**3. Complications**

ventilation should be used (a tidal volume of 6–8 mL/kg of ideal body weight, less than 30 cm

In our ambulatory and short-stay surgical unit, regional procedures are preferred, especially subarachnoid anesthesia with a lumbar approach for surgeries below T6 segment. We also use spinal anesthesia in some patients with combined surgical procedures up to T4. Single injection of spinal anesthetics and adjuvants is safe, rapid, easy to administer, inexpensive, with a certain degree of postoperative analgesia, and fewer immediate and late residual effects than general anesthesia [32, 33]. We do not use subarachnoid anesthesia with a thoracic approach. In breast, nose, and arm surgeries, we prefer general anesthesia. For facial surgery, we use conscious sedation mixed with local anesthesia [34], and we have just adopted Friedberg's recommendation [35] with propofol or ketofol for facial surgery and sometimes as a sedative complement at the end of spinal anesthesia. The characteristics of propofol make it a safe drug when administered by an anesthesiologist and BIS (60–70) monitoring is recommended,

Monitored anesthesia care is a safe technique in ambulatory and short-stay units. It must be done by an anesthesiologist and goes from simple monitoring of the patient to the use of intravenous drugs and local anesthetics for longer procedures as rejuvenation facial surgery. The most used drugs are propofol, ketamine, midazolam, fentanyl, sufentanil, remifentanil,

**Figure 1** shows a schema where the difference between alertness, conscious sedation, deep sedation, and general anesthesia are shown. The vertical line delimits the most relevant clinical data and the appropriate management [34]. Attachment to this scheme is a simple guide to avoid anesthesia complications, especially the airway and cardiovascular and central ner-

**Figure 1.** Scheme showing the differences and limits of alertness, conscious sedation, deep sedation, and general

O), which prevents lung damage, specifically in pro-

H2

longed surgery.

vous systems.

anesthesia.

O peak pressure, and PEEP 6–8 cm H2

136 Anesthesia Topics for Plastic and Reconstructive Surgery

although the Ramsey scale (3–4) can also be used [33, 35].

and dexmedetomidine always supplemented with nasal oxygen [34–39].

A patient may be complicated by anesthesia, surgery, or a combination of both, for example, infections, venous thrombosis, thromboembolism, bleeding (anemia or hematomas), inadequate scarring, neural damage, overhydration, postoperative emesis, or burns, just to name a few. It is usually impossible to attribute these complications to one single member of the team; therefore, all professionals should function as a teamwork and must share responsibilities as in those patients complicated with DVT/PE. In this chapter, we review the expected complications in anesthesia-plastic surgery and a group of rare incidents that could occur in this clinical setting of which we have observed some.

#### **3.1. Anesthesia complications**

Complications of anesthesia can be classified into four different etiological categories: (1) health personnel errors; (2) adverse events to the anesthesia technique; (3) the physical condition of the patients; and (4) sentinel incidents or events. Anesthesia morbidity and mortality rates are approximately the same in countries with a similar life expectancy. The anesthesiologic community of a given country reduces their anesthesia morbidity and mortality data by an acceptable range for their societies using techniques according to their medical culture and historical traditions [40]. Although complications will always exist since erring is human [41], preventive measures are obligatory to reduce complications of anesthesia and to regulate our professional activity to reduce morbidity and mortality statistics [6]. Complications related to anesthesia are rare in plastic surgery, ranging from simple events to catastrophic outcomes, including death.

