Case Report

Case Report on Necrotizing Fasciitis after Liposuction and Abdominoplasty

DOI:

10.3791/69043

⸱

October 3rd, 2025

 ,  ,  ,  ,  ,  , 
1School of Optometry and Ophthalmology, Wenzhou Medical University, 2Department of Orthopedics, The First Affiliated Hospital, Zhejiang University

In This Article

Summary

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A woman developed necrotizing fasciitis 20 days after abdominoplasty and liposuction. Successful management involved aggressive surgical debridement, antibiotic bone cement application, VSD, and skin grafting. Quinolone-susceptible pathogens were identified. Multidisciplinary care achieved infection control and recovery, highlighting cosmetic surgery risks and the critical need for prompt intervention and asepsis.

Abstract

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Liposuction and abdominoplasty are common cosmetic procedures, but they can lead to severe complications such as necrotizing fasciitis (NF), which is a life-threatening infection with rapid progression and significant mortality rates. NF can develop after surgical procedures due to bacterial colonization or inadequate postoperative care. In the case shown here, a 33-year-old woman presented with skin flap fascial necrosis with abdominal wall infection 20 days after undergoing abdominoplasty with liposuction at another private clinic. Initial management included incision and drainage of an abdominal wall sinus tract, debridement of necrotic tissue, and application of antibiotic bone cement, followed by vacuum sealing drainage (VSD). Postoperative blood tests and bacterial culture identified multiple pathogens, all susceptible to quinolones. Subsequent surgeries involved re-debridement and skin grafting. The patient received a comprehensive rehabilitation program, resulting in effective infection control and favorable outcomes. The case underscores the importance of early diagnosis and aggressive surgical debridement in managing NF. The use of antibiotic bone cement provided local high-concentration antibiotics and supported granulation tissue formation, contributing to the treatment of the wound. This rare complication highlights the potential risks of cosmetic surgery and the necessity of strict adherence to aseptic techniques.

Introduction

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In recent decades, the field of plastic surgery has undergone significant expansion. Liposuction has become a common procedure in the field of plastic surgery, employed to decrease locally excessive fatty tissue in specific areas of the body. It serves as a solution for patients who are dissatisfied with the fat accumulation in specific areas of their bodies1. The procedure can either be performed individually or in combination with other body contouring operations, such as abdominoplasty and mammoplasty, to achieve the ideal aesthetic form of the patient2. Liposuction surgery can lead to various types of complications, including asymmetry, infection, skin necrosis, hematoma, seroma, pigmentation, lymphedema, and venous thromboembolism2,3,4. Among these, infection is a relatively common complication, usually induced by Staphylococcus aureus, Streptococcus group A, and Streptococcus pyogenes5, with an incidence rate of 0.1% in single liposuction and 0.7% in combined surgeries6. Although the incidence rate is relatively low, for patients undergoing cosmetic surgery, any kind of complication is usually intolerable, and patients with severe infections may develop necrotizing fasciitis (NF), infectious shock, and even death5,7,8. Understanding the connection between liposuction and potential infectious complications is crucial for effective treatment and also serves as a warning to prevent the recurrence of similar infections. Introducing antibiotics into implant materials such as bone cement can achieve high-concentration aggregation of local antibiotics, which has a significant effect upon preventing and treating bacterial infections, and has been widely used in orthopedic surgeries9. In patients with abdominal infections, placing bone cement at the wound site not only helps prevent infection but can stimulate granulation tissue growth and create conditions for skin grafting10.

Here, we present a female patient who suffered a bacterial infection after liposuction and abdominoplasty, which eventually led to skin infection, abdominal wall abscess, abdominal wall infectious sinus tract, transplanted flap necrosis, lumbar fasciitis, and NF. Detailed admission history, physical examination findings (fever, hypotension), laboratory results (normal white blood cell count, hemoglobin level, and LRINEC score), and imaging studies (revealing multiple areas of subcutaneous exudation in the abdominal wall and lumbodorsal gluteal regions) provide a basis for the diagnosis of NF. On the day of admission, empirical carbapenem antibiotic treatment, such as ertapenem sodium 1.0 g intravenous driponce a day (ivgtt qd), was initiated on the premise that renal function permitted (creatinine clearance rate needed to be monitored). Three aggressive surgical debridements were performed on the 2nd, 9th, and 50th days after the first admission, and antibiotic bone cement was applied intraoperatively for localized sustained antibiotic release, thereby achieving the goals of anti-infection and stimulating granulation tissue growth. Postoperative pathogen identification was achieved through bacterial culture and metagenomic next-generation sequencing (mNGS). Active anti-infective therapy was pursued in the absence of relevant contraindications (e.g., a history of QT prolongation precluding the use of moxifloxacin Tablets (400 mg/tablet): 1 tablet once daily and Faropenem Sodium Granules (0.1 g/sachet): 0.1 g 3x daily. This comprehensive treatment regimen ultimately achieved effective infection control. Beyond its application in this specific case, this integrated strategy may also hold reference value for managing infections arising in general surgery or other cosmetic interventions.

