A 34 year old female patient who had a Brazilian buttock lift.
Introduction: Brazilian Butt Lift Fat Emboli
Fat emboli during a Brazilian Butt Lift surgery remain a detrimental complication that continues to plague this most popular cosmetic surgery. Over the last six years, the number of Brazilian butt lifts performed has continued to rise gradually and including 18,414 in 2016, 23,115 in 2017, 26,774 in 2018, 33,880 in 2019, 44,725 in 2020, and 67,387 in 2021.
Siphoning of Fat during Brazilian Butt Lift
The cause of fat emboli has been determined to be a siphoning of fat into a specific vein identified as the superior gluteal vein. This occurs when fat cells have been inadvertently grafted under the gluteus maximus muscle and following a rip of the vein. The rip is felt to occur once the buttock cheek has been grafted and becomes swollen leading to tethering and tearing of the vein from traction.
This is in contrast to the initial assumption that the vein was penetrated with the liposuction cannula. Regardless, it is prudent to avoid the placement of any fat cells in the proximity of this vein. The other consideration is why the superior gluteal vein in particular and for example, not the inferior gluteal vein which is located just below this vein is not as vulnerable to fat emboli deaths.
This propensity may be due to its larger diameter size of 1.2cm rather than previously throught 3 to 4 mm based on more recent anatomic studies. Another reason for its propensity to embolize the fat to the lungs is that the origin of the superior gluteal vein is in close proximity to the larger iliac vein based on MRI studies.
Research Studies Regarding Fat Emboli
ASERF completed a survey of plastic surgeons who responded to an incidence of 1 in 3,000 fat emboli-related deaths in Brazilian buttock lifts. However, this study was limited by the fact that only 14 plastic surgeons responded to the survey. This study was followed by a survey performed by Dr. Cansancao who demonstrated an incidence of 1 in 20,000 fat emboli deaths in Brazilian buttock lifts. In this study, it was determined that there was a 16-fold increase in death rates when fat was injected into or under the gluteus maximus muscle. The most recent survey performed by the World Association of gluteal surgeons has demonstrated a similar lower rate of deaths at 1:13,000 Brazilian Buttock lift cases.
Cause for Fat Emboli During BBL
We must consider what the cause of fat emboli is. The fact that fat emboli can result in the detrimental consequence of pulmonary emboli, where fat gets siphoned to the lungs leading to immediate death is well understood. The question remains, is Brazilian buttock lift more dangerous than other cosmetic surgeries, or is it a natural progression of it being a newer surgical procedure? To appreciate this we must look at other surgeries and their rate of death.
For example, when tummy tucks were evaluated by Dr. Pitanguy in 1967, the incidence of death was 1 in 3000. In 2021, the incidence of death was estimated at 1 in 13,000. When liposuction was evaluated by Dr. Ilouz in 1983, the incidence of death was similarly 1 in 3000 but it has been estimated at 1 in 38000 in 2021. Thus, it may be more palatable to appreciate that there was a similar evolution for other cosmetic procedures.
Another question is why surgeons cannot control the location of fat grafting to avoid injection of fat into or under the gluteus maximus muscle. Hypotheses for the propensity of this complication have included a)the surgeon lacks experience with BBLs, b)the surgeon was tired and thus lacked finesse while grafting, and c) the injection was actually performed by an assistant and not the actual surgeon.
Anatomical Guidelines for avoiding Fat Emboli
A final consideration is surgeons are not appreciating the location of the superior gluteal vein. Until recently, our only guide was the previously described Bermuda triangle for fat grafting defined by anatomic landmarks that include the greater trochanter, posterior iliac spine, and ischial tuberosity.
More recently, Dr. Constantino Mendieta has described a more focal position of the superior gluteal vein. He identified the position medial to a vertical line drawn from the lateral border of the posterior iliac spine down to the lateral aspect of the ischium. The vertical position is defined by the line drawn between the coccyx and the inferior aspect of the sacral dimple.
In summary, the detrimental consequences of fat emboli during Brazilian Buttock Lift are a serious consideration for surgeons performing gluteal augmentation. It has become a priority for cosmetic surgeons throughout the world to understand and to create protocols to avoid fat emboli.
