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BACKGROUND Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Fat embolism syndrome (FES) is a rare complication in trauma patients (usually with long bone fractures) in which migrating medullary fat precipitates multiorgan dysfunction, classically presenting with dyspnoea, petechiae and neurocognitive dysfunction. Although this triad of symptoms is rare, it nonetheless aids diagnosis of pulmonary fat embolism (PuFE). Typical imaging features of PuFE are not established, although increasing use of CT pulmonary angiography (CTPA) in this cohort may provide important diagnostic information. We therefore conducted a case series of FES patients with CTPA imaging at a Level 1 Trauma Centre in Melbourne, Australia. Medical records and various radiological investigations including CTPA of consecutive patients diagnosed clinically with FES between 2006 and 2018, including demographics, injury and their progress during their admission, were reviewed. Fifteen FES patients with retrievable CTPAs were included (mean age 31.2 years, range 17–69; 12 males [80%]). 93.3% had long bone fractures. CTPA was performed 2.00 ± 1.41 days post-admission. Review of these images showed pulmonary opacity in 14 (93.3%; ground-glass opacities in 9 [64.3%], alveolar opacities in 6 [42.9%]), interlobular septal thickening in 10 (66.7%), and pleural effusions in 7 (46.7%). Filling defects were identified in three (20%) CTPAs, with density measuring − 20HU to + 63HU. Ten patients (66.7%) had neuroimaging performed, with two patients demonstrating imaging findings consistent with cerebral fat emboli. CTPA features of PuFE are variable, with ground-glass parenchymal changes and septal thickening most commonly seen. Filling defects were uncommon.

Background: In the clinic, death from nontraumatic pulmonary fat embolism associated with minor soft tissue contusion, surgery, cancer chemotherapy, hematologic disorders and so on has been reported. Patients often present with atypical manifestations and rapid deterioration, making diagnosis and treatment difficult. However, there are no reported cases of death from pulmonary fat embolism after acupuncture therapy. This case aims to emphasize that awareness of nontraumatic pulmonary fat embolism as a complication of acupuncture therapy needs to be improved. In addition, it suggests that in such cases, autopsy should be used to identify the source of fat emboli. Case presentation: The patient, a 72-year-old woman, experienced symptoms of dizziness and fatigue after silver-needle acupuncture therapy. She experienced a significant drop in blood pressure and died 2 hours later despite treatment and resuscitation. A systematic autopsy and histopathology examination (H&E and Sudan Ⅲ staining) were performed. More than 30 pinholes were observed on the surface of the lower back. Focal hemorrhages were seen surrounding the pinholes in the subcutaneous fatty tissue. Microscopically, numerous fat emboli were observed in the interstitial pulmonary artery and a large number of alveolar wall capillaries, in addition to the vessels of the heart, liver, spleen and thyroid gland. The lungs showed congestion and edema. However, the cause of death was identified as pulmonary fat embolism. Conclusion: This article suggests that high vigilance for risk factors and the complication of pulmonary fat embolism following silver-needle acupuncture therapy should be exercised. In postmortem examinations, examining the peripheral arterial system and the venous system draining from noninjured sites for the formation of fat emboli is helpful to differentiate posttraumatic and nontraumatic pulmonary fat embolism.

Background In 2017, the ASERF Gluteal Fat Grafting Task Force reported gluteal fat grafting to be a high-risk procedure and recommended specific surgical techniques to decrease the risk of pulmonary fat embolism (PFE). Objectives The aim of this study was to determine whether ASAPS and ISAPS members were aware of the 2017 recommendations, what their current surgical techniques were, whether they had changed their techniques based on the 2017 recommendations, and whether the incidence of PFEs had changed since the recommendations were published. Methods An anonymous web-based survey was conducted among members of ASAPS and ISAPS. It included the questions from the 2017 survey, as well as questions about awareness of the Task Force recommendations and subsequent change in surgical techniques. Results In the 2 years following the publication of the recommendations, the incidence of any PFE was 1 in 2492 compared with 1 in 1030 reported in 2017 (P = 0.02). Trends indicated a decreased mortality rate from 1 in 3448 in 2017 to 1 in 14,952 in 2019. Ninety-four percent of respondents were aware of the recommendations. Only 0.8% of surgeons in the current survey reported injecting in deep muscle, compared with 13.1% in 2017 (P < 0.01). Compared with 4.1% in 2017, 29.8% of respondents in our survey reported that they only injected with cannulas ≥4.1 mm (P < 0.01). Only 4% of respondents reported angling the cannula down in the current survey, compared with 27.2% in 2017 (P < 0.01). Conclusions It appears that members were aware of the 2017 recommendations. There was a significant decrease in recent PFE and trends showed a change to safer techniques and an improvement in safety of the procedure.

