30 March 2023: Articles
Feel the Burn: Case Report of Internal Thermal Injury from Liposculpture
Unusual clinical course, Mistake in diagnosis, Unusual or unexpected effect of treatmentAashish Daulat1ABCDEF, Richa Asija2ABCDEF, Amanda Frugoli 3ABCDEF*, Jasmine Heyer4E, Setareh Radparvar1ABCDEF, Michael M. Salehpour 2EF, Brian M. Utz 3ABCDEF
Am J Case Rep 2023; 24:e937881
BACKGROUND: Liposuction is a commonly performed aesthetic procedure. New technology is being integrated to target fine lines or creases in the skin, known as rhytides, and skin laxity that cannot be corrected with liposuction. “Liposculpture” is a new term to describe a variation of liposuction that integrates this new technology for both fat reduction and skin tightening. A new form of liposculpture known as Renuvion, which utilizes a helium-based plasma technology, is being added to improve cosmetic outcomes. In this case report, we describe a case of internal thermal injury masquerading as cellulitis from the use of this new technology.
CASE REPORT: A 37-year-old African-American woman with a history of anemia, hypertension, hyperlipidemia, and depression, with prior breast reduction and liposuction, presented to the emergency room with a 5-day history of waxing/waning fevers that began shortly after undergoing a liposculpture procedure. Imaging demonstrated subcutaneous emphysema and edema in the abdominal wall. Empiric antimicrobials were started given concern for surgical wound infection, but erythema and pain worsened despite treatment. Other infectious markers were negative including negative procalcitonin, normal white blood cell count, and no growth from wound and blood cultures, leading to consideration of a new diagnosis of thermal injury. Antibiotics were subsequently de-escalated to a combination of levofloxacin and doxycycline. She was also treated with topical silver sulfadiazine for her thermal injury. She required multiple rounds of infrared light therapy and lymphatic massage techniques with overall improvement but lasting hyperpigmentation by her 6-month follow-up.
CONCLUSIONS: Thermal injuries have been an extremely rare finding in patients undergoing cosmetic procedures. Treatments targeting skin laxity and rhytides may confer higher risk. It is important to note that presentations can mimic cellulitis or surgical site infection. In this case vignette, we describe a rare complication of thermal injury following a liposculpture procedure using a cold atmospheric plasma device in a previously healthy 37-year-old African-American woman.
Keywords: Cellulitis, Lipectomy, Surgical Wound Infection
Liposuction is a commonly performed aesthetic procedure aimed at slimming and reshaping areas of the body by removing excess fat and improving natural body contours. It is becoming increasingly popular and is also being added as an adjunct to other common surgical procedures. According to the American Society for Aesthetic Plastic Surgery (ASAPS), 1.9 million cosmetic surgical procedures were performed in 2015, an increase of 94% since 1997 . Suction-assisted lipectomy, or liposuction, was the most popular of these cosmetic surgical procedures for both men and women in 2015 . Per the International Society of Aesthetic Plastic Surgery (ISAPS), liposuction ranks second behind breast augmentation surgeries in worldwide cosmetic procedures .
As demand for the procedure increases, additional technology is being integrated into liposuction to target skin laxity and rhytides, which are not readily treated with liposuction. This includes the development of J-Plasma/Renuvion devices and the previously developed technology known as BodyTite. J-Plasma incorporates the proprietary utilization of helium gas under the skin in subdermal applications. Its utilization in practice is relatively new and is proposed to be superior to prior surgical techniques as it allows for precisely controlled delivery of heat to tissue, with minimal thermal spread and near-instantaneous cooling . This cooling effect is provided by the use of helium gas . The heating and rapid cooling properties of the Renuvion/J-Plasma system allow skin tightening via focused coagulation of the surrounding interstitial connective tissue without unnecessary heating of the full thickness of the dermis. The mechanism of action is proposed from coagulation resulting in the predictable contraction of soft tissue via the denaturation of collagen and other proteins.
In general, thermal injuries rarely occur as an adverse event of this procedure. For example, a prospective, multicenter, single-arm clinical study called “The Use of J-Plasma® for Dermal Resurfacing” was performed in 2018 to evaluate the safety and efficacy of J-Plasma in 55 patients who were seeking a procedure to reduce the appearance of wrinkles and rhytides. Though a total of 80 adverse events were reported by 39 subjects, most were anticipated following a skin resurfacing procedure (eg, hypersensitivity, post-inflammatory pigmentation, pruritis, pain) and none were considered serious adverse events. Furthermore, no thermal burns were reported . During our literature review, we identified multiple case reports of thermal burns from a slightly different system for body contouring, called BodyTite, which also uses radiofrequency energy for soft-tissue tightening . Unlike Renuvion, BodyTite does not combine radiofrequency energy with helium. Because it does not have a rapid cooling system, the process is longer, which purportedly may increase the risk for thermal injuries.
