Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis

Limited Incision Facelifts: A Contemporary Review of Approaches and Complications

Limited incision facelifts (LIFs) have gained popularity as an alternative to traditional facelift procedures. While surgical techniques vary, these approaches share a common goal: to rejuvenate the face while minimizing scar visibility. Previous studies also suggest that the reduced tissue dissection in LIFs can lead to decreased postoperative swelling, shorter recovery periods, and fewer complications. In this systematic review we delved into the literature on LIFs, shedding light on the various surgical approaches and their respective safety profiles. A systematic review was conducted by independent evaluators who followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A random-effects model was utilized to summarize complications data, and meta-regressions were conducted to analyze associations with operative variables. The analysis encompassed a total of 20 articles, comprising data from 4451 patients. The vast majority (84%) of these patients underwent either local wide-awake surgery or conscious sedation, while the remaining 16% underwent general anesthesia. Our analysis revealed an overall complication frequency of 3.2%, with hematoma being the most common complication (2%), followed by temporary nerve injury (0.2%), and skin necrosis or wounds (0.06%). Notably, hematomas rarely required operating room interventions. Use of drains or tissue sealants was associated with an 86% decrease in complications. Limited incision facelifts can be performed with a low complication rate, utilizing a variety of techniques. Utilization of tissue sealants and drains may limit hematoma formation, which is the most common complication.

Top 50 Highly Cited Publications in Facelift Surgery: A 50-Year Bibliometric Analysis Review

INTRODUCTION

Facelift surgery, also known as rhytidectomy, is a commonly performed procedure to address aging-related changes in the face and neck. Over the years, its techniques and methodologies have evolved. This study aimed to provide a bibliometric analysis of the top 50 most cited publications related to facelift surgery over a fifty-year period (1973-2023).

METHODS

The authors obtained data from the Web of Science Core Collection on July 15, 2023. Using a predefined search strategy, the most cited articles from 1973 to 2023 on facelift surgery were identified. The publications were analyzed for their type of study, journal of publication, geographic origin, and primary outcomes. Furthermore, the authorship gender distribution was assessed.

RESULTS

The majority of the publications (34 out of 50) were published in the "Plastic and Reconstructive Surgery" journal. The USA contributed to 72% of the research, followed by the UK, Mexico, Australia, and Germany. The primary outcomes varied from surgical techniques, anatomical studies, risk factors, patient-specific outcomes, and facial rejuvenation techniques, to comparative and historical progression of techniques. Notably, male authors dominated the field with 47 out of 50 papers having both a first and senior male author.

CONCLUSION

Facelift surgery has seen substantial research development over the past fifty years. The USA has been at the forefront of this research, with a predominant focus on surgical techniques and anatomical studies. Male dominance in authorship indicates potential scope for increased gender diversity in this specialty. Annual updates are recommended for continued insights.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anesthesia for office-based facial plastic surgery procedures

Objective

The objective of this study is to provide a state-of-the-art review on the use of anesthetics for in-office facial plastic procedures.

Methods

A search was performed on PubMed, Embase, Web of Science, and Cochrane Review using the keywords "anesthesia," "office-based procedures," "local anesthesia," "facial plastics," "oral sedation," "moderate sedation," and "deep sedation."

Results and Conclusions

Over the past few decades, the shift toward in-office invasive procedures has increased patient convenience and decreased hospital resource utilization. Many tools exist to reduce patient anxiety and discomfort in an office-based setting. With proper patient selection and technique, facial plastic surgeons can adequately anesthetize patients to perform Mohs reconstruction, cutaneous excisions, blepharoplasty, face-lifts, and other in-office procedures.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

BACKGROUND

In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.

METHODS

A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.

RESULTS

A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.

CONCLUSIONS

The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery

BACKGROUND

Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient.

METHODS

This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage.

RESULTS

Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens.

CONCLUSION

Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.

Deep Vein Thrombosis (DVT) and Abdominoplasty: A Holistic 8-Point Protocol-Based Approach to Prevent DVT

BACKGROUND

Plastic surgery as a specialty is afflicted with one of the highest incidence rates of thromboembolic events, with abdominoplasty procedures known to assimilate the greatest rates of deep vein thrombosis (DVT).

OBJECTIVES

The aim of this study was to develop a prophylactic protocol to reduce the rate of DVT occurrence postabdominoplasty.

