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Abstract

Background

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

Objectives

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

Methods

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

Results

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

Conclusions

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

Level of Evidence: 4

graphic

Over the past several decades, the medical literature has consistently shown a greater prevalence of psychiatric disorders among patients seeking plastic surgery compared with the general US population.1-4 Additionally, these patients have a higher likelihood of poor surgical outcomes.3,5-13 Although literature exists regarding outcomes of cosmetic or plastic surgery procedures in patients with psychiatric diagnoses, many studies focus on patient satisfaction or worsening of their mental conditions, rather than surgical complications in the 30-day postoperative period, such as wound infection, bleeding, or hospital readmission.14-19 However, literature from other surgical specialties, such as general surgery, orthopedic surgery, and cardiac surgery, consistently found greater rates of these postoperative complications in patients with psychiatric diagnoses.3,8,12,13,20-30 Explanations regarding the higher rate of surgical complications in this group include the underlying physiology of the psychiatric disorder itself, higher rates of multiple comorbidities, including substance abuse, and that these patients often present for medical care at more advanced stages of disease and have poorer access to follow-up care.9-12,31-42

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in other surgical specialties but is not well characterized for reconstructive plastic surgery. Because psychiatric diagnoses are often underrecognized and underdocumented by healthcare providers, the use of a large, insurance-claims database such as the IBM MarketScan Commercial and Medicare Supplemental Databases (IBM, Armonk, NY) provides access to a large dataset to obtain adequate numbers of patients with both a documented psychiatric history, and who underwent a reconstructive plastic surgery procedure. Additionally, as surgical complication rates are generally low, the larger sample size helps identify statistically significant differences between groups of patients undergoing reconstructive plastic surgeries with and without these psychiatric diagnoses. Thus, the objective of this study was to use an insurance-claims database to compare the rate of reconstructive, noncosmetic plastic surgery, as well as 30-day postoperative surgical complications, between patients with and without psychiatric diagnoses. We hypothesize, as documented in the literature from other surgical subspecialties, that patients with psychiatric diagnoses have greater rates of 30-day postoperative complications after undergoing reconstructive plastic surgery than those who do not have these diagnoses.

METHODS

This study was approved by the institutional review board at Stanford University, and was determined to be exempt from human studies review. The IBM MarketScan Commercial and Medicare Supplemental Databases is a national dataset capturing administrative employer-based insurance claims. Claims were examined from patients over 18 years of age, between January 1, 2007 and December 31, 2015 (the date range for which IBM MarketScan data are available at our institution during the data-collection period). From this dataset, the presence of psychiatric diagnoses and comorbid conditions were identified according to the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9) codes (see Supplemental Table 1), which included anxiety, depression, body dysmorphic disorder (BDD), eating disorder, and other psychiatric diagnoses. These diagnoses were made at any time before or during the study period, and by any practitioner caring for the patient in the past or during the study period.

The occurrence of a reconstructive plastic surgery procedure, as determined by current procedural terminology, was also collected, and these procedures included a range of nasal, abdominal, oculoplastic, breast, and local tissue reconstructive procedures (see Supplemental Table 2).

Patients were excluded if they were under 18 years of age, lacked continuous insurance coverage for 1 year before or after the surgery date to ensure continuity of data entry during the study period, or underwent multiple types of procedures on the surgery date of interest (including more extensive procedures, unrelated procedures, and procedures from more than one reconstructive plastic surgery class). Additional sociodemographic and clinical covariates were collected, including age, sex, geographic region, tobacco use, substance abuse, and diagnoses of immunodeficiency, autoimmune disorders, and diabetes within the year prior to surgery (Supplemental Table 1). Overall comorbidity was assessed with the van Walraven modification of the Elixhauser index, which synthesizes 30 common comorbidities into a numeric score closely associated with mortality in the acute setting.43

Two analysis groups were formed. Due to the size of the insurance claims database, parameters were set for data extraction such that 650,000 patients meeting inclusion criteria for each group were randomly selected for analysis via an automated process. The final assessed number in each group was lower after applying the exclusion criteria listed above.

