Opioid-induced respiratory depression in cosmetic surgery: A medico-legal analysis of a fatal adverse event

Aesthetic surgery is an elective procedure intended to enhance physical appearance under controlled and safe conditions. In the eyes of public opinion, life-threatening complications are considered unacceptable, as they violate the core expectation of safety. The authors present a case of death following a cosmetic surgery procedure and offer a literature review on fatalities associated with this type of intervention. The case is of particular interest due to the clinical and medico-legal methodological issues it raises. A middle-aged woman underwent major elective cosmetic surgery under local anaesthesia combined with sedation with Propofol and Sufentanyl. An additional 10 mcg dose of sufentanyl was administered postoperatively. Initially stable, the patient was found unresponsive approximately one hour later. CPR restored spontaneous circulation, but diffuse brain damage had already occurred. The patient died three days later. Autopsy findings ruled out cardiac abnormalities. Toxicological testing was inconclusive. The cause of death was identified as cerebral oedema secondary to cardiac arrest following recent cosmetic surgery. Alternative hypotheses to cardiological abnormalities for cardiac arrest include local anaesthetic systemic toxicity (LAST) or an opioid-induced respiratory depression (OIRD). The latter was considered plausible and was discussed from a medico-legal standpoint. This case underscores the importance of a thorough pathophysiological reconstruction of events, achieved through an integrated medico-legal approach and supported by the contribution of cardiovascular pathology, anaesthesiology, and pharmacology. A precise understanding of the underlying mechanisms is essential both for forensic assessment and for improving clinical risk management.