Introduction
In the contemporary era, advancements in medical technology have been accompanied by a growing public interest in aesthetic procedures. In particular, Korea has witnessed a continuous rise in the number of individuals undergoing aesthetic interventions [1]. In clinical medicine, procedures are usually performed to correct functional abnormalities caused by disease or injury, and treatment is initiated based on the patient's informed decision after the weighing the potential benefits and risks. However, aesthetic procedures differ from those in general clinical practice in that they are undertaken for cosmetic satisfaction despite a medically normal functional status [2,3]. Furthermore, the widespread perception that aesthetic procedures are relatively less invasive, often leads individuals to underestimate their inherent risks.
In this context, most individuals who choose to undergo aesthetic procedures, do not anticipate fatal outcomes or death. Consequently, when an unexpected death occurs, it generates substantial social repercussions and almost inevitably results in medicolegal disputes. In forensic practice, periprocedural deaths associated with aesthetic interventions are not uncommon, and some have been amplified by media coverage, intensifying public concern over the safety of these procedures [4-6]. However, since aesthetic procedures are not covered by the National Health Insurance system in South Korea, official statistical data on periprocedural complications or deaths remain unavailable. Despite this limitation, the Korea Health Industry Development Institute conducted a comprehensive study in 2013 to assess the national landscape of aesthetic procedures and develop user information guidelines [7]. The analysis incorporated diverse data sources including arbitration records from the Korea Medical Dispute Mediation and Arbitration Agency, reports of breast implant-related adverse events submitted to the Ministry of Food and Drug Safety, consumer injury relief cases filed with the Korea Consumer Agency, and publicly accessible domestic court precedents. Although this study provided one of the most detailed and representative overviews of aesthetic procedure practices in Korea at the time, the inherent characteristics of the data sources limited the ability to accurately assess the true incidence or nature of fatal complications associated with aesthetic interventions.
Accordingly, this study aimed to elucidate the current landscape of periprocedural deaths associated with aesthetic interventions through an objective analysis of cases subjected to death investigation and postmortem examination in Korea. Furthermore, it sought to provide foundational data for enhancing patient safety and preventing premature deaths, the ultimate goal of death investigation, along with practical insights and recommendations for real-world forensic practice, thus contributing to improving forensic medical service.
Materials and Methods
The study included cases of death that occurred during or after aesthetic procedures, including both surgical operations and minimally invasive interventions such as filler injections and laser treatments, that were referred for forensic autopsy to the National Forensic Service headquarters and its regional institutes (Seoul, Busan, Daejeon, Daegu, and Gwangju) between January 2016 and December 2024. For each case, the relevant information was comprehensively collected through a detailed review of the materials archived at the respective institutions, including autopsy reports, ancillary testing results, police investigation reports, and available medical records. When medical records were unavailable due to return to the jurisdictional authority (the police), the clinical summary documented in the autopsy report was referenced.
The collected variables included age at death, sex, nationality (domestic or foreign), postmortem findings, clinical manifestations and course, past medical history, type and duration of the procedure, clinical department and board-certification status of the operator, anesthesia type, involvement of an anesthesiologist, and medical facility type. The presence of specific medical documentation, such as outpatient notes, anesthesia charts, operative/procedure notes, results of preoperative evaluation, and consent forms for surgery/procedure and anesthesia, was also reviewed. Procedure duration was defined as the interval between the initiation and termination of the procedure. If an adverse event (e.g., cardiac or respiratory arrest) or death occurred before completion, that time point was considered the end of the procedure.
Because of the wide variation in aesthetic procedures, detailed categorization by each individual procedure type was impractical. Therefore, in accordance with the classification used in the International Society of Aesthetic Plastic Surgery Global Survey Report 2023 [8], procedures were broadly grouped into four categories— with minor adaptations to reflect the characteristics of this study: (1) face and neck, (2) body liposuction, (3) vaginal rejuvenation, and (4) others (including breast surgery, hair transplantation, and body filler procedure). The causes of death, postmortem findings, and clinical features were analyzed according to each category. Descriptive statistics, including means and medians, were calculated using Microsoft Excel version 365 (Microsoft, Redmond, WA, USA).
This study was approved by the Institutional Review Board of the National Forensic Service (906-250219-BR-010-03).
Results
1. Demographic characteristics of decedents
A total of 50 cases of aesthetic procedures-related death were retrieved. The sex distribution showed a marked female predominance, with 41 woman (82%) and nine men (18%). The median age of the woman was 29 years (range, 19 to 82 years), with the majority in their 20s to 40s. In contrast, the median age of the men was 50 years (range, 29 to 69 years), displaying a relatively even distribution across age groups. Regarding nationality, 36 cases (72%) involved domestic decedents, whereas 14 (28%) involved foreign nationals. The median body mass index was 28.4 kg/m² (range, 22.5 to 49.3 kg/m²) among the men and 23.3 kg/m² (range, 16.1 to 34.1 kg/m²) among the women. Analysis of medical histories revealed that 13 decedents (26%) had undergone previous aesthetic procedures. Additionally, 31 decedents (62%) had pre-existing conditions, including obesity, hypertension, diabetes mellitus, hyperlipidemia, allergies, thyroid disorders, or psychiatric illnesses. The average annual number of deaths was 5.6, showing a gradual upward trend over the study period (Table 1, Fig. 1).
