SQU Med J, May 2011, Vol. 11, Iss. 2, pp. 273-275, Epub. 15th May 11
Submitted 10th Oct 10 
Revision ReQ. 14th Dec 10, Revision recd. 8th Jan11
Accepted 15th Feb11

Patient positioning for surgical procedures has long been associated with intraoperative complications; this is 
especially true for surgery in the prone position. 
Reported complications resulting from the prone 
position are usually related to neurovascular injuries, 
eyes and ears. Other reported complications are 
related to loss of airway, monitors and catheters 
or to venous air embolisms.1,2 Ventilatory and 
haemodynamic changes have also been reported 
in the prone position,3 as well as pressure necrosis 
of the skin.4 To the author’s knowledge lip necrosis 
has not been reported before in English medical 
literature as a complication of the prone position. 

Case report
A 16 year-old female, a known case of right thoracic 
scoliosis (idiopathic type) was admitted to the 
Orthopedic Department at College of Medicine, 
King Saud University, Riyadh, Saudi Arabia, for 
elective surgical correction and spinal fusion for 
the scoliotic curve. During the procedure, the 
patient was placed in a prone position as is usual for 

posterior surgical correction in scoliosis surgeries. 

During the operation, gel pads were placed under 
the chest and another one against both iliac crests 
with a pillow under both feet to relax the knees 
which were also supported by separate gel pads. The 
face was supported with a gel pad too, but it was 
placed on the operating table not on a horseshoe 
head support. The endotracheal tube was fixed and 
maintained by tape over an airway protector to 
protect the lips and teeth as well as the tongue. The 
procedure was done under the continuous control 
of the motor evoked potential and sensory evoked 
potential. These give stimulation through the cortex 
and transmit the signals through the spinal cord for 
certain muscles to contract in upper limb as well as 
the lower limbs. In this way, the status of spinal cord 
conductivity and affection during the corrective 
surgery of scoliosis is checked. The time taken for 
the procedure was four hours. 

After the extubation we noticed that the patient 
had a swelling in the left side of the lower lip. 
There was no wound on the lips. The eyes, cheeks, 
chin, ears, and other bony prominent areas were 
not affected. After discussing the case thoroughly 

Orthopedic Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
*Corresponding Author email: alsiddiky@hotmail.com 

Ãfl¢]<Ìu]Üq<ª<h^f”fi˜]<ÌÈ√ïÁ÷<ÌÀ¬^ñ€“<ÌÀé÷]<ܡ™̌


       
 61         



:مفتاح الكلمات

aBstract: During the prone positioning of patients for scoliosis surgery, bony prominences should be protected 
to avoid pressure necrosis and the face should be carefully positioned to protect the eyes and ears, etc. The author 
reports a lower lip necrosis in a 16 year-old female as a complication of improper prone positioning during scoliosis 
surgery. The condition was treated successfully with an advancement flap. 

Keywords: Lip; Necrosis; Scoliosis; Complication; Case report; Saudi Arabia

Lip Necrosis as a Complication of a Prone 
Position in Scoliosis Surgery 

Abdulmonem Alsiddiky

CASE REPORT



Lip Necrosis as a Complication of a Prone Position in Scoliosis Surgery 

274 | SQU Medical Journal, May 2011, Volume 11, Issue 2

with the anaesthetist, we thought that the cause 
of this problem was a direct pressure from the 
endotracheal tube which was pushed against the lip 
by the gel pad support for the face. The swelling in 
the lower lip was observed for few days without any 
spontaneous improvement. Six days later, an area 
of the swollen lower lip became black and necrotic 
[Figures 1 and 2].

The patient was seen by the plastic surgeon who 
continued the observation and dressings for the 
necrotic part of the lower lip for ten more days, but 
no improvement was noticed. The plastic surgeon 
therefore then decided to take the patient for 
advancement lip flap surgery of the lower lip. This 
was done successfully fifteen days after the original 
surgery. The dressing for the lip and the flap were 
changed daily. The patient was followed up by the 
plastic surgeon in his clinic.  Three months later, the 
patient had recovered well with complete healing of 
the lower lip with a very minimal scar [Figure 3a & 
3b]. 

