Updated: Sep 21, 2018
Fat grafting took its place as the Holy Grail of body contouring by providing a way to reshape the body by using one's own tissue, and the excitement of ensuing possibilities grew among physicians and patients alike.
One of the most exciting areas of advancement, rapidly gaining popularity, is gluteal augmentation. Embraced by a cultural shift in social perception of the ideal female form, patients have eagerly sought enhanced buttock shaping and volume at an ever-increasing rate, and surgeons have responded by offering a variety of techniques, including fat grafting and gluteal implants.
Surgeons specializing in fat grafting did not recognize the risk of fat embolus when grafting into the muscle in gluteal augmentation and, in fact, publications prior to 2017 supported this very technique. As these surgeries increased in volume, multiple deaths were reported as the result of fat embolus and guidelines were implemented to avoid these devastating outcomes.
Driven by the determination of Dr. Mark Mofid to protect his colleagues and patients alike as they journeyed together into new advances, a multi-society task force was put in place to set forth safety standards for all, and science moves forward in the nature it always does—through the continual iteration and application of new knowledge.
INTERVIEW: DR. MARK MOFID
Around the end of 2015, an article on patients who had died from fat grafting caught my eye. I had never heard of a single patient who had died from fat grafting. I can tell you in the US it didn’t come across anyone’s radar to my knowledge—- no one was talking about it. Probably anyone who would have read the article would have thought this was due to techniques being used outside the US. Honestly, it just didn’t register; no one paid attention to the article. The response was a great yawn. I don’t think anyone even wrote a reply at that time— that came later. It really just garnered a collective yawn from the perspective of our specialty.
For the better part of 30 years, we had been doing fat grafting in the US, and no one really realized that there were risks associated with the operation. The way the technique had been taught, and the numerous articles that were published, was that intramuscular injection was deemed to be advantageous due to better blood supply in the buttock. Rather than have a 20%-30% take, you could have a fat graft that was enhanced. In fact, I remember a study around 2008/2009 that was an MRI study and you could actually see fat grafting, if it were injected into the muscle and so that is how I always did it. Another sort of interesting thing, is I would have patients come back and say, “I’m not really happy with the BBL, and I want to go bigger,” and I would say, well there aren’t really any more fat stores, so we can do implants and when I would dissect that plane for my intramuscular technique, I could actually see the fat—- you could see the fat I had grafted. It was almost with a sense of pride that I would look at that fat and say, “wow, I did a really good job with the BBL!”
I was giving a lecture at the NY Regional Plastic Surgery Society where I had been invited as a visiting lecturer and I gave a talk on gluteal implants. I was asked the question, “If BBL is an alternative and the fat stores are available, why would you even do implants?” And the statement I made at the time, and this was around April 2016, was ‘my first choice is always to do a BBL. I think fat grafting is always the safest operation, and if the patient fails, or you want to go on to enhance the buttock with another technique, you use the implant. First choice should always be fat grafting.
After I gave that talk, a plastic surgeon came up to me and said, “you know, we’ve had a couple of patients recently who have died from fat grafting. I thought, that’s interesting. I’ve read that study done in Mexico and now I’m hearing this. This is certainly deserving of a little bit more.
I was at ASAPS in 2016, chairing a Resident/Fellow Forum and a resident from Texas written a paper on a series of 80+ patients a surgeon in Texas had done and a number had wound up in ICU with fat embolus—none had died but they had fat embolus. So I started doing some research on PubMed, trying to find out everything there is to know about this. We had an unpublished single surgeon who had pulmonary fat embolism —out of 80 cases, a 5% near fatality rate, a paper from Mexico that says there were 20 deaths, a couple of plastic surgeons in NY with patients who had died, and I thought this is just something that needs to be looked at further.
There was nothing written. I found one article in the Journal of Forensic Pathology that had been written in February of 2015- the very first paper. It was a single case report that a pathologist had written on a patient in Los Angeles who had died from a BBL. He had found that the heart was filled with fat, the same thing the Mexico study had found.
The single most helpful lead to this was an investigative reporter in Miami, Dan Krauth, who had started writing about this in 2011. He thought it was unusual that a patient would die from aesthetic surgery, so he wrote about it. These patients died from fat embolism, not just one case or two, but six or seven cases.
In 2016, I reached out to him and asked if I could gain access to whatever material he had on these patients who had died. He said, “well, I just contacted the coroner’s office directly, that’s what I do”. This is an investigative reporter, this isn’t even a physician. He said he just thought it was an unusual way of dying, especially for a patient who had had surgery, especially since there appeared to be a cluster of them in Miami.
He did a public records request and provided me with a number of autopsy reports, 10 or 15 —all patients from FL, GA, TX, PA, various states—and, of course, I had my own contact with the LA coroner’s office where I think we had 5 deaths, and so I put it all together. Anecdotally, you’d hear someone would have a patient die and I reached out to the surgeons and spoke to ones who were willing to speak with me. I was taking notes and asking questions like how did you inject? What did you do? Did you inject with pressure cannulas? Were you injecting into the muscle? Which size cannulas were you using? I was trying to get as much information as possible. It was 2016 and I was building towards the paper.