#### *3.1.1. Unplanned hypothermia*

It is the most frequent complication in plastic surgery. Under normal conditions, human thermoregulation mechanisms maintain body temperature from 36.5 to 37.5°C. This homeostasis is achieved by thermoregulatory defense mechanisms such as vasoconstriction, vasodilation, sweating, or chills. Hypothermia is considered when body temperature drops below 36°C. It can occur in the perioperative period; preoperative phase is defined as 1 hour before induction (when patients are prepared for surgery), during the intraoperative phase (total anesthetic time) and postoperative phase (24 postoperative hours) [42, 43]. Unintentional intraoperative decrease in body temperature occurs in a large percentage of surgeries and is secondary to multiple factors. In anesthetized patients, body temperature usually drops 2°C but can drop up to 6°C due to changes done by general anesthesia at the center of thermoregulation, a thermal decrease depending on the dose of the anesthetic. Other important factors of hypothermia are the exposure of the patient to the cold environment of the operating rooms and the failure to actively warm patients. Hypothermia has negative effects such as increased infections, delayed healing, increased intra and postoperative bleeding, increased blood transfusion requirements, increased cardiac morbidity, prolonged duration of anesthetics, and coagulopathies [44, 45]. Therefore, it is necessary to use different methods to avoid it, to reduce its intensity, and to manage it with opportunity; mattresses with forced air or water heating, electrical devices, heating of the intravenous or irrigation solutions, room temperature, and thermal blankets, among others, have shown different degrees of efficacy [46–49].

*3.1.4. Nausea and vomiting*

of its side effects.

*3.1.5. Overhydration*

and even death.

Postoperative emesis is a serious complication in plastic surgery as it may interfere with the results. It occurs after general or neuraxial anesthesia and has been associated with the use of opioids, being more frequent in young women, nonsmokers, and patients with a history of postanesthetic emesis. Prevention is necessary using preoperative medication such as dexamethasone and/or serotonergic antagonists. Metoclopramide has fallen into disuse because

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 139

It is associated in tumescent liposuction with large volumes and generous intravenous administration of hydro saline solutions that can induce arterial hypertension, pulmonary edema,

Although these events are not directly attributable to the anesthetic technique, this is one of the factors that may be involved. They are the most feared complications in surgery and are more frequent in liposuction and abdominoplasty [60]. The embolus can be hematic or fatty. The risk factors are young women, contraceptives, air travel of more than 6–8 hours, prolonged surgeries, and thrombophilic pathologies such as factor V Leiden [61, 62]. Preventive measures with elastic stockings and pneumatic compression, early mobilization, antiplatelet agents, heparins, and/or oral anticoagulants are mandatory in high risk patients since this complication is the leading cause of mortality in plastic surgery. In 1,141,418 outpatient surgery procedures, there were 23 fatal events, being the pulmonary embolism the cause in 13 patients. Abdominoplasty was the surgery most commonly associated with death from pul-

Most of these types of complications are sentinel incidents that make prevention, diagnosis, and management difficult. The following paragraphs describe some patients seen in our pro-

This entity occurs in ∼1:60,000 to 1:125,000 anesthetics procedures and is more frequent in cardiovascular and orthopedic surgery, although there are cases described in plastic surgery [64, 65]. It has been associated with prolonged prone position with the head positioned lower than the thorax, anemia, use of vasoconstrictors, or glycine [66, 67]. Transient or permanent postoperative blindness has also been described following facial injections of fillers as described later.

In our practice, we had a 38-year-old patient who underwent abdominoplasty, liposuction, and fat transfer in her buttocks under spinal-general anesthesia. She developed total blindness manifested in the immediate postanesthetic recovery. MRI showed occipital cortical

*3.1.6. Deep venous thrombosis and pulmonary thromboembolism*

monary embolism in an office-based surgery facility [63].

edema (**Figure 2**), establishing the diagnosis of cortical blindness.

*3.1.7. Uncommon complications*

fessional practice or referred by colleagues.

*3.1.7.1. Postanesthesia-surgery blindness*

Some body contouring procedures such as liposuction of various regions, extended or circular abdominoplasty, and multiple surgeries expose body surface in a way that facilitate heat loss. If this is added to the fact that some surgeons are accustomed to utilizing antiseptic solutions in the skin area that will be operated minutes before positioning the patients in the operating table, it accelerates and increases the hypothermia and can be an incident that affects the patient outcome.

Perioperative hypothermia is a complication that must be anticipated, detected early, and treated in a timely manner.

