Tracking surgical outcomes, including postoperative complications and unplanned hospital readmissions, is essential to promote informed decision-making and quality improvement efforts across surgical subspecialties.1 , 2 3 , 4 5
Despite a need for granular complications and readmissions data in aesthetic surgery, published studies are limited in their retrospective, single-center designs. To date, the incorporation of aesthetic surgery data into national databases has been limited. The Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database was established to provide a source of national data on aesthetic surgery outcomes with participation from surgeons across the United States.6–12 9 13 , 14
Given the relative paucity of large national databases on surgical complications and unplanned healthcare utilization in aesthetic surgery, the aim of this study was to use the TOPS database to characterize rates and predictors of surgical complications and unplanned health care use, including readmissions, emergency room visits, and returns to the operating room, across common aesthetic plastic surgery procedures.
PATIENTS AND METHODS
After institutional review board approval, the TOPS database was queried for all adult patients undergoing aesthetic plastic surgery procedures from 2008 to 2019. Deidentified data were collected for patients undergoing the top five most common aesthetic surgery procedures as defined by 2019 ASPS statistics,5
Demographics collected included age; race/ethnicity; sex; body mass index (BMI); and comorbidities including tobacco use, diabetes mellitus (DM), and American Society of Anesthesiologists (ASA) status. Practice characteristics examined included facility type, operative time, anesthetic provider and facility type, and the occurrence of more than one procedure within a single operation. Unplanned healthcare utilization was defined as unplanned hospital readmissions, unplanned emergency room (ER) visits, and unplanned returns to the operating room within 30 days of the index procedure. Perioperative complications examined included hematoma, seroma, wound disruption, surgical-site infection (SSI), need for intravenous (IV) or oral (PO) antibiotics, implant loss (for breast augmentation), blood transfusion, and deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30 days. Combined procedures were identified as procedures recorded on the same date with the same surgeon identification number in the TOPS database. Given that procedure logs in the TOPS database are entered for individual procedures and corresponding CPT codes, complications for combined procedures were recorded under the CPT code in which they were initially reported. All duplicates in the TOPS database were deleted, and variables with a high degree of missingness were excluded from the analysis. Operative times below 30 minutes or above 10 hours were regarded as invalid.
Outcomes of Interest
The primary outcome of interest was the incidence of unplanned healthcare utilization and surgical complications across common aesthetic procedures. Secondary outcomes included demographic and surgical factors associated with risk of unplanned emergency room visits, unplanned returns to the operating room, and unplanned readmissions across procedures. Finally, relative per-year reporting of selected procedures within the TOPS database was performed.
Statistical Analysis
Patient characteristics were summarized using mean and standard deviation, or frequency and percentage for continuous and categorical measures, respectively. Multivariate logistic regression was used to identify predictors of unplanned emergency room visits, hospital readmissions, and unplanned returns to the operating room. Selection of independent variables was based on their importance and relevance to the outcomes. Values of P < 0.05 were considered statistically significant. Analyses were conducted using R (R Foundation for Statistical Computing, Vienna, Austria), Microsoft Excel, and Microsoft Access.
RESULTS
A total of 214,504 procedures were identified in the TOPS database from 2008 to 2019, including 94,618 breast augmentations, 56,756 liposuction procedures, 29,797 blepharoplasties, 8387 rhinoplasties, and 24,946 abdominoplasties. Patient characteristics by procedure type are shown in Table 1 . Briefly, the majority (93.8%) of patients were female, with a mean age of 41.3 years and mean BMI of 24.5 kg/m2 . Comparing demographic characteristics across procedures, the highest proportion of a male patient population was seen in rhinoplasties (21.4%) and blepharoplasties (14.8%). On average, a younger patient population was found to undergo rhinoplasty (32.3 years) and breast augmentation (36.0 years), and BMI was higher among those undergoing liposuction (27.0 kg/m2 ) and abdominoplasty (27.0 kg/m2 ) compared with other studied procedures. The majority of patients were ASA class 1 (53.7%), with medical comorbidities relatively uncommon across the patient population, including current tobacco use (6.0%) and DM type 2 (1.1%) (Table 1 ).
