The Brazilian Butt Lift (BBL) has evolved significantly since the 1960s, with major safety improvements including ultrasound guidance to prevent fatal fat embolism and a shift from prioritizing volume to emphasizing natural shape through the 'OG line' concept. Modern BBL success depends on multiple factors: pre-operative optimization with Fat Vive supplements and iron optimization, intraoperative techniques using Viology for fat cell repair and ultrasound for precise placement, and post-operative care including manual lymphatic drainage, Fibro Guard garments, and red light therapy to ensure fat survival and prevent fibrosis.
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BBLs in 2026: What Changed?Added:
Heat. Heat.
Hey, it's Dr. William. I'm Grab your markers. Have you ever wondered why >> light go through the key area around fill in the hip? Blend that into the leg. I've got my pen and paper out today. I want to talk about >> Okay. Okay. Okay. Okay. Okay.
>> Okay. Okay. Yeah. Okay. Relax.
Welcome to my YouTube channel.
Hi, it's Dr. William and welcome to my live. Tonight we're going to be talking about the state of the union of a BBL.
So, a BBL in 2026. What does that mean?
Why am I with these red lights? I'm going to talk about that in a moment.
And we'll get back to the red lights.
But let's get into this. This is going to be a really good live. I've got a lot to talk about. Uh, as usual, never short of words. And um I want to start with a a little tiny bit of the history of a BBL so we can see where we've been and where we are today because a lot has changed over the time that I've been doing BBLs. I've been doing BBLs since 2008 and or 2009 somewhere in that area and a lot has changed since that time. So if we look back in the the history of the BBL, it's really given credited to to uh being started by Dr. Patanga in Brazil in the 1960s. He was a legend plastic surgeon, died a few years ago, phenomenal uh contributed plastic surgery pioneer. But it really wasn't until the late '9s that the BBL started to become done with some type of frequency. still pretty rare uh in the United States. And then the real boom happened for BBL between 2012 and 2022.
So that 10-year period was a really growth of the BBL in the American um surgical community.
And with that boom, uh we started to see problems with the procedure itself. And this has happened not just with the BBL, but this has happened with many procedures, uh, not just plastic surgery procedures, but a lot of different procedures where we think that they're safe, we think they're fine. We start to do them, we do, they become more popular. We do them with more frequency, and then we start to see some of the complications that don't happen as often, but we start doing more and more, you start to see some of the complications. And that's what happened with a BBL. And that's where we started to see problems with people dying from having the operation. And it really wasn't until a group of plastic surgeons got together and really decid and really figured out, okay, why are these patients dying? There was uh autopsies performed and it found out that the patients were dying from fat that was injected into the blood vessels deep below the muscle. that created a fat emblei and that created the death and that ushered in the the really the major change in a BBL. There's a lot of them we're going to go through, but that ushered in a major change which was the adoption of ultrasound. So, we could actually see where we were injecting the fat. I'm going to show you here a little schematic diagram, a little model here.
Uh, let me just change this out.
a little model here that will actually show you what what happened. So this is a patient here uh and just a little cutout here and I want to show you her glutial area and if we just kind of remove the skin what we find immediately below the skin is fat and there's actually two layers of fat. There's a superficial fat and then there is a deeper fat here and then there's a deeper fat. So that's the fat level and then underneath that is where the muscle is. And that's really when we talk about ultrasound, we're always talking about muscle and how it relates when we're injecting fat to the muscle. So we always want to know now that we want to be above the muscle.
In 2022 became a law in Florida to use ultrasound when performing a BBL. And what we can do is with ultrasound is we can see where that muscle is. And we know that if we're above the muscle, then we're going to be in these two planes here in this fat. And if we're below the muscle, then we're going to be here and potentially getting into these large veins. And I've got a little video I want to just play for you now, which will show uh a real live um demonstration of ultrasound in the operating room.
So, probably the most important development in doing a BBL is this little gadget right here. This is a ultrasound device. So, what does ultrasound really do? How is it valuable? How do we use it when we do a BBL? Well, we put a lot of this goop on top. That's what allows the ultrasonic waves to be transmitted through the tissue. And then this will give us a nice little look. I already have my canula in place, but I haven't injected any fat because I can't see where my canula is. So, let me show you how this looks. And let me just get you oriented first. This here is the top and this is the bottom. So this is top part here is the skin goes all the way down. And then you see these little striations in here.
This tissue looks different than this tissue. This tissue looks different than this tissue because we have skin, fat, and muscle. So this striation here, it looks like kind of like a flank steak if you see it in real life. These striations here tell me where the muscle is. This is all muscle. And then this is the interface between the fat and the muscle is right in here. And I know to stay above the muscle. We know that if injecting into the muscle or below the muscle is dangerous, that can lead to a fat emblei. So once again, you've got your skin, your fat in your muscle. But now let me show you where the canula is.
Canula is going to be this nice bright white object. You see that going across?
This is just a nice bright line. And if I follow that, you'll see it keep going all the way out here, all the way out here, and we're in a nice safe place to inject fat because we're well above the muscle. Okay. So, here's my canula here. And then I'm just going to hold the ultrasound still and I'm just going to move my canula and you're going to see my canula moving as I'm taking it out. Now, let me show you what fat looks like when we inject fat.
So watch right at the end of the canula.
You're going to start to see see that fat start to come in. So we can see that fat come in and it starts it looks gray and it starts to distend. Look, we're already getting projection here and you can see that. But you can see that all the fat itself has been placed above the muscle. So that's how we keep everything safe is we can see these are my eyes. is this is how I'm working by seeing where the canul is we know where to inject and keep everything in a safe.
>> So that was the most important development in terms of safety and that's obviously the most important. The next thing that really has changed a lot and I've seen this over the last you know since 200 2008 I guess 2008 and that is a difference between volume versus shape. So when BBLs first came in, you know, it's like anything new.
You they start getting done and then they improve as time goes on. Well, the main thing when when we started doing BBLs, the main thing was always about size. Patients wanted size. And it it's really the drift has now been back to what I think is a little bit more of a normal kind of configuration where it's no longer size as being important, but what it actually is is shape as being important. And so if we go and we look at some BBLs that were done years ago, uh these are not mine, but this was kind of the the style was to generate a really a large volume was driving everything.
Everything was volume volume. So what you would do is you would get a m mismatch between if you look at the patient's waist, her waist looks nice, her legs look nice, but now you have a really oversized glutial area. We can see that size really took a precedence over shape. And that has been really one of the main changes if we look at BBLs is it's actually the whole concept of shape. And I want to explain to you here what my concept of shape is.
And I call it the OG line. And it's just a very natural line that forms in nature. We find it everywhere. And because it's natural, we as humans tend to like it. It looks natural to us. It looks normal to us. It doesn't look like something that's really done. And so that's for me, it's been my focus for a very long time is always about shape.
I'm always focused on shape. I've always thought whether I do breast or anything.
If I can get the patient a really nice shape, I know they'll be happy. And there could be something else that they're maybe not as happy with. It could be this, it could be that. But if I can get someone a really good shape, I know they're going to be pleased with it. So, I'm going to explain to you here if you don't uh know what the OG line is. And so, here is a before and here is a after. And the patient has had this is before BBL. This is after BBL. These are not photoshopped. These are just regular photos. And what you'll see is is the establishment of that line that I was talking about. And it really just exists right here in this line. So, how do we go from here to here? And how do we focus on shape rather than just trying to get a size, just trying to drive volume? Because let's say this patient here, let's say she wanted to have a little bit more volume. Well, that may be true. I don't think so, but it may be true. But I know that she has a pretty shape and she'll be happy with the shape. And I know that in 10 years from this date of this photo, she'll also be happy in the shape because the results of a BBL are permanent. And those shape changes go on forever. So I would rather have somebody that has a pretty shape that I know that's going to look good in 10 years, 20 years, 30 years, 40 years, rather than somebody that just has a trend and has a very large butt that really doesn't have a nice shape. So, let me point out a few little things that that that we do when we're doing an OG BBL and how you go from here to here.
So, the OG lipo comes with the OG BBL.
That's how we get the fat. So, it's lipo of your whole front, all your sides, and the whole back. And it's very important to do lipo starting high in the back because if we're looking here and we're looking at where the shape is coming from, it's coming from up high in the back. So the lipo has to be very extensive on the whole back that if somebody has a good waist, she naturally has a good waist. You can see her waist here and she naturally has a good waist.
But if we are able to continue to remove the fat through this area, remove the fat through what we call these love handles, but then also very importantly remove the fat through what we call the key area here. The key area is kind of a transition zone between the buttocks and the and the love handles. And if I can lipo through this as well. Just doing the lipo part of the case already sets up this line here. What happens below the key area downwards.
