The $5,000 quest for the perfect butt

How the Brazilian butt lift, one of the world’s most dangerous plastic surgery procedures, went mainstream.

When she woke up from surgery, Kayla Malveaux found herself alone in the clinic recovery room, slumped over in a wheelchair. She felt sharp pain around her face and swollen eyes, but she wasn’t sure why. The operation she’d just had involved fat taken from her abdomen and transplanted into her bottom, an increasingly common procedure called the Brazilian butt lift. Though she can’t say for sure what really happened between the time the surgery was over and the time she woke up, she has a guess. “It’s like they threw me in the wheelchair and then I must have hit my head,” she says.

As the 22-year-old was wheeled out of the Miami cosmetic surgery clinic, she understood. In the waiting room was “a herd of girls,” she says, all waiting for their own procedures with a single surgeon. “I couldn’t see how a doctor can do that many patients a day without overworking themselves, you know?” she says.

Kayla is one of thousands of women who’ve flown to South Florida — or Turkey or Mexico or Thailand — for questionably cheap operations, where a complex, multi-hour surgery not covered by health insurance can run as low as $3,000, although most clinics advertise BBL packages for around $5,500 (not including aftercare, which can double the cost). These procedures often take place in small clinics, where doctors who might have been trained as dermatologists or pediatricians are legally allowed to advertise themselves as “board certified” physicians even though the extent of their plastic surgery training might have consisted of a single weekend course. To make up for the high cost of running an operating room, they squeeze in as many as eight patients every day.

You can see where the Brazilian butt lift — a physically taxing surgery for the doctor as well as the patient — might start to get dangerous. But this hasn’t stopped the thousands of women who’ve undergone it over the past few years; the number of BBLs globally since 2015 has risen 77.6 percent, according to a survey by the International Society of Aesthetic Plastic Surgery, and it is now the fastest-growing cosmetic procedure in the world.

As Kayla arrived at the airport after her surgery, she was told the terminal didn’t have any wheelchairs left. On her flight back to California, she realized she was one of several BBL patients on the plane.

You spend enough time on TikTok and Instagram, and it can start to feel like you’re the only person in the world who hasn’t had their butt done. The BBL silhouette is omnipresent and unmissable, an impossibly tiny middle resting atop a plump bottom and thick thighs; at its most extreme it presents a cartoonish version of a fertile woman, a cross between the Venus of Willendorf and Jessica Rabbit. At its most subtle, a BBL just looks like good genes, the kind of golden ratio associated with the most iconic sex symbols of the last 100 years.

The BBL aesthetic of the 2010s and the present day, however, is most often associated with the Instagram influencer, whose body exists to be consumed by the most people possible (whether or not it has been photoshopped is almost beside the point). After Kim Kardashian, one of the ur-examples of the modern influencer, proved with an X-ray that she hadn’t had butt implants, the next logical question was, “Well, how?” The answer, many have speculated, is that she and some of her sisters had gotten Brazilian butt lifts, which wouldn’t have shown up on an X-ray because the procedure involves the removal and retransplant of one’s own fat.

The platforms that provided the foundation for the rise of influencers are also the reason why the BBL has penetrated the mainstream. Consider “Instagram face,” the button-nosed, cat-eyed, pouty-lipped look popularized by professionally sexy models like Emily Ratajkowski and Bella Hadid, that for the vast majority of the population is only achievable through skillful makeup or, more often than not, a click of a button. Apps like Facetune bring that same kind of one-touch wizardry to bodies, which can be stretched, slimmed, and smoothed to infinity — and can do it convincingly. The BBL, just like any of the fastest-growing cosmetic surgery procedures, attempts to recreate the way we look when our bodies are filtered through the internet.

Until the last decade or so, the BBL was not common practice in the US. Its origins, as its name suggests, are in Brazil, where cosmetic surgery has a storied background, largely due to the country’s history of eugenics. In 1918, Dr. Renato Kehl founded the Eugenics Society of São Paulo, which aimed to erase all signs of Black and Indigenous physical appearance in Brazil. In 1960, a surgeon named Ivo Pitanguy founded the world’s first plastic surgery training center in Brazil, where he pioneered what became known as the Brazilian butt lift and taught surgeons all over the globe how to perform his techniques.