Table 1. -
Demographic Characteristics across Procedures
All Procedures (%)
Breast Augmentation (%)
Liposuction (%)
Blepharoplasty (%)
Rhinoplasty (%)
Abdominoplasty (%)
No.
214,504
94,618
56,756
29,797
8387
24,946
Mean age ± SD, yr
41.3 ± 13.6
36.0 ± 11.4
43.1 ± 12.0
55.8 ± 11.9
32.3 ± 14.6
42.9 ± 11.0
Sex
Female
201,306 (93.8)
94,174 (99.5)
51,131 (90.1)
25,397 (85.2)
6594 (78.6)
24,010 (96.2)
Male
13,195 (6.2)
443 (0.5)
5624 (0.9)
4400 (14.8)
1792 (21.4)
936 (3.8)
Missing
3 (0.0)
1 (0.0)
1 (0.0)
0 (0.0)
1 (0.0)
0 (0.0)
Race/ethnicity
White
161,404 (75.3)
74,313 (78.5)
40,537 (71.4)
22,793 (76.5)
5654 (67.4)
18,107 (72.6)
Black/African American
8463 (4.0)
2149 (2.3)
4058 (7.2)
304 (1.0)
190 (2.3)
1762 (7.1)
Asian
8319 (3.4)
2751 (2.8)
2572 (2.8)
3074 (10.3)
467 (5.6)
455 (1.8)
Hispanic/Latino
17,542 (8.2)
7797 (8.2)
5096 (9.0)
1145 (3.8)
834 (9.9)
2670 (10.7)
Other/unknown
19,473 (9.1)
7959 (8.4)
5686 (10.0)
2515 (8.4)
1268 (15.1)
2045 (8.2)
BMI
No.
151,277
69,964
38,415
18,870
5256
18,772
Mean ± SD, kg/m2
24.5 ± 5.1
22.5 ± 3.9
27.0 ± 5.3
24.9 ± 5.0
22.6 ± 4.3
27.0 ± 5.3
Insurance status
Private insurance
11,627 (5.4)
2766 (2.9)
3012 (5.3)
2810 (9.4)
1017 (12.1)
2022 (8.1)
Medicaid
313 (0.2)
62 (0.1)
37 (0.1)
19 (0.1)
108 (1.3)
87 (0.4)
Medicare
1344 (0.6)
353 (0.4)
89 (0.2)
693 (2.3)
33 (0.4)
176 (0.7)
Self-pay
155,919 (72.7)
70,622 (74.6)
40,943 (72.1)
20,415 (68.5)
5187 (61.9)
18,752 (75.2)
Workers’ compensation
42 (0.0)
12 (0.0)
9 (0.0)
1 (0.0)
17 (0.2)
3 (0.0)
Other
2602 (1.2)
1373 (1.5)
668 (1.2)
235 (0.8)
109 (1.3)
217 (0.9)
Missing/unknown
47,735 (22.4)
20,494 (21.7)
13,244 (23.3)
6884 (23.1)
2224 (26.5)
4889 (19.6)
Tobacco use
Current
12,831 (6.0)
7792 (8.2)
2314 (4.0)
1358 (4.6)
310 (3.7)
1057 (4.2)
Former
11,618 (5.4)
4735 (5.0)
3038 (5.4)
1821 (6.1)
229 (2.7)
1795 (7.2)
Non–tobacco user
133,173 (62.1.5)
58,843 (62.2)
34,477 (60.7)
17,682 (59.3)
5184 (61.8)
16,987 (68.1)
Missing/unknown
56,882 (26.5)
23,248 (24.6)
16,927 (29.8)
8936 (30.0)
2664 (31.8)
5107 (20.5)
DM2
No
148,601 (69.3)
67,855 (71.7)
37,693 (66.4)
19,176 (64.4)
5391 (64.3)
18,486 (74.1)
Yes
2363 (1.1)
461 (0.5)
682 (1.2)
658 (2.2)
26 (0.3)
536 (2.1)
Missing/unknown
63,540 (29.6)
26,302 (27.8)
18,381 (32.4)
9963 (33.4)
2970 (35.4)
5924 (23.7)
ASA status
1
115,218 (53.7)
56,552 (59.8)
27,556 (48.6)
13,649 (45.8)
4826 (57.5)
12,635 (50.6)
2
42,629 (19.9)
14,410 (15.2)
13,460 (23.7)
7093 (23.8)
997 (11.9)
6669 (26.7)
3
1985 (0.9)
412 (0.4)
569 (1.0)
592 (2.0)
36 (0.4)
376 (15.1)
Other/unknown
54,672 (25.5)
23,244 (24.6^)
15,171 (26.7)
8463 (28.4)
2528 (30.1)
5264 (21.1)
