr Surg. 2015;136(1):
et al, who recommend a mainly deep subcutaneous space in­
58-66. doi: 10.1097/PRS.0000000000001364
jection to avoid “blow out fracture, skin changes and surface
5. Mofid MM, Teitelbaum S, Suissa D, et al. Report on mortality
irregularities.”18 Fat viability in the subcutaneous space has from gluteal fat grafting: recommendations from the ASERF
been found to be comparable to that in the muscular plane.31 task force. Aesthet Surg J. 2017;37(7):796-806. doi: 10.
Our findings show that ultrasound guidance of fat transfer 1093/asj/sjx004
to the gluteal region provides accurate visualization, avoiding 6. Pasmiño P, Garcia O. Brazilian butt lift-associated mortality:
inadvertent intramuscular injection and consequently mini­ the south Florida experience. Aesthet Surg J. 2023;43(2):
mizing the risk of macroscopic fat embolism. The limitations 162-178. doi: 10.1093/asj/sjac224
of this study are its retrospective nature, that only 2 surgeons 7. Multi-Society Gluteal Fat Grafting Task Force issues safety
participated in the study, and the lack of postoperative imag­ advisory using practitioners to reevaluate technique.
ing to demonstrate the lack of intramuscular fat. Accessed July 10, 2023. https://www.surgery.org/sites/
default/files/Gluteal-Fat-Grafting-02-06-18_0.pdf
8. Florida Board of Medicine. 22065771, 64B8ER19-1 – Florida
Administrative Rules, Law, Code, Register – FAC, FAR,
CONCLUSIONS eRulemaking. Accessed November 15, 2023. https://www.
flrules.org/Gateway/View_notice.asp? id=22065771
Ultrasound allows for direct visualization of the cannula in 9. Frank K, Casabona G, Gotkin RH, et al. Influence of age, sex,
real time to ensure fat is placed in the safe subcutaneous and body mass index on the thickness of the gluteal subcu­
plane, thereby minimizing the risk of fat embolism. The taneous fat: implications for safe buttock augmentation
NP270 Aesthetic Surgery Journal 44(4)

procedures. Plast Reconstr Surg. 2019;144(1):83. doi: 10. Plast Reconstr Surg. 2018;141(2):306-311. doi: 10.1097/
1097/PRS.0000000000005707 PRS.0000000000004094
10. Condé-Green A, Kotamarti V, Nini KT, et al. Fat grafting 22. Cardenas-Camarena L, Duran H, Robles-Cervantes JA,
for gluteal augmentation: a systematic review of the liter­ Bayter-Marin JE. Critical differences between microscopic
ature and meta-analysis. Plast Reconst Surg. 2016;138(3): (MIFE) and macroscopics (MAFE) fat embolism during lipo­
437e-446e. doi: 10.1097/PRS.0000000000002435 suction and gluteal lipoinjection. Plast Reconstr Surg.

Downloaded from https://academic.oup.com/asj/article/44/4/NP263/7485568 by Universidade Federal da Bahia (UFBA) user on 16 December 2024
11. Ghavami A, Villanueva NL. Gluteal augmentation and con­ 2018;141(4):880-890. doi: 10.1097/PRS.0000000000004219
touring with autologous fat transfer: part I. Clin Plast Surg. 23. Sinno S, Chang JB, Browstone ND, Saadeh PB, Wall S Jr.
2018;45(2):249-259. doi: 10.1016/j.cps.2017.12.009 Determining the safety and efficacy of gluteal augmenta­
12. Cárdenas-Camarena L, Arenas-Quintana R, Robles-Cervantes tion: a systematic review of outcomes and complications.
JA. Buttocks fat grafting: 14 years of evolution and experi­ Plast Reconstr Surg. 2016;137(4):1151-1156. doi: 10.1097/
ence. Plast Reconstr Surg. 2011;128(2):545-555. doi: 10. PRS.0000000000002005
1097/PRS.0b013e31821b640b 24. Rios L Jr, Gupta V. Improvement in Brazilian Butt Lift (BBL)
13. Mendieta CG. Gluteal reshaping. Aesthet Surg J. 2007;27(6): safety with the current recommendations from ASERF,
641-655. doi: 10.1016/j.asj.2007.09.001 ASAPS, and ISAPS. Aesthet Surg J. 2020;4(8):864-870.