Introduction. Fat embolism refers to the presence of fat globules in the lung parenchyma and its peripheral circulation. Obstruction of the lung vessels by fat emboli can lead to acute cor pulmonale when the compensatory capabilities of the pulmonary vasculature are exceeded. Case report. We presented a case of a 78-year old man who suffered a dissection of abdominal aortic aneurysm. Urgent surgical procedure was performed and aneurysm replaced with aortobifemoral bypass grafting using a Dacron graft. Despite the procedure the patient died the following day. The autopsy revealed that the cause of death was hypovolemic shock. There were no bone fractures (also no fractures of ribs and sternum from cardiopulmonary resuscitation) or injuries of the subcutaneous fat tissue or other organs (besides those from the surgery). However, additional autopsy findings included fatty liver change, small liver hemorrhages (confirmed microscopically), as well as a presence of fat droplets in the hepatic veins, as well as in the pulmonary vessels, i.e. pulmonary fat embolism [confirmed with hematoxylin/ eosin (H/E), and Sudan III staining], which could be the contributing cause of death. Conclusion. The presented case indicates that pulmonary (or even systemic) fat embolism should be considered as the possible iatrogenic cause of unexpected and unexplained death in the cases where elective surgical procedures were performed in patients with fatty liver change. Pathologists must be aware of this possibility, since it is not easily recognized on routine H/E staining, and some of the special staining technique should be applied.

Emine Turkmen Samdanci,1 Muhammet Reha Celik,2 Sultan Pehlivan,3 Osman Celbis,4 Dilhan Turkkan,3 Dogus Ozdemir Kara,3 Esra Pamukcu51Department of Pathology, School of Medicine, Inönü University, Malatya, Turkey; 2Department of Thoracic Surgery, School of Medicine, Inönü University, Malatya, Turkey; 3Pathology Laboratory, Council of Forensic Medicine, Ankara Group Chairmanship, Ankara, Turkey; 4Department of Forensic Medicine, School of Medicine, Inönü University, Malatya, Turkey; 5Department of Statistics, Faculty of Science, Fırat University, Elâziğ, TurkeyBackground: Fat embolism (FE) may develop following many traumatic and atraumatic clinical conditions; however, fewer data exist regarding the occurrence of isolated pulmonary FE (IPFE). Cardiopulmonary resuscitation (CPR) is an emergency procedure for maintaining blood circulation and oxygenation during cardiac arrest. In this study, we aimed to evaluate the association of CPR with IPFE in autopsy cases.Methods: A total 402 cases among 4,118 autopsies were diagnosed with IPFE, and the medical background of these cases was retrospectively evaluated. Diagnosis of FE and FE grading were performed with histopathological examinations of postmortem tissue samples, and injury-severity scores of traumatic cases were assessed. Data of traumatic and atraumatic cases were statistically compared.Results: Of the IPFE cases, 298 (741%) were male and 104 (25.9%) female, with overall mean age 53.7 (2–99) years. Causes of death of studied subjects were traumatic for 302 (75.1%) and atraumatic reasons for 100 (24.9%) cases. CPR was performed for 277 cases of which 177 (63.9%) were traumatic and 100 (36.1%) were non-traumatic.. In comparison to traumatic cases, significantly higher CPR frequency was determined in atraumatic IPFE (P=0.001). High grade FE in the traumatic cases, and mild-moderate grade of FE in the nontraumatic cases were found statistically significant(P=0.001).Conclusion: This study indicates that CPR may be one of the leading factors in the development of IPFE in atraumatic conditions, and this procedure was related to mild–moderate IPFE manifestations. Regardless of whether conditions were traumatic or atraumatic, in patients who survive following CPR for manifest ventilation/perfusion problems, it should be remembered that IPFE may have developed due to CPR.Keywords: cardiopulmonary resuscitation, CPR, fat embolism, pulmonary embolism, autopsy

