Bilateral Sciatic Neurapraxia following Combined Abdominoplasty and Mastopexy

Sir: We recently encountered an interesting case of complete bilateral sciatic neurapraxia following combined abdominoplasty and mastopexy, which we found educational for discussion because it highlights the commonly undermined importance of proper surgical positioning. Recently, a 28-year-old healthy woman with a body mass index of 32.4 kg/m2 underwent abdominoplasty and mastopexy performed under general anesthesia. After plication of the rectus abdominis muscles, the patient was repositioned from the supine to the Fowler position (torso inclined, hip flexed 60 degrees, and knees fully extended). Both abdominoplasty and mastopexy were completed in this position over a period of 3 hours. Immediately postoperatively, the patient complained of progressively worsening bilateral lower extremity weakness and numbness. Complete neurologic examination revealed an isolated and complete bilateral sciatic neurapraxia with loss of sensory and motor nerve function. Further examination revealed an area of nonblanching hyperpigmentation suggestive of a stage I decubitus ulcer of the buttocks overlying the area where the proximal sciatic nerve traverses, helping to confirm the diagnosis of sciatic neurapraxia. Unfavorable positioning during surgery is the underlying cause of this complication. Although cases of postoperative sciatic neurapraxia are commonly encountered in orthopedic surgery, obstetrics and gynecology, neurosurgery, and urology because of the frequent use of lithotomy and seated positioning during surgery, no reports of postoperative sciatic neurapraxia have been described following aesthetic surgery. Three mechanisms of postoperative sciatic neurapraxia that have been reported in the literature are relevant to aesthetic surgery: compression neuropathy, traction injury, and piriformis syndrome. Our patient most likely experienced compression of the sciatic nerve caused by a combination of unfavorable surgical positioning and her obese body habitus, resulting in prolonged pressure in the gluteal region. Traction injury was also a contributing factor, because in the Fowler position the knees are left extended and the sciatic nerve is stretched during hip flexion. Few studies have reported the risk factors associated with postoperative sciatic neurapraxia. A retrospective analysis of operations performed in the lithotomy position found that old age (>70 years), prolonged operation time (>180 minutes), and inappropriate positioning were risk factors for developing postoperative lower extremity neuropraxia.1 “At-risk” patient positions also include semi-Fowler (hip flexed 30 degrees, knees extended), Fowler (hip flexed 60 degrees, knees extended), high-Fowler (hip flexed 90 degrees, knees extended), and seated (hip and knee flexed 90 degrees).2 Severe hypotension3 during surgery, obesity,4 and spinal anesthesia may be risk factors as well.3 Although a combined abdominoplasty and mastopexy procedure is a relatively safe procedure,5 attention should be paid to proper patient positioning. We suggest minimizing time in the reflexed position and looking for defects in the operative table padding. If the hip must be flexed, we recommend placing the patient in a “beach chair” position, with an appropriate degree of knee flexion to take tension off of the sciatic nerve. Vinay Rawlani, B.S. Michael J. Lee, M.D. Gregory A. Dumanian, M.D. Division of Plastic and Reconstructive Surgery; Northwestern University Feinberg School of Medicine; Chicago, Ill.