From there, the practice traveled north and exploded once pop culture began to shed its preference for the “tits on a stick” silhouette and started to revere stars like Jennifer Lopez and Nicki Minaj. As the mainstream media began to incorporate the beauty standards that have long been held by Black and Latinx cultures — e.g., that big butts are hot — it continued to idealize the white women who conformed to these standards and, furthermore, allowed them to profit over Black and Latina women whose bodies the fashion establishment had previously critiqued. The idea that certain body types can be considered trendy at all, of course, has a history that has always been laden with classism, racism, and sexism, and it’s easy to argue that the media only began to celebrate big butts when it became financially beneficial to do so.

South Florida quickly emerged as the plastic surgery capital of America, in part because of its huge Latinx population and the fact that Floridians can comfortably wear bikinis year round. By 1999, more than one in 10 plastic surgery procedures performed by board-certified plastic surgeons took place in Florida, and the history of malpractice goes back just as far. Florida, just like every other state in the country, allows medical doctors to practice and treat patients in any field, as long as they obtain consent from the patient.

“You can set up your own clinic and you could be doing liposuction tomorrow with no training in liposuction whatsoever, and it’s perfectly legal,” explains Adam Rubinstein, a board-certified plastic surgeon in Miami. Though these doctors wouldn’t be able to perform plastic surgery in a hospital or legitimate surgery center, where regulations are stricter and have far more oversight, there’s nothing stopping them from opening a clinic of their own, and no higher board they must answer to.

The field of medicine largely relies on the industry policing itself, which makes it difficult for legislators to address the issues. “We have the expertise to do that, but we don’t have the legal authority,” explains Arthur Perry, a plastic surgeon who spent 10 years on the New Jersey State Board of Medical Examiners and who refuses to perform BBLs. “So yeah, I could call myself a cardiac surgeon today, set up an operating room, and do cardiac surgery in my office. You can sue me for malpractice, but that’s a civil penalty as opposed to criminal.”

Helly Larson, a 26-year-old podcaster in Georgia, got her BBL in 2019 at a Miami clinic. Though she’d known plenty of women who’d had BBLs through her work as a stripper, she was making enough money with the body she already had. “Then literally, one day I just was like, ‘Okay, I’m doing it,’” she says. “I scheduled a consultation with a doctor who had done a YouTuber that I was watching, they approved me and I paid my deposit, all within a week.” She’d done further research on the website RealSelf, which acts almost like a Yelp for cosmetic surgeons, where former patients can post reviews and photos.

Like Kayla, she didn’t get the sense that something was off until she was in the bed waiting to start the surgery. Four hours after she was supposed to be anesthetized, she says the doctor came in and complained about the lack of professionalism by the anesthesiologist. “As I’m sitting in the gown, all of the red flags start to come through and I was just like, ‘You’re gonna be okay, it’s gonna be okay,’” she says. “I didn’t even know about the death rates.”

The death rates for BBLs have been, historically, not good. One 2017 study placed the worldwide mortality rate at a whopping one in 3,000; 25 of those deaths occurred in the US in the five years prior. Thanks to more widespread education and better safety techniques, that ratio is widening: In 2019, one survey estimated the mortality risk at one in 14,921, and as of 2020 it is one in 20,117. That’s still higher than the mortality rate from liposuction (1.3 in 50,000) or for outpatient surgery (0.25-0.5 in 100,000). (All figures via the International Open Access Journal of the American Society of Plastic Surgeons.)

BBL deaths have, for the most part, occurred because of improper technique. The problem with inserting fat into the buttock is that your butt contains a lot of very large blood vessels — “as big as drinking straws,” one doctor put it — which, if accidentally injected with fat, can result in that fat traveling to your lungs and cause a deadly pulmonary embolism. That’s part of the reason why most reputable surgeons have a limit to the amount of fat they’ll insert — there’s less likelihood of dead fat, which creates lumps and lopsidedness. (In popular BBL destinations like Turkey, doctors are willing to insert much more fat.)

These issues are compounded when doctors are pumping out clients as fast as they can. At a single plastic surgery clinic, eight women died over the course of six years, seven of them working-class Black and Latina women who reportedly were targets of the clinic’s advertising campaigns. In 2018, a patient died three days after getting a BBL at New Life Cosmetic Surgery; the cause of death was determined to be from liposuction and fat transfer procedure complications. “Miami is the chop shop of plastic surgery,” Helly says. “I think the doctor had, like, five BBLs the day I had mine.” In the lead-up to her surgery, the clinic had been emailing and checking in regularly, but once it was over, she says, “It’s crickets.”

