CDC Reports Deaths After Medical Tourism in the Dominican Republic

There were 93 deaths among U.S. residents who traveled to the Dominican Republic (D.R.) for cosmetic surgery from 2009 through 2022, according to findings in Morbidity and Mortality Weekly Report (MMWR).

While there were a mean of 4.1 deaths after cosmetic surgery from 2009 through 2018, that number rose of 13 during 2019-2020, with a peak of 17 in 2020, Elizabeth Bancroft, MD, of the CDC’s National Center for Emerging Zoonotic and Infectious Diseases in Atlanta, and colleagues reported.

Among a subset of the deaths that occurred during peak years, most “were found to be the result of embolic events (fat emboli or venous thromboembolism) for which a high proportion of the patients who died had risk factors, including obesity and having multiple procedures performed during the same operation,” the researchers wrote.

The researchers noted that the deaths were largely tied to gluteal fat transfer, which is also known as the Brazilian butt lift (BBL). MedPage Today has previously reported that in surgical circles, the BBL is known as the deadliest aesthetic procedure ever performed. Deaths tied to the procedure frequently involve pulmonary fat embolism, where fat globules travel through the bloodstream and cut off circulation.

Medical records were available for 24 of the 29 deaths that occurred in 2019-2020 — and gluteal fat transfer was performed in the majority of these cases (92%). Autopsy reports were available for 20 of the cases with medical records, and 90% of the deaths were due to embolic phenomena, including fat emboli or venous thromboembolism.

All 24 of those patients were women, who had a mean age of 41 years and a mean BMI of 32. Comorbidities associated with increased risk of venous thromboembolism were reported in 92% of cases. Liposuction was performed in all cases, and a mean of three procedures — including gluteal fat transfer, abdominoplasty, and breast augmentation — were performed for each patient during surgery.

The D.R. has become a popular medical tourism hub because of lower costs and shorter wait times, as well as its proximity to the U.S. and existing tourism infrastructure, the authors said. When the mean number of deaths rose after 2018, the U.S. Embassy in the D.R. contacted the CDC, which launched an investigation in collaboration with the D.R. Ministry of Health.

The study was limited by a lack of reliable statistics available on total cosmetic procedures done on U.S. citizens in the D.R. each year, and also by potential underreporting of deaths to the U.S. Embassy. Still, the researchers noted that risks to these patients “might have been mitigated or prevented with improved surgical protocols and postoperative medical care, including prophylactic measures against venous thromboembolism.”

In another MMWR report, the CDC identified 15 cases of Mycobacterium abscessus among patients in nine states who had cosmetic surgery at a single facility in south Florida.

Of these patients, 80% had received a gluteal fat transfer, all had received liposuction, and in 67% of cases, the infected wound site was in the buttocks, Katharine Saunders, DNP, of CDC’s Epidemic Intelligence Service, and colleagues reported.

In February 2023, the CDC contacted the Florida Department of Health about a non-Florida resident with a nontuberculous mycobacteria (NTM) infection who had a cosmetic procedure at a south Florida clinic. The two agencies subsequently identified 14 more cases, all in patients who had seen “a plastic surgeon in solo practice.”

An assessment by the Florida health department revealed “multiple lapses in infection control and prevention” at a second clinic with the same staff as the first facility following its closure for renovation. These included “gaps in environmental cleaning practices, use of proper personal protective equipment, and disinfection during surgical device reprocessing,” Perkins and colleagues reported.

Of the 15 cases, all were women, with a median age of 33. A median of 69 days had passed between procedure and symptom onset. The patients had swelling, purulent drainage, redness, and pain at surgical sites. They were treated with oral and IV antibiotics for up to 2 to 6 months, as well as wound incision, drainage, and debridement. Available samples from seven patients were analyzed with whole genome sequencing, which identified four closely related isolates.

South Florida has documented some of the highest numbers of deaths related to gluteal fat transfer, and has recently begun to crack down on “budget” clinics whose practices put patients at risk.

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