Fat Embolism Syndrome (FES) is the systemic manifestation of fat emboli in the circulation-a rare and potentially lethal complication of trauma, seen mostly after long bone fractures. Hypoxia is the most common and earliest feature of FES, followed by Central Nervous System manifestations. Other than supportive treatment, no exclusive and defined treatment approach has yet been identified. In the ICU, there has been an increased use of High Flow Nasal Cannula Oxygen (HFNC) in situations of acute respiratory failure. In the case under analysis, respiratory failure with hypoxemia occurs in a young patient with risk factors for fat pulmonary embolism, who responded well to supportive care.

Non-thrombotic pulmonary embolism (NTPE) results from the embolization of non-thrombotic materials. It can often be a challenging diagnosis due to non-specific (similar to thrombotic pulmonary embolism) or uncommon clinical and imaging findings. Patients with NTPE often present to the emergency department with acute respiratory distress, and contrast-enhanced computed tomography (CT) of the chest and CT pulmonary angiography are the imaging modalities of choice for respiratory distress. Since the treatment of NTPE is entirely different from thromboembolism, its distinction is essential. Moreover, early diagnosis of NTPE is necessary. Radiologists must be familiar with the diagnostic findings of NTPE, and this article aims to review the imaging features of various causes of NTPE. C1 [Ufuk, Furkan; Sagtas, Ergin] Univ Pamukkale, Dept Radiol, Denizli, Turkey. [Kaya, Furkan] Afyon Kocatepe Univ, Dept Radiol, Afyon, Turkey. [Kupeli, Ali] Erzincan Binali Yildirim Univ, Dept Radiol, Erzincan, Turkey.

Renal angiomyolipoma without local invasion is usually considered benign entity, however, it may extend into the renal vein or the inferior vena cava. Renal angiomyolipoma with venous extension should be treated; however, surgical complications such as iatrogenic pulmonary fat embolism remain a serious concern. We present a case of a 66-year-old Japanese woman without tuberous sclerosis in whom a right-sided renal tumor was incidentally detected on ultrasonography during a health check-up. Further evaluation showed that the tumor extended into the renal vein, and she was successfully treated using preoperative inferior vena cava filter placement and radical nephrectomy. An inferior vena cava filter can prevent catastrophic pulmonary fat embolism during nephrectomy.

Sotos syndrome is a rare congenital syndrome caused by deletions or mutations in the NSD1 gene (chromosome 5q35) which results in overgrowth. A wide range of manifestations may result in unexpected and/or early death, including congenital cardiac malformations and tumours, epilepsy, intra-tumoural haemorrhage or embolism and bleeding diatheses. A case of lethal pulmonary fat embolism complicating revision of a left total hip replacement following spontaneous fracture is reported in a 39-year-old man with Sotos syndrome. This case demonstrates that orthopaedic problems later in life may be added to potential causes of premature death in this syndrome.