One aspect that many clinics don’t always fully explain is what happens after you get a new butt. Many aren’t upfront about the fact that there are limits to how much fat surgeons can remove and implant, and therefore what a single BBL procedure can accomplish. For many women to achieve their desired look, they must come back for two or three procedures. What’s more, not all of the fat inserted into the butt will stay alive — it’s a common complaint among BBL patients to fall in love with their post-surgery butt, only to watch it shrink over the next few months.

Aftercare guidance depends on the patient’s existing body type, but all of them must wear a faja, a corset-like garment that keeps the body shape in place, for about three months as the new fat learns to connect with the existing fat. Sleeping must be done face-down for at least six weeks, and sitting requires a special pillow. To help with circulation, patients must schedule regular post-op massages, which are often painful. Peeing, by the way, is its own hurdle. “I’ve seen people where they’ll keep [the garment] on while they go to the bathroom, they’ll literally just pee all over themselves and live like that,” Helly says.

Outside of the network of cheap clinics, Miami has also seen a spate of surgery recovery centers that offer pickup and dropoff, massages, and other post-op assistance, with names like Prima Dollhouse, Barbie Dolls Recovery House, and Sassy Queen, though it’s also typical to rent an Airbnb and use trusted loved ones as temporary nurses. Sites like YouTube are filled with women’s experiences with their own post-operative care, some decent, some awful; vlogger Latausha Denn chronicled her terrible recovery process in a video titled “THE WORST EXPERIENCE OF MY LIFE.” For Helly, the first week was “absolute hell;” she described walking around a coffee table like running a mile. Long-term effects are common as well; both Kayla, who got her procedure last fall, and Helly, who got hers in 2019, still experience abdominal numbness. Helly also has lingering circulation issues when sitting down, back pain, and trouble sleeping.

These aftereffects are rarely present in the many Instagram and TikTok accounts run by doctors advertising their prowess in creating sculpted hourglass figures. Some have built huge audiences with cheeky sketches on how a BBL means freedom from the gym or how all their patients are having hot girl summers. They field dozens of DMs a day from women hoping to recreate the bodies they’ve seen online.

Edward Chamata, a doctor who works under popular TikToker Dr. Jung at Premiere Surgical Arts in Houston, Texas, sees this as a boon to prospective patients, who enter the consultation room with far more knowledge about different procedures than they would have access to otherwise. “Every kind of plastic surgeon is on Instagram, and it’s a massive reach on those platforms,” he says. “It’s a big part of empowering the patients and informing them on their care, so they almost have a lot of education already at hand.”

Other doctors see it differently. Perry believes that “as doctors, we’re not supposed to be salesmen.” On the rash of self-described BBL experts, Perry quotes Willie Sutton, a famous robber from the 1950s who was asked why he robbed banks and replied, “Because that’s where the money is.”

“Why do these doctors do these procedures? Because that’s where the money is,” Perry says. “But that doesn’t mean it’s right.”

The best — and only, really — way a patient can make an educated choice about where to get any kind of cosmetic surgery is to research as much as they possibly can. Resources like certificationmatters.org and the American Board of Plastic Surgery allow people to look up doctors’ certifications in particular areas. Rubinstein also warns against any surgery that sounds too good to be true: $5,000 isn’t enough to cover the costs of running an operating room, he says, without cutting some serious corners. “I’d say you probably shouldn’t pay much less than $8,000 for a BBL in Miami,” he says. Often, he’ll operate on women who’ve had a botched operation from a less educated doctor.

Ethical guidelines state that doctors should use rigorous screening processes that weed out people who aren’t optimal patients for a BBL — people who are severely under- or overweight, people with a history of eating disorders or body dysmorphia, people who maybe haven’t thought through the enormous decision they’re about to make. “I always ask my patients to bring in wish pics, and many times, they’ll bring in pics from Instagram,” says Chamata. “And a lot of times those photos are photoshopped, with obviously unnatural proportions that just aren’t achievable in the real world.” He says around 30 percent of the patients he sees aren’t appropriate candidates.

