Brazilian butt lifts are among the deadliest of cosmetic procedures. Now Florida is cracking down on "butt-lift mills," issuing new mandates for surgeons that aim to make the procedure less risky.

Florida has become the epicenter of a growing butt-lift crisis as curvy celebrity influencers like the Kardashians have made attaining an hourglass figure especially desirable. There have been 21 butt-lift deaths in Florida since 2015, according to the Florida Department of Health. Last year was the deadliest for patients seeking butt lifts in Florida, with five deaths. And those numbers could be even higher than official counts suggest, according to a study published in the Aesthetic Surgery Journal this month.

One major contributing factor, according to the Florida Board of Medicine, is the state's high-volume surgery centers that have become known as butt-lift mills. These centers offer the procedure at bargain prices by squeezing in as many clients as possible, often compromising quality in the name of quantity. The high number of deaths at such places pushed the medical board to seek ways to make the procedure safer.

"Quite honestly, I got sick of going to meetings and hearing cases of women dying," said Kevin Cairns, the Florida Board of Medicine's vice chairman.

Brazilian butt lifts involve taking fat from the abdomen or thighs and then injecting it into the buttocks. But the procedure can result in severe complications, including death, when that fat injection misses its mark. As the surgery has grown in popularity, a group of leading plastic surgery societies has raised the alarm over the high number of complications. But so far, Florida is the only state to address the dangers of Brazilian butt lifts explicitly.

Florida's medical board is expected to finalize mandates next month that aim to make the procedure safer in three key ways: It will cap the number of butt-lifts a surgeon can perform, forbid surgeons from delegating key parts of the procedure and require the use of ultrasound equipment to reduce the risk of fat being injected into the wrong part of the butt.

At butt-lift mills, well-credentialed surgeons often essentially supervise surgeries, allowing underqualified physicians or medical assistants to perform critical parts of the procedures, said Pat Pazmino, a Miami plastic surgeon who recently published a paper on South Florida's high number of butt-lift deaths.

"The patients probably assume that the doctor who agreed to do the surgery is going to be performing it," said Pazmino. "It's really the way that these clinics are practicing that has put a lot of patients in danger."

Such practices are part of what allows butt-lift mills to perform so many surgeries each day. A butt lift can take up to three hours, so three to five procedures would account for a full day's work for an experienced, qualified plastic surgeon. However, at these high-volume surgical centers, a single doctor might have multiple surgeries taking place at the same time.

Inspectors at the Florida department of health have turned up at a registered physician's office to find mega-centers in place of individual doctor's offices, filled with women who have arrived straight from the airport, suitcases in hand, waiting to go into surgery, according to an inspector's testimony at a board meeting earlier this month.

"Some of these places have 16 operating rooms in an office. That's not an office operating suite. That's like a major hospital without any of the regulations," said David Halpern, president of the Florida Society of Plastic Surgeons.

To curb those practices, the new mandate will forbid physicians from performing more than five Brazilian butt lifts within 24 hours and require that the surgeon of record also perform the complicated parts of the procedure, like fat injection.

The new measures will replace an emergency 90-day order announced in June. They're expected to be finalized at an Oct. 6 meeting and to go into effect soon after. They may also set the stage for other states to follow suit.

In the United States, any licensed doctor can perform cosmetic surgery in their office, whether or not they have undergone the many years of extensive training required to become certified by the American Board of Plastic Surgery. In places with stringent rules and vetting processes, like hospitals, doctors without good credentials would not be allowed to perform cosmetic surgeries. However, the amount of oversight for those procedures in offices varies drastically from state-to-state.

The American Society of Plastic Surgeons, which represents 93% of all board-certified plastic surgeons in the U.S., supports Florida's new rules and earlier this month issued similar guidance to all their members across the country.

"Patients are still dying from this operation," said J. Peter Rubin, the society's president.

However, rules and regulations are just the first steps, said Alexander Earle, a board-certified plastic surgeon in Miami.

"A lot of these high volume centers have the incentive to try to skirt around the rules or not really follow them," he said. "There needs to be enforcement."