That's from the actual fat grafting.
That's from the fat grafting. That's when we're putting fat into it. That's why it's called a BBL. It's a combination of lipo suction. People always say lipo 360 and a BBL. It's really the same operation, but you're doing lipo 3 suction to get the fat and then we're going to fat graft that into the butt. So this convex part of the line, okay, this is a concave part of the line and this is a convex part of the line. Those two meet somewhere around the key area. So once we get below that key area, if you'll notice, she has some fairly nice shape here to begin with, but we're just we want to make this smooth. So, if I look at her line right here, I see this come out, this dips in, and this comes out. We don't want that. We want to have a really nice line that comes down and is nice and smooth, and it's blended into the legs. So by blending into the legs, we avoid this type of look where we have just size that's doesn't that doesn't relate to the legs and that's not a natural look. And some people may like the way her butt looks and that's fine.
But I think if you go on with time and you have a real disconnect between the waist, the butt and the legs, you end up not looking good 10 years down the road.
So the fat gets blended into the legs and that gets you that nice OG shape.
Okay. So that's one of the main developments is emphasizing shape rather than size.
Now I'm going to take you through this whole process. So when we talk about getting the shape, we're talking about the surgical technique. We talked about the key area. Talked about lipo high in the back. There's other things that we consider when we're looking at the shape. So, one of the concepts that I would like you to sort of understand as well is something called a vector. And so, when we look at a vector, what we're doing is we're looking at the patient from the side. So, we're looking at her butt from the side. And when we do that, you can see this shape. Let's say this is the person's front here. So, you see the shape. Oh, that's a pretty shape.
Well, there are different starting points to get to this shape and those are vectors. So, there is a negative vector where someone is really the butt is really coming in. There's a neutral vector which is the most common and then there's a positive vector which is the most desirable. We're always trying to move to this positive vector. It's not always positive. But I can tell you in 2010, 16 years ago, I never thought about a vector. It's a new development to think of this process in not just looking at the butt, but actually looking at the whole body. And it's really when you talk about lipo from the high back all the way down or grafting fat. This is really an operation that's affecting the whole body. And that is a major change. It really used to be just sort of focused on the butt and trying to get as big a butt as possible. But subtle things like understanding the vectors can help me get a better result.
And it can also help me explain to patients where we're starting from because starting from a negative vector will give you a very different outcome than starting with a positive vector.
The other thing that we talk about that relates to shape and technique is a chicken butt. And so again, when I was doing a BBL 10, 12 years ago, I really didn't understand the chicken, but I noticed it sometimes. Now I see it like this. I see it very clearly, very easily. So understanding the anatomy of the butt has been also a big change. And really paying attention to the patient's results and seeing things that are not as attractive. And before I started to really recognize chicken butt and then purposely correct chicken butt. You can't correct it totally but you can get a significant improvement that has really improved the shape. So the shape is now what we really understand as the most important part and as different components in terms of the lipo in the back the key area understanding the vectors understanding chicken but understanding these other components and performing it in a more technical way has allowed us to get a better shape.
Okay. Now in order to get a better shape we're going to have to have the fat survive. So that is a major change in what's been going on and what we do and I'll tell you about it. So fat survival can really we used to just inject the fat and then sort of hope for the best. Now we have a much more strategic way and a much smarter way of thinking about it and thinking about how can we make the fat survive because if you think about it the shape of that butt is going to depend on the survival of the fat. The lipo suction is going to be there but the fat that I put in is going to be be dependent on the ability of that fat to survive. So let's look at some of the things that we can do to help fat survive. So in order to understand that we really have to sort of understand the process and the timing and the factors involved with fat survival. So let me go through and explain that and and let's talk about fat survival.
This is a this is a lot has changed with fat survival uh even in the last 6 months. So when we look at fat survival, we need the fat to survive because that's going to give us the shape. Well, what happens to these little fat cells?
Why don't they survive? What why don't why doesn't 100% of the fat survive? Why don't we just take the fat with lipo and then all of it survives? So what happens to the little fat cell along its little journey? And then I'll show you how we can impact the fat survival at different stages before surgery, during surgery, and after surgery. There are things that you can do to increase your fat survival and maintain the shape. So when we talk about fat survival, I've already mentioned that you're going to have a bunch of fat cells that get removed from lipo suction, and those go in that little canister you've seen. And here are all the fat cells. Well, these fat cells right now at this point they're not alive. And so they have to undergo what we call neo just means new vascularization which just means getting a blood supply. But this is really a very important step. It has to get a blood supply. The fat without a blood supply doesn't doesn't live. It doesn't survive. Your shape won't won't make it.
So with this fat, when you take the fat out of the lip bone, let's just look at one of the little cells. Technically, that cell is no longer alive. There is no blood supply to that. And when you have a situation where you have cells that are not surviving because there's low oxygen, you can develop what's called oxygen free radicals. And those are little things here that will go and they'll attack that fat cell. So, we now actually have a way to diminish the effect of those free radical oxygen on the fat. And that's something with that's new and that's something called Fat Vive. And what that is is that is a it's a supplement that you take one week before surgery and after surgery as well. And what this does, I'll show you.
Actually, I have some right here. It's just literally a supplement powder. You mix it with water.
Um, and then you just consume it and you take it once a day beginning one week before surgery. That increases your total oxygen capac uh antioxidant capacity and it's been shown in studies and animal studies to increase fat survival by 25%. So that is something that can be done pre-operatively.
Now if we look at other things we can do pre-operatively. So let's kind of look at the things that we can do pre-operatively. So before surgery what are the things that I do intraoperatively.
So those are the things that I can do to help fat survive. And then let's look and see what happens post-operatively to help make fat survive. So let's just sort of look at these things. And I've broken it down into a few steps. So one here is Fat Vive because that will help your fat survive. And you start taking that one week before surgery. Increases your antioxidants very very high. Total antioxidant capacity is extremely high with the fat five. It's all made from natural supplements and that will help with the killing of the or or negating the effect of the oxygen free radicals.
The second thing that we can do is we need to have what we call iron optimization meaning you have to have el you have to have appropriate ferotin levels which is the way that we do a lab test to measure your iron how much iron you have in your body. You need to have iron in order to make hemoglobin and you need the hemoglobin in order to carry the oxygen and that's going to help your fat go through the neovascularization and so iron optimization is important. I used to only look at hemoglobin and hemoglobin is an you need iron to make hemoglobin which is the red blood cells in your blood to carry the oxygen. But if I just looked at hemoglobin as the only indicator as to how fit this patient is for surgery and how well she is prepared pre-operatively to make her fat survive, I'd be missing the boat.
You have to look at ferotin levels because that's going to tell you actually your iron stores. So iron optimization is important. Nutritional optimization is important. You hear people saying eat healthy fats and these types of of things. Well, it's really comes down to not just eating uh fat, but eating healthy and eating clean and eating appropriate levels of protein, which is 1.2 g per kilogram. And you're just going to have to convert that. But if you look at say someone who's like say 150 pounds, so they're like 70 kilograms, then they're going to need like 85 grams of protein to eat on a daily basis. So we're going to have antioxidants. We're going to have iron supplementation. We're going to have proper diet diet optimization with appropriate clean diet and appropriate protein levels. These are not these bro science protein levels. These are actually scientific protein levels that we know are adequate for healing. The other thing that that we do, this is has doesn't really have a lot of evidence to it, but I personally like it and suggest patients do it and that is exercise because I think exercise and yoga and stretch are incredibly important to help get the body in the best optimal shape to help your fat survive. Those are the things that are done pre-operatively.
Those are things that you do. I can't do those things. You have to do those things. Now, intraoperatively, you can't do that. You're going to be asleep.
You're not going to be able to do anything. Now, I'm going to be the one that has to do these intraoperative things. So, what has changed is the one number one is the way we harvest the fat. So, in the old days gone by, we used to crank up the lipo and use a smaller canula and we just used to go to town. We now do lipo suction with a little bit less suction and a little bit bigger canulas. So, it's not as hard on the fat. So, more of the fat that we remove will survive. The other thing that we do is um use vi. So vi if you don't know about vi you should. It's it's really something. This is this is a obviously this is a non-sterile. This is their box. And what is vitality do? Well one of the key uh contributors and developments of this product is Dr. Miguel Medina who practices here in Miami. and he's going to be on a podcast with me in a couple of weeks where we're going to be talking about violity. And it really wasn't the the the whole the magic of Vi is not really just the container, although this does have a really good way to filter the fat.