Yet looking “unnatural” has often been one of the goals for many people who’ve undergone plastic surgery. “It’s an interesting sociological phenomenon,” says Perry. “It started with breast implants in the 1960s, where there were so many bad breast implants — too big, too high — that women began to think that that was normal. I’ve actually had people request me to put implants up a little high, so that the bulge is visible under the collarbone. I try to explain to people, this is not normal. It’s the same thing with brows.” (He mentions a certain powerful politician as a particularly bad example of a brow lift done wrong.) “My goal as a plastic surgeon is to help people look normal, and sometimes we forget about that as plastic surgeons who are very interested in just getting everyone and their sister operated on. My job is not to do whatever you ask me to do. It’s to use my aesthetic and ethical judgment, and do what’s right.”

Unsurprisingly, Perry believes the BBL boom will fade out, and perhaps is already starting to. “The people coming in are no longer saying, ‘I want it as big as possible.’ Now they’re saying, ‘I just want it to be round,’” says Rubinstein.

That specific bodies can be “trendy” is, again, an ugly concept with an uglier history. The BBL, however, has an even more complex one. As Sophie Elmhirst put it in her thorough investigation on BBLs at the Guardian:

Following the chain of cultural appropriation that has led to this point is bewildering. The notion of the idealised Brazilian bottom, which some rich white Brazilian women disdain because of its stereotypical associations with biracial women, has become the desired shape among certain white women in the US and Europe, who are in turn emulating a body shape artificially constructed and popularised by an Armenian-American woman, who is often accused of appropriating a Black aesthetic, which some Black women then feel compelled to copy, not having the idealised body shape they believe they’re supposed to have naturally. “You steal a version of what a Black woman’s body should be, repackage it, sell it to the masses, and then if I’m Black and I don’t look like that? That’s a mindfuck,” summarised [Alisha] Gaines, [professor of English at Florida State University].

The stereotype of the Instagram-faced, BBL-bodied influencer is now almost bigger than a person’s physical appearance. On TikTok, where advertisements for and real-life stories about BBLs proliferate, so too does a meme known as “the BBL effect.” Twenty-three-year-old Antoni Bumba came up with the idea for the character, which they call “Miss BBL,” after idolizing a certain type of influencer who weaved seamlessly between the ranks of Hollywood and Instagram baddies — Amber Rose, Kylie Jenner, the Real Kyle Sisters.

“We have 20-something seasons of Keeping Up With the Kardashians, where you see these girls taking 45, 60 seconds just to get out of the car and into the restaurant because they have to serve every single angle for the paparazzi,” says Antoni. Miss BBL is recognizable not with the way she looks but in the little motions that let others know she’s a bad bitch — taking ample time to flick her hair behind her shoulders, eating slowly and carefully, and wearing a constant camera-ready smize. “People who get work done essentially have no problem holding up people’s time to be able to cater to their needs,” they explain. “And it’s so fire because it gives all of these people, especially women, this sort of edge, invoking confidence and self-sufficiency into their day-to-day lives.”

While Kayla and Helly ultimately ended up happy with their results, both wish they’d done more research before going under the knife. “If I were to do anything else again, it would probably be in California,” Kayla says. “Most places in Miami, after they take your money, they don’t really care.”

Helly described how her body dysmorphia got worse after she had the surgery; for about a year, she could barely look at herself in the mirror. “I would say to anybody looking into getting procedures, you’re not just going to magically be a brand new person that has this work ethic and great motivation. You need to find that before you go in and change your whole body.” she says. “If I had seen a girl on TikTok or YouTube talking about the reality behind it, I don’t even know if I would have gone through with it.”

It’s certainly possible that within a decade, the BBL will continue to fade out, just as body types have risen and fallen in popularity throughout history. “Think about the way that nobody has these huge watermelon titties anymore,” Helly says. “Working in the dancer industry, I had a lot of clubs that wouldn’t hire me because I had thick thighs and their mindset was still stuck in the ’90s. All these women are going to start getting their hips and butt reduced because it’s going to go out of fashion.”

Whatever the next most desirable silhouette looks like, what will remain is the cosmetic surgery industry’s willingness to follow aesthetic trends at any cost, offering “pioneering” procedures that haven’t been properly vetted, or doctors who’ve decided they could make more money jumping from podiatry to plastic surgery. Until lawmakers catch up with the reality of the field, over time the BBL could just be one of any number of dangerous operations that promises to build the perfect body.