Cosmetic

Deaths Caused by Gluteal Lipoinjection:

What Are We Doing Wrong?
Lázaro Cárdenas-Camarena,
Background: Intramuscular gluteal lipoinjection has become one of the most
M.D.
commonly used surgical procedures for achieving improvement in the gluteal
Jorge Enrique Bayter, M.D.
contour; however, there are few studies that report and analyze the causes of
Herley Aguirre-Serrano, secondary death from this surgical procedure.
M.D. Methods: An analysis of secondary deaths from gluteal lipoinjection proce-
Jesús Cuenca-Pardo, M.D. dures was performed in Mexico and Colombia over periods of 10 and 15
Guadalajara, Jalisco, México; and years, respectively. In Mexico, the study was performed through a survey of all
Bucaramanga and Bogotá, Colombia members of the Mexican Association of Reconstructive, Plastic and Aesthetic
Surgery. In Colombia, the study was performed through an analysis of deaths
and autopsies documented by the National Institute of Legal Medicine and
Forensic Sciences Regional Bogotá.
Results: A total of 413 Mexican plastic surgeons reported 64 deaths related to
liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine
deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent)
occurred during lipoinjection, whereas the remaining five (38.4 percent)
occurred within the first 24 hours. In Colombia, six deaths (77.7 percent)
occurred during surgery and three occurred (22.2 percent) immediately
after surgery. In the Colombian autopsy results, seven cases of macroscopic
fat embolism and two cases with a microscopic embolism were reported, with
abundant fatty tissue in the infiltrated gluteal muscles.
Conclusions: In this study, the authors found that intramuscular gluteal
lipoinjection is associated with mortality caused by gluteal blood vessel dam-
age allowing macroscopic and microscopic fat embolism; therefore, buttocks
lipoinjection should be performed very carefully, avoiding injections into
deep muscle planes.  (Plast. Reconstr. Surg. 136: 58, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

W
ith the introduction of liposuction in Although liposuction developed into a pro-
1976 by Fischer1 and subsequent refine- cedure that achieved very satisfactory results, it
ments in the technique by Illouz,2 the also gave rise to techniques that had been forgot-
procedures of body contouring in aesthetic sur- ten, including autologous fat transfer, which has
gery underwent a complete change. The proce- become another surgical method that is indis-
dures, with large cuts and deforming scars,3,4 were pensable for any plastic surgeon. The acceptance
transformed into highly gratifying operations with and use of this operation has increased in recent
minimal signs of surgery. years, with hip augmentation by lipoinjection cur-
rently peaking as a treatment.5–8 Lipoinjection has
been used in the buttocks to increase volume, and
From the Instituto Jaliscience de Cirugia Reconstructiva, injection into the muscle is being performed to
INNOVARE Cirugía Plástica Especializada; Security aid in integration. Although most authors believe
Committee of the Mexican Association of Plastic Esthetic
that the procedure is safe, others report many
and Reconstructive Surgery; Anesthesiologist and Reani-
mation Critical and Intensive Care Medicine, Clínica complications, some of which are severe and
“El Pinar”; and Universidad Nacional de Colombia, In- even fatal. Complications can be only local (e.g.,
stituto Nacional de Medicina Legal y Ciencias Forenses abscess development) or general (e.g., pulmonary
Regional Colombia.
Received for publication December 29, 2014; accepted January
30, 2015. Disclosure: The authors have no financial interest
Copyright © 2015 by the American Society of Plastic Surgeons to declare in relation to the content of this article.
DOI: 10.1097/PRS.0000000000001364

