What is a safe BBL?
The safe BBL must avoid fat grafting into or under the gluteus maximus muscle which is felt to the single risk factor for avoiding fat embolus into the superior gluteal vein. Several measures are employed to minimize the risk of fat emboli. These safety measures include:
- Injecting fat only in retrograde fashion while the cannula is moving
- Injecting fat with a grafting cannula that is larger than 4mm
- Injecting fat using a rigid cannula with a single-hole tip
- Placing the patient in a slightly flexed position (ani-flexed)
- Using a sacral port that makes direct injury to the superior gluteal vein impossible
- Knowledge of muscle and vascular anatomy
- Use of a portable ultrasound to guide fat graft transfer
- Limiting the number of BBL procedures performed in a single day
- Excluding the assistance of any other member, but the primary surgeon, for the actual fat injection
Injecting fat only in Retrograde fashion
Injecting fat in a retrograde fashion is a technique commonly used in fat transfer procedures, where fat is harvested from one area of the body and then injected into another area to add volume or improve contour. This technique follows a set of principles to ensure optimal results and enhance the survival of the transferred fat.
The process of injecting fat in a retrograde fashion involves several steps. Firstly, the fat is harvested using a gentle liposuction technique from areas such as the abdomen or thighs. This fat is then processed to remove excess fluid and debris, leaving behind the viable fat cells.
Next, a small incision is made in the target area where the fat will be injected. Using a specialized cannula, the fat is injected in a retrograde fashion, meaning it is deposited in a direction opposite to the natural blood flow. This is achieved by injecting small amounts of fat while slowly withdrawing the cannula, allowing the fat to be evenly distributed throughout the tissues.
The retrograde injection technique is crucial for optimal results as it ensures that the transferred fat has a good blood supply, improving its survival rate. By injecting the fat against the natural blood flow, the fat cells have a better chance of establishing a connection with the surrounding blood vessels, promoting their integration and long-term survival. In addition, by injecting in a retrograde fashion, less pressure is induced upon the cannula thereby reducing the risk of positive pressure forcing fat into a blood vessel.
In summary, injecting fat in a retrograde fashion is a technique that involves harvesting fat, processing it, and injecting it against the natural blood flow using a specialized cannula. By following this step-by-step process and adhering to the principles of retrograde injection, plastic surgeons can achieve optimal results in fat transfer procedures and reduce the risk of embolization.
Injecting fat with a Cannula larger than 4mm
Injecting fat with a cannula larger than 4mm requires specific steps and precautions to ensure safety and prevent complications such as accidental puncture of blood vessels and pulmonary fat embolism. Here are the steps and safety measures involved in the procedure. This is because a 4 mm cannula caliber is less likely to inadvertently penetrate structures. This is in comparison to smaller caliber cannulas such as 2 to 3 mm cannulas that are sharper and more prone to penetrating structures.
Injecting fat with a single-hole cannula
Using a single-hole cannula has the advantage of ensuring that the fat is positioned with more accuracy. This is because the traditional cannula that maintains multiple holes will result in the grafting of fat circumferentially and thus less control. The premise is that the more localized the graft material is positioned, the less likely it is to inadvertently lose track of the transferred fat.
Fat grafting with the patient in semi flexed position
Fat grafting is a popular technique used in cosmetic surgery, particularly in Brazilian Butt Lift procedures, to enhance the shape and volume of the buttocks. One method of performing fat grafting involves positioning the patient in a semiflexed position. This position allows for better access to the targeted areas for both liposuction and fat injection.
The process begins with the patient lying on their stomach, with the knees slightly bent and the upper body raised. This semi-flexed position reduces the risk of inadvertently pointing the cannula into the deeper planes of the buttocks. By avoiding aiming the cannula into the deeper buttock compartment, the risk of injecting any fat in the vicinity of the superior gluteal vein is minimized.
Using a sacral port injection site
A sacral port injection site is a medical procedure used to administer medication or fluid directly into the sacral area of the body. The sacrum is located at the base of the spinal column, just above the coccyx bone. Utilizing a sacral port injection site restricts the ability of the cannula to penetrate the deeper planes of the buttock cavity thereby eliminating any possibility of penetrating the superior gluteal vein.
What is a portable ultrasound?
