Similarly, a case report in the Dutch literature reported a 41-year-old otherwise healthy woman who was admitted for toxic shock-like syndrome with necrotizing fasciitis and myositis, three days after liposuction of the lower abdomen.32 The patient was treated by radical debridement of the skin, subcutis, fascia, and part of the pectoral muscle, plus antibiotics.32 Postoperatively she required artificial respiration for respiratory insufficiency.32 One week after the operation the wound was covered by transplantation of autologous skin.32 The patient survived but was seriously disfigured.32 The authors of this case report emphasized that necrotizing fasciitis is a progressive soft-tissue infection, characterized by widespread necrosis of the superficial and deep fascia, often associated with severe systemic toxic reactions.32 Unless quickly recognized and aggressively treated, the course of necrotizing fasciitis is often fatal.32 Due to the absence of cutaneous findings in the early stages, diagnosis is difficult.32 Important diagnostic aids are routine laboratory tests, contrast-MRI, and a combination of the finger test and frozen-section biopsy.32 Treatment consists of early radical debridement, broad-spectrum antibiotics, and supportive care.32
Infection Risk Associated With TL
TL has a very low complication rate and a particularly low infection rate relative to liposuction performed under general anesthesia. One possible explanation for the low infection rate of liposuction under TL is that the lidocaine, epinephrine, and bicarbonate utilized in the tumescent solution have all been proven to have some antimicrobial effects on a diverse range of pathogens (bacteria, fungi, viruses). Thus, the large dilute volume of anesthetic solution may have a role in the low rates of infection associated with this procedure. However, a more recent study indicated that these antimicrobial properties have only been demonstrated using concentrations of lidocaine above 0.8%, significantly higher than those used in tumescent liposuction.26 A study by Craig SB26 demonstrated that the minimum inhibitory concentration of lidocaine was not less than 0.5% for any of the bacteria, whereas the lowest minimum inhibitory concentration of the combined solution was 0.25%. The lowest inhibitory concentration as determined by spectrophotometric analysis for the combined solution was 0.13% (P<0.01).26 Thus, at the commonly used tumescent mixture containing dilute concentrations of lidocaine, epinephrine, and bicarbonate, these results suggest that there is no significant inhibition of the growth of commonly encountered bacteria.26
The most common infectious complication associated with TL include superficial infections, usually around incision sites, which are typically culture positive for staphylococcus and streptococcus.27 However, there are also rare reports of deeper infections which occur in a delayed fashion several months after the procedure occur with atypical mycobacterial species (Mycobacterium abscessus, M. chelonae, M. fortuitum) and have been associated with improper cleaning and sterilization of surgical instruments.27 Any signs of infection should be evaluated and cultured as soon as possible. With atypical mycobacterial infections, it is important to obtain the culture medium requirements of the laboratory and to notify the laboratory that special processing of the specimen is needed. Rare cases of necrotizing fasciitis have been reported with liposuction.30-32 Thus, any patient presenting with severe pain out of proportion to examination, surface blistering, and tenderness should be promptly evaluated for possible debridement and started immediately on broad-spectrum antibiotics and supportive care.
While TL is associated with very low rates of local and systemic infections,5-27 many dermatologic surgeons administer prophylactic doses of antibiotics pre- and/or postoperatively to performing liposuction under TL. Additionally, there is little or no consensus on the bacterial class and/or type of antibiotics, which are optimal for patients undergoing TL. While there are extensive studies reporting upon the incidence of transient bacteremia and associated risks of endocarditis during dental procedures,33-41 we performed the first study to evaluate the incidence of bacteremia during TL. Additionally, we set out to determine the bacterial type and most appropriate antibiotic class for prophylaxis in these patients.42
Four sets of blood cultures were drawn for each patient at t=0 (prior to start of procedure), t=15 minutes into the procedure t=30 minutes into the procedure and at the conclusion of the procedure. Each time point included an aerobic and anaerobic culture vial.33-41 After 2 weeks of growth, no bacteremia was observed in any of the aerobic or aerobic cultures taken from any patient at each of the three time intervals.33-41
While our study demonstrated no detectable incidence of transient bacteremia during upper extremity and flank TL procedures,33-41 the rare reports of severe, life threatening necrotizing fasciitis and atypical mycobacterial infections29-32 highlight the importance of sterile technique and may warrant prophylactic antibiotic administration in susceptible patient populations.
The incidence of transient bacteremia has been evaluated in a number of procedures in the dental, orthodontic and general surgical literature and has varied documented rates of bacteremia ranging from 10%-96%, depending upon the procedure analyzed.33-42 Specifically, transient bacteremia has been reported after a diversity of procedures, including percutaneous, and transjugular liver biopsies, dental and orthodontic procedures, tattoos and body art and recently, tooth brushing in patients with orthodonture and associated appliances.33-42 One of the primary health concerns related to transient bacteremia during surgical procedures, in addition to overall increased infection risk, is increased risk of bacterial endocarditis, a potentially life threatening condition. There have been a number of case re-