58 www.PRSJournal.com
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 1 • Deaths Caused by Gluteal Lipoinjection

thromboembolism and fat embolism).9,10 There- the 13 deaths caused by lipoinjection (61.5 per-
fore, we analyzed deaths associated with this surgi- cent), death occurred during surgery, and in the
cal procedure in two of the countries where more remaining five (38.5 percent) it occurred between
gluteal lipoinjection is performed, namely, Mex- 1 and 24 hours after lipoinjection. In the analyzed
ico and Colombia. records of the patients who died in Colombia
between 1993 to 2008 that had been diagnosed by
PATIENTS AND METHODS autopsy by the National Institute of Legal Medi-
cine and Forensic Sciences Regional Bogotá, 28
A retrospective study was performed analyz-
deaths were found to be related to liposuction.
ing cases in which death was associated with lipo-
In nine of these cases, there was a combination
suction combined with gluteal lipoinjection. The
of liposuction and lipoinjection. Autopsy revealed
study was carried out simultaneously in Mexico
that the cause of death was macroscopic fat embo-
and Colombia, countries where this procedure is
lism in seven of the nine cases (77.7 percent) and
widely performed. The methodology for captur-
microscopic fat embolism in the two remaining
ing data in each country was different, because of
cases (22.2 percent). There were six deaths during
the feasibility of obtaining data in each of them.
surgery (66.6 percent) and three (33.3 percent)
In Mexico, an online survey was sent to all mem-
within the first 18 hours in the intensive care unit.
bers of the Mexican Association of Plastic, Aes-
All of the patients were women aged between 27
thetic and Reconstructive Surgery (AMCPER by
and 53 years, with an average age of 39.5 years, and
its initials in Spanish), the official organ of Mexi-
all of the patients underwent fat infiltration in the
can plastic surgeons. This survey requested infor-
buttocks to improve contour. The body mass index
mation about the surgical procedures associated
ranged from 19.4 to 27.2 kg/m2, with an average
with liposuction and lipoinjection and deaths over
of 24.1 kg/m2. The amount of fat removed varied
the past 10 years associated with these operations
between 2000 and 7200 cc, with an average of 3697
that occurred during the first 24 hours of initiat-
cc, and the amount infiltrated per buttock varied
ing surgery. In Colombia, the cases were analyzed
between 120 and 300 ml, with an average of 214 ml
by reviewing the records of patients who had died
per buttock. All of the patients died within the first
in that country during a 15-year period and who
18 hours after surgery had started, six during sur-
had been diagnosed by autopsy at the National
gery and three in the intensive care unit within
Institute of Legal Medicine and Forensic Sciences
the first 18 hours after initiation of surgery. The
Regional Bogotá (Instituto Nacional de Medicina
results, with the specific characteristics of the nine
Legal y Ciencias Forenses Regional de Bogotá)
patients, are listed in Table 1. Autopsy findings are
with fat embolism as the cause of death. The data
shown in (Figs. 1 through 10). One representative
were analyzed by descriptive statistics by determin-
case is presented.
ing the frequency and proportions.

RESULTS CASE REPORT

Thirteen-hundred e-mails were sent to Mexi- Case 1
can plastic surgeons that were members of the The patient in case 1 was a 37-year-old woman with a weight
Mexican Association of Plastic, Aesthetic and of 59 kg (130 lb), a height of 1.54 m (5.05 ft), and body mass
Reconstructive Surgery. We received replies from index of 24.88 kg/m2 (Figs. 1 through 3). The patient presented
for consultation and requested improvement of abdominal and
413 plastic surgeons, of whom 378 (91.6 percent)
waist adiposities, buttocks enlargement, and septoplasty. She did
reported performing lipoinjection together with not have a significant medical history. Before surgery, antiembo-
liposuction, and 35 (8.4 percent) who did not usu- lism stockings were placed, and 2500 units of dalteparin sodium
ally perform lipoinjection jointly with liposuction. was administered subcutaneously. Before liposuction, 4000 ml of
From 2005 to September of 2014, 64 deaths were a preparation consisting of 1000 ml of isotonic saline solution,
reported. Fourteen cases (21.87 percent) occurred 1 mg of adrenaline, and 10 cc of 2% lidocaine was infiltrated. A
total of 2600 cc was obtained by liposuction and 120 cc was infil-
in patients who underwent liposuction and gluteal trated into each buttock. While changing the patient position
lipoinjection. Autopsy verified that the cause was from dorsal decubitus to ventral decubitus, the patient was found
fat embolism in 13 cases and myocardial infarction to be hypotensive, with sudden cardiorespiratory arrest that did
in one case. In nine of the 64 deaths (14.06 per- not respond to resuscitative maneuvers, and she died.
cent), death occurred at the time of performing the
lipoinjection, and in the other five (7.8 percent), Autopsy Findings
death occurred after finishing surgery but within The possibility of mechanical injury second-
the first 24 hours of initiating surgery. In eight of ary to the surgical procedure was discarded. One

