Cosmetic Surgery Complications in the ER:When Vanity Turns to Calamity
Jamil Ahmad, MD, FRCSCThe Plastic Surgery Clinic, Mississauga, Canada
Hand Program, University Health Network, Toronto, CanadaDivision of Plastic and Reconstructive Surgery,
University of Toronto, Toronto, CanadaCRITER 2014
Disclosures
• Book royalties from CRC Press
Cosmetic Surgery• Demand continues
increase• Surgical and nonsurgical
procedures
What is an aesthetic surgeryemergency?
An Approach to ER Cosmetic Surgery Emergencies
• Uncommon• Most patients with issues are seen in clinic
However…there are some rare
and devastating complications
Liposuction
• Significant fluid shifts• Lidocaine and epinephrine added to
infiltration solution
Liposuction
• Complexity is underestimated
Liposuction
• DVT/PE• Lidocaine/bupivacaine toxicity• Fat embolism• Intraabdominal injury
Venous Thromboembolism
• DVT or PE• Any procedure• Body contouring
VTE Treatment
• Prevention
• Individual• Procedural• Duration• Decreased
mobility
DVT/PE
DVT• Leg swelling• Leg pain• Warmth• Discolouration• Leg fatigue
• D-dimers• Duplex U/S
PE• Pleuritic chest pain• Shortness of breath• Coughing• Tachycardia/palpitations• Anxiety• Sweating
• D-dimers• ECG• CTA
Wells Scoring System
Remember…If you have a high index of suspicion,
start treatment immediately
Lidocaine/Bupivacaine Toxicity• Lidocaine in infiltration solution• Max dose differs compared with local
anesthetic injection dose• Peak lidocaine serum concentration 6-12
hours after infiltration• Bupivacaine for postop analgesia
Signs and Symptoms of Lidocaine Toxicity
CNS• Perioral tingling• Metallic taste• Lightheadedness• Dizziness• Visual disturbances• Tinnitus• Disorientation• Drowsiness• Convulsions• Loss of consciousness• Coma
Respiratory and CV• Respiratory depression and
arrest• Cardiovascular depression
and collapse
Treatment• Evacuation of local
anesthetic• Supportive• Intralipid 20%
1.5mg/kg IV bolus, 0.25mg/kg IV infusion for 60 mins
Fat Embolism
• Liposuction• Fat injection• Extremely rare• Potentially life
threatening
Signs and Symptoms of Fat Embolism
Respiratory• Dyspnea• Tachypnea• ARDS
Neurological• Precede respiratory
symptoms by 6-12 hours• Disorientation • Coma• Cerebral edema
Signs and Symptoms of Fat Embolism
Petechia• 2-3 days after injury• Head, neck, anterior chest,
subconjuntiva, axilla
Ophthalmological• Macular edema• Retinal hemorrhages
Investigations
• Nonspecific• ABG• Chest x-ray• CT/MRI brain
Treatment
• Supportive
Intraabdominal Injury
• Cannula• Fascial sutures
Intraabdominal Injury• Delay in diagnosis• Soft tissue
infection• Acute abdomen• Hemodynamic
instability
Breast Augmentation
• Hematoma• Implant infection• Pneumothorax
Hematoma
• Expanding• Vascular compromise• Pain
Pneumothorax
• 1 in 3 surgeons have had at least 1 patient
• Subcutaneous emphysema is common
• Gas in pleural cavity is abnormal
Mastopexy/Breast Reduction
• Hematoma• Nipple-areolar complex necrosis
Treatment
• Remove sutures• Evacuate any hematoma• Nitropaste TID
Rhinoplasty
• Epistaxis• CSF Rhinorrhea/
Intracranial injury• Toxic shock syndrome
Epistaxis• Head elevation• Oxymetazoline nasal spray• Pressure• Anterior nasal packing• Removal of internal splints• Irrigation• Silver nitrate• Posterior nasal packing• Exploration in OR• Angioembolization
CSF Rhinorrhea/Intracranial Injury• Septal surgery• Osteotomies• CSF rhinorrhea• Neurological changes• CT head• Neurosurgical
consultation
Toxic Shock Syndrome• Nasal packing/nasal splints• Breast implants• Staph aureus or Group A
Strep
Signs and Symptoms of Toxic Shock Syndrome
Symptoms• Influenzalike syndrome• Confusion• Signs of soft tissue infection
Influenzalike Syndrome• Fever• Chills• Myalgia• Nausea• Vomiting• Diarrhea
Signs and Symptoms of Toxic Shock Syndrome
Symptoms• Fever• Rash• Hypotension• Systemic evidence of
toxicity
CDC Criteria• Fever• Rash• Desquamation• Hypotension• Multisystem involvement in 3
or more systems– GI– Muscular– Mucous membranes– Renal– Hepatic– Hematological– CNS
Blepharoplasty• Retrobulbar hematoma• Blindness
Signs and Symptoms of Retrobulbar Hematoma
Symptoms• Severe pain• Visual changes
– Decreased visual acuity– Amaurosis fugax– Scintillating scotomas
Signs• Tense or expanding proptosis• Diminished extraocular
movements• Retinal/optic disc pallor• Increase intraocular pressure• Loss of pupillary reflexes• Scleral hematoma
Treatment• Remove sutures• 95% O2/5% CO2• 20% mannitol 1.5-2g/kg IV,
12.5g over 3 mins, remainder over 30 mins
• Acetazolamide 500mg/IV• Methylprednisolone 100mg IV• Betaxolol 1 drop• Lateral canthotomy
Soft Tissue Fillers
• 2nd most common cosmetic procedure
• Injectables for filling, volume
• Hyaluronic acid most common
• Everyone is doing it
Intravascular Injection• Inadvertent intravascular
injection• Vascular territory• Ischemia leading to necrosis• Soft tissue fillers or fat
injections• Very rare
Prompt diagnosis critical
Symptoms• Unremitting pain, almost immediate
onset
Treatment• Plastic Surgery/Dermatologist consultation• Gentle massage Injection of hyaluronidase
(10 IU/0.1 mg HA injected)• Warm area• ASA 81 mg PO qday• Nitropaste TID• Hyperbaric oxygen
Blindness
Blindness
• Visual field defect• Ophthalmoscope
exam shows emboli
• Ophthalmology consultation
• Poor prognosis
Energy Based Procedures
• Lasers• RF• IPL
Energy Based Procedures Complications
• Burns• Scarring
Treatment
• Update tetanus• Polysporin• Silver sulfadiazine
cream• Referral
NY Times, June 20, 2010
Dunning-Kruger Effect
• Cognitive bias manifesting in unskilled individuals suffering from illusory superiority, mistakenly rating their ability much higher than is accurate
The Unknown Unknowns‘Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns -- the ones we don't know we don't know. And if one looks throughout the history of our country and other free countries, it is the latter category that tend to be the difficult ones.’
Donald Rumsfeld, 2002
Summary
• You’re going to see these patients• Communication (and documentation) is key• Recognition of major complications