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114
L. Cardenas-Camarena
into the buttocks. Based on this, an important recommendation is that when injecting fat into the buttocks we must be especially careful when using the infra-gluteal
approach. Through this approach, it is the easiest way to introduce the fat in an
intramuscular plane, so it is very important to direct the cannula towards the surface
of the buttock and always control it with touch and sight (Fig.7.20). Using cannulas
with curvature towards the gluteal surface makes it easier to achieve this goal.
Injecting fat into the gluteus through the intergluteal incision is a safer approach
(Fig.7.21).
Undoubtedly, one of the most difcult paradigms to change when inltrating fat
into the buttocks is to change the plane of inltration from an intramuscular plane
that was used for decades, to an exclusively subcutaneous plane. And in order to
understand this, we must analyze the history of why we used intramuscular injection as the plane of choice. At the beginning of fat inltration, and until 40years
Fig. 7.20 Approach with
increased risk of injecting
into the muscle. This
approach should be done
with great caution
Fig. 7.21 Safer approach
to avoid injecting into the
muscle
7 Safety inGluteal Fat Inltration
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115
ago, the survival of the inltrated fat was highly questioned. It was for this reason
that thanks to the work of Dr. Guerrerosantos, rst in rats [23, 24] and later in
humans [25, 26], it was determined that the survival and behavior of fat injected into
muscle was much better than when injected subcutaneously. And this was due to the
greater vascularity of the muscle compared to the subcutaneous tissue. Encouraged
by these ndings we carried this idea to inject it intramuscularly when using it for
gluteal augmentation [3, 11, 12] with the main objective of maintaining the maximum survival of the injected fat. What we never took into account was that, due to
the large caliber of the gluteal vessels, any injury to these vessels would condition
the appearance of this type of pathology. And now we see it, when there is a fat
thrombus in the face there is a localized injury by the caliber of the vessels and for
being micro emboli of fat, but when there is a large fat thrombus in large vessels,
such as the vena cava, the result is already mentioned.
A summary of both pathologies, including all the characteristics of microscopic
fat embolism (MIFE) and macroscopic fat embolism (MAFE), is presented in
Table7.2.
7.5 Final Recommendations
To adequately prevent the ve specic serious pathologies secondary to buttocks fat
inltration, we make these 10 recommendations
1. We must know the entities that appear secondary to buttocks fat inltration in
order to respond adequately and act timely and correctly in case of any
eventuality.
2. Avoid injecting large amounts of fat into small areas to ensure its vascularity
and integration.
3. Keep the patient hospitalized for a minimum of 12h after surgery to have ade-
quate hydration.
4. Avoid injecting fat on intramuscular planes.
5. Inltrate the fat with low manual pressure to distribute it properly.
6. Keep the inltration cannula parallel to the gluteal surface and thus avoid going
deeper. Have manual and visual control.
7. When using the subgluteal approach for fat inltration, the cannula must be in
a lower supper direction.
8. Always use blunt cannulas.
9. Inltrate with gentle technique and without aggressive movements.
10. Use cannulas with appropriate diameter and length, larger than 3mm in diam-
eter and no longer than 25cm.
116
L. Cardenas-Camarena
7.6 Conclusion
Improving the gluteal contour with fat injection has become a highly rewarding
surgical procedure. However, the specic complications inherent in this procedure
can range from very mild and manageable to very serious and fatal. That is why we
must be fully aware of all the pathologies that can occur secondary to this procedure
and apply all relevant measures to try to avoid them. Acting in a prudent and sensible way according to the existing scientic evidence will allow us to perform the
inltration of fat in the buttocks in a safer way, always maintaining the integrity and
safety of our patients.
References
1. https://www.isaps.org/wp- content/uploads/2017/10/ISAPS- Results- Procedures- 2010- 1.pdf.
2. Billings E Jr, May JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg. 1989;83:368–81.
3. Cárdenas-Camarena L, Lacouture AM, Tobar-Losada A.Combined gluteoplasty: liposuction
and lipoinjection. Plast Reconstr Surg. 1999;140:1524–31.
4. Roberts TL III, Toledo LS, Badin AZ.Augmentation of the buttocks by micro fat grafting.
Aesthet Surg J. 2001;21:311–9.
5. Schmeller W, Meier-Vollrath I.Autologous fat grafting (in German). Hautarzt. 2003;54:1185–9.
6. Murillo WL.Buttock augmentation: case studies of fat injection monitored by magnetic resonance imaging. Plast Reconstr Surg. 2004;1140:1606–14.
7. Cardenas-Camarena L. Various surgical techniques for improving body contour. Aesthetic
Plast Surg. 2005;29:446–55.
8. Roberts TL III, Weinfeld AB, Bruner TW, Nguyen K. “Universal” and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plast Surg.
2006;33:371–94.
9. Toledo LS, Mauad R.Fat injection: a 20-year revision. Clin Plast Surg. 2006;33:47–53.
10. Mendieta CG.Gluteal reshaping. Aesthet Surg J. 2007;27:641–55.
11. Cárdenas-Camarena L, Silva-Gavarrete JF, Arenas-Quintana R.Gluteal contour improvement:
different surgical alternatives. Aesthetic Plast Surg. 2011;35:1117–25.
12. Cárdenas-Camarena L, Arenas-Quintana R, Ronbles-Cervantes JA. Buttocks fat grafting: 14
years of evolution and experience. Plast Reconstr Surg. 2011;128(2):545–55.
13. Collina G, Morandi L, Lanzoni A, et al. Atypical cutaneous mycobacteriosis diagnosed by
polymerase chain reaction. Br J Dermatol. 2002;147:781–4.
14. Yang S, Hsueh P, Lai H, etal. High prevalence of antimicrobial resistance in rapidly growing
mycobacteria in Taiwan. Antimicrob Agents Chemother. 2003;47(6):1958–62.
15. Cardenas-Mejia A, Rodríguez-Martínez J, León D, Taylor JA, Gutierrez-Gomez C.Bilateral
sciatic nerve axonotmesis after gluteal lipoaugmentation. Ann Plast Surg. 2009;63(4):366–8.
16. Cárdenas-Camarena L, Durán H, Robles-Cervantes JA, Bayter-Marin JE.Critical differences
between microscopic (MIFE) and macroscopic (MAFE) fat embolism during liposuction
and gluteal lipoinjection. Plast Reconstr Surg. 2018;141(4):880–90. https://doi.org/10.1097/
PRS.0000000000004219.
17. Durán H, Cárdenas-Camarena L, Bayter-Marin JE, Ramos-Gallardo G, Robles-Cervantes
JA.Microscopic and macroscopic fat embolism: solving the puzzle with case reports. Plast
Reconstr Surg. 2018;142(4):569e–77e.
18. Gurd AR, Wilson RI.The fat embolism syndrome. J Bone Jt Surg Br. 1974;56B(3):408–16.
7 Safety inGluteal Fat Inltration
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19. Cárdenas-Camarena L, Bayter JE, Aguirre-Serrano H, Cuenca-Pardo J.Deaths caused by gluteal lipoinjection: what are we doing wrong? Plast Reconstr Surg. 2015;136(1):58–66. https://
doi.org/10.1097/PRS.0000000000001364.
20. Bayter-Marin JE, Cárdenas-Camarena L, Aguirre-Serrano H, Durán H, Ramos-Gallardo G,
Robles-Cervantes JA.Understanding fatal fat embolism in gluteal lipoinjection: a review of the
medical records and autopsy reports of 16 patients. Plast Reconstr Surg. 2018;142(5):1198–208.
21. Del Vecchio DA, Villanueva NL, Mohan R, Johnson B, Wan D, Venkataram A, Rohrich
RJ. Clinical implications of gluteal fat graft migration: a dynamic anatomical study. Plast
Reconstr Surg. 2018;142(5):1180–92. https://doi.org/10.1097/PRS.0000000000005020.
22. Peña W, Cárdenas-Camarena L, Bayter-Marin JE, McCormick M, Durán H, Ramos-Gallardo
G, Robles-Cervantes JA, Macias AA.Macro fat embolism after gluteal augmentation with
fat: rst survival case report. Aesthet Surg J. 2019;39(9):NP380–3. https://doi.org/10.1093/
asj/sjz151.
23. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez MA, Deos M, Diaz P.Longterm survival of free fat grafts in muscle: an experimental study in rats. Aesthetic Plast Surg.
1996;20(5):403–8.
24. Guerrerosantos J.The fate of intramuscularly injected fat autografts: an experimental study.
Aesthetic Plast Surg. 2005;29(1):62.
25. Guerrerosantos J.Simultaneous rhytidoplasty and lipoinjection: a comprehensive aesthetic
surgical strategy. Plast Reconstr Surg. 1998;102(1):191–9.
