Awake Brazilian butt lifts: rising trend prompts safety debate

A growing number of patients in the United States are opting for awake Brazilian butt lifts, a trend in which fat is liposuctioned from areas such as the abdomen, thighs, or back and injected into the buttocks to create a fuller, curvier appearance while the patient remains conscious.

Usually performed in an office setting, awake BBLs rely on local anesthesia and oral sedatives rather than general anesthesia. The approach is marketed as a lower-cost option and a way to avoid hospital or facility fees, though it carries its own risks.

Two main reasons drive interest, according to Dr. Sean McNally, a board-certified plastic surgeon who treats cosmetic and reconstructive patients in Portland. 'One, there’s no anesthesia provider and either a reduced or no facility fee, which makes the procedure more affordable,' he said. 'Two, patients are concerned about the safety profile of standard BBLs, and they feel like being awake makes it safer.' Advocates also point to quicker recovery and less postoperative grogginess, which proponents say can help patients return to daily activities sooner.

'I don’t perform them, and I know many others who don’t,' McNally said. 'It’s not that it’s a bad surgery per se — the big issue is patient comfort versus results.' He notes that there are limits to how much local anesthesia can safely be given based on a patient’s weight and height, which can constrain pain relief during the procedure. He also cited reports of unsafe practices in some outfits that push beyond safe anesthesia limits, telling patients to endure pain for the sake of a better-looking result. 'I have heard absolute horror stories from patients who went to chop shops for cheap liposuction, and once the surgeon hit the max local anesthetic volume they could give them, they were told to hold still and bare it if they wanted a good result,' he said.

There’s also a legal catch: Many states cap how much fat can be removed during liposuction in an office setting, leaving less to work with—and potentially disappointing outcomes. 'You never want to have to balance patient comfort during a case against whether you’re getting the result you and the patient want,' McNally said.

Besides pain, the safety profile of awake BBLs is generally similar to the traditional procedure. Common risks include swelling, bruising, bleeding, infection, contour irregularities where the fat was harvested, variable take of the transplanted fat and fat necrosis. The most dreaded complication is fat embolism — a rare but life-threatening condition that occurs when fat enters the bloodstream and travels to the heart or lungs. This can occur whether the patient is awake or under general anesthesia. 'We help mitigate this risk by being mindful of our injection volumes, and we complete the injection under ultrasound guidance to avoid injecting fat into the muscles where the largest vessels are,' McNally said.

As always, patients should seek a knowledgeable and reputable provider based on experience, not price point. Before undergoing the procedure, he advises having a frank and honest conversation with the doctor about goals and concerns. 'The right provider will help guide you to the option that’s right for you, and if you don’t think that surgeon is a good fit, find a surgeon who is.'

The trend reflects ongoing interest in cosmetic procedures that offer perceived safety, cost benefits, and quicker recovery, but medical professionals emphasize that awake BBLs are not universally suitable. With thousands of BBLs performed annually in the United States, the field continues to evolve as surgeons balance comfort, feasibility, and outcomes for patients seeking a more sculpted silhouette.

Despite the appeal of awake BBLs for some patients, McNally and other practitioners caution that the approach is not appropriate for everyone. The decision hinges on individual anatomy, pain tolerance, and the surgeon’s ability to achieve the desired contour within safe anesthetic limits. For those considering the procedure, the guidance remains clear: pursue care from a qualified, experienced surgeon, and engage in an in-depth conversation about expectations, risks, and the path to the safest possible result.