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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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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.