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CASE REPORT
Year : 2022 | Volume
: 30
| Issue : 4 | Page : 125-127
Is iatrogenic sciatic nerve neuropathy following thigh lift surgery uncommon and preventable?
Cagla Cicek
Department of Plastic, Reconstructive and Aesthetic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
Correspondence Address:
Dr. Cagla Cicek
Department of Plastic, Reconstructive and Aesthetic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_37_22
Obesity is a serious public health problem, and bariatric surgery that is applied for obesity-related morbidities has led to a decrease in obesity-related morbidities and can also improve the quality of life of patients. Plastic, reconstructive, and esthetic surgery plays a major role in the management of skin laxity after bariatric surgery and is therefore generally considered a necessity. However, body contouring surgery can also be associated with some devastating complications. We present a case who developed sciatic nerve neuropathy after medial thigh lift surgery. Complete functional loss of the sciatic nerve was found by clinical and electroneurographic examination on the right side, and full nerve conductance recovery was obtained after 7 months in the patient. It is important to raise awareness about the fact that this significant complication, although rare, can occur even with such a benign and easy procedure and that it is readily reversible with prompt diagnosis and early treatment.
Keywords: Massive weight loss, medial thigh lift, postbariatric surgery, sciatic nerve neuropathy
With the increase in the frequency of obesity, which is now a common problem throughout the world, hundreds of thousands of people dies every year because of obesity-related morbidities. Obesity is a serious public health problem, but it is preventable, and the treatment for this has gained popularity in recent years as obesity-related problems have become better understood. Bariatric surgery that is applied for this purpose has led to a decrease in obesity-related comorbidities and also can improve the quality of life of patients.[1] However, the skin laxity that results from weight loss in different parts of the body after bariatric surgery can cause psychosocial and cosmetic problems.[2] Plastic, reconstructive, and esthetic surgery plays a major role in the management of such skin laxities after bariatric surgery and is therefore generally considered a necessity. However, body contouring surgery can also be associated with common complications, such as seroma, infections, hematoma, and wound dehiscence; as well as with less common complications, such as venous thromboembolism, lymphedema, significant asymmetry, and neuropathy.[3] Our study aims to present an uncommon sciatic nerve neuropathy that occurred following medial thigh lift surgery.
Case ReportA 24-year-old female, who had a body mass index (BMI) of 28.2, was admitted to our outpatient clinic with a request for medial thigh lift surgery. The patient stated that she had had bariatric surgery 5 years earlier, had then lost about 50 kg, and had remained at the same weight for the 2 years that followed. Abdominoplasty and brachioplasty had been performed 2 years earlier in a different healthcare center, and there had been no problem in either of these surgeries. However, in the preoperative examination, it was observed that there was fat and skin excess in both of the patient's inner thighs, and she was uncomfortable with this laxity during walking [Figure 1]. The medial thigh lift surgery was performed under general anesthesia, and the patient was placed in a frog-leg position for easy access to the medial thighs. After applying 700 cc of standard Kline solution per thigh to the areas where the liposuction was planned on the inner thigh and waiting for an average of 15 min, lipoaspirate was obtained using the 600 cc suction method. A 12 cm skin excision was then done from each thigh. The duration of the surgery was approximately 2 h, and the patient's position was not changed during this time. Immediately after recovering from the anesthesia, the patient complained of foot drop on her right side. Clinical examination that was performed by a neurologist found Muscle Power Scale of 0 for all calf and foot muscles. The patient did not have knee flexion or ankle movements in her right leg, and she also had anesthesia in the leg and dorsum of the foot. Superficial ultrasonography found no pathology that could be affecting the sciatic nerve. Comparative magnetic resonance (MR) imaging of both extremities on the 5th postoperative day showed that the sciatic nerve could be followed from the proximal to the knee, and there was no abnormal signal change. Therefore, it was decided that the nerve was intact. Since the needle electromyography did not show major axonal damage, the patient underwent an aggressive physical therapy regimen that involved daily muscle-ranging exercises along with electrical stimulation and mirror box therapy. In addition, once a day, alpha-lipoic acid, Vitamin B complex, and Vitamin D supplementation were recommended. Nine weeks postoperatively, the patient started to have dorsiflexion of her foot and sensation in her leg and foot. Full clinical recovery was achieved after 7 months.
DiscussionThe common causes of perioperative nerve injury are compression, traction, ischemia, local anesthetic toxicity, direct trauma, unknown factors, and combinations of other factors, but the mechanism is often obscure.[4] It is important to note that some of the nerves are more vulnerable to injury because of their anatomical courses (superficial and close to a bony structure and/or joint so that they are amenable to compression or stretching). It is also known that perioperative hypovolemia, hypotension, electrolyte disturbances, and hypothermia are associated with neuropathy that may occur after surgery.[5] In the literature, perioperative neuropathy is often reported as being observed at the upper extremity or peroneal nerve level, and few studies have been conducted on high-level sciatic nerve neuropathy. In addition, while some of the cases that are reported developed during cesarean section and colonoscopy, high-level sciatic nerve neuropathy developed after thigh lift surgery in only one case and following gluteal fat injection in another case.[6],[7],[8],[9],[10] Except in the studies by Silva et al. and Roy et al., all patients were in the frog-leg position and remained in this position for different periods during their surgeries. In our case, the patient stayed in the hip flexion and abduction position, that is, in the frog-leg position, for approximately 120 min to improve the reach to the medial thigh. Before the thigh lift surgery was performed, liposuction was applied only to the medial thigh and did not extend to the posterior of the thigh or the ischial area. Therefore, nerve damage due to liposuction cannula can be excluded. The most common site for sciatic nerve entrapment is between the greater sciatic notch and ischial tuberosity.[11] The patient described a burning pain starting from the hip and running through the posterior thigh during the postoperative recovery and recovery phase. Since the sciatic nerve can be followed from the proximal to the distal, and there was no abnormal signal change in the MR imaging after the surgery, it was thought that the patient developed sciatic nerve neuropathy due to compression. Only one case report in the literature reported that sciatic nerve neuropathy was observed after medial thigh lift surgery. This report presents two cases that were treated in different hospitals, and it was observed that both cases involved combined esthetic procedures.[12] Unlike these cases, in the case that we present, the patient stayed in the frog-leg position for a longer period, and this was not combined with any esthetic procedure. It was thought that because of the patient's position, the sciatic nerve might have been trapped as it passed under the piriformis muscle, and this is consistent with the theory proposed by Kiermeir et al.[12] The occurrences of this sciatic nerve neuropathy have led to an increased awareness of the risk of neuropathy after medial thigh lift surgery. Having more than one surgeon shortening the operation times, correcting the electrolyte imbalances or malnutrition before the operations, avoiding hypovolemia and hypotension during the operations, and changing positions every 30 min could prevent this complication, which can be annoying for both the physicians and the patients. In addition, patients should be informed about the risk of sciatic nerve neuropathy before their operations, and the details about the possibility of developing it should be added to the medial thigh lift informed consent form. It is important to raise awareness about the fact that this significant complication, although rare, can occur even with such a benign and easy procedure and that it is readily reversible with prompt diagnosis and early treatment. In addition, the position changing every 30 min during the operation will be beneficial to prevent this kind of complication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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