METHODS

Over a 7-year period 1078 abdominoplasty patients were enrolled onto a holistic 8-point prophylaxis protocol. For a 4-week period before the operation all patients were required to stop smoking, and to cease hormone replacement therapy and combined oral contraception. All patients were required to have a preoperative BMI of less than 40 kg/m2. Participants were supplied with compression stockings, external pumping devices, and enoxaparin. Individuals with a history of DVT were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol required postoperative ambulation of fit patients within 4 hours.

RESULTS

Between 2008 and 2013, no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients, indicating the potential for this protocol to lead to a significantly lower incidence than any previously published methodology. Previous studies of DVT incidence were reviewd to identify rates statistically significantly similar to our sample, thereby providing conservative incidence rate estimates.

CONCLUSIONS

This 8-point DVT prophylaxis protocol is the first noncriteria-based inclusive protocol aimed at preventing abdominoplasty-associated DVT. A holistic and procedure-specific approach to prophylaxis can drastically reduce the occurrence of DVT in abdominoplasty surgery.With over 116,000 procedures performed annually in the United States, abdominoplasty has become one of the most popular and sought-after surgeries in the plastic and cosmetic field.1 Despite its ever-increasing popularity and the advancement of techniques, abdominoplasty-as with any other surgery-has its complications, including infection, seroma, hematoma, thrombosis, embolism, scarring, and even death. Complication rates as high as 37% have been reported, with some studies reporting a 16% major complication rate.2 One of the most serious and troubling complications for both surgeon and patient is deep vein thrombosis (DVT). With over 1 million patients tested, an estimated 250,000 cases of DVT are diagnosed per year in the United States alone.

LEVEL OF EVIDENCE: 4

Facelift Part II: Surgical Techniques and Complications

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

LEVEL OF EVIDENCE: 4

Evaluating Facelift Complications and the Effectiveness of the SMASectomy Technique: A Single Center's 15-Year Experience

BACKGROUND

Facelift continues to be one of the most common aesthetic procedures performed in the United States. Although there exist many techniques and variations, superficial musculoaponeurotic system (SMAS) manipulation, by way of plication, overlap, or SMASectomy, is common and has been shown to result in favorable cosmesis and durability. However, there is a lack of current complications data in the discussion of this technique.

OBJECTIVES

To assess the benefits and risks of the SMASectomy technique.

METHODS

The records of all patients who underwent a facelift procedure between December 2004 and March 2019 were reviewed for this study. All procedures were performed at an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)-accredited outpatient facility in Marina Del Rey, California. This represents data on 241 total patients. Retrospective chart review was performed to include data on patient characteristics, operative technique, and complications.

RESULTS

Average operative time of 152.68 ± 51.50 minutes and anesthesia time of 175.00 ± 54.07 minutes were observed among those patients who underwent SMASectomy. This was significantly lower (P < 0.000001) than those who did not undergo SMASectomy (average operative time of 265.25 ± 85.25 minutes and anesthesia time of 294.22 ± 85.31 minutes). There were no observed facial nerve injuries among patients who underwent SMASectomy. No deep vein thrombosis (DVT) events were observed in this patient population.

CONCLUSIONS

In the hands of an experienced surgeon, the SMASectomy facelift technique offers the unique advantage of significantly reducing operating time and anesthesia time and can provide extremely favorable and long-lasting aesthetic results.

LEVEL OF EVIDENCE 3

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices

BACKGROUND

Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown.

OBJECTIVES

The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved.

METHODS

Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center.

RESULTS

The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols.

CONCLUSIONS

Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Complications in Facial Esthetic Surgery

Esthetic surgery continues to become increasingly popular both in the United States and globally. Facial esthetic procedures in particular account for a large proportion of procedures performed. This increase in popularity will inevitably result in the number of potential complications associated with these procedures. In this review, the authors describe common complications encountered with frequently performed cosmetic facial procedures and their associated management. This article is meant as a general overview and introduction to potential complications surgeons may encounter, interested readers are encouraged to further review comprehensive subspecialty literature for more detailed discussion.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Searching for the Best Way to Assess the Risk of Thrombosis in Aesthetic Plastic Surgery; The Role of the Caprini/Pannucci Score

INTRODUCTION

There is concern regarding the high incidence of thrombosis in plastic surgery patients. For this reason, we wanted to compare the results of the Caprini/Pannucci score in patients with and without a past history of thrombosis admitted for aesthetic plastic surgery.

