Femoral Condyle Ischaemia: A Possible Complication After Abdominoplasty.

Sir,

Venous thromboembolism is perhaps the major concern in terms of complications during abdominoplasty. Risk assessment and prophylaxis are paramount in such patients. Preoperative, intraoperative, and postoperative measures are usually taken to minimize risk. An increased major complication rate with combined procedures as suction-assisted lipoplasty is expected.[1]

Furthermore, several studies have shown that recti fascia plication during abdominoplasty increases intraabdominal pressure. Use of postoperative compression garments after abdominal wall repair also contributes to intraabdominal pressure increase causing lower extremity venous stasis and venous dilatation.[2]

All these factors participate promoting stasis of blood flow in the lower extremity, hypercoagulability, and endothelial injury as described by Virchow over 200 years ago.

Intermittent pneumatic compression and elastic compression stockings are universal measures to prevent perioperative venous thromboembolism. In selected patients, chemoprophylaxis (unfractionated heparin or low–molecular-weight heparin) or chemoprophylaxis plus mechanical prophylaxis versus mechanical prophylaxis alone are the preferred options for thromboembolism risk reduction. Deep venous thrombosis and pulmonary embolism are the possible and feared evolution of thromboembolism.

We present an undescribed possible complication after abdominoplasty with rectus sheath plication in a 48-year-old male. The patient, operated elsewhere, with a history of recent weight loss underwent abdominoplasty associated with liposuction of the breast without any risk-scoring evaluation. Venous thromboembolism prophylaxis was not administered even if the operation was to be considered at risk (inpatient setting, male, recent weight loss, age, general anaesthesia, 2 regions contoured, surgical procedure to the foot in the past.[3]

The immediate postoperative period was uneventful, but after 5 days, the patient started to have pain to the leg associated with difficulty walking without referring any trauma or injury. After consultation with an orthopaedic surgeon, an MRI of the lower limbs was requested, and signs of ischemia of the lateral femoral condyle were demonstrated. The hypocondrial bone presented a 10 × 4 mm longitudinal area of altered signal (Fig. 1) clearly compatible with bone ischaemia. The patient due to the MRI result started therapy with aspirin with improvement of symptomatology.

Fig. 1.

MRI of the patient’s left knee.

Signs, symptoms, and radiological findings appeared after the procedure and are to be considered strictly related to surgery. Ischemia due to intravascular occlusion from micro thrombi and consequently interruption of blood supply to the subchondral microcirculation of the bone can be considered the aetiology of osteonecrosis of the femoral bone of our patient who did not receive thromboembolism prophylaxis.[4]

As for general and orthopaedic surgery, also in plastic surgery focus must be placed on the relevance of risk assessment of all patients candidates for elective plastic surgery procedures and all prevention measures such as the perioperative use of chemoprophylaxis, intermittent pneumatic compression, and compressive garments in the immediate postoperative period need to be stressed.

These measures will not only prevent dangerous and potentially life-threatening complications but will also prevent patients by the increased annual and lifetime risk for venous thromboembolism.