You're listening to The La Jolla Cosmetic Podcast.

Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. And today we have Dr. Swistun back with us. Welcome.

Thank you.

You've been on the show three times now. So we've talked about some pretty hot topics like removing breast implants, 360 lipo, BBL safety. Have you heard anything from patients who've listened to those podcasts?

Yeah, I think it opens up a lot of our conversations. We get a lot of patients who have heard the podcast and just want to clarify a couple of pieces of information here and there. So it's been a very successful conversation.

Great. Well, today's episode is for a very specific type of person, and we're going to get into what's called the skinny BBL. So generally speaking, the BBL is a very popular procedure where fat is shifted from parts of the body where you don't want it, like your tummy, let's say to the butt where you do want a little curve added.

So we're going to talk about what is a skinny BBL. And before you tell us, Dr. Swistun, here's what the internet says and I'm going to read you some of the answers we found, and have you tell me after each one if these descriptions are accurate or not so much. So here's the first one. Basically a smaller butt.

Could be. I guess it depends on the context of the patient. But yes.

Okay. Someone who just wants hip dips and a round booty.

Yeah, I think that would be a better description of it because hip dips is something that we can almost find in every patient and takes away from the nice hourglass curve, even in a patient who's very thin. So that is a very common area for us to focus on for the thinner patients that want a little bit more curve.

And what does that mean exactly? Can you help us visualize what a hip dip is for those of us in the audience who don't know?

Right. It's a little bit hard to describe it in words, but essentially it's just below the iliac crest, which is basically the bony hip part of your waist on the sides. There tends to be, especially in thinner patients, there tends to be a little bit of a indent in the overall body curvature. And then there's more projection below that, which is at the hips, at the peak projection of the hips.

It's not a bad look, but it's a little bit more of an athletic look, but it is not the perfect hourglass that we sort of imagine sometimes. So a lot of times just adding a little bit of volume just to that area will continue that curve that starts below at the hips, and then that curve will continue all the way up to the waist. And it becomes a nice continuous curvy line rather than a little bit of a dip in between.

Okay. So if somebody thinks the skinny BBL, we saw what somebody said just more natural or maybe smaller.

Yeah, that's a reasonable description as well. I think that comes from the misnomer of the regular or normal BBL in that the goal of a BBL in general is to give somebody a big butt and that's just not true. In fact, I haven't met a patient yet who wanted the Kardashian look, so to speak, which is classically the one that's associated with a really large, round buttock and a very thin waist. And it's almost exaggerated. Most patients don't want that. In fact, I would say none of my patients ever wanted that. They all came in with, "I want to look natural. I just want to look more curvy. And I want the features to be a little bit more accentuated, but not exaggerated."

And here's another definition that somebody said. Someone younger than 50 with a BMI of 24 or less. Do you agree with that?

Reasonable, I don't know if their age is a criteria. Every patient is different and every patient needs to be evaluated separately with regards to their age and clinical predisposition towards handling a major surgery. But the BMI of 24 is pretty much a spot on description because that's a body mass index and that's basically how much fat people have relative to their height.

And classically the regular BBL, the regular Brazilian butt lift is described as patients who are appropriate for that are usually between 25 to 30 BMI. So for someone who's much thinner than that in a healthy 20 to 25 range, they can still get their fat moved around in different places. It's just obviously the volumes are going to be very different, but it still adds up to a very nice result. So that's probably the best description of it thus far here.

Okay. And the last one is, a skinny BBL is for girls that don't have much fat, but still want a more projected rounder and lifted booty.

Yeah, I guess that falls along the same lines as what we just talked about before.

Okay. And so out of all those, how would you define it? Would you define it if you were going to give us a little Webster's Dictionary definition?

Well, I guess it's something that I already do, and it's a very common procedure. I think my definition of it would be someone who is of a lower BMI, probably a very healthy BMI, 20 to 25, who basically is storing fat in an unfavorable place. So there's plenty of people who are very thin, but they're just not as curvy as they'd like to be. And there's just a little bit more fat in the flanks and a little bit more fat in the abdomen and a little bit less fat in, let's say the buttock or those hip dips we mentioned, or sometimes in the breasts. And that's a different conversation I suppose we can have.

