The latest issue of the Plastic Surgery News (June 2017), a publication put out by our national plastic surgical society, had a front page article, “Gluteal fat grafting complications prompt a Global Scale Investigation.” The byline goes on to say, “Mounting concerns over the safety of fat grafting to the buttocks have sparked a worldwide effort to gather and analyze data as leaders in plastic surgery work to develop recommendations aimed at improving patient safety.” Fat grafting is the fastest growing plastic surgical procedure in the US. In one study 200,000 cases were reported, with 32 fatal and 103 non fatal pulmonary fat emboli.
Wow.
First a synopsis of the article and then my thoughts.
- Rates of mortality (death) associated with the procedure range from 1 : 2,000-1 : 6,000.
- The highest risk procedure historically has been a tummy tuck, with a 1 : 13,000 mortality.
- This has so alarmed our national and international societies that they are forming a task force to review the problem
- The deaths involved catastrophic emboli during the procedure- causing an intraoperative or immediate post op death.
- There is no known intervention to reverse it.
- Florida case
- Autopsy showed injury to the inferior gluteal vein with surrounding injected fat, though the doctor in his notes said he stayed “superficial.”
- Analysis supports the theory that fat injected into the buttocks near or into and injured vein allows catastrophic amount of fat to embolize.
- It may not be need to be injected directly into the vein- it may move into the lower pressure system if it is near an injured vein.
- Others say the answer might not be so simple. “We inject fat all over the body and we don’t see this complication. This is unique.”
- The task force will look at
- volume (how much are they injecting with each pass? total volume?)
- technique (do they use pressurized system to inject? are they grafting into the subcutaneous space? or do they try to inject into the muscle? what sized cannulas?)
- locations (muscle vs. subcutaneous injection)
- Nonfatal fat emboli are not like emboli from blood clots. With a blood clot, patients usually recover to have normal lung function. With fat embli, some never fully recover and need lifelong supplemental oxygen.
My thoughts.
Wow. I have known fat grafting to the buttock had risks. A good friend of mine looks at these investigations, and fat grafting to the buttock is known to have higher risks. We just don’t see these complications in fat grafting to the face. There are hypothesis for why, and most center around the complex venous system in the buttock, and the potential issue with injecting into this space. For this reason, I only do the fat injections superficially when doing fat grafting, and I tend to do small amounts. At some of my national meetings, I see surgeons who inject large amounts of fat, who advocate injecting into the muscle for better fat survival, or who use pressurized systems. Do these cause higher risk?
The surgeon in the Florida case reviewed above said he stayed superficial. Autopsy was performed. In their review: “In the operative report, the surgeon noted that he only injected into the superficial layers of the muscle and superficial layers of the fat. But this investigation found there were, indeed, very deep level injections and we found the vessel injury to the inferior gluteal vein.”
SO. The risk is low, but if fat emboli to the lung presents there is no known way to reverse it. The task force will help us figure out trends. For sure I think a board certified plastic surgeon is better than the many “plastic surgeons” popping up who have less knowledge of technique and anatomy. Small amounts are likely safer. Superficial is likely safer. But we should all be concerned regarding the health and safety of our patients.
I will keep updating as we find new information.