Background: Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? Methods: Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. Results: Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. Conclusions: Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Background: With the increase in popularity of fat transfer to the buttocks in body contouring surgery, new patient subsets are emerging. The gender confirmation patient has specific characteristics that must be addressed to achieve the best outcomes. Methods: The authors performed an observational prospective study including 36 consecutive patients who underwent body feminization as a gender affirming operation using large-volume fat transplantation with or without gluteal implants. Results: Thirty-six consecutive male-to-female transgender patients have undergone large-volume fat transplantation to the buttocks performed by the authors, between July of 2016 and January of 2019. In 12 of these 36 cases, large-volume fat grafting was supplemented by intramuscular placement of silicone implants. The mean waist-to-hip ratio before surgery was 1.11, and this improved to 0.81 after surgery (fat transfer–only group, 0.88; fat transfer plus implants group, 0.75). Conclusions: The transgender patient is a unique patient requiring a specific set of surgeon’s skills and intraoperative strategies to achieve good outcomes. Composite solutions with both implants and lipofilling lead to better outcomes in terms of waist-to-hip ratio in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: Fat grafting is the favored option for buttock augmentation by most surgeons, and buttock implants are mostly regarded as second choices. Accepted options for buttock implant pocket dissection are subfascial, intramuscular, and submuscular. To overcome the limitations of both intramuscular and submuscular pockets, and combine the benefits of both, the authors present a novel dual-plane pocket dissection. The dual-plane pocket involves a submuscular plane in the cranial half of the pocket and switching to an intramuscular plane in the caudal half. With this study, the authors describe their experience with this technique and analyze the dissection of the pocket on human cadavers. Methods: The authors reviewed 82 consecutive composite gluteal augmentation cases from March of 2019 to November of 2019. In all cases, the implant was placed in the “dual plane.” The clinical study was supplemented by 10 hemigluteal dissections in five cadavers following the surgical technique, with assessment of the anatomical components of the implant pocket created. Results: Patients who underwent this technique showed excellent soft-tissue coverage over the implants. The main complications observed were seroma formation in five of 82 patients and temporary sciatic pain in four of the patients. The anatomical study confirmed double muscle coverage of both gluteus maximus and partial medius in the upper pocket pole and intramuscular gluteus maximus implant position in the lower pole. Conclusion: The authors present the dual-plane dissection technique as a valuable innovation to improve soft-tissue cover for the upper implant pole in buttock implant surgery.

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