Discussion 
Pressure necrosis of the skin is a well-known 
complication for patients who undergo lengthy 
surgical procedures under general anaesthesia. 
The condition occurs more frequently in patients 
undergoing surgical procedures in the prone 
position.5,6 

It is crucial that both the surgeon and the 
anaesthetist are aware of the risks and the need for 
careful positioning of the face, eyes, ears, breasts, 
genitalia, and other dependent areas to prevent 

pressure sores or skin necrosis.7,8 Other areas that 
also need care include the iliac crests, the chin, 
eyelids, the nose, and the tongue.9,10 

The case reported here had a lower lip necrosis 
secondary to direct pressure of the endotracheal 
tube which had been pushed by the gel pad 
against the lower lip as a result of improper head 
positioning. 

Previously, a horse shoe (c-shape) head support 
which has free space around the lower part of the 
face was routinely used. With this device there 
would not be any risk of pressure around the mouth 
and lower part of the face. It was not used in this 
case because of the anesthetist’s preference for the 
use of a gel pad. This unfortunate complication is 
rare and could be avoided by following the strict 
precautions of prone head positioning and the use 
of the proper devices as well as continuous checkups 
by the attending anaesthetist.

Many devices have been described to be used to 
protect the face during prone position other than 
the well known horse shoe head support. In 2007, 
Mollmann et al. described a foam-cushion face 
mask and a see-through operating table as a new 
setup for face protection and increase safety in the 
prone position.11   

No previous case of direct pressure necrosis 
of the lip has been reported secondary to prone 
positioning. However, lip injury has been reported 
in a single case due to allergic contact dermatitis 
to the face, including the lips of a patient, who had 
become sensitised to the material of the flexible 
polyurethane foam applied to support the face 
during surgery.12

 
Figure 1: Swelling of the lower lip. Figure 2:  Area of necrosis of the lower lip (black arrow). 



Abdulmonem Alsiddiky

Case Report | 275

Conclusion 
In conclusion, lip necrosis can occur if the head of 
the patient is improperly positioned for scoliosis 
surgery. Both the anaesthetist and the surgeon 
should work together to create proper positioning 
for the patient during the surgical procedure and 
always use the appropriate equipment for the 
patient’s safety. The author recommends the use of 
a horse shoe head support in all cases undergoing 
surgery in the prone position and in scoliosis 
corrective surgeries in particular.

a c k n o w l e d g m e n t s

I would like to thank Prof. Mohammed Zamzam, 
Professor of Orthopedics at King Saud University, 
Riyadh and Dr. Mohammed Albarrag, Orthopedic 
Consultant at King Fahad Hospital, Riyadh for 
reviewing this report.

References
1. Cucchiara RF, Faust RJ. Patient positioning. In: Miller 

RD Ed. Anesthesia. 5th ed. New York: Churchill 
Livingstone, 2000. Pp. 1017–32.

2. Anderton JM. The prone position for the surgical 
patient: A historical review of the principles and 
hazards. Br J Anaesth 1991; 67:452–63. 

3. Yokoyama M, Ueda W, Hirakawa M, Yamamoto H. 
Hemodynamic effect of the prone position during 
anesthesia. Acta Anaesthesiol Scand 1991; 35:741–4. 

4. Edgcombe H, Carter1 K, Yarrow S. Anaesthesia in 
the prone position. Br J Anaesth 2008; 100: 165–83.

5. Jain V, Bithal PK, Rath GP. Pressure sore on malar 
prominences by horseshoe headrest in prone 
position. Anaesth Intensive Care 2007; 35:304–5.

6. Moore DC, Edmunds LH. Prone position frame. 
Surgery 1950; 27:276–9.

7. Ray CD. New kneeling attachment and cushioned 
face rest for spinal surgery. Neurosurgery 1987; 
20:266–9.

8. Roth S, Tung A, Ksiazek S. Visual loss in a prone-
positioned spine surgery patient with the head on a 
foam headrest and goggles covering the eyes: An old 
complication with a new mechanism. Anesth Analg 
2007; 104:1185–7.

9. Smith RH. One solution to the problem of the prone 
position for surgical procedures. Anesth Analg 1974; 
53:221–4.

10. Weis K. Threatening necrosis of the tip of the tongue 
during long-term anaesthesia in the prone position. 
Der Anaesthetist 1964; 13:241.

11. Mollmann M, Henning M, Liljenqvist U, Wenk 
M. A foam-cushion face mask and a see-through 
operation table: A new set-up for face protection and 
increased safety in prone position. Br J Anaesth 2007; 
99:597−8.  

12. Jericho BG, Skaria GP. Contact dermatitis after the 
use of the prone positioner. Anesthesia Analgesia 
2003; 97:1706−8.

Figure 3a and 3b: Two views for the lip three months after plastic surgery.