There's a really there's a really nice fine little filter in here um that helps to to collect the fat in a much nicer way. But it's the P188. That's the Oracle cleanse that goes inside here and we wash the fat with that. Now, what is the P188? What is Oracle? Well, that's really cool. And I'll draw you a little diagram here with it. So, if you can imagine, this is a fat cell. So all of our cells are made up of these little phosphod lipo um phosphotidylcholine and all these little things and they sit in here and they've got their little what we call hydrophilic and hydrophobic parts and this is what makes the membrane of a cell. So that's what actually makes a cell. Now you can imagine when you go through lipos suction and you're extracting the fat under vacuum you can have damage to the fat cells and so what can happen with this is you can have a little hole a little damage a little tear in the wall of the cell. So the P188 which is with violity it's the ora cleanse it's it's the little powder that we mix with the water and we wash the fat. So what that does is by exposing those fat cells and some of them are damaged by their journey through the liposuction they get their membranes torn. If we didn't do anything that fat would just die and it would have no chance of survival. The aura cleanse using the violity increases fat survival because it repairs those fat cells that were damaged. So, if you have a little hole here, I'll blow that up. And let's just say you have a little hole here.
And what will happen is the P188 will come in and it will fix and it will repair and it will seal that hole and it will allow that fat to survive. So, they've had really good fat survival rates using Vi in the 85% in some of their studies. So using violity is a way that I can do it in the operating room to increase your fat survival. And then the other thing and you may not be aware of we've already talked about the ultrasound. The ultrasound is very good for safety, right? We can see where the muscle is. We're avoiding those deep vessels. but not not talked about very frequently is the fact that the ultrasound is actually also involved in fat survival. And let me explain that and we'll have time for questions too, but I'm fired up right now. So, I'm going to keep rolling here. So, the ultrasound will help with the survival of fat because we can see where we place the fat. And one of the things that decreases fat survival is by stuffing fat in too tightly and you pack it in and those fat cells can't all compete for the oxygen supply. So what the ultrasound does is allows me to see. So you remember when I was talking about these two different levels of fat. So the ultrasound shows us where the vessels are, shows us where the muscle is. And so we know, okay, well, well, I'm we we we're not we're going to avoid that because we can see it. I can't get this back in, Oscar. Okay, there we go.
So, that's the importance of the ultrasound from a safety point of view.
But from a fat survival point of view, the ultrasound will help differentiate between these two, the superficial and the deep plane of fat. and it will I can literally see directly where the fat is going. And before we used ultrasound, we knew we were in this plane, but we didn't know exactly where which plane we were in. Now I can see specifically and we know we want to put fat down deeper.
If you start and put fat in the superficial fat, the skin gets hard. You don't really get a lot of distension.
You get overfilling. You get a lot of hardness. and the fat doesn't survive.
If you can fill in the deeper, keep in mind we're above the muscle. This is the deeper of the superficial. We film it, we film, we we uh inject fat into this level and we inject it into this level.
And that way we can get better expansion. The fat cells can be spaced out better and we get better survival.
Now, those are the things we can do before surgery. That's your job. After in surgery, my job and then after surgery, your job as well. And so, but there's a lot of things you can do after surgery to help your fat survive. And so, let's go through some of these. So, number one is still fat Vive. So, you're going to continue to take Fat Vive, the neovascularization process where we take one cell and we get that to be vascularized. we get it to have a blood supply. We know if we can get it to have a blood supply, it's going to have a very good chance of survival.
It takes about 3 to 6 weeks for that maturation of that neovascularization.
And during that time, there are still oxygen free radicals that are around. So that's why it's important to continue to take the fat five. So I usually recommend to take it for three months after surgery and that will keep that will help your fat survive by helping the neovascularization.
The other thing to do is in the past we used to have patients wear fajas because we thought they were shapewear and we thought oh we're going to lipo patients and stick them in a tight thing squeeze them and then they're going to look like that. It's not the way it works. It's not even what the faha is doing. The faja is actually doing a lot of other things that h that allow the fat to survive. So this is what I call a is this am I can we still see over here or no?
>> Yeah.
>> So this is a compress well I call a compression strategy.
So we're not just blindly placing any faja on someone and saying okay just crank that down it's going to get you the best shape. No, we're actually trying to increase fat survival by having a under by having a logical compression strategy. It's it's it makes sense. So, we have less compression in the areas where we want to have more blood growth and we have more compression where we've had lipos suction and we don't want the fat to revascularize. We don't need that in that area of liposuction but we need that area in the butt. So, there's variable compression. So, fajas have changed a lot. And the other thing to really know about a faja is that the fajas are also lymphatic activators. And I'm going to be talking about that because that's also very important about fat survival and it's also very important about skin. But I don't want to get ahead of myself. Okay.
So, the fa is helping. The other thing as well again continued proper nutrition 1.2 grams per kilo of protein. You need to be eating the healthy fats. So, not French fries or any fried food, which is delicious, but you're going to want to be eating much healthier fats and unsaturated fats. And a lot of those fats are going to be plant-based fats are going to be helpful. So, nuts and legumes and and avocados and and those types of things that have good healthy um nounsaturated fats in them, unsaturated fats. MLDD.
So MLDD is also something that you probably don't consider as helping your fat survive. What is MLDD? It's manual lymphatic drainage. Those are the massages that are performed properly.
You know, back in the day, patients would would finish surgery and then you would just have a lot of people just pushing on them. They're like, "We got to get the fluid out." And it was just pushing, pushing, pushing. We now know that after that initial fluid comes out within the first couple days, that's when we switch to manual lymphatic drainage or certified by certified lymphatic therapists.
You know who has two thumbs and is a certified lymphatic therapist? This guy.
Yes, I am a certified lymphatic therapist. I took the course to become a lymphatic therapist because it is very very very important for a lot of things but it's also important for fat survival. So you need to have these decongestive s manual lymphatic drainage massages done by a certified lymphatic therapist so that you will remove that lymphatic fluid which can help decrease the inflammation. It what that will help your fat survive. So, it's not just for your skin. It's not just to make you feel better. It's not just to make you look better. It's also plays a role in fat survival by by by decongesting. Now, the other thing, if you were here at the beginning, you would have seen me wearing these glasses, which you don't really need to do when you get red light therapy, but they look good on camera.
So, the other thing is red light therapy. And so again, there's a every time I go through Tik Tok, there's always some red light therapy and it's used for everything from, you know, A to Z, but there is some good data on red light therapy. It's not as strong as our P188 data from Viology, but there is some data that will show that increasing or or having red light therapy post-operatively can increase fat survival and it helps with the neovascularization which is that new blood growth into the fat cells and so red light therapy is also valuable for fat survival. So just to recap, these are the things that you can do to help your fat survive. There are things that you can do before surgery. There are things that I do during surgery and there are things that you can do after surgery. And some things like proper diet and red light therapy and MLDD, you may not have known, but those actually are also fat survival techniques. Okay. So, we've talked about I just want to recap because I want you kind of to to to understand the whole process of the development of BBLs kind of the the way I do and so I want to sort of take you through that and I want you to understand it. So, now we've talked about the difference in technique to be able to get the shape. We're taking shape over size. A BBL is not volume, it's shape. We figured out now, okay, well, how can we in order to maintain the shape, we got to have the fat survive. I told you how the fat survive.
Let's look at something else that's critically important to getting a good result from a BBL. And something that's really changed dramatically in the course of the last 10 years particularly last 5 years where originally the focus was okay let's get a big butt and whatever happens to the but to the skin or okay who cares let there it is it's a BBL it's a Brazilian buttlft we're talking about the butt let's get the butt but we're overlooking a very major piece and that is how does the skin look after having a BBL And so that has also been a major development in taking care of patients afterwards and preparing patients for a BBL and that is what about the skin and this is a very big interest of mine because I've seen it unfortunately quite a few times where I had a patient who was happy with their shape and looked good but they were not happy with their skin and it it it's it I know when patients patients are not happy and they tell a surgeon they're not happy. I I think they only think that they're unhappy and they're kind of venting on the surgeon and I totally get that, but they probably don't realize that we're also not not happy. I don't want to do a nice job, get a good shape, somebody's looks great in clothes, and then they don't have good skin. So, it's also something that I take very seriously and want you to get the very best skin. And that's something that's very different now in a 2026 BBL compared to what it used to be done in the past where it was just good old lipo and whatever happened to your skin happened to your skin.
