On April 19, 2019, it was confirmed by "Billboard" that Madonna and Maluma would perform "Medellín" live for the first time at the "Billboard" Music Awards, which would take place at the MGM Grand Garden Arena in Las Vegas on May 1 of that year. The performance featured four virtual versions of her Madame X alter ego — a secret agent, a musician, a cha-cha instructor and a bride. Elements also present included a garden, rain and bursting blasts of color, provided by augmented reality, marking the first time it was used on American television. The effects were made through volumetric capture and game engine Unreal Engine. Jamie King, Madonna's creative director, said he looked for something special for the performance and settled on the idea of augmented reality, as he wanted to explore a way to involve her Madame X personas into the performance, as well as the possibility of Madonna being able to perform with them. Attendees of the awards show were able to see only through the screens inside the arena.