Fat Embolism Syndrome (FES) involving the brain may have catastrophic complications. The syndrome has an array of presentations varying from light headedness to respiratory failure, neurocognitive deficit and death. Its pathogenesis is poorly understood however moreover is associated with an undiagnosed perforated foramen ovale also known as Patent Foramen Ovale (PFO). Fat embolism following liposuction occurs in 10%-15% of patients with PFO, even when appropriate surgical strategies have been implemented. Current consensus is that PFO screening should not be done routinely except after cryptogenic stroke. There are no current guidelines for screening regarding surgery types to prevent stroke or death. The prevalence of PFO is about 25% in the general population, which increases the risk of cryptogenic stroke by 40% to 50%. Autopsy studies determined that patent PFOs with diameters between 0.2 cm to a 0.5 cm maximum dimension were present in 29% of cases, and PFO with a diameter of 0.6 cm to 1.0 cm in 6% of cases. There is no current treatment for FES or stroke other than supportive care in the setting of neurological impairment. A higher risk procedure that can be associated with fat embolism may be liposuction. Liposuction is one of the most commonly performed procedures in cosmetic and plastic surgery in the developed world. The number of procedures performed has steadily increased in the last five years representing 20% of all surgeries combined, placing it in the top three most requested procedures over the last five years. Doctors have a duty of care to ensure safest surgical outcomes. It is proposed that assessment for PFO should be considered for liposuction or other surgery that carry higher risk of FES. When considering primum non nocere, which is a double edged sword that every cure or intervention may involve potential harm, should a significant PFO be diagnosed before significant surgery, then the significant harm may be avoided.
