Bilateral pneumothorax after liposuction: a rare complication

Abstract

Pneumothorax is a rare complication of liposuction, usually unilateral and following suctioning over the thoracic wall; bilateral pneumothorax and upper-limb involvement are distinctly unusual. A 42-year-old healthy woman presented 11 h after liposuction of the bilateral upper limbs and upper back with dyspnea, left-sided pleuritic chest pain, and upper-body swelling. She was tachycardic and in respiratory distress. Chest radiography showed bilateral pneumothorax with extensive soft-tissue emphysema, and computed tomography confirmed bilateral hydropneumothorax while excluding pulmonary embolism. Bilateral tube thoracostomy achieved lung re-expansion. Hemoglobin fell from 7.4 to 5.9 g/dL despite minimal chest-tube drainage, consistent with occult soft-tissue bleeding, and was corrected by transfusion. She recovered fully. Pneumothorax should be considered in any patient with respiratory symptoms after liposuction, even when the abdomen and flanks are untreated; a normal oxygen saturation on supplemental oxygen should not delay imaging, and vigilance for occult hemorrhage is warranted.

Introduction

Liposuction is a body-contouring procedure that removes subcutaneous fat by suction cannula and is one of the most commonly performed cosmetic procedures, with an overall complication rate of about 2.62% [1, 2]. Most complications are minor and local; serious thoracic events are rare. Pneumothorax is thought to arise from cannula perforation of the chest wall and parietal pleura [3], and typically presents postoperatively with pleuritic chest pain, tachypnea, hypoxemia, and reduced breath sounds [4, 5]. Reported cases are predominantly unilateral and follow suctioning over the thoracic wall. We report an unusual bilateral pneumothorax, with significant occult hemorrhage, after liposuction of the upper limbs and upper back.

Case report

A 42-year-old previously healthy woman was transferred to our emergency department about 11 h after cosmetic liposuction of the bilateral upper limbs and upper back, performed at an outside facility. She reported severe left-sided pleuritic chest pain and shortness of breath from the immediate postoperative period, with upper-body swelling. She had undergone uncomplicated liposuction 5 years earlier. Outside operative records were unavailable.

She was alert but in respiratory distress, tachycardic, with oxygen saturation of 100% on a non-rebreather mask. The upper limbs showed ecchymosis without a defined hematoma, capillary refill under 2 s, and digital saturations of 99%–100%. Upper-body swelling was noted, but subcutaneous emphysema was not palpable on the initial examination and was identified only on subsequent imaging. A venous blood gas on arrival showed pH 7.23, pCO₂ 43 mmHg, HCO₃ 18 mmol/L, base deficit −9.3, and lactate 5.7 mmol/L, indicating a high-lactate metabolic acidosis consistent with tissue hypoperfusion from blood loss. Hemoglobin was 7.4 g/dL, hematocrit 0.230, platelets 294 × 10⁹/L, and white cells 11.5 × 10⁹/L.

An initial chest radiograph showed bilateral pneumothorax with soft-tissue emphysema (Fig. 1). Because the pneumothoraces were small and the patient was hemodynamically stable with an oxygen saturation of 100% on supplemental oxygen and no features of tension, and because the acute dyspnea and pleuritic chest pain in a recent postoperative patient raised suspicion of pulmonary embolism, computed tomography (CT) of the chest was performed before intervention (Figs 2–5). CT confirmed bilateral mild hydropneumothorax (greater on the left), bilateral pleural effusion with atelectasis, posterior upper chest-wall hematomas, and diffuse subcutaneous and intramuscular emphysema, with no pulmonary embolism. D-dimer was not obtained, as it is sensitive but non-specific and is expected to be raised early after surgery; CT pulmonary angiography was therefore used as the definitive test.