Case Presentation:
A 33-year-old patient presented to the First Affiliated Hospital of Zhejiang University due to flap necrosis 20 days after abdominoplasty with liposuction. The patient underwent abdominoplasty with liposuction at another private clinic in China and subsequently developed partial flap necrosis. Without receiving any treatment, the patient came directly to our hospital for medical attention. The patient was previously healthy, without diseases such as hypertension, diabetes, viral hepatitis, heart disease, etc., and had no history of allergies or long-term medication.

On admission, the patient exhibited a body temperature of 39.2 °C and a blood pressure 89/54 mmHg. Physical examination revealed a conscious and alert patient with a flat, soft abdomen; the abdominal wall exhibited skin flap necrosis, which was covered with bandages, and there was no evidence of abdominal tenderness or rebound tenderness. No palpable liver or spleen was identified below the costal margins, and shifting dullness was negative. Abdominal wall reflexes were normal. Neurological examinations showed negative pathological signs. Initial blood tests exhibited a white blood cell (WBC) count of 6.64x 109 cells/L, a red blood cell (RBC) count of 4.56 x 1012 cells/L, neutrophils 58.8%, hemoglobin 122 g/L, sodium 142 mmol/L, glucose 5.21 mmol/L, creatinine 52 µmol/L, a platelet count of 339 x 109 platelets/L (normal: 101-320 x 109 platelets/L), eosinophils 0.4% (normal: 0.5%-5.0%), and high-density lipoprotein cholesterol (HDL-C) 0.77 mmol/L (normal: 0.88-2.04 mmol/L). Abdominal mass MRI plain scan combined with diffusion-weighted imaging (DWI) on admission demonstrated multiple areas of exudation within the subcutaneous soft tissues of the abdominal wall and lumbodorsal-gluteal regions, findings consistent with cellulitis. Correlation with clinical presentation is recommended (Figure 1).

In consideration of the patient's limited physiological tolerance and the need for effective infection control, a staged surgical approach was planned. Preoperatively, a standing order for ertapenem sodium injection 1.0 g ivgtt qd was initiated to mitigate disease progression. At 2 days after admission, surgical procedures were performed under general anesthesia, including incision and drainage of the abdominal wall sinus tract, repair of the chronic ulcer, and harvest and transposition of a pedicled fascial flap for soft tissue coverage. Intraoperative findings revealed an infected abdominal wall defect with swelling in the abdominal and lumbar regions, along with local purulent exudate. The necrotic margins were incised, exposing necrotic fascia and adipose tissue. Debridement was performed on the necrotic tissue. Considering the risk of reinfection in the wound and promoting the growth of granulation tissue, the area was covered and filled with antibiotic bone cement. A vacuum sealing drainage (VSD) device was applied, and two drainage tubes were placed (Figure 2).

Blood tests on the 1st day after the operation showed a WBC count of 5.01 x 109 cells/L, RBC count of 3.85 x 1012 cells/L, neutrophils 59.9%, eosinophils 0.8%, CRP 1.90 mg/L, HDL-C 0.65 mmol/L (normal: 0.88-2.04 mmol/L), hemoglobin 105 g/L (normal: 113-151 g/L), sodium 146 mmol/L, glucose 5.17 mmol/L and creatinine 54 µmol/L. Postoperative bacterial culture and metagenomic sequencing identified Corynebacterium glucuronolyticum, Fingoldia magna, Prevotella buccalis, Prevotella timonensis, Peptoniphilus rhinitidis, Anaerococcus prevotii, and Anaerococcus lactolyticus, confirming the diagnosis (Table 1). All identified bacterial species demonstrated susceptibility to quinolones; therefore, on the 6th day after admission, oral moxifloxacin at a dose of 400 mg 1x daily was initiated and continued for 3 consecutive days.