Portable ultrasound can be used to guide your fat injection. Using specialized cannulas, you can not only visualize the cannula but also the fat as it exits the cannula tip. By being able to visualize the safe plane, the subcutaneous fat, you can localize the transferred fat in between the skin and the muscle fascia. The boxed area in purple above describes an area where the ultrasound should be used as this is the danger zone located near the gluteal veins, the vessels identified in the mechanism of fat emboli.
Not only is an ultrasound helpful in performing a safe BBL, but it can also assist in cases where a buttock implant is involved. Patients who already have a buttock implant or those who desire buttock implant augmentation simultaneously with their fat transfer must be assured that no fat is positioned near the implant. If the fat graft is positioned near the newly placed implant or in the capsule surrounding a previously placed implant, there is a risk of fat dying and getting infected. Another set of patients who have experienced complications with their previously placed buttock implants may desire simultaneous implant removal and fat transfer. In these patients, it is prudent to use an ultrasound to ensure that fat is not replaced within the void pocket created following the removal of the buttock implant.
Knowledge of buttock muscle and vascular anatomy
The buttock muscles, also known as the gluteal muscles, play a significant role in the movement and stabilization of the hip joint. The three main muscles of the buttocks are the gluteus maximus, gluteus medius, and gluteus minimus.
The gluteus maximus is the largest muscle in the buttocks and its primary function is to extend, abduct, and externally rotate the hip joint. It also helps in maintaining an erect posture. The gluteus medius and gluteus minimus are smaller muscles located on the lateral aspect of the hip. They primarily function to abduct and internally rotate the hip joint, as well as stabilize the pelvis during walking or standing on one leg.
The blood supply to the buttock muscles is provided by the superior and inferior gluteal arteries. The superior gluteal artery arises from the internal iliac artery and mainly supplies the gluteus medius, gluteus minimus, and surrounding muscles. The inferior gluteal artery, also originating from the internal iliac artery, supplies the gluteus maximus muscle.
Understanding the vascular anatomy associated with the buttock region is important for surgeons and healthcare professionals involved in procedures such as gluteal augmentation or reconstruction. The knowledge of the vascular supply helps to prevent potential complications during surgical interventions, ensuring optimal outcomes for patients since it will diminish the risk of penetrating the deeper buttock cavity where the gluteal veins reside.
Limiting the number of BBL procedures performed in a single day
To limit the number of BBL procedures performed in a single day, several measures and strategies can be implemented. Setting a Maximum Daily Limit: Establishing a maximum number of BBL procedures per day can help ensure that surgeons are not overburdened and can focus on each patient’s safety and the effectiveness of the procedure and not be negatively affected by fatigue.
The reason this precaution is important is that it has been postulated that the inadvertent placement of the grafting cannula into the deeper buttock cavity may have been perpetrated by surgeon fatigue.
Excluding the assistance of ancillary surgical staff from injecting
The exclusion of ancillary surgical staff from performing injections is rooted in several safety concerns. Injections are delicate medical procedures that require precision and expertise, as well as an understanding of potential complications. Non-surgeons and non-experienced individuals may lack the necessary knowledge and skills to perform injections safely, which can lead to adverse outcomes for patients.
One of the primary reasons to exclude ancillary staff from performing injections is the potential risks associated with their lack of training. These individuals may not have received formal education and hands-on experience in administering injections. Consequently, they may not be familiar with the correct injection technique, appropriate dosage, or potential side effects. This lack of expertise can result in errors, such as injecting the wrong medication, administering an incorrect dosage, or unintentionally causing harm to patients.
In conclusion, excluding ancillary surgical staff from performing injections is justified due to the safety concerns, potential risks, and legal and ethical implications involved. Injection procedures demand a high level of expertise that untrained individuals or non-surgeons may not possess, making it crucial to prioritize patient safety and adhere to legal and ethical standards in healthcare settings.
Conclusion: Safe BBL
In summary, multiple protocols have been recommended to avoid the inadvertent entry of fat cells into the deeper buttock cavity where entry of fat cells into the gluteal vein is feasible. If you are concerned about your BBL safety, we encourage you to make a consultation with a SurgiSculpt surgeon to determine whether you are a good candidate for a safe BBL.