Venous Thromboembolism in Plastic Surgery: Where Are We Now?

Predicting the risk of postoperative venous thromboembolism in rhinoplasty patients: a cohort study

BACKGROUND

Venous thromboembolism (VTE) is a rare complication following rhinoplasty surgery, with an occurrence rate generally estimated to be between 0.5% and 1%. In contrast, the occurrence rate of VTE in orthopedic surgeries, particularly in lower limb fracture surgeries, can reach as high as 10% or more. This significant difference highlights the varying risks associated with different surgical procedures and underscores the importance of identifying risk factors specific to rhinoplasty. Despite its relatively low incidence, the potential for VTE in rhinoplasty patients necessitates a thorough analysis of risk factors to enhance patient safety and guide clinical practice. This study aims to analyze the risk factors for postoperative VTE in rhinoplasty patients and develop a predictive model to assist clinicians in identifying at-risk individuals.

METHODS

A retrospective analysis was conducted on the clinical data of 1100 rhinoplasty patients admitted to a cosmetic hospital from January 2016 to January 2022. Patients were divided into Non-VTE group (1012 cases) and VTE group (88 cases) based on the occurrence of VTE within one month postoperatively. General patient information was collected and subjected to univariate analysis. Multivariate logistic regression analysis was used to identify risk factors for postoperative VTE in rhinoplasty patients and establish a predictive model. Internal validation was performed using bootstrapping technique to assess the accuracy and predictive performance of the model.

RESULTS

Univariate analysis showed that the proportions of IBD, Myocardial infarction, Previous VTE, PICC/central line, Rib graft, and History of nasal surgery were significantly higher in the VTE group compared to the Non-VTE group (all P < 0.05). Multivariate logistic regression analysis identified IBD, Myocardial infarction, Previous VTE, Rib graft, and History of nasal surgery as independent risk factors for VTE (P < 0.05). The constructed predictive nomogram model demonstrated good calibration and predictive accuracy, with an area under the ROC curve of 0.845, indicating excellent discrimination and clinical predictive performance.

CONCLUSION

IBD, Myocardial infarction, Previous VTE, Rib graft, and History of nasal surgery are independent risk factors for postoperative VTE in rhinoplasty patients. The predictive model effectively assesses the risk of VTE in patients, providing important guidance for clinical decision-making.

Application of 4D-Printed Magnetoresponsive FOGS Hydrogel Scaffolds in Auricular Cartilage Regeneration

3D-printed hydrogel scaffolds are widely utilized in auricular cartilage tissue engineering. However, issues such as graft-related inflammation, poor mechanical properties, and the lack of external modulation of 3D-printed scaffolds in vivo have raised significant concerns. To address these challenges, a "fried egg" structure is designed, consisting of chitosan-coated ferroferric oxide magnetic nanoparticles (Fe3O4@CS MNPs), which are uniformly incorporated into hydrogel. Through 4D printing technology, magnetoresponsive hydrogel scaffolds are constructed to overcome the aforementioned limitations. The results demonstrated that, compared to 3D printing, 4D-printed magnetic hydrogel scaffolds significantly enhanced cartilage tissue regeneration in both in vitro and in vivo environments when subjected to an external magnetic field (MF). Furthermore, the mechanical strength of regenerated cartilage approached to that of natural cartilage. The chitosan coating on the surface of MNPs exhibited anti-inflammatory and antibacterial properties, promoting M2 polarization of macrophages and suppressing graft-related inflammation and bacteria. Transcriptomic analysis confirmed that MNPs modulate macrophage immunity by activating JAK2/STAT3 signaling pathway. Taken together, a magnetoresponsive multifunctional scaffold is designed that can be externally controlled by magnetic fields to promote ear cartilage tissue regeneration. The regenerated cartilage exhibits excellent biocompatibility, anti-inflammatory, antibacterial properties, and mechanical performance, providing new insights for auricular cartilage tissue engineering.

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

Patient Weight and Chemoprophylaxis in Abdominoplasty: Does It Result in More Bleeding Events?

BACKGROUND

Bariatric surgery has gained popularity in recent decades as an effective treatment for obesity. Abdominoplasty is one of the most often performed aesthetic procedures all over the world. In post-bariatric patients undergoing abdominoplasty, the diameter size and number of the abdominal wall perforators increase proportionally with increased body weight. Postoperative complications that may occur are haematoma, and venous thromboembolism (VTE). In plastic surgery procedures VTE prophylaxis grades vary due to the lack of consensus and clear guidelines. The aim of this study was to explore the frequency of postoperative bleeding and VTE in patients undergoing abdominoplasty and to explore the risk factors associated with major bleeding.

METHODS

A retrospective single-centre study of adult patients who were operated on by abdominoplasty between 2011 and 2020. Chemoprophylaxis including low molecular weight heparin (LMHW) was recommended when the operating time exceeded 2 h.

RESULTS

A total of 102 patients were included. There were no patients with VTE. Eight patients were re-operated for major haematoma. The weight loss (peak weight to weight before the abdominoplasty) was 14.4 kg larger in the re-operation group (p = 0.03). Eighty-eight percent in the re-operation group and 67% in the other group were treated with LMWH (p = 0.43). Multivariable logistic regression showed that with each decrease from the peak in BMI kg/m2 the risk of re-operation for major haematoma was increased by 22% (p = 0.02).