Facility, anesthesia, and surgical characteristics across procedure types are shown in Table 2 . The majority of procedures were performed in an office or office-based surgery facility (45.9%) or an ambulatory surgery center (33.0%). Among the 18.6% of procedures performed at an acute care hospital, rhinoplasty (25.9%) and abdominoplasty (28.5%) were identified to be most common. Anesthesia was most commonly performed by an anesthesiologist (44.2%) or certified registered nurse anesthetist (39.4%), with general anesthesia performed in 77.2% of cases. The majority of cases were outpatient procedures (93.2%), with inpatient admissions most common for abdominoplasty (11.4%) and rhinoplasty (6.5%). Mean operative time was longer in abdominoplasty (201 minutes) and liposuction (170 minutes) procedures compared with blepharoplasty (157 minutes), rhinoplasty (145 minutes), and breast augmentation (99 minutes), Table 2 .
Table 2. -
Facility, Anesthesia, and Surgical Characteristics across Procedures
All Procedures (%)
Breast Augmentation (%)
Liposuction (%)
Blepharoplasty (%)
Rhinoplasty (%)
Abdominoplasty (%)
No.
214,504
94,618
56,756
29,797
8387
24,946
Facility type
Acute care (hospital)
39,884 (18.6)
15,866 (16.8)
9726 (17.1)
5016 (16.8)
2171 (25.9)
7105 (28.5)
Ambulatory surgery center
70,821 (33.0)
34,207 (36.2)
17,325 (30.5)
8675 (29.1)
2546 (30.4)
8068 (32.3)
Office/office-based surgery facility
98,468 (45.9)
42,177 (44.6)
28,261 (49.8)
15,328 (51.4)
3516 (41.9)
9186 (36.8)
Missing/unknown
5331 (2.5)
2368 (2.5)
1444 (2.5)
778 (2.6)
154 (1.8)
587 (2.4)
Mean operative time ± SD, min
134.0 ± 94.0
98.7 ± 71.9
170.0 ± 93.0
156.7 ± 108.3
144.6 ± 80.9
200.5 ± 87.8
Anesthesia provider
Anesthesiologist
94,886 (44.2)
43,105 (45.6)
23,562 (41.5)
11,871 (39.8)
4477 (53.4)
11,871 (47.6)
CRNA
84,485 (39.4)
42,325 (44.7)
19,834 (34.9)
8563 (28.7)
2573 (30.7)
11,190 (44.9)
Procedural surgeon
16,137 (7.5)
3836 (4.1)
6362 (11.2)
5068 (17.0)
444 (5.3)
427 (1.7)
RN
7299 (3.4)
1380 (1.5)
2923 (5.1)
2311 (7.8)
223 (2.7)
462 (1.9)
Other/unknown
11,697 (5.45)
3972 (4.2)
4075 (7.2)
1984 (6.7)
670 (8.0)
996 (4.0)
Anesthesia type
Conscious sedation
14,150 (6.6)
4389 (4.6)
4305 (7.6)
4192 (14.1)
396 (4.7)
868 (3.5)
General
165,487 (77.2)
79,602 (84.1)
41,049 (72.3)
15,528 (52.1)
6743 (80.4)
22,565 (90.5)
MAC
14,592 (6.8)
6164 (6.5)
3222 (5.7)
4202 (14.1)
470 (5.6)
534 (2.1)
Anesthetic block
1204 (0.6)
663 (0.7)
171 (0.3)
209 (0.7)
36 (0.4)
125 (0.5)
Tumescent
21,548 (10.1)
2103 (2.2)
15,693 (27.7)
874 (2.9)
69 (0.8)
2809 (11.3)
Other/unknown
16,960 (7.9)
5069 (5.4)
4231 (7.5)
5849 (19.6)
800 (9.5)
1011 (4.1)
Admission type,
Outpatient
199,833 (93.2)
90,029 (95.1)
52,733 (92.9)
27,981 (93.9)
7663 (91.4)
21,427 (86.0)
Inpatient
8721 (4.1)
2007 (2.1)
2376 (4.2)
943 (3.2)
544 (6.5)
2,851 (11.4)
Missing/unknown
5950 (2.8)
2582 (2.7)
1647 (2.9)
873 (2.9)
180 (2.1)
668 (2.7)
CRNA, certified registered nurse anesthetist; RN, registered nurse; MAC, monitored anesthesia care.
