Inverted Areola

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A teenager from South Florida, USA, died last Saturday during an operation to correct asymmetrical breasts and an inverted areola.

Two hours into what was supposed to be a routine operation at a plastic surgery facility in Boca Raton, 18-year old Stephanie Kuleba was rushed to Delray Medical Center.

According to a report in ABC News, doctors believe Kuleba had a fatal reaction to anesthesia known as malignant hyperthermia, where increased heart rate and metabolism cause the body temperature to rise as high as 112 degrees F (44.4 degrees C).

Family attorney Roberto Stanziale told the Associated Press that it was too early to tell if any legal action would be taken.

He said there was no indication something like this was going to happen. Kuleba died about 24 hours after the surgery.

Kuleba was captain of her varsity cheerleading team at West Boca High School where she was well liked. She was hoping to become a doctor and had been accepted to study medicine at the University of Florida.

The surgeon who carried out the procedure, board certified plastic surgeon Stephen Schuster said in a statement that he was devastated by the loss and felt for the family, reported ABC News.

The state allows doctors to carry out such procedures at their own premises instead of a hospital if they comply with certain regulations, such as having advanced training in life saving, and special emergency equipment and drugs.

They must also use an an anesthesiologist or specially trained nurse, according to a report in the South Florida Sun Sentinel.

The Sentinel explained that Kuleba arrived at Schuster’s office for surgery at 8 am on the Friday, accompanied by her mother. One hour and 45 minutes later she was showing signs of malignant hyperthermia: her muscles became rigid and her metabolism increased.

A member of the American Society of Anesthesiologists and staff anesthesiologist at Cleveland Clinic in Weston, Dr Jeff Jacobs, told the paper that because malignant hyperthermia is a rare condition, and its symptoms are so general, it is not easy for the anesthesiologist to realize what it is straight away.

Kuleba was given dantrolene and an ambulance called via 911 rushed her to Delray Medical Center, where her symptoms deteriorated: her temperature rose to 108 degrees, her blood stopped clotting, and she started to bleed all over, said Malignant Hyperthermia Association president, Dr Henry Rosenberg, who told the Sentinel that Schuster and the anesthesiologist also called the Association hotline and spoke with an expert from the Mayo Clinic in Minnesota.

Speculating on what may have gone wrong, Rosenberg said Kuleba may not have received enough dantrolene, or her symptoms may have progressed too quickly.

A full-blown case of malignant hyperthermia would need “more than one pair of experienced hands”, an expert in emergency procedures told the Sentinel. Chairman of the University of Miami medical school, Dr David Lubarsky said that emergency procedures are “tricky and labor-intensive”. The patient has to be cooled quickly and the drug mixed precisely. Other drugs may also be necessary to act against some of the effects.

Meanwhile Kuleba’s parking space at her school in Boca Raton has been turned into a makeshift shrine where her high school friends have placed flowers and mementos and gather to mourn their loss.