Fig. 1.
Annual trends in aesthetic procedure-related deaths subjected to postmortem examination between 2016 and 2024.
Table 1.
Demographic characteristics of decedents
| Value (n=50) | |
|---|---|
| Sex | |
| Male | 9 (18) |
| Female | 41 (82) |
| Age (yr) | |
| Total | 29 (19-82) |
| Male | 50 (29-69) |
| Female | 29 (19-82) |
| BMI (kg/m2) | |
| Male | 28.4 (22.5-49.3) |
| Female | 23.3 (16.1-34.1) |
| Nationality | |
| Domestic | 36 (72) |
| Foreign | 14 (28) |
| Historya) | 35 (70) |
| Previous plastic procedures | 13 |
| Face | 10 |
| Breast | 2 |
| Body liposuction | 1 |
| Psychological | 4 |
| Medical | 31 |
| Obesity | 8 |
| Hypertension | 6 |
| Diabetes mellitus | 8 |
| Dyslipidemia | 3 |
| Others | 22 |
| Smoking | 2 |
2. Types of aesthetic procedures
Classification of the 50 aesthetic procedure-related deaths by the procedure type revealed that deaths in the face and neck group were the most frequent, comprising 26 cases (52%). This was followed by the body liposuction group with 11 cases (22%), the vaginal rejuvenation group with six cases (12%), and the other procedures group with seven cases (14%). Nine different procedures were identified in the face and neck group. Rhinoplasty, facelift, and blepharoplasty were the most common procedures. Notably, combined or sequential procedures, in which two or more interventions were performed during the same operative session, accounted for more than half of the cases (14/26, 54%). Other procedures, such as facial contouring surgery, facial fat removal or liposuction, fat grafting, facial filler injection, Botulinum toxin therapy, and skin resurfacing, were also identified. Vaginal filler injections and laser-based vaginal rejuvenation were performed in the vaginal rejuvenation group (n=6). Two decedents (33%) underwent combined treatment using both modalities. The other procedures group (n=7) included breast augmentation or reconstruction in four cases (57%), hair transplantation in two cases (29%), and body filler injection in one case (14%).
3. Death circumstance and procedure duration
In the face and neck group (n=26), most deaths or critical events occurred during the procedure (13 cases; 50%). Immediate post-procedural events or in-hospital deaths accounted for seven cases (27%), while post-discharge deaths at the decedent's residence or temporary accommodation were observed in six cases (23%). The mean procedure duration was 4.2 hours (range, 1.2 to 7.5 hours). In the body liposuction group (n=11), intra-procedural deaths occurred in three cases (27%), and events or deaths mostly occurred immediately after the procedure or during hospitalization (five cases, 46%). The remaining three decedents (27%) died after discharge. Among the 10 cases with available time data, the mean procedure duration was 4.6 hours (range, 2 to 11.2 hours). In the vaginal rejuvenation group (n=6), the procedure duration was short for single-procedure cases (10-20 minutes), whereas the two combined procedure cases lasted 50 minutes and 1 hour 30 minutes, respectively. Intra-procedural death or event occurred in one case (17%), while post-procedural events or deaths comprised the majority of cases (four cases, 66%). One decedent (17%) involved died after discharge. In the other procedures group (n=7), the mean procedure duration was 1.1 hours (range, 0.2 to 2 hours). In this group, intra-procedural events or deaths accounted for most cases (six cases, 86%), with immediate post-procedural death occurring in one case (14%) (Tables 2-6).
Table 2.
Types of aesthetic procedure
| Aesthetic procedure | No. (%) (n=50) |
|---|---|
| Face and necka) | 26 (52) |
| Rhinoplasty | 12 |
| Lift | 10 |
| Blepharoplasty | 9 |
| Facial contouring surgery | 5 |
| Liposuction | 3 |
| Fat graft | 4 |
| Filler injection | 2 |
| Botox injection | 2 |
| Skin resurfacing | 1 |
| Body liposuction | 11 (22) |
| Vaginal rejuvenation | 6 (12) |
| Others | |
| Breast | 4 (8) |
| Hair implant | 2 (4) |
| Body filler | 1 (2) |
Table 3.