METHODS

This was a case-control study of 152 patients undergoing aesthetic plastic surgery procedures. We formed two groups: Group I had 70 patients who had thrombosis after aesthetic plastic surgery and group II had 82 patients without thrombosis. We studied the considered risk factors for thrombosis. We weighted the factors according to the OR and linear regressions. We then related them to the Caprini/Pannucci score.

RESULTS

Patients in group I had a score of 5.68 versus 3.45 in group II (p < 0.001). There was a 9.86% increase in thrombosis for each increased point in the rating. A higher effectiveness of the Caprini score was found in the high-score group; the greatest flaw was in the low-scoring group. The sensitivity was 75.71%, and the specificity was 70.73%. The factors with the greatest impact were the infiltration of fat in the buttocks, degree of obesity and time of surgery. There was an increased risk of thrombosis in patients with gluteal fat injections, varicose veins, obesity and immune disorders as well as those who had previously given birth.

CONCLUSION

To increase the effectiveness of the score and to use the score as a basis on which to decide upon prophylactic care, it is necessary to modify the score and add some factors.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evidence-Based Abdominoplasty Review With Body Contouring Algorithm

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

Venous Thromboembolism in Aesthetic Surgery: Risk Optimization in the Preoperative, Intraoperative, and Postoperative Settings

The purpose of this Continuing Medical Education (CME) article is to provide a framework for practicing surgeons to conceptualize and quantify venous thromboembolism risk among the aesthetic and ambulatory surgery population. The article provides a practical approach to identify and minimize venous thromboembolism risk in the preoperative, intraoperative, and postoperative settings.

Aesthetic Surgical Procedures in Men: Major Complications and Associated Risk Factors

BACKGROUND

The number of men undergoing cosmetic surgery is increasing in North America.

OBJECTIVES

To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures.

RESULTS

Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56).

CONCLUSIONS

Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures.

LEVEL OF EVIDENCE 2

Incidence and Predictors of Venous Thromboembolism in Abdominoplasty

BACKGROUND

The prevention of venous thromboembolism (VTE) is a high priority in aesthetic surgery. Abdominoplasty is the aesthetic procedure most commonly associated with VTE, yet the mechanisms for the development of VTE associated with this procedure are unclear.

OBJECTIVES

The purpose of this study was to analyze the incidence and predictors of VTE in patients undergoing abdominoplasty procedures in outpatient surgery centers using data from the Internet Based Quality Assurance Program (IBQAP).

METHODS

IBQAP data from 2001 to 2011 were queried retrospectively to identify abdominoplasty cases and VTE cases. Patient- and procedure-specific variables were analyzed to identify potential predictors of VTE in abdominoplasty.

RESULTS

Among all outpatient aesthetic surgery cases entered from 2001 to 2011, 414 resulted in VTE, representing a VTE incidence of 0.02%. Of these, 240 (58%) occurred in abdominoplasty cases. Predictors of VTE were age greater than 40 years and BMI greater than 25 kg/m2. Patient sex, duration of anesthesia and surgery, type of anesthesia, type of additional procedure, and number of procedures did not appear to influence the risk of VTE. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which would not be an indication for chemoprophylaxis according to current recommendations.

CONCLUSIONS

Many factors must be considered when determining the true incidence of VTE in abdominoplasty. Research is needed to discover the reason abdominoplasty carries a greater risk compared with other aesthetic surgery procedures so that appropriate steps can be taken to prevent its occurrence and improve the safety of the procedure.

Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice Trends

BACKGROUND

Oral contraceptive pills (OCPs) are currently used by approximately 16% of all women aged 15 to 44 in the United States and have been used by 80% of all sexually active women at some point in their lives. However, no guidelines exist for discontinuation of OCP therapy before or after elective cosmetic surgery.

OBJECTIVES

The aim of this study is to establish current practice trends regarding perioperative OCP management in aesthetic surgery.

METHODS

An eight-item online survey was distributed to members of the American Society of Plastic Surgeons (ASPS). Survey results were analyzed to determine if surgeons' practice setting, years of experience, annual cosmetic volume, or types of cosmetic procedures performed affected their perioperative management of OCPs.