26. Guerrerosantos J. Long-term outcome of autologous fat transplantation in aesthetic facial
recontouring: 16 years of experience with 1936 cases. Clin Plast Surg. 2000;27(4):515–43.
Chapter 8
Deaths Caused by Gluteal Lipoinjection:
What Have WeLearned fromMicroscopic
andMacroscopic Fat Embolism?
HéctorDurán, LázaroCárdenas, DanielDel Vecchio, JorgeBayter,
AlvaroLuizCansançao, andWilliamPeña
8.1 Introduction
From the moment the article by Cardenas etal. [1] was published in July 2015, we
observed that something was wrong with fat inltration in the buttocks. It was from
that article that we understood that gluteal fat grafting had to change, and we should
explain what was going on and how to perform safely this surgery, otherwise our
patients could die.
Plastic surgeons from many parts of the world joined in an investigation about
each one of the aspects related to this procedure, so the mystery seems to have
recently been unveiled. Today, we know that intramuscular fat grafting is related to
the high mortality rate (1:3448 cases) and learned a lot about how fat can penetrate
the bloodstream evolving with extremely serious complications.
The understanding of the pathophysiology of these complications allowed us to
create safety protocols in order to avoid it. The challenge now is to get all plastic
surgeons who perform gluteal surgery around the world to become aware of these
H. Durán (*)
Merida, Yucatán, Mexico
L. Cárdenas
Plastic Surgeon, Private Practice, Innovare, Zapopan, Mexico
D. Del Vecchio
Boston, MA, USA
J. Bayter · W. Peña
Clinica del Pinar, Anestesiologos, Private Practice, Bucaramanga, Colombia
A. L. Cansançao
Plastic Surgeon, Private Practices, Rio de Janeiro, RJ, Brazil
© Springer Nature Switzerland AG 2023
D. Del Vecchio, H. Durán (eds.), Aesthetic Surgery of the Buttock,
https://doi.org/10.1007/978-3-031-13802-7_8
119
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H. Durán et al.
protocols and understand the importance of changing often-rooted concepts and
safely injecting fat into the buttocks.
This article condenses and summarizes what we have learned so far, so that we
can all avoid fatal complications as fat embolism prioritizing patient safety.
8.2 The Selection
We searched in PubMed and Google Academic for articles in plastic surgery journals from July 2015, date of Cardenas’ publication [1], until May 2019.
The keywords used for the search were: Anatomy, Buttock, Safety, Gluteal, Fat
embolism, Complications, Dead, Prevention. Relevant articles related to anatomy,
safety, technique, and complications of buttock fat inltration surgery were identied. Those articles that had information not relevant or not related to the problem
described by the original article were eliminated. Once the articles were identied,
all the authors proceeded to select the important information contained in each of
them and a summary was made to then condense the information and prepare
a report.
A total of 328 items were initially found. After reading them and analyzing their
content, those that were not related to the topic, or that did not provide new information, were discarded. After this selection, 35 items were chosen. These selected
papers addressed important subjects as gluteal anatomy, aspects of gluteal fat injection, how to perform it safely, how fat particles got into the bloodstream, and those
describing the natural evolution of fat embolism, causing microscopic fat embolism
(MIFE) or a Macroscopic Fat Embolism (MAFE).
8.3 Discussion
Despite the risks, gluteal fat grafting continues to have the higher increase in demand
among all plastic surgery procedures, since 2015 (date of Cardenas’ publication) to
2018 the demand raised 64% in the USA [2]. There are many advantages that keep
buttock fat inltration a leading procedure, such as the good outcomes, fast recover,
the absence of implantation of devices that have to be removed or changed, and
specially the signicantly lower ratio of complications (9.9–10.5%), especially
when compared to implants (21.6%).
However, when the mortality ratio was observed, the gure changed. A survey
performed by the Task Force for gluteal fat grafting published by Mod etal. [3]
found a Mortality ratio of 1:3448. In this same survey, 3% of the 692 respondents
experienced a patient fatality and 7% reported a nonfatal pulmonary embolism.
8 Deaths Caused by Gluteal Lipoinjection: What Have We Learned from Microscopic…
121
8.4 MIFE–MAFE
The possibility of having small particles of fat into the bloodstream seems to frequent, and it’s not always a problem. An understanding of the physiopathology and
clinical alterations that happens when this fat in the bloodstream evolves for a lifethreatening situation is most important to prevent, diagnose, and treat it.
