Cosmetic Surgery Complications in the ER:
When Vanity Turns to Calamity
Jamil Ahmad, MD, FRCSC
The Plastic Surgery Clinic, Mississauga, Canada
Hand Program, University Health Network, Toronto, Canada
Division of Plastic and Reconstructive Surgery,
University of Toronto, Toronto, Canada
CRITER 2014
Disclosures
• Book royalties from
CRC Press
Cosmetic Surgery
• Demand continues
increase
• Surgical and nonsurgical
procedures
What is an aesthetic surgery
emergency?
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
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DVT/PE
Lidocaine/bupivacaine toxicity
Fat embolism
Intraabdominal injury
Venous Thromboembolism
• DVT or PE
• Any procedure
• Body contouring
VTE Treatment
• Prevention
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Individual
Procedural
Duration
Decreased
mobility
DVT/PE
DVT
PE
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Leg swelling
Leg pain
Warmth
Discolouration
Leg fatigue
• D-dimers
• Duplex U/S
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
Respiratory and CV
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• Respiratory depression and
arrest
• Cardiovascular depression
and collapse
Perioral tingling
Metallic taste
Lightheadedness
Dizziness
Visual disturbances
Tinnitus
Disorientation
Drowsiness
Convulsions
Loss of consciousness
Coma
Treatment
• Evacuation of local
anesthetic
• Supportive
• Intralipid 20%
1.5mg/kg IV bolus,
0.25mg/kg IV
infusion for 60
mins
Fat Embolism
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Liposuction
Fat injection
Extremely rare
Potentially life
threatening
Signs and Symptoms of Fat Embolism
Respiratory
Neurological
• Dyspnea
• Tachypnea
• ARDS
• Precede respiratory
symptoms by 6-12 hours
• Disorientation
• Coma
• Cerebral edema
Signs and Symptoms of Fat Embolism
Petechia
Ophthalmological
• 2-3 days after injury
• Head, neck, anterior chest,
subconjuntiva, axilla
• Macular edema
• Retinal hemorrhages
Investigations
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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
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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
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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
• Influenzalike syndrome
• Confusion
• Signs of soft tissue infection
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Fever
Chills
Myalgia
Nausea
Vomiting
Diarrhea
Signs and Symptoms of
Toxic Shock Syndrome
Symptoms
CDC Criteria
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Fever
Rash
Hypotension
Systemic evidence of
toxicity
Fever
Rash
Desquamation
Hypotension
Multisystem involvement in 3
or more systems
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GI
Muscular
Mucous membranes
Renal
Hepatic
Hematological
CNS
Blepharoplasty
• Retrobulbar hematoma
• Blindness
Signs and Symptoms of
Retrobulbar Hematoma
Symptoms
Signs
• Severe pain
• Visual changes
• Tense or expanding proptosis
• Diminished extraocular
movements
• Retinal/optic disc pallor
• Increase intraocular pressure
• Loss of pupillary reflexes
• Scleral hematoma
– Decreased visual acuity
– Amaurosis fugax
– Scintillating scotomas
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