A few days after undergoing cosmetic surgery, Chelsea was in a Philadelphia emergency room with what looked like a third-degree burn. The skin around her thighs had turned black, hardened and blistered. The burning sensation was so intense she was struggling to breathe.
Chelsea, 29, had undergone an increasingly popular cosmetic procedure called a Brazilian butt lift, where fat is liposuctioned from one part of the body—usually the abdomen or thighs—and then injected into the buttocks in hopes of giving the patient an hourglass figure.
“I was hoping to do a mommy makeover and it turned into a complete nightmare,” said Chelsea, who did not want to use her last name for fear of hurting her career prospects. Before the surgery, she was studying to become a nurse. These days, she can’t sit without experiencing a burning sensation.
The Brazilian butt lift is among the most dangerous aesthetic procedures. In 2017 it had the highest death rate of any cosmetic surgery in the US, according to a group of leading clinical plastic surgery societies. Patients have been left paralyzed as a result of the surgery, or experience long-term pain due to nerve damage. A taskforce that looked into the high death rate with Brazilian butt lifts found that about 3% of surgeons had experienced a patient death after the procedure.
Despite this, as curvy celebrity influencers like the Kardashians fill social media feeds, Brazilian butt lifts have only grown more popular. Globally, butt augmentation, including silicone implants, was a $1.5 billion market in 2020, according to Grand View Research, which projects the market will grow 22% a year and reach $6.6 billion by 2028. In recent years, the number of surgeries has “increased dramatically,” said Lina Triana, president-elect of the International Society of Aesthetic Plastic Surgery. In 2020, more than 40,000 butt lifts were performed by certified plastic surgeons in the US, twice as many as five years prior, according to ISAPS's latest statistics. These surgeries aren’t cheap and also aren't covered by insurance. The average cost of a Brazilian butt lift is $4,807, according to the statistics from the American Society of Plastic Surgeons. That price doesn’t even cover “anesthesia, operating room facilities or other related expenses,” an ASPS spokesperson said.
The alarming number of problems with Brazilian butt lifts is largely the result of lacking regulations. While plastic and cosmetic surgery may sound synonymous, they are not. Across the US, a couple of months of training earns doctors the right to call themselves a cosmetic surgeon. On the other hand, a plastic surgeon certified by the American Board of Plastic Surgery requires at least six years of specialized training.
Practicing medicine requires a license issued individually by each state. But requirements are murkier when it comes to medical specialties. The federal government does not oversee the training and credentialing of specialists. Instead, the American Council on Graduate Medical Education provides standards for graduate medical training in all specialties. After graduating from specialty-specific residency training, independent nonprofit organizations called specialty boards provide multiyear residencies or fellowships for doctors who want to demonstrate their competence in a particular field of medicine. Board certification can get a physician hospital privileges and credibility. Still, it is an entirely voluntary process.
To further complicate matters, not all boards are equal. The American Board of Medical Specialties, widely accepted as the gold standard in physician certification, recognizes only 24 boards as meeting the criteria for specialty medicine. One of these boards includes the American Board of Plastic Surgery, which requires its doctors to undergo robust training and perform thousands of surgeries over the course of six or more years before they are granted certification. But there are plenty of other boards that don’t meet the AMBS’s nationally recognized standards. The American Board of Cosmetic Surgery, for example, allows doctors to market themselves as board-certified cosmetic surgeons after a one-year fellowship that includes performing a minimum of 300 aesthetic procedures and passing a two-day exam. The American Board of Cosmetic Surgery did not respond to a request for comment for this story. The doctor who performed surgery on Chelsea was not a board-certified plastic surgeon. “You can pay fifty bucks to have a plaque on your wall to say you’re board certified,” said Susan Witt, a medical malpractice attorney representing several women who have experienced the worst side of this issue in Georgia, including Chelsea, who went to Georgia seeking surgery from an Instagram-famous doctor. Often patients shopping for doctors simply don’t know these physicians have minimal surgical training. This blind spot is part of what makes the Brazilian butt lift so dangerous. It can result in severe health problems and even death if an unskilled physician uses improper techniques. For example, if fat is mistakenly injected into the wrong place, then it can travel to a person’s heart or lungs, which causes immediate death.