At 9 days after admission, the second surgery was performed, which was the same as the first one. During the surgery, the bone cement was removed. Fresh granulation tissue was observed in the local wound area, with a small amount of necrotic tissue on the surface. Upon exploration, the flap was found to be well-adhered to the subcutaneous tissue (Figure 3). On the 19th day after admission, the patient was temporarily discharged for conservative treatment and was prescribed two boxes of moxifloxacin tablets, each containing three 400 mg tablets, with instructions to take one tablet daily. At 50 days after the initial hospitalization, the patient was re-admitted to the hospital for the final debridement, and skin grafting was performed using the full-thickness skin from the right inguinal region as the donor site. Postoperative blood tests revealed a WBC count of 8.15 x 109 cells /L, RBC count of 4.03 x 1012 cells/L, neutrophils at 73.0% (normal: 50.0%-70.0%), lymphocytes at 22.6% (normal: 20.0%-40.0%), hemoglobin 107 g/L (normal: 113-151 g/L), sodium 138 mmol/L, glucose 5.51 mmol/L, creatinine 41 µmol/L and CRP level of 0.50 mg/L. After the operation, ertapenem sodium 1.0 g ivgtt qd was continued to be given as the routine anti-infection treatment, which proved effective. At 58 days after the initial hospitalization, the patient was discharged home. Upon discharge, the patient was administered faropenem sodium granules (0.1 g per sachet) 0.1 g per dose, 3x daily, to continue anti-infection therapy.

The patient participated in a comprehensive rehabilitation program incorporating physical therapy and therapeutic exercises, achieving progressive functional recovery. The infection was effectively controlled, resulting in a favorable outcome following the chronic ulcer repair surgery (Figure 4).

Diagnosis, Assessment, and Plan:
The patient was admitted to the hospital with a skin infection as the preliminary diagnosis. MRI+DWI revealed multiple areas of exudation in the subcutaneous soft tissues of the abdominal wall and lumbodorsal-gluteal regions, suggestive of cellulitis. However,a series of symptoms (fever 39.2 °C, hypotension 89/54 mmHg, and abdominal wall skin flap necrosis) indicated severe disease progression, suggesting the possibility of NF.Intraoperative exploration during the first debridementrevealed an infected abdominal wall defect with swelling in the abdominal and lumbar regions, along with local purulent exudate. The necrotic margins were incised, exposing necrotic fascia and adipose tissue. The exploration results changed the postoperative diagnosis to skin infection, abdominal wall abscess, abdominal wall infectious sinus tract, transplanted flap necrosis, lumbar fasciitis, and NF. The diagnosis was further improved through postoperative bacterial culture and metagenomic sequencing, identifying seven pathogens (Corynebacterium glucuronolyticum, Fingoldia magna, Prevotella buccalis, Prevotella timonensis, Peptoniphilus rhinitidis, Anaerococcus prevotii, and Anaerococcus lactolyticus) with universal quinolone susceptibility.

Management employed a multidisciplinary strategy: (1) Staged surgical intervention-radical debridement with vacuum-sealing drainage (VSD) and antibiotic bone cement for infection control (Nov 16), secondary exploration confirming viable granulation tissue (Nov 23), and definitive closure via skin grafting (Jan 4); (2) Culture-guided antimicrobial therapy-initial empirical coverage with ertapenem sodium injection 1.0 g ivgtt qd targeting NF, escalation to moxifloxacin tablets 400 mg, taken orally once a day (po qd) post-identification of quinolone-susceptible pathogens, and eventually switching to oral faropenem sodium granules 100 mg 3x a day (TID) after discharge; (3) Supportive care for symptoms such as fever and hypotension; and (4) Structured rehabilitation, achieving complete wound healing, functional recovery, and eradication of infection without recurrence.

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Protocol

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This study was approved by the Clinical Research Ethics Committee of The First Affiliated Hospital of Zhejiang University School of Medicine (Reference Number: 2024-0844). Written informed consent was obtained. The study complied with the Declaration of Helsinki.

