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Sepsis with multiple abscesses after massive autologous fat grafting
Hi everyone!
I found this case study in the Journal of Aesthetic Plastic Surery (2011 Aug;35(4):641-5. doi: 10.1007/s00266-010-9605-8. Epub 2010 Nov 5). If you have any questions about the medical terminology, leave a comment, and I will respond as soon as I have free time. I must state thst the following complications are rare when working with a board certified surgeon in a sterile environment. Nevertheless, no surgery, even under the best conditions, is without risk. This is not to discourage anyone about fat grafting, but we all should go into surgery argus-eyed about any potential complications.
BACKGROUND: Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting.
METHODS: A 42-year-old woman presented to the authors' emergency department reporting tenderness, swelling, and a sensation of heat in both breasts. The patient had undergone augmentation mammoplasty by autologous fat grafting 7 days previously. Abscess formation was suspected based on the patient's history, physical examination, laboratory findings, and image study.
RESULTS: Incision and drainage were performed immediately with the patient under general anesthesia, and 500 ml of a foul, brown, turbid, purulent fluid containing necrotic fat debris was drained from each breast. Empiric antibiotics were started on the first hospital day, and betadine and saline-irrigation were administered daily for 2 weeks. Incisions were closed on hospital day 19 when laboratory data and local infection signs had improved. At the patient's 9-month follow-up assessment, breast contours were found to be well preserved, and scarring was minimal.
CONCLUSION: Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.
I also found this journal article about atypical mycobacterium infections after autologous fat grafting. Since this bacterium has been seen in quite a few patients returning from the Dominican Republic after plastic surgery, I felt it was good information to pass along to everyone on RealSelf.
Sepsis after Autologous Fat Grafting: Role of Atypical Mycobacteria
Kanjoor, James R. F.R.C.S.
Plastic and Reconstructive Surgery
May 2011
Vol. 127 - Issue 5: pp 2120-2121
It was with great anxiety that I read the case report “Sepsis after Autologous Fat Grafting” by Simon in the October of 2010 issue of the Journal.1 The authors have described acute or early-onset sepsis in a very illustrative manner. I write this to emphasize the dreaded chronic infective complication, atypical mycobacteria in relation to liposuction and fat transfer.
A young healthy woman who had bilateral trochanteric lipodystrophy came for liposuction, and she wanted augmentation of her ear lobules. Tumescent liposuction and fat transfer to the ear lobule was the plan. In a good surgical center, under sterile conditions, tumescent liposuction of the outer thighs was performed. Fat harvesting was performed using 2-ml Luer-Lok syringes. Fat graft was prepared by decantation, and during this process the fat was not transferred to other syringes, not centrifuged, and not left exposed without the plunger.
With a Coleman microinfiltration cannula, 1 ml of fat was infiltrated into each ear lobule, and the patient was satisfied with the augmentation and the fat reduction at the thighs. She came for periodic reviews for 1 month, and the skin was retracting well by the end of 2 months. At approximately the ninth postoperative week, she started experiencing pain and tenderness at the liposuctioned areas. Locally, areas of hyperpigmentation and some areas of fluctuation were observed, suggestive of microabscess. Aspiration revealed serous clear fluid that was sterile for bacterial culture. Zeil-Nielsen staining for acid-fast bacilli was positive on one slide. Empiric antibiotics did not help her. She had multiple discharging sinuses with hyperpigmentation (Fig. 1, left). Under anesthesia, multiple stab incisions were made over the fluctuant areas, and thorough curettage was performed on both sides. The ear lobule too was found to be fluctuant and incised to drain thin serous fluid. Results of repeated microbiological culture were negative. On specific request, polymerase chain reaction restriction analysis of clinical isolates tested positive for atypical mycobacteria and culture in Lowenstein-Jensen medium for mycobacteria did not grow any organism even after 6 weeks. On the advice of an infectious disease specialist, three drugs (i.e., ciprofloxacin, clarithromycin, and parenteral amikacin) were started. Amikacin was used for 2 months and the other two drugs were used for 6 months. The oozing stopped 2 months after starting the medications. The affected area healed well except for mild hyperpigmentation (see original article for pictures)
I feel that articles about liposuction and its complications2–4 are never complete without emphasizing atypical mycobacterial infection. Because this organism spreads from contaminated water, extreme care in sterilization principles prevents its occurrence.5 The long delay and indolent progression of the disease should be considered in any liposuction and liposculpture patient before declaring him or her free of infection. Having been bitten once, I review all my liposuction patients every month for 3 months, mainly to catch this indolent infection early.
