Penetrating Abdominal Trauma from Liposuction: The Miami Experience

Abstract

Liposuction is one of the most commonly performed aesthetic plastic surgery procedures in the world. Although serious complications are rare, intra-abdominal complications such as bowel perforation are one of the most common causes of death after liposuction. We present a case series of six patients who sustained intra-abdominal injuries from liposuction. The acute care surgery (ACS) faculty at a single institution were surveyed for patients. Six patients were identified over a three-year period. The average age was 45 years, and all patients were female. All six underwent a cosmetic procedure in addition to their liposuction. Four (67%) had previous abdominal surgery, and five (83%) were overweight or obese. All patients presented with abdominal pain, tachycardia, and leukocytosis. All six underwent exploratory laparotomies: four patients had small bowel enterotomies, one had cecal volvulus and abdominal compartment syndrome, and one had fascial violation. They underwent an average of four ACS procedures (range 1 to 11) and had an average hospital LOS of 29 days (range 5 to 60) and an average ICU LOS of 11 days (range 1 to 39). Intra-abdominal injuries are a rare complication of liposuction; however, a high index of suspicion must be maintained to diagnose and treat these life-threatening injuries.

1. Introduction

Liposuction is one of the most commonly performed aesthetic procedures worldwide [1,2]. The most common complications from this procedure include contour irregularities, seromas, hematomas, and edema [1,3]. Severe and life-threatening complications can also be encountered, including pulmonary embolism, bowel perforations, necrotizing fasciitis, sepsis, lidocaine toxicity, and fat embolism; these constitute the majority of liposuction-related mortalities [1]. The fatality rate is 19/100,000 liposuction procedures, and 15% of these mortalities are from bowel perforations [1,4]. Mortality is most often related to pulmonary embolism; however, the second most common cause of death results from perforation of abdominal organs [1]. Perforation of abdominal organs is a rare complication but has been described in several case reports and case series [2,5,6,7,8]. Awareness of this possible complication along with a high index of suspicion are necessary in order to identify and promptly treat this potentially lethal complication.

Miami is a common destination for cosmetic tourism, and the complications of aesthetic procedures are frequently seen in our public safety-net hospital, making our center an ideal location to treat rare complications. We present a case series of six patients who sustained intra-abdominal complications from liposuction over a three-year period.

2. Materials and Methods

The institutional review board approved the chart review of ACS patients at our institution (IRB20191053). For this type of study, formal consent is not required. The ACS faculty at a single institution were surveyed for patients they had encountered with intra-abdominal injuries from liposuction from 2018 to 2021. Exploratory laparotomies performed by the ACS service during that time period were identified and screened as well to identify additional cases. Data extracted included the patient’s age, body mass index (BMI), comorbidities, presenting symptoms, initial vitals and laboratory tests, surgeries performed, and length of stay. The average cost of a hospital stay was determined for each patient based on the cost of a day in our county hospital’s ICU and medical-surgical floor.

3. Results

In total, six patients were identified with intra-abdominal injuries after liposuction over a three-year period. All the patients were female, and their ages ranged from 28 to 61, with a mean age of 45 years. The BMI ranged from 21 to 32 kg/m², with a mean of 27 kg/m². Four were classified as overweight, and one was obese. Medical comorbidities were present in two of the patients: both had hypertension and one had diabetes. Four (67%) had previous abdominal surgery: two had a prior Cesarean section, one had a total abdominal hysterectomy, and one had a gastric sleeve (

Table 1. Patient Demographics and Initial Presentation.

