Autologous Fat Injection for Soft Tissue Augmentation in the Face: A Safe Procedure? Dominik L. Feinendegen, M.D., Ralf W. Baumgartner, M.D., Philippe Vuadens, M.D., Gerhard Schroth, M.D., Heinrich P. Mattle, M.D., Franco Regli, M.D., and Hans Tschopp, M.D. Bern, Switzerland Abstract. Autologous fat injection for soft tissue augmentation in the face is claimed to be a safe procedure. However, there are several case reports in the literature where patients have suf- fered from acute visual loss and cerebral infarction following fat injections into the face. Acute visual loss after injection of various substances into the face is a well-known complication of such interventions. We report two further patients who suf- fered from ocular and cerebral embolism after fat injections into the face. For the intravasation of fat particles there are three preconditions: well-vascularized tissue, fragmentation of parenchyma, and, especially, a local increase in pressure in the affected tissue. Fat injections into the face lead to an acute local increase in pressure in highly vascularized tissue. We assume that fragments of fatty tissue reach ocular and cerebral arteries by reversed flow through branches of the carotid arteries after they are introduced into facial vessels. The manifestation of fat embolism appears either immediately after the fat injection or after a latency period. Fat embolism can remain subclinical and may not be recognized, or the clinical features may be misin- terpreted. To minimize the risk of such a major complication, fat injections should be performed slowly, with the lowest pos- sible force. One should avoid fat injections into pretraumatized soft tissue, for example, after rhytidectomy, because the risk of intravasation of fat particles may be higher. Metabolic distur- bances such as hyperlipidemia may also contribute to the clini- cal manifestation of fat embolism. Routine funduscopic exami- nations after fat injections into the face could help to provide data for future estimation of the patient’s general risk. Key words: Fat injection—Face—Fat embolism—Visual loss—Cerebral infarction Autologous fat injection into the face is a frequently used technique in aesthetic surgery. After liposuction a semi- liquid fat graft is injected subcutaneously for soft tissue augmentation. It is claimed to be a safe procedure [6]. However, several patients are reported in the literature who suffered sudden unilateral loss of vision following fat injection into the glabella [8,9,28]. In one case there was a coincidence of middle cerebral artery (MCA) em- bolism [9]. In these cases it was supposed that fat was injected into facial arteries and reached the orbital and cerebral arteries retrogradely. Acute blindness after injections of various substances into the face is a well-known complication. It was re- ported in patients who had paraffin injections for the correction of saddle nose deformity at the beginning of this century [26,32,38]. Later reports relate to corticoste- roid injections into the scalp [33], the nose [18,35], the upper eyelid [31], and the tonsillar fossa [10] and injec- tion of lidocaine into the nose [7]. In these cases it was also presumed that the embolic material was introduced into the arteries of the face and reached the ocular vessels retrogradely. Here we present two additional patients with such complications. We discuss the pathogenesis and the po- tential risk of fat injections into the face. First Case A 45-year-old man underwent bilateral neck and face rhytidectomy and liposuction of the cheeks followed by autologous fat injection into the nasolabial folds, lower Correspondence to D.L. Feinendegen, M.D., Department of Plastic & Reconstructive Surgery, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN, En- gland Aesth. Plast. Surg. 22:163–167, 1998 © 1998 Springer-Verlag New York Inc.