#### *3.1.2. Toxicity and side effects to drugs*

Side effects to drugs used during anesthesia are sporadic. A background of allergies or hypersensitivity should be investigated at the time of the anesthetic evaluation and avoid its use. Among other drugs, there have been reports of allergies to local anesthetics, muscle relaxants, sugammadex, and propofol, with the most severe reactions to latex. Opioids, especially remifentanil, may induce hyperalgesia. There are undesirable reactions like malignant hyperthermia secondary to halogenated and succinylcholine. These patients must be managed with total intravenous anesthesia or regional anesthesia because local anesthetics are safer and have rarely been associated with this entity [50].

For a couple of decades, local anesthetic toxicity has been the subject of multiple publications. In plastic surgery, there is a controversy over the total doses accepted as safe. Since the original description by Klein [51, 52], various data on safe doses of lidocaine 0.1–0.05% plus epinephrine 1:1,000,000 in tumescent liposuction have been published. Segmental infiltration of reduced lidocaine concentration 0.02% has been used in broader liposuctions [53]. The latest research done in 14 human volunteers has shown that 28 mg/kg without liposuction and 45 mg/kg (dose range 9.2–52 mg/kg.) after liposuction are safe dosages. The authors reported serum lidocaine concentration below levels associated with mild lidocaine systemic toxicity. The probable risk of lidocaine toxicity without liposuction at a dose of 28 mg/kg and with liposuction at a dose of 45 mg/kg was ≤1 per 2000 [54]. Timely diagnosis and management of local anesthetic toxicity with intravenous lipids in severe cases are essential. Lipids in initial dose of 1.5 mL/kg, followed by infusion of 0.25–0.50 mL/kg for 30–60 min. This infusion can be increased if hypotension or asystole persists [55]. After the infusion of iv lipids is stopped, a recurrence of local anesthetics toxicity can happen, so these patients need to be observed for at least 24 hours more.

#### *3.1.3. Trigeminal cardiac reflex*

Rhinoplasty is a frequent, relatively simple outpatient procedure that can be catastrophically complicated. The trigeminal cardiac reflex is defined as sudden onset of parasympathetic dysrhythmia, bradycardia that can progress to sudden asystole in addition to hypotension, apnea, and gastric hypermotility. This reflex can be initiated with stimulation of the trigeminal nerve during infiltration of the local anesthetic in the nasal columella or during osteotomy [56–59].

#### *3.1.4. Nausea and vomiting*

heating, electrical devices, heating of the intravenous or irrigation solutions, room temperature, and thermal blankets, among others, have shown different degrees of efficacy [46–49]. Some body contouring procedures such as liposuction of various regions, extended or circular abdominoplasty, and multiple surgeries expose body surface in a way that facilitate heat loss. If this is added to the fact that some surgeons are accustomed to utilizing antiseptic solutions in the skin area that will be operated minutes before positioning the patients in the operating table, it accelerates and increases the hypothermia and can be an incident that

Perioperative hypothermia is a complication that must be anticipated, detected early, and

Side effects to drugs used during anesthesia are sporadic. A background of allergies or hypersensitivity should be investigated at the time of the anesthetic evaluation and avoid its use. Among other drugs, there have been reports of allergies to local anesthetics, muscle relaxants, sugammadex, and propofol, with the most severe reactions to latex. Opioids, especially remifentanil, may induce hyperalgesia. There are undesirable reactions like malignant hyperthermia secondary to halogenated and succinylcholine. These patients must be managed with total intravenous anesthesia or regional anesthesia because local anesthetics are safer and

