Episode 52: Thursday September 1

What's going on with BBL surgery? Recently the Florida Board of Medicine enacted an emergency rule limiting Florida surgeons to performing three Brazilian butt lifts a day and required that they use ultrasound. BBL or Brazilian butt lifts, technically called gluteal fat grafting, involves injecting fat to enlarge or reshape patients’ buttocks.

Dr. Sam Jejurikar @samjejurikar takes us through the use of ultrasound in BBL surgery and discusses the technical aspects of ultrasound can be used help surgeons maximize safety.

Catch every episode with Drs. Salvatore Pacella @sandiegoplasticsurgeon, Sam Rhee @bergencosmetic, and Sam Jejurikar @samjejurikar on YouTube or your favorite podcast app!

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S03E52 USING ULTRASOUND IN BBL BRAZILIAN BUTT LIFT SURGERY

[00:00:00] Dr. Sam Rhee: All right. Welcome to three plastic surgeons and a microphone. Uh, unfortunately Sal isn't with us, uh, for this one. But, uh, we do have Dr. Sam Jejurikar out of Dallas, Texas. Uh, Instagram handle

[00:00:17] Dr. Sam Jejurikar: is. At Sam to

[00:00:20] Dr. Sam Rhee: thank you at Sam to car Sam, Sam Rhee, outta Paraty. I've only said it like 500 times. um, I'm uh, but it's been a while.

Uh, I'm uh, Sam Rhee out of, uh, para New Jersey. My Instagram handle is at Bergen cosmetic, and, uh, Sal is, uh, San Diego plastic surgeon. He's at a LA Hoya, California. Um, and he'll be joining us for other episodes, but, uh, today we have a very special episode. Which will be, which we will be talking about. Some of the recent changes in, uh, BBL or gluteal fat transfer surgery that have occurred in Florida.

And, uh, Sam will be, uh, taking us through some of those, uh, changes and what's occurring. Um, but first let's go through our disclaimer.

[00:01:02] Dr. Sam Jejurikar: Um, to all our listeners, this show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes, only treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified providers with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something you see in this show.

And, um, You know, before I hand it back to you, Sam, I think. I think the real reason Dr. Patella doesn't wanna be with us is he doesn't really love this operation like you and I do and so so, uh, so, so with that, um, any thoughts on, uh, on anything before we sort of get into the meat at the topic?

[00:01:47] Dr. Sam Rhee: Absolutely.

I'm so glad that we're talking about this. There's been a lot of stuff in the media and. And out in public. And I, I feel like if anyone is going to get ahead of this and sort of provide the best information about what's been going on, it's going to be us as plastic surgeons. And so, um, before anyone hears or sees anything that's sensationalistic or, or, or not true, actually, um, I'm really glad that we're, we're sort of.

Breaking down this topic for people.

[00:02:17] Dr. Sam Jejurikar: Perfect. So let's, uh, let's get into it. So let me get my screen loaded up here and, um, we'll just confirm that everyone can see this. Okay. Can you see this? All right, Dr. Re it looks great. Perfect. So, um, just to get started, you know, um, DBLs have had a long, complicated history, um, prior to about, uh, 20 16, 20 17 plastic surgeons largely operated in the state of blissful ignorance, where we didn't realize how deadly this operation was.

2016 studies came outta central, uh, central America and Mexico 2017 in the us. We began to realize that the death rate was in the vicinity of approximately one in 4,000, at least that's what it was being estimated as, um, throughout the world, there was talk of actually banning the procedure, um, in the us, um, as well as most countries in the world.

Um, instead plastic surgeons came up with some very salient recommendations. And the big task force was the multi society, Glu fat grafting task force, uh, which was made up of, uh, by the time it was said and done about 50 plastic surgeons. The recommendations were, um, you need to inject superficially whenever you do fat injections.

The reason for this was people were dying because if deep injections or even injections into the muscle itself, that would cause the fat to go through the muscle. It turns out the back wall ability is Maximus muscle. Is very thin. The front wall is very, very thick and an effective barrier, but if you inject it in the muscle, the fat could actually come down through the muscle.

