Appendicitis as a complication after liposuction

Introduction: The demand for aesthetic plastic surgery has increased steadily mainly for the appearance of new surgical techniques and these procedures greater social acceptance. Most frequent procedures are: breast surgery (augmentation or reduction), liposuction, tummy tuck surgery and facial surgery. Acute appendicitis is the most common cause of acute abdomen. The appendectomy constitutes one of the most common surgery performed worldwide. Appendicitis has a high incidence among young white adult men. We report a case of acute appendicitis as a complication after liposuction, emphasizing such complication correlation with the surgical procedure. Methods: We searched scientific data from June to December 2015 indexed in Medline/PubMed database related to complications in liposuction, especially cases associated with appendicitis. Conclusion: Postoperative complications are distressing for both patient and physician. The number of plastic surgeries is still rising and procedures are becoming more frequent, therefore, procedure-related facts should be further study. The development of predictive score of complications in plastic surgery would help surgeons to define preventive measures, take best choices and perform better discussion related to risks of the patient already in the postoperative period. ■ ABSTRACT


INTRODUCTION
Aesthetic plastic surgery procedures are still rising steadily, mainly for appearance of new surgical techniques and these procedures greater social acceptance.The procedures most common performed are: breast surgery (augmentation or reduction), liposuction, abdominoplasty and facial liposuction surgeries 1 .The liposuction is a cosmetic procedure for fat removal in healthy patients to reduce accumulation of localized fat, the so-called lipodystrophy leading to improvement in body contouring 2 .
The first formal presentation of liposuction to Brazilian surgeons was in 1980 during the Congress of the Brazilian Society of Plastic Surgery (SBCP) in Fortaleza 3 .After that, this technique has improved, became less invasive and has focused on preservation of local circulation 2 .
The help of media, television, advertisements and photos of actors and actresses with thin, toned and sculpted bodies, which are considered almost perfect by the society, lead those who are dissatisfied with their own bodies to seek plastic surgery clinics to achieve the miracle of rapid weight loss and youthful appearance.

CASE REPORT
A.L.R.N.B, 21-year-ol, previously healthy, after perform clinical and laboratorial exams to confirm clinical conditions to proceed with procedures, underwent in July 9 2015 a nasal cosmetic surgery and liposuction in the back, flank and abdomen, and fat injection in the gluteal region,.The wet liposuction technique was used, and approximately 2.5 liters of fat was removed and about 1 liter was reinjected, after washing with saline solution, in the gluteal region.In July 20 2015, the patient had no complaints.At this date, surgical follow-up was done, sutures removal, and the patient was referred to lymphatic drainage.The did not present ecchymosis or any other change in physical examination.
In the morning of July 21 2015, the patient reported high intense epigastric pain.The pain sensation was like burning.The patient had reported similar episodes before, but an endoscopy performed 1 year before did not show changes.Patient underwent treatment at private health hospital.The laboratorial exams showed white blood cell count of 13,000/mm 3 without deviation, normal urinalysis.The abdominal CT scan without contrast did not show changes.The patient was discharged, and analgesics were prescribed.The patient was advised to return if any symptoms appear.
The patient returned to the hospital for the next day complaining of worsening pain and migration to the right iliac fossa, loss of appetite and vomiting.Exams showed white blood cells of 23,000/mm 3 with left deviation.The patient was examined by an urologist and no urinary tract changes were found.The patient was referred in the same day to other public health hospital with diagnosis of acute appendicitis.
Appendectomy performed on 23 July 2015 using infraumbilical midline incision, and surgical report of stage IV appendicitis.The patient was discharged on 25 July 2015, asymptomatic, and with significant improvement of laboratory tests: hemoglobin 11.4 g/dl, LG 9,000/mm³, rods of 2% and neutrophils of 80%.PCR was still high, more than 90 mg/L.

