Small Intestinal Perforation and Necrotizing Fasciitis After Abdominal

Liposuction

Devesh Sharma,1,2 Gregory Dalencourt,1,2 Thomas Bitterly,1,2 and Peter N. Benotti1,2

1Department of General Surgery, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA2Department of Plastic Surgery, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA

Abstract. Liposuction, the most common aesthetic proce-

dure performed in the United States, is not without risk,but the overall complication rate in the literature variesfrom less than 1% to 9.3%. A 55-year-old woman who had

undergone abdominal liposuction with bilateral breastaugmentation was hospitalized in a state of profound septicshock. A diagnosis of necrotizing fasciitis was made on thebasis of findings that included abdominal skin discolor-

ation, subcutaneous emphysema, and air in the subcuta-neous plane seen on abdominal computed tomography(CT) scan. During the operative procedure for abdominal

wall debridement, extensive necrosis of abdominal wallfascia with leakage of bilious fluid from defects in the rectussheath was found. Subsequent peritoneal cavity exploration

showed two perforations in the mid ileum with gross peri-toneal cavity contamination.

Key words: Abdominal liposuction—Intestinal perfora-

tion—Necrotizing fasciitis

Case Report

A healthy 55-year-old woman who had undergonebilateral breast augmentation with breast implantsand abdominal liposuction was transferred from an-other facility with the diagnosis of necrotizing fasci-itis. The patient had bilateral breast implants placedwith the abdominal wall liposuction. She was dis-charged the same evening.

On postoperative day 1, the patient started expe-riencing significant abdominal pain, for which shebegan taking Tylenol with codeine every 4 h. Painmedications did not control the pain, and she con-tacted her surgeon, who prescribed additional anal-gesic medications. On postoperative day 2, herhusband noticed some foul odor about her, but wasnot sure of its source. She was having severeabdominal pain and had limited mobility. She wasseen by her surgeon in a follow-up visit on post-operative day 3, and the analgesic medications wereagain changed. Her pain became worse, and she wasunable to perform her daily routine on the sameday.

By postoperative day 4, the patient was feeling veryweak and becoming confused. She collapsed at herhome in the evening. She was taken to a local hospitalfor evaluation of her worsening condition. There, thepatient appeared to be obviously septic with a foul-smelling discharge noted to be coming from her rightbreast. She was hypotensive with altered mental sta-tus.

The patient was electively intubated, and aggres-sive fluid resuscitation was initiated with intravenousantibiotics. She also required pressors to maintain herblood pressure. She was transferred to GeisingerMedical Center, where critical care management wascontinued, and a computed tomography (CT) scan ofthe chest, abdomen, and pelvis was performed. TheCT scan showed extensive subcutaneous air from theupper chest wall all the way down to her pelvis andaround to her back (Figs. 1 and 2). Pockets of free airand inflammatory changes also were present withinthe peritoneal cavity surrounding the region of theascending colon (Fig. 3). Her left breast implant ap-peared to be ruptured, and there was significant fluidin the breast bilaterally (Fig. 4).

Correspondence to Devesh Sharma; email: devesharma@hotmail.com

Aesth. Plast. Surg. 30:712�716, 2006DOI: 10.1007/s00266-006-0078-8

At examination, the patient was found to behypotensive and tachycardic, with blood pressuremaintained on dopamine drip. The bilateral anteriorchest wall was ecchymosed with a small wound in thelateral right breast draining foul-smelling browndischarge. Extensive subcutaneous emphysema waspresent. The abdomen was distended with extensiveecchymosis of the lower abdominal wall and subcu-taneous emphysema (Figs. 5�7). The patient�sextremities were cool and clammy. She was aggres-sively resuscitated in the intensive care unit, and abicarbonate drip was started. Fresh frozen plasmawas given to correct coagulopathy, and a Swan-Ganzcatheter was placed for monitoring.The patient was urgently taken to the operating

room for debridement. Initially, the breast implantswere removed from previous skin incisions, and

copious foul-smelling discharge was noticed aroundthe implants. Subsequently, the abdomen was openedvia an H-shaped incision. Extensive necrosis of thesubcutaneous tissue and rectus fascia was noted(Figs. 8�10). On the right side, bilious discharge wasleaking from the subcutaneous tissues through twodefects in the rectus fascia. No ventral hernia wasnoticed around the site of the perforation.

Exploration of the peritoneal cavity showed fourperforations in the mid ileum. Approximately 2 feetof small bowel was resected and primarily anasto-mosed. The peritoneum was closed with approxima-tion of the rectus muscle. Skin flaps were left openwith packing using saline-soaked abdominal pads.

After the surgery, the patient was transferred backto the intensive care unit. Arrangements were madeto transfer the patient to the University of Pennsyl-

Fig. 1. Subcutaneous air in the anterior abdominal wall.

Fig. 2. Subcutaneous air in the flanks with significant tissueedema.

Fig. 3. Pocket of free air and inflammation around theascending colon.

Fig. 4. Subcutaneous air around the left breast implant.

D. Sharma et al. 713

vania hospital for further treatment with hyperbaricoxygen and repeated serial debridement of her chestand abdomen. Postoperatively, multiple transfusionsof packed red blood cells and fresh frozen plasmawere required to control blood loss and to correctcoagulopathy.

After her bleeding was controlled and resuscita-tion was completed, the patient was transferred tothe University of Pennsylvania hospital via LifeFlight for hyperbaric oxygen and further debride-ment. Despite the continued aggressive treatment,the patient died within 24 h after her initial hos-pitalization.

Fig. 7. Suprapubic abdominal wall with gangrenous chan-ges.

Fig. 10. Necrotizing rectus fascia and abdominal wall fat.

Fig. 5. Anterior abdominal wall showing ecchymosis in thesuprapubic area.

