October 26, 2026 | Body Contouring, Brazilian Butt Lift, Patient Safety
A 29-year-old mother flew from New York to Miami in August for liposuction and a BBL and died the same day. The medical examiner found fat emboli in both lungs and called it an accident; the sheriff’s homicide bureau has an open case; NBC6 counts at least five other deaths at that clinic since 2018 (Where Is The Buzz, October 23). Two days earlier a British comedian told a talk show she might get one anyway, “because it is the deadliest surgery you can get” (LADbible).
The name is earned. Here is why, and what is different on my table.
The Mechanism
“By visualizing exactly where we’re at, we’re avoiding intramuscular or deeper injections, which can cause fat embolism, a very severe complication. There have been no cases of fat embolus when fat has only been injected in the subcutaneous fat. The only cases of fat embolism have all had intramuscular fat injections. That’s the importance of the ultrasound. It makes the procedure safer by knowing exactly where you’re at at all times.”
Fat in the muscle finds a vein. The vein goes to the lungs. Bilateral pulmonary fat emboli is that sentence on a death certificate.
The Protocol
“Even before 2024, I had already adopted many of the recommendations made beforehand and after by the plastic surgery societies. We continued using blunt tips with cannulas larger than 4 millimeters. We avoided injections into the muscle. We used ultrasound to visualize the location of the tip of the cannula while injecting, making sure not to perform any intramuscular injections. I always use an upward-angled cannula, and the patient is positioned in a jackknife type position.”
“The ultrasound shows us exactly where the tip of the cannula is while we’re injecting fat into the buttock. Ideally, the cannula should be injecting fat into the deep fat layer above the muscle. We inject some fat in the superficial fat layer for shaping, but the bulk of the volume is injected in that deep compartment.”
| Step | What it prevents |
|---|---|
| Ultrasound on the skin, tip in view | Injecting into or under the muscle |
| Blunt cannula over 4 mm | Piercing a vein |
| Upward angle, jackknife position | Drifting deep |
| Deep fat layer for volume, superficial for shape | The muscle plane entirely |
The longer version is in ultrasound-guided BBL safety; the operation itself is on the BBL page.
The One Question
“The most important thing is whether the surgeon is using ultrasound or not. No matter the experience level of the surgeon, there’s always a risk that you can misjudge and be in the wrong plane, and this is completely avoidable with direct visualization.”
“I think the biggest achievement of WAGS while I was Vice President and President was educating patients and surgeons, both members and non-members, about safety. Also incorporating ultrasound into the BBL procedure, and creating a course and a certification for using ultrasound for Brazilian butt lifts.”
The Cheap Quote
“I would also add that sometimes these kinds of prices are actually offered right here in the United States, often in clinics that do very high volumes. These are very common in Florida, for example. A lot of times, we are not sure who is performing the procedure, whether it is a board-certified plastic surgeon or a physician from another specialty. And often the recovery and follow-up are cut down, as these surgeons only come in to perform the procedure, and then the clinic is the one that continues the follow-up.”
“Even though El Paso is a border city, there really aren’t that many other providers performing these procedures. I do think this changes in some areas, like Florida, where non-board-certified practitioners are performing them. But as patients have become more educated, and as they learn there’s a high risk of pulmonary embolism when this procedure isn’t done correctly, they are seeking board-certified plastic surgeons, especially the ones who use ultrasound guidance, like myself.”
What a fee covers here is in BBL cost in Texas.
Britain Moved the Same Week
On October 21 the British government said filler injected anywhere other than the face, the liquid BBL included, will be for qualified medics only, with fines for anyone else. Alice Webb, 33, a mother of five, died in 2024 after a liquid BBL at a Gloucester salon (ITV News). Filler in a salon, fat in a clinic, the same ending. Nobody could see where the tip was.
Who Should Still Say No
“That’s especially true of male patients, who have a very thin fat layer, and also massive weight loss patients, who have a very thin fat layer, so they’re at higher risk for intramuscular injections.”
“I am always an advocate for patients to continue their weight loss journey to get to a healthier weight and BMI to decrease complications.”
“With GLP-1s, it’s a little bit less clear, because the weight loss usually happens in a period between three to nine months, sometimes a year. But the patients seem to plateau a little bit quicker, and they seem to be ready a little bit faster after they plateau, usually about three months.”
Thin fat layer: the probe helps, it does not make fat; buttock implants are the other road. BMI over 35: the BMI post. Still losing weight: three months stable first. Nicotine: not on my table. Recovery is week by week here. The commentary is on drworldwide.com; the checklist is on the Southwest Plastic Surgery post.
Why Choose Dr. Agullo
Dr. Agullo is certified by the American Board of Plastic Surgery and the American Board of Surgery, completed his plastic surgery fellowship at the Mayo Clinic, and serves as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. He has been a Castle Connolly Top Doctor for thirteen consecutive years, 2014 through 2026. He served as Vice President and President of the World Association of Gluteal Surgeons and was among the first plastic surgeons certified by WAGS in ultrasound-guided fat transfer to the buttock.
Ready to Talk?
Ask any surgeon one question before a BBL: is there an ultrasound in the room? Mine is. Come see it.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful
Find me at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