1. Patient admission and clinical evaluation

  1. Initial presentation and history
    1. Skin flap necrosis was presented after the patient underwent prior cosmetic surgery and lasted for 20 days. Detailed medical history information was obtained.
  2. Clinical assessment
    1. Physical examination was conducted, focused on the affected skin area.
    2. The extent of skin necrosis was documented.
    3. Vital signs (fever, hypotension) and laboratory findings (normal WBC, Hb, LRINEC score) were recorded.

2. Imaging and empirical treatment

  1. Diagnostic imaging
    1. The extent of involvement of abdominal wall and lumbodorsal-gluteal subcutaneous soft tissues was evaluated using routine abdominal MRI plain scan and diffusion-weighted imaging (DWI, 3.0T).
    2. Multiple areas of exudation in the subcutaneous soft tissues of the abdominal wall and lumbodorsal-gluteal regions (hyperintensity on T2-weighted imaging (T2WI) and DWI), were revealed, suggestive of cellulitis. Combining clinical manifestations was recommended for evaluation and treatment.
  2. Empirical carbapenem therapy (e.g., ertapenem sodium 1.0 g ivgtt qd) was initiated.

3. Surgical debridement

  1. Preoperative preparation
    1. Patient was prepared for surgical exploration under combined intravenous-inhalational general anesthesia, with strict adherence to aseptic protocols.
  2. Operative procedure
    1. Incisions were made along necrotic margins using a scalpel. The necrotic tissue was then separated and debrided with surgical instruments, including a scalpel, tissue scissors, and forceps, until the absence of non-viable tissues that were identified by black/gray discoloration, leathery texture, and lack of bleeding.
    2. The wound was filled with vancomycin-loaded bone cement.
    3. VSD dressing (AD-1-15 x 5 x 1 cm) was trimmed and then tightly packed into the wound cavity, ensuring full contact with the entire wound bed. Embedded drainage tubes were exteriorized through a separate stab incision made in healthy skin and connected to a negative pressure suction device.
    4. The entire wound surface was subsequently sealed with a transparent occlusive dressing film without wrinkles, and a negative pressure of approximately 125 mmHg was maintained.
  3. Specimen collection
    1. More than three tissue specimens were collected from different wound sitesusing a scalpel for excision and scissors for dissection.
    2. The samples were placed in sterile containers for bacterial/fungal culture and histopathological analysis.

4. Pathogen identification and next-generation sequencing (NGS) testing

  1. Traditional microbiology
    1. Gram staining and bacterial/fungal culture were performed on tissue samples11.
  2. Molecular testing
    1. DNA/RNA was extracted from fresh tissue for NGS12.
  3. Pathogen confirmation
    1. A total of seven pathogens, including Fingoldia magna, were confirmed through bacterial culture and NGS.

5. Post-diagnosis management using a combination of antibacterial therapy and staged surgical debridement

  1. Treatment plan adjustment
    1. Moxifloxacin tablets (400 mg per tablet) were given at one tablet, 1x a day on the basis of the original ertapenem sodium administration following confirmed diagnosis.
  2. Subsequent debridements
    1. Second surgical debridement
      1. The implanted bone cement was separated from the surrounding soft tissues by using instruments such as tissue scissors and curved forceps along the surface of the bone cement. The bone cement was then removed by holding it with forceps like the Allis forceps, and the wound bed was assessed for fresh granulation tissue (wound bed coverage with beefy-red, granular, non-friable tissue; absence of fibrinopurulent exudate) with a few superficial necrotic tissues. The viability of the peripheral flap adherence to subcutaneous tissue was confirmed.
      2. Incisions were made along necrotic margins using a scalpel. The necrotic tissue was then separated and debrided with surgical instruments, including a scalpel, tissue scissors, and forceps, until all necrotic tissue was debrided, and the wound was covered with antibiotic bone cement.
      3. VSD dressing (AD-1-15 x 5 x 1 cm) was trimmed and then tightly packed into the wound cavity, ensuring full contact with the entire wound bed. And embedded drainage tubes were exteriorized through a separate stab incision made in healthy skin and connected to a negative pressure suction device. The entire wound surface is subsequently sealed with a transparent occlusive dressing film without wrinkles, and a negative pressure of approximately 125 mmHg is maintained.
    2. Third surgical debridement
      1. The implanted bone cement was removed, and the wound was assessed for mature scar tissue (tissue firm, non-fluctuant, epithelialized edges; no purulence/slough) with partial skin deficiency.
      2. Radical debridement of necrotic tissue was performed; incisions were made along necrotic margins using a scalpel. The necrotic tissue was then separated and debrided with surgical instruments, including a scalpel, tissue scissors, and forceps, until all necrotic tissue was debrided. Abdominal wall reconstruction was conducted, and the defect site was covered with a free skin graft.
      3. The VSD device was applied.
  3. Post-discharge therapy
    1. Faropenem sodium granules (0.1 g per sachet) 0.1 g each time was prescribed, 3x a day after discharge for continued anti-infective therapy.

