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Necrotizing soft tissue infection after liposculpture; Case report

Highlights • Infections in isolated liposuction procedures are reported as only 0.1 % of cases• One of the most serious complications of liposuction is necrotizing soft tissue infection (NSTI).• Rapid recognition of NSTI is life saving; with urgent extensive debridement and prophylactic antibiotics as the mainstay of treatment for this condition


Introduction
Liposculpture is an aesthetic surgical procedure that consists of removing adipose tissue from certain areas and transferring it to where the patients desire to obtain greater volume to improve body contour. This is accomplished by using suction cannulas through small incisions in the skin with minimal scarring and recurrence.
Worldwide, it is estimated that this procedure has a complication rate of 5%, with the majority being minor complications.
The leading cause of death among liposuction complications is pulmonary thromboembolism followed by fat embolism, pulmonary edema, lidocaine intoxication, and intra-abdominal visceral injury [1]. Infections in isolated liposuction procedures are reported as only 0.1 % of cases, however in multiple procedures it raises to 0.7 % of cases, usually after the presence of hematomas [2][3][4]. Certain risk factor have shown to increase the probability of infections following aesthetic procedures, thus measures have been designed to prevent them, however, in a small percentage of cases, infections can occur even when proper preventive measures are taken. Here we present a case of a 53-year-old female patient who underwent cosmetic surgery and developed a necrotizing soft tissue infection  and we will discuss the importance of early diagnosis, treatment options and our management of this particular case *This work has been reported in line with the SCARE criteria ([17])

Presentation of case
A 53-year-old female patient with a history of multiple cosmetic surgeries, with no additional significant medical history, began her condition after undergoing liposculpture surgery in which wide liposuction of the dorsal region, flanks and thighs with fat graft insertion into the gluteal area was performed in an outpatient surgery clinic at a northern state of Mexico.
Within the first 7 postoperative days, she presented fever and disabling pain at the surgical site with extensive bullae formation; during her fourth postoperative day, she presented signs of septic shock that required vasopressor support and mechanical ventilation, accompanied by acute renal failure, therefore she was admitted to the intensive care unit at her local hospital.
The patient's relatives requested air transportation to bring the patient to our center. Upon admission to our institution, she persisted with septic shock that required vasopressor support and mechanical ventilation; multiple and extensive lesions ranging from the pelvis to the neck were observed with the presence of subcutaneous emphysema, leakage of purulent material, erythema and necrosis at the wound edges ( Fig. 1).
A CT scan of the abdomen was requested, which revealed cutaneous dehiscence towards the left and right flanks, extending to the iliac crests, left gluteal region and perineal region. Extensive generalized soft tissue emphysema from the base of the neck to the assessed portion of the upper third of the thighs. The air dissected some of the muscular planes and striation of subcutaneous fatty tissue was also identified at the thoracic and predominantly abdominopelvic level (Figs. [2][3][4]. The diagnosis of necrotizing soft tissue infection (NSTI) was integrated, we emphasized surgical wound cleansing by mechanical scrubbing and debridement, use of prophylactic antibiotics and correct identification of the pathogen involved.
It was decided to perform a surgical intervention for drainage, debridement of necrotic tissue and placement of a negative pressure therapy system (Fig. 5) [5][6][7][8].
She was admitted to the Intensive Care Unit due to the presence of metabolic acidosis, hyperlactatemia, leukocytosis with a left shift, thrombocytopenia, elevated CRP, ESR, and hyperglycemia.
The patient remained in the intensive care unit for 7 days until the source of infection was controlled and hemodynamic stabilization was achieved.
The patient remained hospitalized for 42 days in which 15 surgical interventions were performed including multiple wound  cleansing and debridement as well as placement of a negative pressure therapy system, advancement of flaps, lesions reconstruction, procurement and placement of grafts. (Figs. 6-9 ).
Secretion cultures were requested during the various surgical procedures in which E. Coli, Finegoldia magna (peptostreptococcus magnus) and Streptococcus mitis were found. During the course of treatment, antibiotic management was imperative with Vancomycin, Meropenem and Clindamycin.
After 42 days the patient was discharged without further complications, followed by an intensive rehabilitation program. To our knowledge, there have been no further complications with this patient.

