The perfect body, in Diana Dayyani’s estimation, belongs to a cartoon character. Not just any animated character, nor Wilma Flintstone or Betty Rubble, but a rabbit. Jessica Rabbit.

“I love that hourglass look,” said Ms. Dayyani, 23, of Houston. “The small waist, the nice, beautiful hips.”

Ms. Dayyani was so enamored with Ms. Rabbit’s physique that in April she decided to acquire it for herself. She enlisted the sculptural assistance of Dr. Patrick Hsu, a board-certified plastic surgeon in Houston. He suggested a breast reduction ($7,400) and a gluteal enhancement, or Brazilian Butt Lift (BBL), for $9,190 plus anesthesia and facility fees.

In the latter procedure, which typically costs around $15,000 and is not covered by insurance, fat would be liposuctioned from her flanks, tummy and lower back and injected into her derrière. “It’s like moving money from your checking to savings account,” she said.

And with that, Ms. Dayyani became another one of the thousands of women worldwide undergoing one of the most popular cosmetic surgeries (some men get it too, but not very many). In 2020 alone, there were 40,320 buttock augmentations, which include both implants and fat grafting, reports the Aesthetic Society. According to Google keyword data, “BBL” was searched roughly 200,0000 times per month between January and May 2021.

It’s also one of the deadliest. A July 2017 report by the Aesthetic Surgery Education and Research Foundation in Aesthetic Surgery Journal noted that one to two out of 6,000 BBLs resulted in death, the highest mortality rate for any cosmetic surgery. In 2018, The British Association of Aesthetic and Plastic Surgery advised surgeons in the United Kingdom to stop performing it altogether, although they couldn’t ban it outright.

It didn’t matter: Women would travel to Turkey or South America for the surgery, where it was significantly cheaper. At least two British fatalities have been traced to a clinic in Izmir, Turkey.

The Deadliest Plastic Surgery

The reason the BBL is so dangerous is fairly straightforward. The buttocks contain a multitude of blood vessels, some as large as drinking straws. These drain into the inferior vena cava, which is a direct line to the heart. With a BBL, fat is injected into the buttocks with a cannula, or long metal tube.

But it can be difficult for doctors to know where exactly they’re injecting; they have sometimes mistakenly injected fat into the gluteal muscle, or right below it. Fat can then travel directly to the heart and into the lungs, obstructing blood flow and causing immediate death.

Concerned about the mortality rate, in 2018 the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery and the International Society of Aesthetic Plastic Surgery, among others, formed the Task Force for Safety in Gluteal Fat Grafting, to develop safety guidelines around the procedure.

Among their recommendations: That doctors stop injecting into the muscle and use bigger instruments. “Those cannulas bend, and if they bend when you put them in the buttock you have no idea where the tip of the cannula is,” said Dr. Luis Rios, a board-certified plastic surgeon in McAllen, Tex., and past president of The Aesthetic Surgery Education and Research Foundation, the research, education and philanthropic arm of the Aesthetic Society. A 2020 follow up study found that 94 percent of doctors are aware of the recommendations.

“When properly done, when carefully done, it is safe,” said Dr. Steven Teitelbaum, a board-certified plastic surgeon in Santa Monica who was involved in drafting the guidelines, but does not perform the surgery. “We know exactly the mechanism that can lead to death, and we know how to avoid it. The surgeon just has to maintain intense focus and concentration.”

Yet people are still dying, most notably at “chop shops”: low cost, high-volume centers typically found in Las Vegas, Los Angeles and Miami — with doctors who may not be board-certified or even surgeons. Over the past eight years, one such doctor, Ismael Labrador, has had eight patients die at clinics he has run, four from botched BBLs, USA Today and Naples Daily News reported. The clinics’ names were changed two times starting in 2016, making it almost impossible for new clients to research him. (Dr. Labrador did not return calls.)

“The problem is not only that these doctors are inadequately trained, but that operating as rogue actors there is no way to either collect their data or send them a warning about the dangers of a procedure,” Dr. Teitelbaum said. “When we started recognizing there was a problem with BBL, we were faced with the problem of figuring out how to find these people to get word out to them, and unfortunately there was no way to do it.”

Neither Brazilian, Nor a Lift

It’s unclear how exactly the Brazilian Butt Lift got its name, since technically nothing’s being lifted. A Brazilian plastic surgeon named Ivo Pitanguy is credited with pioneering the procedure in the 1960s. It slowly migrated north, eventually gaining popularity in the United States around 2010 thanks to Jennifer Lopez, Kim Kardashian and Nicki Minaj, each of whom is revered for her hind. (The women deny having had any surgical help. Ms. Kardashian got an X-ray during an episode of “Keeping Up With The Kardashians.” Doctors found no implants, though fat grafting was not discussed).

But a January 2020 editorial in the journal Plastic and Reconstructive Surgery argued that the procedure was actually named in 1996, when the Learning Channel featured a segment with Dr. Leonard Grossman, a board-certified plastic surgeon who liposuctioned fat from a Brazilian woman and injected it into her glutes. The segment was called “Building the Brazilian Butt,” and a moniker was born. (The authors proposed that the procedure should be called “Safe Subcutaneous Buttock Augmentation” instead.)

Since then, the amounts of fat injected have only increased. “I don’t know at what point in time we got into bigger is better, but we put in larger and larger volumes the moment we realized we could,” said Dr. Oni Garcia, a board-certified plastic surgeon in Miami.

No one knows for sure what the long-term repercussions are. But Dr. Arthur W. Perry, a board-certified plastic surgeon in New York and New Jersey and an adjunct associate professor of surgery at Columbia, is so worried that he refuses to do a BBL.

“What happens to fat when you put a large amount of dead fat into the buttocks?” he said. “Because that’s what it is: Dead fat. We haven’t even begun to see the cosmetic disasters of people walking around with moonscape buttocks, one cheek bigger than the other.

“As far as I’m concerned, at this moment in time it is not a procedure that is routinely and uniformly done safely,” he said.

Life is Full of Risks

Ms. Dayyani wasn’t worried about dying. She trusted Dr. Hsu, who said he has done about 2,000 BBLs over the seven years and has a year and a half long wait list. Plus, she didn’t have any underlying health conditions.

She took a more philosophical approach: “It was like, every time you get on an airplane you get a little bit nervous and there’s a little bit of a risk, but you do it anyway,” she reasoned.

She was more concerned with surviving the surgery with a botched behind. Ms. Dayyani plans to become a lawyer, and worried that she might not be taken as seriously with an outsize backside. “Eventually I want to be standing in front of a judge,” she said. “I don’t want to have crazy features. I just wanted to look like I hit the gym an extra bunch.”

Dr. Hsu assured her he would be conservative; he didn’t want her to look like a caricature, either.

The surgery lasted about three hours, after which she felt like she had been churned in a Nutribullet. Her butt resembled a swollen beach ball, which freaked her out. But Dr. Hsu assured her that it would shrink with time; only about 70 percent of the fat stays in the body.

She also had to get lymphatic massages for a week after the procedure to drain extra liquid in the body. This hurt. (A viral video on TikTok showed a woman screaming in agony while allegedly getting massages post-BBL). She was unable to sit or lie on her back for the first few weeks. To sleep, Ms. Dayyani cut a hole in a lawn chair that her posterior could fit into, while also keeping her breasts lifted.

She said it was worth it. She went from a G Cup to a double D, and her stomach is flat. “I literally have abs now,” she said.

As for her posterior? It is Rabbitesque. “The surgery enhanced my hourglass figure,” she said. “I can’t wear some of my old clothes because my booty doesn’t fit through my pants. I’ve never felt better.”

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