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

Abdominal Fascial Plication and the Risk of Venous Thromboembolism in Abdominoplasty Patients: A Systematic Review of the Literature

BACKGROUND

Repair of the abdominal fascia at the time of abdominoplasty is a valuable method to improve the contour of the abdomen. However, this maneuver has been linked to an increased risk of venous thromboembolism (VTE). This review was undertaken to evaluate the evidence.

METHODS

An electronic literature review was conducted to identify publications on the subject of abdominal fascial repair during abdominoplasty and VTE risk. Key words included abdominoplasty, fascial plication, intra-abdominal pressure, and venous thrombosis.

RESULTS

Three large clinical studies were identified. One retrospective study using matched comparisons reported nearly identical VTE rates for patients treated with and without abdominal fascial plication (1.5% vs 1.7%). Another retrospective study reported significantly more VTEs (2.3%) in abdominoplasty patients undergoing fascial repair compared with panniculectomy patients who did not undergo fascial plication (0.36%). The author also recommended a modified Caprini score, adding fascial repair as a risk factor. Only 1 prospective study reported a large number of consecutive plastic surgery outpatients evaluated with Doppler ultrasound. This group included 188 abdominoplasty patients, all treated with fascial plication and without muscle paralysis. Only 1 VTE was diagnosed on the day after abdominoplasty (0.5%).

DISCUSSION

Retrospective studies are susceptible to confounders and confirmation bias. Caprini scores do not have a scientific foundation. Chemoprophylaxis increases the risk of bleeding without reducing the risk of VTE.

CONCLUSIONS

The best available evidence supports performing a fascial repair. An effective and safe alternative to Caprini scores and chemoprophylaxis is avoidance of muscle paralysis and early detection of VTEs using ultrasound screening.

An In-Depth Analysis of 1370 Consecutive Abdominoplasties: Fascial Plication Increases Risk of Venous Thromboembolism, and Scoring for Plication Improves the Caprini Risk Assessment Model

BACKGROUND

Venous thromboembolism (VTE) is the most dangerous complication of abdominoplasty. One relatively undefined risk factor is plication, which in theory increases VTE risk.

OBJECTIVES

The aim of this study was to assess the thromboembolic risk of plication.

METHODS

A retrospective review of 1370 consecutive abdominoplasties by 1 surgeon was undertaken. Two groups were considered, plicated (n = 1089) and nonplicated (n = 281) patients, and VTE rates were compared between these groups.

RESULTS

There were 25 of 1089 cases of VTE (2.3%) in plicated patients and 1 of 281 cases of VTE (0.36%) in nonplicated patients, which was statistically significant (Fisher's exact test, P = .028) despite the nonplicated group being a higher-risk population. Case-control matching yielded 225 pairs which differed statistically only by the presence or absence of plication; there were 12 of 225 (5.3%) VTE events in the plicated group and 0 of 225 in the nonplicated group (McNemar's test, P = .0015). Logistic regression demonstrated increased VTE risk with increasing age (odds ratio [OR] 1.08, P < .001), BMI (OR 1.34, P = .002), Caprini score (OR 2.17, P < .001), and especially plication (OR 16.76, P = .008). Adding 2 points for plication to Caprini scores offered better risk stratification at a level of 7, with an improved combination of sensitivity and specificity (0.31/0.98 vs 0.69/0.96) and a 27% improvement over the 2005 Caprini risk assessment model (RAM) in the area under a receiver operating characteristic curve (0.826 vs 0.651, Z value -3.596, P = .003).

CONCLUSIONS

Plication was shown to be a powerful risk factor for the development of VTE in abdominoplasty. Abdominal wall plication should be considered in risk assessment, and scoring for plication may improve the performance of the Caprini RAM.

LEVEL OF EVIDENCE: 3

The Preoperative Management of Oral Contraceptive Pills in Aesthetic Plastic Surgery Practice in Saudi Arabia

INTRODUCTION

Oral contraceptive pills (OCPs) are the most popular contraception method in Saudi Arabia due to their accessibility and reversibility. However, there is no recommendation to stop OCP medication before or after elective aesthetic surgery. The study involves identifying plastic surgeons' behaviors and current practices in perioperative OCPs management in aesthetic surgery in Saudi Arabia, which is the first of its kind.

