Jennifer Arias was 29. She flew from New York to Miami in August for liposuction and a BBL, texted her sister at 4:18 in the morning that she was going in, and died that day of fat emboli in both lungs. Her mother had begged her to cancel: “Be a mother first, and a woman second. If something happens to you, what will become of your daughter?” The medical examiner called it an accident. The sheriff’s homicide bureau has an open case. NBC6 counts at least five other deaths at the same clinic since 2018. Where Is The Buzz reported it Friday.
Two days earlier, on a British talk show, Katherine Ryan said she might get one too. “So I might do that, but only mildly, because it is the deadliest surgery you can get.” Then: “So, I might not do it because I might die, but worth it if I don’t.” LADbible ran it under the NHS line that the BBL has the highest death rate of any cosmetic operation.
They are both right about the name. Here is how it earned it, and why I still do the operation.
How It Earned the Name
“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. A vein carries it to the lungs. That is the whole mechanism, and it is why every BBL embolism had one thing in common. Jennifer Arias’s cause of death, bilateral pulmonary fat emboli, is that sentence in a medical examiner’s handwriting.
What Changed
“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.”
“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 name is from the years before the probe. The operation Katherine Ryan is joking about and the one I do in El Paso are not the same operation.
Why Miami Keeps Making the News
“In general, medicine is less expensive outside of the United States. The cost of the OR and anesthesia is lower, and salaries for staff and supplies are lower. But in my experience, the very good surgeons from abroad, and I know many of them, charge very close to top surgeons in the United States. So when you see a really low fee, it is probably a surgeon that is not as busy as they would like, and they have to lower prices to attract patients.”
“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.”
The clinic in the Arias story told reporters the doctors who operate there are independent contractors. Read that sentence twice before you book a flight. The rest of the price conversation is in BBL cost in Texas.
Britain Moved the Same Week
Filler pushed into the buttock, the so-called liquid BBL, is coming off the British high street. On October 21 the government there said only qualified medics may inject filler anywhere other than the face, with fines for anyone else, after Alice Webb, 33, a mother of five, died in 2024 following a liquid BBL at a salon in Gloucester (ITV News). Different substance, same lesson. Nobody could see where the needle was.
The Question That Would Have Saved Her
“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.”
One question. If the answer is no, or a shrug, leave.
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.”
“If I know a patient is smoking, I will refuse to do most procedures, but especially any facelift or neck lift, any breast lift or breast reduction, and tummy tucks. All these procedures rely on flaps and capillary blood flow.”
| Say no, or not yet | Why |
|---|---|
| Thin fat layer, men, massive weight loss | Nowhere safe to put it; the probe helps, it does not create fat |
| BMI over 35 | The BMI read |
| Still losing on a GLP-1 | Weight stable first, three months |
| Nicotine in any form | Not on my table |
| A cheap quote and a flight | See the section above |
“There is a tendency toward the more natural look, so there has been a decrease in the number of BBLs nationally. But at the same time, a lot of patients are turning to fat transfer or donor grafts like alloClae instead. In the Southwest, there’s still a demand for the bigger hips and greater projection.”
Katherine Ryan wants it “only mildly.” Good. That is the version worth having, with a probe on the skin and a board-certified surgeon holding the cannula. The surgical version of this post, with the protocol, is on agulloplasticsurgery.com; the checklist version is on the Southwest Plastic Surgery post. BBL after buttock implants is the other way to projection.
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?
Before you book a BBL anywhere, ask one question: is there an ultrasound in the room? If you want to hear mine answered, come in.
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.