Doesn't your butt look good? Oh, good for you. So, this really here and I made some notes and sometimes it's hard to read my writing. Um so this is when we talk about the skin there's a lot of things we can do for the skin but the the main thing that we're talking about is we want to prevent fibrosis although I will tell you at this stage of my career I think it's even beyond that now it's not even just preventing fibrosis that's kind of how the whole project started like let's see how we can get better skin but now it's not just preventing fibrosis it's like how can we actually even improve the skin quality, never mind just not get fibrosis. So, one of the main factors we want to do is we want to prevent fibrosis. How do we prevent fibrosis? There's a lot of ways to do it. I don't want to repeat every single possible way, but the faja is also uh a way to prevent fibrosis. I think people don't understand and don't realize that. I know because I've talked to patients about this for years and I only realized that over the last several years myself. Now, Fibro Guard, if you don't know Fiber Guard, you should. This has been a complete game changer for my practice. I use it in all my patients of tummies and all patients who have lipo, whether they have a BBL with lipo or just lipo by themselves. Fibro Guard is a garment. It goes on under directly on the skin. And I start patients at 2 weeks after surgery. And this is performing essentially 12 hours a day manual lymphatic drainage. It's not a substitute. So please don't stop getting your manual lymphatic drainage massage because you're using fibergard. It's an adjunct. What you'll see with a lot of the things that we do in looking after patients and in looking after BBL patients and recovering, a lot of it is are multi multimodal. There's not one thing that's just like, yeah, do that.
You don't have to do anything. So, it's multimodal. So, these things kind of stack together. So, the faja is one way to prevent fibrosis and to get good skin. The fibergard stacks on that. The the really the key also is MLDD. And how does MLDD and fiberguard really actually work? Well, we don't we don't have a microscope where we can go in and we can look down and we can see, oh, look at little fiber guy working down there. But we know that it activates the lymphatic system and we know that by activating the lymphatic system, we are getting rid of this high protein and high protein is what leads to the fibrosis. So, let me just kind of draw something here for you. So, here are some of the fat cells after surgery. you know, you've got the blood supply. That's what we were worried about when we're talking about fat survival. We got to get a blood supply. So, they have a blood supply.
Otherwise, they wouldn't still be here.
So, they've got their blood supplies.
These are these are the fat cells here.
But during this early post-operative phase, the body goes through an expansion phase, a swelling phase. And what gets rid of swelling in your body is in large part are these lymphatics.
And so that's why you always hear me talking about the lymphatics. So it's important to understand that when we're talking about the blood supply, the blood supply that's getting oxygen to the to fat cells to make them survive, that's being driven by a pump. That's your heart that's pumping out the blood.
The lymphatics don't have a pump and they need help because as you get swelling those lymphatics are not as good at functioning. And so after surgery you need to help your lymphatics because you want to get rid of these little protein. Protein builds up in what we call the interstatial space. And that protein can also draw fluid. It can prolong swelling by having that fluid the having the proteins there. So by activating the lymphatic system we are removing these proteins and taking them out and getting rid of them. And by removing those proteins you decrease your chances of getting fibrosis. It's these little inflammatory proteins that are here that set everything up that start the scar tissue and that's what gives you the fibrosis. So we need to activate the lymphatic system in order to get good skin. There are many many other lymphatic activators and I've talked about lymphatic activators. I don't want to make this all about lymphatic activators but for for comp for completeness I want you to understand that there are a lot of things that we can do. So these are the vibrational anything vibrational. So the roller the roller vibrates uh we use this on our skin. We use this in a way to activate the lymphatic system. The lymphatic system doesn't have a pump. It needs to be helped after surgery. So anything vibrational. So you can have a roller. You can have the vibrational um plates which are also helpful. Um I've talked about the the manual lymphatic drainage is absolutely key. The other thing as well which can help activate is red light therapy. So I use red light as well for activating the lymphatic system. And so those are the things that can be done to prevent the fibrosis.
Now, this now what I'm going to talk about next I haven't talked about before and it's really interesting to me and this is this is kind of keeping me up at night. So, all of the focus with fiber guard and with your all the the MLDD and the FAA and everything else is on preventing fibrosis.
There are people that who've had lipos suction and haven't done this and have developed fibrosis and there is now coming shortly there will be a treatment for the for fibrosis and it's something called fibro treat and it is a similar um garment to the fibro guard but it's much more easily wearable.
The fiber guard is bulky. It's meant to be worn underneath the faja. It's more heavy duty for patients that have a lot of fluid and we're looking to prevent fibrosis. If someone has fibrosis, there's a bunch of other things that we can do. And I think it's important for you to understand that. And I'll be talking about this more as time goes on, but the fibro treat, which is like a bodysuit that patients will wear.
Fibrosis, we usually see it on the anterior abdomen. And that will be worn, but it'll be worn for greater periods of time, but it's a slim profile, and it could be worn under clothes, and it'll be worn for a longer period of time, probably six months. And then other things here and enzymes. I'm I'm not going to get too detailed into this, but there are enzymes that are um that are in Europe. They're not FDA approved.
Here I have some enzymes and I can use them off label. These are collagenase, lipase and hyaluronidase.
And these are enzymes that we can inject along with using the fibotreat. MLDD will always play a role. you need to have the decongestion. We're removing those proteins. And the other thing that will be very interesting too, which I I I'm using and I have a machine called the lymphotouch.
And so this is a a really cool adjunct to lymphatic therapy because not only does it help with getting rid of the lymphatic fluid, but it actually what when we do lymphatic massage, I I'm sounding like I'm a massage therapist. I am a massage therapist, but I'm not I don't do massage therapist, so I don't really consider myself massage therapist. But so when I say we're doing massage, I'm making it sound like I'm doing the massage. I'm not. But you understand when you're having massage and we're doing the lymphatic activation, all the motions are these small little motions. And what they do is they're not pushing fluid out. What they're doing is they're actually drawing fluid in. It's a subtle difference, but it's very important to actually how it works. Now lymphatouch doesn't do that. Lymphotouch works in a little bit different way and it actually lifts and separates tissue and by doing that it creates a negative vacuum and that will draw fluid in and that is MLDD is is good for fibrosis but we've been using MLDD for fibrosis. It for years it improves it but it hasn't completely got rid of it. And I think by adding the lymphatouch where we're going to be able to separate those those uh planes and some of the fascial planes and be able to activate the lymphatic system is really going to be helpful to treat fibrosis. Okay, I'm not going to talk too much about that. Let's I there is one other thing I want to talk about um which is really exciting and that is how do we actually measure what is going on in a BBL? How do we measure fat survival? So, if you go back to 2020, nobody's talking about, you know, measuring fat survival in any way that was really accurate. There are studies been done and they were the best that that could be done, but we now have new technology to actually measure fat survival. And I I'm going to talk about that after uh the break. Let's that's not really a break, but let's take some um qu should I take some questions? So, we'll take some questions. Oh, you got to write in this phone right here. Okay.
Uh let me just ask you a few questions.
Ah, somebody from Zimbabwe. How are you?
Um okay, let me ask Anchorage, Alaska. I got a lot of people. Houston, Vancouver. I'm from Vancouver, Canada. Um, okay. Let's get by let's get by to where people are watching from.
Uh, any allergy warnings for the supplement? There's nothing specific that the ingredients of Fat Vive are all uh naturally sourced organic uh products. So, if you were allergic to something in say, you know, kale or sour cherry or blueberry or orange or something like that, then yeah. But there's nothing else in there that would Oh, look at there's Monique.
Love Monique. Look at Monique. Where's Monique? I got her. She's right here.
This little Monique. She's so cute. Look at her. So, Monnique is our little uh Fat Vive mascot. It's created by uh Oscar to show. Can you show that video as to it'll show how Fat Five works and while we're talking about it? Let's just watch that video.
>> She's about to become part of a BBL.
First, she will be removed from the belly, then enjoy a rapid journey to her new home, the buttock.
Unfortunately, not all fat will survive this journey. But with a daily sprinkle of Fat Vive, >> your fat will thrive.
>> Meet Fat Vive, your fat's new best friend.
>> So, isn't she adorable? Now, this is kind of fun.
I don't know. I get I I have fun with these things. So, um, when I was when I was a kid and growing up in Canada, we used to drink Red Rose tea and there was always a commercial on TV.
It was only available in Canada and they had British people drinking the tea saying how much they liked it and that it was such a pity it was only available in Canada. But I used to like when my mom bought these boxes of Red Rose Tree tea because they always had a little gift inside. And so I decided, well, let's do that. I don't know if you can see these. Can I put these down over here >> overhead? So there's little things.
There many more. And there's these cute little animals that come with your order of Fat Vive. But get this, and this is how how I must be he's a massive narcissist there. If you get a Fat Five shipment with a little golden Dr. William in it. You will get three months of Fat Five free. Just a little kicker there. Just for fun. We like to have fun. Okay. I can't even remember what I'm talking about. Oh. All right. I'm talking about I'm asking you uh uh questions. I don't have the questions here. Uh all right. Here they are.
Sorry. Okay. Let's get back to some questions.
Uh let's see. Is it necessary to stop taking Marjara before surgery? If so, yes. Yes, it is necessary because mangaro, which I take it myself. Um, it slows gastric emptying and so you want to stop mangaro two weeks before surgery uh so that your stomach will empty properly. We want patients to have an empty stomach when they're having um surgery. Uh let's see.