Objective: The increase in demand for gluteal fat grafting seen in recent years in the United States has not been met with an equal gain in knowledge of the perils of this anatomic territory. The purpose of this study was to identify anatomic landmarks that can be readily used by surgeons to identify the takeoff of the superior and inferior gluteal veins. Method: Six fresh cadaveric gluteal specimens were dissected at the University of Louisville anatomy laboratory. A question mark incision was made for exposure, followed by identification of the sciatic nerve in the proximal thigh. This was traced retrograde to the sciatic forearm. The piriformis muscle was identified dividing the foreman into superior and inferior portions, which corresponded to the takeoff of the superior and inferior gluteal vessels, respectively. The distance of the gluteal vessels from the one-third point of a line from the mid-sacrum to the greater trochanter was measured. Result: Our cadaveric dissection series demonstrated that the superior and inferior gluteal veins were on average 3.28 cm (2-5.9 cm) and 1.25 cm (0-3.5 cm) away from the point one third the distance from the mid-sacral border to the greater trochanter. Conclusion: The mid-sacrum and the trochanter of the femur are the anatomic landmarks used to identify the large gluteal vein trunks. Understanding the location and trajectory of these deep gluteal structures with use of readily identifiable landmarks may assist surgeons in avoiding inadvertent injection of fat to these veins during fat grafting.

We report a patient who sustained catastrophic pulmonary fat embolism post-induction of general anesthesia during laparotomy for haemoperitoneum. The source being the fractured shaft of fracture femur which was missed during the primary survey in the chaos of a positive focused assessment with sonography for trauma and a transient responding patient. In this case report, we want to emphasize the importance of primary survey in a trauma patient, effective communication and documentation to prevent errors and for better management of patients.

PURPOSE This study aimed at assessing the cement leakage rate and the filling pattern in patients treated with vertebroplasty, kyphoplasty and stentoplasty with and without a newly developed lavage technique. STUDY DESIGN Retrospective clinical case-control study. METHODS A newly developed bipedicular lavage technique prior to cement application was applied in 64 patients (45.1 %) with 116 vertebrae, ("lavage" group). A conventional bipedicular cement injection technique was used in 78 patients (54.9 %) with 99 levels ("controls"). The outcome measures were filling patterns and leakage rates. RESULTS The overall leakage rate (venous, cortical defect, intradiscal) was 37.9 % in the lavage and 83.8 % in the control group (p

The aim of the present study was to develop an animal model of pulmonary fat embolism (PFE) caused by femoral intramedullary procedures, and to investigate the initial changes in the hemodynamics, cytokines and risk factors of PFE. Sixteen dogs were randomly divided into two groups: Group A (intramedullary reaming and bone cement injection, n=8) and Group B (surgical approach without opening the medullary cavity, n=8). The hemodynamics, arterial blood gases and relevant cytokines were evaluated, and the lungs were examined using Oil Red O staining. In the animals of Group A, the heart rate, central venous pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and extravascular lung water (EVLW) were increased compared with the baseline levels, while the mean arterial pressure was decreased immediately following the reaming and bone cement infusion (P

We investigated the feasibility of postmortem percutaneous needle biopsy (PNB) for obtaining pulmonary samples adequate for the study of pulmonary fat embolism (PFE). Samples of both lungs were obtained from 26 cadavers via two different methods: (i) PNB and (ii) the double-edged knife technique, the gold standard at our institute. After water storage and Sudan III staining, six forensic pathologists independently examined all samples for the presence and severity of PFE. The results were compared and analyzed in each case regarding the vitality of the PFE and its relationship to the cause of death. The results showed that PFE was almost identically diagnosed and graded on the samples obtained via both methods. The discrepancies between the two techniques did not affect the diagnoses of vitality or cause of death related to PFE. This study demonstrates the feasibility of the PNB sampling method for the diagnosis and interpretation of PFE in the postmortem setting.

We report a patient who sustained catastrophic pulmonary fat embolism, during open reduction, internal fixation (ORIF) of fracture femur' In our opinion, the use of percutaneous cardiopulmonary support with (PCPS), saved the patient from certain death.

