|Year : 2015 | Volume
| Issue : 1 | Page : 68-71
Fat Embolism as a Rare Complication of Large-volume Liposuction in a Plastic Patient
Xiaoliang Fu1, Shang Gao2, Zhenyu Hu2, Yadong Guo1, Jifeng Cai1
1 Department of Forensic Science, School of Basic Medical Sciences, Hunan, China
2 Xiangya Medicine College, Central South University, Changsha 410013, Hunan, China
|Date of Web Publication||29-May-2015|
Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha 410 013, Hunan
Source of Support: None, Conflict of Interest: None
Fat embolism is a dreaded complication in of procedures of multiple disciplines including plastic surgery. As the popularity of liposuction increases, cases of pulmonary embolism after liposuction are increasingly reported. However, documents of cerebral embolism after liposuction are rarely presented. The degree of disability with respect to Fat fat Embolism embolism Symdrome syndrome (FES) is a Gordian Knot in the evaluation of legal medicine. Therefore, it is of great significance for us to that we report the case of a 30-year-old woman who underwent a large-volume liposuction that resulted in serious complications, especially cerebral embolism. Untypical symptoms of fat embolism hamper the clinical diagnosis, particularly after a surgical procedure such as liposuction. Such a seldom-seen case would easily trigger medical disputes, especially in countries like China suffering increasing claims of medical malpractice and, medical negligences and lawsuits. Detailed descriptions of this case are presented below along with the discussion of the clinical symptoms and the diagnostic approaches to fat embolism.
Keywords: Cerebral embolism, complication, fat embolism, liposuction
|How to cite this article:|
Fu X, Gao S, Hu Z, Guo Y, Cai J. Fat Embolism as a Rare Complication of Large-volume Liposuction in a Plastic Patient. J Forensic Sci Med 2015;1:68-71
|How to cite this URL:|
Fu X, Gao S, Hu Z, Guo Y, Cai J. Fat Embolism as a Rare Complication of Large-volume Liposuction in a Plastic Patient. J Forensic Sci Med [serial online] 2015 [cited 2019 Jan 22];1:68-71. Available from: http://www.jfsmonline.com/text.asp?2015/1/1/68/155553
| Introduction|| |
As a commonly performed plastic surgery operation, liposuction is a surgical technique that improves the body's contour by removing excess fat from deposits located between the skin and the muscle.  Although it usually features few clinical side effects, the increasing popularity of liposuction brings more frequent reports of related complications. According to an American Society for Aesthetic Plastic Surgery survey,  the complication rate per 100,000 liposuctions performed by plastic surgery specialists is 0.25%, while the mortality rate is 0.002%. According to the literature, many of these complications have been associated with large-volume and multi-position liposuction. Here we report a case of a 30-year-old woman who underwent a large-volume and multi-position liposuction that resulted in serious complications, particularly fat embolism.
Fat embolism is one of the most serious complications in of liposuction. Cases of pulmonary embolism after liposuction have been reported rather frequently, ,,,, but few of cerebral embolism have been reported  in China or abroad. The atypical symptoms of fat embolism and unavailable related findings impede the clinical diagnosis, especially in cases of surgical procedures such as liposuction. Obviously the diagnosis is difficult to define without pathological anatomy and we might fail to provide objective advice for forensic conclusions just with using the iconographic diagnosis in clinical legal medicine. Legal complications easily result when the patients or the doctors are dissatisfied with the conclusion.
| Case Report|| |
A 30-year-old woman weighing 65 kg without a significant previous medical history underwent lumbodorsal, abdominal, and arm-circumferential liposuction as well as enlargement of her, and her underjaw was enlarged using her own fat. The operation was uneventful and approximately 4900 mL of fatty tissue was removed with approximately 1000 mL of blood lost. After 5 days of supportive treatment, the patient was discharged from the plastic surgery center hospital. Eight days after the operation, she suffered from acute-onset right-sided weakness. She was sent to another hospital the very next day as her condition deteriorated dramatically. The patient's chief complaint was that both of her upper limbs were swollen for days. A massive subcutaneous hemorrhage on her arm and lumbodorsal region initially went unnoticed by her and her care team.