These advents caused by the presence of fat within the bloodstream can evolve
into two different diseases, and since clinical diagnosis is considered the gold standard, understanding the natural evolution of these diseases is very important for
proper patient management [4].
Formerly it was known as FES (Fat Embolism Syndrome), but MIFE (Microscopic
Fat Embolism) when it’s related to liposuction [5]. Clinical symptoms start 24h
after the surgery with hemodynamic instability and hypoxia. Its etiology is the presence of free fatty acids and small fat particles in the pulmonary microcirculation (so
small, that it won’t cause any clotting or plug in the pulmonary but in the alveolar
circulation). The presence of free fatty acids and the response of macrophages generated by the release of free radicals causes inammation that is expressed by the
presence of alveolar uid and the difculty of an adequate gas exchange, with
enough alterations in the oxygen saturation that compromises patient health.
Clinical presentation starts at 24–48h as described by Gurd and Wilson’s. These
clinical items are also present, but for earlier diagnosis and faster attention, it was
proposed to conrm the presence of MIFE with only one positive major criterion,
two minor criterions, and one tomography with positive ndings [6]. The most common ndings in tomography are frosted glass opacities and pleural effusions, present in almost all studies. If adequate and aggressive treatment is present, almost all
patients will survive [6].
MAFE (Macroscopic Fat Embolism) is the sudden presence of a sufcient volume of fat macromolecules in the pulmonary circulation capable of generating a
plug effect, which interferes with an adequate pulmonary blood ow and consequently a right cardiac dysfunction, evolving to collapse and death. This pathology
is presented with the advent of fat inltration in the buttocks and there is nothing
similar in another specialty. Clinical picture is very similar to pulmonary thromboembolism, but two main differences are the sudden character, usually intraoperative
up to an hour after fat injection, and that the clot is composed of adipocytes. The
diagnosis is clinical as the fast presentation and severe nature of the condition does
not allow another option. While reviewing the available literature of the clinical
cases described, all the patients with MAFE died [6]. The rst case that survived
with aggressive maneuvers [7], which opened a new possible treatment strategy for
these patients, was recently described. But nowadays, MAFE still is the most frequent cause of immediate death in the operating room after fat grafting.
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H. Durán et al.
8.5 Fat Inltration Technique
Previously, there was no absolute indication of the layer in which fat had to be
placed, although a combination of subcutaneous, subdermal, and intramuscular
injections was generally performed. Cárdenas was the rst to identify that every
case of fat embolism had fat into the gluteus maximus muscle, lesion of gluteal
venous vessels, and the presence of fat into bloodstream and pulmonary vessels. It
did not take long to understand the association [8]. So, at rst, it was established to
avoid injury or canalization to the gluteal veins. This generated a search to dene
where the vessels were located and how to identify them by means of surface
anatomy.
The lower gluteal vessels are located in a median of 8.3cm from the intergluteal
fold and 10cm from the upper margin of the gluteal muscle. These areas are currently considered to be at risk of fat embolism during fat injection [9]. It was therefore dened as a triangle of risk of muscle inltration [10, 11]. It was also dened
that fat inltration should be avoided, especially from the lower lateral quadrant to
the upper middle quadrant since the probability of perforating and injecting fat into
the main vessels from this direction is greater [12]. The injection angle of 30° or less
from the upper quadrants could decrease the chances of blood vessel damage. The
problems with this recommendations, it was considered the inltration should be
intramuscular because it was necessary for fat survival. To achieve this, the cannula
had to be passed many times along the muscle without damaging the gluteal venous
vessels while inltrating the fat [8, 10].
But now the approach has changed, when Del Vecchio et al., published a new
theory. The gluteus maximus fascia is a robust wall, and functions as a barrier to the
subcutaneous space, so even with multiple perforations of the cannula, the fascia
prevents subcutaneous injections from crossing into the muscle, even under very
high fat injection pressures. If this happens, it spread through the subcutaneous tissue through a process called subcutaneous migration. But when there is an intramuscular injection of fat, it migrates through the major gluteus muscle toward the
depth into the submuscular space, putting at risk the gluteal veins without a direct
cannula trauma. The increase of fat volume generates an increase in pressure and,
therefore, expansion in the subgluteal space, which as the muscle subsequently
expands, generates a traction stretch in the xed venous plexus, potentially causing
venous injury; communicating the negative pressure of the gluteal veins with the
positive pressure subgluteal space allowed a siphon mechanism, passing fat to the
blood circulation [13, 14]. Due to this migration, there is no area within the gluteus
maximus muscle that can be considered safe. The subfascial or intramuscular introduction of fat, which had been considered reasonable to perform in the supercial
muscle and even recommended in the literature, is now considered an inaccurate
and risky surgical technique. For a maximum safety, all injections should be performed exclusively in the subcutaneous tissue [3, 13–16]. Also some positions or
incisions that were though the most adequate [17] seems unnecessary as long as
inltration in the subcutaneous plane is maintained.
