MIAMI \u2014 In hindsight, Nikki Ruston said, she should have recognized the red flags.<\/p>\n

The office in Miami where she scheduled what\u2019s known as a Brazilian butt lift had closed and transferred her records to a different facility, she said. The price she was quoted \u2014 and paid upfront \u2014 increased the day of the procedure, and she said she did not meet her surgeon until she was about to be placed under general anesthesia.<\/p>\n

\u201cI was ready to walk out,\u201d said Ruston, 44, of Lake Alfred in Central Florida. \u201cBut I had paid everything.\u201d<\/p>\n

A few days after the July procedure, Ruston was hospitalized due to infection, blood loss, and nausea, her medical records show.<\/p>\n

\u201cI went cheap. That\u2019s what I did,\u201d Ruston recalled recently. \u201cI looked for the lowest price, and I found him on Instagram.\u201d<\/p>\n

People like Ruston are commonly lured to office-based surgery centers in South Florida through social media marketing that makes Brazilian butt lifts and other cosmetic surgery look deceptively painless, safe, and affordable, say researchers, patient advocates, and surgeon groups.<\/p>\n

Unlike ambulatory surgery centers and hospitals, where a patient might stay overnight for observation after treatment, office-based surgery centers offer procedures that don\u2019t typically require an inpatient stay and are regulated as an extension of a doctor\u2019s private practice.<\/p>\n

But such surgical offices are often owned by corporations that can offer discount prices by contracting with surgeons who are incentivized to work on as many patients per day as possible, in as little time as possible, according to state regulators and physicians critical of the facilities.<\/p>\n

Ruston said she now lives with constant pain, but for other patients a Brazilian butt lift cost them their lives. After a rash of deaths, and in the absence of national standards, Florida regulators were the first in the nation to enact rules in 2019<\/a> meant to make the procedures safer. More than three years later, data shows deaths still occur<\/a>.<\/p>\n

Patient advocates and some surgeons \u2014 including those who perform the procedure themselves \u2014 anticipate the problem will only get worse. Emergency restrictions<\/a> imposed by the state\u2019s medical board in June expired in September, and the corporate business model popularized in Miami is spreading to other cities.<\/p>\n

\u201cWe\u2019re seeing entities that have a strong footprint in low-cost, high-volume cosmetic surgery, based in South Florida, manifesting in other parts of the country,\u201d said Dr. <\/a>Bob Basu<\/a>, a vice president of the American Society of Plastic Surgeons and a practicing physician in Houston.<\/p>\n

During a Brazilian butt lift, fat is taken via liposuction from other areas of the body \u2014 such as the torso, back, or thighs \u2014 and injected into the buttocks. More than 61,000 buttock augmentation procedures, both butt lifts and implants, were performed nationwide in 2021, a 37% increase from the previous year, according to data<\/a> from the Aesthetic Society, a trade group of plastic surgeons.<\/p>\n

As with all surgery, complications can occur. Miami-Dade County\u2019s medical examiner has documented nearly three dozen cosmetic surgery patient deaths since 2009, of which 26 resulted from a Brazilian butt lift. In each case, the person died from a pulmonary fat embolism, when fat entered the bloodstream through veins in the gluteal muscles and stopped blood from flowing to the lungs.<\/p>\n

No national reporting system nor insurance code tracks outcomes and patient demographics for a Brazilian butt lift. About 3% of surgeons worldwide had a patient die as a result of the procedure, according to a 2017 report<\/a> from an Aesthetic Surgery Education and Research Foundation task force.<\/p>\n

Medical experts said the problem is driven, in part, by having medical professionals like physician assistants and nurse practitioners perform key parts of the butt lift instead of doctors. It\u2019s also driven by a business model that is motivated by profit, not safety, and incentivizes surgeons to exceed the number of surgeries outlined in their contracts.<\/p>\n

