Purpose: Elective cosmetic surgery procedures are associated with risks common to all surgical techniques, including infectious, hemorrhagic, neurological, and even lethal complications. Toxic Shock Syndrome (TSS) is an infectious disease caused by the pathogens Staphylococcus aureus (S. aureus) and group A Streptococcus species. It has been identified as a potential outcome of many different surgical procedures, yet it is not often considered among the more common infectious complications following aesthetic surgery. We present the case of a patient who underwent elective abdominoplasty and developed TSS six weeks postoperatively resulting in multisystem organ failure.

Method: Three years following laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity, following a weight loss of one hundred fifty pounds, a forty-seven-year-old female presented complaining of recurrent dermal infections in the suprapubic crease underlying her large abdominal pannus. She requested removal of the excess tissue and improvement in body contour, and subsequently underwent abdominoplasty with abdominal fascia plication, bilateral flank liposuction, and liposuction of the axillae bilaterally. Two bulb suction drains were placed beneath the abdominal wall skin flap at the end of surgery.

Results: Four weeks postoperatively, the patient presented with a 4 x 6 cm area of erythema in the left lower quadrant overlying the incision that was mildly tender to palpation. She was admitted to the hospital with a diagnosis of abdominal wall cellulitis and was treated with intravenous antibiotics. Her cellulitis and focal abdominal wall tenderness completely resolved after seventy-two hours of antibiotic therapy. Two weeks later (six weeks postoperatively), she presented to the emergency room complaining of recurrent abdominal wall erythema associated with severe and diffuse tenderness, fever, chills, nausea, and a vesicular rash of the anterior and posterior trunk. The patient was febrile and toxic appearing on arrival and subsequently became obtunded, tachycardic, and hypotensive. On physical exam, her entire abdominal wall was erythematous. The fluid in her drains appeared murky and contained exudative debris. She quickly developed respiratory failure necessitating endotracheal intubation and mechanical ventilation. She suffered an anterior wall myocardial infarction and developed heart failure requiring multiple intravenous inotropic agents. Serum electrolytes revealed that she was in acute renal failure and she was begun on continuous hemodialysis. Cultures of the fluid in her drains subsequently grew out Staphylococcus aureus. She was admitted to the intensive care unit for management of TSS. The suction drains were removed and the wound was debrided, irrigated, and packed open at the bedside. Cultures from the wound were positive for S. aureus. The patient was started on broad-spectrum antibiotics and XigrisŪ, a recombinant form of human Activated Protein C, to which she responded well. She was weaned from cardiopulmonary support and extubated five days after admission. Her renal function returned to normal within one week and hemodialysis was stopped. She was discharged home eleven days after admission. She continues to do well with stable cardiopulmonary function.

Conclusion: The signs and symptoms of TSS develop rapidly and overwhelmingly, even in healthy individuals. In post-surgical cases the onset of symptoms often occurs on the second postoperative day, but initial symptoms have been reported to present up to 65 days postoperatively. If unchecked the disease may progress to multisystem organ failure. The use of closed suction drains has not been shown to definitively result in increased rates of postoperative infections but they have been associated with decreases in seroma and hematoma formation in numerous types of surgical procedures. In this case, it is likely that prolonged use of closed suction drains may have been the ultimate vehicle for virulent bacterial growth leading to systemic toxicity. Despite its rarity as a complication of cosmetic surgical procedures, we recommend that surgeons have a high index of suspicion for TSS in the appropriate clinical setting and institute early and aggressive surgical and medical treatment. We further suggest judicious use of closed-suction drains and their prompt removal in the postoperative period.
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