Chelsea experienced something called fat necrosis after her procedure. Oxygen flow to some of her body's tissues became restricted, causing the cells to die. Fat necrosis is one of the more serious things that can go wrong with a Brazilian butt lift. It is usually caused by poor technique on the surgeon's part.
It’s not only the credentials of cosmetic surgeons that aren’t regulated. In some states, doctors are free to perform surgery in any office setting, whether or not the facility is equipped to handle complications should they arise. And doctors without good credentials are likely to be prevented from performing cosmetic surgeries in establishments with stringent vetting processes, like hospitals.
In Georgia, neither the attorney general nor the state medical board oversees office-based surgeries. Witt, the attorney, has been publicly lobbying to change that, including by advocating for the creation of a regulatory body to perform office inspections and investigate complaints. The Georgia Composite Medical Board currently does not carry out checks of office-based surgeries but said through a spokesperson that it has taken steps in recent years to improve safety by updating guidelines for physicians. In 2021, the board was given the authority to establish more recommendations for office-based surgery. Some newly proposed rules are pending final approval. Guidelines and regulations for office-based surgeries exist in 34 US states and Washington, D.C., the rest are completely unregulated. The regulations that do exist also differ from state to state and vary widely in stringency. For the average consumer, it’s difficult to assess whether a doctor has the right board and facility accreditations. Opportunistic and under-qualified practitioners are capitalizing on this asymmetry of information.
“You’ve got physicians who can’t earn a living doing what they’re doing, so they branch out into cosmetics. Why? It’s a cash cow. There’s no insurance involved. You want it, you pay for it,” said William Rosenblatt, president of American Association for Accreditation of Ambulatory Surgery Facilities.
“We see horror stories all the time,” Rosenblatt, who is also a plastic surgeon, added. While there is a certain amount of risk with any surgery, the rate of Brazilian butt lift fatalities had become so alarming that in 2017 several plastic surgery societies joined ranks to create a task force designed to tackle the issue.
They found that part of the standard surgical technique for butt lifts was creating unnecessary risk. Instead of injecting fat into muscle, which can send the fat straight to the heart or lungs if a vein is mistakenly punctured, they instead recommended injecting the fat into the tissue between the body’s skin and muscle. They also recommended using larger surgical instruments less likely to puncture a vein.
In light of the recommendations, butt lifts have become less fatal, at least among board-certified plastic surgeons. The most recent survey of certified surgeons showed that the mortality rate for butt lifts dropped to 1 in 15,000 surgeries in 2019 from 1 in 3,000 surgeries in 2017, putting it at a similar risk level as a tummy tuck.
But the number of fatalities may be far higher than the numbers suggest, given a doctor doesn’t need to be a board-certified plastic surgeon to perform a butt lift — and it’s unclear whether physicians who aren’t would have adopted the new procedures. Doctors don't need to report cosmetic procedures that result in hospital transfers or deaths to these various societies. And the lack of state and federal oversight means that deaths and serious adverse events aren’t collected in a centralized way, making it difficult to establish how frequently they occur.
A big part of the problem, said Thomas Terranova, chief executive the American Association for Accreditation of Ambulatory Surgery Facilities, is that aesthetic surgeries simply aren’t seen as an invasive, potentially life-threatening medical procedure.
"It’s looked at as a vanity project like hair, nails, makeup,” he said. “So there’s this lack of sobriety when we evaluate it and I think ultimately that’s one of the big challenges.” A year after surgery, Chelsea has still not fully recovered. She is experiencing burning sensations in her back, stomach and butt area. Nerve damage and bladder incontinence have impacted her social life. She sees a therapist weekly now to deal with the trauma.
“I don’t want to do much of anything,” Chelsea said. “The fun outgoing Chelsea is dead right now and I have to revive her.”