Fig. 8. Gangrenous subcutaneous fat.

Fig. 6. Left flank ecchymosis and gangrene. Fig. 9. Necrotizing subcutaneous fat and fascia.

714 Small Intestinal Perforation and Necrotizing Fasciitis

Discussion

Liposuction is one of the most frequently requestedprocedures performed by cosmetic surgeons. Lipo-suction for abdominal contouring is considered a safeprocedure, with a low incidence of systemic and localcomplications, especially for patients without priorabdominal surgery. However, major complications ofliposuction are as old as the procedure itself. Dujar-rier is generally credited with both the introduction ofliposuction and the first reported major complication,when a liposuction he performed in the 1920s resultedin damage to the femoral vessels, necessitating limbamputation [10]. Since then, refinements in the tech-niques and instrumentation have made this procedurefairly safe.Three large surveys of liposuction outcomes have

been conducted by members of the American Societyof Plastic and Reconstructive Surgeons. The firststudy, published in 1985 and involving 107 surgeonswho had performed 1,249 liposuction proceduresover 2,261 anatomic areas did not document anymajor complications. Two deaths and two nonfatalcases of embolism were discovered after completionof the survey [8]. The second survey, published in1989 and involving 935 surgeons who performed75,591 major liposuction procedures reported twodeaths attributable to fat embolism and pulmonarythromboembolism [12]. These two surveys underes-timated the true incidence of major complicationsbecause participation was voluntary and involvedonly board-certified and presumably experiencedplastic surgeons.The third major survey evaluated the incidence of

fatal outcomes after liposuction [5]. All 1,200 activelypracticing North American board-certified AmericanSociety of Aesthetic Plastic Surgery (ASAPS) mem-bers were polled by facsimile, then by mail, regardingdeaths after liposuction. Responding aesthetic plasticsurgeons (917 of 1,200) reported 95 uniquelyauthenticated fatalities in 496,245 lipoplasties. Inthis census survey, the mortality rate was computedto be 1 in 5,224, or 19.1 per 100,000. Pulmo-nary thromboembolism remained as the major kill-er (23.4% ± 2.6%). Abdominal/viscus perforation(14.6%), anesthesia/medication-related complications(10%), and fat embolism (8.5%) were other importantcauses of mortality. Unknown or confidential reasonscontributed to 28.5% of the mortality in this survey.Major complications documented after liposuction

included pulmonary or fat emboli, hypovolemicshock, lidocaine toxicity in tumescent liposuction [9],intrusion into the peritoneal or thoracic cavity withperforation of hollow viscus, and necrotizing fasciitis.To date, about 10 cases of intestinal perforation afterliposuction have been documented [2,7,11]. Patientsat higher risk for abdominal perforation after lipo-suction include those with ventral hernias includingumbilical hernias, patients who have had previousabdominal surgery, and patients with poor wound

healing because of chronic steroid therapy or che-motherapy. It is easier to miss a ventral hernia in anobese patient with massive adiposity and an abnor-mal abdominal skin contour. The abdominal wall iseasier to penetrate with ultrasound-assisted liposuc-tion.

The incidence of necrotizing fasciitis after liposuc-tion is unknown. Cases of necrotizing fasciitis afterliposuction without intestinal perforation have beendescribed [1,2,4,6]. Many of these cases were per-formed with tumescent anesthesia. One case of nec-rotizing fasciitis attributable to intestinal perforationafter liposuction was reported by Barillo et al. [2] in1997. In that case also, diagnosis could not be madeuntil the first postoperative visit after 7 days, and thepatient died 25 days after the initial surgery.

The risk factors for necrotizing fasciitis includegastrointestinal malignancy, age exceeding 50 years,diabetes, immunosuppresion, alcohol abuse, intrave-nous drug use, peripheral vascular disease, and mal-nutrition, although the disorder can occur in younghealthy patients also. The incidence of necrotizingfasciitis is 0.4 per 100,000 inhabitants.

Clinically, necrotizing fasciitis presents with ery-thema and edema. Later, as the blood supply to theskin is compromised, this may progress to cyanosis,blister formation, and gangrene. The extent of theskin gangrene at the fascia level is typically muchgreater than at the skin surface. From the beginning,there is severe intolerable pain, which is an importantclue to the early diagnosis of the disease. The maindiagnostic tool is surgical exploration. The patho-gnomonic finding is a gray, edematous, subcutaneousfat that strips off the underlying fascia with a sweepof the finger. Mortality rates range from 12.5% to76%, depending on the speed of diagnosis and thetherapy used. Bilton et al. reported a mortality rate of38% in patients with delay in therapy, as comparedwith 4.2% after immediate surgical intervention [3].For cases in which necrotizing fasciitis is not treatedby radical surgery, the mortality rate approaches100%. The patients die of septic complications andmultiple organ failure.

Liposuction is considered a safe and efficaciousprocedure. Still, it can rarely be associated with majormedical and surgical complications, includingabdominal wall perforation with visceral injury. Ifnot recognized early, these complications are associ-ated with a high rate of morbidity and mortality. Anymortality with an elective cosmetic procedure is acause for concern. The reported case illustrates thesignificance of postoperative patient complaints,which mandate immediate attention. If the postop-erative course is in any way complicated, all potentialcomplications should be pursued. Prevention ofsuch complications by careful preoperative workup,which may include preoperative ultrasonography orCT scan, is necessary for high-risk patients. Care-ful postoperative follow-up assessment for earlydiagnosis of such complications is of paramount

D. Sharma et al. 715

importance, and the operating surgeon should becognizant of the potential life-threatening complica-tions of intestinal perforation and necrotizing fasciitisafter liposuction.

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716 Small Intestinal Perforation and Necrotizing Fasciitis