Thromboembolism in High-Risk Aesthetic Surgery ... november...the 17 patients, DVT developed in 12,...

648 • Volume 28 • Number 6 • November/December 2008 Aesthetic Surgery Journal

As a large private group practice with a designatedand well organized clinical research center, it hasbeen our primary goal to increase the safety of

aesthetic surgery. Plastic surgeons must be conscious ofthe potential risk of deep vein thrombosis (DVT) andpulmonary embolism (PE), and should be aware of thepreemptive measures that can significantly reduce thisrisk. To address this problem, we first needed to estab-lish accurate rates of occurrence. Because data weresparse regarding DVT/PE in the context of aesthetic sur-gery, it was first necessary to review relevant data gath-ered from general surgery literature to provide abaseline. These data show an incidence of postoperativeDVT ranging from 16% to 30%,1-3 with an incidence ofclinically significant PE of 1.6%,4,5 and fatal PE ranging

from 0.1% to 0.8%.5,6 Data regarding DVT/PE in aes-thetic surgery reflect incidence rates of 1.2% accordingto Grazer and Goldwyn7 and 0.8% for PE amongpatients who underwent abdominoplasty.2,8

To provide more data on this subject and promotepatient safety, several studies have recently been pub-lished regarding thromboembolism in high-risk aestheticsurgery.9-13 According to Schmitz,14 PE is the most fre-quently reported cause of death resulting from proce-dures performed in the office-based surgery facility;those procedures with the highest level of DVT inci-dence are abdominoplasty and circumferential lipoplas-ty.14,15 In 2004, the American Society of PlasticSurgeons provided additional information on DVT andPE and collaborated on development of a DVT modulein association with the Tracking Operations andOutcomes for Plastic Surgeons (TOPS) program. TheTOPS Committee chair, Dr. Gutowski, reported, “… weare very pleased that the DVT module also gatheredinformation on patient selection criteria and plastic sur-geons’ practice patterns related to perioperative throm-boprophylaxis across facility types.”14

Background: Pulmonary embolism (PE) represents the third most frequent cause of postoperative death inthe United States. In recent years, there has been an increasing demand among plastic surgeons for patientsafety guidelines that specifically address the complications of deep venous thrombosis (DVT) and PE in rela-tion to aesthetic surgery.Objective: In this study, we review 3871 consecutive major body contouring procedures performed over thelast 8 years in our surgery center in an attempt to identify common factors that could have contributed to theonset of DVT/PE in 17 of these patients.Methods: We conducted a retrospective chart review to identify common factors associated with the occur-rence of DVT/PE in high risk patients who undergo aesthetic surgery.Results: Among these patients, we calculated the following incidence rates: 0.46% for DVT and 0.08% for PE.We discovered that a culmination of factors working synergistically play a significant role in the developmentof DVT/PE.Conclusions: We conclude that a carefully planned, comprehensive, appropriately enforced protocol is nec-essary to reduce the rate of thromboembolic events. Practical safety measures and technical recommenda-tions are presented that strongly encourage the use of thromboprophylaxis during the pre-, intra-, and post-operative phases of aesthetic surgical procedures. We feel that DVT and PE prevention should involve a part-nership between patient and surgeon. (Aesthetic Surg J 2008;28:648–655.)

Drs. Patronella, Ruiz-Razura, Newall, and Mentz are in privatepractice in Houston, TX. Dr. Ruiz-Razura was Assistant Professor atthe Division of Plastic Surgery, University of Texas Medical SchoolHealth Science Center, Houston, TX. Dr. Arango is in private prac-tice in Pereida, Columbia. Mr. Assavapokee is an AssistantProfessor at the University of Houston, Houston, TX. Ms. Siarski isa postgraduate student from Texas A&M University.

Thromboembolism in High-Risk AestheticSurgery: Experience With 17 Patients in aReview of 3871 Consecutive CasesChristopher K. Patronella, MD; Amado Ruiz-Razura, MD; Germán Newall, MD; Henry A.Mentz, MD; Monica L. Arango, MD; Tiravat Assavapokee, PhD; and Jana L. Siarski

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Volume 28 • Number 6 • November/December 2008 • 649Thromboembolism in High-Risk Aesthetic Surgery

After a year of collecting data, the committee reportedthat “DVT/PE was 5 times more likely to occur in theacute care setting than the office-based surgery setting.”Dr. Gutowski further stated that “Patient selection crite-ria was also an important factor since patients whoexperienced DVT/PE included an 8% higher incidence inuse of hormonal contraceptives at the time of surgery,7% higher incidence with use of hormone replacementtherapy (HRT) at time of surgery, and a 21% higher inci-dence if patients were obese with a body mass index(BMI) of 30 or greater.”

