Complications and Risks Associated with the Different Types of Abdominoplasties: An Analysis of 55,956 Patients

BACKGROUND

Different types of abdominoplasties have been developed to address individual patient characteristics. However, complication rates and risk factors for complications between different types of abdominoplasties has yet to be reported.

OBJECTIVES

The aim of this study was to evaluate the complication rates and risks associated with each type of abdominoplasty.

METHODS

Using the CosmetAssure database, patients undergoing an abdominoplasty from 2015 to 2022 were identified. Demographic factors and major complications were recorded and analyzed using a chi-square test or ANOVA. A logistic regression was performed to identify the risk associated with each type of abdominoplasty for developing complications.

RESULTS

A total of 55,596 patients underwent an abdominoplasty procedure by any method. The overall complication rate was 2.1%. There was a significant difference in the overall complication rate between all seven types of abdominoplasties (p<0.05), with Fleur-de-lis abdominoplasty having the highest complication rate. The year of surgery, being underweight or morbidly obese, diabetes, and being male placed patients at a significantly higher risk for developing a post-operative complication. Over 15,000 patients (27.2%) had concurrent procedures related to breast surgery, other body contouring, liposuction, or facial surgery. When accounting for various risk factors in a regression model, there was no significant added risk for major complications after a combination procedure with an abdominoplasty compared to abdominoplasty alone.

CONCLUSIONS

Among the different types of abdominoplasties, a Fleur-de-lis abdominoplasty has the highest complication rate. Concurrent cosmetic procedures in addition to an abdominoplasty showed no added risk for major complications compared to abdominoplasty alone.

Preoperative Risk Factors and Complication Rates of Breast Augmentation With Fat Grafting

BACKGROUND

The current literature on the complications and risk factors of autologous fat grafting (AFG) for breast augmentation is scant and inconclusive.

OBJECTIVES

The aim of this study was to use a large, multicenter database to determine the major complications and risk factors of patients undergoing breast augmentation with AFG in comparison to breast augmentation with implants.

METHODS

Patients undergoing breast augmentation with AFG as well as with implants between January 2, 2017 and July 31, 2019 were identified from the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, BMI, smoking, diabetes, facility, ASA class, and anesthetic type were evaluated as risk factors.

RESULTS

Among the 76,128 patients enrolled in CosmetAssure, 789 (1.0%) underwent breast augmentation with AFG, in comparison to 18,544 (24.3%) patients with implants. The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectively. Infection was significantly higher in the AFG cohort (1.1% vs 0.5%). Tobacco users were more likely to have any complication, infection, and pulmonary dysfunction/hypoxia on univariate analysis. ASA Class III/IV was more likely to have any complication and infection. On multivariate analysis, smoking was an independent risk factor for any complication (relative risk = 17.1) and infection (relative risk = 20.2).

CONCLUSIONS

Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with AFG has a higher infection rate than augmentation with implants.

LEVEL OF EVIDENCE: 4

Surgical Site Infections in Aesthetic Surgery

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

The Protective Effect of Breast Implants in Penetrating Trauma

Level of Evidence: 5

The Effect of Smoking in the Cosmetic Surgery Population: Analysis of 129,007 Patients

Background

Smoking has been associated with several postoperative adverse outcomes across multiple surgical disciplines, but the literature is limited for aesthetic surgical procedures.

Objectives

To compare complication rates between smokers and nonsmokers undergoing common cosmetic procedures, identify specific cosmetic procedures where smoking increases the risk of complications, and evaluate smoking as an independent risk factor for major complications following aesthetic surgery.

Methods

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Smoking was evaluated as a risk factor for major complications requiring emergency room visit, hospital admission, or reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, gender, body mass index, type of surgical facility, type of procedure, and combined procedures.

Results

Of the 129,007 patients, 10,621 (8.2%) were smokers. All procedures examined, except breast augmentation, were more frequently performed in the nonsmoker cohort. Overall major complications were similar between smokers and nonsmokers (2.0% vs 1.9%, P = 0.57). In univariate analysis, surgical site infections (0.6% vs 0.5%, P = 0.04) were significantly higher among smokers, but suspected venous thromboembolism (0.2% vs 0.1%, P = 0.01) was significantly higher among nonsmokers. Notably, smokers had a higher risk of major complications after body procedures (2.9% vs 1.0%, P = 0.01), as well as thigh lifts (23.8% vs 3.6%, P < 0.01) and male breast surgery (3.7% vs 1.4%, P = 0.03). In multivariate analysis, smoking was found to be an independent predictor of surgical site infections (relative risk 1.61, P < 0.01).

