The BBL’s Not Going Anywhere

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey, Dr. Koehler.

Dr. Koehler (00:10):
Hey, Kirstin.

Kirstin (00:11):
How are you?

Dr. Koehler (00:12):
I'm good about yourself.

Kirstin (00:13):
Good. What do you want to talk about today?

Dr. Koehler (00:17):
I'll leave it up to you. Fire away. What do you want to talk about?

Kirstin (00:20):
I think we should talk about booties.

Dr. Koehler (00:23):
Booties.

Kirstin (00:25):
Let's talk about BBLs.

Dr. Koehler (00:27):
BBLs. What do you want to know?

Kirstin (00:29):
Well, first things first. Usually when we talk about BBLs or hear about BBLs, there's sometimes a negative connotation there because of safety. But more recently, there's been a tremendous effort by plastic surgeons to get the word out about safe BBLs. So what's been happening with safety?

Dr. Koehler (00:47):
Yeah, actually the safety with BBLs is, there is a little bit of history there, which I can kind of fill you in a little bit. So when I first trained, when we would do BBLs, we were a lot, most people were putting the fat both in the subcutaneous fat, but we were also putting fat in the muscle because the muscle is much more vascular. So the fat take was so much better. But then there was problems, there were some deaths reported, and it started off where there were just a few little case reports, but then as the BL popularity rose, there was significant no numbers. And it was estimated in some publications that it was anywhere between one in 3000 people and one in 20,000 people. But that was really high. And so actually in Florida, I can't remember what year it was, it was just before, I mean, I think it was about 2019, something like that.

(01:45):
There was a ban on BBLs until the medical board could kind of sort through this problem. And one of the things that came through that investigation process is that no longer, the BBL, the fat had to be put in the subcutaneous fat, not into the muscle. So when we liposuction the fat and then we inject it back into the butt, you don't want it in the muscle. And we kind of knew this earlier. And so by that time, I mean, I'd already changed the way that I did, but we were now just putting it into the subcutaneous fat. However, a new step came along in this whole process, and that's where the recommendation in Florida was not only do you put it in the subcutaneous fat, but we want to do an ultrasound to confirm that we're putting it in the right spot. So I'm actually teaching a cadaver course in New Orleans next week. I think you're aware of that.

Kirstin (02:40):
I am aware of that.

Dr. Koehler (02:42):
You are. But anyhow, we are going to have some live models there, and we we're going to be showing doctors how to utilize the ultrasound to make sure that they're putting fat in the proper position. And so the safety has, it's certainly better, but there's still obviously that people who don't do a lot of BBLs or maybe aren't as experienced. So obviously there are still considerations there. But yeah, it's a much more, I want to say, it's definitely the awareness has changed. And so it's safer.

Kirstin (03:11):
So because the people like you that are teaching the correct techniques and proper techniques, the game is changing.

Dr. Koehler (03:18):
I mean, we don't want to stop doing BBLs, but we want to make sure what we're doing is safe for people. I mean, obviously that's the number one concern, especially when we're talking about a surgery that people don't need to have. This is elective, so we want to just make sure it's done safely. So there's actually a lot of things that we do. It's not just doing the ultrasound, I mean how you handle the fat. And there's a lot of things that go into getting the best possible result on a BBL.

Kirstin (03:43):
Have you seen anybody get hurt by surgeons out of the country or far away from them?

Dr. Koehler (03:49):
Not personally, but I mean, you hear stories. I mean, I know of stories of people here locally that traveled out of the country and ended up with a fat embolism, which is what you worry about. So the problem that can happen is if the fat is injected into the muscle, that's not even a problem. But if it gets into the veins, that fat can go back to the heart and then go to the lungs and it creates a clot, a fat clot, not a blood clot, but a fat clot. It's called a fat embolism. So now all of a sudden it blocks the oxygen delivery and people die and it's terrible, terrible, terrible thing. So yeah, I haven't personally seen any patient that's had that happen.

Kirstin (04:32):
What risk are you taking if you decide to go out of the country for something like this?