Incidence of 30-Day Postoperative Complications and Unplanned Health Care Use
Incidence of postoperative complications across procedure types is shown in Table 3 . Overall, the incidence of complications was low across procedure types, with a low overall incidence of seroma [n = 2444 (1.1%)], hematoma [n = 1522 (0.7%)], superficial wound complication [n = 1960 (0.9%)], deep wound complication [n = 403 (0.2%)], superficial SSI [n = 665 (0.3%)], deep SSI [n = 415 (0.2%)], need for IV [n = 353 (0.2%)] or PO antibiotics [n = 2127 (1.0%)], need for blood transfusion [n = 103 (0.05%)], and occurrence of a DVT/PE [n = 258 (0.1%)]. Among patients undergoing breast augmentation, risk of implant loss was 0.2% (n = 211). Comparing procedures, abdominoplasty was associated with the highest incidence of complications, although this incidence was less than 5% for all complications including seroma [n = 1010 (4.1%)], hematoma [n = 252 (1.0%)], superficial wound complication [n = 785 (3.2%)], deep wound complication [n = 185 (0.7%)], superficial SSI [n = 224 (0.9%)], deep SSI [n = 141 (0.6%)], need for IV [n = 115 (0.5%)] or PO antibiotics [n = 690 (2.8%)], need for blood transfusion [n = 47 (0.2%)], and DVT/PE ([n = 125 (0.5%)]. Unplanned health care use is shown in Table 3 , with an overall low incidence including unplanned hospital admissions [n = 728 (0.34%)], unplanned emergency room visits [n = 544 (0.25%)], and unplanned returns to the operating room [n = 1725 (0.80%)]. Comparing procedure types, incidence of unplanned hospital admission, ER visit, and return to the operating room was highest after abdominoplasty (1.2, 0.8, and 1.4%, respectively) (Table 3 ).
Table 3. -
Complication Incidence across Procedures
All Procedures (%)
Breast Augmentation (%)
Liposuction (%)
Blepharoplasty (%)
Rhinoplasty (%)
Abdominoplasty (%)
No.