People seeking Brazilian butt lifts and other cosmetic procedures are commonly lured to office-based surgery centers in South Florida through social media marketing and the promise of discount prices. But many of the centers are corporate-owned and critics say the business model puts profits before patient safety.(Daniel Chang \/ KHN)<\/span><\/figcaption><\/figure>\n
In May, after a fifth patient in as many months died of complications in Miami-Dade County, Dr. Kevin Cairns proposed the state\u2019s emergency rule to limit the number of butt lifts a surgeon could perform each day.<\/p>\n
\u201cI was getting sick of reading about women dying and seeing cases come before the board,\u201d said Cairns, a physician and former member of the Florida Board of Medicine .<\/p>\n
Some doctors performed as many as seven, according to disciplinary cases against surgeons prosecuted by the Florida Department of Health. The emergency rule limited them to no more than three, and required the use of an ultrasound to help surgeons lower the risk of a pulmonary fat clot.<\/p>\n
But a group of physicians who perform Brazilian butt lifts in South Florida clapped back and formed Surgeons for Safety<\/a>. They argued the new requirements would make the situation worse. Qualified doctors would have to do fewer procedures, they said, thus driving patients to dangerous medical professionals who don\u2019t follow rules.<\/p>\n
The group has since donated more than $350,000 to the state\u2019s Republican Party, Republican candidates, and Republican political action committees, according to campaign contribution data from the Florida Department of State.<\/p>\n
Surgeons for Safety declined KHN\u2019s repeated interview requests. Although the group\u2019s president, Dr. Constantino Mendieta<\/a>, wrote in an August editorial<\/a> that he agreed not all surgeons have followed the standard of care, he called the limits put on surgeons \u201carbitrary.\u201d The rule sets \u201ca historic precedent of controlling surgeons,\u201d he said during a meeting with Florida\u2019s medical board.<\/p>\n
In January, Florida state Sen. Ileana Garcia, a Republican, filed a draft bill with the state legislature<\/a> that proposes no limit on the number of Brazilian butt lifts a surgeon can perform in a day. Instead, it requires office surgery centers where the procedures are performed to staff one physician per patient and prohibits surgeons from working on more than one person at a time.<\/p>\n
The bill would also allow surgeons to delegate some parts of the procedure to other clinicians under their direct supervision, and the surgeon must use an ultrasound.<\/p>\n
Florida\u2019s legislature convenes on March 7.<\/p>\n
Consumers considering cosmetic procedures are urged to be cautious. Like Ruston, many people base their expectations on before-and-after photos and marketing videos posted on social media platforms such as Facebook, Snapchat, and Instagram.<\/p>\n
\u201cThat\u2019s very dangerous,\u201d said Basu, of the American Society of Plastic Surgeons. \u201cThey\u2019re excited about a low price and they forget about doing their homework,\u201d he said.<\/p>\n
The average price of a buttocks augmentation in 2021 was $4,000, according to data from the Aesthetic Society. But that\u2019s only for the physician\u2019s fee and does not cover anesthesia, operating room fees, prescriptions, or other expenses. A \u201csafe\u201d Brazilian butt lift, performed in an accredited facility and with proper aftercare, costs between $12,000 and $18,000, according to a recent article<\/a> on the American Society of Plastic Surgeons\u2019 website.<\/p>\n
Although Florida requires a physician\u2019s license to perform liposuction on patients who are under general anesthesia, it\u2019s common in the medical field for midlevel medical practitioners, such as physician assistants and nurse practitioners, to do the procedure in office settings, according to Dr. Mark Mofid<\/a>, who co-authored the 2017 Aesthetic Surgery Education and Research Foundation task force study.<\/p>\n
$\"\"$
Some South Florida cosmetic surgery centers share office space with law firms and other businesses. At Avana Plastic Surgery, an office surgery center in Miami, patients use a separate entrance apart from the main lobby. (Daniel Chang \/ KHN)<\/span><\/figcaption><\/figure>\n
By relying on staffers who don\u2019t have the same specialty training and get paid less, office-based surgeons can complete more butt lifts per day and charge a lower price.<\/p>\n
\u201cThey\u2019re doing all of them simultaneously in three or four different rooms, and it\u2019s being staffed by one surgeon,\u201d said Mofid, a plastic surgeon in San Diego, who added that he does not perform more than one Brazilian butt lift in a day. \u201cThe surgeon isn\u2019t doing the actual case. It\u2019s assistants.\u201d<\/p>\n
Basu said patients should ask whether their doctor holds privileges to perform the same procedure at a hospital or ambulatory surgery center, which have stricter rules than office surgery centers in terms of who can perform butt lifts and how they should be done.<\/p>\n
People in search of bargains are reminded that cosmetic surgery can have other serious risks<\/a> beyond the deadly fat clots, such as infection and organ puncture, plus problems with the kidneys, heart, and lungs.<\/p>\n
Ruston\u2019s surgery was performed by a board-certified plastic surgeon she said she found on Instagram. She was originally quoted $4,995, which she said she paid in full before surgery. But when she arrived in Miami, she said, the clinic tacked on fees for liposuction and for post-surgical garments and devices.<\/p>\n
\u201cI ended up having to pay, like, $8,000,\u201d Ruston said. A few days after Ruston returned home to Lake Alfred, she said, she started to feel dizzy and weak and called 911.<\/p>\n
Paramedics took her to an emergency room, where doctors diagnosed her with anemia due to blood loss, and blood and abdominal infections, her medical records show.<\/p>\n
\u201cIf I could go back in time,\u201d she said, \u201cI wouldn\u2019t have had it done.\u201d<\/p>\n
*KHN\u2019s Chaseedaw Giles contributed to this report.<\/em><\/p>\n*
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