Venous thromboembolism in cosmetic plastic surgery: maximizing patient safety.

Cosmetic surgery is the epitome of elective surgery. Our patients seek us out to improve their physical appearance, which may, in turn, enhance their quality of life. Despite the exhaustive informed consent process, the safety of the procedures is implicit in the minds of our patients. Is cosmetic plastic surgery as safe as it can be? Deep vein thrombosis and pulmonary embolism are among the most common complications for patients undergoing surgical procedures. Advances in perioperative anesthesia and surgical techniques have allowed plastic surgeons to perform more complex and combined procedures safely. The occurrence of postoperative bleeding in these procedures may lead to poor cosmetic results or the need for further surgical intervention. Despite this, many, if not most, plastic surgeons still do not use any form of deep vein thrombosis or pulmonary embolism prophylaxis during their cosmetic surgery procedures. What is the incidence of deep vein thrombosis and pulmonary embolism in patients undergoing cosmetic plastic surgery? In the literature, Drs. Reinisch et al.1 reported an incidence of 0.35 percent deep vein thrombosis and pulmonary embolism in patients undergoing face lifts. In addition, nearly 61 percent of surgeons in their study did not use any form of prophylaxis. The study is limited by its design—a questionnaire sent to a percentage of the American Society for Aesthetic Plastic Surgery membership. The questionnaire asked surgeons to report on their experience in the 12 months prior to the arrival of the survey. Although it is difficult to forget a patient with postoperative deep vein thrombosis and pulmonary embolism, the study based its conclusions primarily on physician memory. This is an inadequate method on which to base any conclusions on the true incidence of deep vein thrombosis and pulmonary embolism in this patient population. Van Uchelen et al.2 reported a 1.4 percent incidence of deep vein thrombosis and pulmonary embolism in 86 patients undergoing abdominoplasty. This was a retrospective study and was not specifically designed to assess deep vein thrombosis and pulmonary embolism in this population. A recent article by Aly et al.3 reported their experience with belt lipectomy at the University of Iowa. The pulmonary embolism rate was 9.3 percent. Sequential compression stockings, early ambulation, and “sometimes” the use of subcutaneous heparin were cited as the modes of deep vein thrombosis prophylaxis. The American College of Chest Physicians’4 recommendations on prophylaxis attempted to stratify patients according to their perioperative risks for deep vein thrombosis. They classified patients as moderate risks if they were undergoing “nonmajor” surgery, were between 40 and 60 years of age, and had no other risk factors. These patients were estimated to have a proximal deep vein thrombosis incidence of 2 to 4 percent, with clinical pulmonary embolism in 1 to 2 percent (fatal pulmonary embolus, 0.1 to 0.4 percent). Patients were considered high risk if they were older than 60 years of age and undergoing nonmajor surgery. The proximal deep vein thrombosis risk in that group was estimated at 4 to 8 percent, with the risk for