Characteristics of periprocedural deaths associated with face and neck aesthetic procedures
| Cause of death | Event during procedure | Event after procedure | Event after discharge | Anesthesia type | Total (n=26) | ||
|---|---|---|---|---|---|---|---|
| General | IV sedation | Local | |||||
| Anesthesia related death | |||||||
| TAD | |||||||
| Hypoxic brain injury | 3 | 0 | 0 | 1 | 2 | 0 | 3 |
| Undetermined | 3 | 1 | 0 | 1 | 3 | 0 | 4 |
| Epinephrine toxicity | 0 | 1 | 0 | 0 | 0 | 1 | 1 |
| Lidocaine toxicity | 1 | 0 | 0 | 0 | 0 | 1 | 1 |
| PAD | |||||||
| SAH related to local anesthesiaa) | 1 | 0 | 0 | 0 | 0 | 1 | 1 |
| Hypoxic brain injury (with bleeding, anesthesia, heart disease) | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
| MH | 1 | 0 | 0 | 1 | 0 | 0 | 1 |
| Procedure related death | |||||||
| Foreign body aspiration following rhinoplasty | 0 | 0 | 1 | 1 | 0 | 0 | 1 |
| Pulmonary embolism | 0 | 2 | 0 | 2 | 0 | 0 | 2 |
| Stress induced cardiomyopathy | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
| Anaphylaxis | |||||||
| Anaphylaxis shock | 2 | 0 | 0 | 0 | 2 | 0 | 2 |
| Natural disease | |||||||
| Acute myocardial infarction | 0 | 0 | 1 | 0 | 0 | 1 | 1 |
| Myocarditis | 0 | 1 | 0 | 1b) | 1b) | 0 | 1 |
| Chronic ischemic disease | 0 | 0 | 1 | 0 | 1 | 0 | 1 |
| Pneumonia | 0 | 0 | 1 | 0 | 1 | 0 | 1 |
| Diabetic ketoacidosis | 0 | 0 | 1 | 0 | 1 | 0 | 1 |
| Others | |||||||
| Undetermined | |||||||
| Psychiatric medications (Q-T prolongation risks, hypothyroidism) | 0 | 0 | 1 | 0 | 0 | 1 | 1 |
| Undetermined | |||||||
| SCD related to hypertrophied heart | 0 | 1 | 0 | 1 | 0 | 0 | 1 |
| SDH and pneumonia | |||||||
| Following facial contouring surgery, unknown patient care issue during admission | 0 | 1 | 0 | 1 | 0 | 0 | 1 |
IV, intravenous; TAD, totally anesthesia-related death; PAD, partially anesthesia-related death; MH, malignant hyperthermia; SCD, sudden cardiac death; SDH, subdural hemorrhage; SAH, subarachnoid hemorrhage.
a) SAH occurred immediately after lidocaine-epinephrine administration during local anesthesia. No aneurysm was identified on postmortem examination; similar cases have been described in a previous report. Based on the clinical course, postmortem findings, and supporting literature, SAH was determined to be associated with local anesthesia and was therefore classified as a PAD;
Table 4.
Characteristics of periprocedural deaths associated with body liposuction
| Cause of death | Event during procedure | Event after procedure | Event after discharge | Anesthesia type | Total (n=11) | ||
|---|---|---|---|---|---|---|---|
| General | IV sedation | Local | |||||
| Anesthesia-related death | |||||||
| TAD | |||||||
| Overdose of local anesthetics | 1 | 0 | 0 | 0 | 1a) | 1a) | 1 |
| PAD | |||||||
| SCD (IHD contributed by anesthesia) | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
| Undetermined (anesthesia combined with anemia) | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
| Undetermined (anesthesia combined with bleeding, long procedure time) | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
| Procedure-related death | |||||||
| Peritonitis due to internal organ injuries | 0 | 1 | 2 | 0 | 3 | 0 | 3 |
| Hemorrhagic shock due to bleeding | 0 | 2 | 0 | 1 | 1 | 0 | 2 |
| Sepsis due to postoperative infection | 0 | 1 | 1 | 0 | 2 | 0 | 2 |
Table 5.
Characteristics of periprocedural deaths associated with vaginal rejuvenation procedures
Table 6.
Characteristics of periprocedural deaths associated with other aesthetic procedures
4. Causes of death
Analyses of all 50 cases revealed that anesthesia-related deaths were the most frequent, accounting for 23 cases (46%), nearly half of all fatalities. This was followed by procedural complications in 16 cases (32%), natural deaths due to pre-existing diseases in six cases (12%), anaphylactic shock in two cases (4%), and other causes in three cases (6%). According to the procedure type, in the face and neck group (n=26), anesthesia-related deaths were the leading cause (12 cases, 46%), followed by procedural complications (four cases, 15%), natural deaths (five cases, 19%), anaphylactic shock (two cases, 8%), and other causes (three cases, 12%). In the body liposuction group (n=11), procedural complications, including internal organ injury followed by peritonitis, hemorrhage, and post-procedural infection, were observed in seven cases (64%), representing a higher proportion than anesthesia-related deaths (four cases, 36%). In the vaginal rejuvenation group (n=6), fatal pulmonary embolism caused by the filler material, categorized as a procedural complication, accounted for the majority of deaths (5 cases, 83%), whereas the remaining case (one case, 17%) was anesthesia-related. The filler materials identified were hyaluronic acid and collagen, used either alone or in combination. In the other procedures group (n=7), anesthesia-related deaths predominated (six cases, 86%), with sudden cardiac death observed in one case (14%) (Tables 2-6).
5. Anesthesia-related deaths
Anesthesia-related deaths occurred across all procedure groups, comprising 23 cases (46%) out of the total 50 fatalities, nearly half of all deaths. Accordingly, these cases were analyzed separately. Anesthesia-related deaths were classified into two categories: totally anesthesia-related deaths (TAD), in which death was entirely attributable to anesthesia, and partially anesthesia-related deaths (PAD), in which anesthesia, along with surgical factors or pre-existing comorbidities, contributed to the fatal outcome [9,10]. TAD accounted for 17 cases (74%), while PAD accounted for six cases (26%). Among the 17 TAD cases, 12 patients (70%) involved cardiac arrest or apnea that occurred during general anesthesia or sedation. Propofol was administered in 11 of these cases (65%), whereas dexmedetomidine was used in one case. The remaining five TAD cases included three deaths due to drug toxicity from local anesthetic overdose, and two cases of malignant hyperthermia associated with the inhalational agent sevoflurane. The six PAD cases were multifactorial, with additional contributing factors beyond anesthesia. Three cases involved procedural complications such as intraoperative hemorrhage. Two involved pre-existing conditions including cerebral hemorrhage and heart disease and one was presumed to involve polypharmacy, where psychiatric medications combined with anesthetic drugs likely contributed to the fatal outcome.
Regarding the type of medical facility, 22 cases (96%) occurred in clinics, while one case (4%) occurred in the outpatient department of a university hospital. An analysis of the attending practitioners’ specialties showed that board-certified specialists performed the procedures in 20 cases (87%); Plastic Surgery (n=16) and Dermatology, Urology, Obstetrics/Gynecology, and Otolaryngology (n=1 each), whereas general practitioners performed three cases (13%). Notably, anesthesiologists were involved in only six cases (26%), indicating limited specialist participation during anesthesia administration (Table 7).
Table 7.
Characteristics of anesthesia-related deaths
| Procedure type | Anesthesia-related death categorization | Procedure timea) | Anesthetics | Anesthesiologist involvement | Primary operatorb) | Facility type | |
|---|---|---|---|---|---|---|---|
| Categorization | Cause of death | ||||||
| Face and neck | TAD | ||||||
| Cardiac arrest and hypoxia | Undetermined | 1 hr 35 min | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Undetermined | 1 hr 43 min | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Undetermined | 1 hr 20 min | Dexmedetomidine | Present | PS | C | |
| Cardiac arrest and hypoxia | Undetermined | 10 min | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Hypoxic brain injury | 20 min | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Hypoxic brain injury | 40 min | Propofol | - | GP | C | |
| Cardiac arrest and hypoxia | Hypoxic brain injury | 2 hr | Sevoflurane, lidocaine | - | PS | C | |
| Overdose of local anesthetics | Epinephrine toxicity | 1 hr 10 min | Epinephrine | Present | DM | C | |
| Overdose of local anesthetics | Lidocaine toxicity | 15 min | Lidocaine | - | PS | C | |
| MH | MH | 5 hr 30 min | Sevoflurane | Present | PS | C | |
| PAD | |||||||
| Disease and local anesthetics | SAH related to local AN | 5 min | Epinephrine, lidocaine | - | PS | UH | |
| Disease, procedure Cx, AN | Hypoxic brain injury (with bleeding, AN, heart disease) | 6 hr | Propofol | Present | PS | C | |
| Body liposuction | TAD | ||||||
| Overdose of local anesthetics | Lidocaine toxicity | 2 hr | Lidocaine | - | PS | C | |
| PAD | |||||||
| AN, disease | SCD (IHD & AN) | 1 hr 15 min | Propofol | NA | Uro | C | |
| AN, procedure Cx | Undetermined (AN, anemia) | 3 hr | Propofol | - | GP | C | |
| AN, Procedure Cx | Undetermined (AN, bleeding, long procedure time) | 11 hr 10 min | Propofol | - | PS | C | |
| Vaginal rejuvenation | TAD | ||||||
| Cardiac arrest and hypoxia | Hypoxic brain injury | 13 min | Propofol | - | OBGY | C | |
| Others | TAD | ||||||
| Cardiac arrest and hypoxia | Hypoxic brain injury | 30 min | Propofol | - | ENT | C | |
| Cardiac arrest and hypoxia | Propofol related deathc) | 40 min | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Propofol related death | 1 hr | Propofol | - | PS | C | |
| Cardiac arrest and hypoxia | Undeterminedd) | 50 min | Propofol | Present | PS | C | |
| MH | Malignant hyperthermia | 2 hr | Sevoflurane | Present | PS | C | |
| PAD | |||||||
| AN, multiple drug administration | Undetermined | 2 hr | Lidocaine, diazepam, midazolam | - | GP | C | |
TAD, totally anesthesia-related death; -, absent; PS, plastic surgeon; C, clinic; GP, general practitioner; DM, dermatologist; MH, malignant hyperthermia; PAD, partially anesthesia-related death; SAH, subarachnoid hemorrhage; AN, anesthesia; UH, university hospital; Cx, complication; SCD, sudden cardiac death; IHD, ischemic heart disease; NA, not available; Uro, urologist; OBGY, obstetrician-gynecologist; ENT, ear, nose, and throat, or otolaryngologist.
a) Procedure time refers to the period from the initiation of the procedure under anesthesia to either the end of the procedure or the time of an adverse event such as cardiac arrest. If an event occurred after the procedure was completed, the endpoint was the time of procedure completion; if the event occurred during the procedure, the endpoint is the time of the event;
b) Primary operator denotes the medical specialty of the physician who primarily performed each aesthetic procedure;
Discussion
This study sought to elucidate the characteristics of periprocedural deaths associated with aesthetic interventions from a public health perspective, based on forensic autopsy cases. Through this approach, we aimed to partially address the lack of official statistics on aesthetic procedure-related mortality in Korea. Geographically, most deaths occurred in the Seoul metropolitan area, and by procedure type, the face and neck group accounted for the largest proportion of deaths. The most frequent cause of death was anesthesia-related death, followed by procedural complications and diseases (natural deaths). Demographically, most decedents were young women, and several decedents were foreign nationals. This distribution might reflect just a general demographic pattern of aesthetic procedure users in Korea, among whom young women constitute the largest proportion. Therefore, this finding should not be interpreted as suggesting a higher mortality risk among young women, especially given the absence of comprehensive national statistics on aesthetic procedure utilization. Moreover, a previous study that analyzed legal disputes related to aesthetic surgery in Korea, based on civil court precedents, demonstrated a similar trend; most disputes arose in Seoul and primarily involved facial procedures [3]. However, direct comparison is not feasible, as these precedent cases were presumed to largely exclude fatal outcomes, and demographic information on the affected individuals was not available.
Anesthesia-related deaths accounted for the largest proportion of fatalities in this study, representing 46% of all cases, regardless of the procedure type. To better characterize these deaths, we referred to a French study based on national health data and mortality statistics [9]. Although the authors of this study emphasized the importance of distinguishing between PAD and TAD, they did not make this differentiation in its actual analysis, and classified all cases collectively as anesthesia-related deaths. The three principal proposed mechanisms of death were as follows: (1) perioperative ischemia in patients with underlying coronary atherosclerosis, (2) hypovolemia due to intraoperative hemorrhage, and (3) aspiration of gastric contents occurring in a relatively hypovolemic state. In contrast, an Italian autopsy-based study explicitly differentiated PAD from TAD [11]. Among the 85 intraoperative deaths analyzed, 33 cases (38.8%) were classified as anesthesia-related (28 PAD and 5 TAD). Multiple contributing factors were implicated in PAD cases beyond anesthesia itself. The primary contributing factors were pre-existing conditions such as coronary atherosclerosis and chronic obstructive pulmonary disease, compounded by surgical complications such as operative trauma, hypoxia, hypothermia, hemorrhage, anemia, fasting, and tracheal intubation-related issues. While previous studies have primarily examined anesthesia-related deaths among high-risk surgical patients, the present study offers a distinct perspective by focusing on fatalities that occurred during elective, minimally invasive aesthetic procedures.
These previous studies were limited in their direct comparability with the aesthetic procedure group, as they primarily involved high-risk surgical patients requiring general anesthesia. Nevertheless, they provide a useful framework for comparing the patterns and distinctive characteristics of anesthesia-related deaths observed in the present study. In this study, most decedents were healthy or had only mild comorbidities and died during relatively less invasive procedures, a pattern that differs from that reported in general surgical population. Notably, the proportion of TAD was higher in our aesthetic procedure group compared to the Italian study. Furthermore, unlike previous studies in which anesthesia-related deaths constituted only a subset of overall intraoperative fatalities, the present study revealed that anesthesia-related deaths accounted for the largest proportion of all aesthetic procedure-related deaths, exceeding those attributed to procedural complications or underlying diseases. This finding suggests that in periprocedural deaths associated with aesthetic interventions, the possibility of anesthesia-related death should be given primary consideration during death investigation and postmortem examination.
Both the previous studies and the present study reaffirm the crucial role of death investigation and autopsy in determining anesthesia-related mortality. Deaths occurring during anesthesia must be clearly distinguished from non-anesthesia-related deaths, such as those resulting from procedural complications or pre-existing conditions. Autopsy enables the exclusion of non-anesthetic causes, whereas a comprehensive review of the clinical course and death circumstances through death investigation allows for a more accurate and reliable determination of the cause of death.