Dr. Koehler (04:36):
Well, I don't know. That's a whole nother topic altogether. It's really, there's good doctors throughout the world and there's well-trained doctors in different parts of the country. So I would hate to say, oh, if you go to Mexico or you go to Brazil, maybe the Brazilian butt lift. You know, there's good doctors in all these countries. And I would just say though that the advantage of being here local is two things. First of all, we have certain regulations in place in the United States that all doctors are required to follow. So the rules are fairly rigid. In some of these other countries, the rules are maybe a little less rigid. So if you didn't have maybe as good a doctor, I mean, they may be a loose cannon, but the real issue is not even that so much. It's the fact that if you do experience a problem, you want to be in the place where your doctor's there to take care of you. Now, obviously with a fat embolism, that typically is going to be something that happens pretty quickly at the time of the procedure, but there's a lot of other procedures where the complications don't necessarily pop up in the first 24 hours and they can happen later. And that's why you don't want to go have a surgery and then come on back and now nobody's there to manage you.

Kirstin (05:44):
Well we talked about the use of ultrasound to make BBL safer. Are there other technologies that you maybe use as far as safety or technique?

Dr. Koehler (05:54):
Well, that's the main one for safety, because we just want to visualize how thick the fat layer is where you can visualize your cannula when you put in that initial bit of fat. So that's the big push on safety. But there's other things, like I mentioned, how you process the fat and there's different methods of doing that. And those things are not so much, I wouldn't say safety, but perhaps in obtaining the best possible results. So you want to treat the fat in a way that you're going to get optimal fat take because all the fat we put in there is not going to stay. And that's one of the downsides of BBLs is it's kind of a, you can't look a patient in the eyes and say, well, this is how much fat's going to stay. We don't exactly know. And it can vary from patient to patient, but there's different methods to treat the fat. And I think as long as you've got a surgeon that takes all those little steps to try to optimize the amount of fat that stays, then you're good.

Kirstin (06:43):
Are there steps that patients can do once they get home to help keep their fat?

Dr. Koehler (06:48):
Yeah, probably the biggest one is just you don't want to have continuous pressure on the surgical site. When we initially put fat, fat in, the only thing keeping those fat cells alive is the surrounding tissue fluid. And so there's a couple of things. One, because of that, there are some limits as to how much fat you can realistically put in somebody's butt in any one session. Because if you put too much fat in the cells, you can put as much as you want in there, but that's going to affect the amount of survival because you need the surrounding nutrients in the tissue fluid to provide that to the cells. And if you choke it off to where there's just no tissue fluid, getting to those fat cells are not going to survive. And so that's what initially provides the survival of those fat cells until the body can start to form new blood vessels to the area, which then will provide a constant source of nutrition to those fat cells.

Kirstin (07:42):
Well, regarding cost, is it important to, do we want to bargain shop or is that something we want to stay away from? Does cost affect the quality of the work?

Dr. Koehler (07:53):
Well, again, kind of a difficult question because I mean, I think sometimes you get what you pay for, but I couldn't tell you where that point is. I think the key is to just research your doctor and make sure they're well trained. I mean, I always say you shouldn't be making your decision based solely on price. I mean, obviously everybody's ability, some people are like, oh, money's no object and other people, money's important to me. You just got to find the right doctor that's in your price range for what you're wanting to do. And I don't think necessarily that price correlates a hundred percent with the quality of the work, but there's definitely some correlation there. But

Kirstin (08:27):
Well, and potentially if there are complications later on, those might be more costly than the surgery itself. So I would suggest not to bargain shop for a BBL.

Dr. Koehler (08:38):
Yeah. Well, I mean, I definitely don't think you'd want to go to the lowest price in town. It always has me concerned when people do that. And I'll tell you why. And probably the bigger reason, and actually I'm going to tell you why. When in Florida they had this ban, well, one of the that came, and I can't remember what the limit was, but I think they also put a limit on how many BBLs a doctor could do in a day. The reason is is that some of these clinics, although they charged lower prices, they were kind of mills and they kind of churned patients out at a higher rate. So they charged less per patient, but they were doing more patients in a day, and there was the fatigue of the surgeon. And then also they would have other ancillary staff helping with the procedure. So maybe the doctor wasn't liposuctioning. They had some first assistant that was doing that. And so that's where you start to get into trouble when you start bargain shopping, you can end up getting perhaps lesser quality care.