For a couple of decades, local anesthetic toxicity has been the subject of multiple publications. In plastic surgery, there is a controversy over the total doses accepted as safe. Since the original description by Klein [51, 52], various data on safe doses of lidocaine 0.1–0.05% plus epinephrine 1:1,000,000 in tumescent liposuction have been published. Segmental infiltration of reduced lidocaine concentration 0.02% has been used in broader liposuctions [53]. The latest research done in 14 human volunteers has shown that 28 mg/kg without liposuction and 45 mg/kg (dose range 9.2–52 mg/kg.) after liposuction are safe dosages. The authors reported serum lidocaine concentration below levels associated with mild lidocaine systemic toxicity. The probable risk of lidocaine toxicity without liposuction at a dose of 28 mg/kg and with liposuction at a dose of 45 mg/kg was ≤1 per 2000 [54]. Timely diagnosis and management of local anesthetic toxicity with intravenous lipids in severe cases are essential. Lipids in initial dose of 1.5 mL/kg, followed by infusion of 0.25–0.50 mL/kg for 30–60 min. This infusion can be increased if hypotension or asystole persists [55]. After the infusion of iv lipids is stopped, a recurrence of local anesthetics

toxicity can happen, so these patients need to be observed for at least 24 hours more.

Rhinoplasty is a frequent, relatively simple outpatient procedure that can be catastrophically complicated. The trigeminal cardiac reflex is defined as sudden onset of parasympathetic dysrhythmia, bradycardia that can progress to sudden asystole in addition to hypotension, apnea, and gastric hypermotility. This reflex can be initiated with stimulation of the trigeminal nerve during infiltration of the local anesthetic in the nasal columella or during

affects the patient outcome.

treated in a timely manner.

*3.1.3. Trigeminal cardiac reflex*

osteotomy [56–59].

*3.1.2. Toxicity and side effects to drugs*

138 Anesthesia Topics for Plastic and Reconstructive Surgery

have rarely been associated with this entity [50].

Postoperative emesis is a serious complication in plastic surgery as it may interfere with the results. It occurs after general or neuraxial anesthesia and has been associated with the use of opioids, being more frequent in young women, nonsmokers, and patients with a history of postanesthetic emesis. Prevention is necessary using preoperative medication such as dexamethasone and/or serotonergic antagonists. Metoclopramide has fallen into disuse because of its side effects.

#### *3.1.5. Overhydration*

It is associated in tumescent liposuction with large volumes and generous intravenous administration of hydro saline solutions that can induce arterial hypertension, pulmonary edema, and even death.

### *3.1.6. Deep venous thrombosis and pulmonary thromboembolism*

Although these events are not directly attributable to the anesthetic technique, this is one of the factors that may be involved. They are the most feared complications in surgery and are more frequent in liposuction and abdominoplasty [60]. The embolus can be hematic or fatty. The risk factors are young women, contraceptives, air travel of more than 6–8 hours, prolonged surgeries, and thrombophilic pathologies such as factor V Leiden [61, 62]. Preventive measures with elastic stockings and pneumatic compression, early mobilization, antiplatelet agents, heparins, and/or oral anticoagulants are mandatory in high risk patients since this complication is the leading cause of mortality in plastic surgery. In 1,141,418 outpatient surgery procedures, there were 23 fatal events, being the pulmonary embolism the cause in 13 patients. Abdominoplasty was the surgery most commonly associated with death from pulmonary embolism in an office-based surgery facility [63].

#### *3.1.7. Uncommon complications*

Most of these types of complications are sentinel incidents that make prevention, diagnosis, and management difficult. The following paragraphs describe some patients seen in our professional practice or referred by colleagues.

#### *3.1.7.1. Postanesthesia-surgery blindness*

This entity occurs in ∼1:60,000 to 1:125,000 anesthetics procedures and is more frequent in cardiovascular and orthopedic surgery, although there are cases described in plastic surgery [64, 65]. It has been associated with prolonged prone position with the head positioned lower than the thorax, anemia, use of vasoconstrictors, or glycine [66, 67]. Transient or permanent postoperative blindness has also been described following facial injections of fillers as described later.

In our practice, we had a 38-year-old patient who underwent abdominoplasty, liposuction, and fat transfer in her buttocks under spinal-general anesthesia. She developed total blindness manifested in the immediate postanesthetic recovery. MRI showed occipital cortical edema (**Figure 2**), establishing the diagnosis of cortical blindness.

*3.1.8. Attempted murder*

reinject muscle relaxants.