But it's a very common patient that we see in the clinic. Very healthy patient, very young patient, very athletic, but basically they just say, "I just cannot lose the weight in my flanks. So can we remove that with liposuction? And by the way, I've always wanted just a little bit more curvature in my buttock, a little bit more projection," just like you said, "And can we use that fat somewhere else?" And it becomes a little bit of artistic challenge because the resources are limited. They don't have a lot of fat. So we make the best of what we can with what we have.

So you talked about BMI, body mass index. So how do you calculate it?

There is a formula for it. Type in BMI calculator on Google, it's the first thing that comes up because it's one of the most common references in the health realm, but it's basically the height to weight ratio. The formula takes those two factors, how tall you are, and how much you weigh and it calculates it into a number. And it's basically just an accepted number of what's healthy and what's not.

So a BMI of 20 to 25 is considered perfectly healthy. References will say 19 to 24 depending on the reference that you read. Anything below 20 is considered a little bit too thin. And anything above 25, 25 to 30 is considered overweight. 30 to 35 is considered obese, and 35 and up is considered morbidly obese.

Okay. And we also have on our website a BMI calculator. So we'll have that in the show notes for you. So how is the BBL surgery going to be different for someone who has a lower BMI or the skinny patient, let's call her?

The major difference between a patient requesting a regular BBL and a skinny BBL is that patient coming in for a skinny BBL will have a lot less fat. So that presents to me a different set of challenges. It's not necessarily easier just because they have less fat. In fact, I consider that more challenging because these are patients who are already healthy with a really good weight, and they usually have very nice definition of their muscle tone in other places. And it's easy to be too aggressive and actually give them a little bit of a contour deformity if we are too aggressive about removing the fat from certain places.

So we have to be very careful how much fat we remove. We still have to leave a very thin layer of fat on the outside so that the result is nice and smooth. And that's where a challenge comes in. I typically use very fine cannulas for this as opposed to bigger cannulas for bigger patients. And that takes a little bit more time, but I think it's worth it because after we're done, the patient doesn't have obvious tell tales that they had liposuction with some of those contour deformities that we can see.

And then the fat is usually limited. So that's the other difference is, we only have so much because the patient doesn't come with this unlimited amount of fat that we can just use as much as we want to. So then I always have conversations with patients about priorities. What would you like the most as far as your result? Let's say we have a defined amount of fat and then we typically have a list of priorities and they say priority one, I want my hip dip filled so that when you look at me from the front, I have a nice hourglass curvature. And then if there is any fat left over, we can also place it towards the back of the buttocks so that we can increase my buttock projection from the side. And then if there's any fat leftover after that, they might want to add it to the hips a little bit to increase their overall roundness as well.

And I think our VECTRA System really helps out with that because I can have this conversation. Basically we have a 3D scanner of the patient's body that we can then manipulate right in front of them and give them a nice idea of what the result may look like. And that gives me an opportunity to say like, "Okay. If we make this change, this is what it's going to look like. Whereas if we allocate the fat in another place, this is what it's going to look like." And it's very much a two-way conversation, decision-making process so that the patient's very happy afterwards.

That's really interesting to think about having to have some priorities about what's the most important.

Yeah.

So Dr. Swistun, when I see tall, skinny people, they're kind of straight up and down like a green bean or a pole, and they don't have a lot of curves. And if they're thin, how could a patient expect to have a tangible change if they really don't have a lot of fat to start with?

It's important to mention that it is a combination of the liposuction and the fat grafting that really, even though there's subtle changes, they really add up to a very tangible result. The liposuction will thin out the waist a little bit, and then the fat grafting will project the hips a little bit more and that adds up to a nice overall hourglass curve, which is definitely visible from far away once the result is completed. And it's a huge difference between a patient that comes in kind of boxy and square and comes out a lot more curved.

Now, where on the body do you normally find fat to remove or especially in a thin person?

Most commonly the fat that I can almost always find is in the flanks, in the posterior flanks, which is in the back waist area. I've done this with patients who are as thin as a BMI of 17. So very, very thin. And this is a patient that actually had a breast surgery where we removed her implants and she had absolutely no volume in her breast, and she just did not want to be concave and caved in. So we ended up removing a little bit of fat from there and fact grafting her breast and it turned out really well.