Um, put some pressure on some very thin walled, deep veins, cause a hole in those veins, it would get, uh, sucked up into your circulation, travel to the lungs and cause what's known as a. Fatal pulmonary fat embolism and sudden death. So the fat grafting task force said, Hey, don't do that inject in front of the muscle, stay superficial where you have that nice barrier.

So patients won't have death use blunt, cannulas, um, and, and big cannulas that are at least 4.1 millimeters or greater. Don't use a lot of pressure when you do the injections and don't angle your hand downwards. It seemed to help, you know, um, I don't know about you Dr. Reba in my community. I hadn't heard about anybody dying.

Um, same for you.

[00:04:33] Dr. Sam Rhee: Yeah. I think the biggest issue where it was either overseas, uh, in the Caribbean or in Florida, where there were a number of high volume surgical centers that were not very well regulated or. Overseeing that really resulted in a, a significant patient morbid day mortality. And that's what raised the alarm

[00:04:53] Dr. Sam Jejurikar: with this.

Yeah. You know, and in fact, when you break down, um, the first couple of years after the recommendations came out, um, particularly 20 18, 20 19, there weren't a lot of deaths in Florida, but then. And eight then in the last year, uh, basically 2020, or I'm sorry, 2021. There were eight deaths in south Florida and this caused a major ruckus, um, you know, south Florida, just like you alluded to as a very different plastic surgery market than other places in the country.

People throughout the country are flying there to get their surgeries. Um, they basically meet their surgeons right beforehand, beforehand. There's in these clinics where, um, You know, they basically specialize in doing Brazilian butt lifts. Um, 10 or 15 of them are being done in a day. Um, probably several happening, uh, simultaneously.

Um, and so the Florida medical board, uh, put in an emergency action, uh, they basically said, okay, Enough's enough. Um, we're not gonna limit the number of Brazilian butlers that can be performed today to only three. Uh, the rationale is that it limits fatigue, uh, and ensures the same surgeon is actually doing the surgery.

Um, and I think, you know, if you think about it logically if a Brazilian, but lift takes the average surgeon, say three hours, um, it makes sense. That's, that's nine hours in a day. That's that that would limit, you know, the fatigue and, and it's hard to envision how you could do a lot more than that. Um, The other thing they said was, um, you have to do ultrasound guidance during the injection of the fat to ensure that superficial injections are actually being performed.

And so that's the emergency action that went into place on June 3rd. Um, there's been a group of seven plastic surgeons that have actually challenged this. Um, they basically argued that plastic surgeons aren't trained in the use of ultrasound. Um, and they say that because other surgeons aren't, I'm sorry, other procedures aren't being exempted.

Argument about physician fatigue is sort of nonsensical. Meaning a surgeon can perform 10 tummy tucks in a day. Why are they only eliminated three BBLs? So what do you think about that, Sam? I mean, is, is ultrasound something that you feel like you have no experience with?

[00:07:06] Dr. Sam Rhee: Well, no, that's not true. Um, this is an interesting.

So basically the Florida medical board are responding to these issues and whether or not this is correct or not. Florida has always had sort of a unique situation when it's come to, to medical care and plastic surgery. Um, even before this, they have regulations that we in other states do not have. For example, uh, they limit the amount of liposuction that you can perform at the same time as.

Adjunct procedure, such as a tummy tuck, um, up to about a leader. For example, if you're doing it in an office based environment, and again, a lot of these issue, a lot of what they're doing is based on. These high volume plastic surgery clinics, or cosmetic surgery clinics that are occurring in Florida. And, um, I wanted a, I am very glad we're talking about this because I, I really would like to know more about the reasoning behind this and about the plastic surgeons who are also challenging this in Florida.

This only came out a couple weeks ago. Um, so. What's your take on this right now, Sam.

[00:08:10] Dr. Sam Jejurikar: So it's, it's just personal speculation. I don't have any data to, to back this up, but I mean the business model in south Florida is one of low cost and high volume people fly there from across the United States because they know they can get surgery for a substantially discounted rate than what they might be able to get in my office or in your office, or in most plastic surgeons, offices, you sort of eliminate.