DISCUSSION
The SBCP, which is of the largest plastic surgery association in the world, reports along with the research institute Datafolha that 629,000 plastic surgeries are carried out yearly in Brazil, 73% of them are aesthetic and 27% reconstructive surgeries.Liposuctions represents 20% of all cosmetic procedures, behind only to augmentation mammoplasty 2 .
As has been shown in the literature, the growth of plastic surgery procedures increases frequency of complications.Patient safety is undoubtedly the most discussed topic in medical events and scientific publications; this topic discussion is particularly high in plastic surgery 1 .
The plastic surgeon should evaluate the patient considering the same rigorous standards adopted in other types of surgery, including detailed preoperative evaluation, physical examination and laboratory tests, as well as monitoring in surgery and immediate after surgery to ensure safety and quality of the operation.It is important to collect data on drug use or abuse, consumption of alcoholic beverages and smoking, as well as guidance before the procedure.
Preoperative evaluation is key for a safe surgical procedure, and it includes detailed anatomical and physiological knowledge, as well as decision on the most appropriate technique for the patient 1 .Aesthetic plastic surgery undergone in certified surgical sites presents low incidence of complications, even when they are not done in hospitals 1 .
However, the physiological stress associated with surgical procedure is a safety factor that must be considered when choosing the most appropriate place to the surgery.Among the main factors that can lead to physiological wear, those caused by blood loss during surgery can be cited, such as hypothermia, liposuction combined with other procedures, procedure duration and risk of thrombosis or pulmonary embolism 1 .
One of the most critical attributes to be analyzed in relation to patient safety is the time, including surgery time and average length of stay in the post-anesthetic care unit.Most plastic surgery procedures last for over an hour.In addition, when more than one procedure are done simultaneously the duration of the surgery increases.In our case the surgery duration was 3 hours including anesthesia.
A study in the 70s already reported that surgeries lasting more than six hours dramatically present an increase in the incidence of cardiac, renal and pulmonary complications after the surgery 1 .In liposuction a major risk factor for the development of complications is the excessive fat removal.
In Brazil, the Federal Council of Medicine resolution no.117, Article 9, 2003 describes the safe limits for suction.The resolution states not exceed 5-7% of patient's body weight and respect 40% limit of the body surface.These both recommendations were followed in our case.
Bacterial infection has as main risk factors the poor hygiene, early discharge, and patients unsuitable for surgery.Possible predictors of surgical complications are: a) malnourished patients; b) associated procedures; and c) duration of the surgery 1 .
Currently, adipocytes are known to be the main storage triglycerides and also linked to maintenance of systemic inflammatory condition because of their lipid metabolism, and action of a variety of mediators.However, no evidence exist on relationship between this inflammatory process and acute appendicitis, particularly because studies have shown that liposuction may increase or decrease inflammatory mediators with interleukin-6, interleukin-10, tumor necrosis factor alpha 8 .
Acute appendicitis pictures are usually diagnosed by clinical history and physical examination 9 .However, typical signs such as migratory pain to the right iliac fossa may be absent in one-third of cases, therefore, attesting the important of complementary exams.
In the literature, the ultrasonography shows 75 to 93% sensitivity and 91 to 100% 6 specificity compared with CT it has lower cost.Ultrasonography has limitations such as patient's obesity, equipment availability and experienced examiner 6 .
Our patient underwent abdominal CT scan without contrast and no signs were seen for positive diagnosis of appendix equal to or greater than 6 mm, periappendiceal enlargement or appendiceal inflammatory changes.

COLLABORATIONS João Márcio Prazeres dos Santos
Av. Presidente Itamar Franco, 2100/302 -São Mateus -Juiz de Fora, MG, Brazil Zip Code 36025-290 E-mail: jmprazsantos@hotmail.com *Corresponding author: JMPS Analysis and/or interpretation of data; final approval of the manuscript; completion of surgeries and/or experiments; writing the manuscript or critical review of its contents.

NJC
Analysis and/or interpretation of data; writing the manuscript or critical review of its contents.