59
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Table 1.  Results of the Autopsies of the Dead Patients in Colombia

60
Height Weight
Gluteal
BMI Moment of Liposuction Lipoinjection
2
Patient Age (yr) Meters Feet Kilograms Pounds (kg/m ) Death (cc) (cc) Most Significant Data from the Autopsies
1* 39 1.54 5.05 59 130 24.88 During 2600 120 Presence of thrombi at the level of pulmonary vessels,
surgery corresponding to massive fat embolism, in small, medium,
and large vessels, associated with pulmonary edema, mas-
sive fat embolism
2 27 1.60 5.24 55 121 21.48 During 6000 300 Special coloration for positive intravascular fat in lung with
surgery focal infarctions; negative for intravascular fat in the brain;
vessels with presence of intravascular fat in the marrow
3† 42 1.54 5.05 55 121 23.19 During 2300 150 Large and medium pulmonary vessels with large fragments of
surgery adipose tissue, with septa of fusiform cells typical of the adi-
pose matrix; embolism adipose tissue in small and medium
vessels in the brain; fragments of fat in the right cavities of
the heart
4 39 1.60 5.24 60 132 23.44 1 day after 4500 260 Presence of adipose tissue in small pulmonary and cardiac
surgery, in vessels, in lung in both veins and arteries, abundant fat
intensive globules surrounded by fibrin and occasional white cells
care unit or mature adipose tissue; in the heart in venous vessel
fragments of adipose tissue; suprarenal capsule with abun-
dant lipids and cerebral edema
5 53 1.63 5.34 69 152 25.95 18 hr after 3000 180 Presence of fat embolisms in the brain and the lung circula-
surgery, in tion; in small and medium vessels of the lung, yellowish
intensive white embolisms protrude, consistent with fat embolisms;
care unit histologically mature adipocytes in the arteries
6‡ 51 1.54 5.05 60 132 25.30 10 hr after 2000 200 Lung vessels with fat thromboembolism, thrombi of fibrin;
surgery, in acute tubular necrosis; thrombi with fat vacuoles in small
intensive brain vessels; pulmonary and brain fat thromboembolism;
care unit noncrepitant lung with fat globules in all pulmonary lobes
and segments; no blood thrombi found
7 28 1.61 5.28 68 150 26.23 During 4000 250 Drops of fat are seen in pulmonary vessels of lower lobes;
surgery abundant adipose tissue inside of the blood vessels
8 52 1.53 5.01 65 143 27.27 During 7200 230 Presence of large fragments of adipose tissue with some
surgery fusiform cells typical of the matrix of this tissue, which fills
large and medium pulmonary vessels; no fibrin thrombi
in vessels; no hemorrhaging or fat globules observed in
kidneys; section of upper gluteal vein seen
9§ 25 1.47 4.82 42 93 19.4 During 1680 240 Abundant adipose tissue in the vena cava, cardiac ventricles,
surgery and pulmonary vessels; upper right gluteal vein perforation;
hematomas in subcutaneous and dorsal and abdominal mus-
cle planes, extensive hematoma mediastinal; section of upper
gluteal vein seen
Mean ± 39.5 1.56 5.11 59.22 130.5 24.12 6 during 3697 ± 1900 214.44 ± 57 Fat embolism
SD ± 11 ± 0.5 ± 0.5 ± 8.2 ± 8.2 ± 2.5 surgery
3 after
surgery
BMI, body mass index.
*Photographs of this patient’s autopsy are shown in Figures 1 through 3.
†Photographs of this patient’s autopsy are shown in Figure 4.
‡Photographs of this patient’s autopsy are shown in Figure 5.
Plastic and Reconstructive Surgery • July 2015

§Photographs of this patient’s autopsy are shown in Figures 6 through 10.

Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 1 • Deaths Caused by Gluteal Lipoinjection

Fig. 1. Case 1. Presence of macroscopic fat in the vena cava in a patient

who died during surgery at the time of lipoinjection. (Printed with per-
mission from Aguirre-Serrano H, Bernal M, Navarro A, Montes G, Morales
P, Téllez N. Embolia grasa macroscópica por lipoinyección glútea. ¿Una
nueva patología?. Rev Colomb Cir Plast Reconstr. 2011;17:43–48.)

Fig. 2. Case 1. Macroscopic adipose tissue in the right atrium in a patient who died
during surgery. (Printed with permission from Aguirre-Serrano H, Bernal M, Navarro
A, Montes G, Morales P, Téllez N. Embolia grasa macroscópica por lipoinyección
glútea. ¿Una nueva patología?. Rev Colomb Cir Plast Reconstr. 2011;17:43–48.)

Fig. 3. Case 1. Compression of the lung obtaining adipose tissue from a

patient with macroscopic fat embolism. (Printed with permission from Agu-
irre-Serrano H, Bernal M, Navarro A, Montes G, Morales P, Téllez N. Embolia
grasa macroscópica por lipoinyección glútea. ¿Una nueva patología?. Rev
Colomb Cir Plast Reconstr. 2011;17:43–48.)

hundred cubic centimeters of clear liquid was increased in size and were edematous, with sub-
found in the pleural cavities without the pres- pleural purplish hemorrhagic areas based on
ence of any fibrous adherences. The lungs had predominantly right lower lobe firm purplish

61
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • July 2015

Fig. 4. Case 3. Pulmonary tissue with presence of large frag- Fig. 5. Case 6. Noncrepitant lung with fat globules in all pulmo-
ments of fat globules. nary lobes and segments.

clots that were similar in appearance to tooth- the survey of Mexican plastic surgeons, 92 per-
paste, which is consistent with thrombi. A micro- cent reported that they usually combine gluteal
scopic study showed that the lungs contained a lipoinjection when performing lipoinjection.
pink material in the alveoli and histiocytes with Because of multiple studies and clinical series
pigment inside. Obstructive thrombi were found with very good results,4–8,12–15 lipoinjection has
in large, medium, and small vessels, consisting become a procedure widely accepted by the
of fibrin, blood cells, and abundant fat. All cuts entire medical community worldwide. In the
showed fat thrombotic damage. There were focal search for better survival, experimental stud-
points of autolysis. The kidneys, heart, and spleen ies in rats have shown that injecting the fat into
showed congestion. The brain weighed 1200 g muscle allowed a high integration of adipose tis-
and was found to have edema and vascular con- sue.16 This procedure provided the adipocytes
gestion. In the peritoneal cavity, 600 cc of hematic with greater vascularity, and survival of the adi-
serum fluid was found, with marked congestion pose cells was much greater than when fat was
of the intestinal areas. The retroperitoneum pre- injected outside of the muscle.
sented with an adipose appearance with a slight Initially, lipoinjection was used in small vol-
right hematoma that contained approximately umes and very circumscribed areas to achieve
100 cc of blood. No perforation was found. precise localized improvements, especially in the
The principal findings were massive pulmo- face.12–22 Because of the excellent results, its use was
nary fat embolism with pulmonary edema and extended to other areas to achieve improvement
generalized visceral vascular congestion. The of body contouring. Therefore, it was applied to
cause of death was a massive pulmonary fat embo- areas such as the buttock, an area where it pro-
lism with pulmonary edema (Figs. 1 through 3). duces more benefit and which previously had few
treatment options.5 Gluteal lipoinjection became
DISCUSSION a treatment with excellent results regarding the
Body contouring surgery has evolved since volume and shape of these areas.5–8 With longer
1976 with the appearance of liposuction.1,2 fat survival through muscular injection, which
Because of perfecting the techniques, the fat has been shown by experimental studies16 and
obtained was used in improving results by ratified with clinical studies,12,14,18 fat injection was
implementing the transfer of autologous fat by performed into the muscular area of the buttock.
lipoinjection.5–8 According to reports from the However, the fact that the application of an experi-
International Society of Aesthetic Plastic Sur- mental study for a clinical purpose is completely
gery, liposuction was the second most common different was never taken into account. Cases with
aesthetic surgical procedure worldwide in 2013,11 fat embolism and fat embolism syndrome began
and although there are no exact data on the fre- to occur. Studies have reported that during fat
quency of gluteal lipoinjection combined with management during liposuction or lipoinjec-
liposuction, there are multiple reports regard- tion, particles of fat can enter the bloodstream
ing the combination by multiple doctors.4–8 In and facilitate the appearance of a fat embolism