Discussion
Infections in isolated liposuction procedures are reported as only 0.1 % of cases, within the preparation of a patient for a liposculpture procedure, which is defined as a liposuction of less than 4 L with or without fat grafting. It is recommended to start antibiotic prophylaxis, preferably with a second-generation cephalosporin, one hour prior to scheduled surgery and continue it for 5-6 days afterwards [9,10]. Likewise, prophylaxis with Flucloxacillin or gentamicin is recommended in the case of liposuction and or abdominoplasty [11][12][13]. In this case, there is no information on prophylactic or antibiotic treatment prior to the first intervention.
The microorganisms most frequently isolated in postliposuction infections are Staphylococcus aureus, Streptococcus group A, Streptococcous pyogenes, and synergistic infections with anaerobes and facultative [9,13].
Among the culture results, Finegoldia magna was found, grampositive anaerobic cocci common to the gastrointestinal and genitourinary flora. It can be found in the context of polymicrobial infections, such as the case described here, considered a contami-nant in cultures that involve access through the oral cavity or skin, however it has been proposed as a possible cause of toxic shock syndrome [14]. Another pathogen isolated in this patient was Streptococcus mitis.
In comparison to other cases, we find our case unique because of the extension of the wounds and our management with negative pressure wound therapy. We followed the World Society of Emergency Surgery (WSES) Guidelines for Management of Skin and Soft Tissue Infections recommendations and even when negative pressure wound therapy is not part of the conventional recommendations, and according to other studies, its use is still controversial, we had positive outcomes with this approach in terms of wound healing and pain control [7,[17][18][19][20][21][22][23].
One of the most serious complications of liposuction is necrotizing soft tissue infection (NSTI), which is an infection of the subcutaneous tissue that spreads to the underlying dermis and sometimes beyond including the fascia and muscle, attributed to perforation of the abdominal viscus, inadequate sterilization of instruments or direct contamination of the wound [9,10,15,16].
Main risk factors for NSTI include: Diabetes Mellitus, peripheral vascular disease, immunosuppression, malnutrition, major traumatic injuries, as well as minor injuries to the skin or mucosa [3,4,10]. Among the highlights of this case, is the fact that NSTI can occur in a small percentage of the population even when appropriate prophylactic measures are taken and no risk factors are present, thus, surgeons must remain aware of this complications and have an early diagnostic suspicion that allows timely management, which as seen in this case, can be lifesaving. Should our patient have not been transferred in a timely manner to a center with the appropriate resources and facilities, outcomes could have been fatal. This case has been reported in line with the SCARE Guideline 2018. [24]

Conclusion
In all patients undergoing elective surgery, surgeons must be aware of the degree of pain and abnormal or unusual signs during postoperative follow-up. Consider antibiotic prophylaxis as well as therapy if necessary. Rapid recognition of NSTI is life saving; with urgent extensive debridement and prophylactic antibiotics as the mainstay of treatment for this condition, multiple debridement procedures may be necessary for successful outcomes. Negative pressure wound therapy system was of utmost importance for our case in order to increase tissue perfusion, avoid bacterial overgrowth, pain management and wound edge approximation for primary closure.

Declaration of Competing Interest
There was no conflict of interest.

Funding
There was no sponsorship for this study.

Ethical approval
There was no need for ethical approval.

Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request

Author contribution
Raul Alexander; Cuevas Bustos MD: Data collection, data analysis, writing the paper Oscar Cervantes Gutierrez MD: Data collection, data analysis Felix Alejandro Perez Trsitan MD: Data collection, data analysis Alejandro Acuña Macouzet MD: Data collection, data analysis Angel Flores-Huidobro Martinez MD: Data collection, data analysis Marcos; Jafif Cojab MD: Data collection, data analysis, writing the paper Guarantor Raul Alexander; Cuevas Bustos MD