Commentary on: Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons’ Practices Free

Aimé et al¹ report survey results of The Aesthetic Society members to examine venous thromboembolism (VTE) practice patterns. The authors distributed a 55-question survey and present an extensive Results section that includes 15 tables. Although the sheer volume of information may prove difficult for some to digest, the “Ten Highlights” format of the Discussion does an admirable job summarizing the data and fitting data into the context of what is known.

There have been several similar surveys of board-certified plastic surgeons, each of which has targeted a slightly different surgeon base. Reinisch et al² surveyed members of The Aesthetic Society performing facelifts; Broughton et al³ surveyed American Society of Plastic Surgeons (ASPS) members performing facelift, liposuction, and abdominoplasty; Pannucci et al⁴ surveyed ASPS members performing tissue-based breast reconstruction; and Clavijo-Alvarez et al⁵ surveyed ASPS members performing post-bariatric body contouring. The current work by Aimé et al builds particularly on previous work by Reinisch and Broughton, providing updated data to describe how aesthetic surgeons conceptualize VTE.

Surgeon experience with VTE has not changed—these events continue to plague our patients. Aimé et al note in this paper that 50% of surgeons reported a patient with deep vein thrombosis and 40% reported a patient with pulmonary embolus. These numbers are eerily similar to surgeon experience reported 10 years ago,^4,5 which confirm that the majority of plastic surgeons have had these events occur in their practice. Alarmingly, 6.3% of surgeons (1 in 16) in this survey report having had 1 of their patients die from a postoperative pulmonary embolus. Sadly, this is stable to increased from previously reported numbers for surgeons performing general aesthetics (3%),³ flap-based breast reconstruction (4%),⁴ and post-bariatric body contouring (7%).⁵ The surgeon-reported, procedure-specific VTE risks from this study generally mirror and reinforce the patient-level, procedure-specific risks that have been elucidated from CosmetAssure.⁶

Previous surveys report that the majority of surgeons were following institutional (53%) or “other” (27%) guidelines to guide VTE prevention practices.⁴ This shows that a decade ago, in the absence of clear guidance, surgeons created their own standard. In stark contrast, the data presented here demonstrate the results of plastic surgery’s 10+ year effort to produce primary data, pooled analyses, and specialty-specific guidelines.^7-11 I was enthused to see that 94% of respondents are utilizing some form of individualized VTE risk stratification, most commonly the Caprini Risk Assessment Model¹² (74%). These practices are directly in line with existing consensus guidelines from the ASPS¹⁰ and the American Association of Plastic Surgeons.⁹

Nine years ago, surgeons who chose not to anti-coagulate patients cited bleeding risk (84%) and lack of plastic surgery-specific data (50%) as reasons.⁵ Interestingly, Aimé et al report a similar proportion of surgeons (70%) who do not anti-coagulate due to bleeding risk, but a much smaller proportion (20%) who cite an absence of specialty-specific data. As noted above, these clear changes in surgeon knowledge base are a nod to a specialty-wide, decade-long effort to produce primary data and consensus opinion statements. Surgeons most commonly (approximately 70%) report utilization of enoxaparin or another low-molecular-weight heparin as a prophylactic anticoagulant, based on specialty-specific data on safety and effectiveness.^13-16 However, approximately 15% of surgeons report utilizing Factor Xa inhibitors, likely influenced by the drug class’ oral administration. Although these drugs are not supported by multicenter clinical trials in plastic surgery patients, several smaller studies describing their safety, but arguably underpowered to show effectiveness, have been published.^17,18

The authors note that all aesthetic surgery patients do not require anticoagulation, and I certainly agree with them.¹⁹ Similarly, the majority of surgeons responding to the survey did not uniformly provide chemical prophylaxis to aesthetic surgery patients, and I am pleased that surgeons are utilizing individualized VTE risk stratification tools like the 2005 Caprini score to form this judgement.

This paper by Aimé et al provides an important snapshot into VTE prevention patterns being employed by aesthetic surgeons in 2020 and provides an interesting contrast to existing data from 15 to 20 years ago. As plastic surgeons, we have made enormous and demonstrable progress in the past decade to better understand optimal VTE prevention strategies. Despite these advances, VTE events still occur in aesthetic surgery patients, suggesting that we can continue to improve our care to optimize patient safety.

Disclosures

Dr Pannucci currently receives direct grant support from Mentor for an unrelated study in breast implants and chest wall trauma. Within the past 24 months, Dr Pannucci has received direct grant support from the CHEST Foundation for an unrelated study examining enoxaparin metabolism after thoracic surgery.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes