Fatal fat embolism in cosmetic surgery: Comparing gluteal fat grafting to other lipofilling procedures

Autologous fat grafting, or lipofilling, is a technique commonly employed in cosmetic/aesthetic procedures for facial, breast, and gluteal augmentation. Although it is considered a safe procedure, fat embolism is a known, albeit rare, catastrophic complication of lipofilling, and gluteal fat grafting is specifically associated with a high mortality rate. This narrative review aims to identify the mechanisms of fatal fat embolism in cosmetic lipofilling procedures and compare the risks of gluteal, breast, and facial fat grafting procedures. Anatomical studies, autopsy reports, and clinical studies suggest that the increased mortality rate associated with gluteal fat grafting is attributable to the interplay of three major contributing factors: the presence of significant intramuscular gluteal veins, the technique of fat grafting, and the amount of fat transferred in gluteal augmentation procedures. In contrast, breast and facial lipofilling procedures are associated with different anatomical environments and injection techniques, which are associated with significantly lower risks of pulmonary fat embolism, with unique risks of arterial fat embolism in facial procedures. The literature has highlighted certain shortcomings in the current body of evidence, including the lack of uniform reporting of complications and the lack of standardized data on procedures performed. It is suggested that enhanced training of surgeons, adherence to strict subcutaneous fat injection, and the use of ultrasound technology in fat grafting procedures, as well as the establishment of mandatory complication registries, are essential strategies for reducing mortality associated with gluteal fat grafting procedures.