RESULTS

A total of 220 questionnaires were collected (11.9% response rate). Only 31.8% of surgeons reported any discontinuation of OCPs pre- or postoperatively. Among physicians, 7.3% reported only preoperative discontinuation, 24.5% reported OCP discontinuation both pre- and postoperatively, and 0.0% of physicians reported discontinuation of OCPs only postoperatively. There was no statistically significant difference between the percentage of surgeons in academic practice who discontinue OCPs perioperatively (P = 0.335). There was no statistical significance towards overall years in practice (P = 0.152). There were no significant differences between the three groups in the number of cosmetic procedures performed annually or percentage breakdown of procedures performed.

CONCLUSIONS

Despite OCP therapy being a known risk factor for venous thromboembolic events, a majority of surgeons performing cosmetic surgery do not routinely recommend perioperative cessation.

Strategies for Reducing Fatal Complications in Liposuction

BACKGROUND

Liposuction has become one of the most common cosmetic surgical procedures, and severe complications secondary to this procedure have also increased significantly. That is why we carry out a research work to know the most frequent severe complications reported in the scientific literature to indicate criteria for prevention.

METHODS

English-language scientific publications about liposuction and its complications were analyzed using the PubMed.gov, from the beginning of PubMed's history through June 10, 2017. Five terms were used to define liposuction and its complications: "liposuction," "liposuction AND complications," liposuction AND major complications," "liposuction AND complications AND death," and "liposuction AND death." The quantities of results for the 5 phrases were analyzed, along with their contents.

RESULTS

One thousand sixty-three results were obtained from 1973 through June 10, 2017 for the phrase "Liposuction and Complications" in humans; for "Liposuction and Major Complications," 153 articles were found; for "Liposuction and Deaths," 89 articles were found; and 42 articles were obtained with the terms "Liposuction and Major Complications and Deaths." After final depuration, all those that were not specific to severe liposuction complications were eliminated, leaving a total of 39 articles that were included in our study. Five problems proved to be the most serious complications when performing liposuction: Thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion.

CONCLUSIONS

The 5 most important complications that can cause death in liposuction are easily preventable using simple measures and proper safety protocols that are described in this work.

Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients

Background

Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties.

Objectives

This study analyzed the risk factors for VTE in cosmetic surgical procedures.

Methods

A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.

Results

A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%).

Conclusions

The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Caprini Scores, Risk Stratification, and Rivaroxaban in Plastic Surgery: Time to Reconsider Our Strategy

Limited data are available regarding the pathophysiology of venous thromboembolism in plastic surgery patients. In an effort to identify patients at greater risk, some investigators promote individual risk assessment using Caprini scores. However, these scores do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false positive rate). Caprini scores make many body contouring patients candidates for chemoprophylaxis, an intervention that introduces risks related to anticoagulation. Caprini has financial conflicts with several companies that manufacture products such as enoxaparin, commonly used for chemoprophylaxis. Rivaroxaban, taken orally, has been used by some plastic surgeons as an alternative to enoxaparin injections. However, this medication is not United States Food and Drug Administration approved for venous thromboembolism prophylaxis in plastic surgery patients, and a reversal agent is unavailable. This article challenges the prevailing wisdom regarding individual risk stratification and chemoprophylaxis. Alternative methods to reduce risk for all patients include safer anesthesia methods and Doppler ultrasound surveillance. Clinical findings alone are unreliable in diagnosing deep venous thromboses. Only by using a reliable diagnostic tool such as Doppler ultrasound are we able to learn more about the natural history of this problem in our patients. Such knowledge is likely to better inform our treatment recommendations.

Analysis of the American Society of Anesthesiologists Physical Status Classification System and Caprini Risk Assessment Model in Predicting Venous Thromboembolic Outcomes in Plastic Surgery Patients

BACKGROUND

Venous thromboembolism (VTE) can be a fatal outcome of plastic surgery. Risk assessment models attempt to determine a patient's risk, yet few studies have compared different models in plastic surgery patients.

OBJECTIVE

The authors investigated preoperative ASA physical status and 2005 Caprini scores to determine which model was more predictive of VTE.

METHODS

A retrospective chart review examined 1801 patients undergoing contouring and reconstructive procedures from January 2008 to January 2012. Patients were grouped into risk tiers for ASA scores (1-2 = low, 3+ = high) with 2 cutoffs for Caprini scores (1-4 = low, 5+ high; 1-5 = low, 6+ = high), then re-stratified into 3 tiers using Caprini score cutoffs (1-4 = low, 5-8 = high, 9+ = highest; 1-5 = low, 6-8 = high, 9+ = highest). Median scores of VTE patients were compared to those without VTE. Odds ratio and chi-squared analyses were performed.