62
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 1 • Deaths Caused by Gluteal Lipoinjection

Fig. 6. Case 9. Dissection in suprapiriformis canal, showing globules of

complete adipose tissue and section of the superior gluteal vein.

Fig. 7. Case 9. Vena cava with adipose tissue.

Fig. 8. Case 9. Section of gluteus maximus muscle and the presence of

lipoinjected tissue, a common finding in the autopsies.

syndrome or a fat embolism.23–28 The physiopathol- attention can resolve the manifestations without
ogy of these two entities is different; therefore, the major sequelae. In fat embolism, the problem is
clinical manifestations are different as well. We immediate and caused by blockage of medium and
feel that the amount and size of the fat particles large vessels, which occurs during lipoinjection.
along with the speed with which the fat particles This occurs at the time of the fat infiltration, when
enter the bloodstream determine the type of clini- signs and symptoms indicate a blockage at the car-
cal manifestations that appear. The fat embolism diac level or in pulmonary vessels, and the patient
syndrome is caused by a systemic inflammatory usually dies despite immediate attention.27 If dur-
response.23,27,28 In contrast, fat embolism is essen- ing lipoinjection a patient shows sudden cardiovas-
tially a mechanical problem. In addition, although cular changes, such as hypoxia and bradycardia,
the fat embolism syndrome is serious, critical we must think of this problem. In these cases, we

63
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • July 2015

Fig. 9. Case 9. Heart with adipose tissue in the interior of the Fig. 10. Case 9. Right ventricle saturated with
right atrium. adipose tissue.

can speak of a macroscopic fat embolism, which and large vessels, such as the vena cava, right car-
has been rarely reported in the medical literature. diac cavities, and pulmonary tissue (Figs. 1, 2, 4
It is undeniable that fat injection in highly vas- and 7 through 10). In contrast, patients who died
cularized beds involves better survival of the adi- during the first 24 hours after surgery had a less
pose tissue, but it is also true that any injection evident embolism, observed in small pulmonary
into highly vascularized tissues involves a higher vessels using special dye for fat tissue. These data
risk of producing entry of the injected substance guide us toward understanding the difference
into the blood vessels of the area. In addition, between these two manifestations, which are dif-
in the case of fat, the consequences can be very ferent but have the same causal agent, fat in the
serious. There are multiple reports of permanent bloodstream. It is important to emphasize that the
blindness29–32 and even damage to other organs amounts of fat infiltrated were not large volumes,
from the occlusion of arteries resulting from fat with the largest amount being 300 cc per buttock,
infiltration.32–37 Regarding the buttocks, the large with an average of 214 cc. We consider that the
venous vessels in the area—specifically, the gluteal main factor causing the problem is the muscle
vein in the subpiriformis or suprapiriformis chan- area where fat is injected. At the time of autopsy,
nels—and the large muscular vascularity facilitate fat was found in the deep muscle tissue near the
entrance of fat into the bloodstream. Secondary vessels, with rupture of venous vessels.
to its entry into the bloodstream, a fat embolism Mortality studies on buttocks fat infiltration are
syndrome or fat embolism may be produced, controversial and insufficient. The diagnosis of fat
depending on the factors listed above. embolism cannot be established easily with clinical
A consensus of Colombian plastic surgeons studies, laboratory tests, or pathologic evaluation.
and Colombian anesthesiologists shows that they Therefore, the diagnosis is often only suspected,
considered buttocks lipoinjection to be a risk fac- when the cause cannot be determined.1–15,38–45
tor and the cause of fulminant massive throm- Many cases with a diagnosis of death from unknown
boembolism.38 In our studies of both series, we cause or exacerbation of a disease may be related
found that 12 of the 21 deaths (57.1 percent) to fat embolism, which would increase the percent-
occurred at the time of lipoinjection during the age of mortality attributable to this cause. The fat
surgical procedure, whereas nine (42.8 percent) globules that enter the circulation during surgery
occurred immediately postoperatively within the may have obstructive, inflammatory, and immune
first 24 hours after initiation of surgery. Coin- effects, and the amount circulating, inflammatory
cidentally, in patients with data from the opera- diseases, and patient sensitivity are responsible for
tion and the autopsy, it was found that the deaths the magnitude of the response.46–48
during surgery occurred when the fat embolism This study shows through necropsy the presence
was clearly macroscopic, and damage to blood of fat in large, medium, and small vessels secondary
vessels was found, specifically, the gluteal vein. to gluteal lipoinjection. This confirms that buttocks
In these cases, fat was found obstructing medium lipoinjection can lead to entry of fat into the gluteal

