On Sept. 20, 2007, Krista Stryland, a lovely, vibrant, 32 year old professional woman, tragically went into cardiac arrest immediately following a liposuction procedure in Toronto. Peri-operative death in cosmetic surgery in general, and liposuction surgery in particular, is such a rare occurrence that the knee-jerk reaction is to assume that someone caused it. The focus right now is on who caused the death, rather than on what caused it. Let’s stand back and examine the whats first.
The whats, or established causes of death in liposuction surgery comprise (i) a blood clot or a piece of dislodged fat traveling to the lungs (instrumentation), (ii) malignant hyperthermia reaction (genetic), (iii) an irregular heart rhythm, usually ventricular fibrillation (from either pre-existing heart dysfunction or damage or from a reaction to intraoperative medications), (iv) congestive heart failure (intraoperative fluid overload), (v) heart attack (a random and totally unpredictable event). A new, unexplored, potential cause of death is a bolus of liquefied fat and cellular debris – arising from the use of devices which burst fat cells and liquefy fat prior to suctioning – traveling to heart or lungs.
The whos, or contributing factors include: (i) the patient’s underlying physical status (pre-existing organ damage or dysfunction), (ii) medical acts of commission or omission by the surgeon and/or anaesthetist prior to cardiac arrest, (iii) medical acts of commission or omission by the surgeon and/or anaesthetist immediately following cardiac arrest. (These medical acts could range from errors in judgment – which happens to most doctors during their careers - to medical negligence - falling below the accepted standard of care).
An intra-operative death can occur in the hands of any doctor, no matter how skilled or experienced. I will never forget a day during my anaesthesia training, when a healthy young man died of a massive heart attack under a routine general anaesthesia in a Toronto teaching hospital, during a simple toenail extraction. The senior anaesthetist remained devastated for months, even though he had done everything correctly. The senior surgeon who performed the most trivial of surgeries was severely affected. When a patient suffers a medical misadventure, it is horrible for everyone: family, doctors, doctors’ families. There’s great pressure to identify a villain. Let’s remember that the cause of death can only be determined by autopsy. The contributing factors, if any, will be identified at a Coroner’s Inquest. It is grossly unfair to the patient’s family and friends to speculate that were it not for the actions of the attending doctor, the patient would have been alive today.
It is even more unfortunate that blame is prematurely being attributed by some plastic surgeons to the physician who performed the procedure, simply because she is not a member of their sub-section of the medical community. When a liposuction-related death occurred in Toronto some years ago, the identical invective from plastic surgeons was directed at the esteemed ear, nose and throat specialist who performed the surgery. Their argument is simple: Only plastic surgeons should have the right to perform cosmetic surgery. They insist that regardless of training or expertise, no other category of physician (including ear, nose and throat specialists, dermatologists, general surgeons, gynecologists, anaesthetists, general practitioners) should be permitted to perform cosmetic procedures. This blatant vested-interest attempt to establish a monopoly failed decades ago and is now being resurrected by the new generation of plastic surgeons.
Are they not aware that some of North America’s most respected experts in cosmetic surgery, in terms of both innovation and skill, are from Toronto and notably come from fields outside of plastic surgery? To name a few, Walter and Martin Unger, dermatologist and surgeon, Peter Adamson and David Ellis, ear, nose and throat surgeons, David Seager, GP, have made significant contributions to advancements in the field of cosmetic surgery. This non-monopoly policy is historically consistent with other fields of medicine. Without being Royal College-certified obstetricians/gynecologists, doctors deliver babies, perform Caesarian sections, tubal ligations and hysterectomies. Similarly, Ontario boasts very competent GP-anaesthetists, GP-surgeons, anaesthetist-surgeons, dermatologist-surgeons.
A most telling and ironic argument against limiting the field of cosmetic surgeons to plastic surgeons, be it for liposuction or any other cosmetic procedure, is the case of Jeffrey Klein. Dr. Klein is a California dermatologist who, in the mid-80’s, single-handedly invented and introduced tumescent technique, the greatest advance in safety in the field of liposuction. Klein’s 4 innovations were:
(1) Eliminating the greatest risk of surgery, general anaesthesia. Klein’s liposuction is performed under local anaesthetic on a conscious patient.
(2) Decreasing the risk of bleeding and infection. Immediately prior to removing fat, large volumes (1-4 litres) of very dilute, buffered local anaesthetic combined with tiny amounts of vasoconstrictor are infused.
(3) Decreasing the risk of fat embolus. Klein’s technique employs much finer, blunt cannulae (hollow tubes) to remove fat.
(4) Decreasing the risk of venous thrombosis and pulmonary embolus. The ability of the awake patient to mobilize immediately rather than lying in bed for days, prevents blood from sludging in the legs and clotting.
Post-operative morbidity and mortality dropped dramatically as a result of the Klein technique. Ironically, while Klein’s tumescent liposuction was readily and eagerly embraced by the various branches of the cosmetic surgery community, plastic surgeons were last to make tumescent liposuction the norm. Many plastic surgeons modified the Klein technique, calling it “the wet technique”, rather than giving a dermatologist the credit he deserves. To this day, they rely on this technique for safe liposuction.
I mourn Krista’s untimely passing. Right now, I feel deep compassion for her family. I equally sympathize with the medical professionals who treated her. Even without the public and professional scrutiny they will surely undergo, I’m sure they are tormented by regret and self-doubt. To the plastic surgeons who are so quick to castigate, I caution: Only last year, a similar liposuction catastrophe occurred in Montreal, in a highly respected, private Plastic Surgery Clinic. Rather than use this tragedy for political reasons, stop speculating and casting aspersions. Respectfully await the results of the inquest. Cosmetic surgeons of all disciplines would better serve their patients by collaborating on how to make liposuction – a relatively safe procedure – even safer. Be humble, for there, but by the grace of God, go you.