The relationship between the volume of fat flowing in the bloodstream and the degree of pulmonary fat embolism has remained unclear. In this study, in order to examine whether the volume of fat particles in the bloodstream could be estimated from the degree of pulmonary fat embolism, 0.05, 0.1, 0.15, 0.2 and 0.25 ml of triolein were injected into male rats weighing 300–320 g, through the caudal vein. Consequently, it was noted that the severity of pulmonary fat embolism tended to gradually increase in proportion to the volume of injected triolein, with the severity of pulmonary fat embolism being significantly augmented by the injection of 0.2 and 0.25 ml of triolein, based on morphometric analysis. In application to human cases, about 60 ml of fat particles was estimated to flow into the bloodstream after the occurrence of a pelvic fracture. Moreover, the results of this study led to the hypothesis that the prognosis of pulmonary fat embolism is affected by the severity of preceding conditions which have caused fat embolism.

Objective To report the case of a fatal pulmonary fat embolism as a complication of spinal fusion surgery. Design Case report. Setting Pediatric intensive care unit at a freestanding tertiary care children's hospital. Patient An adolescent female with neuromuscular scoliosis who underwent spinal fusion surgery with instrumentation and suffered a fatal pulmonary fat embolism. Conclusion Spinal fusion surgery for neuromuscular scoliosis is a common operative procedure. Pulmonary fat embolism as a complication of this procedure is rare. This case emphasizes the need to be aware of this potentially fatal postoperative complication. Specifically evaluating for this rare complication may lead to understanding cases of unexplained deterioration and death.

An adult osprey (Pandion haliaetus) was evaluated because it was unable to fly and was experiencing severe respiratory distress. Despite supportive care, the bird died. Significant histopathologic findings included widespread, multifocal hemorrhage in parabronchi and air capil- laries and emboli consisting of adipose connective tissue containing hematopoietic islands demon- strated in medium-sized pulmonary arteries. This is the first reported case of pulmonary fat em- bolism in a bird.

Fat embolism is a common complication of pelvic and long bone fractures. Macroscopic fat emboli in the pulmonary arteries on computed tomography have been reported postoperatively after fixation of long bone fractures for trauma, however the quantification of attenuation values of fat emboli have been infrequently reported in the literature. We present a case of pulmonary fat embolism in a 52-year-old female after acute bony trauma sustained during a motor vehicle accident. To the authors' knowledge however, pulmonary fat embolism has not been described on the initial trauma CT scan.

A 64-year-old man with a subcapital femoral fracture after falling with a scooter underwent a total hip prosthesis. Two days after surgery he developed sudden dyspnea and tachycardia, improved with the administration of supplemental oxygen at 2 liters per minute. Arterial blood gas analysis revealed a pO2 of 75 mmHg.

In the last century, studies established the origin of pulmonary fat embolism (PFE) and identified mechanical trauma as main source for PFE. This prospective study focused on determining a possible influence of cardiopulmonary resuscitation (CPR), in the context of an aging population, on the occurrence of PFE. Lung tissue samples from 256 bodies were examined using the twin-edged knife technique without preliminary fixation but after staining with Sudan III. PFE grading was determined according to Falzi and performed at a 10× magnification. For statistical analysis, bodies were grouped by age, gender, and putrefaction and categorized following whether they had experienced trauma, CPR, the combination of both, or no mechanical impact. There was a significant correlation of trauma, CPR, and the combination of both to PFE but no noticeable influence of gender or putrefaction. An age over 70 years promotes a PFE due to resuscitation.

El síndrome de embolia grasa (SEG) sigue siendo un reto diagnóstico para los médicos. Se asocia fundamentalmente en fracturas de los huesos largos y es una importante fuente de morbilidad y mortalidad en pacientes politraumatizados. La mortalidad general se encuentra entre el 5 a 15% en todos los estudios. Esto nos motiva a presentar el caso de una mujer joven que 72 horas después de fracturas sufridas durante el terremoto ocurrido en Chile el 27 de febrero del 2010, presentó un SEG. Es importante conocer este síndrome, ya que se puede confundir con otras patologías graves que requieren un manejo distinto y al tener una alta sospecha en el contexto adecuado, se permite un diagnóstico oportuno, tratamiento precoz y mejorar el pronóstico. Fat embolism syndrome (FES) remains a diagnostic challenge for physicians. It is commonly as associated with fractures of long bones and it is a major source of morbidity and mortality inpatients with multiple injuries. Overall mortality is between 5-15% in all studies. These facts motivate us to present the case of a young woman suffering bone fractures in both legs during the earthquake in Chile on February 27, 2010. She presented a FES 72 hours later. It is important to understand this syndrome, as it can be confused with other serious diseases that require different management. We should be able to have a high FES suspicion in the appropriate context, in as much as an early diagnosis, and treatment may improve the prognosis of this severe condition.