Physical examination showed that the patient was awake but in a compulsive position with a normal temperature, heart rate, respiratory rate, and blood pressure. Her operative incision (4 × 6 cm) had become infected with purulent secretions and her arms and lumbodorsal area developed a massive subcutaneous hemorrhage. The patient also suffered a zero-degree myodynamia of the upper right limb and a first-degree myodynamia of the lower right limb, but the muscle strength and tension of her left limbs and her muscle tension were normal. The superficial sensation over the right limbs and trunk was slightly impaired. Cranial magnetic resonance imaging (MRI) showed cerebral vascular disease with a minor hemorrhage [Figure 1]a. Brain computed tomography (CT) indicated a large low-density lesion in the left frontal and parietal lobes, which was considered as cerebral infarction [Figure 1]b. Lung CT angiography (CTA) revealed multiple embolisms of the bilateral pulmonary arteries and a bilateral pleural effusion. Color doppler ultrasonography (CDU) of the bilateral lower limbs suggested the possibility of venous thromboembolism from the left popliteal vein to the posterior tibial vein.
|Figure 1: (a) Cranial magnetic resonance image taken after acute-onset right-sided weakness showing cerebral vascular disease with a minor hemorrhage in the left parietal lobe (b) Simultaneously, computed tomography of the brain indicated a large low-density lesion in the left frontal and parietal lobes that is considered a cerebral infarction.|
Click here to view
This patient's diagnosis was cerebral embolism, which has a higher likelihood of fat embolism, pulmonary embolism, postoperative infection, moderate anemia, left-lower-limb deep venous thrombosis, and arteriovenous malformation of the left frontal and parietal lobes with possible hemorrhage. The patient was discharged 33 days after hospital admission with improved right-sided weakness. The muscle strength, muscle tension, and superficial sensation of her right limbs and trunk all returned to normal. The infected wound has recovered and reviews of lung CTA showed good contrast agent filling of the main pulmonary artery and its bilateral branches and a limited filling defect of part of the right inferior branches.
| Discussion|| |
Liposuction is a widely performed cosmetic surgical procedure that consists of the removal of excess fatty tissue from healthy bodies. The operation is performed under general or local anesthesia according to the extent of the area to be treated.  Intervention may be performed using various surgical techniques: Wetting solution techniques, standard liposuction or suction-assisted lipoplasty, internal ultrasound-assisted liposuction, vasserVASSER-assisted liposuction, external ultrasound-assisted liposuction, laser-assisted liposuction, power-assisted liposuction, and vibro liposuction.  Minor and major complications after liposuction surgery have frequently been described. ,,, Reported minor complications consist of seroma (clear serous fluid collection), irregularity, hematoma, hyperpigmentation, and penile or vulvar swelling. The most serious major complications include sepsis,  perforation of abdominal or thoracic viscera, , hemorrhage, hypotension,  pulmonary embolism,  fat embolism,  pulmonary edema and necrotizing fasciitis,  and cardiac arrest. 
According to the survey conducted by the American Society for Aesthetic Plastic Surgery,  the complication rate per 100,000 liposuctions performed by plastic surgery specialists is 0.25%, while the mortality rate is 0.002%. Statistics of abdominal dermolipectomy between January 1991 and 1996 show rates of hemorrhage in 1.2%, infection in 7%, skin necrosis in 6.6%, and thromboembolic accidents in 1.2%.  A review of 26,259 patients treated with different liposuction techniques over 25 years showed that 5% of patients experienced a postsurgical seroma. Postsurgical fibrosis developed to some degree in 2.3% of patients, anemia was present in 18%, postoperative pain occurred in 90%, and deep vein thrombosis occurred in 0.03% in addition to the incidence of pulmonary embolism. The mortality rate was 0.01% and was mainly caused by pulmonary embolism.  Many of these complications have been associated with large-volume liposuction.
In the case reported here, the plastic surgery hospital used the wetting solution technique in liposuction, which destroys the cytomembrane of the subcutaneous fat cell using the injection of isotonic or hypotonic normal saline into the operative site prior to liposuction. Destruction of the cytomembrane eases the extraction of the subcutaneous fat tissue and reduces the rate of injury.  The subcutaneous fat is abundant in nerve and blood vessels. The nature of subcutaneous fat tissue injury by liposuction is the same as that of bruising of subcutaneous soft tissue. The level of surgical influence on the body is directly relative to the fat suction volume, surgical scope, and patient's general condition.  The free fat would appear in the postoperative blood and urine when 900 mL of fat tissue was removed and the lipase in the plasma would resolve quickly. As such, it is practically impossible to incur serious complications. However, when the fat tissue is badly damaged and surpasses the ability of plasma to decompose, large amounts of free fat enter the blood and cause fat embolism syndrome (FES). This is the most significant complication causing mortality in liposuction. 