RESULTS

Of the 1598 patients included in the study, 1.50% developed VTE. Median ASA scores differed significantly between comparison groups but Caprini scores did not vary regardless of cutoff. When examining the 2-tiered Caprini scores, using low risk = 1-5 showed a significant relationship between risk tier and DVT development (P = 0.0266).

CONCLUSION

The ASA system yielded the highest odds ratio of VTE development between low and high-risk patients. The Caprini model captured more patients with VTE in its high-risk category. Combining the two models for a more heuristic approach to preoperative care may identify patients at higher risk.

LEVEL OF EVIDENCE

4 Risk.

Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients

BACKGROUND

Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies.

OBJECTIVES

This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures.

METHODS

A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility.

RESULTS

Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥ 25 (relative risk 2.8) increased infection risk.

CONCLUSIONS

Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥ 25, and combined procedures are independent risk factors. LEVEL OF EVIDENCE 2: Risk.

Method of Breast Reconstruction Determines Venous Thromboembolism Risk Better Than Current Prediction Models

Background:

Venous thromboembolism (VTE) risk models including the Davison risk score and the 2005 Caprini risk assessment model have been validated in plastic surgery patients. However, their utility and predictive value in breast reconstruction has not been well described. We sought to determine the utility of current VTE risk models in this population and the VTE rate observed in various methods of breast reconstruction.

Methods:

A retrospective review of breast reconstructions by a single surgeon was performed. One hundred consecutive transverse rectus abdominis myocutaneous (TRAM) patients, 100 consecutive implant patients, and 100 consecutive latissimus dorsi patients were identified over a 10-year period. Patient demographics and presence of symptomatic VTE were collected. 2005 Caprini risk scores and Davison risk scores were calculated for each patient.

Results:

The TRAM reconstruction group was found to have a higher VTE rate (6%) than the implant (0%) and latissimus (0%) reconstruction groups (P < 0.01). Mean Davison risk scores and 2005 Caprini scores were similar across all reconstruction groups (P > 0.1). The vast majority of patients were stratified as high risk (87.3%) by the VTE risk models. However, only TRAM reconstruction patients demonstrated significant VTE risk.

Conclusions:

TRAM reconstruction appears to have a significantly higher risk of VTE than both implant and latissimus reconstruction. Current risk models do not effectively stratify breast reconstruction patients at risk for VTE. The method of breast reconstruction appears to have a significant role in patients’ VTE risk.

Ultrasound screening for deep venous thrombosis detection: a prospective evaluation of 200 plastic surgery outpatients

Background:

Our understanding of the pathophysiology of venous thromboembolism is largely based on the experience of orthopedic patients undergoing total joint replacement. Little is known regarding the natural history of venous thromboembolism in plastic surgery outpatients. Today, ultrasound screening, including compression and Doppler color flow imaging, represents the standard for detecting deep venous thromboses.

Methods:

Ultrasound screening was offered to 200 consecutive plastic surgery outpatients undergoing 205 operations. Patients were scanned before surgery, on the day after surgery, and approximately 1 week after surgery. No patient declined to participate (inclusion rate, 100%). Spontaneous breathing, Avoid gas, Face up, Extremities mobile anesthesia was used, with no chemoprophylaxis. Patient surveys were administered.

Results:

Six hundred ultrasound screening tests were performed. All scans performed the day after surgery were negative. Only one examination was positive, 8 days after a lipoabdominoplasty. Subsequent scans revealed complete resolution of the thrombosis with anticoagulation. Ninety percent of surveyed patients would choose to have ultrasound screening in the future.

Conclusions:

The natural history of thromboembolism in plastic surgery outpatients differs from orthopedic patients. The risk of a deep venous thrombosis in a patient treated with Spontaneous breathing, Avoid gas, Face up, Extremities mobile anesthesia is approximately 0.5%. Thromboses are unlikely to develop intraoperatively. In the single affected patient, the thrombosis was located distally, in a location that is less prone to embolism and highly susceptible to anticoagulation. Ultrasound screening is an effective and highly feasible method to identify affected patients for treatment.

Venous Thromboembolism-Incidence of Deep Venous Thrombosis and Pulmonary Embolism in Patients with Head and Neck Cancer: A Tertiary Care Experience in Pakistan

Introduction Although venous thromboembolism (VTE) is seen with morbidity and mortality in various surgical specialties, scarce data are available in the head and neck surgery domain.

