UK surgeons were strongly warned this week by the British Association of Aesthetic Plastic Surgeons to stop performing Brazilian butt lifts.

As many as four out of five[1] plastic surgeons in recent years have noted a wild increase in patients requiring revision after botched cosmetic surgery abroad – but NEW research unveiled at the Annual Scientific Meeting of the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) breaks down the considerable burden to the Health Service as well as revealing some of the most common procedure culprits.

Most importantly, the BAAPS has decided  that the results of one particular treatment are disturbing enough for them to dissuade ALL members from performing this specific surgery, until more data can be collated.

The Brazilian Buttock Lift (BBL) is a procedure in which fat is taken from another part of the body, then injected into the buttocks. However, surgeons warn it has the highest death rate (thought to be as high as 1 in 3,000 operations)[2] of all cosmetic surgery procedures, due to the risk of injecting fat into large veins that can travel to the heart or brain and cause severe illness and death. This risk has galvanised the BAAPS to distribute a recommendation to all members, suggesting they refrain from performing BBLs, at least until more data is available. This is going even further than the American and Australian[3] Societies, which only alert members to reporting outcomes.

One striking study presented at this international BAAPS conference analysed a single UK NHS hospital, recording a six-fold rise in cases needing urgent follow-up care from procedures done abroad, since 2013. All but one of the complications deemed ‘major’; based on cost and level of emergency care input (including intensive care); were for buttock enhancement, also known as gluteal augmentation. These patients required an average ward stay of 20 days, costing the hospital just under £32,500. Added to other procedures, the hospital shelled out over £63,000 to pick up the pieces of botched-abroad surgery, including the removal of industrial-grade, banned PIP silicone implants.

Complications from BBL ranged from severe bacterial infections including MRSA and Pseudomonas, tissue dying (necrosis), scarring, wound ruptures (dehiscence) and abscesses – among others. One patient alone, excluded from this study, had a ‘flesh eating’ infection (Necrotising Fasciitis), treatment of which cost the Service nearly £47,000. The no. 1 most cited reason for choosing to travel, unsurprisingly, was cost (85% of respondents).

Surgeons ascribe this specific phenomenon, in part, as a possible result of aggressive marketing campaigns – particularly targeting vulnerable people through social media. Celebrities unashamedly pursuing the curviest of curves on their Instagram feeds, such as Kim Kardashian and rapper Cardi B can trick the public into thinking that (just as one medical tourism website advertises) “Surgery is just like make-up!” and inadvertently leading them to danger. Hence the Society has called a moratorium on the procedure in the UK, until more research is conducted.

Author of the paper, junior trainee in plastic and reconstructive surgery (ST3) Mohammed Farid, conducted this study at the Royal London Hospital. He comments;

“As a trainee, it’s been staggering to see the lengths – and the damage – these patients will go through in the quest for cheaper options. Especially for the kind of surgery which requires such specialist training. I remember in one procedure, we found a piece of Latex which had been left inside the patient’s buttock! This was one of the most shocking moments in my career, and the one that inspired me to conduct the study.”

The most popular destination was Turkey, claiming a quarter (25%) of cases; followed by Belgium (15%) and many others such as France, Cyprus, Tunisia and Colombia. Interestingly, when examined, many patients would simply have been ruled out in the UK, due to key medical history – for example smoking and weight (BMI) – and possibly psychological issues as well.

Another, separate study also presented at the conference, highlights the seasonality of ‘New Year, New You’, with a high influx of patients arriving with complications at the beginning of the year, after splurging on aesthetic procedures abroad after the holidays. Over two thirds (67%) of patients required surgery on the NHS, and all patients requiring an inpatient stay cost the hospital nearly £24,000, averaging£4,000 per patient.