The first analysis group compared 2 cohorts of patients, one with and one without psychiatric diagnoses, and the 1-year incidence of reconstructive plastic surgery between these groups were compared. The second analysis group compared 2 cohorts of patients with and without psychiatric diagnoses, all of whom underwent a reconstructive plastic surgery procedure, and the rates of 30-day postoperative complications of these groups were compared.

For the first analysis group, each patient in the 2 cohorts (with/without psychiatric diagnoses) was assigned a randomly generated date, after which procedure codes for the included reconstructive plastic surgery procedures, as previously defined, were tracked for a 1-year period. This process was used to assess the 1-year incidence of a reconstructive plastic surgery procedure in each of the cohorts.

For the second analysis group, all of whom underwent a reconstructive plastic surgery procedure, the date of surgery was used to determine the incidence of a surgical complication within 30 days of this date, and compared between those with and without psychiatric diagnoses. Postoperative complications were defined as superficial and deep surgical site infections (SSIs) (with a superficial SSI defined as cellulitis, and a deep SSI defined as an abscess requiring incision and drainage), wound-healing complications, postoperative bleeding or hematoma, and postoperative hospital admission occurring within the 30-day postoperative period (see Supplemental Table 3 for associated ICD-9 codes).

Univariable and descriptive statistics were calculated for demographic variables and comorbidities comparing patients with and without psychiatric diagnoses for both analysis groups. For the first analysis group, the rates of reconstructive plastic surgery within this 1-year period were calculated. A multivariable logistic regression was performed to calculate 1-year odds of undergoing reconstructive plastic surgery comparing patients with and without psychiatric diagnoses. A multivariable logistic regression was also performed in the second analysis group to assess differences in overall and specific 30-day postoperative complications between patients with and without psychiatric diagnoses. A stepwise logistic regression (P < 0.2 for initial inclusion to allow for a wider range of confounding variables to be assessed) was used to identify relevant patient characteristics to include in the final model, which were age, sex, geographic region, van Walraven index, procedure class, and past-year comorbidities, including substance abuse. Calculated P values were 2-tailed, with significance defined as P < 0.05 in the final model. Outcomes of the multivariable logistic regression were reported as the adjusted odds ratio (aOR) and 95% confidence interval (CI). With the exception of calculating the van Walraven index with R version 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria), data extraction and statistical analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS

The first analysis group included 1,019,128 patients: 505,715 patients in the cohort with psychiatric diagnoses and 513,423 patients in the cohort without psychiatric diagnoses. Table 1 compares characteristics between the 2 cohorts. Patients with psychiatric diagnoses were more likely to be female (181,046 males [35.8%] and 324,669 females [64.2%] with psychiatric diagnosis, compared with 245,416 males [47.8%] and 268,007 females [52.2%] without psychiatric diagnosis, P < 0.01) and younger (mean [standard deviation] age, 35.3 [17.2] years, range, 18-87 years, compared with 44.3 [18.0] years, range, 18-91 years, P < 0.01) than those without psychiatric diagnoses. The most common psychiatric diagnosis class was anxiety (38.3%), and the most common comorbid condition among patients with psychiatric diagnoses was diabetes (7.6%), followed by tobacco use (5.1%). One-year surgery rates among patients with psychiatric diagnoses ranged between 4.8% and 7.0%, depending on the psychiatric diagnosis class, compared with 1.6% in those without psychiatric diagnoses. Patients with BDD (7.0%) and depression (6.5%) had the highest reconstructive plastic surgery rates. Multivariable logistic regression was conducted to determine the odds of undergoing reconstructive plastic surgery of each psychiatric diagnoses class compared with those without psychiatric diagnoses (adjusted for age, sex, region, van Walraven index, and past year comorbidities, including substance abuse); the results are shown in Table 2. Diagnosis of BDD was associated with the greatest odds of undergoing reconstructive plastic surgery (aOR, 3.16; 95% CI, 1.76-5.67), followed by anxiety disorders (aOR, 3.08; 95% CI, 2.97-3.17). All psychiatric diagnosis classes, however, showed greater odds of undergoing reconstructive plastic surgery within a 1-year period compared with patients without these diagnoses.