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123
8.5.1 The EVL (Expansion Vibration Lipoinjection)
Currently there are techniques of subcutaneous fat inltration with adequate aesthetic results [18] and the EVL serves to modify and increase the expansion so that
you can inltrate more fat [19], but also, using a device with vibration (power
assisted liposuction), allows us to obtain an awareness of the three-dimensional
location of the cannula, including the depth of the tip. The vibratory expansion ller
can potentially increase the capacity of the subcutaneous receptor site and allow
effective gluteal lipolling without the need to resort to muscle [13].
8.5.2 The Volume ofFat Inltrated
The total volume of fat grafts has not been directly correlated with deaths, and
numerous authors have reported good results with low to high volume buttock fat
transplantation [16, 18]. Also, high volume fat transfer has been reported with subcutaneous only inltration without any major difference [18, 20].
8.5.3 The Flexibility Misguidance
This is a phenomenon that can be seen when ne caliber injection cannulas and
syringe with Luer-lock connection are used for fat grafting. To prevent the cannula
from bending, the surgeon must keep it at an angle that prevents it from inadvertently deviating from rigid tissue densities (ligaments and fascial condensations)
[16, 21]. For avoiding this problem the cannula has to be strong enough, especially
in its connection to the syringe.
8.5.4 The Subcutaneous Space intheButtock
If the adequate space for inltration is the subcutaneous, we have to know it very
well. There are two spaces, the supercial and the deep subcutaneous, divided by
the fascia supercialis. When we are aging, the thickness of the deep fat layer
increases (but not the supercial fat layer), while with increasing BMI the supercial layer increases mainly in thickness (compared to the deep fat layer) [22].
Ultrasound has become a fabulous tool, not only for depth studies but also to precisely locate the area of inltration. The evaluation of the depth and location of the
cannula can be performed in real time with ultrasound, accurately and reliably identifying the fat injection planes. If the surgeon is not condent about the layer he’s
working, the real-time ultrasound-assisted gluteal fat grafting is reliable to help to
locate the two subcutaneous layer, and can avoid injuring the gluteal fascia, or even
the deep blood vessels, further decreasing the risk of major complications [23].
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H. Durán et al.
8.5.5 Will theFat Inltrated intheSubcutaneous
Space Survive?
The intramuscular layer was thought to be the best for fat retention [24–26], but
nowadays study of fat behavior at subcutaneous level helps us to understand that fat
at subcutaneous level is adequate, and that according to other studies, it would survive as much as intramuscular. A study by Cansanção and Condé found that after fat
inltration in the subcutaneous layer, it survives as much as if it’s inltrated intramuscular. They found following the thickness of the buttocks with ultrasound,
12months after the operation, a fat retention rate of 81.8% [27]. So, it demonstrates
that fat inltrated in the subcutaneous layer survives.
8.6 Recommendations Based ontheEvidence
There are recommendations generated by the Task Force that are considered important for preventing a MAFE from occurring [3, 16, 17, 28, 29].
However, according to the evidence so far, we can only endorse the following
recommendations:
– Know adequately the anatomy, especially the spaces, ligaments, and
vascularity.
– Understand MIFE and the MAFE, to make an adequate differential diagnosis and
deliver a fast response.
– For fat graft inltration, use cannulas with a strong base (Toomey type), do not
use Luer-lock base cannulas or with diameters smaller than 4mm.
– Only inltrate fat at subcutaneous level.
– Any incision site is good as long as the inltration remains in the subcutane-
ous space.
– Train in the different subcutaneous fat inltration techniques.
– If in doubt, use ultrasound for guidance through the inltration planes in real time.
– Include the risk of fatal fat embolism and surgical alternatives in the informed
consent process.
8.7 The Future
Patient safety is a priority, and preventive measures should improve safety, select
the correct patient, and correct placement of muscle grafting, [30–32]. All the prevention measures described in these 5years are focused on avoiding the MAFE, but
almost none on avoiding the MIFE.We will probably see new prevention measures
and successful treatment strategies for both problems. Also, we think in a future
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