On average, patients stayed 4 nights at the plastic surgery unit, which covers all of Northern Ireland. Half of patients had undergone multiple procedures abroad; e.g. breasts and tummies simultaneously. In at least one instance, a patient had been turned down for surgery in the UK (implant size she requested were deemed ‘too large’), so she sought a provider abroad. A third of all cases presented with necrotic wounds (dead tissue), infected breast implants, as well as wound infections. Common destinations also included Turkey and Belgium, as well as Poland and Estonia

According to consultant plastic surgeon and outgoing BAAPS President Simon Withey;

“People are experiencing a rude awakening when they arrive back on British shores, many disappointed, and some desperately ill. Surgery is simply not something you can return at the January sales, and it should never be tied to seasonal discounts and incentives.

“Crucially, the Brazilian Buttock Lift is a complex technique, and its death rate of 1/3,000 (or as much as 1/2,000! is the highest for any aesthetic procedure. An international task force[4] has already been assembled to analyse and hopefully prevent, future tragedies. So far, all BBL deaths seem to stem from injecting fat into veins, causing emboli (blockage of a blood vessel) to travel to the heart or lungs. However, at the BAAPS we will go a step further and recommend that all surgeons refrain from performing these procedures until we have more proven data.

“A vulnerable group of patients are openly being targeted through social media and the Web to travel abroad for cheaper cosmetic surgery – and this trend is likely to rise. The outcome of having these operations away from home can be devastating. It’s not just medical history than needs evaluating, but also mental health screening, which we take very seriously at the BAAPS. Indeed, psychological wellbeing is a regular, yet critical part of our yearly Scientific Meetings.”

A new psychological screening mnemonic is also being presented at the Annual Meeting, aiming to help surgeons perform pre-operative psychological assessment of patients seeking cosmetic surgery, which surgical trainees say is a valuable exposure to consultations for procedures that are exclusively cosmetic (increasingly unavailable in the NHS). Researchers note that as the popularity of aesthetic surgery grows, so does the trend for vulnerable people to attempt to solve emotional problems with a nip or tuck, and surgeons must be able to identify any red flags or psychological disorders that could demonstrate the need for further clinical psychology evaluation, or mean the patient is not a suitable candidate for treatment.

The new ABCDE screening tool unveiled at the BAAPS Meeting allows surgeons to more comprehensively assess key facets of patient’s behaviour as well as their underlying motivations for wanting aesthetic surgery, better enabling them to determine those who do not meet mental health criteria and should therefore not be offered treatment. The tool is of great use in consultation, steering the process to shed light on key areas – for instance patients’ external drivers for pursuing treatment; their cultural background; and level of distraction. Building on existing and well-established markers such as excessive preoccupation with a perceived defect and overall body image, the ABCDE tool encourages surgeons to maintain awareness of discrepancies between patients’ words, and their actions, as well as underscoring the importance of their own intuition in recognising patients who may be psychologically vulnerable and inappropriate for treatment. By following this straightforward mnemonic, surgeons will more easily and effectively be able to screen for issues such as BDD (Body Dysmorphic Disorders).

According to consultant plastic surgeon and BAAPS President-Elect Paul Harris;

“Medical tourism may not be a new phenomenon in itself, but in cosmetic surgery it’s clearly increasing at a galloping pace, and botched procedures are over-burdening our Health Service. Countries around the world vary in their requirements of medical professionals – some require insurance, some don’t, some follow a strict screening process or cooling-off period, and many don’t. Therefore, many patients find themselves having to rely on care back in the UK.

At the BAAPS we are committed to training the next generation of surgeons, which is why we offer unique Fellowships which allow trainees exposure to aesthetic procedures they wouldn’t otherwise encounter – that includes both physical and psychological screening of patients.”

Uniquely, this year’s Scientific Meeting combines both surgical and non-surgical treatments. According to consultant plastic surgeon and BAAPS Council member Mary O’Brien;

“The unique contribution of bona fide Plastic Surgeons to patients seeking aesthetic procedures is that they can provide truly individualised care, as they have a diverse set of highly developed skills which can be decanted in the most effective combination for that particular individual. They can combine both surgery and non-surgical approaches, and are trained to provide careful patient selection with safety as the main priority. They have an appreciation of the importance of psychological wellbeing as well as physical health. They provide continuity and have the expertise to deal with any unexpected complications that may arise.”