214,504
94,618
56,756
29,797
8387
24,946
Seroma
2444 (1.1)
317 (0.3)
1030 (1.8)
82 (0.3)
5 (0.06)
1010 (4.1)
Hematoma
1522 (0.7)
779 (0.8)
246 (0.4)
232 (0.8)
13 (0.2)
252 (1.0)
Superficial wound disruption
1960 (0.9)
445 (0.5)
607 (1.1)
117 (0.4)
6 (0.1)
785 (3.2)
Deep wound disruption
403 (0.2)
83 (0.1)
123 (0.2)
6 (0.02)
6 (0.07)
185 (0.7)
Superficial SSI
665 (0.3)
134 (0.1)
234 (0.4)
56 (0.2)
17 (0.2)
224 (0.9)
Deep SSI
415 (0.2)
108 (0.1)
146 (0.3)
12 (0.04)
8 (0.1)
141 (0.6)
Need for IV antibiotics
353 (0.2)
105 (0.1)
118 (0.2)
11 (0.04)
4 (0.05)
115 (0.5)
Need for PO antibiotics
2127 (1.0)
575 (0.6)
696 (1.2)
124 (0.4)
42 (0.5)
690 (2.8)
Implant loss
N/A
211 (0.2)
N/A
N/A
N/A
N/A
Need for blood transfusion
103 (0.05)
11 (0.01)
45 (0.08)
0 (0.0)
0 (0.0)
47 (0.2)
DVT or pulmonary embolism
258 (0.1)
26 (0.03)
97 (0.2)
8 (0.03)
2 (0.02)
125 (0.5)
Unplanned hospital admission
728 (0.34)
147 (0.16)
248 (0.44)
33 (0.11)
9 (0.11)
291 (1.2)
Unplanned ER visit
544 (0.25)
123 (0.13)
191 (0.34)
18 (0.06)
4 (0.048)
208 (0.83)
Unplanned OR return
1725 (0.80)
903 (0.95)
275 (0.48)
172 (0.58)
21 (0.25)
354 (1.42)
Risk Factors for Unplanned ER Visits
Risk factors for unplanned ER visits are shown in Table 4 . After multivariate adjustment, independent risk factors for unplanned ER visits included higher BMI (OR, 1.06; 95% CI, 1.06 to 1.10; P = 0.001], black/African American race (versus white) (OR, 1.52; 95% CI, 1.07 to 2.10; P = 0.015), ASA class 2 (OR, 1.97; 95% CI, 1.58 to 2.45; P < 0.001) or 3 (OR, 2.94; 95% CI, 1.67 to 4.90; P < 0.001) statuses (versus ASA class 1), increasing operative time (OR, 1.0016; 95% CI, 1.0004 to 1.0026; P = 0.006), surgery at an acute care hospital (versus office-based surgery facility) (OR, 1.58; 95% CI, 1.23 to 2.02; P < 0.001), pursuit of abdominoplasty (versus breast augmentation) (OR, 2.52; 95% CI, 1.86 to 3.44; P < 0.001), and pursuit of a combined aesthetic procedure (OR, 1.69; 95% CI, 1.34 to 2.12; P < 0.001). Pursuit of blepharoplasty (versus breast augmentation) (OR, 0.20; 95% CI, 0.04 to 0.81; P < 0.001) was associated with lower risk. The Hosmer-Lemeshow test value gave a value of P = 0.520 (>0.05), indicating no evidence of poor fit of the regression model.
Table 4. -
Multivariate Logistic Regression Model Assessing Predictors of Unplanned ER Visits, Unplanned Hospital Admissions, and Unplanned Returns to the Operating Room after Breast Augmentation, Liposuction, Rhinoplasty, Blepharoplasty, and Abdominoplasty
Unplanned ER Visit
Unplanned Hospital Admission
Unplanned Return to OR
OR (95% CI)
P
OR (95% CI)
P
OR (95% CI)
P
Age
1.00 (0.99–1.01)
0.923
1.02 (1.01–1.03)
<0.001
1.01 (1.00–1.01)
0.015
BMI
1.06 (1.04–1.08)
<0.001
1.08 (1.06–1.10)
<0.001
1.02 (1.01–1.03)
0.001
Race/ethnicity
White (Ref)
Asian
0.39 (0.10–1.04)
0.110
1.14 (0.54–2.10)
0.695
0.68 (0.43–1.01)
0.074
Hispanic/Latino
0.72 (0.47–1.05)
0.100
0.62 (0.41–0.91)
0.019
0.76 (0.60–0.95)
0.019
Black/African American
1.52 (1.07–2.10)
0.015
1.20 (0.85–1.65)
0.280
0.87 (0.64–1.16)
0.354
Tobacco use
Non–tobacco user (Ref)
Former
1.11 (0.79–1.50)
0.537
1.14 (0.86–1.49)
0.334
1.33 (1.10–1.59)
0.002
Current
0.64 (0.39–0.99)
0.061
0.75 (0.48–1.12)
