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The Fat Is Not Rotting: What 33,000 Searches a Month Get Wrong About the BBL

Black and white photograph of a woman seen from behind in a fitted garment, holding a phone at an angle with the screen unreadable. Illustrative image, not a patient. Commentary on the "BBL smell" search term by Frank Agullo, MD, FACS.

I browse the search metrics for my practice site on occasion, and one statistic never fails to catch my eye. Roughly 33,000 searches a month are done for “bbl smell.” Not “bbl safety.” Not “bbl recovery.” BBL. Smell.

I have a strange tug of war with myself about ranking for it.

The term became an infamous joke a while back, complete with the hashtag, the reaction videos and a few celebrities getting a laugh out of it on air, and somewhere in that explosion it hardened into something that sounds medical enough to be credible. The fat is rotting, went the theory. They cut out fat, stuff it into a butt, the fat dies, and it causes a stink you can smell on the bus.

I was a founding vice president of the World Association of Gluteal Surgeons and became its president a couple of years later, so a good part of my career has centered on this single procedure. Of all the things I am sure about related to the BBL, this is the one I am surest of: the fat is not rotting.

A search term is not a symptom

Nobody gets to 33,000 searches a month on a complication rate. It reached that level of notoriety because culture put it there. The BBL exploded, a lot of it was performed inexpensively and in volume, and many patients were left with a garment, a pillow and minimal instruction on the critical second week. Some of those patients noticed an odor, and the internet amplified the message.

That is the intriguing part for me, more so than the odor. Anyway, I already composed the full explainer for my practice site, and the hygiene protocol lives here. This column is neither. It is about the query.

What walks in the door

When a patient presents believing she smells, in the order I see things, it typically looks like this.

Most commonly, the garment. The patient has been wearing it round the clock for a week and a half straight. Sweat builds between garment and skin, a little lymphatic fluid is still weeping through the port incisions, and all of it has been cooped up under fabric the entire time. That is a laundry issue dressed up as medical history, not a BBL issue.

Occasionally, a seroma. That is a fluid collection in one of the liposuction sites, and it may smell when it starts draining. A quick drainage in the office normally remedies it.

Now and then, a stitch. A suture works its way out from under a scab, and the patient reads online that it must be dead fat. Our nurse practitioner runs into this one on the follow-up calls all the time: “Sometimes it could be the suture, sometimes it could be a scab. If the scab looks like it’s coming, you could ask your massage therapist, because sometimes you might have a little suture underneath it and it just needs to be removed so that way it could completely heal.”

Infrequently, it is an infection. I said this in a Q&A on recovery a couple of weeks ago and I will say it again here, because it is the honest answer: “Usually, it’s a very straightforward procedure with very low complication rates. But we’re always vigilant for any signs of infection, like redness, purulent discharge, pain in one area that continues to increase, or fluid buildups in the areas of liposuction, which could be seromas.”

Did you notice what is not on that list by itself? Smell.

The nurse practitioner has the best way of handling these calls, a simple test I definitely did not come up with: “As long as it’s not red, it’s not draining, it doesn’t smell foul, then it’s not an infection. It just means it’s healing from the inside out.”

Red. Draining. Foul. You need all three. A sniff coming off the compression garment on day ten does not make that list. It is a straightforward reminder that the garment needs washing.

What the search term really represents

This is where my personal opinion comes in, and it may not thrill my colleagues.

I believe “bbl smell” has far more to say about the sale of the operation than about the procedure itself. Someone is selling high volume at rock bottom prices. Patients often do not meet their surgeon until the morning of surgery, if at all. They get a pamphlet at discharge and zero plan. Nobody referred them to a lymphatic drainage therapist, nobody handed them a backup garment, and there is no number to call on day ten. Their only recourse is the comment section, full of other women with the identical issue, and not one of them has a surgeon available either.

Run enough patients through that model and some will smell something in week two with nowhere to take it. Thus a search query, which morphs into a joke. What disturbs me about the gag is that the butt of the joke ends up being the patient. The responsibility rests on whoever sent her home with that little guidance.

