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Print version ISSN 0034-7094
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.4 Campinas July/Aug. 2007
Subcutaneous emphysema during breast augmentation. Case report*
Enfisema subcutáneo durante inclusión de prótesis mamaria. Relato de caso
Talita FrancoI; Diogo FrancoII; Natan Treiger, TSAIII
Titular da UFRJ; Membro Titular da Academia Nacional de Medicina; Chefe do Serviço
de Cirurgia Plástica do HUCFF-UFRJ
IIDoutor em Cirurgia Plástica; Professor Adjunto da UFRJ
IIICoordenador dos Anestesiologistas da 33ª Enfermaria da Santa Casa do Rio de Janeiro
OBJECTIVES: Subcutaneous emphysema of the thoracic wall during a surgical
procedure with infiltration of local anesthetics may suggest the presence of
pneumothorax and its complications. The development of pneumothorax during breast
augmentation has already been reported; however, we did not find any reports
in the literature on isolated subcutaneous emphysema during this type of procedure.
The objective of this report was to emphasize the importance of adequate intraoperative
monitoring of the patient, integration of team members, and describe the isolated
subcutaneous emphysema in a patient during breast augmentation.
CASE REPORT: A 27 years old patient with 1.70 m and 54 kg, with bilateral hypomasty, underwent breast augmentation in a retroglandular plane. It was done under inhalational general anesthesia associated with infiltration of an anesthetic solution in the subcutaneous tissue in the area to be manipulated. During the procedure, crepitation, characteristic of subcutaneous emphysema, was observed over a large area of the anterior thorax. There were no changes in monitoring parameters. Postoperative chest X-rays confirmed the clinical diagnosis and ruled out the presence of other complications.
CONCLUSIONS: Subcutaneous emphysema during breast augmentation can be an innocent sign, but it is important to evaluate the patient to rule out the presence of a pneumothorax.
Key Words: COMPLICATIONS: subcutaneous emphysema; SURGERY, Plastic: mammaplast
Y OBJETIVOS: La incidencia de enfisema subcutáneo en la pared torácica
durante procedimiento quirúrgico donde se realizó infiltración
de anestésico puede sugerir la presencia de neumotórax y sus posibles
complicaciones. La incidencia de neumotórax durante mamoplastía
de aumento ya fue descrita, pero no se encontraron en la literatura investigada,
relatos de presencia aislada de enfisema subcutáneo en este tipo de procedimiento.
El objetivo de este relato fue resaltar la importancia de un adecuado monitoreo
del paciente en el intraoperatorio, de la integración de los miembros
del equipo y describir el enfisema subcutáneo, aislado, en paciente sometida
a la inclusión de prótesis mamarias.
RELATO DEL CASO: Paciente con 27 años, 1,70 m, 54 kg, presentaba hipomastia bilateral, habiendo sido sometida a la inclusión de prótesis mamarias en plan retroglandular. El procedimiento fue realizado bajo anestesia general inhalatoria, asociada a la infiltración de solución anestésica en plan subcutáneo, del área a ser manipulada. Durante la operación se notó crepitación, característica de enfisema subcutáneo, en extensa área anterior del tórax. No hubo alteración en los parámetros de monitoreo de la paciente. La radiografía realizada en el postoperatorio confirmó el cuadro clínico y descartó la incidencia de otras complicaciones.
CONCLUSIONES: La incidencia de enfisema subcutáneo durante inclusión de prótesis mamarias puede ser un dato insignificante, pero es importante verificar las condiciones clínicas de la paciente y apartar la posibilidad de neumotórax.
Mammoplasty for breast augmentation is one of the most common aesthetic surgical procedures, and has been performed since the 20th Century, using several techniques and materials. However, its popularity was established from 1961 on, when Cronin preconized the use of silicone implants, reducing the rate of complications. Early complications include hematoma, seroma, infection, and extrusion; late complications include retraction of the capsule and rupture of the implant. There are only a few reports on the literature on the development of pneumothorax after this type of surgery, although it is assumed that its occurrence is not so rare. It can be secondary to the infiltration of local anesthetic on deep planes, pleural damage during dissection of the pectoral muscle, or ventilatory trauma during general anesthesia. A literature search was positive for reports of pneumothorax during breast augmentation, but we did not find any reports on isolated subcutaneous emphysema.