Patient	Age	Sex	Comorbidity (BMI)	Previous Abdominal Surgery	Procedure	Symptoms	Initial Vitals	Physical Exam	Initial WBC	Initial H/H
1	61	F	None (25.3)	hysterectomy	Liposuction, abdominoplasty	Confusion, nausea, vomiting, abdominal pain	unknown	Abdominal wall erythema and tenderness, feculent drainage from JP	-	-
2	56	F	HTN, DM (29.8)	C section	Liposuction abdomen, BBL	SOB, palpitations, weakness, chills, abdominal and buttock pain	T 36.5 HR 152 RR 22 BP 146/90	peritonitis, bilateral buttocks with induration and erythema	15.7	11.9/35
3	46	F	None (28.1)	C section	Liposuction, abdominoplasty	Vomiting, abdominal pain	T 36.8 HR 120 RR 34 BP 175/111	Abdominal tenderness	16.6	13.5/42
4	28	F	None (25.0)	none	360 liposuction, BBL	Abdominal pain	T 37.4 HR 111 RR 16 BP 112/71	peritonitis	18.3	10.6/31
5	44	F	HTN (32.0)	Gastric sleeve	Liposuction, BBL	Nausea, vomiting, weakness, abdominal pain	T 37.8 HR 126 RR 24 BP 92/50	Abdominal tenderness, purulent drainage from flank wounds	17.1	7.9/25
6	36	F	None (20.8)	unknown	Liposuction, BBL	Nausea, vomiting, weakness, abdominal pain	T 36.5 HR 136 RR 24 BP 80/52	Tender to palpation	20.1	9.7/29

Abbreviations: BBL—Brazilian Butt Lift; BMI—body mass index; BP—blood pressure; H/H—hemoglobin/hematocrit; HR—heart rate; JP—Jackson Pratt drain; RR—respiratory rate; T—temperature; WBC—white blood count.

).

All six underwent a second cosmetic procedure in addition to liposuction: four underwent gluteal fat grafting, or the so-called “Brazilian butt lift” (BBL), and two underwent abdominoplasty. All six patients had their cosmetic surgeries performed at an outside institution; four patients had the procedures at private clinics in the Miami area, one at an outside hospital, and one was unknown. Patients presented to the emergency department (ED) on a mean post-op day (POD) of 5 (range 0 to 8) with abdominal pain. One patient was transferred to our institution on POD 10 after several exploratory laparotomies at an outside hospital. Five patients presented with tachycardia, and two were hypotensive. Other presenting symptoms included nausea, vomiting, confusion, weakness, chills, and shortness of breath. On physical examination, all six had abdominal tenderness and two had peritonitis. Five presented with leukocytosis and four were anemic (hemoglobin < 12.5). Initial vitals and labs were not obtainable for one patient, as she arrived as a transfer from an outside hospital.

Upon presentation to our institution, all six patients required exploratory laparotomies: four patients had small bowel enterotomies, one had cecal volvulus and abdominal compartment syndrome, and one had violation of the fascia with an intra-abdominal collection that was likely liposuction tumescent fluid. Of the four patients with small bowel enterotomies, one underwent small bowel resection, while the other three had the injuries repaired primarily. The cecal volvulus and abdominal compartment syndrome were likely secondary to abdominoplasty with associated fascial plication (Figure 1). She subsequently underwent a right hemicolectomy. In addition to the intra-abdominal injuries, one patient had bilateral buttock cellulitis, and two had necrotizing fasciitis of the abdominal wall. They underwent an average of four ACS procedures (range 1 to 11) and had an average hospital length of stay (LOS) of 29 days (range 5 to 60) and an average intensive care unit (ICU) LOS of 11 days (range 1 to 39) (

Table 2. Surgeries and Hospital Course.