**3.2. Surgical complications**

*3.2.1. Surgical infections*

Anecdotal situation has been reported on few occasions. We had a case where the spouse tried to assassinate his wife at the end of conscious sedation for rhytidectomy. He injected her with vecuronium, but the timely resuscitation initiated by the recovery area nurse and the clinical suspicion followed to the administration of neostigmine reversed the respiratory failure. The patient was transferred to intensive care unit where the husband made two failed attempts to

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 141

Some surgical complications are listed because of their importance and relation to anesthesia.

Infections are frequent in plastic surgery, from 4% up to 14%, including local infections, bloodborne infections, and distal infections such as pneumonia or infective endocarditis. Breast surgery—implants or reconstructions—body contouring procedures such as liposuction and abdominoplasty, or multiple procedures have been described with more risks of postoperative infections, especially if there are predisposing factors such as diabetes, HIV, cancer, or immunosuppressive treatment. Infections in plastic surgery can be minor due to microbial skin flora to severe cases affected with atypical or multiresistant opportunistic bacteria [70, 71]. The type of infection varies depending on the surgery and the patient. Choice of antibiotics must be meticulous based initially on the clinical suspicion, escalating the antimicrobial when the bacterium is isolated, and its sensitivity is known. The most isolated germs in implant-based reconstruction infections are *Staphylococcus epidermidis, Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, Enterococcus, Escherichia coli, Enterobacter, Group B streptococcus, Morganella morganii, Propionibacterium,* and *Corynebacterium.* Initial cellulitis can be managed with oral fluoroquinolones. If this treatment fails, intravenous imipenem, gentamicin, and/or vancomycin must be prescribed [72, 73]. Severe infections with methicillin-resistant *Staphylococcus aureus* (MRSA) should be treated aggressively with vancomycin, teicoplanin, or tigecycline, in addition to draining infected sites. Cases with nontuberculous mycobacterial infections are fairly atypical, difficult to diagnose and treat [74–79]. The antimicrobial treatment must be aggressive and prolonged, and when there are implants, these must be removed. **Figure 3** shows a patient infected with *Mycobacterium chelonae* after liposuction. Necrotizing fasciitis is a rare, potentially fatal, complication in plastic surgery that occurs more in liposuction. It requires extensive, repetitive debridement, and appropriate antimicro-

bial scheme. The most common germ is *Streptococcus pyogenes* [80].

These are uncommon complications, although it does occur in patients undergoing prolonged procedures, especially in the postbariatric ones. A hematoma is present in up to 6% of patients

*3.2.2. Transoperative bleeding and hematoma*

**Figure 2.** Blindness secondary to cerebral occipital cortical edema.

#### *3.1.7.2. Transient deafness*

This rare effect has been reported in subarachnoid anesthesia attributing to sudden changes in endolymph. We had a young patient from Russia who lost her auditory acuity during 5 days after spinal anesthesia for liposuction-gluteal lipoinjection.

#### *3.1.7.3. Broken heart syndrome*

Takotsubo's cardiomyopathy or broken heart syndrome is a stress-induced heart disease with sudden left ventricular failure without coronary damage [68]. A young woman developed this syndrome few minutes after nasal infiltration with lidocaine and epinephrine under anesthesia with sevoflurane. The surgery was canceled, and the patient was transferred to a nearby hospital where she was successfully managed.

#### *3.1.7.4. Awakening during general anesthesia*

It is a very rare entity with an estimated incidence of 0.1–0.2% but has the potential to cause adverse evolution in the psychological area inducing posttraumatic stress [69]. A 43-year-old patient who underwent transoperative awakening during general anesthesia with enflurane.

#### *3.1.8. Attempted murder*

Anecdotal situation has been reported on few occasions. We had a case where the spouse tried to assassinate his wife at the end of conscious sedation for rhytidectomy. He injected her with vecuronium, but the timely resuscitation initiated by the recovery area nurse and the clinical suspicion followed to the administration of neostigmine reversed the respiratory failure. The patient was transferred to intensive care unit where the husband made two failed attempts to reinject muscle relaxants.

