Beware of fat grafting to the buttock. Doing a little bit to shape the buttock if the surgeon stays very superficial is likely okay. But doing large volumes always involves going deeper. Add to that the number of clinics that are off the radar, budget, non-board-certified, non-plastic surgeons, sometimes even the surgical “assistant” does the surgery…. even some are board-certified plastic surgeons. You just need to be careful.
This is in the August 2022 Aesthetic Surgery Journal. “Two Cases Surviving Macro Fat Emboli Complications Following Gluteal Fat Grafting.” I was super happy to see these two cases survived. Many of these emboli complications present with “catastrophic cardiopulmonary compromise and death.” Many of these cases die on the operating table or within 3 hours of surgery.
So what did the article say?
They discuss how there has been an alarming number of deaths from intravenous passage of the injected fat during gluteal fat transfer. Micro emboli (<1 cm in diameter) can cause damage, but differ from the larger emboli which tend to present to heart and lung failure followed by death.
With these two cases they survived. They were transferred quickly to a tertiary care setting. In the other journal articles they described how transfer to the ICU and big centers did not prevent death. So what did they do here?
CASE 1:
28 year old woman at local accredited center. During surgery had loss of blood pressure, increased heart rate, cyanosis, and hypoxia. She was transferred to ER.
- Immediately: Intubated. pH=6.92.
- ICU: norepinephrine drip, 100% fraction of inspired oxygen. CT scan showed multiple pulmonary emboli. Nitric oxide, steroid, antibiotics were given.
- Patient was unstable, requiring increasing blood pressure and ventilator support.
- EKG showed reduced heart function.
- ECMO was done. She did 6 days of ECMO. She gradually improved.
- On Day 16 she was extubated. She still required kidney dialysis.
- On Day 24, she was discharged with a dialysis catheter. Her kidneys never recovered and she is now on a waitlist for kidney transplant.
CASE 2:
26 year old woman arrived in ER 6 hours after liposuction with fat transfer to buttocks. She had respiratory distress and was discovered in the recovery unit of the surgery center.
- ER arrival pH 7.09. She was intubated.
- CT showed pulmonary emboli and emboli in spleen and kidneys.
- Admitted to ICU. Breathing and blood pressure improved.
- Day 3 she had a stroke. She has emergency brain surgery to decrease the pressure on her brain and had a filter placed into her vena cava to filter out further emboli clots.
- She had a complicated recovery, with many blood clots (not fat emboli) which could not be treated because they couldn’t put her on blood thinners due to recent brain surgery.
- The patient did recover her strength, and on Day 17 they planned to discharge her.
- She returned 1 month later with infection draining from her skull incision site.
- She had further surgery, 6 weeks of antibiotics. They are still awaiting replacement of bone flap.
In the discussion, they state how early intervention and the young age of the patients saved them. The authors tried to get the patient’s records – how much fat? what plane injected in? etc- but could not. They stress repeatedly you MUST STAY IN THE SUPERFICIAL PLANE.
My thoughts?
Small, superficial, shaping fat transfer to the buttock is okay. Anything else seems to not be. They quote stats in the beginning of this article that in surgical hands the mortality is 1/15,000. Others have estimated as high as 1/3,448. Those numbers may not sound big, but reading these cases is heartbreaking.