Objective We aim to determine the incidence of VTE in patients receiving surgery for head and neck cancer.

Methods Four hundred thirteen patients who underwent head and neck surgery procedures between 2005 and 2013 were reviewed retrospectively. All patients with head and neck surgery had received thromboprophylaxis (i.e., compression stockings and subcutaneous heparin). Patient demographics, operating time, and length of hospital stay were analyzed. The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) during the initial postoperative hospitalization was assessed.

Results Twelve patients were identified who developed VTE. Three patients developed DVT, and nine developed PE. The incidence of DVT and PE was 0.72 and 2.17%, respectively. Interestingly, all of these patients had undergone excision of extensive head and neck cancers accompanied by a reconstructive procedure. Patients who developed PE had a longer hospital stay compared with those who only had DVT. There were overall three mortalities in the nine patients who developed PE.

Conclusion Although VTE has a low incidence, it is a known complication of extensive head and neck surgeries with life-threatening outcomes. We recommend early mobilization and physiotherapy with the possible aid from appropriate mechanical and pharmacologic thromboprophylaxis.

Doppler ultrasound imaging for detection of deep vein thrombosis in plastic surgery outpatients: a prospective controlled study

BACKGROUND

Venous thromboembolism is a serious surgical complication. Risk stratification does not reliably predict which patients will be affected, and anticoagulants introduce additional risks. The Doppler ultrasound scan is the definitive test for the detection of deep vein thrombosis.

OBJECTIVES

This prospective, controlled study was undertaken to determine the feasibility of Doppler ultrasound imaging as a screening tool for deep vein thromboses in plastic surgery outpatients.

METHODS

Doppler ultrasound screening was offered to 100 consecutive outpatients undergoing a variety of cosmetic plastic surgeries. Total intravenous anesthesia was administered by propofol infusion, and a laryngeal mask airway was inserted. SAFE (spontaneous breathing, avoid gas, face up, and extremities mobile) principles were observed. No patient received anticoagulants. Ultrasound scans were performed before surgery, 1 day after surgery, and approximately 1 week after surgery. Deep veins of the lower extremities, including the calf veins, were analyzed by compression, color Doppler imaging, and Doppler waveform analyses. Twenty-five control participants who did not undergo surgery were evaluated with ultrasonography. A survey was administered to all participants after the scans.

RESULTS

No thromboses were detected in the outpatient or control group. Few survey respondents reported discomfort during the scan, and most indicated that ultrasound scans are a valuable screening tool for blood clots.

CONCLUSIONS

Doppler ultrasound imaging of the lower extremities is a valuable, noninvasive method for detecting deep venous thromboses in plastic surgery outpatients. Additional study of this modality is warranted. LEVEL OF EVIDENCE 2: Diagnostic.

Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored.

AIM

The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery.

METHODS

A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005-2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case's length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores.

RESULTS

VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings.

CONCLUSIONS

This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.

The Case against Chemoprophylaxis for Venous Thromboembolism Prevention and the Rationale for SAFE Anesthesia

SUMMARY

The Venous Thromboembolism Prevention study concludes that anticoagulation is effective in reducing the risk of thromboembolism in patients who are identified as higher risk by Caprini scores. This report critically assesses the statistics used in the Venous Thromboembolism Prevention study, its method of data presentation, and its conclusions. The usefulness of risk stratification and the value of anticoagulation-both prevailing concepts in risk reduction today-are challenged. Actual data show that chemoprophylaxis has no proven benefit in plastic surgery. Complications of anticoagulation predictably include excessive bleeding and hematomas, which may be serious and life-threatening. Several large published series of patients undergoing elective plastic surgery under total intravenous anesthesia have shown a much reduced risk of thromboembolism. A SAFE (Spontaneous breathing, Avoid gas, Face up, Extremities mobile) anesthesia method is discussed as a safer and more effective alternative to traditional general endotracheal anesthesia and anticoagulation. The choice for plastic surgeons is not between a venous thromboembolism and a hematoma. The choice is between a thromboembolism and adjusting our anesthesia and surgery habits to reduce the risk to a baseline level.