METHODS

A validated self-administered survey was distributed in February 2022 among all board-certified plastic surgeons in Saudi Arabia via social media. The questionnaire was developed to gather information on the perioperative management of OCPs in aesthetic surgery.

RESULTS

A total of 46 board-certified plastic surgeons participated (overall response rate of 48.4%). Among the participants, 32 surgeons (69.6%) indicated that they instruct their patients to discontinue OCPs preoperatively. More than half of surgeons have instructed their patients to stop OCPs after plastic surgery (52.2%). Based on the three occupational characteristics of the surgeons, we found no significant associations between surgeons' practice patterns regarding OCP discontinuation preoperatively or postoperatively.

CONCLUSION

In light of the fact that OCPs are reported to pose a risk for venous thromboembolic events, our survey found that most aesthetic surgeons cease their use both preoperatively and postoperatively. There is a need for a guideline regarding perioperative measures for OCPs.

Venous Thromboembolism Prophylaxis in Plastic Surgery Patients Undergoing Facelift

Background

In 2011, the American Society of Plastic Surgeons approved the Venous Thromboembolism (VTE) Task Force Report, which recommended the use of the Caprini scoring system, which has been adopted for VTE prophylaxis by most surgical societies in America.

Objectives

The aim of this study is to investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing facelifts at a single institution who did not undergo VTE chemoprophylaxis based on the Caprini scoring system.

Methods

A retrospective chart review was conducted of patients who underwent facelift at a single institution. Patients were included if they were operated on between 2016 and 2021 by the lead surgeon and excluded if they received VTE prophylaxis. Descriptive statistics were conducted to analyze the collected data.

Results

In total, 136 patients were isolated after chart review, and no patients were found to have had DVT or VTE. The average Caprini score was 5.625 and ranged from 3 to 10. There were 3 patients with evidence of postoperative hematoma (Caprini score = 5, 5, 7). The overall hematoma percentage was 2.21%.

Conclusions

Based on the average Caprini score for the patients, all patients should have received VTE chemoprophylaxis. The authors found no VTE-related events in the patients without chemoprophylaxis. This study suggests that while the Caprini scoring system is a critical diagnostic tool for certain surgical procedures, it might not be optimal in predicting VTE in aesthetic patients undergoing surgical procedures.

Level of Evidence: 4

The risks and benefits of early venous thromboembolism prophylaxis after elective spinal surgery: A single-centre experience

BACKGROUND

There is a wide ranging incidence of venous thromboembolism after surgery and it continues to be a major cause of morbidity after spinal procedures.This study's aim was to investigate the relationship between timing and administration of venous thromboembolism (VTE) pharmacologic chemoprophylaxis after spinal surgery and the resulting VTE and bleeding complications by reviewing current practices and outcomes at a high-volume single institution to better define opportunities for perioperative intervention to prevent VTE without increasing bleeding complications.

METHODS

All patients who underwent elective one or two-stage lumbar spinal fusion procedures were identified. A logistic regression was used to evaluate (1) risk of symptomatic VTE within 30 days of surgery and (2) bleeding-related complications. The odds of developing a VTE as well as bleeding-related complications were compared among the three treatment groups: no chemoprophylaxis, chemoprophylaxis < 24h of surgery and chemoprophylaxis given > 24h post-surgery.

RESULTS

When adjusted for doses administered, the odds of developing a postoperative VTE within 30 days were 0.189 (95% confidence interval (0.044, 0.808)) in patients who received anticoagulation < 24h postoperatively, compared to those who received no anticoagulation (p = 0.025). There was no difference in bleeding rates.

CONCLUSION

Patients undergoing elective spinal surgery who received anticoagulation within 24h of the conclusion of their procedure had an 81% reduction in the odds of developing a deep vein thrombosis within 30 days with no significant difference in bleeding complications.

Prophylaxis of Venous Thromboembolism in Ankle and Foot Surgeries

Venous thromboembolism (VTE) is among the most feared complications by orthopedists both for due to its potentially lethal outcome and the uncertainties related to its prevention. Despite the vast literature on VTE prevention in major orthopedic surgeries, little is known about it in ankle and foot procedures. In orthopedics, adequate thromboprophylaxis requires a careful assessment of the thrombotic and hemorrhagic risks based on the procedure to be performed, as well as and knowledge on anticoagulant agents. The presentis review has the goal of assessing the risk of developingdiscusses VTE risk assessment, the modalities of thromboprophylaxis modalities, and the drugs used, with an emphasis on foot and ankle surgeries.

