Essentials of Aesthetic Surgery

122
Part III Safety





Class 1
A normal healthy patient
Healthy, nonsmoking, no or minimal alcohol
use
Class 2
A patient with mild systemic disease
Mild diseases only without substantive
functional limitations. Examples include (but
not limited to) current smoker, social alcohol
drinker, pregnancy, obesity (BMI = 30-40),
well-controlled DM/HTN, mild lung disease
Class 3
A patient with severe systemic
disease
Substantive functional limitations; One or
more moderate to severe diseases. Examples
include (but not limited to) poorly controlled

active hepatitis; alcohol dependence or abuse,
implanted pacemaker, moderate reduction of
ejection fraction; ESRD undergoing regularly
scheduled dialysis; premature infant PCA

TIA, or CAD/stents
Class 4
A patient with severe systemic
disease that is a constant threat
to life
Examples include (but not limited to) recent
(<3 months) MI, CVA, TIA, or CAD/stents;
ongoing cardiac ischemia or severe valve
dysfunction; severe reduction of ejection
fraction; sepsis; DIC; ARD or ESRD not
undergoing regularly scheduled dialysis
Class 5
A moribund patient who is not
expected to survive without the
operation
Examples include (but not limited to) ruptured
abdominal/thoracic aneurysm; massive


cardiac pathology or multiple organ/system
dysfunction
Class 6
A declared brain-dead patient
whose organs are being removed
for donor purposes


MONITORING AND MINIMIZING PHYSIOLOGIC STRESSES RELATED
TO THE SURGICAL PROCEDURE
HYPOTHERMIA
Core body temperature
Incidence: 50%-90% of surgical patients if no preventative measures are used.11

• Thermoregulatory mechanisms are impaired by anesthesia.
• Core-to-peripheral heat redistribution begins soon after anesthesia.
• Patient loses body heat to ambient temperature of OR.
12

123
Chapter 9 Safety Considerations in Aesthetic Surgery
Increased blood loss,
coagulation disorders, increased
risk of cardiac events, increased
risk of surgical site infection,
postoperative shivering, and
lengthened hospital stays.
• All of these factors
secondarily contribute to
increased costs.
13
Use of cutaneous
warming devices, forced-air
warming blankets, and

Chapter 5)
• Actively prewarm patients for
preoperative with forced-air heating
• Patients not prewarmed are prone to hypothermia within 30 minutes of anesthesia
induction (Fig. 9-1).
12

procedures should be limited to and

9
BLOOD LOSS
If the anticipated blood loss is the procedure should be performed in a facility in
which postoperative monitoring and blood replacement products are readily available.9
DURATION OF THE SURGICAL PROCEDURE

procedures.9

numerous studies.2-6
Some studies have correlated the length of the ambulatory surgical procedure with
increased rates of postdischarge readmission to a hospital.14
State regulations must be checked for details, because some states have more
aggressive regulations/restrictions.
POSTOPERATIVE PAIN AND NAUSEA

process, the patients’ overall satisfaction with the procedure and facility, and ultimately
patient safety.

15
• Postoperative pain is the main reason for delayed discharge and hospital
readmission after ambulatory surgery.16
• Inadequate pain control can also cause PONV.
• PONV has received less attention than pain management but actually represents
the It is also a major factor in
and

15,17
Temperature
before
treatment
Temperature before
anesthesia
(60 minutes)
Temperature after
anesthesia
(60 minutes)
36.7
Procedure
36.8
37.1
36.1
34.9
No Warming
Pre-Warming
Two-group comparison of prewarming.

124
Part III Safety

PONV after discharge with no access to treatment.17

reduce PONV.

18
• Multimodal pain and PONV management are recommended in the preoperative,

• Multimodal PONV involves treating all receptor systems
19,20:
21
2. Dopamine (DA)
3. Histamine (H-1)
4. Acetylcholine (Ach)
5. Neurokinin (NK-1)
For additional details, see Chapters 7 and 8.
LIPOSUCTION
According to the 2016 American Society for Aesthetic Plastic Surgery Cosmetic
Surgery National Data Bank statistics, liposuction procedures (414,335) were the
most commonly performed aesthetic procedures in the United States.
22 Most of these

ANESTHESIA see C


monitoring devices during the procedure is recommended.
Bupivacaine (Marcaine) should
long half-life, and the inability to reverse toxicity.
23
For larger-volume liposuction, the amount of lidocaine used should be reduced.
Superwet (1:1) technique rather than tumescent (3:1) technique is used to reduce

If regional or general anesthesia is used, not using or reducing the lidocaine dose
should be considered.
The recommended maximal dose is , although up to
10 mg/kg have been used safely.24
Epinephrine is avoided for patients with comorbid medical conditions that prohibit
its use, including hyperthyroidism, severe hypertension, cardiac disease, peripheral
vascular disease, and pheochromocytoma.

24


treatment for obesity. It is generally not recommended for patients with a
25
VOLUME
24

125
Chapter 9 Safety Considerations in Aesthetic Surgery

hospitalization should be strongly considered.
FLUID MANAGEMENT

Box LIPOSUCTION FLUID RESUSCITATION GUIDELINES


a
a
b
b

0.25 ml of intravenous crystalloid per


a
bSeventy percent is presumed to be intravascular.
COMBINATION PROCEDURES

multiple surgical procedures are combined in one setting.


Some states have recently restricted the combination of liposuction with any other type
of surgery.

regulations.
MORTALITY
A survey study of ASAPS members showed 95 deaths in close to 500,000 lipoplasty
procedures for a mortality rate of 1 in 5224 (19.1/100,000 versus 3/100,000 for
elective inguinal hernia repair)
26 (Table 9-2).
was the most common cause of death
Overall lipoplasty mortality rates have been reported as 0.0021%-0.019%.26,27
Fatal Outcomes from Liposuction



Fat embolism

11

8.5
Anesthesia-related complications

13

10.0
Hemorrhage

6

4.6
Thromboembolism

30

23.1
Cardiorespiratory failure

7

5.4
Gastrointestinal perforations

19

14.6
Massive infection

7

5.4


37

28.5

126
Part III Safety
COMBINATION SURGICAL PROCEDURES
After the 2000 Florida moratorium banned the combination of abdominoplasty and

procedures has increased.
28
Many states have imposed arbitrary restrictions on allowable lengths of surgery for

Florida mandates that procedures lasting
setting, whereas Pennsylvania and Tennessee have imposed arbitrary on

Balakrishnan et al29 reviewed the current available data and concluded: “As they [states]

exist to formulate immediate evidence-based policy.”
A review of the literature revealed that most studies have addressed the combination of
abdominoplasty with either liposuction or gynecological procedures.30,31
Unlike previous reports,30,31
combining abdominoplasty with gynecological procedures, these studies established

procedures with abdominoplasty.
32,33
32:
complication rates between a group of patients who underwent abdominoplasty
with a breast procedure compared with a control group who underwent
abdominoplasty alone.

33: Aside from a single episode of PE in their abdominoplasty-
only group (incidence 1.03%), they reported no other major complications or
mortality in either study group (i.e., abdominoplasty versus abdominoplasty with
another aesthetic procedure).
• A 2006 retrospective Canadian study
34 compared a group of 37 inpatient
abdominoplasty procedures with 32 patients who underwent outpatient
abdominoplasty. Most patients underwent concomitant aesthetic procedures. There

groups.
Although these studies support the safety of combining aesthetic surgical procedures,
both abdominoplasty and high-volume liposuction have been established as

26,27,35 and it is prudent for surgeons to approach the
combination of these two procedures with caution and maximize patient safety with
appropriate VTE prophylaxis. In higher-risk patients these combination procedures
should be performed in a hospital, or consideration should be given to not combining
the procedures.
36 reviewed 1200 consecutive facial plastic surgeries performed in an


• Patients whose surgeries lasted <4 hours served as a control group for the lengthier
procedures.

127
Chapter 9 Safety Considerations in Aesthetic Surgery

been established due to a paucity of objective level 1 evidence.9,28
<6 hours for outpatient surgery,
9
VENOUS THROMBOEMBOLISM
Incidence
• An ASPS study of existing data that 18,000 cases/year of DVT may occur.37
• The overall incidence of DVT in the United States is 84-1550 per 100,000 per year.38
• The incidence of PE in the United States is 125,000-400,000 cases per year.39
• PE is the accounting for
approximately 150,000 deaths per year.
• The incidence of VTE varies greatly between medical and surgical specialties, as well
as within a specialty, depending on the procedure performed
40 (Table 9-3).
Absolute Risk of DVT in Hospitalized Patients


Major general surgery

15-40
Major orthopedic surgery

40-60
Spinal cord injury

60-80
Multiple trauma

40-80
Neurosurgery

15-40
Stroke

20-50
Major gynecological surgery

15-40
Major urological surgery

15-40
Critical care patients

10-80
Medical patients

10-20
McDevitt41 found that in patients undergoing elective surgery who received no
prophylactic treatment the incidence of fatal PE was 0.1%-0.8%.
Medical comorbidities that may increase the incidence of VTE42,43:


2.
Family history of thrombotic syndromes
3.

4.
Trauma
5.
Severe infection
6.
Polycythemia
7.
Central nervous system disease
8.
Malignancy
9.
Homocystinuria
10.
History of pelvic or lower extremity radiation
11.

12.