Conclusions

Smoking is an independent risk factor of major surgical site infections following aesthetic surgery. Body procedures, as well as thigh lifts and male breast surgery, have higher complication rates in smokers.

Level of Evidence 2

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

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 Risk Factors for Major Hematomas in Aesthetic Surgery: Analysis of 129,007 Patients

BACKGROUND

Postoperative hematomas are one of the most frequent complications following aesthetic surgery. Identifying risk factors for hematoma has been limited by underpowered studies from single institution experiences.

OBJECTIVES

To examine the incidence and identify independent risk factors for postoperative hematomas following cosmetic surgery utilizing a prospective, multicenter database.

METHODS

A prospectively enrolled cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major hematomas requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis was used to identify potential risk factors for hematomas including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.

RESULTS

Of 129,007 patients, 1180 (0.91%) had a major hematoma. Mean age (42.0 ± 13.0 years vs 40.9 ± 13.9 years, P < 0.01) and BMI (24.5 ± 5.0 kg/m2 vs 24.3 ± 4.6 kg/m2, P < 0.01) were higher in patients with hematomas. Males suffered more hematomas than females (1.4% vs 0.9%, P < 0.01). Hematoma rates were higher in patients undergoing combined procedures compared to single procedures (1.1% vs 0.8%, P < 0.01), and breast procedures compared to body/extremity or face procedures (1.0% vs 0.8% vs 0.7%, P < 0.01). On multivariate analysis, independent predictors of hematoma included age (Relative Risk [RR] 1.01), male gender (RR 1.98), the procedure being performed in a hospital setting rather than an office-based setting (RR 1.68), combined procedures (RR 1.35), and breast procedures rather than the body/extremity and face procedures (RR 1.81).

CONCLUSIONS

Major hematoma is the most common complication following aesthetic surgery. Male patients and those undergoing breast or combined procedures have a significantly higher risk of developing hematomas.

LEVEL OF EVIDENCE

2.

Safety of Cosmetic Surgery in Adolescent Patients

Background

Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents.

Objectives

The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients.

Methods

A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.

Results

Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P < 0.01), lower mean body mass index (22.6 ± 4.1 vs 24.4 ± 4.6, P < 0.01), lower prevalence of diabetes (0.8% vs 1.9%, P <0.01), and fewer smokers (5.9% vs 8.3%, P < 0.01) compared to the older patient cohort. Most commonly adolescent patients underwent breast followed by face and body procedures. Overall adolescent patients demonstrated a lower incidence of major postoperative complications compared to older patients after single (0.6% vs 1.5%, P < 0.01) and combined (1.2% vs 3%, P = 0.03) cosmetic procedures. Adolescent patients had lower complications rates after face, breast, and body procedures compared to the older cohort. The most common postoperative complications in adolescent patients were hematoma (0.34%) and infection (0.28%).

Conclusions

Cosmetic surgical procedures in adolescent patients are safe with a lower rate of major postoperative complications compared to older patients.

Level of Evidence

2.

Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients

Background

Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts.

Objectives

The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study.

Methods

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

Results

A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications.

Conclusions

The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries.

Level of Evidence

2.

Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases

Background

Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging.

Objectives

To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures.

Methods

A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated.

Results

Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation-mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation-mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03).

Conclusions

Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications.

Level of Evidence

2.

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.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities

BACKGROUND

There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned.

OBJECTIVES

This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed.

RESULTS

Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01).

CONCLUSIONS

Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3.

Preoperative Risk Factors and Complication Rates of Thighplasty: Analysis of 1,493 Patients

BACKGROUND

Despite a rise in thighplasties, outcomes and risk factors have not been well described.

OBJECTIVES

This study investigated the incidence and risk factors of major complications following thighplasty in a large, prospective, multicenter database. It further evaluated the safety of combined procedures.

METHODS

Patients undergoing thighplasty between 2008 and 2013 were identified within the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 30 days postoperatively. Age, gender, body mass index, smoking, diabetes, type of facility, and combination procedures were evaluated as risk factors.