Kirstin (09:34):
Yeah. Okay. Well, let's switch gears a little bit and talk about diaper booty. What's diaper booty?

Dr. Koehler (09:42):
Diaper booty?

(09:44):
I don't even know that I've heard that term before. You might have to tell me what diaper booty is. But I guess I've actually not heard that term. But I guess what you're referring to is just sort of when people, as they get older, they'll get some deflation of their buttocks and have some sagginess there. And yeah, that's where, so BBLs can be done for different reasons. I think the common thing people associate with a BBL is like when the Kardashians and all the people that had these really big booties that everybody, the thought was everybody wants to have a huge booty. And the reality of it is there are people that want that, but there's a lot of people that just want to have a little bit more fullness and improve the shape. And so that's really what you're talking about in those circumstances is providing some fullness and shape to the buttocks.

(10:31):
But there are some limitations there. And one thing I'd like to comment is that it's called a Brazilian butt lift, but it really isn't lifting things. It's augmenting, it's adding volume, but it's not really lifting the buttocks. There are surgical procedures that we can do that, they involve incisions, and it's not something that you would typically do for your average patient. It's typically done in weight loss patients. But anyhow, so you can add volume. You have to be able to have enough fat to do that. And then there even then can be limitations because I guess I tell people sometimes it's kind of like a breast augmentation. If you start off and your breast has a conical shape to it and we put an implant in there, we will make the breast bigger. And that's the goal of breast augmentation. But sometimes the shape, you haven't changed the breast tissue and that breast tissue sitting on top of the implant. So if it's conical shaped, it's still going to have a bit of a conical shape to it. So if the shape of the buttocks has some issues, some of those things can be really hard to crack. Somebody can't just show you a picture and say, this is how I want my butt to look. It depends on the existing shape.

Kirstin (11:38):
So I'm going to switch gears again because you spoke about implants. Are there implants, well, obviously now we know that you can do, butt or gluteal implants. Is that something that you do?

Dr. Koehler (11:50):
I used to, I don't anymore. And the main reason I quit doing 'em is that it was just a procedure that I wasn't doing really frequently. And you get to a point in your career where it's like, can I do it? Sure, yeah, I know how to do it and I can do it. But then there's the question of does it make sense for me to do it? I don't do lots and lots of these. And quite frankly, that's where one of those procedures where it was kind of a pain in the butt for me, no pun intended. And I got to a point, I was like, I'm going to let somebody who does them on a regular basis. And there's certain surgeons that have built their reputation around that type of an operation. Gluteal implants are good for people that don't have fat to transfer, but gluteal implants can be put in two ways.

(12:32):
That can be, just like with breast implants, we can put it above the muscle or we can put it inside or under the muscle. And the butt implants that are put on top of the muscle tend to look really bad. I mean, it looks like a baboon's butt. It doesn't look good. You can see, especially in the thin person, I mean, you can just see everything. It just doesn't look good. So you then have to put this implant in between the gluteus maximus and medias muscles, and then there's nerves that are there. There are vital structures that affect your ability to walk and things. So it's a procedure that you really want to have somebody that does it regularly if you're going to do gluteal implants, in my opinion.

Kirstin (13:09):
Interesting. So if you have a smaller BMI, that would probably be a better option for you versus a BBL?

Dr. Koehler (13:19):
No, I mean, my first choice is always a BBL to an implant. And for a couple reasons, it's your own fat, so you're not having to deal and implants, although they can be great, they are not once and done procedure. At some point in your life, you'll have to address it. It could be 30 years from now, but at some point you're either going to have to change it, remove it, there can be issues. And sometimes an implant can last a lifetime, but you can't go into it with that understanding. And so implants can have their own set of problems, just like fat grafting has its set of problems. But the nice thing about fat, it's your own and whatever stays is going to be a long lasting result. So that as long as there's enough fat to get, we can augment the butt. The question is, will it meet the patient expectations? So if we're just talking about a smaller augmentation, maybe just a couple hundred ccs of fat in each buttock, well, sure, you can do that, and you might be able to find the fat. But if they have absolutely no fat, then those patients are probably looking at an implant.