A survey by Broughton et al1 published in January2007 showed that only 48.7% of surgeons performingface lifts, 43.7% of surgeons performing lipoplasty, and60.8% of surgeons performing a combined procedureactively use DVT prophylaxis on a continual basis.

These publications clearly support a growing need foreducational guidelines concerning aesthetic surgery pro-cedures and DVT, and additional study should take placeon this important issue.

OBJECTIVES It is the purpose of this study to review 3871 consecutivehigh-risk cases, and to identify common factors thatcould have contributed to the onset of DVT/PE in 17 ofthese patients. A close evaluation of these 17 patientswas conducted to identify the contributing factors thatcould have been prevented, or at least promptly man-aged, while finding practical and efficient ways to avoidthem in the future.

Safety guidelines are presented, resulting from thereview of these 17 patients, to be used for the implemen-tation of thromboprophylaxis in high- and highest riskpatients. We also provide recommendations for pre-,intra-, and postoperative phases of surgery based on ourexperience with these 3871 cases.

METHODSThis retrospective study involves 3871 consecutive pro-cedures performed by experienced board-certified plasticsurgeons in our American Association for Accreditationof Ambulatory Surgery Facilities–certified office-basedsurgical facility over the last 8 years (August 25, 1999 toJuly 30, 2007). The procedures included abdomino-plasty, large volume lipoplasty, breast surgery, and vari-ous body lift/contouring procedures. In all cases, a board-certified anesthesiologist administered generalanesthesia. All patients followed a standard DVT throm-boprophylaxis protocol. An exhaustive analysis was con-ducted on the 17 patients who, despite establishedpreventive measures, developed serious complications ofDVT and PE. In terms of risk factors, the GeorgetownRisk Management Classification was used in all patients(Table 1).8,16 In addition, patients were subjected to apreoperative evaluation based on the American Societyof Anesthesiologist’s (ASA) classification standards(Table 2).8,16,17 The most recent data regarding patientcondition were obtained directly from the patient via

telephone interviews conducted by an outside independ-ent professional.

Among those patients presenting with complications,the following parameters were carefully evaluated: age,weight, BMI, medical history (including medications),and surgical, family, and social history. During thecourse of surgery, we evaluated the duration of the pro-cedure, amount of tumescent infiltration, the patient’stotal aspiration volume, and the amount of tissueremoved. The patient’s temperature was monitoredthroughout the pre-, intra-, and postoperative periods. Apostoperative evaluation was also performed, taking intoaccount any complications, such as the date and timewhen signs and symptoms were first noticed and ananalysis of the different methods used to verify suchcomplications, including venous Doppler scan, spiralcomputed tomography scan, and V/Q scan.

After collecting preliminary information from the 3871patients, a group of statistics was designed to provideseveral analyses and projections. First, patients wereplaced into 2 groups, and a sample size was determinedfor each group. Group I included patients in whomDVT/PE had developed (sample size, 17). Group IIincluded patients that did not present signs and symp-toms of DVT/PE complications (sample size, 3854). The2-sample t test was applied to compare both groups anda logistic regression model was created to predict theprobability of DVT complications in patients (Table 3).The statistical evaluation was performed by theDepartment of Industrial Engineering Section ofStatistics at the University of Houston.

RESULTSAfter evaluating the data gathered from all 17 patients ingroup I, overall averages in each category were calculat-ed and reported as follows: median age, 39 years; medi-an height, 5’4”; median weight, 185 pounds; andmedian BMI, 29.9. It was apparent that the majority ofpatients examined were categorized, according to ASAstandards, as low-risk patients (ASA I or ASA II). Of the17 patients that developed serious complications, 31%were categorized as ASA I, 56% were categorized asASA II, and 13% were categorized as ASA III. Whenthese data were combined with the information derivedfrom the Georgetown Risk Assessment Classificationmodel, it was verified that all of the patients were at thehigh or highest risk level for venous thromboemboliccomplications. Using the Georgetown Classification mod-el, 7 of 17 patients fell into the high-risk category, whilethe other 10 fell into the highest risk category. All of thepatients in the highest risk category exhibited more than4 factors, shown by our research, predisposing them toDVT and PE.