This case report describes a rare occurrence of a thermal injury following a liposculpture procedure using the relatively new skin-tightening technology described above, called Renuvion. The manufacturer does list the following as associated risks: unintended burns (deep or superficial), scars, temporary or permanent nerve injury, pain, discomfort, gas buildup resulting in temporary and transient crepitus or pain, infection, hematoma, seroma, asymmetry, and/or unacceptable cosmetic results. Though thermal injuries are reported as a possible post-procedural complication, it has been documented as a rare complication [4,7]. As a new procedure, it is important to increase physician awareness of atypical presentation of thermal injury to allow for appropriate interventions and management.
A 37-year-old African-American woman with a medical history of anemia, hypertension, hyperlipidemia, and depression, with prior breast reduction and liposuction, presented to the emergency room with a 5-day history of waxing/waning fevers that began shortly after undergoing a liposculpture procedure. She also noted intermittent surgical wound drainage from the incisional sites along her pelvis and back. She reported diffuse abdominal pain with bloating, crepitus, back pain, and nausea during her postoperative course. Her only home medication was amlodipine 5 mg p.o. daily. Per her surgeon, she had postoperatively been provided Norco for pain and Keflex for postoperative infection prophylaxis. She did not report any known drug allergies.
On examination, the patient’s vital signs were within normal limits. Crepitus was palpated over the sternum, bilateral flanks, abdomen, and lower back. The patient’s abdomen was distended and diffusely tender to palpation with the presence of a discolored, warm, and tender area of induration with erythema in the right upper abdomen (Figure 1). Two surgical entry incisions were also noted in the pelvis bilaterally with a single 2–3 cm irregularly shaped skin lesion noted in the mid back with no drainage.
Her initial lab results were notable for low hemoglobin of 9.6 and elevated inflammatory markers including an erythrocyte sedimentation rate of 116 and a C-reactive protein of 16.60 but did not show any elevation in creatine kinase, white blood cell count, procalcitonin, or lactate. Her urine studies, respiratory PCR, panel for infections, and blood cultures were unremarkable. Further evaluation with computerized tomography (CT) scan demonstrated postsurgical changes along the abdominal wall with increased fluid density/edema and a moderate amount of subcutaneous emphysema (Figure 2). A CT chest angiogram also yielded similar findings including moderate subcutaneous emphysema and a small amount of pneumomediastinum. Neither of these imaging studies demonstrated an acute intrathoracic or intra-abdominal infectious process.
Her presentation was concerning for cellulitis or a surgical site infection. Therefore, she was started on empiric antimicrobials with intravenous ceftriaxone and vancomycin. The patient’s surgeon was notified and was able to provide consultation that included extensive subcutaneous emphysema is a common finding postoperatively throughout the treated regions and typically self-resolves, but pneumomediastinum is atypical. The patient clinically worsened during her hospital course, both subjectively, with patient reports of ongoing abdominal pain, and objectively, with the advancement of erythema and induration. However, the observation of no changes in white blood cell count and a normal procalcitonin did not support systemic infection or necrotizing soft-tissue infection. Infectious disease and general surgery were also consulted. The infectious disease specialist consultants recommended, given the lack of clinical improvement and her somewhat indeterminate clinical diagnosis, that her antibiotic regimen be broadened by adding Zosyn to the vancomycin, in place of ceftriaxone, for
Upon discussing the CT results and physical exam findings with general surgery, reevaluation of the diagnosis was expanded to include thermal injury, especially given her lack of improvement with broad spectrum antibiotic therapy. This was further supported by input from the plastic surgeon who performed the procedure, though he had not yet seen this type of complication associated with the Renuvion procedure. A renewed emphasis was placed on pain control and treatment for suspected thermal injury. Antibiotics were subsequently de-escalated to a combination of levofloxacin and doxycycline. She was also provided with topical treatment using silver sulfadiazine for her thermal injury. Outpatient follow-up consisted of visits with her infectious disease specialists and her plastic surgeon
The 6-month follow-up demonstrated significant improvement. She was no longer experiencing tactile fevers or pain. She did receive further outpatient treatment including multiple rounds of infrared light therapy and lymphatic massage techniques. She reported that the thermal injury to her right upper abdomen was far less indurated and erythematous than during her hospitalization, but that some discoloration persisted.
Thermal injuries or burns are common injuries that occur when tissue is exposed or destroyed by heat, electrical discharge, friction, chemicals, or radiation. Burns accounted for the primary diagnosis in 424,000 visits to the emergency room in the United States in 2014 . They are estimated to cause approximately 180,000 deaths per year worldwide, mostly in low- to middle-income countries . Thermal burns cause both local injuries and, if severe (>20% of body surface area), will lead to a systemic response .