Personal care, right? Your initial consultations oftentimes are done virtually or via email. Um, but the way that these, these businesses will, will survive economically is by doing a large number. If you limit the number of procedures that can be done in a day to three, you. Potentially harm the viability of some of these practices, um, that are out there in terms of the use of ultrasound.

I mean, I believe most plastic surgeons, um, who are of our generation or younger have extensive use, um, experience with ultrasound. I mean, I did much like you extensive general surgery training before plastic surgery, where we use ultrasound and we're very comfortable looking at soft tissue. Um, and so, um, I don't think that's really true personally.

Um, I think the physician fatigue argument, you know, um, yeah, I mean, I, I do think that. Look at your performance near the end of the week. Um, during multiple, you know, multiple long operations, multiple long days. I mean, there is a tendency to get tired, uh, to, to, you know, to, to be tired. Um, I don't know if that's actually what the Florida medical board is going after, or if they're just trying to make sure that surgeons are actually doing the procedure though, to be honest with you, because one of the things that I've heard from a plastic surgeon that's there is they're trying to get to the point where they actually have plastic surgeons.

These videotapes doing the procedure with a timestamp to prove that they're actually the ones doing the operation. So that's, that's kind of my thought.

[00:10:02] Dr. Sam Rhee: They actually, uh, have instituted that in Korea because there was such a high number of ghost surgeons where surgeons were ostensibly doing the procedure, but they were actually not.

So that's that there is a precedent for that actually occurring in other countries.

[00:10:17] Dr. Sam Jejurikar: So I wanna, um, kind of focus on the, the ultrasound aspect of things. So. Over the last few years, uh, since 20 17, 20 18, there have been multiple techniques described with the use of ultrasound to do Brazilian butlers and all of these seem to be great in theory, and very difficult in practice because they were two surgeon, techniques were basically one surgeon was injecting fat and moving their cannula.

Back and forth while they were doing the procedure. And the other surgeon was trying to mimic the motions of the other surgeon and go back and forth and follow the cannula at all times. And the problem with that is, um, it's very easy to lose track of where the cannula is. Um, if you're going back and forth, even if you are controlling, You know, the, the ultrasound with your other hand, but with two different people, there's no way to know exactly where they're gonna go.

And so most of these never really took off. They were thought they'd be slow, inefficient, not that reliable, but recently a technique has been described, um, by Dr. Patino and Dr. Uh, Dan DeLeo. And they've really sort of pioneered a new way of doing ultrasound guided BBLs, which is. Very efficient, very reproducible, um, and very safe.

Um, it changes the way that we do the injections in the sense that we are not moving our cannula back and forth while we are doing the injections. But it, um, it, it allows us to put it in the safe plane and then it allows us to redistribute the fat afterwards. Have you seen any of these presentations, Dr.

Re no. No, no, not yet. Well, um, I have. Adopted much of their technique. Um, and I've been doing it now for the last few months. And so, um, the first thing is I wanna this from the case I did this past week

sort of explain to. What I did. I bought an ultrasound probe. Um, it's a few thousand dollars in a month in a yearly subscription of a few hundred dollars. So it's not that expensive. It's wireless with Bluetooth technology. So it basically links to an iPad or my iPhone, we put it in a sterile glove and then we use ultrasound gel and we get great quality images.

So what are we looking at? Um, I think, you know, um, This is the key. So when we are doing a gluteal fat grafting case, okay. What we're looking at is we're trying to make sure we stay away from the muscle. So on the bottom, you see this striations on the bottom. Can you see that Sam? That's the gluteus Maximus muscle.

Yes, right here. Okay. What we see here, this, this very, uh, radio opaque or bright line, like straight line right here is my injection cannula. So we know that if this is the edge to the gluteus max muscle right here, we're staying above that. Well, one of things that Dr. Stave and Sino have really kind of hit home and it makes a ton of sense is.

In the subcutaneous tissue you have, or a subcutaneous issue is, is another word for fat. You have a, what's called an investing fascia called Scarpa fascia. And for our listeners, that's what sort of divides the superficial fat from the deeper fat. Again, deeper fat is still in a safe anatomic plane, cuz it's above the muscle.