In terms of surgical data, the following was found:the average surgical duration was 5 hours 25 minutes(ranging from 1 hour 5 minutes to 9 hours), the averageaspiration volume was 6437 mL, and the average bodytemperature was 35.1°C (range, 31.8°C to 38.0°C). After



closely monitoring the patients, it was discovered that ofthe 17 patients, DVT developed in 12, PE developed in 3,and both events developed in 2 patients. From this data,an incidence rate of 0.42% was derived, and no mortali-ty was encountered in this study.

In terms of the DVT/PE complications, the symptomsthat were found included exquisite pain and swelling ofthe affected extremity, shortness of breath, chest pain,syncope, and anxiety. These symptoms appeared withina range of 3 to 23 days postsurgery (average, 11 days).Upon close review, 70% of these patients were diag-

nosed as having a predisposition for thrombogenesiscaused by either increased levels of clotting factors orinherited or acquired thrombophilias. Further, it was dis-covered that at least 58% of the patients suffering fromDVT/PE were on regimens of oral contraceptives or HRTat the time of surgery. Laboratory results also indicatedthat acquired and inherited thrombophilias were presentfactors among the patients. In fact, one of our patientstested positive for lupus, which is a clearly identifiedacquired thrombophilia. In reference to inherited throm-bophilias, one patient was positive for factor V Leiden

Table 1. Risk assessment model of the Division of Plastic Surgery, Georgetown Medical Center

Step I: Exposing risk factors

1 factor 2 factors 3 factors 5 factors

Minor surgery Major surgery Previous myocardial infarction Hip, pelvis, or leg fracture

Immobilizing plaster case Congestive heart failure Stroke

Patients confined to bed for >72 hrs Severe sepsis Multiple trauma

Central venous access Free flap Acute spinal cord injury

Step II: Predisposing risk factors

Clinical setting Inherited Acquired

Age 40–60 yrs (1 factor) Any genetic hypercoagulable disorder (3 factors) Lupus anticoagulant (3 factors)

Age >60 yrs (2 factors) Antiphospholipid antibodies (3 factors)

History of DVT/PE (3 factors) Myeloproliferative disorders (3 factors)

Pregnancy or <1 mo postpartum (1 factor) Heparin-induced thrombocytopenia (3 factors)

Malignancy (2 factors) Hyperviscosity (3 factors)

Obesity >20% IBW (1 factor) Homocystinemia (3 factors)

Oral contraceptive/HRT (1 factor)

Step III: Total of steps I and II

Step IV: Risk assignment

1 factor 2 factors 3–4 factors >4 factors

Low risk Moderate risk High risk Highest risk

DVT, deep venous thrombosis; HRT, hormone replacement therapy; IBW, ideal body weight; PE, pulmonary embolism.Plastic surgery risk assessment models for venous thromboembolism prevention (according to Davison).16

Table 2. American Society of Anesthesiologists preoperative risk classification system (used to stratify patients)

Status of Limitations on ASA grade Patient’s health underlying disease activities Risk of death

I Excellent; no systemic None None Nonedisease; excludes persons at extremes of age

II Disease of one body system Well controlled None None

III Disease of more than one body Controlled Present but No immediate dangersystem or one major system not incapacitated

IV Poor with at least 1 severe Poorly controlled Incapacitated Possibledisease or end stage

V Very poor, moribund — Incapacitated Imminent

American Society of Anesthesiologists grade I excludes the very young and very old.17


mutation; this patient was also taking oral contracep-tives at the time this study was conducted. Anotherpatient, who was also taking HRT, tested positive for aprothrombin mutation and exhibited low levels of pro-teins C and S. Another patient possessed a genetic muta-tion related to elevated levels of homocysteine in thebody. Other interesting findings of equal importanceinvolved 2 patients who had a recent history of smoking,while one of these patients had a documented history ofanemia.

As part of our findings, we present in Table 4 the inci-dence rates associated with DVT and PE that were foundin this study as compared with other studies.

After performing a number of statistical analyses onthe 2 groups (group 1, patients with DVT complication[n � 17]; group 2, patients without DVT complication [n � 100]), the following conclusions were reached(Tables 5 and 6):

(1) The mean value of patient weight before surgeryin group 1 was statistically significantly greater thanin group 2 (P � .076).(2) The mean value of patient height in group 1 was sta-tistically significantly smaller than in group 2 (P � .03).(3) The mean value of patient BMI before surgery ingroup 1 was statistically significantly greater than ingroup 2 (P � .017).