CONCLUSION

Abdominoplasty in patients after massive weight loss has a higher risk of postoperative bleeding. Having a clear protocol for chemoprophylaxis should be considered.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Short-term versus extended chemoprophylaxis against venous thromboembolism in DIEP flap breast reconstruction: A retrospective study of 424 patients

BACKGROUND

Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction.

METHODS

This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates.

RESULTS

Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8.

CONCLUSION

In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.

Peer Review: How to Review a Plastic Surgery Manuscript

ABSTRACT

Little information is available regarding how to review a plastic surgery manuscript. This vital responsibility ensures that publications meet an acceptable scientific standard. Thoughtful and thorough reviews are essential to protect patients and surgeons from unscientific practices and products. This discussion provides information for the reviewer, gained from the author's experience, including examples of a thorough review, likely to be useful to the editor, and a cursory one that is unhelpful.The first consideration is relevance. Prerequisites for publication include institutional review board approval, disclosure of financial conflicts, and discussion of the regulatory status of devices. Particular attention is needed to check for conflicts of interest, which are endemic in plastic surgery today. In view of the common practice of using computer-generated imaging, reviewers need to be especially vigilant for inauthentic "photoshopped" photographs. Examples of published images that have been digitally altered are provided.If data are available, it may be possible to check the statistical tests. Reviewers need to be aware of the practice of p-hacking. A quick literature search can identify relevant but unreferenced publications. The manuscript needs to be properly organized into sections. Minor points may be made regarding style. The study design and methodology need to be evaluated to be sure that the conclusions are well supported by data. Randomized studies are rarely feasible. Fortunately, well-done prospective observational studies in consecutive patients can be just as useful. Realistic complication rates are expected. Meta-analyses in plastic surgery are often subject to confounding variables. Comments should be available to the authors; confidential comments hidden from authors are discouraged. Like honesty, transparency is the best policy. Manuscripts should be evaluated solely for merit, not the identity of the author or institution. Timeliness of submission of the review is appreciated by authors.Evidence-based medicine is concerned solely with the facts. The 2 basic criteria are a solid scientific basis and reliable evidence of efficacy. Reviewers need to keep an open mind. Studies that challenge the status quo are often the most valuable ones and are needed for the advancement of the specialty.

Deep venous thrombosis in a 41-year-old female with May–Thurner syndrome following abdominoplasty and medial thigh lift

Deep venous thrombosis (DVT) is a feared occurrence following body contouring surgery as it can result in pulmonary embolism. Acute presentation can range from lower extremity edema and pain to being totally asymptomatic. Surgical literature reports reveal many risk factors for developing DVT, and surgeons must risk stratify their patients to best prevent this outcome. However, there are conditions which place patients at risk that are difficult to account for when making such decisions as they can be undiagnosed and are not a part of standard screening protocols. We present a case of DVT in a 41-year-old female with undiagnosed May–Thurner syndrome following abdominoplasty and medial thigh lift for massive weight loss. The authors discuss the current literature as well as challenges faced by surgeons who strive to appropriately risk stratify their cosmetic surgery patients to avoid complications such as venous thromboembolism.

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

Mechanical Thromboprophylaxis Alone in Body Contouring Surgery for Post Massive Weight Loss Patients: Is this Good Enough?

BACKGROUND

Although the use of pharmacological thromboprophylaxis effectively reduces Deep vein thrombosis (DVT) incidence after body contouring surgery, this might increase the risk of bleeding and hematoma formation. In this scenario, the use of mechanical prophylaxis alone could be an attractive alternative. We aimed to evaluate the incidence of DVT in patients with massive weight loss undergoing body contouring surgeries in whom mechanical prophylaxis alone was indicated.

METHODS

This retrospective cohort study included all patients who underwent body contouring surgery after massive weight loss between 09/01/16-12/31/19 and received solely mechanical prophylaxis of VTD. Data collected included smoking habit, body mass index, history of cancer, use of contraceptives, magnitude of weight loss, Caprini scale, American society of anesthesiology physical status (ASA-PS) classification, and type and length of procedures. An analysis of DVT events during the postoperative period up to 90 days was undertaken.

RESULTS

Sixty-four patients, in whom 82 BCS were performed, were included in this study. Most of them (89.1%) were female with a mean age of 47 ± 12 years. Mechanical prophylaxis methods used were elastic compression stockings, intermittent pneumatic compression boots, and early deambulation. In all cases, the average length of hospital stay was 26.3 ± 9.6 hours. Surgical times were less than 155,7 minutes in all procedures. Global incidence of DVT was 1.2% in a patient receiving mechanical prophylaxis alone. There were no bleeding complications or pulmonary embolism episodes.

CONCLUSIONS

In this series, DVT incidence in patients with mechanical prophylaxis alone was deemed acceptable if compared to the incidence reported in the literature. Individualization of the risk of thrombosis and bleeding in this group of patients is of paramount importance to reduce complications.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery

BACKGROUND

Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient.

METHODS

This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage.

RESULTS

Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens.

CONCLUSION

Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.