14. Villanueva NL, Del Vecchio DA, Afrooz PN, Carboy JA, doi: 10.1093/asj/sjaa098
Rohrich RJ. Staying safe during gluteal fat transplantation. 25. Del Vecchio DA, Villanueva NL, Mohan R, et al. Clinical im­
Plast Reconstr Surg. 2018;141(1):79-86. doi: 10.1097/PRS. plications of gluteal fat migration: a dynamic anatomical
0000000000003934 study. Plast Reconstr Surg. 2018;140(5):1180-1192. doi: 10.
15. Alvarez-Alvarez FA, Gonzalez-Gutierrez HO, Ploneda- 1097/PRS.0000000000005020
Valencia CF. Safe gluteal fat graft avoiding a vascular or 26. Turin SY, Fracol M, Keller E, et al. Gluteal vein anatomy: lo­
nervous injury: an anatomical study in cadavers. Aesthet cation, caliber, impact of patient positioning, and implica­
Surg J. 2018;39(2):174-184. doi: 10.1093/asj/sjy237 tions for fat grafting. Aesthet Surg J. 2020;40(6):642-649.
16. Pazmiño P, Garcia O. BBL mortality in south Florida: an up­ doi: 10.1093/asj/sjz260
date from ground zero. Aesthet Surg J. 2023;43(3): 27. Wall S, Del Vecchio D, Teitelbaum S, et al. Subcutaneous
223-224. doi: 10.1093/asj/sjac325 migration: a dynamic anatomical study of gluteal fat graft­
17. Pasmiño P. ultraBBL: Brazilian Butt Lift using real-time ing. Plast Reconstr Surg. 2019;143(5):1343-1351. doi: 10.
intraoperative ultrasound guidance. Ultrasound-Assisted 1097/PRS.0000000000005521
Liposuction. 2020;1:147–172. doi: 10.1007/978-3-030- 28. Del Vecchio D, Kenkel JM. Practice advisory on gluteal fat
26875-6_10 grafting. Aesthet Surg J. 2022;42:1019-1029. doi: 10.1093/
18. Pazmiño P, Del Vecchio D. Static Injection, Migration, and asj/sjac082.
Equalization (SIME): a new paradigm for safe ultrasound- 29. Oni G, Chow W, Ramakrishnan V, Griffiths M. Plastic
guided Brazilian Butt Lift: safer, faster, better. Aesthet Surg surgeon-led ultrasound. Plast Reconstr Surg. 2018;141(2):
J. 2023;43:1295-1306. doi: 10.1093/asj/sjad142 300e. doi: 10.1097/PRS.0000000000004071
19. Florida House Bill 1471: Health Care Provider Accountability 30. Cansancao AL, Condé-Green A, Vidigal RA,
Act. Accessed November 13, 2023. https://www.flsenate. Rodriguez RL, D’Amico RA. Real-time ultrasound-assisted
gov/Session/Bill/2023/1471/?20Tab=VoteHistory gluteal fat grafting. Plast Reconstr Surg. 2018;142(2):372.
20. Murillo WL. Buttock augmentation: case studies of fat in­ doi: 10.1097/PRS.0000000000004602
jection monitored by magnetic resonance imaging. Plast 31. Cansancao AL, Condé-Green A, David JA, Vidigal R.
Recons Surg. 2004;114(6):1606-1614. doi: 10.1097/01.PRS. Subcutaneous-only gluteal fat grafting: a prospective study
0000138760.29273.5D of the long-term results with ultrasound analysis. Plast
21. Mendieta C, Stuzin JM. Gluteal augmentation and enhance­ Reconstr Surg. 2019;143(2):447-451. doi: 10.1097/PRS.000
ment of the female silhouette: analysis and technique. 0000000005203