(4) The mean value of duration of surgery in group 1was statistically significantly greater than in group 2(P � .023).(5) The mean value of patient temperature in group 1was statistically lower than in group 2 (P � .105).(6) The mean value of total surgical fat removal ingroup 1 was statistically significantly greater than ingroup 2 (P � .08).(7) The proportion of abdominoplasty procedures ingroup 1 was statistically significantly greater than ingroup 2 (P � .008).(8) The proportion of body lift procedures in group 1was statistically significantly greater than in group 2(P � .024).In this study, a number of student t tests were per-

formed to compare the mean values of many key factorsin the 2 groups. The first group consisted of 17 patientswith a thrombogenic complication after surgery; the sec-ond group consisted of 100 patients without a thrombo-genic complication after surgery, randomly selected fromour study population of 3854 consecutive cases. The firstgroup of patients is referred to as the “thrombogenicgroup” and the second group is referred to as the “non-thrombogenic group.”

Based on results obtained from the student t tests, thefollowing conclusions were reached: there was statisticalevidence demonstrating that mean values of weightbefore surgery, BMI, length of surgery, and amount ofsurgical fat removal in the thrombogenic group were sig-nificantly higher than those in the nonthrombogenicgroup. In addition, the proportion of patients with tum-my tuck and body lifting operations was statisticallyhigher in the thrombogenic group than those in the non-thrombogenic group. Finally, there was also statisticalevidence illustrating that the mean values of patientheight and temperature in the thrombogenic group weresignificantly lower than those in the nonthrombogenic

Table 4. Deep venous thrombosis and pulmonary embo-lism incidence rates

Incidence DVT PE

In the United States 1.2% 0.8%27

ASPS (abdominoplasty) 1.2% 0.08%8

ACPS 0.46% 0.8%27

ASPS, American Society of Plastic Surgeons; ACPS, Aesthetic Center forPlastic Surgery; DVT, deep venous thrombosis; PE, pulmonary embolism.

Table 3. Explanation of statistical analysis model used in this study

A logistic regression model to predict the probability of having DVT complication based on the values of these patient characteristics can bepresented as follows:

Pr(DVT) =

Where:

Pr(DVT) = probability of the patient having the DVT complication

BMI = the value of patient body mass index

Temp = the value of the room temperature in the patient in fahrenheits

TT = 1 if a “tummy tuck” procedure is performed on the patient, 0 if otherwise

BodyL = 1 if the body lifting procedure is performed on the patient, 0 if otherwise

We used this model to predict the probability of DVT complication in 117 patients. The model correctly predicts the result about 90% of the time.

1

1 + e –(22.5057+0.10989(BMI)–0.295474(Temp)+0.811581(TT)+2.2755(BodyL))




Table 5. Comparative analysis between the thrombogenic and nonthrombogenic groups

Group 1: Group 2: Thrombogenic (N = 17) Nonthrombogenic (N = 100)

P forCategory Mean SD Mean SD comparing mean

Age (yr) 39.94 9.74 39.2 11.1 .389

Presurgery weight (lbs) 178.5 33.1 165.4 34.6 .076

Height (cm) 162.11 6.49 165.63 7.95 .03

Body mass index 30.95 6.41 27.23 4.59 .017

Length of surgery (min) 282 135 201 131 .023

Patient temperature (°F) 95.23 1.97 95.93 1.57 .105

Total fat removed (cc) 6509 4883 4715 2889 .08

Intravenous fluids (mL) 2533 1767 2174 998 .228

Proportion of patients undergoing tummy tuck 0.706 0.47 0.379 0.488 .008

Proportion of patients undergoing body lift/contouring 0.294 0.47 0.046 0.211 .024

SD, standard deviation.

Table 6. Recommendations (based on this study) and traditional guidelines for DVT and PE prevention

Preoperative Intraoperative Postoperative

ASA, American Society of Anesthesiologists; SQ, subcutaneously.

