Plastic & Reconstructive Surgery:
Reducing Venous Thromboembolism Risk without Chemoprophylaxis
Swanson, Eric M.D.
Swanson Center, 11413 Ash Street, Leawood, Kans. 66211, firstname.lastname@example.org
Pannucci et al. retrospectively evaluated a multicenter database of 3334 inpatients who underwent a wide variety of predominantly reconstructive procedures under general endotracheal anesthesia.1 The authors point out that their analysis cannot be extrapolated to outpatients treated with other forms of anesthesia. Nevertheless, they aim to identify plastic surgery patients who are at a greater risk of venous thromboembolism and are therefore appropriate candidates for chemoprophylaxis. Surveys reveal that many plastic surgeons have not adopted prophylactic anticoagulation in their practices.2 Are they neglecting an important safety measure, or are they being wisely cautious?
Figure. No caption a...Image Tools
Let us take a few steps back before acceding to an intervention that has potentially harmful side effects. One of the four centers participating in the authors' study reported a 5 percent incidence of venous thromboembolism after abdominoplasty despite the use of enoxaparin in high-risk patients.3 Serious side effects were reported. Bleeding, hematomas, operating times, and blood transfusions were all significantly increased in patients who received enoxaparin. Increased bleeding is hardly a welcome alternative complication, and blood transfusions should rarely be necessary for cosmetic surgery patients. Postoperative anemia is a common cause of morbidity. Our goal should be to reduce this problem,4 not to exacerbate it. It is reasonable to consider a safer way of preventing postoperative thromboembolism.
Fortunately, a superior remedy is available. For decades, plastic surgeons have used general endotracheal anesthesia. Prone patient positioning with a pelvic bolster remains popular among surgeons performing liposuction. Total intravenous anesthesia without prone positioning (Fig. 1) offers a safer alternative.4 Plastic surgeons who do not use general endotracheal anesthesia for abdominoplasty report a very low incidence of venous thromboembolism.4,5 One experienced investigator reports never seeing a postoperative deep venous thrombosis in 4000 cases treated under intravenous sedation with no thromboembolism prophylaxis.5 This reduced risk extends to face lifts as well.5 In the absence of muscle relaxants, sympathetic tone to the leg veins is preserved,4,5 avoiding a decrease in peripheral vascular resistance and thereby removing a risk factor for deep venous thrombosis.3 Avoidance of prone positioning eliminates this source of pelvic pressure, which might inhibit venous return from the lower extremities, increasing the risk of deep venous thrombosis.3 Effective local anesthetic and epinephrine infusion of the tissues decrease blood loss and operating time,4 thereby minimizing another risk factor.1 Recovery time is shortened,4 allowing earlier ambulation. Other benefits include eliminating the risk of malignant hyperthermia. Negative inotropy from anesthetic gas and ventilator-induced respiratory alkalosis (causing hypokalemia6) are averted. As an additional safety measure, higher risk belt lipectomies3 may be staged in massive weight loss patients, who are likely to require more than one operation anyway.
The benefit of an intervention must clearly outweigh its risk. If the incidence of deep venous thrombosis is 1 percent or less after abdominoplasty,4,5 the balance is unlikely to favor the intervention. Prevention of venous stasis is undeniably the most effective form of prophylaxis; dissolving a clot in progress is arguably therapeutic rather than truly prophylactic. It is risky to rely on numerical scores derived from a large group of disparate patients and procedures, influenced by numerous confounding variables, such as a cancer history, which is a risk factor in itself.1 Similarly, widely referenced guidelines published by the American College of Chest Physicians are based on an entirely different population of patients, disease processes, and operations, making them inapplicable to predominantly healthy plastic surgery outpatients.2
By adopting safer (“goldilocks”4) anesthesia and intraoperative positioning, we may reduce the risk of venous thromboembolism, possibly closer to the baseline risk, and minimize the need for chemoprophylaxis, which may still be added in selected individuals. The remedy may call for a change in some entrenched habits. The seriousness of this complication would seem to provide sufficient justification.
Eric Swanson, M.D.
Swanson Center, 11413 Ash Street, Leawood, Kans. 66211, email@example.com
The author has no financial interest to declare in relation to the content of this communication. There was no outside funding for this study.
1. Pannucci CJ, Barta RJ, Portschy PR, et al.. Assessment of postoperative venous thromboembolism risk in plastic surgery patients using the 2005 and 2010 Caprini Risk score. Plast Reconstr Surg. 2012;130:343–353.
2. Clavijo-Alvarez JA, Pannucci CJ, Oppenheimer AJ, Wilkins EG, Rubin JP. Prevention of venous thromboembolism in body contouring surgery: A national survey of 596 ASPS surgeons. Ann Plast Surg. 2011;66:228–232.
3. Hatef DA, Kenkel JM, Nguyen MQ, et al.. Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg. 2008;122:269–279.
4. Swanson E. Prospective study of lidocaine, bupivacaine and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702–722.
5. Mustoe TA, Buck DW II, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg. 2010;126:165e–176e.
6. Lipschitz AH, Kenkel JM, Luby M, Sorokin E, Rohrich RJ, Brown SA. Electrolyte and plasma enzyme analyses during large-volume liposuction. Plast Reconstr Surg. 2004;114:766–775; discussion 776–777.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
©2013American Society of Plastic Surgeons
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.
David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, firstname.lastname@example.org
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read