Renuvion is a relatively new, helium plasma based skin rejuve-nation device that was approved by the FDA in 2012. This device was created to serve a number of functions, including as an adjunct to liposuction known as “subdermal skin tightening,” as was the case with our patient . The skin-tightening portion of the procedure is often performed after liposuction to treat the skin laxity that results due to the removal of the underlying adi-pose tissue . Skin tightening occurs as a result of the wound-healing cascade following tissue injury, regardless of whether the wound was caused by surgical, thermal, or chemical trauma . The endpoint of collagen contraction and skin tightening occurs in the last phase of wound healing as a realignment of collagen bundles which allows overall contraction of the soft tissue . Renuvion uses energy delivered from plasma rather than light or radiofrequency only . Plasma typically is generated by an energy discharge which causes ionization, excitation, or dissociation of gas or liquid molecules, leading to creation of various gaseous plasmas; in this case helium . The energy delivered produces a heating action that removes old photo-damaged epidermal cells at the skin surface and promotes collagen growth at the dermis . Among the proposed benefits of Renuvion is that it is designed in a way that allows for the delivery of precise, localized effects with limited unwanted tissue injury . This is related to the aforementioned use of helium plasma which focuses radiofrequency energy for greater control of tissue effects, enabling a high level of precision . Though burns are listed as a potential adverse effect, there has been minimal evidence of this occurring in patients treated up to this point . In fact, a 2019 review of Renuvion/J-Plasma by Gentile indicated that there were no documented events of any skin burns or necrosis associated with the subdermal use of Renuvion in more than 100 procedures to date . This was further supported by a more recent article by Neinstein and Funerburk in 2020, who had not seen any reports to date of significant complications resulting from the Renuvion/J-Plasma system per their review of the literature . They did, however, include a disclaimer that published, peer-reviewed evidence of this system had been limited up to that point . Lastly, a retrospective electronic medical record chart review of patients who had undergone subdermal coagulation procedures with the use of Renuvion from a single surgeon’s institution over the course of 9 months concluded that Apyx Medical’s Renuvion system appears to be safe and effective in the short term with a limited adverse-effect profile . However, as stated earlier, it is important to mention that this liposculpture procedure using the Renuvion system was developed fairly recently, in 2012. There is a similar, well-established liposculpture procedure called BodyTite which has been noted to have resulted in burns in multiple patients, seen postoperatively . It is possible that if and when Renuvion becomes utilized more frequently in clinical practice, we will gain greater insight into the extent of its adverse-effect profile and the likelihood that a patient may sustain thermal injuries from procedures performed with this device.
In our patient’s case, the outcome of this procedure certainly could have been influenced by the experience of the surgeon with this system and whether certain areas of the patient’s body were overtreated, thus resulting in thermal injuries to the area. There is, in fact, some variation in how the system can be utilized. For example, Renuvion can be used in “continuous painting mode” or “intermittent pulsed technique mode” . Gentile and McCoy recommend using a pulsatile technique to reduce the excessive energy that is often applied by the continuous-flow, freehand technique that has classically been taught with this device . They further reduced energy delivery with a fractionated technique using a heat-resistant grid . With both the fractionated and pulsed techniques, they noticed a reduction in recovery times for procedures using Renuvion, but more robust research would need to be performed to determine whether or not this is indeed the case . It is possible that our patient was treated with a continuous-flow, freehand technique, thereby increasing the amount of thermal energy her tissue was exposed to and increasing the likelihood of thermal injury.
The management of our patient’s thermal burns included topical silver sulfadiazine to apply to the affected area, a treatment that is well supported in the literature for thermal injuries . She also was treated with multiple rounds of infrared light therapy and lymphatic massage techniques, which she reported significantly improved the induration and pain associated with her thermal injuries, but unfortunately, the hyperpigmentation persisted. These treatment modalities mirrored those utilized in a report by Hurwitz and Smith in 2011 in which 4 patients who developed focal areas of induration after radio-frequency-assisted liposuction using the BodyTite system experienced expedited resolution after receiving massages and low-level laser treatments . Unfortunately, given the paucity of reports on thermal injuries associated with Renuvion, there is no true algorithm for the management of resulting thermal injuries. However, given that our patient improved with the aforementioned treatment modalities, which are additionally supported by the more extensive literature on the BodyTite system, it is our hope that this report may help provide treatment options and ideas for other clinicians treating thermal injuries associated with this procedure. Additionally, we highlight that this technology has had a recent FDA review and a warning from July 2022 that was released: “Do not use the Renuvion/J-Plasma device for dermal resurfacing or skin contraction, alone or in combination with liposuction” .
Thermal injuries have been an extremely rare finding in patients undergoing procedures using cosmetic technology. It is important to note that some presentations can mimic cellulitis or surgical site infection. This case report and literature review highlight a rare case of thermal injury associated with this technology. The patient described in this article experienced significant improvement in her thermal injury with topical silver sulfadiazine, infrared light therapy, and lymphatic massage techniques, but with persistence of the hyperpigmentation associated with the injury 6 months after her hospitalization.
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