cosmetic surgery complications in the er: when vanity turns to calamity jamil ahmad, md, frcsc the...

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