Another example is, I had a patient who actually qualified for Olympics recently. So you can imagine she had really, really defined body and very little fat throughout, but that area still held a little bit of fat, and that's the area that we went after to remove. And then we got a decent amount out. So almost everybody has that area has a backup plan.

That hidden fat.

Correct, correct. And then depending on the body build, sometimes some people store it towards the front. Everybody's a little bit different and the physical examination really help guide where we can make a difference.

Now, how much do you have to take out to be able to put some back in? Is there a loss?

Again, everybody's a little bit different. It actually varies a little bit between patients ethnicities. But in general, if we were to remove, let's say 300 CCS, probably about 200 of that would be usable. Usually about half to two thirds is usable. So not a lot, but it can make all the difference in the world.

And then about how much of that sticks around in the long run?

Yeah. Again, it depends on the patient, but typically, I just mentioned about 50% of it sticks around in the long run. So we typically over-correct if we can, if we have enough fat to do that, and we will fill in those areas. And I always tell patients that it'll actually look a lot bigger immediately after the surgery because your surgical swelling is going to be there, as well as all of the fat that we put in there is going to be there.

And in about six weeks, the surgical swelling will go away. So the volume will go down. In about four months, the fat that did not vascularize, that did not take blood supply and basically didn't survive will also go away. And that'll be about half of the fat that we grafted it. But what did take, what did get blood supply and survived is basically yours to keep forever.

Now, you were talking about cannulas, the handpiece or tool that you used to extract the fat. So how big is that normally? And then so what does that incision look like and how do you camouflage that?

Right. So the incisions are very small for almost all the cannulas. They're about three to four millimeters. That's like an eighth of an inch maybe. And the cannula is basically a very long rod that is hollow with some holes at the end of it. And that allows me to get under the skin. And once I can get that under the skin, then I can reach different areas of the body and go ahead and remove the fat.

One other trick that I do in order to camouflage these... Again, these are very small incisions. They typically heal very well and it almost looks like you had a mole removed or nothing at all, depending on how you heal. But even with that, I try to actually place the incisions asymmetrically, which goes... It's counterintuitive to most plastic surgeons, but it's actually better because if I place the incisions at different heights at different parts of the body, then it doesn't draw as much attention. It almost looks like a little mark or a mole or something different and masks itself that way.

My biggest pet peeve is when I see someone at the beach with a telltale of a very, very symmetric, little cannula incision ports throughout their bodies, it's like two in one area, two in another area, two in another area. And then from far away, you can tell like, "Oh, that patient had liposuction because of the symmetrics of those heeled scars." If you just vary them even just a little bit, they just don't draw attention.

Interesting. Now, if you're thin and doing lipo to parts of the body that don't have a lot of fat to start with, does that end up being lumpy or bumpy?

Yeah, so that goes back to already what we discussed, and me considering the thinner patient's a bigger challenge. So there's all ways a risk of having a contour deformity, like a lumpy or bumpy skin left behind after any liposuction. And that's true for any patient, big or small. And it has everything to do with technique. And which fat do you go after?

The simple way to think about it is that everybody has deep fat and then superficial fat or fat that is immediately under the skin. And the deep fat is fair game to go after in liposuction, but the superficial fat, the fat that's immediately under the skin basically is there to keep that skin smooth. And if someone is too aggressive and tries to remove too much fat and goes into that layer too much, then the skin will dimple in the areas where that fat was removed. And when that heals, that's what gives us counter-irregularities. So again, technique is key.

So if they had enough fat, where else could you transfer fat?

So it's priorities. So I can transfer fat pretty much anywhere because it's your own fat, it'll survive. So the most common area is either the buttocks or the hip dip like we talked about. The second most common area is actually the breasts. A lot of patients who want a little bit more volume or fullness in certain areas, but want to avoid an implant and that is nice, tangible result as well. It may be a very subtle result if you don't have a lot of fat, but it's still something. And fat grafting to the face is another very, very good option. And these are typically for older patients, but not necessarily. If you have a younger patient with hypognathia or basically a deficiency of the chin, sometimes we can fat graft to the chin and just give her a little bit more projection as a very common area to do.