Table 1.
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One-Year Rates of Reconstructive Plastic Surgery Among Patients With and Without Psychiatric Diagnoses (n = 1,019,128)

CharacteristicWith psychiatric diagnosesWithout psychiatric diagnosesP
Number505,715 [49.7]513,423 (50.3)—
Male (n, %)181,046 [35.8]245,416 (47.8)<0.01
Age (years, [standard deviation])35.3 [17.2]44.3 (18.0)<0.01
Region (n, %)<0.01
 Northeast82,937 (16.4)69,312 (13.5)
 North central141,600 (28.0)134,003 (26.1)
 South161,828 (32.0)221,798 (43.2)
 West97,097 (19.2)80,607 (15.7)
 Unknown22,253 (4.4)7703 (1.5)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.02
Comorbidities (n, %)
 Tobacco use25,791 (5.1)22,077 (4.3)<0.01
 Substance abuse14,160 (2.8)5134 (1.0)<0.01
 Diabetes38,434 (7.6)27,724 (5.4)<0.01
 Immunodeficiency2022 (0.4)513 (0.1)<0.01
 Autoimmune disease1517 (0.3)2053 (0.4)<0.01
Psychiatric diagnosis class (n, %)a
  Anxiety193,688 (38.3)—
  Depression92,040 (18.2)—
 Body dysmorphic disorder71,305 (14.1)—
  Eating disorder29,331 (5.8)—
  Other138,060 (27.3)—
One-year plastic surgery rates by psychiatric diagnosis class (n, %)b
 Anxiety9297 (4.8)—
 Depression5982 (6.5)—
 Body dysmorphic disorder4991 (7.0)—
 Eating disorder1701 (5.4)—
 Other7731 (5.6)—
 No psychiatric diagnoses—8214 (1.6)
CharacteristicWith psychiatric diagnosesWithout psychiatric diagnosesP
Number505,715 [49.7]513,423 (50.3)—
Male (n, %)181,046 [35.8]245,416 (47.8)<0.01
Age (years, [standard deviation])35.3 [17.2]44.3 (18.0)<0.01
Region (n, %)<0.01
 Northeast82,937 (16.4)69,312 (13.5)
 North central141,600 (28.0)134,003 (26.1)
 South161,828 (32.0)221,798 (43.2)
 West97,097 (19.2)80,607 (15.7)
 Unknown22,253 (4.4)7703 (1.5)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.02
Comorbidities (n, %)
 Tobacco use25,791 (5.1)22,077 (4.3)<0.01
 Substance abuse14,160 (2.8)5134 (1.0)<0.01
 Diabetes38,434 (7.6)27,724 (5.4)<0.01
 Immunodeficiency2022 (0.4)513 (0.1)<0.01
 Autoimmune disease1517 (0.3)2053 (0.4)<0.01
Psychiatric diagnosis class (n, %)a
  Anxiety193,688 (38.3)—
  Depression92,040 (18.2)—
 Body dysmorphic disorder71,305 (14.1)—
  Eating disorder29,331 (5.8)—
  Other138,060 (27.3)—
One-year plastic surgery rates by psychiatric diagnosis class (n, %)b
 Anxiety9297 (4.8)—
 Depression5982 (6.5)—
 Body dysmorphic disorder4991 (7.0)—
 Eating disorder1701 (5.4)—
 Other7731 (5.6)—
 No psychiatric diagnoses—8214 (1.6)

IQR, interquartile range. *P < 0.01. aSum of percentages adds up to >100% as some patients had psychiatric diagnoses from >1 class. bDenominator of percentages is the total number of patients within a given psychiatric diagnosis class.

