Radiologic Validation of the Danger Zone Concept to Microscopic (MIFE) Fat Embolism Associated with Gluteal Lipoinjection

Purpose:

There has been a great effort from Plastic Surgery Societies recently to provide recommendations to decrease the risks of fat embolism associated with gluteal lipoinjection ¹. One of the most common published recommendation is a gluteal area that is more dangerous to inject intramuscularly. Those recommendations are derived from necropsies published in 2015 showing the following triad: tear in gluteal vein wall, intravascular fat, and macroscopic fat embolism (MAFE)  in lung tissue ². More recently, there have been fatal and nonfatal fat embolism cases which did not show the above triad but diagnosed free oil in lung microvasculature, which has been called microscopic fat embolism (MIFE) ³. Free oil from the lipoaspirate can access intravascular space even in intact vessels due to its lipophilic walls ⁴. Indirect venography is the gold standard to radiologically show the presence of veins, its caliber, and trajectory.  In this paper, we sought to look after a danger zone within the gluteal region by means of indirect venography with the highest concentration of veins that should be avoided during gluteal fat grafting to prevent either MAFE or MIFE occurrence.

 

Methods and materials:

Indirect venography from different patients was analyzed to highlight constant patterns of vein distribution in the gluteal region. The area with the highest concentration of veins was demarked and its anatomical boundaries objectively described. Finally, a correlation between this area of highest vein concentration and the muscle mass present within this area was described to locate the area most prone to permit MAFE and MIFE events.

 

Results:

The Danger Zone concept, already published by the authors to avoid MAFE ⁵, can also be applied to prevent MIFE, because it not only compromises the inferior gluteal vein, which is one of the main concern to be damaged and allow fat into bloodstream (MAFE) but also includes the muscle area with highest density of vessels in gluteal region that could allow absorption of free oil without direct vessel wall rupture (MIFE).

 

Conclusions:

The delimitation of a gluteal topographic area that should be avoided for intramuscular fat injection is updated to also compromise MIFE risk factors and ensure maximal safety in gluteoplasty with autologous fat tissue.

 

1. Mofid MM, Teitelbaum S, Suissa D, et al. Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force. Aesthet Surg J. 2017;37(7):796-806.
2. Cardenas-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.
3. 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. Plastic and Reconstructive Surgery. 9000;PRS Online First.
4. Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes following liposuction. Aesthetic Plast Surg. 2008;32(5):731-736.
5. Rosique RG, Rosique MJF. Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong? Plastic and Reconstructive Surgery. 2016;137(3):641e-642e.