However, even when a death is classified as anesthesia-related, clearly establishing a causal relationship with medical negligence or substandard care, such as inadequate anesthesia care or perioperative management, remains challenging. This difficulty arises from the inherent complexity of defining and diagnosing anesthesia-related deaths and the numerous factors that must be considered throughout the continuum of clinical care. In the French study based on national health and mortality data, only approximately 2% of anesthesia-related deaths were judged to have fully met the standard of care [9]. The vast majority of the cases were found to deviate from the standard in at least one aspect. However, root-cause analysis revealed that, while some errors were attributable to clinical practice (e.g., excessive drug dosage during induction and insufficient management of hypotension), many were linked to systemic and institutional issues, such as inadequate organizational structures, insufficient staffing or facilities, suboptimal clinical environment, and procedural deficiencies. Similarly, the Italian study reported that several PAD cases involved substandard postoperative management, and most TAD cases demonstrated errors in anesthetic practice that led to legal disputes [10]. Nevertheless, medical negligence has rarely been identified in most anesthesia-related fatalities. Moreover, these previous studies of anesthesia-related mortality based on epidemiological surveys have inherent limitations in establishing a definitive causal relationship between anesthesia and death. Both studies emphasized the necessity of a comprehensive investigation into the clinical course and circumstances surrounding death, supported by expert consultation, to achieve an accurate diagnosis of anesthesia-related mortality.
In this study, equipment-related issues were identified in two cases, including malfunctioning of n drug infusion and monitoring devices. Excessive administration of local anesthetics was confirmed in three cases. However, in many instances, it was difficult to determine whether anesthesia care and perioperative management adhered to the standard of care. This limitation reflects a structural constraint of the Korean death investigation system; information available at the autopsy stage is often restricted, and the medical records provided in the early phase of the investigation tend to be incomplete. Among the 23 anesthesia-related deaths analyzed in this study, anesthesiologists were involved in only six cases (26%). In most of the remaining cases, only brief procedural notes were recorded in the outpatient charts, and in some instances, documentation was entirely absent. Consequently, reconstructing the actual clinical course based solely on fragmented medical records was challenging. Moreover, the inherent risks associated with anesthesia must be recognized. Sedation exists along a dynamic continuum ranging from minimal to deep sedation and general anesthesia, and in real-world clinical practice, patients can easily drift into a deeper-than-intended level of sedation [11]. Therefore, when legal disputes concerning anesthesia or perioperative management arise, cautious and comprehensive evaluation supported by thorough investigation and expert consultation, is essential.
In 2016, the Korean Society of Anesthesiologists (KSA) introduced the “Practice Guideline for Propofol Sedation by Non-Anesthesiologists” as part of the National Clinical Research and Patient Safety Policy Project [11]. This guideline presented comprehensive recommendations for ensuring safe sedation, encompassing all stages of the process, including pre-sedation patient evaluation and preparation, qualification of personnel responsible for sedation, availability of appropriate monitoring equipment, drug administration protocols, post-sedation care, documentation, and education and training requirements. Furthermore, the Korea Health Industry Development Institute (KHIDI) developed the “Guideline and Standards for the Safety of Cosmetic Surgery (Procedures) Users” [12], which outlines safety standards related to facility conditions, procedural environments, management across pre-, intra-, and postoperative phases, and protocols for emergency response and patient transfer.
However, despite the presence of these national guidelines, the present study was limited in its ability to assess real-world implementations. The analysis was conducted solely based on medical records available prior to autopsy, which restricted the evaluation of institutional characteristics such as facility infrastructure, staffing composition, and the overall clinical environment. Moreover, the completeness and reliability of the available documentation were insufficient. In particular, medical records prepared immediately after the incident may have contained omissions, representing one of the key limitations of this study.
Within the analytical scope of this study, it is noteworthy that 49 of 50 cases (98%) occurred in private clinics. Only seven cases (14%) had all five essential types of medical documentation, including outpatient records, anesthesia records, surgical or procedural notes, preoperative tests, and consent forms, and involved the direct participation of an anesthesiologist. The remaining cases exhibited varying degrees of documentation deficiency. In some cases, an anesthesiologist participated but records other than the anesthesia chart were incomplete. In others, the procedure was conducted without an anesthesiologist, or no documentation regarding the procedure or anesthesia was available at all. Interestingly, among the seven well-documented cases involving an anesthesiologist, no anesthesia-related deaths were observed except for one case of malignant hyperthermia associated with an inhalational anesthetic agent. The remaining deaths in this subgroup were due to non-anesthetic causes, such as sudden cardiac death, myocarditis, pulmonary embolism, pneumonia, and airway obstruction following rhinoplasty.
