The Dark Side of Plastic Surgery

Introduction

The physiological complications associated with plastic surgical procedures are fewer when compared to other surgical procedures. Usually, cosmetic surgical procedures are performed on outpatients who are mostly healthy individuals. Yet, several postoperative complications are associated with plastic surgery, including infections, electrolyte and hematologic abnormalities, nerve damage, damage to visceral organs, wound complications, and local anesthetic systemic toxicity (LAST). The complications can occur immediately, like LAST, or may occur after some time, like a hematoma (collection of blood in an extravascular space).

What Are the Complications of Plastic Surgery?

The post-surgical complications include the following:

Infections at Surgical Site (Surgical Site Infections) or SSI:

• The dissection of the subcutaneous layer performed during the procedure provides an optimal site for bacterial growth. The most typical organism associated with infection is Staphylococcus aureus. Infections can be mild, can result in cellulitis, and even lead to necrotizing fasciitis, which is life-threatening.
• Breast surgeries are commonly associated with wound complications, including infections. While in other plastic surgical procedures, the incidence of infection is only one percent.
• There are two types of SSI (surgical site infection) - Superficial and deep SSI. Superficial SSIs are infections that involve the dermis and subcutaneous tissue. Deep SSI extends to the deep fascia and visceral organs. The patient presents with fever, erythema, local warmth, and tenderness.

Hematoma (Collection of Blood Outside the Blood Vessel Resulting in Localized Swelling):

• Usually, hematoma develops within 24 hours of surgery.
• Small hematomas are asymptomatic.
• Moderate size hematomas present with swelling, ecchymoses (purpuric flat skin patches), and localized pain.
• Large hematomas present with active bleeding and may lead to hemorrhage shock.
• Implant rupture is one of the common causes of localized fluid collection.

Post-operative Hemorrhage (Bleeding):

• The incidence of postoperative bleeding is less than two percent. But postoperative hemorrhage is the cause of death in 4.5 percent of cases.
• The most common cause of postoperative bleeding is capillary disruption. Other causes are organ and vascular perforation.
• The condition becomes worse due to postoperative coagulopathy.

Skin Necrosis (Cell Death):

• Skin necrosis occurs in three to four percent of cases.
• The risk of necrosis increases in procedures that use autologous fat transfer. The transplanted fat cause localized inflammation and tissue destruction at the site.
• Clinically patients present with ecchymosis, tissue breakdown, and tenderness to palpation at the affected site.

Wound Dehiscence:

• Wound dehiscence (improper healing leading to separation of wound edges that were previously approximated) is a rare complication that occurs in 0.75 percent of cases.
• Usually occurs secondary to an infection but may also occur secondary to necrosis or local collection.

Fat Embolism Syndrome (FES):

• Studies show that in the case of patients undergoing liposuction surgery, fat deposits get dislodged and enter pulmonary circulation resulting in FES.
• The overall mortality rate is 10 to 15 percent.
• FES affects multiple organ systems.
• The clinical manifestations include increased heart rate(tachycardia), petechial rashes, respiratory distress (fluid collects in the air sacs of the lungs), breathing difficulties, and focal neurologic symptoms.
• Neurologic symptoms occur in 80 percent of cases and can be mild disorientation or even coma.
• Petechial rashes are characteristic of the condition and are mostly seen in the upper body.

Venous Thromboembolism (VTE):

• Venous thromboembolism is responsible for postoperative death in 21 percent of cases.
• Risk of VTE increase when procedures are combined and carried out.
• An increase in VTE is seen when liposuction is combined with other surgeries like abdominoplasty.
• The incidence of VTE in abdominoplasty is 0.8 percent, and the incidence of pulmonary embolism is 1.3 percent.

Visceral Perforation (Damage to Visceral Organs):

• Liposuction may lead to bowel wall perforation, the incidence of which is 14 per 100,000 procedures performed.
• Ileal perforation is the most common.
• Patients presenting with severe pain postoperatively should be checked for visceral perforation.

Complications Associated With Anesthesia:

• Local anesthetic systemic toxicity (LAST) is a serious complication that occurs as a result of anesthetic administration.
• As per FDA, (United States Food and Drug Administration), the maximum dosage of lidocaine for local anesthesia is 7 mg/kg. But in a tumescent liposuction procedure, this dosage administered may increase to 35 to 65 mg/kg. The tumescent liposuction procedure involves local anesthesia application and is mostly done as an outpatient procedure.
• The systemic complications associated with local anesthesia occurring as a result of tumescent liposuction is mainly due to allergic reaction or toxicity to medicines like epinephrine.
• The allergic response clinically presents as urticaria (presents as red itchy skin bumps), angioedema (swelling that occurs beneath the skin), and anaphylaxis (a severe allergic reaction that requires immediate care).

Nerve Damage:

• Injury to the nerve is a complication associated with all surgical procedures.
• The patient may feel a tingling sensation or a feeling of numbness.
• The condition is temporary in most cases.

Unsatisfied Result:

• This occurs in cases where the patient is not satisfied with the final result of the procedure.
• This may occur as a result of unrealistic expectations of the patient or due to failure in the procedure.
• Scarring may also occur due to surgical procedures, which may not be acceptable for the patient.

How to Manage the Complications of Plastic Surgery?

• Management of Infection - Management of infection requires aggressive surgical debridement. Broad-spectrum antibiotic therapy should be administered.
• Management of Hematoma - For the management of hematoma, consultation with the surgical team is done. Surgical drainage, needle aspiration, and follow-up are done.
• Management of Postoperative Hemorrhage - In unstable patients, hemodynamic resuscitation is required.
• Management of Wound Dehiscence - Pain management is done. Other underlying causes are evaluated, which in most cases is infection. Wound debridement, dressing, and closure are done. Follow-up visits may be required.
• Management of Necrosis - Necrosis management involves surgical debridement, antibiotic therapy, and hyperbaric oxygen therapy.
• Management of FES (Fat Embolism Syndrome) - Management includes endotracheal intubation, maintenance of fluid and electrolyte balance, and administration of supplemental oxygen.
• Management of Anesthetic Complications - Immediate management includes stopping further administration of local anesthetic injections, maintaining an adequate airway, endotracheal intubation if required, and ensuring adequate lung ventilation.

What Are the Risk Factors of Plastic Surgery?

The following condition has a greater risk of developing postoperative complications:

• Older age.
• Those having elevated BMI (body mass index).
• Smokers.
• Alcoholics.
• Diabetic mellitus patients.
• Immunocompromised patients.
• Patients with hypertension.
• Patients on anticoagulant therapy.
• Malignancy.

Conclusion

The number of people undergoing plastic surgery procedures is increasing worldwide. There is also a rise in cosmetic tourism in countries like Europe, Southeast Asia, and America, further increasing the number of cosmetic surgical procedures performed. As with any surgical procedure, plastic surgical procedures also present with complications like infection, blood loss, nerve damage, visceral damage, wound complications, anesthesia complications, and more. It's high time we look into the complications of plastic surgery, too, in our quest to achieve perfection.