We report a fatal pulmonary fat embolism syndrome arising consequent to an above knee amputation in a child. Pre-existing poor respiratory reserves, as a result of severe scoliosis, may have contributed to the fatal outcome.

Pulmonary and systemic fat embolization has been recognized as a serious and life-threatening complication of pelvic and/or long bone fractures. However, articles on pulmonary and systemic fat embolism resulting from bilateral femoral shaft fractures alone are rarely found in the literature and the fates of such cases are under-reported as well. The authors recently experienced an early severe pulmonary and systemic fat embolism following bilateral femoral shaft fractures, resulting in a sudden death about 5 hours after injury. The authors report such a case and also review the relevant literature as to its cause, pathophysiology, clinical presentation, diagnosis, and treatment.

Fat embolism syndrome (FES) is a common complication of fractures, usually of the long bones and pelvis. Common computed tomography findings of pulmonary FES include areas of consolidation, ground-glass opacities, and small nodules of various sizes, whereas filling defects in pulmonary arteries are rarely described in nonfulminant syndromes. We present an unusual case of nonfulminant pulmonary FES in which computed tomography disclosed multiple macroscopic pulmonary fat emboli associated to diffuse ground-glass attenuation in both lungs.

We previously demonstrated that pulmonary fat embolism was induced by elevation of the core body temperature, in rats with a fatty liver. The aim of the present examination was to investigate the core body temperature at which pulmonary fat embolism developed capillaries through exposure to a high temperature, in rats with a fatty liver. Following heat stress, pulmonary fat embolism was observed to a slight degree at a core body temperature of 41 and 42 degrees C, whereas the severity of pulmonary fat embolism was greatly increased and was classified as severe at a core body temperature of 43 degrees C. Moreover, the concentrations of aspartate aminotransferase and alanine aminotransferase within plasma were significantly increased at a core body temperature of 43 degrees C. These results clearly indicate that the development of pulmonary fat embolism could be related to hyperthermia at above 42 degrees C following heat stress, and that fat emboli may be derived from the fatty liver itself. It is thus likely that pulmonary fat embolism can be considered as one form of evidence of hyperthermia in an individual with a fatty liver.

The aim of this study was to investigate whether a fatty liver contributes to pulmonary embolism under a high ambient temperature. As an experimental model, we exposed fatty liver rats to a high temperature (45 degrees C) and then looked for fat emboli in the alveolar capillaries using the fat-staining method. Fat emboli were detected in the alveolar capillaries of the fatty liver rats, but not in those of the normal liver rats. Moreover, the degree of pulmonary fat embolism tended to become more severe in proportion to the severity of the fatty liver. In addition, fat emboli did not appear at a core body temperature of 40 degrees C, but were detected at a core body temperature of 44 degrees C. From these results, we conclude that a fatty liver may contribute to the formation of pulmonary fat embolism and that high temperatures act as a trigger for the onset of pulmonary embolism. Moreover, it is possible that fatty liver affects the development of heat stroke induced by exposure to a high ambient temperature and that pulmonary fat embolism is a significant finding which helps to enable a diagnosis of heat stroke in autopsy cases.

During excavation work at the bank of the River Inn the corpse of a 32-year-old alcoholic male was recovered. Head injuries suggested a crime of violence. Postmortem examination demonstrated conspicuous milky turbidity of the blood, which was found by laboratory testing to be due to hyperchylomicronemia. The findings are interpreted and their relevance to the determination of postmortal head injuries is discussed. The inadequacy of double-edged knife specimens and frozen-section biopsies for the estimation of pulmonary fat embolism as a vital reaction is considered.