Complete a thorough medical history and stratify patients according to ASA classification17

Complete a thorough risk assessment evaluation using Georgetown Classification16

Discontinue all hormone therapies at least 4 weeks before the procedure

Consider multivitamins with folic acid, B complex, and iron supplementation at least 2 weeks before surgery

Avoid hypothermia in the holding area

1. Use Bair Hugger gown

2. Warm intravenous fluids

3. Use warm blankets

Continue to avoid hypothermia

1. Use humidified oxygen

2. Use upper and lower Bair Huggers whenpossible

3. Minimize surface area exposure withsterile warmed blankets

4. Use warm fluids for irrigation

5. Use warm tumescent solution

Minimize venous stasis

1. Use intermittent pneumatic compressiondevices

2. Use positional aids: popliteal pillow (5° ofknee flexion)

3. Change patient body position constantly

4. Place regional infusion pain pumps

Avoid hypothermia

1. Administer low-molecular-weightenoxaparin, 40 mg administered SQ 1hour after surgery and then q 12 hours �72 hours, but only for those cases notinvolving combination breast surgery

2. Use warmed blankets in recovery room

3. Use new Bair Hugger gown

4. Perform active plantar flexion anddorsiflexion of feet

5. Start infusion of pain pump (marcaine)

6. Use intermittent pneumatic compressiondevices until patient is discharged the nextday

7. Use graded elastic compression stockings

8. Initiate early ambulation

9. Use compression garments for 4–6 weeks

Frequent outpatient monitoring

1. Home visits by a registered nurse

2. Increased visits with the surgeon at theoffice

3. Close monitoring for the first 4 weeksafter surgery

4. Avoid lengthy car rides or air travel for 4weeks



group. Table 5 illustrates the summary of the results andP values from these student t tests.

DISCUSSIONDVT results from the synergistic effects of combined fac-tors. We recommend that a variety of techniques be usedto maintain a proper balance between thrombogenesisand thrombolysis. The signs and symptoms of DVT/PEare unpredictable. Symptoms may range from floridmanifestations, involving shortness of breath and chestpain, to asymptomatic manifestations that are difficult todiagnose.8 Therefore, a high level of suspicion is neces-sary to perform an effective diagnosis.1,8,16 Patients mustbe informed preoperatively of these symptoms anddirected to seek emergency medical assistance at thefirst sign of complications. Among the patients studied,symptoms of DVT/PE arose from the third postoperativeday to up to 23 days following surgery.

A reliable diagnosis of DVT/PE requires the surgeonto closely evaluate all clinical findings, including positivetests, and, using the process of elimination, to rule outother possibilities. Examinations that support final diag-noses have a low sensibility. For instance, an abnormalchest radiograph is seen in only 80% of cases for pul-monary embolism, and nonspecific electrocardiographicabnormalities occur in only 70% to 75% of cases.28

Although plethysmography and Doppler ultrasound aremore advanced methods of detection, their sensibility isonly moderate, and they can be cost prohibitive.8,18 A D-dimer test is highly sensitive with a moderate false (�)and a very low false (–) rate.

Because the patients who present the highest risk forcomplications of DVT/PE were those considered eitherhigh or highest risk according to the GeorgetownClassification model,8,16 this particularity prompted us toanalyze the following: (1) patient selection criteria; (2)surgical procedures; (3) known complications; (4) predis-position factors; and (5) postoperative management.Although there was not one specific precipitating factorcommon among all patients in whom a thromboembolicevent developed, we noticed a trend of certain predispos-ing factors. It was found that 12 of 17 (70%) of patientswere suspected to have had a previous hypercoagulablestate. Of these 12 patients, 10 (58%) were using oral con-traceptives or HRT. In addition, 8 of these 10 patients(80%) using HRT were at least 20% heavier (or more)than their ideal body weight, which increased the risk ofthrombosis 10-fold in comparison with women who didnot exhibit either risk factor. It should be noted thataccording to previous studies, the combination of HRTand body weight 20% or greater than ideal produces agreater increase in the risk of thromboembolism than thatproduced by an inherited hypercoagulability state.8

Previous hypercoagulable conditions relating to throm-bophilias were present when symptoms of DVT/PE werenoticed, prompting us to perform specific coagulopathystudies. It was disclosed that hematology diseases werediverse. One of the 17 patients in this study was positive

for previously undetected factor V Leiden mutation. Thisgene mutation is the most common inherited throm-bophilia in the United States, and its incidence rate is 3%to 7% in whites.8 Factor V Leiden modulates inactivationby activated protein C; consequently, it persists longer inthe blood, creating a 4- to 8-fold increase in the risk ofthromboembolus. When it is combined with oral contra-ceptives (as happened with this particular patient), itproduces a 35- fold increase in risk.5

