An Unusual Complication Following Gluteal Fat Grafting

A Case Report

Ariel Neiman, MD; Omer Sadeh, MS; Shay Dudaie, BS; Aziz Shoufani, MD


Plast Reconstr Surg Glob Open. 2021;9(4):e3515 

In This Article


Our patient developed a high fever and abscess in the lateral thigh following a gluteal fat grafting performed abroad. This twice prompted transcutaneous drainage under ultrasound with a catheter drain. The patient's aesthetic procedure prompted us to delay an invasive and aggressive procedure in our initial conservative approach to avoid any unnecessary disfigurement. Despite this consideration, surgical drainage with fasciotomy was required due to a persisting high fever and fluid accumulation in the lateral thigh.

Subfascial abscesses are difficult to diagnose. The absence of local inflammation signs are due in part to the infection residing deep within the tissues, resulting in a delayed diagnosis. In our case, mild erythema and severe swelling were the only symptoms at admission. Early radiological studies can facilitate diagnosis of deep infections.

Transcutaneous drainage under ultrasound was not sufficient in this case, despite the drainage of a large amount of purulent fluid. This is evidently due to the aggregation of large fat particles and blood clots that could not be removed and that blocked the drains. The transcutaneous drainage ultimately provided partial treatment, which gave the impression of improvement, yet resulted in an extended hospital stay.

Grafted fat intended for gluteal augmentation should be placed exclusively in the subcutaneous space. It is unclear how the grafted fat intended for the gluteal region reached below the vastus lateralis fascia. The first explanation relates to direct penetration of the cannula through the muscle fascia layer of the lateral thigh, which could cause the fat to collect underneath the vastus lateralis muscle fascia. The second explanation relates to the fat underneath the gluteus muscle fascia. Notably, the computer tomography imaging of our patient revealed fat-filled accumulation in the gluteal muscles. We suggest 2 explanations for the migration of fat from the subfascial gluteal space to the subvastus lateralis space. The first relates to direct subfascial diffusion from the subfascial gluteal space to the subvastus lateralis space. The second relates to undocumented intercompartment connections between the gluteal region and the lateral thigh.

Delvecchio et al[3] investigated the migration of injected fat into the gluteal muscle and the relation of pressure with each intramuscular injection, a phenomenon termed "Deep Intramuscular Migration." The authors noted a sudden drop in injection resistance during a series of gluteal subfascial fat injections, followed by a decrease in pressure. This raises the possibility of fat migration into a deeper plane and other compartments due to the increased pressure. An alternative explanation by Wall et al[4] expresses the concern of possible fat migration from the subcutaneous to the subfascial space. They described the potential recipient-site pressure gradient that can occur during lipofilling, relevance of fascial integrity, and the resultant path of least resistance for fat flow.