If you have a defibrill, can you have a BBL with cardiac clearance? you probably can, but I I wouldn't do it uh personally just because if somebody has that I don't have the things in my office, you need magnets to to turn them off and and special monitoring for that and I and we do that in the hospital.
So, I would recommend if you have that to have surgery in a hospital. Um possible to get a BBL with anemia? No, it's not a good idea to have a BBL with anemia. And not just because you it's going to increase your risk of transfusion, but it's also going to decrease your survival of your fat. So, you want to have surgery when you're optimized. So, let's just talk about anemia just for a moment. It's a massive massive subject, but and I'm not a hematologist. I'm not an expert in anemia, but I've educated uh myself as it pertains to doing lipo and plastic surgery. And that's as I mentioned before that you can have anemia. But anemia just means that you don't have enough red blood cells. Means your your blood counts are low. Your hemoglobin is low. That's how we measure because hemoglobin has iron in it. And so but by the time you get to that point where your hemoglobin is low, you you've been an you've your iron stores are pretty low. So what we actually do is we look at the iron stores. We don't just look at the hemoglobin. We look at the iron stores. So there are ways to increase your iron and there's different techniques. I'm going to be doing a podcast shortly with this. Really amazing doctor. I really like him. He's in um England and he's a phenomenal doctor. We're going to be having a whole podcast on anemia and he's taught me a lot about anemia as well. I've talked to him. I've read his books. Uh he's good.
And now when we do the um podcast with him, I'll um I'll show you his book.
It's it's really good um because it's a very simple, clean way to understand anemia. But you'd want to get that um first. Do you do revisions? What if you have low fat? Uh yes, I do revisions. I will say that you have two options if you have low fat. Number one, a lot of people uh think that they need a lot more fat than they actually do. So, a lot of times patients will come in and I'll look at them and I'll say, "I don't really have enough fat for BBL, but I want a revision. I want to fill in my hip dip a little bit more." Then, absolutely, we can do that if they have enough fat. But they usually think, "Oh, I don't have enough fat." But quite often patients will still have residual fat, particularly fat in the back and in the upper back. Sometimes we use a new area like an arm um and get some more fat. But usually we can do it with a patient's fat even in particularly thin patients. If you absolutely have no fat, there is another option for you. I'll write it down here. It's called alo clay and that is fat that's called cataic fat. Uh it's also it's from fat that people that have passed on, dead people's fat people call it. Um we use a lot of things in medicine that are gained from catarics. So corial transplants, we use heart valves. Um there's uh skin that we've used. There's many many things that get used. Bone um cartilage, tendon, uh ligaments, all types of things that get used in medicine. When we talk about fat from a cat, people will sometimes give me the old but that's what it is. But if you don't have enough fat of your own, that's the best option that we have uh right now.
And that fat, and you'll hear me talking about it more um in the fall, later in the summer and in the fall. U but alo clay is something that is available to patients with low with no fat themselves. Uh what is your BMI limit for BBL? I really don't talk about that because it's not relevant at all and it's more important to have low internal fat. Um, is there more risk having no spleen for a BBL? Uh, so theoretically yes there is. But you as long as you have your proper uh are up to date with your proper immunizations cuz there's specific immunizations that patients will get if they don't have a spleen to pre protect for some infections that you particularly can get if you don't have a spleen. It's possible, but you it has you have to have clearance and you have to make sure that you're going to um take those immunizations.
Um yeah, I would stop someone's on zepp I I stop at two weeks for everyone. Um iron infusion. So that's a good question. I'm going to be talking about that too on the podcast. That's really interesting.
And there was just a paper published a couple uh maybe I don't know now four or five months ago talking about IV uh infusion.
It was a paper uh from Italy where they have access to a couple of different products that we don't have access to.
But the bottom line is is that if you are anemic or if your iron stores are low or you're always kind of teetering, I would talk to your doctor about getting an iron infusion. That is the most effective and rapid way to build up your iron stores and to correct your iron deficiency anemia. You'd want to have that done about 3 weeks prior to surgery. Having it done the day before is not going to be as effective. So you you but I would talk to your family doctor about that or or um have them refer you to a hematologist.
Um someone's called me Willy Wonka. It's probably true. Um, let me go.
Q. Arm lift with BBL. Can it be done? I would not recommend doing an arm lift with a BBL. A BBL is a very difficult recovery. I have other videos on my YouTube channel where I think there's like 4 hours of video where in two separate parts where I've talked about the recovery from a BBL. There are some things that have changed now, but that's a good starting point to go through, but you'll see that it's a difficult recovery and you're going to need your arms available. Lipo suction will slow your arms down, but it won't completely impede them. But if you have an arm lift, which is an actual incision here where the skin is removed, that makes it much more difficult to um recover from a BBL.
Uh the last thing I said to prevent fibrosis something I do at the practice well preventing fibrosis I it's really faja fiber guard uh manual lymphatic drainage anything vibrational so rollers plates um and red light therapy as well uh is is helpful for preventing fibrosis. It's it's really a multi-pronged approach because fibrosis is a very difficult problem. It's a harder problem to treat. So, we really focus on trying to prevent it. Okay, let me take Oh, I lost the questions here.
>> Okay, I will let me move on and I'll take we'll do one more um section of of uh questions here in a minute, but I want to talk to you now. Um I had said before we took the break that there is something new and so if if you look let's just kind of I want to just I want to summarize a little bit here. So if we just go through this and we say okay 1960s that's where where we started Dr. Pangen in Brazil started to um you know do experiment with fat transfer and moving fat and things like that really didn't BBL really didn't take off until the late 90s. So let's just say I don't know 1998 or something. So, it started to get some popularity and some not really popularity, but people are starting to do it. But it really wasn't until sort of this 2010 that area era where I sort of considered the boom from 2012 to 2022.
And during that time, the main focus was taking the fat and getting a big butt.
Wasn't as much focus on shape. There wasn't as much focus on skin. there wasn't as much focus on recovery. All of these things have then sort of developed. So then we talked about okay how shape is now more important than just size. How skin is phenomenally important. How making the fat survive is phenomenally important. And there are things that we do. preventing fibrosis, treating fibrosis, all of these types of things have developed over the last, you know, 15 years to be able to take us to where we are now. But the one thing that has been lacking with any real accuracy during that whole time is how do we measure? Like when you ask a surgeon and he says or she says, "Yeah, you're going to have 90% of your fat survive." They don't know that. that there is no data.
There is no paper that says that. There are some studies here and there, but there's no good definitive paper that shows. We are now working on that and have been working on that for quite a for over six months now as to actually determine how much fat survives. So, what we're doing is we're using something this is really interesting, exciting technology. I wish I could explain to you how it works.
This was developed by a doctor, a PhD um and she holds the patents. She's I've met with her many times. She's very brilliant person and she works with a company called Fit Match Fit Match.
And it's an AI technology company. And what she has been able to to do is to design an AI algorithm that is phenomenally good at calculating volumes and measuring human beings. So this technology is being used in in a lot of sports industries. Major League Soccer is a big player, but it's been used in baseball and and and all throughout professional sports because those teams want to measure their athletes. They want to see how they improve. They want to see their muscle uh they want to see their bone. They want to see their fat composition. They want to see that their training programs are working. They need a very accurate and fast way to measure.
Well, turns out that's actually very helpful for me as well in order to measure. So, I partnered with Fit Match and I'm using their system, Quadroscan, which is absolutely amazing because it runs right off a phone. And so, if you have surgery with me, you'll get scanned before your surgery. And that will be a detailed down to the millimeter.
And it generates a um avatar. It's like a 3D. So, one of these kind of little 3D things that sometimes you'll see me play with these little 3D models. This is a this is a before and after. And what it'll do is it'll generate an avatar and they can use that and they can measure.
And so with more time, we will be able to look at patients and scan them before surgery.
And then we know the amount of fat that we've added and we can then follow that out post-operatively at intervals to see their fat survival. And so not only are we able to do a better technique to be able to get a better shape to be able to have the fat survive to be able to get better skin to be able to prevent fibrosis.
We're now actually able to measure this.
So hopefully my goal is within two years if you say to me how much fat survives after BBL I will be able to give you a number and I will actually able to give you a number that's based on data and science and technology so that you actually know how much of your fat has survived and it will help us I think it'll be a stepping stone for further studies and further advancements in what we do because we if we don't know how much fat survived and we're just ballparking it off the top of our heads, we're going to get better results if we can actually see if what our little interventions are doing are hap helping fat survive. Okay, those those are the main points that I wanted to get across to kind of show you what's happened over the last 15 years or longer with the de with the development of a BBL and where we are today. And it's really exciting because I can tell you personally when I started doing BBLs, we didn't even know there was a lot of discussion over well, how do you treat the fat? Should we centrifuge it? I mean, I remember working in in um or having in my O large centrifuges and when I was at Duke, we had even bigger centrifuges and we would fill up the fat in the operating room. The problem is the centriuge was not sterile. So then you'd have to have these special tubes and then you'd have to the nurse and then the fat would spin around and it wasn't balanced. It'll be like this and then so a lot of work went into that.