Distal Deep Vein Thrombosis Causing Pulmonary Embolism after Outpatient Plastic Surgery: A Case Report

A distal deep vein thrombosis is generally believed to be clinically unimportant because of a low incidence of pulmonary emboli. To the author’s knowledge, a symptomatic pulmonary embolism has not been reported in association with an isolated calf deep vein thrombosis in a plastic surgery outpatient. This case report provides the clinical details of a pulmonary embolism occurring after routine ultrasound detection of a distal deep vein thrombosis. Proximal deep venous thromboses originate in the calf and are dangerous because they frequently embolize. Ultrasound surveillance provides early detection of subclinical distal deep vein thromboses. Anticoagulation is initiated, suppressing propagation of the thrombosis to the deep veins of the thigh, and reducing the risk of a catastrophic pulmonary embolism.

The Effect of Sequential Compression Devices on Fibrinolysis in Plastic Surgery Outpatients: A Randomized Trial

BACKGROUND

Sequential compression devices are often considered a mainstay of prophylaxis against deep venous thromboses in surgical patients. The devices are believed to produce a milking action on the deep veins to prevent venous stasis. A systemic fibrinolytic effect has also been proposed, adding a second mechanism of action. The plasma levels of tissue plasminogen activator and plasminogen activator inhibitor-1 reflect fibrinolytic activity.

METHODS

A randomized trial was conducted among 50 consecutive plastic surgery outpatients undergoing cosmetic surgery performed by the author under total intravenous anesthesia and without paralysis. Patients were randomized to receive calf-length sequential compression devices or no sequential compression devices during surgery. Blood samples were obtained from the upper extremity preoperatively and at hourly intervals until the patient was discharged from the postanesthesia care unit. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels were measured. Ultrasound surveillance was used in all patients. There was no outside funding for the study.

RESULTS

All patients agreed to participate (inclusion rate, 100 percent). No patient developed clinical signs or ultrasound evidence of a deep venous thrombosis. There were no significant changes in tissue plasminogen activator levels or plasminogen activator inhibitor-1 levels from the preoperative measurements at any hourly interval and no differences in levels comparing patients treated with or without sequential compression devices.

CONCLUSIONS

No significant change in systemic fibrinolytic activity occurs during outpatient plastic surgery under total intravenous anesthesia. Sequential compression devices do not affect tissue plasminogen activator or plasminogen activator inhibitor-1 levels, suggesting no fibrinolytic benefit.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options

The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.

The Expanding Role of Diagnostic Ultrasound in Plastic Surgery

Supplemental Digital Content is available in the text.

Background:

Ultrasound in plastic surgery is quickly finding new applications. Ultrasound surveillance may replace ineffective individual risk stratification and chemoprophylaxis for deep venous thromboses. Abdominal penetration can be a catastrophic complication of liposuction. Preoperative screening for fascial defects may reduce risk. Limiting buttock fat injections to the subcutaneous plane is critical for patient safety, but it is difficult to know one’s injection plane.

Methods:

The author’s use of diagnostic ultrasound was evaluated from May 2017 to May 2018. Ultrasound scans were used routinely to detect deep venous thromboses. Patients undergoing abdominal liposuction and/or abdominoplasty were scanned for possible hernias. Other common applications included the evaluation of breast implants, breast masses, and seroma management. The device was used in surgery in 3 patients to assess the plane of buttock fat injection.

Results:

One thousand ultrasound scans were performed during the 1-year study period. A distal deep venous thrombosis was detected in 2 patients. In both cases, the thrombosis resolved within 1 month, confirmed by follow-up ultrasound scans. A lateral (tangential) fat injection method was shown to safely deposit fat above the gluteus maximus fascia.

Conclusions:

Ultrasound scans are highly accurate, noninvasive, and well-tolerated by patients. Some of these applications are likely to improve patient safety. Early detection of deep venous thromboses is possible. Unnecessary anticoagulation may be avoided. Subclinical abdominal defects may be detected. Ultrasound may be used in the office to evaluate breast implants, masses, and seromas. In surgery, this device confirms the level of buttock fat injection.

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.