James R. Kanjoor, F.R.C.S.
I found this case study in the Journal of Aesthetic Plastic Surery (2011 Aug;35(4):641-5. doi: 10.1007/s00266-010-9605-8. Epub 2010 Nov 5). If you have any questions about the medical terminology, leave a comment, and I will respond as soon as I have free time. I must state thst the following complications are rare when working with a board certified surgeon in a sterile environment. Nevertheless, no surgery, even under the best conditions, is without risk. This is not to discourage anyone about fat grafting, but we all should go into surgery argus-eyed about any potential complications.
BACKGROUND: Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting.
METHODS: A 42-year-old woman presented to the authors' emergency department reporting tenderness, swelling, and a sensation of heat in both breasts. The patient had undergone augmentation mammoplasty by autologous fat grafting 7 days previously. Abscess formation was suspected based on the patient's history, physical examination, laboratory findings, and image study.
RESULTS: Incision and drainage were performed immediately with the patient under general anesthesia, and 500 ml of a foul, brown, turbid, purulent fluid containing necrotic fat debris was drained from each breast. Empiric antibiotics were started on the first hospital day, and betadine and saline-irrigation were administered daily for 2 weeks. Incisions were closed on hospital day 19 when laboratory data and local infection signs had improved. At the patient's 9-month follow-up assessment, breast contours were found to be well preserved, and scarring was minimal.
CONCLUSION: Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.
I also found this journal article about atypical mycobacterium infections after autologous fat grafting. Since this bacterium has been seen in quite a few patients returning from the Dominican Republic after plastic surgery, I felt it was good information to pass along to everyone on RealSelf.
Sepsis after Autologous Fat Grafting: Role of Atypical Mycobacteria
Kanjoor, James R. F.R.C.S.
Plastic and Reconstructive Surgery
May 2011
Vol. 127 - Issue 5: pp 2120-2121
It was with great anxiety that I read the case report “Sepsis after Autologous Fat Grafting” by Simon in the October of 2010 issue of the Journal.1 The authors have described acute or early-onset sepsis in a very illustrative manner. I write this to emphasize the dreaded chronic infective complication, atypical mycobacteria in relation to liposuction and fat transfer.
A young healthy woman who had bilateral trochanteric lipodystrophy came for liposuction, and she wanted augmentation of her ear lobules. Tumescent liposuction and fat transfer to the ear lobule was the plan. In a good surgical center, under sterile conditions, tumescent liposuction of the outer thighs was performed. Fat harvesting was performed using 2-ml Luer-Lok syringes. Fat graft was prepared by decantation, and during this process the fat was not transferred to other syringes, not centrifuged, and not left exposed without the plunger.
With a Coleman microinfiltration cannula, 1 ml of fat was infiltrated into each ear lobule, and the patient was satisfied with the augmentation and the fat reduction at the thighs. She came for periodic reviews for 1 month, and the skin was retracting well by the end of 2 months. At approximately the ninth postoperative week, she started experiencing pain and tenderness at the liposuctioned areas. Locally, areas of hyperpigmentation and some areas of fluctuation were observed, suggestive of microabscess. Aspiration revealed serous clear fluid that was sterile for bacterial culture. Zeil-Nielsen staining for acid-fast bacilli was positive on one slide. Empiric antibiotics did not help her. She had multiple discharging sinuses with hyperpigmentation (Fig. 1, left). Under anesthesia, multiple stab incisions were made over the fluctuant areas, and thorough curettage was performed on both sides. The ear lobule too was found to be fluctuant and incised to drain thin serous fluid. Results of repeated microbiological culture were negative. On specific request, polymerase chain reaction restriction analysis of clinical isolates tested positive for atypical mycobacteria and culture in Lowenstein-Jensen medium for mycobacteria did not grow any organism even after 6 weeks. On the advice of an infectious disease specialist, three drugs (i.e., ciprofloxacin, clarithromycin, and parenteral amikacin) were started. Amikacin was used for 2 months and the other two drugs were used for 6 months. The oozing stopped 2 months after starting the medications. The affected area healed well except for mild hyperpigmentation (see original article for pictures)
I feel that articles about liposuction and its complications2–4 are never complete without emphasizing atypical mycobacterial infection. Because this organism spreads from contaminated water, extreme care in sterilization principles prevents its occurrence.5 The long delay and indolent progression of the disease should be considered in any liposuction and liposculpture patient before declaring him or her free of infection. Having been bitten once, I review all my liposuction patients every month for 3 months, mainly to catch this indolent infection early.