In light of these findings, although it is impossible to fully predict all potential risks prior to aesthetic procedures, it is essential to actively incorporate the recommendations in the existing guidelines into clinical practice. Whenever possible, triggering agents should be avoided, and appropriate preparedness must be ensured to enable an immediate response in the event of an adverse incident. Private clinics may face inherent limitations in terms of the available resources, such as personnel, equipment, and emergency response systems. Nevertheless, even within these practical constraints, proactive consultation and adaptation of the relevant guidelines to suit the institutional context are crucial. This can not only strengthen patient safety and help prevent anesthesia-related deaths but also demonstrates that clinicians are providing care consistently with good medical practice [13]. Therefore, it is important for each institution to establish an efficient and feasible emergency response system tailored to its own capacity.
In Korea, the courts tend to place considerable weight on the standard of care when determining medical negligence and liability in litigation, and physicians face a significantly higher rate of criminal prosecution than in other countries [14,15]. Given this judicial context, caution is required to ensure that the clinical guidelines for patient safety are not misconstrued as legally binding standards of care. Clinical guidelines represent systematically developed recommendations intended to assist healthcare professionals and patients in making optimal care decisions; they should be clearly distinguished from the standard of care, which constitutes the legal duty to provide reasonable and appropriate treatment to an individual patient with a specific condition under a particular set of circumstances [13,16,17].
In this study, non-anesthesia-related causes of death included pre-existing diseases, procedural complications, and other miscellaneous factors. Across different procedure types, deaths were associated not only with well-recognized postoperative complications such as inflammatory reactions, surgical site infections, and pulmonary embolism, but also with adverse drug reactions. Notably, documentation confirming medical history was available in only 33 of 50 cases (66%), while in the remaining cases, there was no record indicating whether such information had been reviewed. Two deaths (4%) were attributed to drug hypersensitivity reactions. In one case, the specific causative drug could not be identified with no medical history. However, in the other case, despite the absence of any documented allergy in the medical records, the subsequent police investigation uncovered a history of hypersensitivity to nonsteroidal anti-inflammatory. Moreover, seven (14%) cases involved procedures lasting longer than six hours, with one extending beyond approximately 11 hours. These findings collectively underscore the importance of comprehensive preoperative risk assessment and careful procedural planning to prevent deaths unrelated to anesthesia. In particular, as emphasized by the KHIDI study and guideline, thorough evaluation of the medical history, physical condition, and risk factors such as thrombosis or embolism, as well as limiting the procedure duration to within 6 hours, are essential for ensuring patient safety [12]. These observations highlight the critical importance of adhering to such recommendations in real-world clinical settings to reduce preventable fatalities and enhance procedural safety.
This study also examined procedure-specific characteristics and distinctive complications across different aesthetic intervention types. In the face and neck procedure group, three notable fatal cases were identified: (1) airway obstruction leading to asphyxia following rhinoplasty, in which fibrin glue was suspected to have contributed to upper airway occlusion; (2) fatal subdural hemorrhage after reduction malarplasty; and (3) stress-induced cardiomyopathy occurred during several facial procedures. Previous literature indicates that rhinoplasty-related respiratory complications may arise through mechanisms such as posterior displacement of nasal packing causing laryngeal obstruction, obstructive sleep apnea induced by nasal packing, or nasopulmonary reflex-mediated airway compromise [18]. These mechanisms suggest that the rhinoplasty-related death in this study may likewise have resulted from similar pathophysiological processes. A domestic case report described traumatic intracerebral hemorrhage attributable to secondary intraoperative injury due to reduction malarplasty [19]. In the malarplasty case in the present study, no additional cranial trauma beyond the operative facial bone sites was identified. However, due to the limited clinical information available, potential inpatient management-related factors affecting patient safety could not be fully excluded, making it difficult to definitively attribute the death solely to a procedural complication. The third case involved a 30-year-old woman who developed dyspnea, fever, tachycardia, and elevated cardiac enzyme levels during several procedures under sedation, with echocardiography indicating cardiac dysfunction. The deceased was clinically diagnosed with stress-induced cardiomyopathy, which subsequently deteriorated into multi-organ failure and death. Based on the clinical course and autopsy findings, the case was classified as procedure-related stress-induced cardiomyopathy.
In the body liposuction group, fatalities were associated with intra-abdominal organ injury leading to peritonitis, hemorrhagic shock, and sepsis secondary to surgical site infection. These complication patterns were consistent with the findings of a German study reporting fatal outcomes of liposuction procedures [20]. However, unlike the previous report, no deaths due to fat embolism were identified in the presnet study. Fatal complications, such as intra-abdominal organ injury or postoperative infection, may initially present with nonspecific symptoms, including localized pain at the surgical site after discharge. If these warning signs are underestimated or overlooked, critical conditions may progress unnoticed. Therefore, continuous postoperative monitoring and close follow-up are essential for the prompt detection and management of potential complications.
