This was a discussion by Dr. Teitelbaum of Santa Monica about the prior article “Understanding Fatal Fat Embolism in Gluteal Lipoinjection: A Review of the Medical Records and Autopsy Reports of 16 Patients.”
He starts by stating every plastic surgeon should be shocked to see a journal article about death in elective cosmetic surgery patients, who are young and healthy. He states the journal article was only able to be done because Colombian law formerly allowed researchers access to medical records in the coroners office. That is no longer true there, and is not true in the US. There were 16 deaths in this review of fat grafting to the buttock from 2000-2009. There are only 13 million people in that country. The procedure is now more popular, done on more people, and because of legal issues, there is not a real true discussion of complications.
He cites here in the US there was a death from BBL, and a group of plastic surgeons helped the coroner analyze what happened. But existing law prevented the coroner from releasing unidentifiable (protecting HIPPA) photographs of the dissections, MRI and CT scans.
So this study was important because it allowed us to see what happened, evaluate it, and try to find patterns.
His important take aways:
- The risk is NOT related to volume
- It then follows that high pressure alone does not lead to fat emboli
- There must be a venous injury? The data did not contain information about this.
- He does not feel microscopic or macroscopic (can be seen with naked eye) is an important distinction to make, and if there is no real importance to this distinction, remove it from the discussion (in the article they did indicate macroscopic fat had an earlier and more severe presentation, though all died).
- He questioned their conclusion to avoid the top part of the lipoaspirate because of free fatty acids (I agree with this comment. They did not analyze why they recommended this, and this should have no effect if there is not injury to the small blood vessels)
- He also questioned whether bigger fat is in fact safer? Would larger and clumpier fat be less likely to embolize? So he suggested going back — look at cannula size and fat preparation methods. This needs to be researched. I agree.
- “Hydration helps clear fatty acids” Why? I agree, again has no research behind it.
- Avoid injecting into vascular areas is speculative. The autopsies showed the veins injured in the autopsies were the superior or inferior gluteal veins deep to the muscle.
- Why inject methylprednisolone or ciclesonide? Again no supporting evidence or discussion.
My thoughts?
I really liked his discussion. I think the original article had GREAT points and insights about the findings of the cases and autopsies. The only place I was confused was by their conclusions, where they made tons of statements which had not been discussed at all in the study and article.
It is good we are discussing this. Dr. Teitelbaum states, ” I know many plastic surgeons who were busy performing and teaching gluteal augmentation since that publication (of deaths) who were either unaware of it, didn’t discuss it with patients, or did not teach about it from the podium.” “Until a large series demonstrates how to do safely perform intramuscular injections, it behooves every surgeon to follow the most conservative recommendation, which is to inject only into the subcutaneous space.”
Hear hear. I agree.
I blog a lot. Many of my blogs are about articles and studies I read about in my societies’ publications. It keeps me constantly updated on new findings. Many, like these, are important for patient safety and health.