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An Exceptional Case of Skin Necrosis Secondary to an Error of Infiltration

Chaput, Benoit M.D.; Fade, Geraldine M.D.; André, Aymeric M.D.; Grolleau, Jean Louis M.D.; Garrido, Ignacio M.D., Ph.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 765e-766e
doi: 10.1097/PRS.0b013e318245e9f5
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Liposuction is the most performed procedure in plastic surgery.1 Tumescent liposuction uses a solute infiltration containing isotonic saline (sodium chloride 0.9%) and lidocaine/epinephrine and is carried out by operating room nurses before any intervention. This solution allows reduction of bleeding associated with liposuction.

We report a case of a 24-year-old patient, without a medical history, who had excess fat localized to subtrochanteric regions. She underwent tumescent liposuction for aesthetic purposes. An error in the realization of the infiltration solution was identified: hypertonic saline (sodium chloride 3%) of close presentation, used for the sterilization of liver hydatid cysts, was substituted for normal saline. The next day, the patient showed signs of injured skin on the right thigh that evolved into cutaneous fat necrosis by 48 hours (Fig. 1). She did not present clinical or biological signs of infection. Her left thigh was not injured because it was infiltrated with another preparation. The lesions were extremely painful and required an opioid analgesic treatment. In total, three surgical procedures under general anesthesia were performed. The first was performed in the immediate aftermath, and the other two were performed at days 26 and 35. Ultimately, healing by secondary intention was preferred rather than skin grafting. The outcome was favorable and the wounds were healed completely by 110 days (Fig. 2). The patient has dystrophic sequelae in the right thigh.

Fig. 1
Fig. 1:
Wounds at 3 days.
Fig. 2
Fig. 2:
Wounds at 110 days.

The trivialization of liposuction means that some forget that it is far from devoid of complications. The incidence of complications ranges from 0.1 to 9.3 percent.1,35 Contour irregularity is the most common, but infections and hematomas also occur. Moreover, serious complications have been reported, including pulmonary embolism, cerebral fat embolus, intestinal perforation, and also, rarely, death.1 Many cases of skin necrosis have been reported in the literature, but this is the first reported case attributable to hypertonic saline. The most common cause of extended skin necrosis remains septic necrotizing fasciitis.3

In our treatment plan, we decided to promote the scar retraction phenomenon with the hope of reducing the loss of substances to a minimum size. A skin graft would have been poorly integrated and ugly. Later, we will be able to offer a scar revision if necessary, with a prior step of expansion.

The volume of infiltration recommended for tumescent liposuction varies from 1 to 3 liters per liter of adipose tissue extracted, with 500 mg of lidocaine and 1 mg of epinephrine per liter.5 To avoid such errors, it will be necessary to ask the nursing staff to keep the pocket of initial solute and to annotate the additions at each step.

Regarding the legal issue in the private sector, members of the operating room staff are the direct responsibility of the surgeon. Errors committed by staff can be directly attributed to the surgeon. In this instance, the patient began legal proceedings against the surgeon, and the proceedings are underway.

In conclusion, certain acts of surgery seem perfectly controlled in terms of risk. However, this type of incident shows that they are unfortunately too commonplace because of repetition. We must remain cautious because even simple interventions can lead to severe complications.2

Benoit Chaput, M.D.

Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France

Geraldine Fade, M.D.

Plastic and Reconstructive Surgery Unit, CHU Bordeaux Pellegrin, Bordeaux, France

Aymeric André, M.D.

Jean Louis Grolleau, M.D.

Ignacio Garrido, M.D., Ph.D.

Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France


1. Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial liposuction: A review of 2398 cases. Plast Reconstr Surg. 2011;127:863–871.
2. Mole B. Liposuction and extensive cutaneous necrosis: Apropos of a clinical case (in French). Ann Chir Plast Esthet. 1994;39:251–254.
3. Gibbons MD, Lim RB, Carter PL. Necrotizing fasciitis after tumescent liposuction. Am Surg. 1998;64:458–460.
4. Desrosiers AE III, Grant RT, Breitbart AS. Don't try this at home: Liposuction in the kitchen by an unqualified practitioner leads to disastrous complications. Plast Reconstr Surg. 2004;113:460–461.
5. Illouz YG. Liposculpture et chirurgie de la silhouette. In: Techniques Chirurgicales: Chirurgie Plastique Reconstructrice et Esthétique. Paris: Elsevier Masson SAS; 2008:45–120.


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