The BAAPS Calls For Urgent Regulation Of BBL Procedures
23 October 2024 (Last updated: 8 Nov 2024 20:02)
The British Association of Aesthetic Plastic Surgeons (BAAPS) is gravely concerned about the lack of regulatory oversight of Brazilian butt lift (so-called BBL) procedures. Whilst the term originally referred to buttock augmentation using fat transfer, it is now more broadly used to include buttock augmentation using dermal fillers such as hyaluronic acid and poly-L-lactic acid fillers and biostimulators. Dermal filler buttock augmentation is also called the ‘liquid BBL’. The injection of sometimes very large amounts of substance into an area of complex anatomy poses significant risks and requires the appropriate specific skills, knowledge and practical training uniquely pertaining to specialist plastic surgeons.
The recent death of Alice Webb has brought the spotlight back on to safety in aesthetic procedures and the consequences of unqualified non-medical (indeed non-healthcare!) trained individuals performing invasive procedures within unsafe and unsuitable environments. Unfortunately, this was a tragedy waiting to happen. The BAAPS have repeatedly over several years called for regulation of access to and use of dermal fillers. While this is a particularly sad situation with the loss of a life, many others have suffered severe complications at the hands of unscrupulous people and suffered consequent sepsis, tissue necrosis (tissue death), infections and scarring. The BAAPS also campaigned for increased safety in the BBL using fat transfer and in 2018 recommended against our members performing this procedure at all, because of the specific risks resulting from the anatomical complexity of the buttock, and the associated deaths reported internationally from fat embolism (where the injected fat enters the large veins underneath the buttock muscles and can then travel to the heart and lungs causing death in some instances due to blockage of blood vessels there). We instituted a moratorium on these procedures. In 2021, following international research and safety improvements, BAAPS released updated guidance (Superficial Gluteal Lipofilling Guidelines) on performing this procedure safely with the key recommendations that fat is only injected into the safer superficial layers, and the procedure carried out under ultrasound guidance so that there is direct visualisation during the surgery of where the fat is placed.
The government and the public must understand that these procedures are invasive, surgical in nature, and carry significant risks. They must also understand that these procedures should only be performed by those who are adequately qualified and trained to do so and in settings where complications can be treated should they occur (i.e. CQC regulated medical clinics and hospitals rather than beauty clinics, hotel rooms and private homes). They must understand the dangers of ordering cheap fillers online through unlicensed providers. We have some of the laxest regulations (or lack of regulation) in the world in this regard. We find ourselves therefore in the situation where invasive devices, often containing a substance with medical use such as local anaesthetic, are being inserted in the body in unlicensed premises by non GMC (General Medical Council) registered individuals - in fact individuals lacking even the basics of any healthcare qualification of any description let alone a medical degree.
Some of these deficiencies are being addressed. A consultation on a licensing scheme for non surgical cosmetic procedures by the Department of Health and Social Care, advocating a three tier system categorizing procedures according to risks, dermal fillers being included in the highest risk category, has now closed. The JCCP (Joint Council of Cosmetic Practitioners), supported by BAAPS and the Royal Colleges of Surgeons, published this month a set of guidances aimed at environmental health officers for buttock augmentation and other body augmentation procedures, emphasizing the surgical nature of these procedures and the requirement for the procedures to be limited to doctors with specialist surgical qualifications and knowledge within CQC regulated premises. Regarding fillers themselves, before Brexit occurred, the UK had actively participated in shaping the new tightened European Medical Device Regulation, including the new Annex XVI category of devices without a medical purpose, which includes dermal fillers; after diverging from it, the UK is now considering an approach for UK regulations that will broadly mirror the EU model.
The BAAPS feels that with regard to BBL, all these do not go far enough. The specific risks pertaining to injection into the buttock, from wound problems to often life threatening injuries, mandate a knowledge of anatomy and a facility with ultrasound use to support injection into the right subcutaneous layer of these often large amounts of substance, in addition to knowledge of the safe dosage and effects of local anaesthetics, appropriate tissue handling competency as well as the ability to recognise and treat early signs of sepsis and other complications. These capabilities lie usually within the strict domain of specialist plastic surgeons, who are regularly assessed through ongoing appraisal and training in the UK. There also needs to be stronger prosecution of those non-qualified individuals who inject unregulated substances in the buttocks. Finally, we commend the work of environmental health officers and reinforce the need for prosecution of unregulated non CQC registered clinics in which BBL procedures are carried out.
In summary, nobody should be performing BBL procedures if the procedures are outside of their scope of training and practice and this scope lies uniquely within the specialist qualification of GMC registered plastic surgeons (and other individual GMC registered surgeons able to demonstrate their specialization and ongoing competencies to perform BBL). There must be consequences for those who act with impunity and disregard for the safety of others. The consequences must be severe enough to act as a deterrent. With the continually increasing demand for dermal filler enhancements, we are sitting on the edge of a public health catastrophe if we do not act now.
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