Abstract Introduction Most complications of cosmetic chest surgery are local—seroma, hematoma, or contour irregularity—rather than cardiopulmonary. Pneumothorax is rare but has been reported after liposuction and implant procedures, from pleural breach during deep cannula passes or pocket dissection. Venous thromboembolism (VTE) is also uncommon, occurring in less than 0.02% of aesthetic surgeries, yet remains a leading cause of postoperative mortality. We report a case of large pneumothorax and intermediate-risk pulmonary embolism (PE) following chest liposuction, mastopexy, and pectoral implants. Description A 53-year-old man with no prior comorbidities underwent elective chest wall liposuction, mastopexy, and pectoral implant placement. Three days later, he developed worsening shortness of breath and chest discomfort. At surgical follow-up, oxygen saturation was 70% on room air, prompting transfer to the hospital. In the emergency department, he was tachycardic (113 bpm), tachypneic (RR 20), and hypoxemic (SpO2 91% on 15 L non-rebreather). Examination showed diminished breath sounds on the left. Initial chest radiography was inconclusive due to implant shadowing. CT pulmonary angiography demonstrated a large left pneumothorax with extensive subcutaneous emphysema and predominantly right-sided lobar PEs with an RV/LV ratio of 1.3, consistent with right-heart strain. Duplex ultrasound revealed acute deep vein thrombosis in the right peroneal and left gastrocnemius and posterior tibial veins. A transthoracic echocardiography was done and showed mild right ventricular dilation consistent with intermediate risk PE. Troponin was 491 ng/L, D-dimer 23.17 ug/mL, and BNP was normal. Radiology placed a left pigtail chest tube with immediate re-expansion of the lung and heparin infusion was started for an acute PE. After full resolution of the PTX, the chest tube was removed, and anticoagulation was transitioned to apixaban. The patient remained hemodynamically stable and was discharged home on hospital day five with a three-month course of therapy for provoked VTE and planned outpatient imaging. Discussion Postoperative hypoxemia warrants a broad differential, as PTX and VTE can coexist through independent mechanisms—plural injury versus perioperative hypercoagulability. Subcutaneous emphysema should prompt urgent imaging to exclude a large PTX. In dual pathology, decompression should precede anticoagulation; unfractionated heparin allows procedural flexibility until hemostasis is secure, followed by a DOAC. An RV/LV ≥ 1.0 with biomarker or echo evidence of strain indicates intermediate-risk PE, guiding therapy while avoiding thrombolysis in recent surgical patients.This case highlights that even elective chest surgery can produce life-threatening pulmonary complications via distinct mechanisms. Maintaining suspicion for dual pathology in postoperative dyspnea allows timely, sequential management and improves outcomes. This abstract is funded by: None
Abuzaid et al. (Fri,) studied this question.