64
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 136, Number 1 • Deaths Caused by Gluteal Lipoinjection

vessels, which affects the pulmonary vessels, which references

results in heart failure and can cause death. It is evi- 1. Fischer G. First surgical treatment for modeling body’s cel-
dent that this is only possible if the fat is injected into lulite with three 5 mm incisions. Bull Int Acad Cosm Surg.
1976;2:35–37.
a highly vascularized area, such as muscle. There- 2. Illouz YG. The fat cell “graft”: A new technique to fill depres-
fore, the indication of intramuscular lipoinjection sions. Plast Reconstr Surg. 1986;78:122–123.
to achieve gluteal contour improvement is a proce- 3. Peer LA. The neglected free fat graft. Plast Reconstr Surg
(1946) 1956;18:233–250.
dure that must be performed very carefully, avoiding 4. Hsu VM, Stransky CA, Bucky LP, Percec I. Fat grafting’s past,
fat injection deep into the muscle. Efforts should be present, and future: Why adipose tissue is emerging as a criti-
made to inject the fat only into the subcutaneous area, cal link to the advancement of regenerative medicine. Aesthet
Surg J. 2012;32:892–899.
and in superficial muscle planes. To achieve this, we 5. Cárdenas-Camarena L, Lacouture AM, Tobar-Losada
must keep the cannula always parallel to the gluteal A. Combined gluteoplasty: Liposuction and lipoinjec-
surface to avoid entering the subpiriformis or supra- tion. Plast Reconstr Surg. 1999;104:1524–1531; discussion
1532–1533.
piriformis channels where gluteal vessels are located. 6. Cárdenas-Camarena L, Arenas-Quintana R, Robles-Cervantes
JA. Buttocks fat grafting: 14 years of evolution and experi-
ence. Plast Reconstr Surg. 2011;128:545–555.
CONCLUSIONS 7. Cárdenas-Camarena L, Silva-Gavarrete JF, Arenas-Quintana
Lipoinjection is a multifaceted surgical pro- R. Gluteal contour improvement: Different surgical alterna-
cedure. Its performance and technique are com- tives. Aesthetic Plast Surg. 2011;35:1117–1125.
8. Nicareta B, Pereira LH, Sterodimas A, Illouz YG. Autologous
pletely different, depending on the area treated gluteal lipograft. Aesthetic Plast Surg. 2011;35:216–224.
and the required objective. Lipoinjection in the 9. Talbot SG, Parrett BM, Yaremchuk MJ. Sepsis after autolo-
intramuscular tissue contributes to survival of gous fat grafting. Plast Reconstr Surg. 2010;126:162e–164e.
10. Bruner TW, Roberts TL III, Nguyen K. Complications of but-
the adipocyte but also increases the morbidity tocks augmentation: Diagnosis, management, and preven-
of the procedure, which in the case of the glu- tion. Clin Plast Surg. 2006;33:449–466.
teal area is often fatal. Gluteal lipoinjection is 11. Industry Insights, Inc. ISAPS international survey on aes-
thetic/cosmetic procedures performed in 2013. Available at:
a surgical procedure with excellent results, and http://www.isaps.org/news/isaps-global-statistics. Accessed
although fat survival is greater when injecting May 13, 2015.
it into muscle, its injection into muscular tissue 12. Guerrerosantos J. Long-term outcome of autologous fat trans-
plantation in aesthetic facial recontouring: Sixteen years of
increases the risk of a fat embolism syndrome or experience with 1936 cases. Clin Plast Surg. 2000;27:515–543.
fat embolism because of damage of gluteal ves- 13. Coleman SR. Long-term survival of fat transplants: Controlled
sels, the consequences of which are usually very demonstrations. Aesthetic Plast Surg. 1995;19:421–425.
14. Guerrerosantos J. Evolution of technique: Face and neck lift-
serious. Therefore, intramuscular lipoinjection
ing and fat injections. Clin Plast Surg. 2008;35:663–676.
in the gluteal area is a procedure that should be 15. Rosing JH, Wong G, Wong MS, Sahar D, Stevenson TR, Pu
performed very carefully to avoid injury to the LL. Autologous fat grafting for primary breast augmentation:
deep gluteal vessels. A systematic review. Aesthetic Plast Surg. 2011;35:882–890.
16. Guerrerosantos J, Gonzalez-Mendoza A, Masmela Y, Gonzalez
Lázaro Cárdenas-Camarena, M.D. MA, Deos M, Diaz P. Long-term survival of free fat grafts in
muscle: An experimental study in rats. Aesthetic Plast Surg.
INNOVARE Cirugía Plástica Especializada
1996;20:403–408.
Av Verona 7412 17. Charjchir A, Benzaquen I. Liposuction fat grafts in face