The BBL in the videos is not the one I do

I use ultrasound guidance for the fat grafting, which lets me place the fat only in the subcutaneous layer, never into the muscle. That single change is the biggest safety advance this operation has had, and championing standards like it across borders is the reason the gluteal surgeons’ association exists. I also keep the volume conservative, enough to alter the shape without taxing the surrounding tissue past its capacity. Fat grafted gradually into the correct layer with blood supply on all sides survives. Fat forced into areas the tissue cannot support does not, and the “necrosis” stories people have seen are a direct result of the latter, not the former.

This holds true for my standard Brazilian Butt Lift and for the Supercharged BBL, where I keep the grafting at the same reasonable level and add an intramuscular implant instead of depending on fat alone for projection.

Then there are all the extras the lower-tier version neglects. My patients go home with a garment plan that keeps one in the wash and one on the body, Hibiclens, a bidet on the shopping list, lymphatic drainage booked two to three times a week for the first month, and calls from a nurse practitioner who has handled every conceivable version of the second week. That is not a handout. It is a program, it costs me something to run, and it is precisely why the BBL I perform does not cause an odor. I am not backing down on this. It does not happen.

If anything, the surprise tends to go the other way. From the same Q&A: “Most patients are surprised that the procedure itself and recovery are easier than they thought.”

If you Googled it late at night

Wash the garment. Rinse rather than wipe. Keep your scheduled massages. The smell you may encounter in week two is almost certainly fabric, a hot day and the healing process. Then try the red, draining, foul test. All three present, call your surgeon right away. None, well, it is time to wash the garment.

One final thought. If the surgeon you are considering cannot tell you who will answer your call on day ten, that is your odor. Move on.

I am double board-certified, fellowship-trained at Mayo Clinic, and a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly has recognized me as a Top Doctor for 13 consecutive years. I helped start the World Association of Gluteal Surgeons because this operation needed a standard, and 33,000 searches a month is what it looks like when the standard is not met.

Ready to Talk?

If the Brazilian Butt Lift has crossed your mind and you want the version that includes a dedicated recovery program, the first step is a consultation. Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

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Where the Fat Goes: The Science of BBL Survival, From My OR

Moody greyscale photograph of a woman resting face down on a recovery lounge in a surgical compression garment. BBL fat survival science explained by Frank Agullo, MD, FACS, Dr. WorldWide.

Every BBL I consult ends the same way: “So, how much of that fat stays long-term?”

Patients arrive from the internet convinced the fat basically just melts away. Colleagues outside the field ask because they suspect the results will not last. Both parties have a mistaken perception of what the surgery does, so here is the answer I would give across the conference table: the biology.

The Number, and Why It Is a Range

Fifty percent to eighty percent. So the difference is a 30% span? Yeah, that is kind of the magic. But that difference is not random; there is really little random variance from one patient to another.

A fat graft is living tissue that comes from the recipient. I took fat tissue that had its blood source detached, squeezed it through a syringe-like tool called a cannula and then put it in a place where it can only rely on diffusion to get to nutrients for the first 2 weeks until it is able to build a blood supply. The tissue that successfully reattaches will last for the next few decades. In contrast, the tissue that did not attach will simply be absorbed into your body, resulting in volume loss.

It is much more than just moving tissue. Every decision the surgeon makes is focused on making sure those cells can live on for two weeks.

The Wash Most Patients Never Hear About

Surgeons often want to see my fat-washing protocol more than any other piece of my entire fat-grafting procedure. And before all that nice soft fat goes back to the patient, I am washing that fat thoroughly with AuraClens, a solution that contains Poloxamer 188.

What is the best way? First is housekeeping. When you get lipoaspirate harvested from patients, it is not clean: it includes tumescent solution, free oil due to burst adipocytes, as well as dead adipocytes. This process removes the sludge to deliver a concentrated product of viable cells. Each cc injected contains the maximal amount of living fat possible. Now you double pay when you inject nonviable debris. That mass will disappear as the cellular detritus dissolves, and this trash creates a massive amount of inflammation among the living adipocytes attempting to survive.