128
Part III Safety
and HRT are common within our aesthetic surgery
patients.
Many body contouring surgeries are performed on patients who are trying to achieve
improved appearance but may present at borderline obese BMIs or have previously
been morbidly obese and underwent bariatric surgery, increasing their risk for VTE.
Most aesthetic surgery patients are female, and although there are limited data on
the incidence of use of birth control pills or HRT within these distinct aesthetic surgery
populations, most patients probably use these.
• A recent review and meta-analysis in the British Medical Journal of eight
observational studies and nine randomized controlled trials showed a


as well as for women who are considered higher risk for VTE.

compared with the oral route of administration and appears to be safe in regard
to thrombotic risk.
44
• Men receiving estrogen therapy for prostate cancer are also at increased risk of VTE.
compounds the VTE risk of patients who are taking oral contraceptives.
• The prothrombotic mechanism of estrogen is related to
Smoking
exacerbates this clinical scenario.

replacement should be discontinued before surgery to minimize VTE risks, but it has
been suggested that this should be done at least
42
Despite the recent interest in VTE prevention, evidence clearly establishing the true

• The earliest report on the incidence of VTE in the plastic surgery literature was in
1977 when Grazer and Goldwyn
45 reported an incidence of DVT of 1.1% and PE of

• Hester et al
31 reported that combining abdominoplasty with another surgical
procedure increased the incidence of PE.
• Voss et al reported a 6.6% incidence of PE when abdominoplasty was combined with
intraabdominal gynecological procedures.
46

129
Chapter 9 Safety Considerations in Aesthetic Surgery

procedures and PE accounted for the largest percentage of deaths.26
• DVT and PE in large-volume liposuction procedures have been reported as ranging
from 0%-1.1%.
26,27,44
• When liposuction is combined with other procedures, the incidence of mortality
increases from 1 in 47,415 to 1 in 7314, an almost sevenfold increase.27
RISK ASSESSMENT
History and physical examination
Risk assessment module
to calculate risk
Risk assignment
Low risk
factors: 1
Moderate risk
factors: 2
High risk
factors: 3-4
Highest risk
factors: >4
Proper positioning
Early ambulation
Proper positioning
Early ambulation
IPC/ES
Proper positioning
Early ambulation
IPC/ES
Consider LMWH
Proper positioning
Early ambulation
IPC/ES with LMWH
Consider warfarin
Algorithm for venous thromboembolism prevention in plastic surgery patients. ( ,
Elastic compression stockings; , intermittent pneumatic compression stockings; , low-
molecular-weight heparin.)

130
Part III Safety
Recently, a number-scoring risk assessment model was developed by Caprini and
43 to adapt it to plastic surgery patients (Table 9-4).
Hatef et al47

circumferential abdominoplasty, high incidence of hormone use in plastic surgery

Exposing and Predisposing Risk Factors (Davison-Caprini)



(each item represents one risk score)

Minor surgery
Age 40-60

Pregnancy or <10 month postpartum
Oral contraceptive/hormone replacement therapy

(each item represents two risk scores)

Major surgery
Immobilization

72 hours
Central venous access

Malignancy

(each item represents three risk scores)

Previous myocardial infarction
Congestive heart failure
Severe sepsis

History of DVT/PE
Any genetic hypercoagulable disorder

Antiphospholipid antibodies
Myeloproliferative disorders
Heparin-induced thrombocytopenia
Hyperviscosity
Homocystinemia


Fracture of the hip, pelvis, or leg
Stroke
Multiple trauma
Acute spinal cord injury

131
Chapter 9 Safety Considerations in Aesthetic Surgery





Minor surgery
Age 40-60


Major surgery
Immobilization
Central venous access

Current malignancy
Obesity
Over-the-counter progesterone (OCP)
Hormone replacement therapy (HRT)


Previous myocardial infarction (MI)
Previous congestive heart failure (CHF)
Severe sepsis

Circumferential abdominoplasty
History of venous thromboembolism
Hypercoagulable disorder

Fracture of the hip, pelvis, or leg
Stroke
Multiple trauma
POSTBARIATRIC SURGERY PROCEDURES AND VENOUS
THROMBOEMBOLISM
Often these procedures combine with extensive
liposuction to achieve body contouring objectives.
Circumferential abdominoplasty procedures combine circumferential dissection/


mobilization.
• Aly et al
48 reported an incidence of PE of 9.4% in 32 belt lipectomy procedures.
• Hatef et al47
patients based on risk factors, BMI, type of procedure performed, and the
administration of low-molecular-weight heparin for VTE prophylaxis.

132
Part III Safety






heparin, the incidence of DVT was 0% for those who received enoxaparin versus
20% for those who did not receive enoxaparin therapy.

incidence of DVT and VTE in the highest risk group of patients, as well as in those



0.9%) in the enoxaparin groups.

increased the incidence of VTE (6.8% versus 2.4%), which approached statistical
p = 0.083).
47
POSTBARIATRIC BODY CONTOURING
In 2015 alone, according to American Society for Bariatric Surgery data, 196,000
Americans underwent bariatric surgery.49
Unlike many aesthetic surgery patients who are relatively healthy, most massive-
weight-loss patients have preexisting medical conditions, such as diabetes mellitus or
pulmonary dysfunction, as a result of their elevated BMI.
Even if these medical conditions have resolved after their bariatric surgery, the sequelae
result in a

plastic surgery patients.
To optimize aesthetic outcomes and improve safety, surgeons must address these
issues during the preoperative workup and planning phase.
showed evidence of
anemic on routine evaluation.50

gastric bypass procedures and because of the patients’ altered diets in the postbariatric
period during weight loss.
absorbed in the duodenum and proximal jejunum, and
B12, which binds to intrinsic factor in the stomach and is required for vitamin
B12 to be absorbed in the terminal ileum, can lead to 51
Observational data from body contouring surgeons showed that many of these patients
are both and 52
Hypocalcemia can increase general anesthesia risks, whereas low potassium levels are
associated with persistent emesis and can lead to PONV.
The evaluation and treatment of anemia in these patients is important, because most
of the body contouring procedures involve extensive excisional procedures associated
with moderate blood loss.

133
Chapter 9 Safety Considerations in Aesthetic Surgery
Preoperative treatment of anemia can reduce the need for blood transfusions and their
associated risks in this patient population.
The ASPS/ASAPS Joint Post-Bariatric Task Force recommended an extensive
preoperative laboratory workup before any proposed body contouring procedures to

52
• Routine preoperative laboratory test for the massive-weight-loss patient should
include:52






12


procedures performed at each stage. These factors include:
• Patient’s BMI
• Setting of surgery (outpatient versus inpatient)
• Size of the operating team (solo versus team surgery)
• Surgeon’s experience
• Coverage (insurance versus fee for service)
• Patient’s goals/desires
• The most important factor is

procedures.




postbariatric body contouring procedures,
53,54 in particular, risk of DVT.55
Staging of procedures can limit surgical/anesthetic times, minimize surgical blood loss,
and lead to decreased surgeon fatigue, thus improving patient safety and outcomes.
The use of a or the use of
can also limit operative times and allow combination of procedures. This means fewer
surgical procedures from which patients must recover.
Usually, staged procedures should be performed at a
to allow adequate recovery time (Table 9-6).
Surgical Planning



I
Abdomen
Body lift, liposuction thighs
II
Flank excision
Upper body lift
III
Breast
Thigh lift, revisions
IV
Thighs and arms
N/A
V
Arms and thighs
N/A
VI
Face
N/A

134
Part III Safety
• The ASPS/ASAPS Joint Post-Bariatric Task Force provided an extensive review of body
contouring after massive weight loss which details the preoperative, perioperative,
and postoperative care of this unique patient population.
52
Consensus recommendations based on a recent review of the literature are summarized
in Box 9-2.
Box CONSENSUS GUIDELINES
• Weight loss is complete and stable prior to surgery.
• Preoperative smoking cessation is strongly recommended.
• Venous thromboembolism prophylaxis is initiated preoperatively and postoperatively.
•
dose of unfractionated or low-molecular-weight heparin should be administered within
12 hours of surgery.
• Nutritional status is assessed based on patient history and laboratory tests to detect
anemia and protein malnutrition.
• Body contouring procedures should only be performed at accredited surgical facilities.
• Intraoperative hypothermia is prevented with forced-air warming blankets, warming

• Patient safety is ensured with positioning and prevention of compression injuries. When
prone, the patient should be placed in 15-degree reverse Trendelenburg position to
decrease intraocular pressure.
SURGICAL SITE INFECTIONS
When proper measures are employed, up to 60% of SSIs can be prevented.56,57
SOURCES OF WOUND CONTAMINATION

It is impossible to sterilize the skin.

The patient’s own skin is direct source of contamination in only 2% of cases.
Experiments using albumin microspheres as tracers reveal 100% of surgical wounds are
contaminated with particles from sites remote to the surgical wound.

OR personnel (poor hand hygiene, loose surgical masks, staphylococcus carriers, poor
sterile technique)
Analysis of 655 cases revealed that of surgical gloves had a perforation by the end
of the case.
Double gloving reduces perforation of the inner glove and reduces risk of
contamination.
PREVENTION OF SURGICAL SITE INFECTIONS

The introduction of computers, tablets, radios, and cell phones into the OR creates
unnecessary sources of contamination. Among these devices, 44%-98% carry resistant
microorganisms (gram-negative rods and ).