When I left the ASAPS meeting in 2016, I had already decided I was going to do a survey, just send it out on my own, and at the California Society of Plastic Surgeons meeting which is usually held around Memorial Day of every year, and this is 2016, I was with Steve Teitelbaum in the back of the room talking about this work I had been doing and I was interested in pursuing it further and he said—-he was the incoming ASERF president at the time —-and he said, “ I’m going to throw my weight behind this and let’s get a task force together and we will study this. If you want to write a paper you can do it, but let’s do it under the ASERF— that’s what we’re here for. So we started working on it in June of 2016, and we decided we were going to get a task force together and we invited all sorts of people and some people decided to be part of it and some people didn’t.
I think some people didn’t take it seriously. At any given time, there’s 10-20 ideas floating around that people end up latching themselves onto one way or another and I think people looked at this task force as kinda like a study group.
We got 10-15 people together. Probably half the people we got together were people that saw this as a problem and the other half were authorities in the field who viewed this as interfering in a good operation, like don’t bring too much negative attention to a good operation.
In 2017, BBLs were up another 25%. When you are at that place on the growth curve of any operation you don’t want to impact it negatively in any way. For certain surgeons on the task force, this was their bread and butter and so I think half the surgeons on the task force felt it was a good thing we were studying this as a society or from a research standpoint, but it probably shouldn’t go too much past the beyond asking questions phase. Steve (Teitelbaum) was one of the biggest supporters of this and making sure it prospered, and the lions share of the credit really goes to him as there were roadblocks along the way.
I remember one conference call that ended fairly abruptly, where there were a number of surgeons who were just livid at what was being said and some of the preliminary data coming in from the survey showing what even surprised us and I just remember one of the surgeons saying something along the lines of “why are we doing this? I’ve done so many of these operations and I’ve never had a complication and I can’t sit here and support it. My only purpose for now serving on this task force or on this committee is to uniformly condemn whatever it is you are doing.” I guess I was kinda taken aback by that because, again, I didn’t have a dog in the fight. For me, this was an interesting academic exercise, plus it was an operation I enjoyed doing, and I had an autopsy report linking a death from pulmonary fat embolism to that very surgeon who was speaking. So I was kinda taken aback and I thought “Do I out him?” “Do I say something?”
I was so taken aback, I asked this surgeon —-we were on a call with about other people, I asked him if he could please repeat what he had said as I thought I had misunderstood it and at one point I confronted him and said I don’t believe that what you are telling me is accurate as I actually have an autopsy report that shows that one of your patients died from this very cause, and he said, “well, no, I know what you are talking about and that patient actually died from something else.”
I actually had a multiple page autopsy report that found exactly what the Mexican surgeons had found and what Dennis had found, who was the pathologist from Los Angeles who wrote case report and I said, you have a death from precisely this cause and you more than anyone else should be looking for answers and for us to get the information out so we can find ways to avoid it. He was kinda quiet and shortly thereafter two of the plastic surgeons who were on the task force—-these were well-known people—resigned. They sent certified letters to Steve, I’m sure he kept a copy of those letters, resigning and voicing opposition and lack of camaraderie and professional respect or whatever it was because they felt I had said something that was potentially embarrassing to that one individual.
No one, no one wanted to volunteer. Let’s say there was a plastic surgeon in PA and I had gotten an autopsy report that showed a patient died, I’d just call out of the blue and sometimes they would suspiciously get on the phone with me and say, “I can’t really talk about this because we've got to be really sure what’s going to happen from a legal standpoint so I’ve been instructed by my attorneys not to answer any questions. Sometimes it wouldn’t go much further. I’d have people that would absolutely refuse to speak to me— I’d have to call them 3 to 4 times.
My point was once the data came in we weren’t saying moratorium, moratorium... my feeling about it was there is a way to do this operation safely. It’s like doing anything else, if you find that doing cardiac surgery with patients on a bypass is more dangerous than not putting them on a bypass then you stop putting them on a bypass. It’s a learning experience. You don’t just say no one gets cardiac surgery.
I can tell you, the people who really wanted to see this go somewhere were Lazaro Cardenas, Arturo Montanana, Steve Teitelbaum, Dennis Astarita and me. The majority of the other people on the task force wanted this to die. They were serving on it to some extent to maintain their knowledge of what was going on at the time. I think they also had concerns that if we deemed this to be a dangerous operation they wouldn’t be able to perform it anymore.
We got all of the information that we really needed to around Oct 2016. That’s when I presented it at ISAPS in Japan. Steve presented it at ASPS in Oct 2016 and from there it was just a matter of getting the paper ready for publication. I asked Peter Pronovost, at Johns Hopkins, to write an article on it. There were 3 responses written to that article and the paper was published in the Spring of 2017. It was met, again, with a collective yawn.
More papers were written since we published our paper. Steve and I came to the conclusion when we were finished with this project and we knew what should be done. We kinda watered down, if you will, the recommendations. I would have preferred at that point, mid-2017, to have said no one should ever inject into the muscle anymore, it should only be subcutaneous injections. I think Steve would have gone along with that but, again, some of the other authors/task force members were basically threatening to resign because they said, “Well, then what you are saying is I’m committing malpractice based on the way I do this operation.” So, we kinda watered down our conclusions saying injections should be superficial, you should be aware of it, and more research is needed.
I think a lot of people wanted it to stop short of making standard of care statements. Even Steve and I were concerned about hurting our colleagues. Let’s say someone were to go back on an autopsy and let’s say someone died of a pulmonary embolism, at that point does that surgeon lose their license? Do they lose a million dollar lawsuit? It’s a life-changing thing.
I don’t think anyone’s going to be held to a standard that was established in 2018. You can’t hold someone who experienced a complication a year or two ago to the standard of what we have identified now.