Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_994_Библиотеки_им_академика_М_И_Перельмана

Based on the above we will be able to witness two types of clinical presentations in the spectrum of fat embolism. One of these will be instaurated within the rst 12h and even in more severe cases in the transoperative period in a subtle way and with signicant hemodynamic alterations, while the other presentation will be established progressively between 24–72h after the surgical event with design and alteration of consciousness. Due to this difference in the presentation of fatty embo­lism we infer that within the same pathology we face two totally different events but with one factor in common. Sudden scenarios are usually produced by the passage into the bloodstream of particles of greater volume than when embolism produce an obstruction with the consequent decrease in tissue perfusion of the affected organs, an event known as macroscopic fatty embolism (MAFE), when the presentation is a product of the biochemical phase of fat micelles that reach the bloodstream we will be talking about microscopic fat embolism [40].

Once the diagnosis is made, it is important to immediately initiate support man­agement for the patient since the specic pharmacological management has been shown to be ineffective and the mortality is very high in the presence of conrmed fat embolism [42].

By being identied as a triggering factor for the passage of macroscopic fat tis­sue into the bloodstream, the laceration of medium-sized vessels of the gluteal region can conclude that it is a problem derived from the injection technique of the area where very deep invaded areas try to leave a considerable amount of fatty tissue at the intramuscular level to grant the best integration given the abundant muscular irrigation [46]. It should be noted that the recommended way to perform a fat trans­fer to the gluteal region emphasizes leaving this tissue in a supercial muscular plane, depositing small amounts in a retrograde direction following a pattern trying to avoid lesions in the sciatic nerve and ending at the subcutaneous level [47, 48]. Hence, this technique becomes dependent on the skill, experience, and mastery of

Depositing the fat in the subcutaneous cellular tissue is the main recommenda­tion with which we will avoid the risk of any vascular lesion and with this a macro­scopic fat embolism; however, frequently we will have difculty to deposit the fat uniformly and without irregularities, which we can decrease or avoid if we previ­ously make a release of the ischiocutaneous ligament [53] with a basketball cannula that will allow us to distribute the injected fat evenly. In order to perform the injec­tion procedure, it is preferred to use syringes with the prepared fat either by decanta­tion or centrifugation, however it has been proposed to use a power-assisted system together with its infusion pump for fat injection while still maintaining the safety of the procedure when deposited at low pressure speeds, with 4mm basketball can­nulas that will allow a better separation of the tissues [54, 55]. In cases where due to the morphological characteristics of the patient, the injection of a large volume of fat is required to achieve expectations, it is advisable to detach the tissues with a vibration technique simulating the steps performed with which we will achieve an adequate tissue expansion that will give us more space to transfer large volumes of fat without increased tissue pressure and risks of necrosis [56], besides it will be done quickly when using the infusion pump.