135
Chapter 9 Safety Considerations in Aesthetic Surgery
Do not wear scrub attire outside the OR.


PREPARATION OF THE SURGICAL TABLE
Surgical table preparation should be coordinated with draping, which is the step with
the greatest risk of contamination.
Placing the patient on the OR table, prepping, and draping results in a fourfold increase
in airborne contamination.
Containers and instruments should be covered when not in use.
The duration of instrument tray opening correlates directly with the contamination rate
(4% after 30 minutes, 15% after 1 hour, and 30% after 4 hours).
PATIENT ELATED RISK FACTORS
Age
Diabetes/glucose control
• Several studies have determined that hyperglycemia before and after surgery (in
diabetics and nondiabetics) is associated with a increase in SSI.

produced a increased risk of SSI.

Smoking
Immunosuppressive medications
Nutrition
Remote sites of infection
Preoperative hospitalization
PROCEDURE ELATED RISK FACTORS
Preparation of patient
Hair removal: Shaving increases the risk of infection 2.4-fold62
Skin preparation
63

with 4% povidine or 4% chlorhexidine.
64
• In an analysis of 655 operations, perforations were found in of gloves.
• Glove perforations raises the risk of SSI
• Double gloving is associated with less perforation of the inner glove
Antimicrobial prophylaxis
Hypothermia
Oxygenation
ANTIBIOTIC PROPHYLAXIS

Contaminated cases
Clean contaminated cases where the aerodigestive track is entered
Cases that involve an implant
Breast surgery, because the ducts contain bacteria
For other clean cases, the evidence does not support using prophylactic antibiotics.

136
Part III Safety

The timing of antibiotic administration should be adjusted to maximize prophylactic

Therefore prophylactic antibiotics should be administered within
of incision.
Prophylactic antibiotics (with the exception of vancomycin, aminoglycosides, and

1500 ml or greater.

• European data65 (Table 9-7)



• U.S. data
66 (Table 9-8)
Relationship to SSI Rates: European Data

RR
OR
p
<30 minutes before incision
2.0
2.0
0.02
30-59 minutes before incision
1.0
1.0
*
60-120 minutes before incision
1.8
1.7
0.05
*No p value is listed for antibiotic infusion times from 59-30 minutes before incision because that timing had
the lowest risk of SSI and therefore serves as the reference or standard to which all other infusion times are
compared.
OR, Odds ratio; RR, relative risk.
Relationship to SSI Rates: U.S. Data

RR

p

2.54
2.11 (0.68, 6.59)
0.07
61-120 minutes before incision
1.49
1.25 (0.74, 3.00)
0.26
31-60 minutes before incision
1.48
1.74 (0.98, 3.08)
0.13
1-30 minutes before incision
1.0
1.0
*
1-30 minutes after incision
2.44
1.96 (0.65, 5.95)
0.09

4.12
4.18 (1.37, 12.75)
0.02
*No p value is listed for antibiotic infusion times from 0-30 minutes before incision because that timing had
the lowest risk of SSI and therefore serves as the reference or standard to which all other infusion times are
compared.
OR, odds ratio; RR, relative risk.

137
Chapter 9 Safety Considerations in Aesthetic Surgery
SPECIAL CONSIDERATIONS IN SURGICAL SITE INFECTIONS
STAPHYLOCOCCUS COLONIZED PATIENTS

Athletes
Military personnel
Men having sex with men
Prison inmates
IV drug users
Homeless persons
Recent hospitalization
Recent course of antibiotics

One third of the population carries staphylococcal organisms all the time; one third,
part of the time; and one third, never.
Studies examining preoperative decolonization have been inconclusive.
Known carriers and high-risk individuals can be decolonized with mupirocin and
chlorhexidine showers.

Showering with chlorhexidine the evening before and the morning of surgery decreases
skin colonization.

than showering.
Showering with chlorhexidine has not been shown to prevent SSI.

Patients with breast implants do not need prophylactic antibiotics for dental
procedures.

Bacterial colonization of the drain is an independent predictor of SSI. Of patients
developing an infection, 83% were of the same bacterial species documented in the

The probability of bacterial colonization of the drain rose from 33% to 80.8% between
postoperative days 7 and 14.
Despite this, drain-associated infection rates seem low and do not appear to be related
to duration of use.


Aggressive management of the drain insertion site with a chlorhexidine disc and

antibiotics for prevention of drain-associated SSI.

138
Part III Safety
SENIOR AUTHOR TIP: Patient Safety Dos and Dont’s for Plastic Surgeons56
Do:
Consider not giving prophylactic antibiotics for clean cases that do not involve an
implant or the breast.

prophylaxis.
For beta-lactam allergic patients clindamycin is a better choice than vancomycin for
prophylaxis.

incision is made. Any other time results in a greater risk of SSI.
Cefazolin should be redosed for cases lasting longer than 3 hours or if there is an
estimated blood loss 1500 ml or greater.
Use vancomycin for prophylaxis only when absolutely necessary (MRSA) carrier.
Consider not giving prophylactic antibiotics after wound closure in clean cases.
Double glove and practice good hand hygiene.


with a cotinine test).
Maintain tight glucose control in diabetics HbA1C <7, and glucose <200 mg/dl.
Have patients shower with chlorhexidine the morning of surgery.

Consider giving supplemental oxygen (FiO2 of 80%)
Maintain normovolemia.

concerns when they feel something is not right.
Stay focused: Double tasking and distractions lead to errors.

Never use broad-spectrum antibiotics for prophylaxis.
Do not shave to remove hair at the incision site.
Have patients stop shaving for hair removal 2 weeks before and after surgery.
Drains and implants do not justify prolonged antibiotics.
Never operate on patients with infections at remote sites.
Don’t give antibiotics to implant patients for dental procedures.
Don’t bring unnecessary items such as brief cases and back packs into the operating
room.

139
Chapter 9 Safety Considerations in Aesthetic Surgery
TOP TAKEAWAYS

Develop a system of quality of care with continual evaluation focused on
improving patient care/safety.


choice for prophylaxis.

Consider not giving prophylactic antibiotics after wound closure.

Have patients stop smoking for a minimum of 4 weeks before and after surgery.
REFERENCES


surgery facility: a review of 5316 consecutive cases. Plast Reconstr Surg 112:636, 2003.
3. Keyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety using an
internet-based quality improvement and peer review program. Plast Reconstr Surg 113:1760,
2004.

facility: a report on more than


anesthesia care/sedation in 4778 consecutive plastic surgery procedures. Plast Reconstr Surg
111:150, 2003.

Reconstr Surg 99:1496, 1997.

Plast Reconstr Surg 122:1, 2008.



Surg 110:1337, 2002.


2002.

Surg J 26:551, 2006.
12. Sessler, DI. Complications and treatment of mild hypothermia. Anesthesiology 95:531, 2001.
13. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery: a prospective study.
Can J Anaesth 45:612, 1998.
-
sion of scheduled ambulatory surgery patients. J Clin Anesth 9:446, 1997.

nausea and vomiting. Plast Reconstr Surg 118:1060, 2006.
16. McGrath B, Elgendy H, Chung F, et al. Thirty percent of patients have moderate to severe pain
24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth 51:886, 2004.
17. Watcha MF. Postoperative nausea and emesis. Anesthesiol Clin North Am 20:709, 2002.
18. Kim SI, Han TH, Kil HY, et al. Prevention of postoperative nausea and vomiting by continuous
infusion of subhypnotic propofol in female patients receiving intravenous patient-controlled
analgesia. Br J Anaesth 85:898, 2000.

140
Part III Safety
19. Habib AS, Gan TJ. Evidence-based management of postoperative nausea and vomiting: a re-
view. Can J Anaesth 51:326, 2004.
20. White PF, O’Hara JF, Roberson CR, et al; POST-OP Study Group. The impact of current anti-
emetic practices on patient outcomes: a prospective study on high-risk patients. Anesth Analg
107:452, 2008.
21. Buck DW, Mustoe TA, Kim JY. Postoperative nausea and vomiting in plastic surgery. Semin Plast
Surg 20:249, 2006.
22. American Society for Aesthetic Plastic Surgery. 2016 Cosmetic surgery national data bank
statistics. Available at
23. Fodor PB. Wetting solutions in ultrasound-assisted lipoplasty. Clin Plast Surg 26:289, 1999.
-
tice advisory on liposuction. Plast Reconstr Surg 113:1478, 2004.
25. Iverson RE, Pao VS. MOCS-PS CME article: liposuction. Plast Reconstr Surg 121:1, 2008.
26. Grazer FM, DeJong R. Fatal outcomes from liposuction: census survey of cosmetic surgeons.
Plast Reconstr Surg 105:436, 2000.
27. Hughes CE III. Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthet Surg J
21:120, 2001.
-
toria—six years of Florida data. Plast Reconstr Surg 118:777, 2006.



surgical procedures. Int J Gynaecol Obstet 99:257, 2007.
31. Hester TR, Baird W, Bostwick J, et al. Abdominoplasty combined with other major surgical
procedures: safe or sorry. Plast Reconstr Surg 86:997, 1989.
32. Stevens WG, Cohen R, Vath SD, et al. Is it safe to combine abdominoplasty with elective breast
surgery? A review of 151 consecutive cases. Plast Reconstr Surg 118:207, 2006.
33. Melendez MM, Beasley M, Dagum AB, et al. Outcomes of abdominoplasty performed in an

-

clinic. Plast Reconstr Surg 118:517; discussion 523, 2006.

factors for seroma formation. Plast Reconstr Surg 117:773; discussion 780, 2006.
36. Gordon NA, Koch ME. Duration of anesthesia as an indicator of morbidity and mortality in

8:47, 2006.

safety. Plast Reconstr Surg 112:871, 2003.

39. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and
pulmonary embolism: a 25-year population-based study. Arch Intern Med 158:585, 1998.

surgery. Aesthet Surg J 26:157, 2006.
41. McDevitt NB. Deep vein thrombosis prophylaxis. Plast Reconstr Surg 104:1923, 1999.
42. Seruya M, Baker SB. MOC-PS CME article: venous thromboembolism prophylaxis in plastic
surgery patients. Plast Reconstr Surg 122:1, 2008.

surgery patient. Plast Reconstr Surg 114:43e, 2004.

141
Chapter 9 Safety Considerations in Aesthetic Surgery

thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ
336:1227, 2008.
45. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications.
Plast Reconstr Surg 59:513, 1977.
46. Voss SC, Sharp HC, Scott JR. Abdominoplasty combined with gynecologic surgical procedures.
Obstet Gynecol 67:181, 1986.

enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg 122:269,
2008.
48. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: the University
of Iowa experience. Plast Reconstr Surg 111:398, 2003.
49. American Society for Bariatric and Metabolic Surgery. Estimate of bariatric surgery numbers,
2011-2015. Available at

M, Cowan GM Jr, eds. Update: Surgery for the Morbidly Obese Patient: The Field of Extreme

-
tant after roux-en-Y gastric bypass? J Gastrointest Surg 2:436, 1998.
52. Rohrich RJ. Body contouring surgery after massive weight loss. Plast Reconstr Surg 117:S1,
2006.


54. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the
massive weight loss patient. Plast Reconstr Surg 117:414, 2006.
-
touring surgery. Plast Reconstr Surg 119:1590, 2007.

1999. Centers of Disease Control and Prevention (CDC) Hospital Control Practices Advisory
Committee. Am J Infect Control 2:97; discussion 96, 1999.
57. Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Guidelines
for clinical care. Arch Surg 128:79, 1993.
58. Anderson DJ. Surgical site infections. Infect Dis Clin North Am 25:135, 2011.
59. Richard RD, Bowen TR. What orthopaedic operating room surfaces are contaminated with
bioburden? A study using the ATP bioluminescence assay. Clin Orthop Relat Res 475:1819,
2017.

operating-room trays. J Bone Joint Surg Am 90:1022, 2008.
61. Olsen Ma, Nepple JJ, Riew KD, et al. Risk factors for surgical site infection following orthopaedic
spinal operations. J Bone Joint Surg Am 90:62, 2008.
62. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor prepara-
tion. Am J Surg 121:251, 1971.
63. Humphreys H. Preventing surgical site infection. Where now? J Hosp Infect 73:316, 2009.
64. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site
infections. Ann Surg 253:1082, 2011.

Surg 247:918, 2008.
66. Steinberg JP, Braun BI, Hellinger WC, et al; Trial to Reduce Antimicrobial Prophylaxis Errors
(TRAPE) Study Group. Timing of antimicrobial prophylaxis and the risk of surgical site infec-
tions: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 250:10, 2009.

142
Part III Safety
67. Gould IM. Antibiotics, skin and soft tissue infection and methicillin-resistant Staphylococcus


of Staphylococcus aureus. N Engl J Med 362:9, 2010.
69. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent
surgical site infection. Cochrane Database Syst Rev 2:CD004985, 2015.
70. Atiyeh BS, Dibo SA, Hayek SN. Wound cleansing, topical antiseptics and wound healing. Int
Wound J 6:420, 2009.

of chlorhexidine showers before elective plastic surgical procedures. Infect Control Hops Epi-
demiol 30:77, 2009.

56:20, 2008.
73. Chim JH, Borsting EA, Thaller SR. Urban myths in plastic surgery: postoperative management
of surgical drains. Wounds 28:35, 2016.
74. Phillips BT, Wang ED, Mirrer J, et al. Current practice among plastic surgeons of antibiotic
prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and im-
plications for postoperative care. Ann Plast Surg 66:460, 2011.

143
Successful outcomes in aesthetic surgery and nonoperative cosmetic procedures
demand meticulous preparation and aftercare to ensure optimal results and minimize
risk of complications.
Preparation and aftercare regimens are commonly procedure, technique, and
practitioner dependent, but general principles and considerations may be applied.
Involving patients in their own management before and after cosmetic interventions
promotes understanding, empowers them to invest in their own results, and may help
to manage expectations.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
COMORBIDITIES
Elective aesthetic surgery patients are usually healthy. The presence of chronic
disease (including diabetes, hypertension, coronary heart disease, chronic obstructive
pulmonary disease, hepatic or renal dysfunction, cancer) necessitates
by the patient’s primary care physician or specialist.
Poor glycemic control places diabetic patients at increased risk of surgical
site infection and delayed wound healing.
1,2
Uncontrolled hypertension increases risk of bleeding and hematoma
in all aesthetic procedures, and visual loss after blepharoplasty.3
Hematologic consultation should be considered for patients with
history of coagulopathy or venous thromboembolism (VTE).
• Most elective plastic surgery procedures performed in the United States are performed

and results in a
• VTE risk is increased if combined with cancer, travel, immobilization, use of oral
contraceptives, hormone replacement therapy, and estrogen receptor antagonists.
In low-risk ambulatory plastic surgery patients, preoperative laboratory testing is costly,
4
A patient’s mental health should be preoperatively assessed and
appropriately addressed before proceeding with any elective procedure.5 Patients with
mental health conditions—whether psychiatric disorders, such as body dysmorphic
disorder or substance abuse diagnoses—who undergo outpatient aesthetic surgery seek
hospital-based acute care within 30 days postoperatively
(see Chapter 1).
Every patient’s medications must be carefully reviewed. Table 10-1, although
not exhaustive, lists medications associated with postoperative complications and/or
interference with some anesthesia and may require discontinuation or special precautions.

144
Part III Safety
Medications Requiring Discontinuation or Special Precautions

Acarbose


ACTOS



Amiloride
APIDRA
ATACAND
AVANDAMET

AVANDIA
AVAPRO
BENEMID
BENICAR
Benazepril
Bumetanide

BYETTA
CAPOTEN
Captopril
Chlorothiazide
chlorproPAMIDE
Chlorthalidone


DIOVAN

DUETACT
EDECRIN
Enalapril
ENDURON
Eplerenone
Exenatide
Fosinopril
FUROCOT
FUROMIDE
Furosemide
Glimepiride




glyBURIDE




Hydrocort
Indapamide
INSPRA



detemir, insulin
glargine):
Arrive at hospital
before 10
AM: Hold
morning dose
Arrive at hospital
after 10 AM: Half
of usual dose
insulin aspart,
glulisine, lispro
JANUMET
JANUVIA






Mannitol

Methyclothiazide
Metformin
Metolazone
MICARDIS

MIDAMOR
Miglitol
Moexipril

Nateglinide



Perindopril
Pioglitazone
Polythiazide
PRANDIN
PRECOSE


Quinapril
Ramipril
RENESE
Repaglinide
Rosiglitazone
Sitagliptin
Spironolactone






Torsemide
Trandolapril
Triamterene
Valsartan
VASOTEC

ANTARA
APOKYN
Apomorphine
Bromocriptine
Cholestyramine
Colesevelam

Colestipol

EMSAM
Ezetimibe







NEUPRO
Niacinamide

NIACOR
NIASPAN
NICOMIDE-T

OMACOR
Omega-3-
acid ethyl esters
Pergolide

Pramipexole

QUESTRAN
REQUIP
Ropinirole
Rotigotine
Selegiline

TRICOR

145
Chapter 10 Decreasing Complications in Aesthetic Surgery

Abciximab
ACTRON





AMIGESIC
ANACIN
Anakinra

ANSAID
ANTURANE

ARGESIC
ARTHRA-G
ARTHROPAN
ASCRIPTIN
ASPER-BUFF
ASPERCIN
ASPERGUM
ASPIRTAB
ASPIR-TRIN
ASPROJECT
Astropan

BAYER
Betamethasone
BUFF A
BUFFAPRIN
BUFFERIN
BUFFETTS

CAMA

Celecoxib
Cilostazol

Clopidogrel
COPE
CORICIDIN
Cortisone
COUMADIN
Dalteparin
Danaparoid
DARVON
DASIN
DAYPRO
DECADRON
Dexamethasone
Diclofenac

Dipyridamole

DOANS

ECOTRIN
EFFICIN
EMPIRIN

ENCAPRIN
Enoxaparin
Ephedra

EQUAGESIC
Etanercept
Etodolac


Fenoprofen


Fludrocortisones
Flurbiprofen
FRAGMIN
Gamma-
butyrolactone/
gamma-
hydroxybutyric acid