Patient	Initial ACS Procedure	Total ACS Procedures	Diagnosis	Infection	LOS (Cost)	ICU LOS
1	Exploratory laparotomy (OSH)	6	enterotomies	Sepsis, SSI, intra-abdominal abscesses	43 ($25,299)	2
2	Exploratory laparotomy, 2 Small bowel resections, Repair of partial thickness lacerations of sigmoid colon, Debridement of necrotic abdominal wall skin, subcutaneous tissue, fascia, and muscle, Temporary abdominal closure, Incision and drainage of bilateral buttock cellulitis	5	small bowel perforations, sigmoid colon lac (not full thickness), mesenteric lac, anterior abdominal wall necrotizing fasciitis, bilateral buttock cellulitis	Sepsis, cellulitis	60 ($69,834)	39
3	Exploratory laparotomy with removal of abdominoplasty plication sutures, right hemicolectomy with primary anastomosis	1	Abdominal compartment syndrome, cecal volvulus	sepsis	5 ($4627)	2
4	Diagnostic laparoscopy converted to laparotomy, 3 enterotomy repairs, 7 serosal injuy repairs, drainage of intra-abdominal abscesses, abdominal washout, placement of 3 JP drains	2	Small bowel perforation	Intra-abdominal abscess	7 ($7623)	4
5	Diagnostic laparoscopy converted to exploratory laparotomy, adhesiolysis, primary repair of 7 small bowel enterotomies, drainage of intraabdominal small bowel mesenteric abscess, abdominal washout, washout and excisional debridement of subcutaneous fat and fascia 45 × 30 cm, temporary abdominal closure	11	7 Small bowel enterotomies	Necrotizing fasciitis	52 ($45,455)	18
6	Exploratory laparotomy, abdominal washout	1	Fascial violation	none	9 ($5850)	1

Abbreviations: ACS—Acute Care Surgery; JP—Jackson-Pratt; LOS—length of stay; OSH—outside hospital; SSI—surgical site infection.

).

Four of these patients were from out of town, and two were from Miami. Of the four from out of town, two had Blue Cross Blue Shield, one had Medicaid, and one was self-pay. Blue Cross Blue Shield is a health insurance company. Medicaid is a joint federal and state program in the United States that provides health insurance to eligible groups, such as low-income families [9]. The mean cost of the hospital stay based on their LOS was $26,448 (range $4627 to $69,834).

4. Discussion

Liposuction is a commonly performed and profitable procedure that has been perceived as low-risk and simple to perform. However, there remain minimally restrictive laws regarding the procedure, allowing it to be performed by non-plastic surgeons and non-physicians in settings such as cosmetic centers that are ubiquitous in Miami [2,10]. Some of these centers have appeared in the news for patient morbidity and mortality and for violations of the Florida Administrative Code [11,12]. Patients with various complications from procedures performed by these centers are frequently treated by the ACS service at our hospital. These complications include symptomatic anemia requiring blood transfusions, abscesses requiring drainage, and intra-abdominal injuries requiring surgery. As many of these patients are traveling from out-of-state and their insurance, if they have any, may not cover these treatments, the complications of cosmetic tourism come at a significant cost to tax-payers in the area. To our knowledge, this is the largest case series of intra-abdominal injuries from liposuction since 2015, and it is the largest from a single institution [6,13]. The most important new finding from our study is that it is not uncommon for these patients to undergo multiple ACS procedures.

Liposuction is the surgical removal of superficial and deep subcutaneous fat using a blunt cannula attached to a suction device to improve body contour [14]. There are several liposuction techniques; however, tumescent liposuction is the gold standard in terms of safety. During the procedure, a tumescent solution consisting of normal saline or lactated ringer’s, epinephrine, and a dilute local anesthetic such as lidocaine is infiltrated into the subcutaneous tissue. Epinephrine causes vasoconstriction to reduce bleeding, while lidocaine provides local anesthesia [15]. The cannula moves back and forth blindly through a small skin incision to remove the fat. Manual control of the cannula and knowledge of anatomy are necessary to safely perform the procedure [2]. Careful postoperative management is vital for a successful outcome, particularly in large-volume cases where pain management, fluid and electrolyte management, and monitoring for complications are important [14]. Since some of these procedures are completed at outpatient centers, emergency medicine physicians, plastic surgeons, and general surgeons at local hospitals are left to manage the complications.