## **3.2. Surgical complications**

Some surgical complications are listed because of their importance and relation to anesthesia.

#### *3.2.1. Surgical infections*

*3.1.7.2. Transient deafness*

*3.1.7.3. Broken heart syndrome*

with enflurane.

This rare effect has been reported in subarachnoid anesthesia attributing to sudden changes in endolymph. We had a young patient from Russia who lost her auditory acuity during 5 days

Takotsubo's cardiomyopathy or broken heart syndrome is a stress-induced heart disease with sudden left ventricular failure without coronary damage [68]. A young woman developed this syndrome few minutes after nasal infiltration with lidocaine and epinephrine under anesthesia with sevoflurane. The surgery was canceled, and the patient was transferred to a

It is a very rare entity with an estimated incidence of 0.1–0.2% but has the potential to cause adverse evolution in the psychological area inducing posttraumatic stress [69]. A 43-year-old patient who underwent transoperative awakening during general anesthesia

after spinal anesthesia for liposuction-gluteal lipoinjection.

**Figure 2.** Blindness secondary to cerebral occipital cortical edema.

140 Anesthesia Topics for Plastic and Reconstructive Surgery

nearby hospital where she was successfully managed.

*3.1.7.4. Awakening during general anesthesia*

Infections are frequent in plastic surgery, from 4% up to 14%, including local infections, bloodborne infections, and distal infections such as pneumonia or infective endocarditis. Breast surgery—implants or reconstructions—body contouring procedures such as liposuction and abdominoplasty, or multiple procedures have been described with more risks of postoperative infections, especially if there are predisposing factors such as diabetes, HIV, cancer, or immunosuppressive treatment. Infections in plastic surgery can be minor due to microbial skin flora to severe cases affected with atypical or multiresistant opportunistic bacteria [70, 71]. The type of infection varies depending on the surgery and the patient. Choice of antibiotics must be meticulous based initially on the clinical suspicion, escalating the antimicrobial when the bacterium is isolated, and its sensitivity is known. The most isolated germs in implant-based reconstruction infections are *Staphylococcus epidermidis, Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, Enterococcus, Escherichia coli, Enterobacter, Group B streptococcus, Morganella morganii, Propionibacterium,* and *Corynebacterium.* Initial cellulitis can be managed with oral fluoroquinolones. If this treatment fails, intravenous imipenem, gentamicin, and/or vancomycin must be prescribed [72, 73]. Severe infections with methicillin-resistant *Staphylococcus aureus* (MRSA) should be treated aggressively with vancomycin, teicoplanin, or tigecycline, in addition to draining infected sites. Cases with nontuberculous mycobacterial infections are fairly atypical, difficult to diagnose and treat [74–79]. The antimicrobial treatment must be aggressive and prolonged, and when there are implants, these must be removed. **Figure 3** shows a patient infected with *Mycobacterium chelonae* after liposuction.

Necrotizing fasciitis is a rare, potentially fatal, complication in plastic surgery that occurs more in liposuction. It requires extensive, repetitive debridement, and appropriate antimicrobial scheme. The most common germ is *Streptococcus pyogenes* [80].

#### *3.2.2. Transoperative bleeding and hematoma*

These are uncommon complications, although it does occur in patients undergoing prolonged procedures, especially in the postbariatric ones. A hematoma is present in up to 6% of patients

in facial and breast surgery. Inappropriate scarring is an unpredictable risk and sometimes

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 143

Liposuction is one of the procedures that are performed more frequently, and its complications are minimal such as seromas, deformities, and lymphoedema. Serious complications are rare, for example, hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and PE (0.06%). When it is combined with other procedures, complication rates are higher. It has also been associated with catastrophic lesions such as pleuropulmonary, abdominal viscera,