Hormone
replacement
Hydrocortisone
HUMIRA
IBREN
Ibuprofen
INDOCIN
Indomethacin

INNOHEP
Isocarboxazid
JANTOVEN
Ketoprofen
Ketorolac
KINERET




MAGAN



Meloxicam
Methotrexate
methylPREDNISolone

MOBIC
MOMENTUM
MOTRIN
Nabumetone


NAPROSYN
Naproxen

NASACORT
NEOPROFEN
Oral contraceptives
ORGARAN
ORUDIS

Oxaprozin
PARNATE

Phenelzine
Piroxicam

Prednisone


Rasagiline

REMICADE
REOPRO
RHINOCORT


Selective estrogen
receptor modulators

Sulindac

Ticlopidine
Tinzaparin


Tolmetin

Triamcinolone
TRIGESIC
Unfractionated
Heparin
Valerian
VANQUISH

Warfarin

146
Part III Safety
SUPPLEMENTS see C
Use of herbal medicines and supplements is more prevalent in the cosmetic surgery
population than in the population at large (49% versus 42%, respectively).6
Nutritional supplements are not routinely recommended in lieu of a healthy, well-
balanced diet.
of patients do not report use of supplements.7
Many herbal medicines and supplements are cited for adverse reactions and should not
be taken for 2-3 weeks before and after surgery8 (Box 10-1), according to the American
Society of Anesthesiologists.
Box HERBS AND SUPPLEMENTS TO AVOID TWO TO THREE WEEKS BEFORE
AND AFTER SURGERY
Bilberry
Cayenne
Chondroitin* (postoperative bleeding)
Dong quai
Echinacea* (potentiates barbiturate and
halothane toxicity, allergic reaction,
immunosuppression)
Ephedra* (hypertension and cardiac
instability)
Feverfew
Fish oil
Garlic* (perioperative bleeding)
Ginko* (postoperative sedation,
perioperative bleeding)
Ginger
Ginseng* (perioperative bleeding)
Glucosamine* (hypoglycemia)
Goldenseal* (volume depletion,
postoperative sedation,
photosensitization)
Green tea
Guarana
Hawthorne
Kava kava* (postoperative sedation)

Ma huang
Meadowsweet
Melatonin
Milk thistle* (volume depletion)
Niacin
Red clover
Saw palmetto
St. John’s wort
Turmeric
Valerian
Vitamin E
Yohimbe
White willow
*Top ten herbal and supplemental medications used by cosmetic patients.8

Pineapple extract

to potentiate antibiotics
500-1500 mg/day taken in divided doses 1-2 weeks preoperatively and postoperatively
More randomized, controlled clinical trials necessary to determine its clinical potential9

Reported to reduce ecchymosis and edema postoperatively; contradictory evidence10
May be equivalent to steroids in reducing postrhinoplasty edema when used
postoperatively11

147
Chapter 10 Decreasing Complications in Aesthetic Surgery

Impairment of wound healing caused by use of corticosteroids can be reversed by the
oral administration of vitamin A (retinoic acid), use 15,000 IU daily for 7 days; however,
this is not common surgical practice.
12

6 (pyridoxine), vitamin B1 (thiamine),
or vitamin B2
supplementation.13

surgical risks.

and de
which may be reversed by vitamin C supplementation.14

poor surgical candidates.
SURGEON ATIENT COMMUNICATION
Patient satisfaction is highly dependent on the initial consultation. This interaction not

with surgical and overall outcomes.
15
Behaviors that lead patients to not recommend surgeons to friends and family
members include failure to adequately explain medical condition, failure to show
interest in the patient, failure to ask if the patient has questions, and failure to answer
questions.
16
LIFESTYLE MODULATION

need to be addressed with the patient before the procedure (Box 10-2).
Box RELATIVE AND ABSOLUTE CONTRAINDICATIONS FOR OFFICE-BASED
AESTHETIC SURGERY

Poorly controlled systemic disease
Moderate to severe obstructive sleep apnea
Morbid obesity
Myocardial infarction in last 6 months
Cerebral vascular accident in last
3 months


Unstable psychological disease
Acute substance abuse
History of malignant hyperthermia (if use
of triggering agent planned)
History of end-stage renal failure,
undergoing dialysis
Sickle cell disease
Myasthenia gravis
Younger than 3 years old



High-volume liposuction with second
procedure
Multiple procedures with abdominoplasty

148
Part III Safety


resulting in tissue hypoxia and ischemia.17
A common recommendation is a 4-week period of no smoking both before and after
surgery.18
Pharmacologic (nicotine replacement, bupropion) and nonpharmacologic (counseling,
behavioral therapy, hypnosis, psychotherapy, electrical stimulation) smoking cessation
strategies should be considered.
If noncompliance is suspected, a urine cotinine (a nicotine metabolite) test is
recommended preoperatively.19,20
Alternatively, a blood test can measure multiple nicotine metabolites (cotinine,
anabasine, nornicotine) to give a clearer picture of active smoking, passive smoke
inhalation, and use of nicotine replacement therapies.
TIP: A urine cotinine test is a simple and inexpensive measure to determine whether
a patient has smoked within the last 4 days.

Potentially alcohol-induced disorders of the liver, pancreas, and nervous system

metabolic stress response, and induces muscular dysfunction.

Dose-response relationship between alcohol intake and an increase in postoperative
morbidity
• Complication rate is about in patients who drink
compared with 0-2 per day.
21
Recommend decreasing and even abstaining from alcohol 1-2 weeks preoperatively
and postoperatively to decrease risk of perioperative bleeding.22

The following foods may potentiate bleeding, and some physicians advise decreased
intake 1-2 weeks before and after surgery (Box 10-3).

149
Chapter 10 Decreasing Complications in Aesthetic Surgery
Box FOODS THAT MAY POTENTIATE BLEEDING
Avocados
Apples
Apricots
Blackberries
Cherries
Cucumbers
Currants
Dewberries
Fish (especially
salmon)
Garlic
Gooseberries
Grapefruit
Grapes

Melons
Nectarines
Onions
Oranges
Peaches
Peppers
Plums
Potatoes
Prunes
Raisins
Raspberries
Root beer

Soybeans
Spicy foods
Strawberries

Sweet potatoes
Tomatoes
Wheat germ oil
DECOLONIZATION AND SKIN ANTISEPSIS
Surgical site infection can be a devastating complication of aesthetic surgery, especially
when implanting a prosthetic material (e.g., breast augmentation).
is the leading cause of surgical site infection, and the prevalence
of methicillin-resistant (MRSA) surgical site infection is increasing.
Presurgical decolonization and skin antisepsis have been demonstrated to decrease
surgical site infections drastically, particularly in cardiac and orthopedic surgery
implant-based procedures, and support is emerging for similar practice in plastic
surgery.
23-25

• Two to 4 weeks before surgery, patients who may have an increased likelihood of
MRSA infection (e.g., history of infection, health care worker, immunocompromised)
are screened for nasal carriage as outpatient procedures, with samples
collected from both nares on a single swab. (The association with nasal carriage of
and subsequent infection is well established.
26,27)
• Patients with nasal cultures positive for are instructed to apply 2%
mupirocin nasal ointment twice daily to both nares and to bathe with chlorhexidine
(40 mg/ml Hibiscrub) daily for 5 days immediately before the scheduled surgery.
Patients with a history of MRSA infection or
type I allergy to penicillin and patients who are MRSA carriers receive vancomycin
1 g 60 minutes before surgery; all others receive cefazolin 2 g 30-59 minutes before
surgery.
2
DVT RISK ASSESSMENT see C
The
prophylaxis decisions. Patients at should be considered for
postoperative chemoprophylaxis.
28
Overall, postoperative enoxaparin does not increase rates of reoperative hematoma.12

150
Part III Safety
INTRAOPERATIVE MEASURES TO REDUCE COMPLICATIONS
The World Health Organization has developed a guideline of items to prevent mortality
and postoperative complications. These include three phases (sign in, time out, and
sign out) (Box 10-4).
Box ELEMENTS OF THE SURGICAL SAFETY CHECKLIST



and given consent.
• Surgical site has been marked (if applicable).
• The pulse oximeter is attached to the patient and functioning.
• Team members are aware of patient allergies (if applicable).
• Airway and risk of aspiration have been assessed; appropriate equipment and assistance
are available.

more than 500 ml (or 7 ml/kg of body weight for children).


• All team members introduce themselves by name and role.

and given consent.
• A review of anticipated critical events is completed by team.
• Surgeon describes critical or nonroutine steps, expected duration of the procedure, and
anticipated blood loss.


other anticipated concerns.

incision (if applicable).



following:
• Nursing team reviews all of the following with the entire team:
– Name of the procedure performed


– Any equipment issues that will need to be addressed
• Surgeon, anesthesia team, and nursing team all verbally note the key concerns for the
patient’s recovery and care.

151
Chapter 10 Decreasing Complications in Aesthetic Surgery

procedure, surgical site, and approval. The correct site is marked, allergies are reviewed,

takes place after anesthesia induction and before surgical incision. All team
members must participate and introduce themselves. Patient identity, operative site,



counts, labeling of surgical specimens, and revision of any problems in the use of
devices.