Table 1.
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One-Year Rates of Reconstructive Plastic Surgery Among Patients With and Without Psychiatric Diagnoses (n = 1,019,128)

CharacteristicWith psychiatric diagnosesWithout psychiatric diagnosesP
Number505,715 [49.7]513,423 (50.3)—
Male (n, %)181,046 [35.8]245,416 (47.8)<0.01
Age (years, [standard deviation])35.3 [17.2]44.3 (18.0)<0.01
Region (n, %)<0.01
 Northeast82,937 (16.4)69,312 (13.5)
 North central141,600 (28.0)134,003 (26.1)
 South161,828 (32.0)221,798 (43.2)
 West97,097 (19.2)80,607 (15.7)
 Unknown22,253 (4.4)7703 (1.5)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.02
Comorbidities (n, %)
 Tobacco use25,791 (5.1)22,077 (4.3)<0.01
 Substance abuse14,160 (2.8)5134 (1.0)<0.01
 Diabetes38,434 (7.6)27,724 (5.4)<0.01
 Immunodeficiency2022 (0.4)513 (0.1)<0.01
 Autoimmune disease1517 (0.3)2053 (0.4)<0.01
Psychiatric diagnosis class (n, %)a
  Anxiety193,688 (38.3)—
  Depression92,040 (18.2)—
 Body dysmorphic disorder71,305 (14.1)—
  Eating disorder29,331 (5.8)—
  Other138,060 (27.3)—
One-year plastic surgery rates by psychiatric diagnosis class (n, %)b
 Anxiety9297 (4.8)—
 Depression5982 (6.5)—
 Body dysmorphic disorder4991 (7.0)—
 Eating disorder1701 (5.4)—
 Other7731 (5.6)—
 No psychiatric diagnoses—8214 (1.6)
CharacteristicWith psychiatric diagnosesWithout psychiatric diagnosesP
Number505,715 [49.7]513,423 (50.3)—
Male (n, %)181,046 [35.8]245,416 (47.8)<0.01
Age (years, [standard deviation])35.3 [17.2]44.3 (18.0)<0.01
Region (n, %)<0.01
 Northeast82,937 (16.4)69,312 (13.5)
 North central141,600 (28.0)134,003 (26.1)
 South161,828 (32.0)221,798 (43.2)
 West97,097 (19.2)80,607 (15.7)
 Unknown22,253 (4.4)7703 (1.5)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.02
Comorbidities (n, %)
 Tobacco use25,791 (5.1)22,077 (4.3)<0.01
 Substance abuse14,160 (2.8)5134 (1.0)<0.01
 Diabetes38,434 (7.6)27,724 (5.4)<0.01
 Immunodeficiency2022 (0.4)513 (0.1)<0.01
 Autoimmune disease1517 (0.3)2053 (0.4)<0.01
Psychiatric diagnosis class (n, %)a
  Anxiety193,688 (38.3)—
  Depression92,040 (18.2)—
 Body dysmorphic disorder71,305 (14.1)—
  Eating disorder29,331 (5.8)—
  Other138,060 (27.3)—
One-year plastic surgery rates by psychiatric diagnosis class (n, %)b
 Anxiety9297 (4.8)—
 Depression5982 (6.5)—
 Body dysmorphic disorder4991 (7.0)—
 Eating disorder1701 (5.4)—
 Other7731 (5.6)—
 No psychiatric diagnoses—8214 (1.6)

IQR, interquartile range. *P < 0.01. aSum of percentages adds up to >100% as some patients had psychiatric diagnoses from >1 class. bDenominator of percentages is the total number of patients within a given psychiatric diagnosis class.