The second benefit is the one worthy of a journal club. Poloxamer 188 is a membrane-active surfactant; it does more than simply scrub/clean the membrane. What makes it so unique is how it actually works to repair and stabilize the adipocyte membrane, essentially patching up damaged holes in cell walls and making them resist apoptosis, the programmed self-destruction that stressed adipocytes would carry out, whereas the ones scheduled for elimination instead just keep kicking along.

The Patient’s Half of the Equation

I can scrub and prep the fat perfectly and still lose the graft to a barstool. Pressure destroys grafts in the first two weeks, which is why my sitting protocol is non-negotiable. For two weeks: nothing hard under the buttock, a BBL cushion shifting the weight onto the thighs for any sitting, and stomach sleeping, or a wedge-supported beach chair position for anyone who cannot manage the stomach.

The other patient-side lever is the massage table. Lymphatic drainage two, preferably three times a week for the entire first month, and honestly as often as the schedule allows: it works scar tissue and fluid out of the donor sites. My patients run theirs through the post-surgical massage program at Southwest Plastic Surgery. It is an unsexy part of the operation and the one that makes the most substantial difference in the final contour.

The payback comes fast. Final volume is essentially there at week four, when every restriction lifts, and the settled result is declared at three to six months. Out-of-town patients, most of my practice, fly home on day five.

What I Tell Colleagues About the Long Game

If the fat makes it through its first month, it is no longer vulnerable. It is permanently on the payroll and it behaves like fat behaves. Weight loss will cause it to shrink; weight gain will cause it to expand. The ruined results I occasionally witness are almost never a result of the surgery itself. They are yo-yo cycles, losing and regaining weight, which stretch out the skin, sag the mound I painstakingly created, and leave contour issues that no revision entirely fixes.

For all my fellow plastic surgeons: We choose our patients not only for their anatomy but also for their understanding of what it will take to maintain results. Before an op, tell those considering significant weight fluctuations that the size of their gluteal graft will inevitably follow their weight journey. The full patient-facing timeline, week by week, lives on my practice page for the Brazilian butt lift.

Where I Sit in This Field

The procedure itself started to really coalesce as an entity in the last 10 years, partially through my contribution, as I am a founding vice-president of the World Association of Gluteal Surgeons. Back then, all you heard about was the normal BBL; now you have the ultrasound-guided BBL and the supercharged BBL, which pairs fat grafting with intramuscular implants. That means you have a variety of approaches just as rhinoplasty now has different styles to choose from and all of them stem from the science behind the survival.

The Mayo Clinic taught me to treat every graft like the transplant it truly is. The liposuction that harvests it, the wash that protects it, and the two weeks that anchor it are one operation, not three separate events. Surgeons who treat them separately end up stuck at the fifty percent end of the range, wondering why.

Ready to Talk?

Whether you are a patient counting weeks or a colleague comparing protocols, my door is open.

Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments.

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

  • Week-by-week patient guide on agulloplasticsurgery.com: “BBL Recovery Week by Week: What Actually Happens After a Brazilian Butt Lift” (link once live)
  • Aftercare version on swplasticsurgery.com: “The Aftercare That Makes a BBL: Massages, Garments, and the Two-Week Rules” (link once live)
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After the Shelf: What a BBL Reversal Actually Involves

Black and white photo of Dr. Frank Agullo in black scrubs making pre-operative markings on a BBL reversal patient's hip in an exam room. BBL reversal editorial by Dr. Frank Agullo, MD, FACS.

A patient called me from the East Coast for a virtual consultation. Years ago I had done her BBL myself, a supercharged one, implants plus fat. Since then she had babies, started her family, and moved somewhere more conservative. She wanted her body back, or at least a quieter version of it. More discreet. More athletic.

She is not an outlier. She is a wave.

