In hindsight, I should have recognized the warning signs, said Nikki Ruston, who had cosmetic surgery in Florida.

The Miami practice where she scheduled what is known as a Brazilian butt lift had closed and transferred its records to a different center, she said. The price she was offered, which she paid up front, increased the day of the procedure, and she didn’t meet her surgeon until shortly before receiving general anesthesia.

“I was ready to go,” said Ruston, 44, of Lake Alfred, Central Florida. “But I had already paid for everything.”

A few days after the procedure Ruston was hospitalized for infection, blood loss and nausea, according to her medical records.

“I looked for the cheapest, that’s what I did,” Ruston recalled recently. “I looked for the lowest price and I found it on Instagram.”

People like Ruston are lured to go to surgery centers in South Florida practices. It happens through social media marketing that portrays the Brazilian butt lift, and other cosmetic surgeries, as deceptively painless, safe and affordable, according to researchers, patient advocates and surgeon associations.

Unlike outpatient surgery centers and hospitals, where a patient can stay overnight for observation after treatment, office-based surgery centers offer procedures that typically do not require hospitalization, and are regulated as an extension of a doctor’s private practice.

But these centers are often owned by corporations that offer reduced prices by hiring surgeons who are incentivized to see as many patients as possible per day, in as little time as possible, according to state regulators and physicians who are critical of these centers.

Ruston said he now lives in constant pain. After a series of deaths, and in the absence of national standards, Florida regulators were the first to enact rules in 2019 aimed at making procedures safer. More than three years later, data show deaths still occur.

Patient advocates and some surgeons anticipate the problem will get worse. Emergency restrictions imposed by the state medical board expired last September, and the business model popularized in Miami has spread to other cities.

“We’re seeing entities with a strong footprint in high-volume, low-cost cosmetic surgery, based in South Florida, popping up in other parts of the country,” said Bob Basu, vice president of the American Society of Plastic Surgeons and a physician in Houston, Texas.

During a Brazilian butt lift, fat is removed by liposuction from other areas of the body, such as the torso, back or thighs, and injected into the buttocks.

The Miami-Dade County coroner has documented nearly three dozen deaths of cosmetic surgery patients since 2009, 26 of which resulted from a Brazilian butt lift. In each case, the patient died of a pulmonary fat embolism, i.e., the blockage of blood vessels by fat that entered through veins in the buttock muscles and prevented blood from flowing to the lungs.

Globally, about 3% of surgeons have had a patient die as a result of the procedure, according to a 2017 report by a task force of the Foundation for Aesthetic Surgery Education and Research.

Medical experts said the problem stems, in part, from having physician assistants and nurses performing key parts of the butt lift instead of physicians.

It is also the consequence of a business model motivated by profit, not safety, that incentivizes surgeons to exceed the number of operations stipulated in their contracts.

In May, after the fifth patient in several months died of complications in Miami-Dade County, physician Kevin Cairns proposed an emergency state rule to limit the number of butt lift operations a surgeon could perform per day.

“I was sick of reading about women dying and seeing cases come before the board,” explained Cairns, a former member of the Florida Board of Medicine.

Some physicians were performing as many as seven surgeries, according to disciplinary files against surgeons opened by the Florida Department of Health. The emergency rule limited them to no more than three, and required the use of ultrasound to help surgeons reduce the risk of pulmonary fat clots.

But a group of doctors who perform Brazilian butt lift operations in South Florida responded by forming the organization Surgeons for Safety. They argued that the new requirements would worsen the situation by driving patients to dangerous medical professionals who don’t follow the rules.

Surgeons for Safety declined repeated interview requests from KHN. While the group’s president, Constantino Mendieta, M.D., wrote in an editorial in August that he agreed that not everyone has followed the standard of care, he called the limits imposed on surgeons “arbitrary.” The rule sets “a historic precedent of controlling surgeons,” he said during a meeting with the Florida medical board.

In January, Florida Republican Senator Ileana Garcia introduced a bill before the state legislature proposing that there be no limit on the number of Brazilian butt lifts a surgeon can perform in a day. Instead, it requires office-based surgery centers, where the procedures are performed, to have one doctor per patient, and prohibits surgeons from working on more than one person at a time.

The bill would also allow surgeons to delegate some parts of the procedure to other physicians under their direct supervision, and the surgeon must use an ultrasound.

The Florida legislature reconvenes on March 7.

Like Ruston, many people base their expectations on before-and-after photos and marketing videos posted on social media platforms such as Facebook, Snapchat and Instagram.

“That’s very dangerous,” said Dr. Basu, of the American Society of Plastic Surgeons.

The average price of a butt lift in 2021 was 4,000, according to data from the Aesthetic Society. A “safe” Brazilian butt lift performed at an accredited center and with proper postoperative care costs between 12,000 and 18,000, according to a recent article on the American Society of Plastic Surgeons website.

It’s common for mid-level medical professionals, such as physician assistants and nurses, to perform the procedure in an office setting, according to Mark Mofid, M.D., co-author of the 2017 study by the Aesthetic Surgery Education and Research Foundation task force.

By relying on staff who don’t have the same specialized training and receive less pay, office-based surgeons can complete more butt lifts per day and charge a lower price.

Basu said patients should ask if their doctor can perform the same procedure in a hospital or outpatient surgery center, where there are stricter rules than in offices in terms of who can perform butt lifts and how they should be done.

Bargain hunters are reminded that cosmetic surgery can have other serious risks beyond deadly fat clots, such as infection and organ perforation, as well as kidney, heart and lung problems.

Ruston’s surgery was performed by a board-certified plastic surgeon he said he found on Instagram. He was initially quoted 4,995. But when she arrived in Miami, she recounted that the clinic added charges for liposuction, and for post-surgical garments and devices.

“I ended up paying about 8,000,” Ruston said. A few days after returning to Lake Alfred, Ruston began feeling dizzy and weak, and called 911.

Paramedics took her to the emergency room, where she was diagnosed with anemia from blood loss and blood and abdominal infections, according to her medical records.

“If I could go back in time,” she concluded, “I wouldn’t have had it done.”

KHN’s Chaseedaw Giles contributed to this report.

KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth health journalism. It is one of three major programs of KFF, a nonprofit organization that analyzes the nation’s health and public health issues.


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