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?
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, firstname.lastname@example.org
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.
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