Col Villa Verona wrinkles and hemifacial atrophy. Aesthetic Plast Surg.
Zapopan, Jalisco 45019, México 1986;10:115–117.
[email protected] 18. Guerrerosantos J, Haidar F, Paillet JC. Aesthetic facial con-
tour augmentation with microlipofilling. Aesthet Surg J.
2003;23:239–257.
acknowledgments 19. Tzikas TL. Lipografting: Autologous fat grafting for total
facial rejuvenation. Facial Plast Surg. 2004;20:135–143.
The authors thank the Mexican Association of 20. Ciuci PM, Obagi S. Rejuvenation of the periorbital com-
Reconstructive, Plastic and Aesthetic Surgery for provid- plex with autologous fat transfer: Current therapy. J Oral
Maxillofac Surg. 2008;66:1686–1693.
ing them with the information of the survey to its mem-
21. Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast
bers about liposuction and lipoinjection. In addition, Surg. 2013;29:46–57.
they would like to thank the Colombian Society of Aes- 22. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue
thetic and Reconstructive Plastic Surgery for allowing augmentation. Plast Reconstr Surg. 1989;84:921–934; discus-
sion 935.
them to use some of the information in their journals in 23. Costa AN, Mendes DM, Toufen C, Arrunátegui G, Caruso P,
this work. de Carvalho CR. Adult respiratory distress syndrome due to

