They come to Miami from all corners of the country, to the city that has established itself as the mecca of the Brazilian butt lift, or BBL, a cosmetic surgery procedure to increase the butt. Despite the problems that have accumulated over the years, including clinics operating in legal gray areas and the highest number of cosmetic surgery deaths in the country, the latest statistics show that nothing can move Miami from the top spot. While mortality has decreased thanks to stricter regulations and more precise surgical methods, all is not rosy and much of this vibrant industry remains in the shadows.
Thousands of people travel to South Florida each year to undergo this surgery, which involves extracting fat from various parts of the body through liposuction and injecting it into the buttocks. According to the latest statistics, of the nearly 30,000 buttock augmentation surgeries performed in the United States last year, half were performed in the Southeast region, which includes Florida. Miami, with hundreds of plastic surgeons and dozens of clinics, is the epicenter of the dynamic American cosmetic surgery industry, and the BBLs are the crown jewel.
It is the fastest growing cosmetic surgery procedure in the last decade. While the number nationally has remained flat in recent years, between 2022 and 2024, it has doubled in the Southeast, according to data from the American Society of Plastic Surgeons. BBLs were also the cosmetic surgery with the highest mortality rate. South Florida leads the nation in the number of cosmetic surgery-related deaths, and the majority of cases were from BBLs. Concerned, state lawmakers have passed laws regulating the practice, and the industry appears to have matured with a greater focus on patient safety. But the field still operates in a large regulatory vacuum, and complications still occur, particularly in postoperative care, according to surgeons and experts consulted for this story.
The BBL explosion in Miami predates the image spread by the Kardashians. Experts point out that its popularity is largely due to the influence of the aesthetic ideals of the large Latin American diaspora living in the region, the warm climate and an image-obsessed culture, fascinated by the promise of physical transformation. Studies show that many patients believe that reshaping their figure boosts their confidence and see BBL as a way to achieve an ‘ideal physique’. The studies also point to the influence of social comparison, with exposure to “edited images of curvy bodies” on social media as an important factor in the conception of these norms.
“This procedure is so popular because it is so powerful — there is no other that can produce these results,” explains Dr. Pat Pazmiño, a Miami plastic surgeon and ASPS member. “In the past, in plastic surgery, when we wanted to define contours or increase volume, we used implants. But you introduce a foreign body and the implants have to be replaced. On the other hand, when you use the patient’s own fat graft, you can create any contour, of any size, in many areas where implants should not be used.
Pazmiño was part of a team that found that most deaths from BBL occurred due to a complication called pulmonary fat embolism (PFE), which occurs when fat enters the bloodstream through the veins of the gluteal muscles and blocks blood flow to the lungs. To avoid this, the adipose tissue must be injected directly over the muscle, avoiding penetration, a method that was implemented as state law and widely adopted in the profession. Pazmiño also promoted the use of ultrasound during surgery to improve visibility and avoid puncturing the muscle.
The problem seemed to have been solved, but the deaths continued, mostly in low-cost clinics that had helped boost Miami’s popularity as a BBL mecca. “Women from all over the US were coming to Miami to get BBL and they were dying. It gave Florida and Miami a terrible image,” says Pazmiño. “They offer dangerously low prices. If you go to Google and type in ‘BBL price Miami,’ you’ll see prices as low as $2,000 or $2,500 at these clinics, which is crazy. Because when you’re working with a certified surgeon, our prices are five or six times that amount,” he adds.
In 2023, more laws were passed, but this time, instead of focusing on method, they focused on practice. For example, the doctor had to see the patient for the first time at least 24 hours before the operation and could only see one patient at a time.
“Many of these surgeons in low-budget clinics met patients for the first time a few minutes before the procedure. It is not possible to create a strong doctor-patient relationship in such a short period of time,” said Pazmiño. State law also states that surgeons cannot outsource the liposuction or fat grafting portion of the procedure to others, nor can they leave the operating room during the procedure.
There is no national system to track the outcomes of BBL cases, but the measures appear to have caused a major shift in the South Florida market, with surgeons, patients and lawmakers “overlooking” the safety issue, Pazmiño says. “The good news is that the number of deaths from PFE has decreased significantly in the year since the law was passed in 2023. The bad news is that patients are still dying from BBL, but from other causes, including infections, hemorrhagic shock from bleeding, abdominal organ perforation, and inadequate postoperative recovery care.”
Current regulations do not require the surgery to be performed in a hospital or outpatient surgery center, where the patient can spend the night for observation, and many procedures are performed in offices in shopping malls that do not offer postoperative care.
Competition is fierce in Miami’s bustling BBL market, and he’s turned to social media to find new customers. Dozens of cosmetic surgery centers seek to attract customers with Christmas or Halloween sales, packages or combinations of simultaneous surgery and installment plans. A single BBL, for example, can cost $4,500 and a tummy tuck $3,500, but the combined price is $8,500. The combined price may include more procedures, to “save time and money,” the ads say.
Surgeons explain the benefits and decisions in videos on TikTok, Facebook or Instagram, and clinics post before-and-after photos, patient interviews and tips for achieving the desired result. Images of patients in underwear or half-naked show the areas the surgeon will work on with dotted lines painted with markers, and post-procedure images — sometimes so fresh that bruises are visible on the skin — accompanied by hashtags like #BBLMiami or #totaltransformation.
Those interested look to Facebook groups for recommendations on which doctor to use or where to get post-op care, making sure it’s a “legitimate place, with certified professionals.”
Post-operative care is one of the least regulated areas of the industry. There is a whole network of post-operative care services revolving around BBLs, particularly for those from abroad. Videos on social media show some post-surgery patients lying face down in the back of a car on disposable absorbent pads wrapped in compresses from the clinic to a hotel. Others offer bedside care, helping them change pads, dress or bathe. Still others offer “shaping” massages to help “sculpt” the desired figure. At the Miami airport and nearby hotels, it is common to find post-surgery patients wearing tight compression garments around their waist, thighs and buttocks.
That concern led Philadelphia resident Valerie Fiorentino to cancel her plans to hold a BBL in Miami. “I ended up hearing so many horror stories about complications and not getting proper care after surgery. I heard from girls booked into recovery homes with the intention of being under the care of a registered nurse, only to be lied to and not given proper treatment for blood clotting and infections,” she notes.
Dr. Michael Salzhauer, known on social media as Dr. Miami, where she has millions of followers, says that “aftercare is just as important as the surgery itself, especially from a safety standpoint,” and that many don’t anticipate “how much medical attention and care will be needed” after these procedures. Salzhauer created a team of nurses he says he trained over the years who watch over his patients 24/7 for days at a hotel just yards from his clinic in the affluent Bal Harbor neighborhood north of Miami Beach. “If you don’t take care of them right — if you don’t clean them, if you don’t get their vitals, if the drugs aren’t given at the right time — there are a lot of things that can go wrong,” says the surgeon, who estimates that half of plastic surgery deaths in South Florida occur after surgery.
“People need to know that it’s a serious operation. It’s surgery. It’s not like they’re going to get a haircut. They have to think about all the medical details, the aftercare and all that, so that the result is good and there are no problems,” he adds.
Dr. Pazmiño, for his part, stresses the importance of people ensuring they are treated by a certified surgeon, but adds that “you have to be a little more specific, because it’s like telling someone, when they get into a car, to drive carefully.” Patients should ask their doctor if a hospital would allow them to perform the surgery, to ensure they are actually board certified. The Florida Department of Health did not respond to a request for comment.
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