29
ANTIBIOTIC ADMINISTRATION

cephalosporins) is within before surgical incision.
and vancomycin require a longer period for administration and
should begin before incision.
Ancef
.
dosing is 900 mg and should be redosed
The Surgical Care Improvement Project has emphasized limiting postoperative
antibiotics; however, withholding postoperative antibiotics in prosthetic breast
reconstruction is associated with an increased risk of surgical site infection.
30
Postoperative antibiotic prophylaxis is not routinely indicated for septorhinoplasty.31
SURGICAL SITE PREP
In a review of common skin prep agents, 2% chlorhexidine gluconate (CHG) and 4%
CHG (Hibiclens) demonstrated inferior antimicrobial activity to isopropyl alcohol (IPA)
(70%) or 2% CHG combined with IPA (ChloraPrep).
32
A Cochrane analysis also suggested
33
with an aqueous base.
CAUTION:

ChloraPrep is superior to povidone-iodine for preoperative cleansing.
PATIENT POSITIONING
Poor patient positioning can make any procedure more challenging and lead to poor
results. It can also lead to patient morbidities such as pressure sores, peripheral nerve
injury, and alopecia.
after vigorous movement of the head and neck during
surgery and after prone positioning has been reported.34

152
Part III Safety
Prone positioning places
increased pressure on
the knees, chest, and
pubis. Gel rolls, pillows,
or foam egg crates
should be used. It can
also result in increased
ocular pressure, and
padded goggles are
recommended (Fig.
10-1).
35
A 1990 analysis of the
American Society of
Anesthesiologists Closed
Claims Project database
showed that 15% of
claims were
<90 degrees reduced the risk of nerve compression.
36
STERILIZATION OF INSTRUMENTS LASHING

instrument but can lead to

37
only be performed when instruments are properly cleaned and inspected before
sterilization, delivered directly to their point of use, handled aseptically during transfer,

38
NORMOTHERMIA

Anesthetic agents disrupt the body’s natural thermoregulatory mechanisms and can
inhibit shivering, vasoconstriction, and sweating.
can result in by impairing immune
defenses and decreasing local oxygen tension.

perioperative myocardial events.39
Patient temperature can be maintained passively through blankets, surgical drapes, and


6).
Standards of the Surgical Care Improvement Project require that patients have at least

the documented anesthesia end time.
Patient
positioning.

153
Chapter 10 Decreasing Complications in Aesthetic Surgery
SUTURE CHOICE
Barbed sutures may expedite wound closure and decrease wound tension. The suture

Pharmaceuticals) (see Chapter 28).
Barbed sutures are associated with higher rates of minor wound complications and may
result in incision site erythema.40 Foreign materials may be trapped by the suture barbs
and induce an immune response. Consequently,

Despite decreased skin closure and anesthesia times with barbed sutures, current costs
are six to seven times those of Vicryl or Biosyn and twice as much as Monocryl.
POSTOPERATIVE MEASURES TO DECREASE COMPLICATIONS
PAIN CONTROL
Uncontrolled postoperative pain can delay recovery, result in unanticipated
readmission, and decrease patient satisfaction.

decreases postoperative pain in breast reduction and abdominoplasty, but additional
product cost must be considered.
Ketorolac is associated with increased hematoma rates and is safe to use in
aesthetic plastic surgery.41

perioperative pain management after facelift surgery.42
VENOUS THROMBOEMBOLISM PROPHYLAXIS see C
The incidence rate of VTE in aesthetic surgery is 43
seems to have the highest probability of VTE compared with other
plastic surgery procedures, with a DVT incidence of 1.1% and pulmonary embolism (PE)
incidence of 0.8 % in abdominoplasty patients.
with circumferential body contouring operations are
at even greater risk, with a
Every provider and institution should adopt a formal, active strategy designed to
prevent VTE.

of VTE.
and on the operating table are logical measures
that should be applied to all patients undergoing surgery, regardless of their risk.

surgery patients have not been validated to date, but Table 10-2 presents the latest
recommendations.
44

154
Part III Safety
Venous Thromboembolism Prophylaxis

Healthy patients having
outpatient surgery
General or regional anesthesia
procedure lasting <1 hour or
Sedation procedure <2 hours
General or regional anesthesia


Proper positioning and early
ambulation
Intermittent pneumatic
compression or venous foot
pumps

Patients with 0-4 risk factors
having surgery requiring
admission and recovery in
the hospital
Abdominoplasty patients
Normal risk of bleeding and
3-4 risk factors
High risk of bleeding or 0-2
risk factors*
Enoxaparin 30 mg SQ daily
and intermittent pneumatic
compression or venous foot
pumps
First dose given 12 hours
postoperatively
Intermittent pneumatic
compression or venous foot
pumps


having surgery requiring
admission and recovery in
the hospital
Body contouring patients
having other intraabdominal
or pelvic procedures
Normal risk of bleeding
High risk of bleeding*
Enoxaparin 40 mg SQ daily
and intermittent pneumatic
compression or venous foot
pumps
First dose given 12 hours
postoperatively
Intermittent pneumatic
compression or venous foot
pumps
*Mechanical thromboprophylaxis should be switched to anticoagulant thromboprophylaxis when high
bleeding risk decreases.
RISK FACTORS
Major surgery
Erythropoiesis-stimulating medications

Central venous access
Trauma
Paroxysmal nocturnal hemoglobinuria
Immobility of lower extremities
Medications
Cancer (excluding skin)
Myeloproliferative disorders
Cancer therapy (chemotherapy/radiotherapy)
Obesity

Thrombophilia

155
Chapter 10 Decreasing Complications in Aesthetic Surgery
Nephrotic syndrome
Pregnancy/postpartum

Oral contraceptives (with estrogen)
Acute medical illness
Hormone replacement therapy
Selective estrogen receptor
ADJUNCTIVE THERAPIES

The evidence that decrease facial swelling and
ecchymosis following facelift remains and may be
associated with increased cost and risk for complications, including exacerbation of
hypertension, deterioration of glucose control, an increased rate of infection, and the
potential for avascular osteonecrosis.
46-48
For perioperative corticosteroid use
ecchymosis. Preoperative use is superior to postoperative use, and extended dosing is
superior to singular.
11,49-51

Clears the main lymphatic collectors, favoring mobilization of edema, which can
notably improve the decongestion of the face, neck, and/or extremities
• In some instances, graduated support garments may replace or augment lymphatic
massage postoperatively.
Usually performed by trained aestheticians or physical therapists and has become
particularly popular after facelifts with common protocols advocating one to three
sessions spaced over postoperative days.*
Contrary to the procedure in which drainage of the facial skin of the nonoperated face is
massaged to promote drainage to the parotid, submaxillary, and occipital lymph nodes,
after a facelift, the massages must be in direction, that is, to the
and from there to the deep nodes of the neck.

patients, reducing postoperative anxiety.52
SCAR MANAGEMENT

• Applied to fresh surgical incisions and replaced every 3-7 days for up to 12 weeks
is useful in low-risk patients to improve scar cosmesis and prevent hypertrophic
scarring.
54-56

• Most accepted modality in the treatment and prevention of hypertrophic scar in
high-risk patients (i.e., those who have previously had abnormal scarring or are
undergoing a procedure with high incidence of poor scarring such as breast
surgery)
• Should begin soon after surgical closure, when the incision has fully epithelialized,
and be continued for at least 1 month
*References 12, 14, 20, 21, 24, 27, 28, 33, 39.

156
Part III Safety
• Silicone gel sheets should be worn for a minimum of 12 hours daily, and if possible
for 24 hours daily with twice-daily washing.

preventing scarring, but they may be more appropriate on the head and neck
27
Topical vitamin E, cocoa butter, onion extract cream (e.g., Mederma), allantoin-
sulfomucopolysaccharide gel, glycosaminoglycan gel, and creams containing extracts
from plants such as Bulbine frutescens and Centella asiatica have been shown to
consistently improve scar appearance as single agents.

associated with their application; thus deep wound massage therapy is a common

limited.
41,43,44
A new device designed to minimize tension on the scar (Embrace; Neodyne

a prospective, randomized multicenter clinical trial.
57,58
TOP TAKEAWAYS

Management of comorbidities must be optimized before elective aesthetic
intervention.


outcomes and should be addressed.

Decolonization and skin antisepsis should be considered to reduce surgical site
infection, especially for prosthetic implantation.

Basic skin care underpins success in achieving aesthetic rejuvenation and
consists of routine exfoliating, cleansing, moisturizing, photoprotection, and
antiaging treatment (i.e., topical retinoids).

Risk of perioperative VTE can be reduced by following current guidelines.

Adjunctive therapies such as lymphatic massage and graduated compression
garments can expedite healing and enhance well-being postoperatively.


to favorably modulate scar maturation.
REFERENCES
1. Guyuron B, Raszewski R. Undetected diabetes and the plastic surgeon. Plast Reconstr Surg
86:471, 1990.
2. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce postoperative complications
in plastic surgery. Plast Reconstr Surg 137:351, 2016.
3. Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: incidence, management, and
preventive measures. Aesthet Surg J 31:21, 2011.
4. Fischer JP, Shang EK, Nelson JA, et al. Patterns of preoperative laboratory testing in patients
undergoing outpatient plastic surgery procedures. Aesthet Surg J 34:133, 2014.
5. Wimalawansa SM, Fox JP, Johnson RM. The measurable cost of complications for outpatient
cosmetic surgery in patients with mental health diagnoses. Aesthet Surg J 34:306, 2014.

157
Chapter 10 Decreasing Complications in Aesthetic Surgery
6. Broughton G II, Crosby MA, Coleman J, et al. Use of herbal supplements and vitamins in plastic
surgery: a practical review. Plast Reconstr Surg 119:48e, 2007.

supplement use in facial cosmetic patients. Plast Reconstr Surg 132:78, 2013.
8. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and supplemental medicines used
by cosmetic patients: what the plastic surgeon needs to know. Plast Reconstr Surg 117:436,
2006.
9. Orsini RA. Bromelain. Plast Reconstr Surg 118:1640, 2006.