Deep venous thrombosis: prevention and management

This article summarizes current information on the risk and the assessment of risks for deep venous thrombosis (DVT) resulting from plastic surgery procedures. Risk assessment is the foundation for recommended methods of prevention of DVT and, in turn, possible pulmonary emboli. If prevention fails, treatment of DVT is required to avoid the major complication of pulmonary emboli. The significant risk of DVT and pulmonary emboli after an abdominoplasty is confirmed in this article.

Venous thromboembolism after facelift surgery under local anesthesia: results of a multicenter survey

BACKGROUND

Venous thromboembolism (VTE) is a serious complication of cosmetic surgery, and studies have suggested that the incidence is not insignificant in facelift surgery. Use of local anesthesia over general anesthesia and shorter operative times are probable contributing factors to lower VTE incidence. Because there have been no large-scale assessments of VTE in facelifts as such, we investigated VTE incidence and relevant factors in facelift surgeries performed under local anesthesia only.

METHODS

We conducted a retrospective multicenter survey of facelift surgeons who utilize the American Society of Anesthesiologists level 1 oral anxiolysis and local diluted lidocaine anesthesia technique. Anonymous online surveys were sent to surgeons with questions regarding facelifts performed and VTE incidence over the previous 19 months.

RESULTS

Seventy-seven surgeons (93 % response rate) completed the survey, with 74 eligible surgeons reporting at least one facelift. Respondents reported five VTE events, for an overall VTE incidence of 1 event in 5,844 surgeries. Surgeons who reported performing facelifts at high volumes (>500 facelifts in 19 months) had a significantly lower VTE incidence than lower-volume surgeons (p = 0.011). High-volume surgeons also reported a significantly lower average operative time (p = 0.016), but for surgeries that did or did not result in VTE, there was no significant difference between surgeon-reported average operative times.

CONCLUSION

The low VTE incidence in this facelift series supports prior understanding that there is a low risk of VTE in surgery performed under local anesthesia and in surgery with shorter operative times. Limiting ancillary procedures to the face likely reduces operative time and likely also contributes to a lower VTE rate. The data further suggest that physicians performing facelifts more frequently tend to have shorter average operative times and overall lower VTE incidence.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prevention of perioperative and anesthesia-related complications in facial cosmetic surgery

Although office-based anesthesia for facial cosmetic surgery remains remarkably safe, no anesthesia or sedation performed outside the operating room should be considered minor. Proper organization, preparation, and patient selection, close collaboration with the surgeon, and expert and effective anesthesia care will increase patient safety and improve perioperative outcomes and patient satisfaction. This article presents a comprehensive overview of anesthesia in terms of facial plastic surgery procedures, beginning with a broad review of essentials and pitfalls of anesthesia, followed by details of specific anesthetic agents, their administration, mechanism of action, and complications.

Chemoprophylaxis for venous thromboembolism prevention: concerns regarding efficacy and ethics

SUMMARY

Chemoprophylaxis has been recommended for plastic surgery patients judged to be at increased risk for venous thromboembolism. Several investigators have encountered this complication in patients despite anticoagulation therapy. An increased rate of complications related to postoperative bleeding has been reported. This article examines the efficacy and safety of this intervention, along with ethical considerations, in an attempt to determine whether any benefits of chemoprophylaxis justify the additional risks. The statistical methods and conclusion of the Venous Thromboembolism Prevention Study are challenged. Other preventative measures that do not cause negative side effects are discussed as safer alternatives.

Facelift complications and the risk of venous thromboembolism: a single center's experience

BACKGROUND

The number of facelifts performed in the United States has steadily increased over the past decade. Moreover, the risk of venous thromboembolism in plastic surgery has been established in recent studies.

OBJECTIVES

The authors investigate the overall complication rate in a single-center series to identify risk factors and determine the risk of venous thromboembolism.

METHODS

A retrospective chart review was performed for patients who underwent a facelift procedure at a private clinic in Atlanta, Georgia, between January 2004 and December 2010. A total of 630 patients were included. The data collected included patient demographics, comorbidities, body mass index, smoking history, operative time, and concurrent procedures. All postoperative complications were recorded.