Although potentially fatal, visceral perforations often present with an insidious onset and subtle symptoms. Common initial clinical signs and symptoms include worsening abdominal pain and distension, which progress to tachycardia, tachypnea, and deterioration due to septic shock [13]. The ileum is the most commonly injured organ, followed by the jejunum, spleen, cecum, and colon [15]. These complications require aggressive intervention with hemodynamic support, antibiotics, intravenous fluids, and surgical consultation. Swift intervention is key, as these intra-abdominal injuries are the second most common cause of mortality after a liposuction procedure [15]. On average, the patients in this series presented to the ED on POD 5. One presented to the ED three times before being diagnosed with bowel perforation on POD 9. She was sent home the first time, as they attributed the abdominal pain to normal post-operative pain. She was admitted for the second time with a diagnosis of small bowel obstruction. During the third visit, she was diagnosed with bowel perforation. Fortunately, all six of our patients survived to hospital discharge.

One of the major risk factors for the development of severe complications is the performance of multiple simultaneous procedures, as was completed in all six of our patients [1]. However, multiple surgical procedures are often completed concurrently with body contouring. For example, abdominoplasty is now performed concurrently with liposuction in 90% of cases [15]. Abdominoplasty is used to reshape body contours by removing skin and fat tissue to remodel the abdominal wall. Techniques for abdominoplasty include abdominal flap dissection, plication of the rectus abdominis fascia, umbilical transposition, and removal of skin and subcutaneous fat. In addition, liposuction is inherently needed to perform a BBL, and combined procedures are widely accepted by plastic surgeons. As it is well known that multiple procedures performed during a single operation increase the potential for complications, it is recommended that large-volume liposuction combined with certain other procedures be avoided [14]. However, limited liposuction aspiration volume can be completed routinely and safely with additional plastic surgery procedures.

An additional risk factor for intestinal perforation during liposuction is the presence of abdominal scars, possibly secondary to undiagnosed incisional hernias or bowel loops adherent to the scar [6,16,17]. In our study, four of the six patients had a history of abdominopelvic surgery. A patient’s surgical history must be obtained and a physical exam performed in order to identify scars from previous surgeries. During the liposuction procedure, access points should be chosen carefully to avoid having the cannula cross these scars. Some recommend a pre-operative computed tomography scan in these cases [17].

Finally, Lehnhardt et al. [10] found that the risk of complications is associated with physician’s expertise, experience, and technical deficiencies. The American Society of Plastic Surgeons (ASPS) Committee on Patient Safety has previously recommended that physicians performing liposuction procedures be trained as surgeons, be certified by a surgical board, and complete training in liposuction/body contouring [14]. As this procedure is also performed by non-physicians, medical societies should advocate for legislation requiring the procedure only be performed by licensed physicians who have completed training in this technique.

This study presents some limitations. There are a small number of patients in our series; however, this is the largest case series of intra-abdominal complications from liposuction from a single institution. Another limitation was the way in which patients were identified. We surveyed the ACS faculty in order to retrospectively identify patients that they had encountered rather than systematically identify patients, so it is possible that we missed some patients who had been treated at our institution with this complication. This study was limited to a chart review, so we were unable to identify who performed the procedures to determine how many were board-certified plastic surgeons, and as such, we were unable to request the operative reports to identify any intra-operative risk factors. We are also unable to identify the number of liposuction procedures performed in our area during this time period to have a denominator. As part of the time period for our study overlapped with the COVID-19 pandemic, it is likely that elective cases during this time decreased, making it even more difficult to identify an accurate denominator. Future work can determine the incidence of these injuries.

5. Conclusions

Intra-abdominal injury is a possible complication of liposuction. Certain factors, including previous abdominal surgery and the performance of concurrent cosmetic procedures, may increase the risk of this devastating complication. Tertiary centers must maintain a high index of suspicion to diagnose and treat these life-threatening injuries.