Deaths of U.S. Citizens …

Discussion

A total of 93 U.S. citizens were reported to have died in the Dominican Republic during 2009–2022 soon after receiving cosmetic surgery. Medical records were available for 24 of 29 decedents during 2019–2020, most of whom were young to middle-aged women. Among the 20 fatalities during 2019–2020 with an autopsy report available for review, 18 (90%) deaths were attributed to embolic phenomena. A large proportion of decedents had personal (92%) or procedural (100%) risk factors for perioperative embolism. Among deaths due to fat emboli, all patients had undergone liposuction and gluteal fat transfer. Fat embolism is a recognized risk associated with fat injections, particularly as used in gluteal augmentation, a procedure in which fat is harvested from the patient and then injected into the buttocks to augment the body silhouette (4). Recommendations to avoid injecting the fat into the deep muscular layers of the buttocks to reduce the possibility of fat embolism have been previously published (4,5). Risk factors for venous thromboembolism in this report included BMI ≥25 kg/m² (96% of patients), aged ≥40 years (50%), having undergone procedures on the trunk of the body (100%), or having undergone two or more procedures during the same operation (100%) (6–8). Preoperative ascertainment of patient risk for venous thromboembolism should be considered an expected standard of care during the preoperative evaluation and can be accomplished using validated risk-assessment models (e.g., Caprini score)** to help guide and incorporate the appropriate use of mechanical methods (e.g., early ambulation or compression devices) and chemoprophylaxis (e.g., anticoagulant and antithrombotic agents) to protect against periprocedural venous thromboembolism^†† (9). The findings in this report highlight the importance of considering patient and operative risk factors when determining whether to proceed with elective cosmetic surgery.

Limitations

The findings in this report are subject to at least three limitations. First, no reliable statistics on the number of U.S. citizens who receive cosmetic surgery in the Dominican Republic each year are available, precluding calculation of the risk for perioperative death. Second, this report might be an underestimate of the number of deaths among U.S. citizens receiving cosmetic surgery in the Dominican Republic because it only included deaths that were reported to the U.S. Embassy. Other investigators have documented adverse outcomes from cosmetic surgeries performed in the Dominican Republic that were only recognized after the patient had returned to the United States (1,2). Finally, perioperative deaths are rare complications of cosmetic surgery, and this report does not address other well-documented adverse events such as postsurgical infections that can result in substantial morbidity (1,2).

Implications for Public Health Practice

Public health departments can make recommendations to improve medical care within their jurisdictions, and surveillance can identify new or ongoing health concerns. In 2019, the Dominican Republic MOH issued safety and quality recommendations to cosmetic surgeons, including training and licensure requirements, specific recommendations for patients to have cardiac and pulmonary evaluations before surgery, and that no more than two major procedures should be scheduled during one operation (5). After CDC shared preliminary results of the investigation of cosmetic surgery–associated deaths, the MOH distributed the safety and quality guidelines (5) to cosmetic surgeons in the country, made monitoring visits to 77 facilities that offered cosmetic surgery, and certified infection control committees for high volume cosmetic surgery centers. The MOH created a multilateral commission, including representatives from the Dominican Society of Plastic Surgery, to review perioperative adverse events, including deaths, and recommend disciplinary or administrative sanctions when warranted. Results of ongoing passive surveillance by the Dominican Republic government are provided to the U.S. Embassy regarding deaths of U.S. citizens after medical care.

As a result of this investigation, the U.S. State Department updated the Medical Tourism and Elective Surgery advisory on the website of the U.S. Embassy in the Dominican Republic^§§ to provide a list of steps to take to reduce the risk for adverse outcomes, including a recommendation to obtain international travel insurance to cover medical evacuation back to the United States.

U.S. citizens considering cosmetic surgery abroad should consult with their primary health professionals about their inherent risk for adverse events after surgery and preventive measures they can take to reduce the risk. They should consult with a travel medicine specialist ≥1 month before travel, and, as air travel and surgery independently increase the risk for blood clots, patients should allow adequate time between flying to and from a destination for surgery to reduce the risk for complications (10).