This is a report of a case of bilateral subcutaneous emphysema during the dissection of the retroglandular space to place the silicone implants.
A 27-year old patient, 1.70 m tall, weighing 54 kg, with bilateral and symmetrical breast hypoplasia was scheduled for an augmentation mammoplasty. Pre-anesthetic evaluation revealed the patient to be a moderate smoker, but was otherwise healthy (ASA I). Pre-anesthetic medication consisted of 7.5 mg of sublingual midazolam 30 minutes before induction. General anesthesia was induced after venipuncture for the administration of Ringer's lactate, and consisted of: atropine (0.5 mg), propofol (150 mg), and rocuronium (40 mg). Controlled ventilation with 100% O2 was done for 3 minutes; afterwards, the patient was easily intubated with a 34F latex, wire reinforced, cannula, the balloon was inflated, and the tube was fixed to the teeth at 22 cm. A volume-limited mechanical respirator was used with initial settings of 400 mL of tidal volume, an O2/N2O mixture (1:1) and 2% enflurane, respiratory rate of 10 rpm, in a circular system of partial CO2 rebreather. A positive end-expiratory pressure (PEEP) of 5 cm H2O was observed as soon as the ventilator started working, which was corrected with a reduction in the flow of gases and increase in the opening of the pop-off valve, until it was completely gone. The reservoir balloon was maintained with a median volume, without tension. The inspiratory pressure did not go over 20 cm H2O, and SpO2 remained at 100% with a capnometry of 30 mmHg of expired CO2.
Before the incision, the contour of the breasts and the sites of incision were infiltrated by the surgeons with approximately 40 mL of a solution containing 0.5% lidocaine and adrenaline at 1:200,000, using a 20 mL syringe with a 1.3 mm ´ 5.1 mm needle (BD Angiocath® 18 GA). Ninety minutes after the beginning of the anesthesia and 70 minutes after the beginning of the surgery, when the surgeon was already working on the second breast, it was observed a crepitation of the loose retroglandular tissue with each inspiratory movement, indicating the presence of air bubbles within the tissue. A diagnosis of subcutaneous emphysema was made; the use of the ventilator and anesthetics were discontinued; the patient was manually ventilated with small volumes; the muscular blockade was reversed; and shortly afterwards the patient began ventilating spontaneously. Physical exam and monitoring did not show evidence of hemodynamic changes or signs of a pneumothorax. When the surgery was restarted, the patient reacted to the local stimulus, 3% enflurane was restarted, and the surgery finished 40 minutes later, with the patient breathing spontaneously. Pulmonary auscultation was normal on both lung fields, without ronchi, wheezing, or signs of hyperresonance. The jugular veins were not engorged, and palpation revealed crepitation of the subcutaneous tissue around both breasts, with the upper limit below the clavicle. The patient was extubated, remaining eupneic, awake and calm, and remained so during the entire postoperative period (Figure 1).
Chest X-rays done 14 hours after the end of the procedure showed "extensive soft tissue emphysema of the anterior thoracic wall", but the thoracic cavity and the lungs were normal (Figure 2).
Since the patient did not have a pneumothorax, she was discharged home without any complications, and the subcutaneous emphysema resolved in approximately one week.
The most common cause of subcutaneous emphysema during a surgical procedure, especially under general anesthesia and affecting the thoracic wall, is damage to the respiratory system. The most frequent lesions, during anesthesia, are secondary to intubation maneuvers, positive end-expiratory pressure (barotrauma), infiltration of local anesthetics in the thoracic wall, and attempts to catheterize neck veins 1-5.
During a difficult intubation, the improper use of the guide wire inside the ET tube can damage the trachea. The rupture may be temporarily sealed by the inflated balloon and the pneumomadiastinum only occurs after the extubation. Sometimes the subcutaneous emphysema is the only sign, and it can affect the face, eyelids, neck, and upper part of the trunk 5-9.