I wrote earlier this year about how beauty standards keep moving, and the buttock is where that pendulum is swinging hardest right now. So let me explain what a BBL reversal actually is, because it is more interesting, and more surgical, than the headlines suggest.

Why They Come Back

The most important reason is time. A BBL is a procedure where liposuction is done in the trunk, including the upper back, lower back, lateral chest, abdomen, and sometimes the thighs and arms, and that fat is transferred to the buttock. Once liposuction is done in those areas, they do not increase in volume as much when the patient gains weight. The buttock becomes the one area that increases the most.

So a patient gains weight years later, and the proportions run away from her. The buttock is no longer proportionate, or has developed cellulite or even droopiness. Some patients develop a double butt crease deformity, which patients themselves call elephant butt or frog butt. Their words, not mine, and they are not wrong about the shape.

Another portion of patients have not gained anything. They just want a more natural, less aggressive body contour. And a certain percentage were never happy in the first place: exaggerated hips, too much projection, a lower back scooped too aggressively, a buttock that doesn’t transition well into the thighs.

The Reversal Toolkit

Reversal surgery can involve a combination of a lot of procedures, and the plan is assembled per patient.

Tool What it does
Liposuction Reduces buttock volume and recontours
Renuvion J-Plasma Radiofrequency with helium plasma for skin contraction
Morpheus8, stacked on top Microneedling with radiofrequency, more contraction
Buttock lift, lateral thigh lift Removes loose skin and lifts when volume loss is significant
Miami thong lift Corrects the double butt crease deformity
Implant removal For the supercharged BBLs of the 2010s

The honest caveat: when we perform liposuction, the skin often becomes looser, and the buttock can droop more. Renuvion and Morpheus8 help create skin contraction, but the amount of contraction is hard to predict, as each patient reacts differently to these technologies. If we’re removing a significant amount of fat, then oftentimes a buttock lift, and even a lateral thigh lift, is necessary. Skin quality work continues afterward with microneedling when needed.

I prefer to do the surgery all at once, which gives the best results. The exception is the patient trying to avoid scars, who declines the lifts in hopes that the energy devices create enough contracture. Those patients know that at three or six months, if they develop buttock ptosis or loose skin, the lift conversation returns.

Can You Get Your Old Body Back?

We can get patients to their pre-BBL body, although most patients don’t really want to go that far back. They’re looking for a result in between: tighter contours, tighter skin, sometimes a more athletic look. That target gets set at consultation, along with an honest answer about whether it is achievable given which procedures they are willing to undergo.

How the East Coast Case Went

Her plan: buttock implant removal, liposuction of the lateral thighs, saddlebags, and buttock, a buttock lift with a lateral thigh lift, and a Miami thong lift to correct the double crease and create a sweeping curve where the lower buttock meets the thigh.

Four and a half hours under general anesthesia. Hotel the same day. My nurse saw her the next morning with IV fluids, helped with her first shower, got her into her garments. Lymphatic massages every other day. Drains out on day seven, and she flew home. No complications, and at four months she is mostly healed and very pleased with the new contour. Most of my reversal patients fly in exactly like this; the majority had their original surgery out of town or in another country, usually more than five years ago. This kind of travel case is routine in my body contouring practice.

Recovery in general runs about a week to get back to normal activity and driving, and about four weeks to return to the gym, running, and jumping. The risks specific to reversal are asymmetries, development of cellulite, and buttock ptosis if a lift is not performed at the same time.

No, the BBL Era Is Not Over

The BBL era is far from over. Patients’ desires have shifted, but it really depends on their culture and each person’s definition of beauty. I still perform minimal BBLs, or skinny BBLs. I also still perform some exaggerated ones.

The tendency is toward a reduced size: maybe only the hip dips and a little projection, more of an upside-down heart shape than a shelf, some reduction in hip width. And still, plenty of patients want a very small waist with larger hips.

My tool for keeping everyone honest: photographs. The buttock is a hard anatomical place to describe with words, so I have patients bring pictures of what they want to the consultation, and again on the day of surgery, so that we’re both on the same page.