One of the 17 patients tested positive for a prothrom-bin mutation, accompanied by low levels of proteins Cand S, and was also using HRT. This is the second mostcommon cause of inherited thrombophilia, producing anincident rate of 1% to 2% among Caucasian patients. Toclarify, a prothrombin mutation also results in slowerinactivation and persists longer in the circulation, whichcreates a threefold increase for thromboembolism.Another patient involved in our study produced positiveresults for a genetic mutation that causes elevated levelsof homocysteine. Homocystinemia has been implicatedin the development of venous thromboembolism.Statistics show that levels may be elevated in 5% to 7%of the population and can result from factors such asgenetic mutation, B complex and folic acid deficiencies,and cigarette smoking. In addition, it has been docu-mented that the presence of lupus anticoagulant andantiphospholipid antibody can predispose one to throm-boembolus. One of our patients was positive for sys-temic lupus erythematosus. This is a chronic systemicinflammatory disease that is predominant in AfricanAmerican women in their twenties and thirties.

RECOMMENDATIONSOur recommendations emphasize the effective use ofsequential compression devices and anticoagulants toserve as a preventive measure among surgical candidateswho present elevated risk factors. It is not cost effective toconduct extensive tests on all patients for each type ofcoagulopathy disorder. In lieu of this, for those patientswho exhibit the aforementioned factors (placing them intoa high risk category), we highly suggest that the plasticsurgeon implement a standard antithrombolytic regimento decrease the incidence rates of DVT/PE. (Please refer tothe recommendations summarized in Table 6.)

We feel that sequential compression devices shouldbe used both intra- and postoperatively as the standardof care in all patients under general anesthesia for 2hours or more. Further considerations include the tem-porary discontinuation of all hormonal therapy at least 4weeks before surgery to ensure the return of fibrinogento normal levels.19 It is also advisable for patients tobegin multivitamins that contain folic acid and B com-plex19 to avoid elevated homocysteine levels at least 2weeks before surgery. Reducing the patient’s risk ofhypothermia may theoretically reduce the risk of DVT byavoiding vasoconstriction and venous stasis.20,21 Studieshave demonstrated that hypothermia precipitates clotformation more than degradation.22,23

648-655_YMAJ592_Patron_CP 12/3/08 12:37 PM 53


We feel that perioperative normothermia can beaccomplished by employing the following: core pre-warming with (1) preoperative use of Bair Hugger gowns(Arizant, Eden Prairie, MN); (2) warmed intravenousfluids and tumescent solutions; (3) warm humidifiedoxygen applied as a circuit warmer (Humidi-Heat) to theanesthesia breathing circuit; and (4) minimizing the sur-face area of exposure during surgery by using warmedsterile blankets. These measures are an addition to thewell known and established guidelines published in theliterature.22-26

The use of regional infusion pain pumps is advised tohelp induce early ambulation along with the administra-tion of low-molecular weight heparin such as enoxa-parin, 40 mg/day beginning on postoperative day 1 andcontinuing for 2 more days. The senior author’s (CP)experience is that if this medication is given in high riskpatients who are having additional breast procedures, ahigher incidence of hematomas can be expected.Therefore, its use with breast surgery should be cau-tioned. The senior author feels comfortable recommend-ing this medication for high-volume lipoplasty and bodycontouring procedures that do not involve large breastdissections and undermining. It is his experience that toavoid the risk of postoperative bleeding and hematomaformation, enoxaparin should not be administered inpatients who undergo mastopexy/breast reduction orbreast augmentation as an added procedure.

In a study by one of our partners, Newall et al,8 thatreviews his personal experience of 291 consecutive caseswith high-risk aesthetic surgery combination proceduresusing 40 mg of enoxaparin subcutaneously beginning 1hour after surgery and continuing for 3 days, there was a0% incidence of DVT and PE. In the coming months, Dr.Newall will be completing a retrospective review of morethan 2000 high-risk patients that underwent abdomino-plasty, high volume lipoplasty, and breast reduction/aug-mentation/mastopexy procedures concurrently, withouta significantly higher hematoma rate than that reportedin the literature.

Lastly, it is imperative to maintain close observationof the patient for the first 4 weeks after surgery and toadvise the patient to avoid long periods of immobiliza-tion, such as prolonged car rides or air travel.