6. Recovery and follow-up

  1. Definitive wound closure
    1. Skin grafting was performed using the full-thickness skin from the right inguinal region as the donor site after confirming complete necrotic tissue excision.
  2. Follow-up schedule
    1. Assessments were scheduled for 2 weeks, 1 month, and 3 months postoperatively. Wound healing, flap viability, recurrence, and infection signs were monitored.
  3. Outcomes documentation
    1. Clinical progression, imaging, lab results, and final outcomes were analyzed. Comprehensive case materials for reporting/publication were compiled.

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Results

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This case demonstrates the synergistic effect of stepwise surgical debridement combined with antimicrobial stepping therapy and also highlights the efficacy of novel diagnostic methods like pathogen mNGS.The patient successfully underwent surgical exploration. Preoperative broad-spectrum antibiotic coverage with ertapenem sodium (1.0 g ivgtt qd) provided a safe window for surgery. Three staged debridement procedures progressively and thoroughly removed necrotic tissue. Culturing and mNGS of samples obtained during the in...

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Discussion

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Liposuction and abdominoplasty are currently among the most common cosmetic surgical procedures. They achieve patients' desired aesthetic outcomes by reducing localized excess adipose tissue in specific body areas, making them highly popular1,2,13. The fact that patients receiving cosmetic surgery are typically in good health and have high expectations makes it challenging for them to accept complications. Therefore, despite...

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Disclosures

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The authors have nothing to disclose.

Acknowledgements

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The authors have no acknowledgments.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
3.0T MRI ScannerGeneral Electric CompanyNot specified
Allis tissue forcepsTonglu Changsheng Medical Instrument Co., Ltd.CS-AL012
Bandage 8*600Yongkang Weizhong Medical Instrument Co., LTDWZ-BD822
Cotton ballsHenan Saizhong Medical Instrument Co., LTDSZ-MQ100
Drain tube Zhejiang Daweier Medical Technology Co., LTDDW-YLF815
DressingYongkang Weizhong Medical Instrument Co., LTDWZ-FT326
Electrosurgical pencilXi 'an Surgical Medical Technology Co., LTDXW-DDUNI25
Ertapenem sodium injectionStone Pharmaceutical Group Ouyi Pharmaceutical Co., LTDH20133325
Faropenem sodium granulesHunan Warner Pharmaceutical Factory Co., LTDH20080152
Fine gauzeHenan Saizhong Medical Instrument Co., LTDSZ-SS422
Medium curved clampTonglu Changsheng Medical Instrument Co., Ltd.CS-ZW150
Mosquito forcepsTonglu Changsheng Medical Instrument Co., Ltd.CS-WS160
Moxifloxacin tabletsBayer Pharma AGH20140721
Nerve dissectorShengxiang Medical Instrument Co., LTDSX-BLZ280
Plastic surgery forceps, smoothShanghai Jinzhong Medical Instrument Co., LTDJZ-YS344
Plastic surgery forceps, toothedShanghai Jinzhong Medical Instrument Co., LTDJZ-WS368
Saline CSPC Pharmaceutical Group Limited  CSPC-SS600
Scalpel handle #3Shanghai Jinzhong Medical Instrument Co., LTDJZ-DB334
ScissorsShanghai Jinzhong Medical Instrument Co., LTDJZ-ZZ580
Small suction tipYangzhou Pengyan Biotechnology Co., LTDPY-FSXT106
Two-prong retractorShanghai Jinzhong Medical Instrument Co., LTDJZ-LG253
VSD(AD-1-15*5*1)Shanghai XiuHui Technology Co., Ltd.Not specified

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Liposuction ComplicationsAbdominoplasty ComplicationsSurgical Site InfectionSkin Flap NecrosisSurgical DebridementAntibiotic Bone CementVacuum Sealing DrainageSkin GraftingPostoperative Infection

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