RESULTS

Among the 129,007 patients enrolled in CosmetAssure, 1493 (0.8%) underwent thighplasty. One thousand and eighty-eight (72.9%) thighplasties were combined with other procedures. Ninety-nine (6.6%) developed at least one complication. The most common complications were infection (2.7%), hematoma (2.1%), suspected venous thromboembolism (VTE) (1.1%), fluid overload (0.5%), and confirmed VTE (0.3%). Thighplasties performed in a hospital had higher complications (8.1%) than ambulatory surgical center (6.2%) and office-based surgical suite (3.1%). When thighplasty was performed alone, smoking was an independent risk factor to develop at least one complication (RR = 9.51) and hematoma (RR = 13.48). Compared to thighplasty alone, complication rate did not increase with the addition of concomitant procedures (4.7% vs 7.4%, P = .079).

CONCLUSION

Infection and hematoma are the most common major complications. In thighplasty alone, smoking is the only independent risk factor for overall complications and hematoma formation. The addition of concomitant cosmetic procedures does not increase complication rates.

LEVEL OF EVIDENCE

2 Risk.

Incidence and Risk Factors of Major Complications in Brachioplasty: Analysis of 2,294 Patients

BACKGROUND

Brachioplasty is a popular procedure to correct upper arm ptosis. However, current literature on complications and risk factors is scant and inconclusive.

OBJECTIVES

Using a large, prospective, multicenter database, we report the incidence of major complications and risk factors in patients undergoing brachioplasty.

METHODS

Patients who underwent brachioplasty between 2008 and 2013 were identified from the CosmetAssure (Birmingham, AL) database. The primary outcome was the occurrence of major complication(s), defined as complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Risk factors including age, gender, body mass index (BMI), smoking, diabetes, combined procedures, and type of surgical facility were evaluated using univariate and multivariate analysis.

RESULTS

Within the 129,007 patients enrolled in CosmetAssure, 2294 (1.8%) underwent brachioplasty. Brachioplasty patients were more likely to be older than 50 years (50.1%), obese (36.3%), diabetic (5.5%), but less likely smokers (5.5%). Major complications occurred in 3.4% brachioplasties with infection (1.7%) and hematoma (1.1%) being most common. Combined procedures, performed in 66.8% cases, had a complication rate of 4.4%, in comparison to 1.3% for brachioplasties performed alone. Combined procedures (RR = 3.58), males (RR = 3.44), and BMI ≥ 30 kg/m(2) (RR = 1.92) were identified as independent risk factors for the occurrence of any complication. Combined procedures (RR = 12.42), and the male gender (RR = 8.89) increased the risk of hematoma formation.

CONCLUSIONS

Complication rates from brachioplasty are much lower than previously reported. Hematoma and infection are the most common major complications. Combined procedures, male gender, and BMI ≥ 30 kg/m(2) are independent risk factors for complications. LEVEL OF EVIDENCE 2: Risk.

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients

BACKGROUND

Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results.

OBJECTIVES

This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database.

METHODS

A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility.

RESULTS

Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56).

CONCLUSIONS

Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Evaluation of Diabetes Mellitus as a Risk Factor for Major Complications in Patients Undergoing Aesthetic Surgery

BACKGROUND

Diabetes mellitus has been linked with a variety of perioperative adverse events across surgical disciplines. There is a paucity of studies systematically examining risk factors, including diabetes, and complications of aesthetic surgical procedures.

OBJECTIVES

The purpose of this study was to compare incidence and type of complications between diabetic and non-diabetic patients undergoing various aesthetic surgical procedures, to identify specific procedures where diabetes significantly increases risk of complications, and to study diabetes as an independent risk factor for major complications following aesthetic surgery.

METHODS

A prospective cohort of 129,007 patients who enrolled into the CosmetAssure insurance program and underwent cosmetic surgical procedures between May 2008 and May 2013 were reviewed. Diabetes was evaluated as risk factor for major complications, requiring hospital admission, emergency room visit, or a reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, smoking, obesity, gender, type of procedures, and surgical facility.