Soft tissue volumetric augmentation with filler injections is the second most frequent nonsurgical procedure performed in plastic surgery, being the face and buttocks the areas more frequently injected. The increased use of a wide range of fillers has shown that they are not harmless, so it is crucial to briefly review possible complications. The transfer of autologous fat in the facial regions is the most used filling substance. There are a great variety of synthetic fillers that can be atoxic and nonimmunogenic or act as a foreign body and induce an immune reaction, granulomas, infections, fibrosis, and long-lasting or permanent body deformities [83–85]. Although very rare, transient or permanent blindness and cerebrovascular emboli are the most devastating complication of forehead and facial injection of synthetic fillers or autologous fat. It is believed that the injected filling can act as a retrograde embolus upon entering the ophthalmic artery or through the normal anastomosis between frontal branch of superficial temporal artery from external carotid artery and supraorbital artery from ophthalmic artery [86]. Cannata et al. [87] described a patient who was injected with polymethylmethacrylate microspheres in the legs, soon after developed infection at the site of injection, followed by postinfectious glomerulonephritis. Kidney biopsy revealed translucent, nonbirefringent microspherical bodies compatible with the injected filler. **Figure 5** shows facial deformations

produces neural entrapment with secondary chronic postoperative pain.

*3.2.4. Other injuries*

and vascular damage [81, 82].

*3.2.5. Cosmetic filler complications*

**Figure 5.** Severe facial deformities secondary to an unknown illegal filler.

**Figure 3.** *M. chelonae* after liposuction.

after breast surgery. Facial surgery is rare but compromises long-term results. Most patients are reluctant to hemotransfusion. It is possible to correct moderate anemia without hemodynamic compromise with iron, folic acid, and erythropoietin. **Figure 4** shows typical cases of bleeding that may complicate the definitive outcome of surgery.

#### *3.2.3. Neural damage*

Nerve ending injuries are common in liposuction and abdominoplasty and manifest as neuropathic pain. Preventive use of gabapentinoids is useful. Major nerve damage can be seen

**Figure 4.** Transoperative active bleeding and residual postsurgical hematomas.

in facial and breast surgery. Inappropriate scarring is an unpredictable risk and sometimes produces neural entrapment with secondary chronic postoperative pain.

#### *3.2.4. Other injuries*

after breast surgery. Facial surgery is rare but compromises long-term results. Most patients are reluctant to hemotransfusion. It is possible to correct moderate anemia without hemodynamic compromise with iron, folic acid, and erythropoietin. **Figure 4** shows typical cases of

Nerve ending injuries are common in liposuction and abdominoplasty and manifest as neuropathic pain. Preventive use of gabapentinoids is useful. Major nerve damage can be seen

bleeding that may complicate the definitive outcome of surgery.

**Figure 4.** Transoperative active bleeding and residual postsurgical hematomas.

*3.2.3. Neural damage*

**Figure 3.** *M. chelonae* after liposuction.

142 Anesthesia Topics for Plastic and Reconstructive Surgery

Liposuction is one of the procedures that are performed more frequently, and its complications are minimal such as seromas, deformities, and lymphoedema. Serious complications are rare, for example, hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and PE (0.06%). When it is combined with other procedures, complication rates are higher. It has also been associated with catastrophic lesions such as pleuropulmonary, abdominal viscera, and vascular damage [81, 82].

#### *3.2.5. Cosmetic filler complications*

Soft tissue volumetric augmentation with filler injections is the second most frequent nonsurgical procedure performed in plastic surgery, being the face and buttocks the areas more frequently injected. The increased use of a wide range of fillers has shown that they are not harmless, so it is crucial to briefly review possible complications. The transfer of autologous fat in the facial regions is the most used filling substance. There are a great variety of synthetic fillers that can be atoxic and nonimmunogenic or act as a foreign body and induce an immune reaction, granulomas, infections, fibrosis, and long-lasting or permanent body deformities [83–85]. Although very rare, transient or permanent blindness and cerebrovascular emboli are the most devastating complication of forehead and facial injection of synthetic fillers or autologous fat. It is believed that the injected filling can act as a retrograde embolus upon entering the ophthalmic artery or through the normal anastomosis between frontal branch of superficial temporal artery from external carotid artery and supraorbital artery from ophthalmic artery [86]. Cannata et al. [87] described a patient who was injected with polymethylmethacrylate microspheres in the legs, soon after developed infection at the site of injection, followed by postinfectious glomerulonephritis. Kidney biopsy revealed translucent, nonbirefringent microspherical bodies compatible with the injected filler. **Figure 5** shows facial deformations