Dr. Coleman, huge pioneer in fat grafting and studying and all these other doctors that went through and looked at these techniques. Those are all now wellestablished.
And now we have that and now we have violity. Now we're actually giving a drug during the surgery that will go in and repair the fat cells. I mean that to me is mindblowing. We suggest take the fat, spin it down, suck it out, and push it in and hope for the best. And today is completely different. the way we think about it, the things that we do are so much more purposeful that we're getting much much better results and long permanent results. And now with the fit match, we have a way to actually measure it. So that is super exciting to me. Okay, let me take a few more um questions here.
I'll take any question you have. I'd prefer to talk about BBLs if you could.
Um, but I will take any question. But if we can stay on BBL's. Oh, I do want to say one thing. This is kind of a silly thing, but to me it's actually quite important.
So, I have this concept here. Okay, bear with me. I have this concept here of this little bus. It's the OG bus. Manuel did this OG bus. And this is this is a three 3D printed version. But we have a concept that I call the OG bus. And guess who's the bus driver? This guy's a bus driver. So I say to patients when they start asking, "Well, what about this? What about that? Should I do this?
Should that?" I say, "Listen, you don't need to worry about a thing. I have everything completely worked out." I try to encourage people to read this guide before surgery. Have caregivers read this guide before surgery. This is chocked full of information. It's phenomenal information in here.
Everything you really need to know. So, what I say to patients is everything's in here. I've got it all worked out.
We've been working on this for years.
Extremely proud of the protocol of how to do, what to do, when to do it. And so, I say to people, it's like the bus.
All you have to do is get on the OG bus, sit down, and I'll take you to your destination. I've taken this tour bus.
I've driven this tour bus many times.
I've been off-road in it. I know how to get back on the road. I've been I know where all the bathroom stops are. I know where the best food stops are. I know where it's safe to sleep and not safe to sleep. I know where the amusement parks are. I know the whole journey. I've taken the whole journey many, many times as the bus driver. Many, many times. So, I say just get on the bus and I will take you to your destination. All of these types of things. what to do to help fat survive before, during, and after. All of that is covered here. Make it dead easy. Just follow the protocol and that will take you there. Okay, enough about the bus. I do love this little bus though.
Now, let's go through and let me ask you uh some questions.
And uh Dana says, "Your guidance has put me at ease and I feel confident, trust in journey." So, I I'm really appreciate you. I I legitimately appreciate you saying that it is a journey and I really do feel that if you just get on the bus and follow the the protocol that we've laid out and don't just come up with something for the sake of coming up with something when we're talking about a fat cell having to get a blood supply. How do we make that fat survive? Then I read a study in our journal that talks about fat survive for survival in animals. I partnered with that surgeon in Turkey.
We developed fat vive and so these things are being done purposefully based on the best science that we have and it's my opinion that if you just follow that that is how you're going to have the end up with the best uh results.
Okay.
Uh, are we rushed out after BB after waking up from anesthesia? I've heard some bad stories from other clinics in Miami. I'm sure PA patients may get rushed out sometimes. My patients don't get rushed out. They get they get discharged when they meet what we call discharge criteria. So, you have to have a certain heart rate. You have to have a certain blood pressure. You have to have certain awareness. You have to have certain pain score. You have to have making proper urine. All of these types of things. So once all of those criteria are met, the patient is then safe for discharge to their caregiver. Some patients will reach that sooner and some patients will reach that later. It's just like recovery. Everybody is different in recovery. I had someone today, she thought she was kind of lagging and I'm like, you're way in front. Everyone recovers at different rates. It's it's not a race. It's no big deal. It's just you you're not going to get kicked out of the recovery room until you've met the criteria. And some people take longer and some people take uh slower. Oh, this is really good. Um, I can't read your name, but Simmons, how do you determine hip to thigh ratio and projection ratio to make sure the hips and legs match? How do you make sure projection matches the legs? So imagine if you're me and you have a patient on the table. Keep in mind that that that the patient is only exposed to the operative parts that we need because we're trying to keep everything sterile and trying to keep the patient warm. So there's no way you can measure a, you know, hip to thigh ratio and do these types of detailed measurements. And no, I don't do any of those types of things.
And those are only ideal measurements anyway. If you've ever seen those um types of studies where they look at facial symmetry and the golden rule and they look at exactly how big your eye should be and it should be the equivalent to the width of your nose and that same width of your nose should be the space in between your eye. All these different numbers, how high your eyebrow is, all that stuff. So all of that is good and it's ideal, but you can still have a supermodel and she looks way better than somebody with an ideal version of of her face. So those types of ideal ratios are just theoretical to me. They're not practical. I can't use them in the operating room. But what I do to make sure everything matches is actually very easy. It's so so simple.
It's because I just follow the OG line and it will never disappoint. It takes me exactly where I need to go. So, when I'm looking at trying to match the leg with the butt, I'm just still following the line. That's it. That's that's how I do it. I'm not measuring to do that. I'm just using the line. And then whatever fat I need to place, if I need to place some in the lateral part of the leg, more in the posterior part of the leg, try to get more to the front of the leg, wherever I need to place the fat, it's not based on a number ratio. It's just simply based on the OG line. And filling in fat will just fill out the line. And I know if I get the line, then I'm I'm going to be good. Um Cashley, what is time frame? Lab should be done 30 days prior to surgery.
Uh there's this there's things with pricing. I don't do any of the pricing.
Um uh I can't say your name. Puk 6724. Is it too late to take 5A fat 5 one year after BBL? Yes, it is. Fat five is going to work based on our studies um that are not not published yet. Um FAT 5 is better to be to be taken beforehand. So you can reach peak uh total uh antioxidant capacity prior to surgery and then it should be maintained for that post-operative. What the actual time frame is we haven't worked out yet.
What we know based on how long it takes fat to regain a blood supply and for those fat cells to become stable it's my recommendation is 3 months we do sell it at 6 months do I think you need to take it there I don't the truth is I don't know I know for sure that taking it early before and during that early post-operative period probably the the 6 to 12 weeks is going to be the sweet spot but this is still new we're still working these things out. But certainly intuitively, it would not make sense to take Fat Vibe one year out because you're past all the anti- um uh the the free oxygen radicals and all of that inflammatory stage has settled down. So, I don't think FAT five would help you at all. I personally take it every day because it's a massive antioxidant and every study that you read about every single type of cancer and heart disease say that you should have as much antioxidants as you can which is why they recommend a diet high in in uh fruit and in vegetables with high antioxidants. So anyway, okay. Um what if the outcome of a vector is not as positive as expected? Can it be redone?
That's a really good question. Um, so the value to me of the vector and see I love to share something like a vector with you because I didn't have any concept of a vector and it's these types of things where you keep observing observing patients and seeing your results and going through things and then you start to notice things and that's where the the concept of the vectors has come in because I realized that patients starting with a negative vector vector did not look as good as those patients starting with a positive vector. So I use a vector in my mind. I can see the vector very quickly. It's not a difficult thing to do, but I I see it and then I really use it more of a tool to explain to the patient what the expected outcome can be. So if you have a very triangular shaped pelvis and you have a very negative vector, that outcome is not going to be as good as somebody with a positive vector with a more narrow pelvis at the top. And so I can improve a negative vector and I can I mean I have sometimes got a negative vector to a positive vector, but that's not as that's not as as common. You really have to have very soft tissue to be able to do that. But I can usually get a negative vector to a neutral vector or a little bit past a neutral.
So that's a massive improvement. But I need to tell the patient, you're not going to have this. You might be disappointed by this amount of projection. So it's very important for me to be honest with patients and be transparent. So I use vectors. I use chicken butt. I use visceral fat. I use hip dips, tissue distensibility, you know, these types of things, tissue tightness to explain to patients so that they can have the best idea of how they're going to look. It's impossible to tell someone how they're going to look. I mean, it's impossible. It it's it's like telling someone, you know, how something is going to taste and you never had it's somebody can say, "Well, it tastes like chicken." Okay, but it's a little bit more sophisticated than that. So, I use it to try to say to someone, listen, I want you to be happy with this, but I know that I'm going to fall short in this way. And if you're not okay with that, we shouldn't do the surgery. And because I realized many years ago, if someone is not happy with their surgery, the reason is not necessarily because a surgeon did something wrong, although that's probably what 100% of people think. What it really is is it's a disconnection between what you as a patient are expecting and what you receive. Now, there's some different op um combinations. If you're expecting to look great and you look great, you're happy. If you're expecting to look good and you look good, you're happy. But if you're down here and you're expecting to look absolutely fantastic and you don't, you're not happy. And so the patients expectations are what really determine their happiness after surgery. And I've had patients that are really happy because they didn't really expect they will tell me like I didn't expect to look this good. They didn't realize that they had a positive vector. They didn't realize that they had a small waist.