In 1998, the American Society of Plastic Surgery Task Force on Lipoplasty and the Plastic/Cosmetic Surgery Committee of the Medical Board of California both defined large-volume liposuction as the removal of >5000 mL of fat tissue. However, recent surveys have shown that this definition is kind of arbitrary since large-volume liposuction can be performed relatively safely when this procedure is treated with the respect it deserves and when practitioners exercise sound surgical judgment, use appropriate techniques, and avoid using minimal settings for the sake of saving the patient money.  Statistics also show that the development of pulmonary embolism may be associated with the amount of fat removed during liposuction surgery (>1500 g).  In this case, the patient underwent lumbodorsal, abdominal, and arm-circumferential liposuction as well as enlargement of, and her underjaw was also enlarged by using her own fat. A total of 4900 mL of fatty tissue was removed with a total blood loss of 1000 mL. Large-volume and multi-position liposuction causes pulmonary and cerebral embolism, postoperative infection, and left-lower-limb deep venous thrombosis.
Cases of pulmonary embolism and deep venous thrombosis after liposuction have been frequently reported, ,,,, while few of cerebral embolism have been proposed  domestically and internationally. Our case reported here was related to cerebral embolism, although the patient had many other complications. At first, both of her upper limbs were swollen and she developed a massive subcutaneous hemorrhage on the surgical sites that, unfortunately, went undetected by both hospital staff and the patient herself, which led to the deterioration of her condition. An examination of her muscle strength and muscle tension indicated that something was wrong with her nervous system, and cranial MRI and brain CT revealed cerebral embolism.
Embolized fat within the capillary beds can cause direct tissue damage and induce a systemic inflammatory response resulting in neurological and pulmonary symptoms.  In fact, 75% of a fat embolism generally invades the pulmonary microcirculation. Whether this would cause respiratory system symptoms depends on the emboli amount.  The patient's respiratory rate would increase at the beginning of the process. Dyspnea and cyanopathy would also occur along as the symptoms exacerbated.  Fat emboli can also reach the systemic circulation, and impact other organs, due to a patentthe patency of the oral foramen ovalein the interatrial septum, the existence of pulmonary arteriovenous micro fistulas, or deformation of the fat microglobules that cross the pulmonary capillaries. ,, If fat emboli cross over from the pulmonary circulation to the central nervous system, then cerebral embolism symptoms like loss of consciousness, delirium, or coma would occur.  Laboratory findings such as spotted and patchy shadows on chest radiography, hematocrit decent, platelet rate reducing, low partial pressure of oxygen or carbon dioxide, blood coagulation alterations, and the presence of free fat in the sputum or urine could reflect the pathogenic condition. ,
The typical clinical symptoms of FES include acute respiratory failure, global neurological dysfunction, and a petechial rash.  Nevertheless, one or more of these findings may absent, making diagnosis and prevention difficult. Once symptoms appear, some active interventions such as positive end expiratory pressure, high-dose corticosteroids, and globulin treatment should be implemented immediately.  Early diagnosis and timely treatment save patient lives.
The complex process of cerebral fat embolism symptoms make rapid clinical diagnosis difficult and complicates the ability of medicolegal experts to provide advice about the degree of patient disability. Here we confirmed the patient's diagnosis using imaging studies and the doctor's clinical conclusion. However, drawing a forensic conclusion with the clinical manifestation alone cannot provide a prognosis of the disease, and the Chinese medicolegal standards do not contain a specific clause that includes all symptoms of FES. Such a serious complication causes severe aches and pains for the patient. Although the attending doctor would not expect this situation to occur, we should consider all elements such as symptoms, prognosis, and future treatments into account to estimate the disability level.
We subjected the patient to comprehensive testing 18 months after her discharge. Except for the liposuction surgery scars, we found only that muscle strength of the right upper limb was weaker than that of the left. Taking the social impact and patient's situation into consideration, we arrived at a reasonable conclusion about her degree of disability. The patient and hospital subsequently reached a final agreement. However, the determined degree of disability was not impeccable. Our findings of this case suggest that the current clinical forensic medicine appraisal standard requires thorough improvement.
| Acknowledgement|| |
This study was supported by the National Natural Science Foundation of China (Nos. 81373249, 81302615) and the Central South University Student Innovation Test Plan (2282014bks163, CY14231).
| References|| |
Fodor PB. Reflections on lipoplasty: History and personal experience. Aesthet Surg J 2009;29:226-31.