RESULTS

Overall, 2506 patients (1.9%) had a major complication. Diabetics had significantly more complications compared to non-diabetics (3.1% vs 1.9%, P < 0.01). In univariate analysis, infectious (1.1% vs 0.5%, P < 0.01) and pulmonary (0.3% vs 0.1%, P < 0.01) complications were significantly higher among diabetics. Notably, diabetics had higher risks of complication in body cases (4.3% vs 2.6%, P < 0.01) and specifically abdominoplasty (6.1% vs 3.0%, P < 0.01). In multivariate analysis, diabetes was found to be an independent risk factor of any complication (relative risk 1.31, P = 0.03) and infection (relative risk 1.70, P < 0.01).

CONCLUSIONS

Diabetes is an independent risk factor of major complications, particularly infection, after aesthetic surgical procedures.

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.

Safety of Cosmetic Procedures in Elderly and Octogenarian Patients

BACKGROUND

The proportion of elderly patients in North America is increasing. This has resulted in an increased number of elderly patients undergoing cosmetic procedures.

OBJECTIVES

The purpose of this study was to determine the incidence of postoperative complications in elderly patients (age ≥65) undergoing elective aesthetic plastic surgical procedures compared with younger patients.

METHODS

A total of 183,914 cosmetic surgical procedures were reviewed using the prospectively enrolled cohort of patients in the CosmetAssure database. Comorbidities and postoperative complications in elderly and younger patient groups were recorded and compared. A separate analysis of postoperative complications was performed in the octogenarian subgroup (age ≥80).

RESULTS

A total of 6786 elderly patients who underwent cosmetic procedures were included in the study. Mean ages (±standard deviation) in elderly and younger patients were 69.1 ± 4.1 and 39.2 ± 12.5 years, respectively. The elderly patient population had more men, a higher mean body mass index (BMI), a higher prevalence of diabetes mellitus (DM), and fewer smokers compared with the younger patients. The overall postoperative complication rate was not significantly different between elderly and younger patients. When stratified by type of cosmetic procedure, only abdominoplasty was associated with a higher postoperative complication rate in elderly compared with younger patients. The most common postoperative complications in elderly patients were hematoma and infection. The overall postoperative complication rate in octogenarians was 2.2%, which was not significantly different from the younger population.

CONCLUSIONS

Cosmetic procedures in elderly patients, including octogenarians, remain safe with an acceptable complication rate compared to younger patients.

Glucocorticoid rescue for late-phase acute respiratory distress syndrome in trauma/surgical critical care patients

High-dose glucocorticoid therapy (GCT) for the late fibroproliferative phase of acute respiratory distress syndrome (ARDS) is controversial and has shown mixed results in medical patients. No studies have evaluated GCT in trauma/surgical critical care patients. The purpose of this study is to review the outcomes of trauma/surgical critical care patients with refractory ARDS treated with GCT. From January 2001 through September 2005, a pharmacy log was used to identify critically ill trauma/surgical patients in refractory ARDS (7 males and 2 females) who received GCT in an attempt to salvage them. GCT consisted of 200 mg intravenous methylprednisolone bolus for one dose and then 3 mg/kg per day divided every 6 hours for 6 weeks or until weaned off the ventilator. All patients as well as the survivors were analyzed. Outcome data was analyzed with SPSS (Chicago, IL) and the paired sample test. A P value < or = 0.05 was considered significant. Data is presented as mean +/- standard deviation. The Institutional Review Board approved this retrospective chart review. Seven patients (6 males and 1 female; age, 31 +/- 16 years) survived (78%), weaned off of the ventilator, and were discharged from the hospital. The 2 deaths were secondary to refractory respiratory failure as well as cardiac arrest (n = 1) and anoxic brain injury from septic hypotension (n = 1). In survivors (n = 7), hospital length of stay (LOS) and intensive care unit LOS was 71 +/- 30 days and 53 +/- 16 days, respectively. Duration of GCT administration was 17 +/- 6.4 days (range, 11-30 days). Ventilator time before GCT, during GCT, and after GCT was 22 +/- 8.4, 15 +/- 7.5, and 1.6 +/- 6.0 days, respectively. During GCT, 8 patients developed pneumonia, 5 had urinary tract infection, and 3 had bacteremia. All infections were effectively treated with broad-spectrum antibiotics, except in one patient who died of sepsis. PaO2/FIO2 ratio just before and after GCT was 100 +/- 36 and 247 +/- 56, respectively (n = 7; P < 0.001). Sequential organ failure assessment score just before and after GCT was 9.1 +/- 2.3 and 5.0 +/- 1.6, respectively (n = 7; P < 0.001). GCT rescue may have a role in salvaging critically ill trauma/surgical critical care patients in late-stage ARDS. More patients, however, need to be studied.