Table 6 summarizes our own prevention guidelines forDVT and PE and the established traditional guidelines thatplastic surgeons have followed over the past 10 years.

CONCLUSIONSThe central purpose of this article is to create moreawareness among plastic surgeons regarding the risk ofDVT and PE by closely reviewing the negative factorsthat can contribute to such complications. In all 17patients in this study that encountered a venous throm-boembolic event, an early diagnosis with immediate andaggressive treatment was instituted, preventing a poten-tial catastrophic death. The prevailing conclusion of thisarticle is that patients need to be educated preoperative-

ly by the surgeon and staff for signs and symptoms of PEand DVT. In addition, the surgeon is strongly encouragedto maintain close communication with the patient, andto stress with the patient the importance of keeping allfollow-up appointments. It is also imperative that effec-tive lines of communication be maintained between thepatient and the patient’s family, and between the sur-geon and his staff, to promote prevention and ensureearly detection of DVT and PE. Phone calls by thepatient for any symptoms related to potential DVT/PEshould be encouraged.

It is not our recommendation that every patientundergo arduous and costly preoperative examinationsto detect all potential disorders that may become mani-fest during aesthetic surgery, since this is not a realisticapproach in terms of cost effectiveness.

We cannot emphasize enough the need to have athorough understanding and a comprehensive andproactive approach to DVT and PE, by the surgeon,anesthesiologist, and the entire surgical and nursingstaff. Being vigilant and reacting promptly and effective-ly to the early signs of thromboembolism has saved usfrom many problems and prevented potential fatalities.

We appreciate the cooperation of our patients inallowing us to collect the much needed data thatenabled us to report our experience with the intent ofpromoting patient safety and the advancement of throm-boembolism prophylaxis in aesthetic plastic surgery. ◗

ACKNOWLEDGEMENTS

We would like to acknowledge the contributions of Hamid R.Parsaei, PhD, Marvin Karson, PhD, and Tiravat Assavapokee, PhD,of the Section of Statistics, Department of Industrial Engineering,University of Houston, Houston, TX, for their invaluable assistancein the statistical analysis of this study.

DISCLOSURES

The authors have no disclosures with respect to this article.

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therapeutic implications. Ann Intern Med 2001;135:367–373.Bauer KA. Screening for inherited thrombophilia in asymptomatic popula-

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Accepted for publication September 11, 2008.

Reprint requests: Christopher K. Patronella, MD, 12727 Kimberley Lane, Ste.300, Houston, TX 77024. E-mail: [email protected].

Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/$34.00

doi:10.1016/j.asj.2008.10.002



www.aestheticsurgeryjournal.com

Volume 28, Issue 6, November/December 2008

Aesthetic Surgery JournalA Peer-Reviewed International Journal

IN THIS ISSUE

Comparison of Results of Wire Subcision Performed Alone, With Fills,and/or With Adjacent Surgical Procedures

The Aesthetic Jaw Line: Management of the Aging Jowl

Techniques in Facial Fat Grafting

Pocket Conversion Made Easy: A Simple Technique Using Alloderm toConvert Subglandular Breast Implants to the Dual Plane Position

Pain Control in Augmentation Mammaplasty Using Indwelling Catheters in 687 Consecutive Patients: Data Analysis

Thromboembolism in High-Risk Aesthetic Surgery: Experience With 17 Patients in a Review of 3871 Consecutive Cases

Fraxel Laser Indications and Long-Term Follow-Up

Official English-Language Journal of:

• Brazilian Society of Plastic Surgery • Colombian Society of Plastic, Aesthetic, Maxillofacial and Hand Surgery • Costa Rican Association of Plastic, Reconstructive and Aesthetic Surgery • Dutch Society for Aesthetic Plastic Surgery

• Indian Association of Aesthetic Plastic Surgeons • Israel Society for Plastic Surgeons • Japan Society of Aesthetic Plastic Surgery • Korean Society for Aesthetic Plastic Surgery

• Mexican Association of Plastic, Aesthetic and Reconstructive Surgery • Society of Plastic and Reconstructive Surgeons of Thailand

OFFICIAL PUBLICATION OF THE AMERICAN SOCIETY FOR AESTHETIC PLASTIC SURGERY

ISSN 1090-820X

NOW INDEXED IN MEDLINE/PUBMED

Cov1_YMAJ_Nov-Dec08_CP 12/2/08 10:23 AM Page 1

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