Kirstin (14:17):
You know there are tons of trends on TikTok. And right now there are tons of videos saying the BBL era is over, the Kardashians are getting smaller butts, whether they've got BBLs or implants or whatever. And there is an Atlanta surgeon making a lot of noise about BBL reversals. So do you think the trend is really over?

Dr. Koehler (14:37):
I don't know if it's over, we're still doing BBLs on people, but just like I mentioned, I mean, I have lots of patients that come in, they're like, I don't want a big butt. I just want to help the shape, or I want it. So we're still seeing it, but I think the trend of everybody wanting really large butt, but I mean, there's still people out there that are wanting that. But again, it's just like everything else. It's like with breast implants, what's your taste? I mean, some people, there's this thought that, oh, there's a trend. Women want smaller breast implants, and maybe that's so, but I've also still seen lots of women that come in that want larger implants. So it's whatever your taste is. But the thing about people that want to have that larger, really full buttocks, those people need to go into it knowing that it may be a couple of sessions of fat grafting. You just don't go from point A to point B with one session of fat grafting, because as I mentioned, not all the fat is going to stay, and we won't really know that for a good three to six months. And then at that point, we may have to go, look, we need more fat, and hopefully they have enough fat to be able to do another round.

Kirstin (15:38):
Have you heard of this other internet trend that we're about to talk about called this skinny BBL? Did you know this was a thing?

Dr. Koehler (15:46):
I'm not on TikTok, so no, sorry. No TikTok for me. But I mean, I think that the skinny BBL is probably what I was referring to, which is just people who are, they don't like the hip dips or they just want to have a little bit of fullness, then that sort of thing is definitely a doable thing. And I think that to me is a very reasonable thing. I mean, it's kind of like what we're doing with liposuction. Liposuction is not a weight loss procedure. Some people use it as that to try to remove as much fat as possible, but that's really not the goal. Liposuction is a contouring procedure where if you've got a saddlebag or a bulge, we're going to take it down and the hip dip is no different. We're just going to build it up. And so instead of just, you can call it a skinny BBL, but really it's contouring. And that's really what we're looking at doing. And that's the goal to me for most BBLs, is just to get the shape looking good. And in fact, I think a lot of times the BBLs look much better when the shape just looks good and it's not just big. Big is okay, I guess, but getting the shape good is more ideal in my mind.

Kirstin (16:55):
What did you say? We like upside down hearts. Is that right? Or am I wrong?

Dr. Koehler (17:01):
Oh, well, it depends. Yeah. But yeah, little upside down heart, you want to have a little thin waist and then some more fullness. But there's some cultural things there too. Some people like to have more fullness on the side. Some people like to have more projections. So there are some differences there. And that's why where you got to really communicate what your goals are to your doctor to make sure that we're on the same page.

Kirstin (17:25):
Yeah. Well, if you have a thinner person, where on the body do you usually find fat to remove?

Dr. Koehler (17:30):
Yeah, you just got to look, it depends. And most people will have a little bit on the love handle area, so you can usually get some there. And we really like to sculpt that area anyhow as part of a BBL. If we can make your waist look narrower, it makes your butt look fuller, but then upper arms, sometimes outer thighs. I mean, it just depends. But yeah, that can be the challenge on skinny patients.

Kirstin (17:54):
Is it ever possible that they need to gain weight first in order to have it removed? Or do you not usually recommend that?

Dr. Koehler (18:00):
Let me say this. It can be helpful only from the standpoint of it makes it easier maybe to harvest the fat. So let's say a patient puts on 15 pounds and you go, oh, great. Well, now I've got more fat and it makes it easier for me to harvest it, and then I put it in their buttocks. But if they then go and lose that weight, those fat cells are going to shrink down. And so you'd have to maintain the weight you're at and keep once that fat stays. So if you gain the weight and then lose the weight, I mean, your fat cells don't really reproduce. You don't get more fat cells, once you're an adult. I mean, the number of fat cells you have is kind of what you have, but the fat cells get bigger or smaller, and that occurs with weight gain and weight loss. So now if you've put the fat in the butt and you gain weight, you're going to put more fat on in your buttocks, but you're not going to put on as much in your waistline if that's where we took it from. So anyhow, yeah, that's fine. Sometimes it can be helpful to put on weight for some of those thinner patients, for sure.