Surg112:1164, 2003.
11. Totonchi A, Guyuron B. A randomized, controlled comparison between arnica and steroids
in the management of postrhinoplasty ecchymosis and edema. Plast Reconstr Surg120:271,
2007.

collagen synthesis. Ann Surg 177:222, 1973.

and joint disorder: microscopic, radiographic and biochemical evidence. Br J Nutr 71:919, 1994.

1994.

importance of preoperative information and patient-physician communication. Plast Reconstr
Surg 132:212e, 2013.

patients to not recommend the surgeon to family members or friends: analysis and impact.
Surgery 140:616; discussion 622, 2006.
17. Jensen JA, Goodson WH, Hopf H, et al. Cigarette smoking decreases tissue oxygen. Arch Surg
126:1131, 1991.
-
ing, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg
255:1069, 2012.
-
ing cessation: a systematic review and meta-analysis. Arch Surg 147:373, 2012.

plastic surgery. Plast Reconstr Surg 108:1063, 2001.
20. Rohrich RJ, Coberly DM, Krueger JK, et al. Planning elective operations on patients who smoke:
survey of North American plastic surgeons. Plast Reconstr Surg 109:350, 2002.

evidence for best practice. Br J Anaesth 102:297, 2009.

23. Chen AF, Wessel CB, Rao N. Staphylococcus aureus screening and decolonization in orthopaedic
surgery and reduction of surgical site infections. Clin Orthop Relat Res 471:2383, 2013.
24. Craft RO, Damjanovic B, Colwell AS. Evidence-based protocol for infection control in immediate
implant-based breast reconstruction. Ann Plast Surg 69:446, 2012.
25. Feldman EM, Kontoyiannis DP, Sharabi SE, et al. Breast implant infections: is cefazolin enough?
Plast Reconstr Surg 126:779, 2010.

of Staphylococcus aureus. N Engl J Med 362:9, 2010.

158
Part III Safety
-
dence of postoperative wound infection. J Hosp Infect 31:13, 1995.
28. Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative enoxaparin prevents symptomatic
venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg 128:1093,
2011.
29. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med 360:491, 2009.
-
lactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of
infection. Plast Reconstr Surg 130:495, 2012.
31. Georgiou I, Farber N, Mendes D, et al. The role of antibiotics in rhinoplasty and septoplasty: a
literature review. Rhinology 46:267, 2008.
32. Hibbard JS. Analyses comparing the antimicrobial activity and safety of current antiseptic
agents: a review. J Infus Nurs 28:194, 2005.
33. Dumville JC, McFarlane E, Edwards P, et al. Preoperative skin antiseptics for preventing surgical
wound infections after clean surgery. Cochrane Database Syst Rev 2015:CD003949, 2015.
34. Bund M, Heine J, Jaeger K. [Complications due to patient positioning: anaesthesiological con-
siderations] Anasthesiol Intensivmed Notfallmed Schmerzther 40:329, 2005.
35. Shermak M, Shoo B, Deune EG. Prone positioning precautions in plastic surgery. Plast Reconstr
Surg 117:1584; discussion 1589, 2006.
36. Miller RD, ed. Miller’s Anesthesia, ed 8. Philadelphia: Elsevier Saunders, 2015.
37. AAMI/ANSI ST79. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health
Care Facilities, ed 4. Arlington, VA: Association of Advanced Medical Instruments, 2013.


surgical patient. Clin Plast Surg 40:429, 2013.

an analysis of outcomes. Aesthet Surg J 35:178, 2015.
41. Stephens DM, Richards BG, Schleicher WF, et al. Is ketorolac safe to use in plastic surgery? A
critical review. Aesthet Surg J 35:462, 2015.

pain in face-lift surgery. JAMA Facial Plast Surg 16:306, 2014.
43. Abboushi N, Yezhelyev M, Symbas J, et al. Facelift complications and the risk of venous throm-
boembolism: a single center’s experience. Aesthet Surg J 32:413, 2012.

surgery patient: current guidelines and recommendations. Aesthet Surg J 29:421, 2009.

Reconstr Surg 132:352e, 2013.

surgery. Archiv Otolaryngol Head Neck Surg 120:1137, 1994.
47. Owsley JQ, Weibel TJ, Adams WA. Does steroid medication reduce facial edema following face
lift surgery? A prospective, randomized study of 30 consecutive patients. Plast Reconstr Surg
98:1, 1996.

plasty: a prospective, randomized study. Plast Reconstr Surg 96:1547, 1995.
49. Hatef DA, Ellsworth WA, Allen JN, et al. Perioperative steroids for minimizing edema and ec-
chymosis after rhinoplasty: a meta-analysis. Aesthet Surg J 31:648, 2011.

Otolaryngol Head Neck Surg 117:990, 1991.

159
Chapter 10 Decreasing Complications in Aesthetic Surgery
-
tive bleeding in rhinoplasty. Ann Plast Surg 51:570, 2003.
52. Mottura AA. Face lift postoperative recovery. Aesthetic Plast Surg 26:172, 2002.
53. Khansa I, Harrison B, Janis JE. Evidence-based scar management: how to improve results with
technique and technology. Plast Reconst Surg 138:1655, 2016.
54. Atkinson JA, McKenna KT, Barnett AG, et al. A randomized, controlled trial to determine the


55. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar manage-
ment. Plast Reconstr Surg 110:560, 2002.

Surg 96:1715, 1995.

advanced scar therapy device to reduce incisional scar formation. Plast Reconstr Surg 134:536,
2014.
58. Havlik RJ. Vitamin E and wound healing. Plastic Surgery Educational Foundation DATA Com-
mittee. Plast Reconstr Surg 100:1901, 1997.

160
VTE is a life- or limb-threatening complication that can occur after surgical procedures.
It has been designated by the CDC as the
and has been designated by the Centers for Medicare and Medicaid
Services as a “never event” for some surgical procedures.
The annual estimate of VTE events is 500,000 cases with 100,000 deaths in the United
States.
VTE occurs in and, although this may seem
rare, it can be particularly devastating when it occurs in elective aesthetic surgery
patients.
Surgeons should consider patients’ VTE risk as part of the standard aesthetic surgery
workup.
Although research in plastic surgery patients has clearly demonstrated that all VTEs are
not preventable, surgeons can minimize VTE risk preoperatively, intraoperatively, and
postoperatively.
WHAT DO THE GUIDELINES SAY?
Both the American Society of Plastic Surgeons (ASPS) (2012) and American Association
of Plastic Surgeons (AAPS) (2016) have published

1,2

the 3

on baseline VTE risk, characterized by Caprini score and by procedure type.

SUMMARY OF CURRENT GUIDELINES
The 1 makes recommendations for aesthetic surgery patients who
have surgery under general anesthesia. Direct quotes are provided from their 2012
manuscript.
•

•

161
Chapter 11 Venous Thromboembolism and the Aesthetic Surgery Patient
•







The AAPS published a systematic review/meta-analysis and consensus panel on DVT/
PE prevention in 2016. Source data were largely derived from inpatient surgery, but
several recommendations were applicable to the aesthetic surgery population.
2 Direct
quotes are provided from their manuscript.
•


•


•

•


•

•

UNDERSTANDING THE CAPRINI RISK ASSESSMENT MODEL
This is a VTE risk assessment model that has been
including plastic, general/vascular/urology, gynecology oncology, and otolaryngology/
head and neck.
The Caprini RAM is a that is easy to complete at either the
patient’s initial consultation or preoperative visit (Fig. 11-1).


• An aggregate risk factor score is generated and correlates with a

• Using this information, physicians can make a decision about chemoprophylaxis and
other risk-reduction strategies.
Current recommendations support the use of the 2005 Caprini RAM and not
which places more patients in a higher-risk category but does not
increase the sensitivity of predicting VTE.
4

162
Part III Safety
WHAT AESTHETIC SURGERY PATIENTS ARE AT HIGHEST RISK?
Among cosmetic procedures,
The procedure type with the greatest risk is
circumferential abdominoplasty, which has an associated VTE frequency of
5
The Doctors Company has seen an increase in malpractice claims involving VTE, and a
major issue is
• In a review of 12 claims, 8 were abdominoplasty cases (6 of those 8 were combined
procedures). Half of all patients had general anesthesia, the other half had IV
sedation. Death occurred in 9 patients.
Why is the risk of VTE increased with abdominoplasty?
Contributing causes include length of procedure (venous pooling
with general anesthesia), prone positioning for hip liposuction (increased venous


6
and decreased postoperative mobility.














month)



Caprini risk assessment model.