Hughes CE 3 rd
. Reduction of lipoplasty risks and mortality: An ASAPS survey. Aesthet Surg J 2001;21:120-7.
Costa AN, Mendes DM, Toufen C, Arrunátegui G, Caruso P, de Carvalho CR. Adult respiratory distress syndrome due to fat embolism in the postoperative period following liposuction and fat grafting. J Bras Pneumol 2008;34:622-5.
Rothmann C, Ruschel N, Streiff R, Pitti R, Bollaert PE. Fat pulmonary embolism after liposuction. Ann Fr Anesth Reanim 2006;25:189-92.
Conkbayýr C, Kenan S, Emiroðlu O. Massive pulmonary thromboembolism after abdominoplasty and liposuction. Turk Kardiyol Dern Ars 2011;39:410-3.
Spring MA, Gutowski KA. Venous thromboembolism in plastic surgery patients: Survey results of plastic surgeons. Aesthet Surg J 2006;26:522-9.
Miszkiewicz K, Perreault I, Landes G, Harris PG, Sampalis JS, Dionyssopoulos A, et al
. Venous thromboembolism in plastic surgery: Incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg 2009;62:580-8.
Shaikh N, Hanssens Y, Kettern MA, Deleu D, Ruiz-Miyares F, Mesraoua B. Cerebral fat embolism as a rare complication of liposuction with abdominoplasty. Rev Neurol 2008;47:277-8.
Regatieri FL, Mosquera MS. Liposuction anesthesia techniques. Clin Plast Surg 2006;33:27-37, vi.
Mann MW, Palm MD, Sengelmann RD. New advances in liposuction technology. Semin Cutan Med Surg 2008;27:72-82.
Grazer FM, de Jong RH. Fatal outcomes from liposuction: Census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436-48.
Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction. Aesthetic Plast Surg 2006;30:712-6.
Mallappa M, Rangaswamy M, Badiuddin MF. Small intestinal perforation and peritonitis after liposuction. Aesthetic Plast Surg 2007;31:589-92.
Thomas M, Menon H, D'Silva J. Surgical complications of lipoplasty-management and preventive strategies. J Plast Reconstr Aesthet Surg 2010;63:1338-43.
Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med 1999;340:1471-5.
Triana L, Triana C, Barbato C, Zambrano M. Liposuction: 25 years of experience in 26,259 patients using different devices. Aesthet Surg J 2009;29:509-12.
Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: A review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg 2008;121:396e-403e.
Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mimoun M. Abdominal dermolipectomies: Early postoperative complications and long-term unfavorable results. Plast Reconstr Surg 2000;106:1614-23.
Guo E. Xian dai Zheng Xing Waikexue. Vol. 1. Beijing: People's Military Medical Press; 2000. p. 1101-4.
Wang X, Zhao B. Hengxing Meirong Shaoshang Waike Shoushu Changjian Wenti Yu Duice. Vol. 10. Beijing: Military Medical Science Press. 2008. p. 324.
Albin R, de Campo T. Large-volume liposuction in 181 patients. Aesthetic Plast Surg 1999;23:5-15.
Gravante G, Araco A, Sorge R, Araco F, Nicoli F, Caruso R, et al
. Pulmonary embolism after combined abdominoplasty and flank liposuction: A correlation with the amount of fat removed. Ann Plast Surg 2008;60:604-8.
Kwiatt ME, Seamon MJ. Fat embolism syndrome. Int J Crit Illn Inj Sci 2013;3:64-8.
Li S. Zheng Xing Waikexue. Vol. 1. Beijing: People's Medical Publishing House Co. Ltd; 2009. p. 710.
Filomeno LT, Carelli CR, Silva NC, Filho TE, Amatuzzi MM. Embolia gordurosa: Uma revisão para a prática ortopédica atual. Acta Ortop Bras 2005;13:196-208.
Fabian TC. Unravelling the fat embolism syndrome. N Engl J Med 1993;329:961-3.
Pell AC, Hughes D, Keating J, Christie J, Busuttil A, Sutherland GR. Brief report: Fulminating fat embolism syndrome caused by paradoxical embolism through a patent foramen ovale. N Engl J Med 1993;329:926-9.
Fourme T, Vieillard-Baron A, Loubières Y, Julié C, Page B, Jardin F. Early fat embolism after liposuction. Anesthesiology 1998;89:782-4.