Saturday, August 05, 2006

Back alley liposuction death

In a story from near Boston that echoes a number of cases from immigrant communities, Fabiola DePaula, 24, died after respiratory arrest on July 30 after a Brazilian couple, unlicensed to practice medicine, gave her liposuction on a massage table in their basement. The Brazilian couple who performed the fatal liposuction on DePaula ran an underground ring, charging people around $3,000 relying on word-of-mouth referrals among Latino immigrants. The "surgeon", Luiz Carlos
Ribeiro, claims to be a licensed doctor in Brazil, and that he and his wife had come up to Framingham on a 30-day work visa just to perform the surgeries in the basement of the Framingham apartment complex.

In a sick display of hypocrisy,in a yet-to-be-broadcast interview recorded the week prior with Brazilian community leader Ilma Paixao, she said Ribeiro spoke of the risks, the procedures and the precautions people needed to follow before undergoing cosmetic surgeries. I guess the topic of operating in a basement under non-sterile conditions never came up!

I have to assume this was a scenario where the patient was over-sedated during conscious sedation anesthesia with a benzodiazepene-class drug (like Valium or Versed) and lost their airway (as there likely was no emergency airway equipment present. Other issues that can happen in the peri-operative period are fluid overload, toxicity from the local anesthetic (usually Lidocaine), and perforation of the abdominal wall with underlying bowel injury. Unlike respiratory failure, these other things present hours or even days later (in the case of bowel perforation).

This highlights several issues.

1. Black-market Plastic Surgery continues to flourish in immigrant communities. There have been a lot of issues in Florida, Texas, and California with major complications.

2. Liposuction IS real surgery and should be treated as such and should ideally be performed by surgical specialists.

3. The safety of surgery done outside the hospital or ambulatory surgery center is an issue that will continued to be debated. In 2000, an anonymous survey of Plastic Surgeons reported that for every 5,000 liposuction procedures from 1994 to 1998, one patient died - 95 in all. Among the causes were blood clots, anesthesia problems and internal injuries after the liposuction procedure. These are only the ones we know about. Throw in thousands of practicioners doing office based surgery who are under no obligation to report any complications and you can assume the true number was much higher for that period.

The American Society of Plastic Surgery has been the clear leader in responding to this data. Some practice guidelines were issued in 2004 and can be found here. There has been a tremendous amount of time and money spent educating surgeons about how to perform this procedure more safely for the patient. Many thanks go out to some of our leadership on this by Drs. Rod Rohrich and Jeff Kenkel (from the University of Texas-Southwestern), Dr. Peter Fodor, Drs. Patrick Maxwell & Mary Gingrass (from Nashville), and many others.

I think in some future post I'll wax poetic on some of these safety issues and the politics of office-based surgery.


Plastic Surgery

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