**Figure 5.** Severe facial deformities secondary to an unknown illegal filler.

Anesthesiology is a science, with a high risk of undesirable events secondary to the use of drugs and techniques with narrow safety margins that facilitate unexpected complications. On the other hand, plastic surgery is a specialty where the unrealistic high expectations of many patients mean that despite adequate results—surgeons and anesthesiologists can trigger demands—when these results are not what the patient expects, and even when there are no complications. A growing number of patients establish negligence or malpractice claims justified or not—and our practice tends toward an environment with a high incidence of litigation that sometimes forces specialists to search for geographic areas with a lower incidence of lawsuits [92]. Frequently, decisions of the legal system do not depend on the opinions of medical experts, or medical experts are not properly trained to review the events of a lawsuit in all specialties of medicine and surgery. Patients, their families, and lawyers usually make demands that do not progress due to lack of elements that support malpractice. An attorney

Perioperative Complications in Plastic Surgery http://dx.doi.org/10.5772/intechopen.82269 145

should not file a lawsuit without the opinion of a physician skilled in the subject [93].

key in the doctor-patient relationship, as mentioned in a previous publication [6].

Lawyers have promoted the lawsuit as a part of their modus vivendi. "Have you suffered as a result of a cosmetic procedure that you believe is due to the negligence of the surgeon? If you believe that your surgeon acted negligently and outside of his/her duty to care for you as a patient, we can help you." This type of information is found on the Internet, and it is associated to websites that guide patients on how to formulate their demands. In Colombia, doctors have expressed their concerns about the rigidity of their penal system [96], which temporarily suspended a plastic surgeon, in addition to imposing a prison for less than a year and compensation to the patient for 150,000,000 Colombian pesos (approximately 52,290 USD) in a complicated liposuction with necrotizing fasciitis. The authors discuss different

Park et al.'s [94] study of negligence claims in plastic surgery found responsibility between 30 and 100% of the cases, although the courts recognized that the economic compensation should be adjusted according to the victim, especially when there are associated pathologies which limit and make fairer compensation. Paik et al. [5] reviewed 292 cases of verdicts and liquidation reports in cosmetic breast surgery; the most common lesion was breast disfigurement in 53.1%, and negligent misrepresentation was 98% more likely to be resolved in favor of the complainant, while fraud was 92% more amenable to the complainant. The most common causes of citation were negligence in 88.7% and lack of informed consent in 43.8%. About 58.3% of the cases were in favor of the defendant and 41.7% in favor of the plaintiff. The compensation percentage agreed was 33.4 and 8.3% settlement. Payments ranged from \$ 245,000 to \$ 300,000 USD. A study with 88 cases of demand found in the west legal database [95] examined facial surgery procedures and found that 62.5% were decided in favor of the surgeon, 9.1% made agreements out of court, and 28.4% went to court for damages due to medical malpractice. The average payment was \$ 577,437 USD, and the jury average was \$ 352,341 USD, with blepharoplasty and rhytidectomy being the most litigated. In 38.6% of these cases, there were faults in the informed consent. There were also quarrels and disfigurements, functional considerations, and postoperative pain. The authors emphasize the importance of communication between patients and physicians regarding expectations as well as document benefits, alternatives, and specific risks. These studies show that negligence favors the demands in this clinical environment and emphasize that adequate transparency and communication are the

**Figure 6.** Deformities in the buttocks secondary to unknown substances. Observe extreme fibrosis.

secondary to injection of unknown filler, and **Figure 6** is an MRI that shows fillers injected in the buttocks, which produce fibrosis and deformations of the region by erratic migration, which are very difficult or impossible to correct.