65
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • July 2015

fat embolism in the postoperative period following liposuc- following facial injection of autologous fat. Arch Ophthalmol.
tion and fat grafting. J Bras Pneumol. 2008;34:622–625. 2001;119:777–778.
24. Cárdenas-Camarena L. Lipoaspiration and its complications: 36. Thaunat O, Thaler F, Loirat P, Decroix JP, Boulin A. Cerebral
A safe operation. Plast Reconstr Surg. 2003;112:1435–1441; fat embolism induced by facial fat injection. Plast Reconstr
discussion 1442–1443. Surg. 2004;113:2235–2236.
25. Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embo- 37. Yoon SS, Chang DI, Chung KC. Acute fatal stroke imme-
lism syndromes following liposuction. Aesthetic Plast Surg. diately following autologous fat injection into the face.
2008;32:731–736. Neurology 2003;61:1151–1152.
26. Aguirre-Serrano H, Navarro A, Téllez N. Resultado de las 38. Ibarra P, Arango J, Bayter J, et al. Consenso de la Sociedad
investigaciones judiciales de muertes por procedimien- Colombiana de Anestesiología y Reanimación, SCARE y de
tos lipoplásticos sometidas a necropsia médico-legal en la Sociedad Colombiana de Cirugía Plástica, sobre las reco-
Bogotá entre 1993 y 2007. Rev Colomb Cir Plast Reconstr. mendaciones para el manejo de pacientes electivos de bajo
2011;17:36–42. riesgo. Rev Col Anest. 2010;37:390–403.
27. Aguirre-Serrano H, Bernal M, Navarro A, Montes G, Morales 39. Hughes CE III. Reduction of lipoplasty risks and mortality:
P, Téllez N. Embolia grasa macroscópica por lipoinyección An ASAPS survey. Aesthet Surg J. 2001;21:120–127.
glútea. ¿Una nueva patología?. Rev Colomb Cir Plast Reconstr. 40. Fourme TH, Vieillard-Baron A, Loubièrs J, Julié C, Page B,
2011;17:43–48. Jardin F. Early fat embolism after liposuction. Anesthesiology
28. Laub DR Jr, Laub DR. Fat embolism syndrome after liposuc- 1998;89:782–784.
tion: A case report and review of the literature. Ann Plast 41. Ross RM, Johnson GW. Fat embolism after liposuction. Chest
Surg. 1990;25:48–52. 1988;93:1294–1295.
29. Coiffman F. Lipoinjection complications. In: Hinderer U, 42. Gutowski KA; ASPS Fat Graft Task Force. Current appli-
ed. Plastic Surgery. Vol. II. Amsterdam: Excerpta Medica; cations and safety of autologous fat grafts: A report
1992:759–760. of the ASPS Fat Graft Task Force. Plast Reconstr Surg.
30. Teimourian B. Blindness following fat injections. Plast
2009;124:272–280.
Reconstr Surg. 1988;82:361. 43. Kaufman MR, Bradley JP, Dickinson B, et al. Autologous fat
31. Dreizen NG, Framm L. Sudden unilateral visual loss
transfer national consensus survey: Trends in techniques for
after autologous fat injection into the glabellar area. Am J harvest, preparation, and application, and perception of short-
Ophthalmol. 1989;107:85–87. and long-term results. Plast Reconstr Surg. 2007;119:323–331.
32. Hong DK, Seo YJ, Lee JH, Im M Sudden visual loss and mul- 44. Gir P, Brown SA, Oni G, Kashefi N, Mojallal A, Rohrich RJ.
tiple cerebral infarction after autologous fat injection into Fat grafting: Evidence-based review on autologous fat har-
the glabella. Dermatol Surg. 2014;40:485–487. vesting, processing, reinjection, and storage. Plast Reconstr
33. Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro I. Middle
Surg. 2012;130:249–258.
cerebral artery embolism and unilateral visual loss after 45. Murillo WL. Buttock augmentation: Case studies of fat

autologous fat injection into the glabellar area. Stroke injection monitored by magnetic resonance imaging. Plast
1993;24:615–616. Reconstr Surg. 2004;114:1606–1614.
34. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, 46. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction.
Tschopp H. Middle cerebral artery occlusion AND ocular fat N Engl J Med. 1999;340:1471–1475.
embolism after autologous fat injection in the face. J Neurol. 47. Kwiatt ME, Seamon MJ. Fat embolism syndrome. Int J Crit Illn
1998;245:53–54. Inj Sci. 2013;3:64–68
35. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports
48. Mentz HA. Fat emboli syndromes following liposuction.

and small case series: Ocular and cerebral ischemia Aesthetic Plast Surg. 2008;32:737–738.

66
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.