0.182
1.21 (0.99–1.46)
0.054
ASA status
1 (Ref)
2
1.97 (1.58–2.45)
<0.001
1.79 (1.47–2.17)
<0.001
1.54 (1.35–1.75)
<0.001
≥3
2.94 (1.67–4.90)
<0.001
1.65 (1.00–2.63)
0.042
1.20 (0.74–1.86)
0.424
DM2 (yes)
1.29 (0.74–2.10)
0.334
1.83 (1.24–2.64)
0.002
1.33 (0.91–1.87)
0.120
Operative time
1.002 (1.0004–1.003)
0.006
1.004 (1.003–1.005)
<0.001
OR 1.003(1.002–1.004)
<0.001
Facility type
Office-based surgery facility (Ref)
Ambulatory surgery center
1.02 (0.80–1.29)
0.884
1.13 (0.90–1.42)
0.281
0.92 (0.81–1.05)
0.220
Acute are (hospital)
1.58 (1.23–2.02)
<0.001
2.16 (1.73–2.69)
<0.001
1.02 (0.88–1.19)
0.765
Procedure type
Breast augmentation (Ref)
Liposuction
1.22 (0.90–1.67)
0.201
1.13 (0.85–1.52)
0.392
0.36 (0.30–0.43)
<0.001
Blepharoplasty
0.20 (0.10–0.39)
<0.001
0.33 (0.20–0.52)
<0.001
0.41 (0.32–0.51)
<0.001
Rhinoplasty
0.25 (0.04–0.81)
0.056
0.57 (0.20–1.26)
0.220
0.21 (0.11–0.36)
<0.001
Abdominoplasty
2.52 (1.86–3.44)
<0.001
2.45 (1.86–3.25)
<0.001
0.92 (0.77–1.08)
0.312
More than one type of procedure
1.69 (1.34–2.12)
<0.001
1.28 (1.04–1.56)
0.017
0.83 (0.72–0.96)
0.013
Ref, reference level; DM2, DM type 2.
Risk Factors for Unplanned Readmission
Risk factors for unplanned readmission are also shown in Table 4 . After multivariate adjustment, independent risk factors for unplanned readmission across studied procedures included age (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), BMI (OR, 1.08; 95% CI, 1.06 to 1.10; P < 0.001), ASA class 2 (OR, 1.79; 95% CI, 1.47 to 2.17; P < 0.001) status (versus ASA class 1), ASA class 3 (OR, 1.65; 95% CI, 1.00 to 2.63; P = 0.042) status (versus ASA class 1), DM (OR, 1.83; 95% CI, 1.24 to 2.64; P = 0.002), increasing operative time (OR, 1.004; 95% CI, 1.003 to 1.005; P < 0.001), surgery at an acute care hospital (OR, 2.16; 95% CI, 1.73 to 2.69; P < 0.001), pursuit of abdominoplasty (versus breast augmentation) (OR, 2.45; 95% CI, 1.86 to 3.25; P < 0.001), and pursuit of a combined aesthetic procedure (OR, 1.28; 95% CI, 1.04 to 1.56; P = 0.017). The Hosmer-Lemeshow test gave a value of P = 0.109 (>0.05), indicating no evidence of poor fit of the regression model.
Risk Factors for Unplanned Reoperation
Risk factors for unplanned reoperation are also shown in Table 4 . After multivariate adjustment, independent risk factors for unplanned reoperation included increasing age (OR, 1.01; 95% CI, 1.00 to 1.01; P = 0.015), BMI (OR, 1.02; 95% CI, 1.01 to 1.03; P = 0.001), former tobacco use (OR, 1.33, 95% CI, 1.10 to 1.59; P = 0.002), ASA class 2 (OR, 1.54; 95% CI, 1.35 to 1.75; P < 0.001) status (versus ASA class 1), and increasing operative time (OR, 1.0032; 95% CI, 1.0025 to 1.0038; P < 0.001). The Hosmer-Lemeshow test gave a value of P = 0.194 (>0.05), indicating no evidence of poor fit of the regression model.
Per-Year Reporting in TOPS
Finally, we examined trends in per-year reporting of all procedures (breast augmentation, liposuction, blepharoplasty, rhinoplasty, and abdominoplasty) in the TOPS database. Although reporting of blepharoplasty, abdominoplasty, and rhinoplasty remained stable in TOPS from 2008 to 2019, relative per-year reporting of breast augmentation decreased Figure 1 .
