Abstract 18212: The Fat Embolism Enigma: Unveiling the Intricate Complications of Breast Reconstructive Surgery

Background: Fat embolism can occur after plastic surgery, especially when injecting fat into subcutaneous tissue. It can be asymptomatic or can have hypoxia, mental status changes, and petechiae rash. Diagnosis is challenging but the workup includes imaging to exclude other differentials including pulmonary thromboembolism. Echocardiography assists in identifying fat emboli. Case Presentation: A middle-aged female with no prior cardiac history was undergoing right-sided breast reconstructive surgery with liposuction from the abdomen and fat grafting. Intraoperatively, the patient became hypoxic and hypotensive. The patient was started on vasopressors. A CT-Angiogram Chest revealed multiple bilateral pulmonary emboli, with some emboli having negative Hounsfield units (HU). Anticoagulation was started. Fat emboli could not be excluded. The patient was ultimately transitioned to venoarterial extracorporeal membrane oxygenation. Transthoracic echocardiogram showed right ventricular (RV) hypokinesis with preserved apical function and multiple, mobile, irregular masses in the RV. Figure 1 With the patient’s history, this was concerning for fat emboli. A transesophageal echocardiogram (TEE) showed multiple (4 visualized) masses seen in the RV, caught into the subvalvular tricuspid apparatus on the chordae and the RV trabeculation. (Largest mass: 1 cm in diameter). Figure 2 A bilateral lower extremity venous duplex was negative. The patient was diagnosed with obstructive shock secondary to fat embolism. She was eventually weaned off of mechanical support and discharged in stable condition.

Discussion: Autologous fat grafting (AFG) has gained popularity in reconstructive and aesthetic surgery. It is important to remain vigilant about fat embolism as a complication that presents as sudden hypoxia and obstructive shock in the appropriate setting. DVT should be ruled out. Echocardiography can assist in diagnosis. Treatment is supportive.