In the vaginal rejuvenation procedure group, all cases involving vaginal filler injection resulted in fatal pulmonary embolism caused by the filler materials. The substances used were hyaluronic acid and collagen. According to the previous studies, other materials such as silicone, polyacrylamide gel, and polylactic acid have also been used for vaginal augmentation, and pulmonary embolism has been reported with all of these agents [21]. While some patients survived after treatment, most reported cases had fatal outcomes, which is consistent with the findings of the present study. Importantly, over the past three decades, pulmonary embolism has been consistently reported in the literature, regardless of the type of filler material used, underscoring the inherent risk associated with vaginal filler injections. From a patient safety perspective, these findings highlight the need for heightened awareness, strict procedural regulation, and cautious consideration before such procedures are undertaken.
Given these observations, both practitioners and patients should recognize that body liposuction and vaginal filler injections carry inherent and sometimes unpredictable life-threatening risks. Therefore, to ensure public health safety, an informed decision-making process must be established that allows individuals to fully understand the safety of the procedure and its necessity and clinical justification before undergoing the procedure.
In this study, two cases (4%) were identified in which multiple psychotropic drugs were detected and presumed to have contributed to death. In both cases, medical records documented a history of panic disorder. One case was classified as a PAD, with postmortem blood concentrations of psychotropic medications exceeding the therapeutic range. The other case was categorized as an “other death,” where the individual was discharged following the procedure and found dead at home approximately two hours later. Toxicological results revealed psychotropic drugs at toxic concentrations, and a comorbid history of hypothyroidism was also identified. Intentional drug overdose was ruled out in both cases.
Given the pharmacological profiles of the detected drugs, potential adverse effects arising from drug interactions, including QT prolongation and arrhythmia, enhanced central nervous system depression, delayed respiratory suppression, and cumulative drug toxicity, can be considered to contribute to death. Nevertheless, it was difficult to determine the extent to which sedation, or the aesthetic procedure itself contributed to the fatal outcome. Previous studies have emphasized that patients receiving psychotropic therapy require careful preoperative evaluation due to the potential for drug interactions and challenges in managing psychiatric symptoms [22,23]. Furthermore, for patients with thyroid dysfunction, appropriate perioperative management has been recommended [24]. Therefore, these findings suggest that a thorough pre-procedural assessment of medical history and current medication use is essential in aesthetic practice to prevent premature deaths and enhance patient safety.
Based on the findings of this study and previous literature, the key considerations for postmortem examination of aesthetic procedure-related deaths are summarized in Fig. 2. Prior to autopsy, it is essential to thoroughly review the medical records to understand the specific details of the procedure performed and the associated clinical course. In addition, information regarding the type of medical facility, availability of equipment and resources, medical staff specialties, the decedent's medical history, and the circumstances and scene of death should be reviewed to obtain a comprehensive understanding of the case. During the autopsy, all procedure sites should be carefully examined during the external examination to identify any lesions or findings that may indicate procedural complications. During internal examination, the evaluation should not be limited to the procedure site itself, but should also include a comprehensive assessment of potential complications such as cardiovascular disease, airway obstruction, venous thrombosis, and pulmonary embolism.
Fig. 2.
Checklist for systematic approach to postmortem examination of aesthetic procedure-related deaths.
Furthermore, specific considerations should be given to the type of aesthetic procedure. In cases involving face and neck procedures, particularly rhinoplasty, a detailed examination of the upper airway, including the nasal cavity, nasopharynx, and laryngopharynx— should be performed to identify any foreign material or obstruction. In cases of facial contouring surgery such as reduction malarplasty, intracranial injury or hemorrhage should be carefully assessed. For body liposuction, attention should be paid to the possibility of internal organ injury, surgical site infection, sepsis, and fat embolism. Histopathological examination and bacterial cultures are recommended for identifying these complications. In vaginal filler procedures, pulmonary embolism caused by the filler material has been reported as the major cause of death. Therefore, pathological examination of the pelvic organs and lungs is essential. If the injected filler substance can be identified in advance, special histochemical staining or other ancillary pathological tests may assist in confirming the presence of the embolic material and substantiating the diagnosis.
In summary, this study involved a comprehensive forensic analysis of deaths related to aesthetic procedures subjected to medicolegal autopsy in Korea. It characterized the demographic features of the decedents, the procedural contexts, leading causes of death, and key considerations for death investigation practice. The findings clearly demonstrate the essential role of medicolegal autopsy and death investigation in establishing the cause of death in aesthetic procedure-related fatalities. The high proportion of anesthesia-related deaths, limited involvement of anesthesiologists, incomplete medical documentation, insufficient perioperative assessment and management, and lack of public awareness regarding the necessity, efficacy, and safety of aesthetic procedures collectively underscore urgent areas for improvement. Strengthening these aspects is crucial to ensure the safety of both practitioners and clients, despite inherent constraints in clinical resources. Ultimately, by presenting scientific data on aesthetic procedure-related deaths, this study bridges the gap left by the absence of official mortality statistics, in addition to establishing foundational evidence for preventing premature deaths and promoting safer clinical practice. It further contributes to strengthening the credibility and professional standards of the medicolegal death investigation system.
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