They didn't realize that they already brought a nice convexity to the table that the the potato salad. They didn't know those types of things and so they were pleasantly surprised. I'm not worried about that group of patients because they're going to be happy. If I see someone with a small waist, I usually say, "Oh, you got a good waist."
But I don't always point that out. But if somebody has a wider waist and they say, "I want to look like Karina, who's my medical assistant whose waist is this big." I I'll say, "Hey, that doesn't sound in my mind. I'm like, okay, that's not a realistic expectation because her waist is not naturally, you know, small where I can remove the fat and we can really chisel out that waist." So, I use vectors really as one of those tools to explain to patients, hey, you're starting from a different starting point. Do you see where this is? And I it helps to frame their expectations.
Okay. Is anyone in the room an overexplainer? This guy is an overexplainer.
Okay. Are you adding a doctor for rib remodeling? I don't have plans on doing that. We are um bringing in another surgeon, Dr. Susman, who you heard me talk about, uh who's an expert in face.
He's coming from New York. He's absolutely an an angel of a human being and a really good surgeon. Um he doesn't do ri remodeling. I personally am not a fan of ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri ri rem rem remodeling for a few reasons and it's kind of like high definition lipo to me as well. So you know I started off this talk saying that a lot has changed over this time frame where we're doing a BBL. Okay. Well, what has happened?
We're not we're we're trading. We're not doing this anymore where we just have a huge butt. We're trying to get a pretty butt. We're trying to get a nice shape.
Well, to me, this shape here is nice because it's natural. It's natural because it just follows the OG. And the OG is is a supernatural line.
When you have rib remodeling, you're not you're you're technically fracturing the ribs, but not in the way that you kind of think of like breaking them. But ribs are the type of thing that you can break one of what we call the cortex. Let me just draw that out so you can understand that. So, and and and I'm I'm not a rib remodeling expert. So, I'm just going to give you my opinion. And I've also had a broken rib before. Uh when I was in high school in 11th or 12th grade, I remember going up playing rugby to block my opposing player's kick and I got he followed through in the right in my ribs. Um, and so what happened is I actually did that on a Saturday playing a game and I immediately felt very short of breath. I was extremely winded and I was in a lot of pain. And when I got home, keep in mind this is in the 80s, early 80s. So when I got home, I happened to tell my mom, "Hey, I got kicked in the ribs and it it it really hurts." So, my mom's like, "Okay, well, let's take you to the hospital." So, I went to the hospital. I got an X-ray.
The doctor there said, "Hey, no, no fracture, no pneumothax. You're all good to go." I went home, still had a lot of pain. The next day, they called from the hospital and they said, "Oh, by the way, your son has a broken rib. Don't worry, there's nothing to do. It's just going to hurt for six weeks and he'll be fine." So, when I did break that rib, it was in a way like a remodeling. It wasn't on the same ribs that you do for remodeling, but it was it was it was a remodeling in a way. And what I mean by that is if we look at our um sternum, okay, that's our chest bone. Well, the ribs come in to the to the um sternum and they articulate with the sternum through this little bit of cartilage here. So, that's it's nice and flexible. So that's why, you know, you can do like a bench press and let the let the bench let the bar hit your chest and it can move a little bit because there's cartilage there. So you need that. You need that for expansion of your lungs. When you're going in, you have to have those ribs move a little bit. And then as you go all the way down, there's ribs at the bottom that we call floating ribs. And there's a few of them. And that means they're attach Oh, sorry. They're attached to the spine.
um but they're not attached to the front of the sternum and those are the lower ribs that protect your liver and your your uh spleen and etc kidneys. So um what happens with these ribs is when they do rib remodeling is they will just fracture one half of the rib. So it's called a cortex. So if here's a rib, let's say this is a rib like this and there's two sides to it. They will just break one of them and they'll put a little crack in it and when they do that it weakens it. It's kind of similar to what we do when we're doing a rhinoplast. We break the bone in the nose. We're not actually going through and breaking the whole bone. We're just breaking one side of the bone to allow that part to come in. So that's what they do when they do rib ro modeling.
And they're they're doing more and more ribs. I don't know exactly the number, but I I know that they started only doing one or two and they're doing more now. And so when they do that, they can fracture those ribs and bring them in.
For my own personal taste, I don't like the look. It looks a little bit exaggerated to me. If you like the look, that's fine. I I have literally no issues. Um whatever anyone wants to do, however anyone wants to look, no problem. Um, we get comments all the time. If I post something on a breast augmentation, patient like, "Oh, they look way better before. I don't like big breasts. I don't like it." It's okay.
No, you don't have to. That person likes them and that's what she wanted to get.
And that's good for her. And that's the whole point of living here and and being able to make all the choices that we want. So, I'm not saying don't do rib remodeling. I'm just saying for me who I live, eat, and breathe the OG line, which is a very natural line. I like that shape. I don't want to see something that's going to come in and then sort of come in in in an in a way that doesn't look natural to me. So, I don't have plans on doing ribb remodeling. And it's interesting too to me because over time you see things come and go in plastic surgery. And when they they used to do rib remodeling years ago, it's a more refined technique now because it can ultrasound and you can see and has lower risk of injuring your lung and things like that. So, but no, no immediate plans. That's the 10-minute answer explaining no immediate plans.
I'm bringing in someone to remodel. Yes, Karina's very nice. Thank you. That's really nice of you to say that.
Um, okay. And does is there an age limit for this procedure? And does a patient's age affect the likelihood of achieving successful results? A super good question. Um, I think I think I'm educating you guys too much to the point where you're really challenging me. I'm like, these are excellent questions. I love it. Okay, so no, there is no age limit. Um, but as you age, tissue changes. I mean, just look at my skin as wrinkly as can be. Obviously, skin changes, the soft tissue changes. So results in somebody who is 54 compared to the results of somebody who's 24 probably going to be different. Now that being said, there are patients that are 54 that have taken really good care of themselves, exercised, avoided the sun, ate proper diet, didn't drink, didn't smoke, didn't have over sun exposure, you know, and those patients can have and good genes, which is probably the number one, and they can have a really nice result. You can have somebody who's younger than them and hasn't done all those things to take care of themsel and not get as good a result. So your your quality of your result is based on you not so much your age but on all those other attributes. And if you're in really good shape and very healthy and have a good hemoglobin then you can be a good candidate even if you think you might be a little bit older for the procedure.
Okay. Um, so this is another this is a good question too. Cashley, I don't know who you are. You're asking some great questions. Um, MLDD includes massaging the actual butt. So, in my world, it would.
But what does that happen? No.
I need to work very carefully with a massage therapist to be able to get them to massage the butt because we have to balance this pressure and compression and decreasing the inflow of the blood supply and the neovascularization versus lymphatic fluid. So I think if it could be done very gently and very carefully, I would start a week after surgery, then I think that would be helpful. It's just not an area that's that a lot of therapists have a lot of experience with. And so my advice right now, unless I really really really trusted that therapist, my advice and what I tell patients is not to do lymphatic therapy on the butt. But let's just say you your spouse or your friend or you know you know someone really well and they're they're very seasoned lymphatic therapist, then I probably would let them do that.
Um, your phone died. Okay, you're back. Do you re recommend lipo with fat transferred to hips even if it's still if he's still plan on having kids? Yes.
Um, someone asked me that question today actually during a consultation. And there's no bearing on having children and having a BBL. Having a BBL is just lipo suction and we take your fat and we move it to your butt. that doesn't affect your ability to conceive or your ability to carry a baby or your ability to deliver a baby. So, they're not related at all. Karina is my ma Jazelle.
And if you meet her, you will like her, too. Um, and you will also think she has a very small waist. Um, okay. Let me ask, let me answer.
Uh, oh, this is so nice. You see? You see? Look at this. Glamorous life 328.
And she's from the 30 on three. She's from Detroit, which is which is where I spent seven years of my life. I love it there. So, thank you so much. Surgery is 519. Happy with my results. I'm recovering well. Following a process.