Fig. 1.: Trends in per-year breast augmentation, liposuction, blepharoplasty, rhinoplasty, and abdominoplasty as reported in TOPS, 2008 to 2019.
DISCUSSION
In this large, contemporary analysis of surgical outcomes in the TOPS database for 214,504 patients undergoing common aesthetic surgery procedures, we report the incidence of surgical complications and demographic and procedural risk factors for readmission and unplanned reoperation. We identify an overall low complication rate associated with five of the most common aesthetic surgery procedures as reported in TOPS. Furthermore, we identify demographic and procedural predictors of unplanned readmission, ER visits, and reoperation across procedure types. We aim for this study to emphasize the overall safety of aesthetic surgery when performed by board-certified plastic surgeons, and also to identify demographic subgroups at risk for unplanned healthcare utilization who may benefit from additional planning, optimization, and counseling in the preoperative setting.
To date, the incorporation of the aesthetic surgery population into large national databases has been limited. Existing reviews of complications data are limited to retrospective reviews15 6 , 14 , 16–26 27 14 8 26
The low overall complication rate identified in our study highlights the safety of the most common aesthetic plastic surgery procedures when performed by board-certified plastic surgeons. We identify a less than 2% overall incidence of all complications, including hematoma, seroma, wound complications, infection, and thrombotic events, across procedures. These data parallel complication rates identified in the CosmetAssure,14 , 16 , 17 , 19 , 21–23 , 26 , 28 8 29 16 , 30
With recent shifts in health care dynamics, unplanned healthcare utilization, including unplanned readmission, emergency room visits, and reoperation, have become proxies of care and quality metrics by which health care systems and surgeons are judged. As such, increasing emphasis has been placed on initiatives to improve these metrics across surgical patient populations. Likely attributable to the preponderance of self-pay patients and relative infrequency of unplanned health care use in aesthetic surgery, few studies have reported risk factors for readmission, emergency room visits, and reoperation after aesthetic surgery.2 , 31 32 31 , 33 2 34 35 31
Despite these low overall rates, identifying risk factors for unplanned health care use remains essential to guide both internal quality improvement and preoperative counseling. Unsurprisingly, we find that medical comorbidities, including age, DM, higher BMI, and higher ASA class, are independent risk factors for hospital readmissions, all of which have been reported as risk factors for unplanned health care use in prior studies across our selected procedures.2 , 35–37 7 16
In addition, we find that pursuit of abdominoplasty and combination aesthetic procedures were associated with risk of unplanned hospital admissions and ER visits. Abdominoplasty is often performed as a combined case in conjunction with other aesthetic procedures because of benefits including reduced occurrences of anesthesia, time, and costs. However, prior studies have demonstrated higher overall complication rates associated with combined operations involving abdominoplasty. Using CosmetAssure, both Gupta et al.17 16 17 7 , 16
There are limitations to this study with implications for its interpretation, many of which are inherent in the design of the TOPS database. Notably, TOPS entry is dependent on manual data entry by surgeons, which may result in reporting bias of complications, with potential underreporting of adverse events, as opposed to databases such as the NSQIP that rely on third-party data entry.8
CONCLUSIONS
Postoperative complications and unplanned healthcare utilization are uncommon after breast augmentation, liposuction, blepharoplasty, rhinoplasty, and abdominoplasty. However, medical comorbidities, including obesity and DM, are associated with a higher risk of unplanned healthcare utilization. In addition, abdominoplasty is associated with a higher risk of unplanned ER visits, readmission, and reoperation compared with other aesthetic procedures, a risk that is compounded when performed as a combined procedure. These data emphasize the overall safety of aesthetic surgery when performed by board-certified plastic surgeons, but also identify subgroups of aesthetic surgery patients at risk for unplanned health care use who may benefit from additional planning, optimization, and counseling in the preoperative setting. Continued entry of aesthetic surgery patients into large national databases is essential for internal benchmarking within the specialty.
DISCLOSURE
The authors have no relevant financial disclosures to report.
ACKNOWLEDGMENT
The authors would like to acknowledge the TOPS ASPS committee for study support. In addition, the authors would like to acknowledge Shen Yin for prior statistical support.
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