I served as founding vice president of the World Association of Gluteal Surgeons. I have watched this pendulum from the front row, in both directions. The surgeons who did the shelf era well are the ones patients now trust to quiet it down.

Ready to Talk?

If your BBL no longer fits your life, there is a surgical path back, and it can usually be planned from a virtual consultation. Call (915) 590-7900, text 1-866-814-0038, or book online. #StayBeautiful

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

Companion reads: the clinical reversal guide on agulloplasticsurgery.com, and the destination-patient overview at swplasticsurgery.com.

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Jingle Bells, Your Butt Smells: A Surgeon’s Protocol for the BBL Recovery Nobody Talks About

Jingle Bells, Your Butt Smells: A Surgeon's Protocol for the BBL Recovery Nobody Talks About. Dr. Frank Agullo, MD, FACS, double board-certified plastic surgeon at Southwest Plastic Surgery in El Paso, Texas.

Australia’s GP-trade journal, Medical Republic, opened a piece on me last month with the line above, and I will admit to laughing out loud when the alert hit my phone. The piece, titled “Jingle bells, your butt smells,” reprinted the four-bullet post-operative hygiene protocol I wrote for Brazilian Butt Lift patients, credited me as a founding vice-president of the World Association of Gluteal Surgeons, and pushed the conversation out of the back rooms of the practice and into the GP literature halfway around the world.

The reason it traveled is that the topic genuinely is one of the least discussed parts of BBL recovery. The reason I wrote the protocol down in the first place is that nearly every BBL patient in my practice eventually asks me a quieter version of the same question. So here is the longer surgeon-to-surgeon version of the protocol, with the clinical reasoning behind each step.

What the Inside of a Fresh BBL Looks Like at Week Two

A BBL is two operations done together. A liposuction harvest from the donor sites, which can include the abdomen, the flanks, the back, the lower back, the inner thighs, and any other compartment from which the fat has been planned. And a structured gluteal injection, in which the harvested and processed fat is distributed in the subcutaneous compartment of the gluteal region using anatomic, low-pressure cannula technique that respects the safe planes.

By week two, the patient is in the compression garment most of the day. She is sleeping prone or side-lying. She is restricted from sitting in the conventional way. Sweating is increased because the garment is occlusive. Lymphatic fluid is weeping slowly through the small liposuction port incisions. The perineum and the intergluteal cleft are spending most of the day inside a humid, occluded, bacterially friendly environment.

That environment, without disciplined hygiene, produces three predictable problems. A surface odor. A surface skin breakdown. And, in the worst case, a low-grade bacterial colonization of an incision that should have closed cleanly. The patient experiences all three as a single, embarrassing question she does not want to ask out loud, and the answer to that question is a protocol she can run at home.

The Four-Part Protocol, With the Why

Chlorhexidine (Hibiclens) as a Body Wash, Days One Through Twenty-One

Hibiclens is a chlorhexidine gluconate antibacterial wash widely used in pre-operative skin preparation. It has a meaningful residual antibacterial effect on the skin after rinsing, which means the protective effect carries past the shower into the hours when the patient is back in the compression garment. For BBL patients, the perineum and intergluteal cleft are the highest-risk zones in the first two weeks, and a daily Hibiclens wash to that area measurably reduces the bacterial load on the skin without requiring a prescription.

Above the neck, normal soap. Off the eyes, the ears, and any frankly broken or rashy skin. In the small subset with a chlorhexidine sensitivity, substitute a different antibacterial wash, but in my practice the substitution is rare and the protocol holds.

Bidet for the Perineum and the Intergluteal Cleft

Toilet paper after a BBL is abrasive, leaves residue, and tends to drag through tissue that has been freshly operated on. A bidet (full installed unit, sprayer attachment, or a peri-bottle, in that order of luxury) rinses without abrading. The compression garment then goes back on over genuinely clean tissue. Dry gently with a soft towel after the rinse. The same hardware that fifty percent of new mothers swear by after a vaginal delivery serves the same function after a BBL.