Wish I could send you some Chicken Shack. Okay. Chicken Shack. If you live in Detroit or in the suburbs, you'll know about Chicken Shack. So yes, I wish you could send me some Chicken Shack, but I probably don't need to eat any Chicken Shack and living there seven years and having Chicken Shack fairly close to my house was not particularly helpful to my health. So now I'm on Mangaro. Okay, let's see. I worry my skin elasticity is not good. Uh have you seen good results from people with this issue?
So thin area. Oh, that's it. So, okay, that's gonna it's gonna it's gonna make a longer answer, but I haven't figured this out completely yet. Okay. But I've noticed it. I just haven't put it together yet.
And and honestly, that's one of the things I love about my job and being a surgeon is we see things all the time and we don't always notice them or always understand them. So, with tissue on the hips, okay? So, when I fill in a hip dip, let me just explain this to you. This will this will help explain things a little bit. Um, so we're talking about tight, your question is about tight tissue on the hips and have you seen people that have a good result? That's kind of how I'm taking this. So, um, if if we look at Oh, let me use a model. That's going to be easier. Okay.
Can you see this overhead?
>> Okay. Are these What about this?
Can you see those?
We're good here.
>> Yes.
>> Okay. So, is is this is the before and this is the after.
And this is a this is obviously not a real patient, but this is a real p this is a mo 3D model made from real patient uh scans. And so nothing has been altered or changed. So this is this person and you could see differences between the sides cuz that's everyone has that. So I'm talking about filling a hip dip and this I'd like to introduce you if you don't know this concept about the trench. And so here's a patient.
Let's move this one here. She comes in and she has these hip dips that are here and she wants them to be filled and I say, "Sure, no problem. I will try to fill your hip dips. And by the way, I'm also going to lipo in this key area here. And by reducing this right away, even without adding fat here, that's going to decrease the amount that your hip or the the depth that it'll make you think, "Oh, my hip dip's not that bad."
Because we've removed some of the hill and the valley doesn't look as deep.
Okay? So that in order to go from here to here, we have to fill in that hip dip and we just follow this OG line. And that's what someone was asking me before about the hip leg ratio and how do I know to put more fat and everything. It's just because I just follow this line. So, but in order to fill this hip dip in, I need a couple of things. I need this tissue here to be distensible, meaning it will move and it will when I put fat in here, it's going to respond. There are some people that have very very tight tissue and there are other people and this is the part that said I haven't really put together. There are some people that also have very thin skin here. I don't know exactly why, but I've seen it many times and I point it out to patients. I don't talk about the thin skin, but I tell patients, you don't have very distensible tissue, but the there is a group of patients there who I think will not will just not get their hip dip filled. Most of the patients we're going to get them filled to some degree and then a fewer amount of patients will be able to have it filled. Even if I think it's tight, it'll be filled perfectly.
So there is variability there. I wish that I was had kind of put it all together and was able to really give you a good answer to tell you like yes this person will get perfect fill. No this person will not there even if I think in my mind oh and I used to do this thing called pop or not and I used to think oh will this patient pop or not and patients had said to me like oh well you know if they're going to pop or not. I'm like no that's why I'm making the video.
really don't know if they're going to pop or not. Um because I have been fooled many many times and I've had patients who are really tight and lo and behold they get a really nice hip and I've had other patients who are really tight and they're not able to get a really good hip. Everyone will get something. Everyone will get an improvement but it kind of goes back to that whole thing is where I need to prepare the patient and say, "Hey, you need to be aware of this. I'm not 100% certain which path we're going to take here. But if I'm unable to get you a full hip, it's not because I wasn't trying. It's because the tissue wasn't distending. Now, can can you go through and put more fat in there later at a second time to fill the hip dip in?
Yeah, I think you can. I think that initial fat grafting will help that tissue get softer. We know fat gets softer. I've seen it gazillion times in the breast. So that fat will help soften that tissue and get you better expansion of the hip. And also by providing a little bit of fat in there, particularly if you have that thin skin and you don't have a lot of fat, by doing a BBL the first time, we get a little bit of fat in there and I can then add to it and graft in there. The other concept you should really understand, and since I've already drawn on this drawn on this, I'll I'll just go right ahead. Go gang busters here. I'm all in. Okay. So, but in order to fill in the let me just see where this is. So, in order to fill in her hip dip here, you'll actually see that I would let this is how I Oh, am I blocking that? No, this is really what I'm looking at when I'm operating. So, I want to fill this in right here.
And I want that to blend with this line. And but in order to do this, you can actually see this is her before photo. You can actually see I don't Can you see this? There's there's a depression here.
Maybe hard to see. There's a depression here. It runs right in here. You can actually see it on the model, which I never even realized before. That's awesome. But I call this here the trench because I can and I do it in the O and I put my hand in there and I can feel where that trenches and some people's trench goes more horizontal. I'd say this is the most common configuration, but some people's trenches also go here.
And then occasionally I'll get one that kind of marches more like this. But you have to fill in the hip dip. In order to fill the hip dip, you have to graft fat.
Wherever that trench is, you have to graft fat. So if you had a hip, if you had very tight tissue and you had a hip dip that wasn't filled in completely, it might be because of the tight tissue or it might also be because the trench was not filled in. And I envision it um like the surgeon in uh Dr. Delvcio describes it. I envision it as a sand castle. And so if you imagine this is your hip dip here and we want to fill that in. If we don't fill in the trench to support this, then the hip dip just collapses.
So, in somebody that has tight hip dips and they they weren't able to get a fill or the trench wasn't filled in, usually we can get an improvement in those at a second round. Okay, it's getting late.
Let me take a couple more questions because I'm having fun.
Let's do this. Uh oh, that's a really good question, Natalie. Uh, Natalia could and I'm gonna a um pow I'm gonna ask um our doctor friend uh our hematologist when we do the podcast this question. I think I know the answer and that is it's a really good question though. Could low ferotin levels affect recovery even with good hemoglobin levels? The answer to that is yes because iron is not only involved in the transport of oxygen but it's also involved in a lot of other metabolic processes. So having low iron we usually focus on the anemia but it also plays a role in healing and having a low iron before surgery can negatively impact your recovery as well. But I'll get you the real answer uh when I do the podcast from the expert. Uh do you wear the fibergard under the fall? Uh yes, the fibergard I start fibergard two weeks after surgery.
Uh I because the first two weeks patients wear boards and foams. They're wearing boards and foams to prevent a seroma. Seroma risk is present in the first two weeks. After that time you don't have a seroma. You don't need to compress. When you compress, you're just squishing in all of those proteins in the interstatial space. You're closing down the lymphatics and you're causing your cell fibrosis. So foams and boards are necessary, but not for the shape.
They're necessary to prevent the seroma.
So they get used for the first two weeks to hammer things down to close the dead space so we don't get the seroma. Then after those two weeks, we switch to the fiber guard because we want to do the opposite. We don't want to be squishing and smashing. We want to be opening and bringing the fluid in and activating a lymphatic system. Okay, one more question and then we will go. Uh, this is a freebie. Will there be drains after BBL? No, I don't use drains.
All right, let me just let me go rap.
Let me see if I can go rapid. Trying to discipline myself to not talking giving 10-minute explanations for everything.
How can I get a virtual consultation with you? just call the uh phone number.
It's 3052099371.
It's our phone number. Um and just if you call them, you can get a schedule a virtual appointment. I don't do them every day, but they'll be able to help you. Um how do I balance avoid a wide upper body and a snatched waist after lipo? Well, there's always going to be some variance in between your shoulders and everyone.
Some people are going to have wider shoulders, narrow shoulders, smaller waist, wider waist, all of these things.
But um I think the problem comes from inadequate lipos suction high in the back. And that's why I make a point of doing the lipo suction high in the back in order to be able to get a smoother, softer look. But the most common thing that I see after a BBL if someone's not happy is that they tend to have a lot of fat from their midback up. And so just by removing that will give you a little bit more um balance to it.
Uh do I apply foams and boards right after surgery? That happens on the uh first day. There are no drains used for my BBLs.
Um, talked about that.
Um, okay. I think we're going to call it here.
Is that good? Anything else I need to say or remind people of? Okay. Well, thank you so much. Um, I love doing these lives and I I really appreciate you being here and I really appreciate the questions and I learn from from questions. People ask me about recovery all the time and it is kind of funny to me because I think to myself like well I've never recovered from a BBL. How would you why would you ask me about a recover from BBL? But obviously I know a lot about recover from a BBL but I've learned it all from the patients. All from the patients. So I learn from you.
It's a two-way street. So, I appreciate you watching and thank you very much and I look forward to seeing you again soon.
>> Hey, it's Dr. William. I'm Grab your markers. Have you ever wondered why go through the key area around fill in the hip? Blend that into the leg. I've got my pen and paper out today. I want to talk about Okay. Okay. Okay. Okay. Okay. Okay.
Okay. Yeah. Okay. Relax.
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