If yes:

















month)


therapy



premature birth with toxemia or growth-
restricted infant

163
Chapter 11 Venous Thromboembolism and the Aesthetic Surgery Patient
WHAT CAN BE DONE BEFORE SURGERY ISK STRATIFICATION
Complete a full history and physical examination and a VTE risk assessment tool such as
the 2005 Caprini RAM. This tool reminds surgeons to ask about
genetic hypercoagulability, and current estrogen
usage, among other often missed risk factors.
• Studies among plastic surgery inpatients
7 and surgical outpatients8
an 18- to 20-fold variation in VTE risk among the overall surgical population.

risk.
NOTE:

Data from plastic surgery inpatients not given chemoprophylaxis can be used to
estimate VTE risk.9
0.32% 60-day VTE risk
1.22% 60-day VTE risk
2.55% 60-day VTE risk
8.54% 60-day VTE risk

provided and discussed during the informed consent process.5,10,11
• Circumferential abdominoplasty: 3.4%
• Abdominoplasty with intraabdominal procedure: 2.1%
• Abdominoplasty with concomitant procedure: 0.67%
• Abdominoplasty alone: 0.34%
• Breast augmentation: 0.02%
• Facelift: 0.02%
can be considered if patients have family
member(s) with VTE or other notable risk factors.12

circumstances.
• Hypercoagulability testing is best ordered and interpreted by a hematologist.
• Hematologists can help to estimate level of VTE risk and can make
recommendations for VTE prevention strategies in high-risk patients.
• Aesthetic surgery is elective and can be delayed until the entire workup is complete.
WHAT CAN BE DONE BEFORE SURGERY ISK MODIFICATION
3
• BMI, presence of central line or chemoport, use of estrogen-based contraceptives,
among others
• Encourage patients to lose weight, have a general surgeon remove a chemoport,
wait at least 30 days between procedures, and hold estrogen products and

will theoretically decrease VTE risk.
13

Studies have associated and
with higher risk for VTE.5,14-16 The two are related, and the driving
force is unknown.

164
Part III Safety

factor.

than any other surgical specialty for patient convenience (single recovery),





17


• For example, compared with abdominoplasty alone, abdominoplasty plus
intraabdominal procedure has (0.34% versus 2.17%), and
abdominoplasty plus other procedure has (0.34% versus 0.67%).
5
• In another example, Tracking Operations and Outcomes for Plastic Surgeons (TOPS)
and CosmetAssure data suggested that among those having combined procedures,

for those having an abdominoplasty, compared with single procedures.
10


that
• The clinical relevance of these asymptomatic DVTs is unclear.

4.5% to 0.24%.
18
• Systematic review of air travel and VTE showed that elastic compression stockings,
but not aspirin or low-molecular-weight heparin, prevented DVT.19
For patients at very high risk, the decision to perform a surgical procedure is the last


procedure.
WHAT CAN BE DONE DURING SURGERY ISK REDUCTION

increases risk, compared with other anesthesia types.

versus IV sedation (OR: 0.11, CI: 0.03-0.43).
20
as
well as other mechanisms.
• Nongeneral anesthetic, when feasible for surgeon and patient, is preferred and safer.
options include elastic compression stockings and
intermittent pneumatic compression.

minimizes stasis.

21
• Intermittent pneumatic compression physically pumps blood from caudal to
cranial, re-creating the action of the calf muscle pump, and activates the body’s

22

165
Chapter 11 Venous Thromboembolism and the Aesthetic Surgery Patient
• The AAPS consensus statement recommended intermittent pneumatic compression
as superior to elastic compression stockings.2
on a pillow can promote venous egress.

intraabdominal pressure.6,23 This may cause inferior vena cava and femoral vein stasis,
predisposing to DVT.
• Surgeons should plicate only when clinically necessary, and not as a matter of course.
WHAT CAN BE DONE AFTER SURGERY ISK REDUCTION

Postoperative abdominal binders and compression garments can constrict the common
24,25
Mechanical prophylaxis (intermittent pneumatic compression) can be used to mimic
the calf muscle pump after surgery, at least until patients are ambulatory.
• There are no data on VTE risk reduction with postdischarge mechanical prophylaxis.
• Chemoprophylaxis, including unfractionated heparin and enoxaparin/low-molecular-
weight heparin, has been studied extensively among plastic surgery inpatients.
prophylaxis provided for the duration of inpatient

but not in lower-risk patients (Caprini scores of 3-4 and 5-6).
9

26
among aesthetic
surgery patients and is

risk in
27 and 28 surgery.

relationship.
2

opposed to all patients.


prophylaxis in nonorthopedic surgery patients.


29
Current guidelines explicitly recommend against aspirin as a single-agent
chemoprophylaxis for VTE.30
Screening duplex ultrasound for all patients, instead of other mechanical and
pharmacologic means of prophylaxis, has been recommended.31
• Among 200 aesthetic surgery patients, the rate of asymptomatic DVT was 0.5%.
SENIOR AUTHOR TIP: I strongly disagree with this practice of screening via duplex
ultrasound when performed instead of other mechanical and pharmacologic means.
• Current American College of Chest Physicians guidelines explicitly recommend
against screening duplex ultrasound, even in high-risk patients.

166
Part III Safety
TOP TAKEAWAYS


factors.

Considering patients’ risk based on their individual characteristics will allow
surgeons to modify risk factors and implement VTE prevention strategies in the
preoperative, intraoperative, and postoperative settings.

Generally, outpatient aesthetic surgical procedures should be <6 hours; all
patients should undergo a VTE risk assessment; appropriate measures for risk
reduction should be taken; and surgeons should have a low threshold to stage
cosmetic procedures.
REFERENCES

prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr
Surg 130:168e, 2012.

thrombosis and pulmonary embolus in plastic surgery: a systematic review and meta-analysis
of controlled trials and consensus conference. Plast Reconstr Surg 137:709, 2016.
3. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 51:70, 2005.
4. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of postoperative venous thromboembo-
lism risk in plastic surgery patients using the 2005 and 2010 Caprini Risk score. Plast Reconstr
Surg 130:343, 2012.
5. Hatef DA, Trussler AP, Kenkel JM. Procedural risk for venous thromboembolism in abdominal
contouring surgery: a systematic review of the literature. Plast Reconstr Surg 125:352, 2010.
6. Huang GJ, Bajaj AK, Gupta S, et al. Increased intraabdominal pressure in abdominoplasty:
delineation of risk factors. Plast Reconstr Surg 119:1319, 2007.
7. Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in
plastic and reconstructive surgery patients. J Am Coll Surg 212:105, 2011.
8. Pannucci CJ, Shanks A, Moote MJ, et al. Identifying patients at high risk for venous thrombo-
embolism requiring treatment after outpatient surgery. Ann Surg 255:1093, 2012.
9. Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative enoxaparin prevents symptomatic
venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg 128:1093,
2011.
10. Alderman AK, Collins ED, Streu R, et al. Benchmarking outcomes in plastic surgery: na-
tional complication rates for abdominoplasty and breast augmentation. Plast Reconstr Surg
124:2127, 2009.

anesthesia: results of a multicenter survey. Aesthetic Plast Surg 38:12, 2014.
12. Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist’s
perspective. Plast Reconstr Surg 136:545e, 2015.
13. Gupta V, Winocour J, Rodriguez-Feo C, et al. Safety of aesthetic surgery in the overweight
patient: analysis of 127,961 patients. Aesthet Surg J 36:718, 2016.
14. Kim JY, Khavanin N, Rambachan A, et al. Surgical duration and risk of venous thromboembo-
lism. JAMA Surg 150:110, 2015.
15. Howland WS, Schweizer O. Complications associated with prolonged operation and anesthesia.
Clin Anesth 9:1, 1972.

167
Chapter 11 Venous Thromboembolism and the Aesthetic Surgery Patient
16. Gravante G, Araco A, Sorge R, et al. Pulmonary embolism after combined abdominoplasty and

17. Haeck PC, Swanson JA, Iverson RE, et al. Evidence-based patient safety advisory: patient selec-
tion and procedures in ambulatory surgery. Plast Reconstr Surg 124(4 Suppl):S6, 2009.
18. Belcaro G, Geroulakos G, Nicolaides AN, et al. Venous thromboembolism from air travel: the

19. Philbrick JT, Shumate R, Siadaty MS, et al. Air travel and venous thromboembolism: a systematic
review. J Gen Intern Med 22:107, 2007.
20. Hafezi F, Naghibzadeh B, Nouhi AH, et al. Epidural anesthesia as a thromboembolic prophylaxis
modality in plastic surgery. Aesthet Surg J 31:821, 2011.
21. Sachdeva A, Dalton M, Amaragiri SV, et al. Elastic compression stockings for prevention of deep
vein thrombosis. Cochrane Database Syst Rev 2010(7):CD001484.


23. Al-Basti HB, El-Khatib HA, Taha A, et al. Intraabdominal pressure after full abdominoplasty in
obese multiparous patients. Plast Reconstr Surg 113:2145; discussion 2151, 2004.

venous stasis in the common femoral vein? Plast Reconstr Surg 135:85e, 2015.
25. Clayburgh DR, Stott W, Cordiero T, et al. Prospective study of venous thromboembolism in
patients with head and neck cancer after surgery. JAMA Otolaryngol Head Neck Surg 139:1143,
2013.

reoperative hematoma. Plast Reconstr Surg 129:160, 2012.

enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg 122:269,
2008.

dectomy. Plast Reconstr Surg 118:502; discussion 508, 2006.
29. Hunstad JP, Krochmal DJ, Flugstad NA, et al. Rivaroxaban for venous thromboembolism pro-
phylaxis in abdominoplasty: a multicenter experience. Aesthet Surg J 36:60, 2016.
30. Gould MK, Garcia DA, Wren SM, et al; American College of Chest Physicians. Prevention of VTE
in nonorthopedic surgical patients. Antithrombotic Therapy and Prevention of Thrombosis, 9th
ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest
141(2 Suppl):e227S, 2012.
31. Swanson E. Ultrasound screening for deep venous thrombosis detection: a prospective evalu-
ation of 200 plastic surgery outpatients. Plast Reconstr Surg Glob Open 3:e332, 2015.

(Trang không có chữ)

PART IV
Skin Care

(Trang không có chữ)