Glucocorticoid Rescue for Late-Phase Acute Respiratory Distress Syndrome in Trauma/Surgical Critical Care Patients

High-dose glucocorticoid therapy (GCT) for the late fibroproliferative phase of acute respiratory distress syndrome (ARDS) is controversial and has shown mixed results in medical patients. No studies have evaluated GCT in trauma/surgical critical care patients. The purpose of this study is to review the outcomes of trauma/surgical critical care patients with refractory ARDS treated with GCT. From January 2001 through September 2005, a pharmacy log was used to identify critically ill trauma/surgical patients in refractory ARDS (7 males and 2 females) who received GCT in an attempt to salvage them. GCT consisted of 200 mg intravenous methylprednisolone bolus for one dose and then 3 mg/kg per day divided every 6 hours for 6 weeks or until weaned off the ventilator. All patients as well as the survivors were analyzed. Outcome data was analyzed with SPSS (Chicago, IL) and the paired sample test. A P value ≤0.05 was considered significant. Data is presented as mean ± standard deviation. The Institutional Review Board approved this retrospective chart review. Seven patients (6 males and 1 female; age, 31 ± 16 years) survived (78%), weaned off of the ventilator, and were discharged from the hospital. The 2 deaths were secondary to refractory respiratory failure as well as cardiac arrest (n = 1) and anoxic brain injury from septic hypotension (n = 1). In survivors (n = 7), hospital length of stay (LOS) and intensive care unit LOS was 71 ± 30 days and 53 ± 16 days, respectively. Duration of GCT administration was 17 ± 6.4 days (range, 11–30 days). Ventilator time before GCT, during GCT, and after GCT was 22 ± 8.4, 15 ± 7.5, and 1.6 ± 6.0 days, respectively. During GCT, 8 patients developed pneumonia, 5 had urinary tract infection, and 3 had bacteremia. All infections were effectively treated with broad-spectrum antibiotics, except in one patient who died of sepsis. PaO2/FIO2 ratio just before and after GCT was 100 ± 36 and 247 ± 56, respectively (n = 7; P < 0.001). Sequential organ failure assessment score just before and after GCT was 9.1 ± 2.3 and 5.0 ± 1.6, respectively (n = 7; P < 0.001). GCT rescue may have a role in salvaging critically ill trauma/surgical critical care patients in late-stage ARDS. More patients, however, need to be studied.

Development of sustained delivery system as a novel technique for tissue culture

One of the greatest advances for biomedical research has been the use of tissue culture to study the effects and the mode of action of various organic compounds. However, there are myriad problems associated with the classical approach to pharmaceutical studies in tissue culture, such as contamination, the logistical problems inherent in intermittent dosing, and near-lethal drug doses required to achieve effective physiological doses. This has given impetus to a search for better means of effective delivery routes in a tissue culture setting. The specific objectives of this investigation were: (1) to develop a ceramic delivery system for the novel purpose of releasing sustained levels of the anti-cancer drug combination inositol hexaphosphate (IP6) + inositol (I) in a tissue culture setting; (2) to assess the proliferation rate and viability of HTB 122 Intraductile Breast Cancer (IBC) cells exposed to sustained levels of IP6 + I compared to conventional means of drug delivery (dissolved in media); (3) to evaluate the morphological changes associated with this treatment process. Sterile aseptic techniques were employed during the entire study (72 hours of incubation). Data obtained from this investigation suggests the following: (1) TCPL delivery system can be utilized in the tissue culture setting to deliver IP6 + I in a sustained manner for 72 hours; (2) the use of IP6 + I at the physiological dose did not induce any significant change in the biochemical marker (MDA); (3) morphological evaluation of cells treated with sustained delivery resulted in cellular atrophy, as well as fragmentation, compared to the treatment by conventional means and to the sham group (empty capsule); and (4) regardless of route of administration, treatment with IP6 + I resulted in a decrease in total protein content compared to the sham capsules and control groups. In conclusion, this approach is a novel use of ceramic delivery systems in tissue culture that gives breakthrough information for basic research on limiting and eliminating contamination and the logistical problems associated with intermittent dosing in tissue culture.