Two Compression Garments in Rotation, Washed Daily

This is the change with the largest single effect on odor and on incision-site comfort. Own two garments. Wear one. Wash one. Rotate every twenty-four hours. Cold to warm wash with a gentle detergent. No fabric softener. Flat air dry. Dryer heat tends to break down the medical-grade fabric over time. Patients who try to run a single garment for the entire six weeks discover that the inside of the garment is doing a lot of the work the protocol is supposed to be preventing.

Post-Operative Manual Lymphatic Drainage by an Experienced Therapist

Two to three sessions a week for the first two weeks, weekly through week six, tapering through week twelve. The technique mobilizes lymphatic fluid out of the donor sites and the gluteal compartment along the body’s natural drainage pathways. The recognized benefits, less swelling, faster bruise resolution, less fibrosis, better contour at six weeks, are the headline reasons. The hygiene-related benefit, which is less discussed but real, is that a well-drained donor site is a less hospitable environment for low-grade skin colonization than a poorly drained one.

The Protocol at a Glance

Part What When Why
Hibiclens body wash Chlorhexidine wash, body, not face Days 1 through 21 Residual antibacterial effect on the high-risk skin
Bidet Rinse perineum and intergluteal cleft Every bathroom use Cleans without abrading, no residue under garment
Two-garment rotation Wear one, wash one, swap daily Six weeks Removes the humid environment from inside the garment
Lymphatic drainage Trained therapist, structured cadence Weeks 1 through 12 Less swelling, less fibrosis, less substrate to colonize

Why the World Association of Gluteal Surgeons Exists

I serve as a founding vice-president of the World Association of Gluteal Surgeons. The organization was founded because the BBL became, very rapidly, one of the most commonly performed aesthetic body procedures in the world, and the field needed an organized peer body that could push safety standards, training standards, and post-operative care standards across borders. The hygiene protocol is one of a series of standards that exist because the early operation, while transformative, was also producing avoidable post-operative problems that better technique and better aftercare could prevent.

Ultrasound-guided injection has been the largest single safety advance in BBL technique in the past five years. The hygiene protocol is one of the largest single comfort-and-infection advances in BBL aftercare. Neither is exotic. Both are now table stakes.

What This Protocol Does Not Replace

It does not replace the antibiotic course if one has been prescribed. It does not replace the surgical follow-up cadence. It does not replace the position restrictions and the activity restrictions of the early weeks. And it does not replace a phone call to the operating surgeon if any of the warning signs appear: a fever above 100.4 F, focal redness, swelling, increasing pain, or a frank wound discharge. The protocol is the layer on top of the surgical plan that quietly prevents the problems nobody wants to discuss out loud. The surgical plan, the follow-up, and the patient’s communication with the operating surgeon are still primary.

How I Built the Protocol

I built the protocol the same way every honest piece of clinical guidance gets built. By doing a high volume of the operation, by listening to the patients who came to follow-up visits, and by writing down the steps that, repeated reliably, eliminated the problems they kept describing. By the time the Medical Republic piece picked it up, the protocol had been in my recovery handout for years and the GP author had simply found that handout via the BBL recovery post on my practice site.

It is short. It is repeatable. It costs almost nothing in dollars. And it does as much work as any peri-operative antibiotic in keeping a BBL recovery on the curve the patient expected when she scheduled the operation.

Ready to Talk?

If a BBL is on your mind and you want to know what a serious recovery plan looks like before you book the operation, the first step is a consultation. The protocol is part of the plan from the beginning, not a handout at discharge.

For the clinical patient-facing version, see What Nobody Tells You About BBL Recovery on agulloplasticsurgery.com. For the practice-program version with the in-house recovery support, see The BBL Recovery Program at Southwest Plastic Surgery. If you got here by searching the phrase itself, the causes-and-prevention explainer is BBL Smell: Is It Real?, and my take on why 33,000 people a month search it is The Fat Is Not Rotting.

Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful.

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.