RESULTS

The mean age of the patients in this series was 58.4±7.3 years. A small percentage of the patients were men (8.1%); 23.2% had hypertension; 4.9% were smokers; and 3.5% had a history of taking prophylactic aspirin. The mean operative time was 255.6±81.6 minutes. Almost a quarter (23.6%) of the patients underwent concurrent procedures. There were 38 complications, including 29 hematomas, two deep vein thromboses (DVTs), two eye infections, two instances of partial skin loss, and one ectropion. Risk of complications was significantly higher in men, patients over 55, and those with a body mass index>30 kg/m2. The risk of hematoma was higher (P<.05) in men, patients over 55, those with a history of hypertension, and those taking aspirin. The risk of DVT increased when the procedure time was longer than five hours. Both patients who developed DVT had undergone a facelift in combination with another procedure. There was also an increase in the risk of complications when the facelift was combined with two or more procedures.

CONCLUSIONS

Identifying various risk factors for complications, especially DVT, can help to minimize those factors in the postoperative period and treat complications effectively when they occur. The data indicate that the number of concurrent procedures is a specific risk factor for development of DVT, so care should be taken when planning for multiple treatment sites. Combining facelift with other procedures also increases the risk of complications, especially DVT.

LEVEL OF EVIDENCE

4.

Venous thromboembolism in abdominoplasty: a comprehensive approach to lower procedural risk

BACKGROUND

Venous thromboembolism (VTE) is a serious and potentially life-threatening surgical complication. However, there is little consensus regarding appropriate VTE prophylaxis for plastic surgery patients. Risk factors as they apply to plastic surgery patients are unclear, and recent recommendations for chemoprophylaxis in these patients may expose them to other additional risks.

OBJECTIVES

The authors examine perioperative and intraoperative measures, specifically those that have enabled a large number of patients to undergo outpatient abdominoplasty safely, with a reduced risk of VTE.

METHODS

A retrospective review was performed of 404 consecutive abdominoplasty patients who were treated at a single outpatient surgery center between 2000 and 2010. Graded compression stockings and intermittent pneumatic compression devices were placed on all patients, and perioperative and intraoperative warming was strictly applied. Progressive tension suturing technique was performed in all cases and drains were eliminated. All patients received pain pumps, ambulated within one hour of surgery, and were discharged home the same day. Patient VTE risk factors were scored with the Caprini/Davison risk assessment model (RAM). Perioperative and intraoperative measures were taken to reduce factors that may increase VTE risk in abdominoplasty. Complications were recorded, including VTE events, seromas, hematomas, and infections.

RESULTS

In this series, 247 abdominoplasty procedures were performed alone and 157 were combined with additional procedures. Under the RAM, 297 patients were considered "high risk" and 17 "highest risk." Abdominoplasty operative time was 100 ± 29 minutes. Only one case of deep vein thrombosis (DVT) occurred, in the calf.

CONCLUSIONS

A comprehensive approach to perioperative and intraoperative patient care has allowed outpatient abdominoplasty to be safely performed without VTE chemoprophylaxis in patients with fewer than six risk factors.

Management of hypertension in the facelift patient: results of a national consensus survey

INTRODUCTION

In the facelift patient, uncontrolled perioperative hypertension is a difficult, acute condition that can lead to significant complications. Although the treatment of hypertension in the ambulatory medical setting has been standardized, its management in the cosmetic surgery setting has been ambiguous.

OBJECTIVES

The authors evaluate the results of a survey to assess current national trends in perioperative facelift hypertension management.

METHODS

A 13-question survey regarding perioperative hypertension management was sent by postal mail to 1776 members of the American Society for Aesthetic Plastic Surgery (ASAPS). Respondents were queried about their geographic location, caseload volume, facelift method, and hematoma rate.

RESULTS

A 35.4% response rate was attained (629 respondents). Superficial musculoaponeurotic system (SMAS) plication performed under general anesthesia as an outpatient procedure was the most common facelift technique. Perioperative blood pressure management was consistent among all respondents. Beta-blockers were commonly utilized throughout the preoperative period. Administration of alpha agonists was reported more frequently by surgeons with higher-volume caseloads and more years in practice. Reported hematoma rates did not vary with medication. Medical treatment at an intraoperative systolic blood pressure (SBP) threshold below 100 (p < .04) and a postoperative SBP of greater than 139 (p < .05) significantly increased reported hematoma rates.

CONCLUSIONS

The data generated from the survey suggest that the timing of treating hypertension deserves more attention than the actual medication administered. Proper perioperative care of the facelift patient is paramount in the reduction of hematoma rates. Preexisting hypertension correlates with a higher hematoma rate, though this study also suggests that normotensive anesthesia, as well as strict postoperative blood pressure control did contribute to a reduction in hematoma rate.