In hindsight, Nikki Ruston said, she should have recognized the red flags.
The office in Miami where she scheduled what's known as a Brazilian butt lift had closed and transferred her records to a different facility, she said. The price she was quoted — and paid upfront — 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.
"I was ready to walk out," said Ruston, 44, of Lake Alfred in Central Florida. "But I had paid everything."
A few days after the July procedure, Ruston was hospitalized due to infection, blood loss, and nausea, her medical records show.
"I went cheap. That's what I did," Ruston recalled recently. "I looked for the lowest price, and I found him on Instagram."
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.
Unlike ambulatory surgery centers and hospitals, where a patient might stay overnight for observation after treatment, office-based surgery centers offer procedures that don't typically require an inpatient stay and are regulated as an extension of a doctor's private practice.
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.
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 meant to make the procedures safer. More than three years later, data shows deaths still occur.
Patient advocates and some surgeons — including those who perform the procedure themselves — anticipate the problem will only get worse. Emergency restrictions imposed by the state's medical board in June expired in September, and the corporate business model popularized in Miami is spreading to other cities.
"We're 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," said Dr. Bob Basu, a vice president of the American Society of Plastic Surgeons and a practicing physician in Houston.
During a Brazilian butt lift, fat is taken via liposuction from other areas of the body — such as the torso, back, or thighs — 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 from the Aesthetic Society, a trade group of plastic surgeons.
As with all surgery, complications can occur. Miami-Dade County's 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.
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 from an Aesthetic Surgery Education and Research Foundation task force.
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's 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.
In May, after a fifth patient in as many months died of complications in Miami-Dade County, Dr. Kevin Cairns proposed the state's emergency rule to limit the number of butt lifts a surgeon could perform each day.
"I was getting sick of reading about women dying and seeing cases come before the board," said Cairns, a physician and former member of the Florida Board of Medicine.
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.
But a group of physicians who perform Brazilian butt lifts in South Florida clapped back and formed Surgeons for Safety. 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't follow rules.
The group has since donated more than $350,000 to the state's Republican Party, Republican candidates, and Republican political action committees, according to campaign contribution data from the Florida Department of State.
Surgeons for Safety declined KHN's repeated interview requests. Although the group's president, Dr. Constantino Mendieta, wrote in an August editorial that he agreed not all surgeons have followed the standard of care, he called the limits put on surgeons "arbitrary." The rule sets "a historic precedent of controlling surgeons," he said during a meeting with Florida's medical board.
In January, Florida state Sen. Ileana Garcia, a Republican, filed a draft bill with the state legislature 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.
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.
Florida's legislature convenes on March 7.
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.
"That's very dangerous," said Basu, of the American Society of Plastic Surgeons. "They're excited about a low price and they forget about doing their homework," he said.
The average price of a buttocks augmentation in 2021 was $4,000, according to data from the Aesthetic Society. But that's only for the physician's fee and does not cover anesthesia, operating room fees, prescriptions, or other expenses. A "safe" Brazilian butt lift, performed in an accredited facility and with proper aftercare, costs between $12,000 and $18,000, according to a recent article on the American Society of Plastic Surgeons' website.
Although Florida requires a physician's license to perform liposuction on patients who are under general anesthesia, it's 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, who co-authored the 2017 Aesthetic Surgery Education and Research Foundation task force study.
By relying on staffers who don’t have the same specialty training and get paid less, office-based surgeons can complete more butt lifts per day and charge a lower price.
"They're doing all of them simultaneously in three or four different rooms, and it's being staffed by one surgeon," said Mofid, a plastic surgeon in San Diego, who added that he does not perform more than one Brazilian butt lift in a day. "The surgeon isn't doing the actual case. It's assistants."
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.
People in search of bargains are reminded that cosmetic surgery can have other serious risks beyond the deadly fat clots, such as infection and organ puncture, plus problems with the kidneys, heart, and lungs.
Ruston's 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.
"I ended up having to pay, like, $8,000," Ruston said. A few days after Ruston returned home to Lake Alfred, she said, she started to feel dizzy and weak and called 911.
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.
"If I could go back in time," she said, "I wouldn't have had it done."
KHN's Chaseedaw Giles contributed to this report.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.