Kirstin (19:02):
As far as recovery, we talked about not putting a lot of pressure on your buttocks and stuff like that. Are there other things that we need to remember for recovery or how difficult is recovery for a BBL?

Dr. Koehler (19:16):
I think the liposuction is more painful than the injection of the fat into the buttocks, and also depending on how many areas you had to liposuction to get that fat. So sometimes the donor site is a little more uncomfortable than the recipient site. But anyhow, yeah, there's garments that we'll recommend for people to just help keep some compression and to hold the shape. I don't know that those, I mean some doctors put all their faith in the garment that that's going to be the critical thing to give you the end result. I think it's helpful. I think it certainly helps with the swelling and the recovery. I'm not against a garment. I just don't think that if somebody says, I didn't wear my garment for four hours, I'm like, I wouldn't sweat it. You're not going to lose your result because you took a break from your garment. And just like people are like, well, how am I supposed to go to the bathroom? I'm like, well, sit down and go to the bathroom.

Kirstin (20:01):
Let's expel this myth that you have to lay on your stomach for six weeks.

Dr. Koehler (20:04):
Well, yeah, I don't think you need to lay on your stomach. I think you can lay on, there's wedges and things that you can put and you can kind of lay on your side and alternate back and forth. The key thing is you just don't want to keep constant pressure on one spot. And another thing, when I tell people about sitting down, you're like, well, what am I going to do for the next six weeks? I'm not going to get to sit. Well, if you think about it, I recommend people actually don't sit in a, you don't want to sit in a recliner necessarily because the recliners going to put you back and put your weight kind of on your butt. But if you were sitting on, let's say you had a wooden chair at home and you sat down on it, you could actually put the weight on the back of your thighs and you can be sitting down and you're not really putting any pressure on your butt at all. So you can change the position of how, and you can sit. But yeah, you just don't want to stay in one position for a long period of time putting pressure on that area. That's what you're trying to avoid.

Kirstin (20:58):
When are you back to normal? Is it about six weeks?

Dr. Koehler (21:01):
Yeah, that six weeks is when you can kind of resume physical activity. You can go work out and all that kind of stuff. And then I tell patients as far as the healing goes, so at first, maybe at one week when they'll come in for a follow-up, they're like, oh, it's beautiful, it's super full. It's tight. And then I'll see 'em at six weeks and they're like, oh, I think all the fat's going away. And I always try to tell people it's kind of a curve. So we put the fat in, that's where the most fat is. But we already told you that not all the fat's going to stay, so maybe only 50% of the fat goes. So then we're already starting to see some fat loss, but then the fat cells still don't have their blood supply. So the fat cells are going to survive off of the lipid that's within the cell and provide energy for it. And so the fat cell is going to shrink. So now whatever fat stays is there, but the cells have shrunk down, and then once the blood supply picks back up, those swells will become puffy again. They'll be fuller. So that process takes between three and six months. So if you feel like, oh, your butt is shrinking at six weeks, it is. But we don't know where you're going to ultimately end up for three to six months because it will rebound.

Kirstin (22:16):
Perfect answer.

Dr. Koehler (22:17):
There you go.

Kirstin (22:18):
I love it. Is that all?

Dr. Koehler (22:19):
I don't know. I feel like there should be some music playing or something. Right?

Kirstin (22:24):
Sing it. Sing it.

Dr. Koehler (22:24):
I like big butts and I cannot lie. <laugh>

Kirstin (22:27):
I knew it. <laugh>

Dr. Koehler (22:30):
 I don't know.

Kirstin (22:31):
They just played that at the Mardi Gras ball I was at, and it was probably the favorite song of the night. So

Dr. Koehler (22:35):
There you go.

Kirstin (22:36):
Everybody knew every word.

Dr. Koehler (22:37):
Yeah, the BBL's not gone. It's not going anywhere.

Kirstin (22:40):
That's right. That's right. All right. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the Beautiful podcast.com. We would love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (22:56):
Thank you. It was fun.

Kirstin (22:57):
Go back to making Alabama beautiful.

Dr. Koehler (22:59):
Alright.

Announcer (23:00):
Got a question for Dr. Koehler? Leave us a voicemail at Alabama the beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.