James R. Kanjoor, F.R.C.S.
I made a decision that is going to make my peers have a heart attack!
So, I decided to go to the Dominican Republic to have surgery! After extensive research, I have been unable to find a US surgeon who can sculpt a body like Dra Agustina Duran. The only time I will be able to travel is next December (2015). I dread telling my fellow doctors in training and my mentor, because I know I will get a lecture for my decision. My husband is a nurse, so he will be with me when I travel. We plan to utilize the next year to continually conduct research to ensure I have the best possible outcome.
Hey ladies! I am new mom and physician in...
Hey ladies! I am new mom and physician in training, and I want my curves back. When I was pregnant, I had severe polyhydramnios (excessive amniotic fluid) which caused my abdomen to expand at a rapid rate. I was as big as someone having triplets, and I could literally feel my skin tearing as the condition worsened. Needless to say, it ruined my formerly beautiful body that was crafted by military service and gymnastics. I also gained A LOT of weight after giving birth although I was nursing. I unfortunately tend to be the type of person who stress eats, and I had a rough recovery after having my child. As a physician in training, I can obtain access to some reputable plastic surgeons in the USA. However,many plastic surgeons in the US are not sculpting the tiny waistlines and well-proportioned gluteals like I have seen in some work in the Dominican Republic. For example, I love Dra Duran's work, and Dra Almonte (in my opinion) does the cleanest incisions I have seen so far in a Dominican surgeon.
As someone involved in healthcare, my number one concern with going overseas is the risk of infection. The CDC issued a warning about seeking surgery in the DR after 17 or 19 women contracted serious infections. When I read this, I automatically thought about HIV transmission. I would like to ask some questions that maybe some of you women can answer:
1. What clinics and doctors have the best track record for sanitation and safety in the DR?
2. Have there been instances of HIV or hepatitis transmission with any of the doctors or clinics/hospitals in the DR? Please provide me links to articles if you have them.
3. Which doctors in the DR are consistent about post-operative care, and were you able to contact him or her back in the US if you experienced complications?
4. Can you recommend any US surgeons who have perfected the 'coke bottle body' look that is equivalent to Dra Duran's muñecas (dolls) in the DR?
5. Name your top three doctors, either in the US or DR, you would recommend for sculpting the best coca cola bottle body.
I probably have more questions, but I haven't slept in 24 hours. Thank you all in advance for decreasing countless hours of research by answering my questions . If I cannot find a doctor in the US, then I will consider traveling overseas only if I can find a clinic that has no current or prior sanitation or sterilization issues. Thanks for your help!
As someone involved in healthcare, my number one concern with going overseas is the risk of infection. The CDC issued a warning about seeking surgery in the DR after 17 or 19 women contracted serious infections. When I read this, I automatically thought about HIV transmission. I would like to ask some questions that maybe some of you women can answer:
1. What clinics and doctors have the best track record for sanitation and safety in the DR?
2. Have there been instances of HIV or hepatitis transmission with any of the doctors or clinics/hospitals in the DR? Please provide me links to articles if you have them.
3. Which doctors in the DR are consistent about post-operative care, and were you able to contact him or her back in the US if you experienced complications?
4. Can you recommend any US surgeons who have perfected the 'coke bottle body' look that is equivalent to Dra Duran's muñecas (dolls) in the DR?
5. Name your top three doctors, either in the US or DR, you would recommend for sculpting the best coca cola bottle body.
I probably have more questions, but I haven't slept in 24 hours. Thank you all in advance for decreasing countless hours of research by answering my questions . If I cannot find a doctor in the US, then I will consider traveling overseas only if I can find a clinic that has no current or prior sanitation or sterilization issues. Thanks for your help!