Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force

Abstract

Background: Gluteal fat grafting is among the fastest growing aesthetic procedures in the United States and around the world. Given numerous anecdotal and published reports of fatal and nonfatal pulmonary fat embolism resulting from this procedure, the Aesthetic Surgery Education and Research Foundation (ASERF) formed a Task Force to study this complication.

Objectives: To determine the incidence of fatal and nonfatal pulmonary fat embolism associated with gluteal fat grafting and provide recommendations to decrease the risks of the procedure.

Methods: An anonymous web-based survey was sent to 4843 plastic surgeons worldwide. Additional data on morbidity and mortality was collected through confidential interviews with plastic surgeons and medical examiners, public records requests for autopsy reports in the United States, and through the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF).

Results: Six hundred and ninety-two (692) surgeons responding to the survey reported 198,857 cases of gluteal fat grafting. Over their careers, surgeons reported 32 fatalities from pulmonary fat emboli as well as 103 nonfatal pulmonary fat emboli. Three percent (3%) of respondents experienced a patient fatality and 7% of respondents reported at least one pulmonary fat embolism in a patient over their careers. Surgeons reporting the practice of injecting into the deep muscle experienced a significantly increased incidence rate of fatal and nonfatal pulmonary fat emboli. Twenty-five fatalities were confirmed in the United States over the last 5 years through of autopsy reports and interviews with surgeons and medical examiners. Four deaths were reported from 2014 to 2015 from pulmonary fat emboli in AAAASF facilities.

Conclusions: Despite the growing popularity of gluteal fat grafting, significantly higher mortality rates appear to be associated with gluteal fat grafting than with any other aesthetic surgical procedure. Based on this survey, fat injections into the deep muscle, using cannulae smaller than 4 mm, and pointing the injection cannula downwards should be avoided. More research is necessary to increase the safety of this procedure.

© 2017 The American Society for Aesthetic Plastic Surgery, Inc.

Figures

Figure 1.

Percentage of surgeons stratified by surgical experience.

Figure 2.

Illustration of injury to a gluteal vein wall by fat grafting cannula and transit of macroscopic fat particles from within the extravascular space into the lumen of the vein. (A) Depiction of a preinjury schematic of the gluteal vein wall and (B) depiction of an injury to the vein wall allowing intraluminal entry of fat.

Figure 3.

Middepth, midbody intramuscular dissection at the interface of the gluteus maximus and medius of the superior gluteal vein in a cadaver demonstrating a 4 mm in diameter vessel. The superior and inferior gluteal veins are even larger than this intramuscular tributary.

Figure 4.

(A) Axial maximum intensity projection (MIP) from a blood pool MR angiogram following 10 mL gadofosveset in a 37-year-old female. The curved blue arrow indicates the typical large gluteal artery/vein bundle traversing in the plane between gluteus maximum (white arrowhead) and gluteus medius (green arrowhead) supplying multiple smaller perforating vessels through gluteus maximus to supply subcutaneous tissues. The superior gluteal vein travels between the gluteus medius and minimus toward the iliac wing. The superior gluteal vein (straight yellow arrow) and inferior gluteal vein drain into iliac veins (red arrow). Courtesy of Martin Prince, MD, PhD Columbia University. (B) A coronal oblique view shows how the superior gluteal veins (curved yellow arrow) and inferior gluteal veins (green triangles) flow directly into iliac veins (red arrows) and inferior vena cava (IVC).

Figure 5.

Posterior coronal illustration of superior and inferior gluteal vessels relative to bony anatomic landmarks.

Figure 6.

Illustration of superior and inferior gluteal vessels and their tributaries leading into the internal iliac vein and inferior vena cava.

Figure 7.

Sagittal illustration of the sciatic nerve and superior and inferior gluteal veins with perforators through the gluteus musculature.