Lung alveoli resist well to short episodes of high intrapleural pressure > 100 cm H2O (cough, sneeze, laryngeal spasm, pulmonary expansion when the baby is born); however, they can rupture during controlled ventilation, even without excessive inhalational volume 3. A small, sustained, increment in the expiratory pressure (PEEP), or the excessive inflation of the balloon, therefore causing it the reach the tip of the ET tube, are enough to cause the rupture of pulmonary alveoli. Under these circumstances, with each inspiration more air will be added to that residual volume that was not completely expired, causing distension and rupture of the alveoli, which does not always reach the visceral pleura. At first, the air infiltrates through the damaged alveoli and the interface of bronchial and vascular structures, dissecting them towards the hilum, originating an interstitial emphysema in the lungs. From the hilum, the air reaches the mediastinum or the pleural space 3. From the mediastinum, it escapes to the pleural space or goes towards the cervical fascia, originating a subcutaneous emphysema, which can resolve spontaneously 10.
A hyperinflated lung during inspiration with positive pressure, during combined general anesthesia with infiltration of local anesthetics, facilitates the contact of the tip of the needle with the pleura and, therefore, damaging it. To avoid this from happening during surgeries of the thoracic wall, especially in patients with scarce subcutaneous tissue, the movements of the hands of the anesthesiologist on the reservoir balloon should be coordinated with the advancing needle 5.
Benumof and Saidman 1 stated that after the damage caused by the needle during local anesthesia of the chest wall, it might take from 6 to 12 hours for the accumulation of air in the pleural space to become apparent and that the development of subcutaneous emphysema in the thoracic wall is a clear sign of pneumothorax.
Osborn and Stevenson 11 reported that 1 in every 3 members of the California Society of Plastic Surgeons had at least one case of pneumothorax during augmentation mammoplasty, although there are very few reports in the literature. Pfulg et al. 4 reported that in cases of iatrogenic pneumothorax, 43% are due to pleural lacerations, 37% to perforations with the needle of local anesthesia, 16% result from the rupture of pulmonary blebs during or after the procedure, and 3% are caused by high pressure ventilation during anesthesia.
A review of the literature did not find any references to a similar event in breast implant surgeries. However, there are several reports of subcutaneous emphysema during other surgeries in other parts of the body 12-16.
In these reports, one observes the coincidence of bloody areas in contact with cavities with air that suffered some type of pressure, which introduced the air into the loose connective tissue, giving rise to the emphysema. Subcutaneous emphysema of different sizes can also be caused by surgeries involving abdominal laparoscopy 17-20.
In the case described here, the magnitude of the emphysema caused concern. However, a few of the other patients who underwent the same procedure developed small areas of subcutaneous emphysema around the surgical area, even in those cases without infiltration of the wall with local anesthetics, but none were as extensive as the present case. Those cases affected especially thin patients, leading to the belief that the loose connective tissue with small amounts of subcutaneous tissue is more vulnerable to the penetration of air bubbles originated during detachment maneuvers. The routine in our service is to insert the implants in the retroglandular space, using the areola or the lower breast crease as the entry point. A small incision, a large detachment area, the introduction of the test prosthesis followed by placement of the implants, causing traction of the tissues and pressuring the retained air, are a logical explanation for the development of subcutaneous emphysema.
It is obvious that it will always be necessary, in case of the development o subcutaneous emphysema, to perform a clinical evaluation of the patient and rule out the possibility of a pneumothorax, especially when local infiltration has been done.
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Dr. Diogo Franco
Praia de Botafogo, 528/1.304-A
22250-040 Rio de Janeiro, RJ
Submitted em 14
de julho de 2006
Accepted para publicação em 23 de abril de 2007
* Received from Serviço de Cirurgia Plástica do Hospital Universitário Clementino Fraga Filho da UFRJ (HUCFF-UFRJ), Rio de Janeiro, RJ