Sort of like a natural chin implant?

Correct. It's very subtle. It's not going to substitute for an actual chin implant, but it avoids the complications of an actual foreign body implanted into the chin. So it does always risks and benefits to every surgery we do. But if grafting the cheek's very common, the chin is very common. Grafting the prejowl sulcus, which is this little dip that forms as we age right there to smooth out the jaw, that's another common area to graft. And for older patients, temporal hollowing right there, that's a sign of aging that we can fill in with a little bit of fat. And I would say for people who are thin, that's probably the best use of it because, especially for the most thin people, we don't have a lot of fat to go with, but usually we can get enough fat to address all the areas of the face because you really don't need a lot to do that.

Now, what if somebody's just really too thin? Would you ever suggest for them to gain weight to have the surgery?

Typically, I don't. The way to think about fat in your body is that you're born with all the fat cells that you're ever going to have in your life. And they're basically very, very small when you're thin and they gain volume when you gain weight. But the number of the fat cells doesn't really change.

So what we're doing here is redistributing where the fat cells live inside your body. And we take them away from the places where you don't want them, let's say the waistline, and then we put them in the places where you do want them, let's say the face or the buttocks. And once they survive, they act the same way.

So I always recommend just for the patient to come in with their healthy weight, with their preferred maintainable healthy weight. And the assumption is that they're going to keep that same weight for the rest of their lives. So there's no reason to gain some just for the procedure.

Yeah. Now, for the thin patient, they might think, "Well, how about, Dr. Swistun, you do a fat transfer and a buttock implant?" What do you tell them?

I try to avoid buttock implants. I know people who do that surgery. I've done that surgery in my training, but a buttock implant has its own set of complications that in my personal opinion are too high to justify doing that cosmetic procedure. The long term complication rate in any patient with buttock implants is I think like 70%, upwards of 70%. Basically, it's an implant that you sit on every day, so that just predisposes it to a lot of trouble. And it's not something that I offer.

There are some patients that I've seen with buttock implants in our practice who basically wanted a little bit more fat added on top of that. And their implants were fine at the time, although they were a little bit mobile. And a lot of times the patients that I've seen basically wanted fat grafting because the implants have shifted to a different position, and they wanted to go back to where they used to be. So they thought the fat grafting was going to be the appropriate intervention. And that's something that's possible to do.

Now, what about Sculptra or any other dermal fillers or volume stimulators?

So that's another option certainly. And that's for patients who basically run out of fat. Then yeah, you could use some fillers. Sculptra is the most common one. It becomes very expensive at that point because I know that a small amount of Sculptra is very, very expensive. So to make a significant difference on the part of the body like a buttock, you need a lot of Sculptra to that.

Now, how many BBLs have you done roughly in your career?

Somewhere between 50 and 100 I would say.

How many would you say were skinny?

At least a third of them. If not, half even. It's a very common request.

Now, some people might think, "Well, if I'm skinnier, the surgery will be shorter and my recovery will be easier." Is that true?

No, I wouldn't say that that's true. And in fact, to me, like I mentioned before, the skinny patient is actually the more challenging patients because the margins are very thin. Oh, I used the same terminology again. But because of how thin the margins are, you have to be a lot more careful and that just actually adds time.

Now, does it change in their healing time at all?

I would say it's about the same. There's a broad spectrum of how patients heal from the BBL, from that procedure. There are some patients that tolerated very well. And then there are some that are just having a little bit more of a hard time. They're down for a little bit longer. It depends on the patient. And there's not necessarily anything different between one procedure and another. But I think pain tolerance is one thing, the amount extracted and then just how they are in general.

Well, this has been so informative. Thanks everybody for listening. And if you are listening and you've gotten this far, we want to ask you for a special favor. If you love our podcast and if you've learned something from it, it's helped you make a decision, or... Please tell your friends and write a review of our show on Apple podcasts or good pods, wherever you're listening. We love reviews. We're all about reviews at La Jolla Cosmetic. So our podcast is no different. And check our show notes for the links. And you can also find links to Dr. Swistun's bio and all of his beautiful photos. So thank you to again Dr. Swistun for joining us.

Thank you very much for having me.

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