The general surgery team inserted bilateral chest tubes, each draining approximately 200 ml of blood at insertion with no further output; a radiograph confirmed position and re-expansion (Fig. 6). Tubes were placed on low intermittent suction, with analgesia, cefazolin, thromboprophylaxis, and daily radiographs. The plastic surgery team advised topical fusidic acid dressings, limb elevation, cold compression, and relocation of intravenous access to the lower limbs to protect the fat grafts; no acute surgical intervention was required.

Overnight the hemoglobin fell to 5.9 g/dL and two units of packed red cells were transfused, after which it rose to 8.9 and then 10 g/dL before discharge. As the tubes had drained little and then nothing, the loss was attributed to occult bleeding within the liposuction planes and chest-wall hematomas rather than the pleural space, and no surgical hemostasis was needed. A minimal persistent pneumothorax was noted with a failed clamping trial (Fig. 7). On day 5 the right chest tube was clamped and removed after 4 h of stability, and the left was removed the next day (Figs 8 and 9). The apparent change in the left tube’s position between the supine post-insertion film and the later erect radiographs was projectional rather than true migration, and the tube remained appropriately sited and functional throughout. At outpatient review she was well, with full resolution of the pneumothoraces (Fig. 10).

Discussion

This case illustrates bilateral pneumothorax after liposuction of the upper limbs and upper back, with extensive soft-tissue emphysema and concurrent anemia requiring transfusion. Pneumothorax is an uncommon but serious complication; in a series of 16 215 procedures, seven pneumothoraces occurred (0.043%), six after axillary treatment [3]. Delayed recognition can cause respiratory deterioration, so awareness is important when respiratory symptoms follow liposuction near the thoracic wall [3, 6, 7].

Direct cannula penetration of the intercostal muscles or pleura is the most likely mechanism, favored by treatment near the axilla or posterior chest wall, long cannulas, prior scarring, positive-pressure ventilation, and positioning [3, 6, 7]. Most reported events are unilateral and follow axillary, posterior thoracic, back, or truncal treatment [3, 6, 7]; bilateral complications have been described mainly after combined abdominoplasty and extensive truncal liposuction [8]. Radiography is the usual first investigation, with CT useful when the pneumothorax is small or occult or when pulmonary embolism must be excluded [4]. Management depends on size and stability, ranging from observation to tube thoracostomy [3, 6–8].

Our case is unusual in being bilateral and following treatment that included the upper limbs, without abdominal or circumferential trunk liposuction [3, 6–8]. Air tracking along disrupted planes may explain the marked emphysema [9]. The hemoglobin fall despite minimal chest-tube output was also notable and was attributed to concealed soft-tissue bleeding. Extensive subcutaneous emphysema should raise suspicion of pleural injury rather than being ascribed to liposuction planes alone [9], and serial hemoglobin monitoring is warranted when chest-tube output does not explain a hematologic decline. A normal oxygen saturation on supplemental oxygen should not delay imaging.

This single report cannot establish incidence, and the outside operative details, preoperative hemoglobin, and exact site of pleural injury were unavailable, so the mechanism and the source of blood loss cannot be confirmed with certainty.

Conclusion

Bilateral pneumothorax is a rare but serious complication of liposuction that may follow treatment of the upper limbs and upper back and may be accompanied by occult hemorrhage. Pneumothorax should be considered in any patient with respiratory symptoms after liposuction, even away from the abdomen and flanks. Prompt radiography, CT when findings are subtle or embolism must be excluded, timely tube thoracostomy, and vigilance for concealed bleeding support full recovery.

Acknowledgements

The authors thank the general surgery, plastic surgery, and radiology teams at King Abdullah bin Abdulaziz University Hospital for their contributions to the patient’s care.

Author contributions

J.A. and M.A. contributed equally as co-first authors and drafted the introduction and discussion, including the literature review. S.A. wrote the case presentation and conclusion, conceived the report, and supervised and critically revised the manuscript. H.A. provided clinical oversight as the consultant responsible for the patient’s surgical care and senior supervision of the work. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Conflicts of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Author notes