The latest issue of Plastic and Reconstructive Surgery Journal November 2018 had tons of articles on fat grafting to the buttock, also known as the Brazilian Butt Lift or BBL. This article was entitled, “Understanding Fatal Fat Embolism in Gluteal Lipoinjection: A Review of the Medical Records and Autopsy Reports of 16 Patients.”
What does the title mean?
- Fatal = Death
- Fat Emboli = Tiny fat globules that end up in your blood stream, like a blood clot but made up of fat, which then clog the blood flow. They can’t be reversed like blood clots can.
- Gluteal Lipoinjection = fat grafting to the buttock. The BBL. Buttock Augmentation. Brazilian Butt Lift.
- Autopsy Reports = When someone dies, you dissect their body to find out why.
Report:
- This was a retrospective study from 2000-2009, looking at 16 patients who died.
- They looked at cause of death and involvement in other organs, not just the lungs and heart.
Findings:
- NO statistical significance in age, BMI, or volume of liposuction or fat injected.
- Ages 23-53
- weight average 60kg
- BMI average 23 (range 20-27)
- They were anesthesia class I (which indicates a low risk surgical patient). Only one had diabetes, and two had controlled high blood pressure.
- The volume of liposuction was 800-6500cc
- The volume injected per gluteus was 120-350.
- They all had microembolisms.
- In the most severe cases, they had macroembolisms as well.
How did they present?
All of the cases presented the same way in the operating room. The heart rate slowed (bradycardia) with severe hypotension (low blood pressure) and hypoxemia (your blood shows low oxygen percentage- it should read 95-100%).
- Five cases the problem started at the time of injecting fat into the buttock. These had heart/lung failure and died immediately.
- Seven presented while still in surgery, after the buttock fat injection was done, and the surgery had to be stopped.
- Four were discharged and developed the clinical picture in the post op recovery area, around two hours after surgery.
- The eleven patients who did not die immediately were all transferred emergently to the ICU. They died an average of 4 hours after having been admitted.
What did they die of? (Remember: emboli means blockage)
- All had micro fat emboli in the lung, pulmonary vessels (blood vessels of the lung), and cardiac vessels (blood vessels of the heart)
- Micro emboli only tended to present a little later, but all died in ICU
- Ten of them had macroscopic fat emboli (that means BIG fat emboli) in the same places
- Three of these had fat in other organs: two in the brain and one in the kidney
- Five of these were the ones who died immediately on the table
- Four of these had onset during surgery
In their analysis, they found it was not related to the amounts of fat harvested or injected, their ages, weights, or other medical issues. Macroscopic fat led to sudden onset and more severe behavior. They suggest that vigorous ICU resuscitation helped the patients survive for some hours. Since they were evaluating patients who died only, there is the possibility that other have had similar conditions but survived.
Their recommendations in their conclusion: (I do not know where these recommendations stem from as the sources are not cited in the conclusion)
- Do not inject the upper fraction obtained during lipo- these has more free fatty acids, which could be a factor favoring microscopic fat emboli
- Adequate hydration – this helps get rid of fatty acids in the blood
- Don’t inject in highly vascular areas like the muscle
- Deep muscle injections, especially in the medial area near the piriformis muscle, should be avoided.
- If the patient suddenly deteriorates, stop the surgery
- Consider use of methylprednisolone or ciclesonide before surgery as a prevention measure.