But if you can inject your fat in a plane, Below this Scarpa's fascia. Okay. You'll notice here. Now this fat is starting to blow up. Can you see the fat going in there? Yep. The fat is actually pushing the muscle down and conversely, it's bringing, um, it's bringing your skin out. So, um, so what does that look like on the skin?

So what I'll do is I'll stick my cannula I'll stick my canula.

The skin in the fatty layer, I'll confirm using the

I'll use the ultrasound to confirm the Safeline and then I'm moving my hand at all. This is not very exciting of a watch, but if you look okay, we'll start on this image on the right first, you can start to see the skin is slowly starting to pop up. Do you see that fat? Up here. You're not as slowly coming up.

Mm-hmm you look on the left right here. You slowly start to expand. So literally what I'm doing is putting in my probe, verifying that the can is in the right verifying that the injections are starting off in the right plane. And then in just three or four, That's in the entire buttock, I'll put in a few hundred CCS in each spot.

So it's actually not that much slower to do it because you're actually blowing with all this fat. It actually sort of gets localized in various compartments within the fatty tissue. And then you just spread it out when all said and done. So what you're actually doing is you're, you know, you put all the fat in and I'm demonstrating the hip, but in this area right here, and then, um, And then.

What we'll do is we'll sort of we'll, we'll see our results. And so what I'm finding is I'm using the same amount of fat as I always have in patients. So in this patient here on the left, it's a preoperative view. It actually puts some fat in the hips already from the front. So she, Rhee has a fairly nice curve, but you can kind of see how there's not a lot of projection.

It's, it's pretty flat here. I did an ultra on the right, and this is from this past week, I did an ultrasound guided VBL. You can see the amount of projection that she has. So I'll put the fat in just in three or four. You see how much that Bud's popping there. Sam mm-hmm. Can you see that? Yep. How much that comes out.

Yes. Um, and, um, you just spread it around all said and done wall. What we have here is we have a doing things which is easy. probably 30 minutes to learn how to do this at the most. It is. Reproducible, uh, and it's safe. We know, with, with complete a hundred percent certainty that all of our fat is in, is in the, is in the, um, is in the fatty layer.

And it's not in the muscles. They're not gonna die of fat embolism. Here's um, other case maybe. Um, so another case from this week, again, this patient is, um, before pretty flat. One central projection. Again, we use ultrasound guidance and you see that there is this nice projection. And we know that this is, uh, this, um, I think that, um, even if this only becomes a rule in Florida and no other state adopts this, I, I think you're gonna see more widespread adoption of this technique in plastic surgery over the ensuing months and years to come.

I don't see any downside to it. Really, um, other than the, the cost of an ultrasound and a little bit of extra time, but in my hands, at least over the last few months, um, I haven't seen any compromise and results and it's an added safety measure so that I can, I can, I can look and be a hundred percent sure that my cannula is in the safe place.

And what I will say is that, um, you know, done a hundred percent confident. I knew which lane, um, I was, I. I was injecting it. And now what, I'm, what I'm, uh, what I'm seeing is that, um, can you see me okay? Is everything yeah. Mm-hmm um, you there? Yes. Go ahead. What I'm, what I'm seeing is probably in every case, or at least every other case, they're gonna be a period of time, um, where.

Thinking I'm getting in the deep fatty layer. And I check with the, with the ultrasound and it actually is in the very superficial muscle. It's actually kind of scary about how, how we can end up in the muscle and actually think we're in the fatty layer. So I really like this added safety measure. I think

[00:18:33] Dr. Sam Rhee: that, uh, it's super interesting, Sam, thanks for sharing that.

Um, I am not sure. Uh, like you said, this is something that's extremely new in terms of, I don't think, uh, anyone a year ago or two years ago, would've thought that this was gonna be something that was either mandated in Florida or something that, um, would be considered to be routine. And I think that there is certainly a lot here to unpack in terms of.

Changing surgeon's techniques. Um, I know that you and I have both done thousands of BBLs in the past, um, safely and well, uh, added safety measures are always, uh, welcome and, uh, and should definitely be looked at, um, I always worry a little bit about regulation in terms of mandatory, anything for surgeons.

Unfortunately, I feel like, um, the ones who generally. Force our hands are the inexperienced surgeons or the surgeons that don't really sort of do well with particular techniques. But in this case, this, this is really interesting. It looks like the results are amazing. Um, I'm really interested to see, you know, I'm, I'm always a little bit more of a conservative guy.

I like to see, um, in your hands, obviously, Sam, this is a. Superior, but you're an exceptional surgeon. Sam let's face it. You're not just an average surgeon. You're an exceptional surgeon. And how about when this gets into everyone? Else's hands in my hands in other people's hands. Um, what are those results going to be like?

What are the long term results going to be like? I have a feeling Sam, no matter what technique you use, you're gonna get an amazing result. You are extremely experienced and you're really good. Um, I would like to see. Uh, multiple systems, multiple surgeons, you know, uh, more results. Um, I feel like, uh, everyone has their own personal.

Preference in terms of what they do. And I know that I, you know, when one of the biggest things I've learned talking to you and Sam or Sal is that we all have similar goals and similar outcomes for many, many things that we do. But we also have little tweaks about how we do certain things. And, um, I feel like this is really exciting.

Um, I certainly am going to explore this and, uh, and find out more, um, I know the two surgeons that you've mentioned who have sort of pioneered some of this work is. Uh, they, they have been on the forefront of fat grafting for a long time. Um, I will say that this is definitely different in terms of the technique.

Like I am so used to dynamically injecting fat, you know, the whole concept of static fat injection. This is the first time, uh, I've heard of it or seen it, um, uh, presented and it's, it's very exciting. Um, but like you said, it does take a little bit of. Of learning and maybe not all surgeons can learn it in 30 minutes.

Like you can just because they're not as, uh, quick as, as you. Um, so I'm really excited. Can't wait to see more. Um, if, if this is something that proves to be, uh, helpful in Florida, as well as everywhere else, um, we very may, may well see this. Uh, widespread. Uh, so it's, it's great that you're on the forefront of it that, uh, you're ch you're examining it and incorporating it.

And I, I look forward to hopefully me and, and other people looking at it and, and doing the same.

[00:22:01] Dr. Sam Jejurikar: Yeah, I maybe I'm exaggerating when I say it takes 20 or 30 minutes to learn how to do the technique. Uh, I, I do have a baseline comfort with ultrasound as I, as I know you do as well. Um, but you know, it is a, it is a, as you allude to, it's a very different way for doing fat injection.

One of the ways that we have always been taught is that you need to be moving your hand while you inject fat. And, um, You know, the reason we do that though, is to avoid one. You know, the major reason we do that is to avoid trauma to blood vessels. So with ultrasound visualization, the stationary injection ensures that we are avoiding those major blood vessels that actually can cause an issue.

So from a safety aspect, if you have that confirmation, it's actually a very, very safe way to do things. Um, the thing that's always a. Concerning the first time you do it is when you're done with these injections. And I didn't, I should have put some pictures of this up. The butt looks kinda lumpy. You know, it looks like you've got four distinct heads of, of broccoli or, you know, cauliflower.

And so it takes a couple minutes to spread it out afterwards to make it look even. Um, but if you are good about injecting in that plane, deep to scarper fascia, but superficial to the anterior gluteal FAS. Meaning in the deep fatty layer. Um, it's very easy to spread it around. It looks good very

[00:23:23] Dr. Sam Rhee: quickly.

I know our national meetings coming, coming up in October and I'm sure we're gonna see a lot more of this as well in there probably.

[00:23:31] Dr. Sam Jejurikar: Yeah, absolutely. Absolutely. Are you planning?

I'm not, this is so the technique I, I presented right here is, was presented as the, at the aesthetic society and a baker Gordon by Delvechio. Okay. There was a, and, and the aesthetic society has really pushed, uh, uh, this a lot. Um, Again, this is a mod, a slight modification of the technique of Patino and Dan Del.

Um, this is their, this is their technique, their

awesome. Wonderful. Well, I think that's, uh, all we got for today. Hopefully our, our, our viewers got something out of this and, uh, thanks again. Uh, I'll see you soon. See you.

[00:24:21] Dr. Sam Rhee: Thank you so much, Sam. I really appreciate it. Take care.