Table 2.
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Odds of Undergoing Reconstructive Plastic Surgery Among Patients with Psychiatric Diagnoses Compared With Those Without

Psychiatric diagnosis classaOR (95% CI)a
Depression1.99 (1.93-2.07)*
Anxiety3.08 (2.97-3.17)*
Body dysmorphic disorder3.16 (1.76-5.67)*
Eating disorder2.21 (1.96-2.53)*
Otherb2.29 (2.10-2.50)*
Psychiatric diagnosis classaOR (95% CI)a
Depression1.99 (1.93-2.07)*
Anxiety3.08 (2.97-3.17)*
Body dysmorphic disorder3.16 (1.76-5.67)*
Eating disorder2.21 (1.96-2.53)*
Otherb2.29 (2.10-2.50)*

aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01. aAdjusted for age, sex, region, van Walraven index, and past-year comorbidities (tobacco use, substance abuse, diabetes, immunodeficiency, autoimmune disorders) when compared with cohort not undergoing surgery. bOther psychiatric diagnoses include personality disorders, obsessive compulsive disorder, posttraumatic stress disorder, and bipolar disorder.

Table 2.
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Odds of Undergoing Reconstructive Plastic Surgery Among Patients with Psychiatric Diagnoses Compared With Those Without

Psychiatric diagnosis classaOR (95% CI)a
Depression1.99 (1.93-2.07)*
Anxiety3.08 (2.97-3.17)*
Body dysmorphic disorder3.16 (1.76-5.67)*
Eating disorder2.21 (1.96-2.53)*
Otherb2.29 (2.10-2.50)*
Psychiatric diagnosis classaOR (95% CI)a
Depression1.99 (1.93-2.07)*
Anxiety3.08 (2.97-3.17)*
Body dysmorphic disorder3.16 (1.76-5.67)*
Eating disorder2.21 (1.96-2.53)*
Otherb2.29 (2.10-2.50)*

aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01. aAdjusted for age, sex, region, van Walraven index, and past-year comorbidities (tobacco use, substance abuse, diabetes, immunodeficiency, autoimmune disorders) when compared with cohort not undergoing surgery. bOther psychiatric diagnoses include personality disorders, obsessive compulsive disorder, posttraumatic stress disorder, and bipolar disorder.

Included in the second analysis group were 1,234,206 patients, all of whom underwent a reconstructive plastic surgery procedure: 613,400 (49.7%) patients formed the cohort with psychiatric diagnoses, and 620,806 (50.3%) patients formed the cohort without psychiatric diagnoses (Table 3). As with the first group, more patients with psychiatric diagnoses were female (206,102 males [33.6%] and 407,298 females [66.4%)] with psychiatric diagnosis, compared with 277,500 males [44.7%] and 343,306 females [55.3%] without psychiatric diagnosis, P < 0.01) and younger (mean age, 37.1 [16.3] years, range, 18-88, compared with 42.1 [17.0] years, range, 18-90) than those without psychiatric diagnoses. Again, the most common psychiatric diagnosis class was anxiety (60.5%), followed by depression (43.2%), and the most common comorbid condition among patients with psychiatric diagnoses was diabetes (8.4%), followed by tobacco use (5.3%) and substance abuse (3.2%). The majority of patients in both cohorts underwent either nasal or soft tissue reconstructive procedures. Comparison of the 2 groups resulted in statistically significant differences in all variables tested due to the large sample size; however, the greatest differences were seen in the higher percentage of females (66.4% vs 55.3%), substance abuse (3.2% vs 0.5%) and other comorbidities among those with psychiatric diagnoses compared with those without (Table 3).

Table 3.
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Thirty-Day Postoperative Complications Study Population Characteristics

CharacteristicWith psychiatric diagnosesMinus psychiatric diagnosesP
Number613,400 (49.7)620,806 (50.3)-
Male (n, %)206,102 (33.6)277,500 (44.7)<0.01
Age (years, [standard deviation])37.1 [16.3]42.1 [17.0]<0.01
Region (n, %)<0.01
 Northeast125,747 (20.5)61,459 (9.9)
 North central146,602 (23.9)170,721 (27.5)
 South216,530 (35.3)294,882 (47.5)
 West109,185 (17.8)89,396 (14.4)
 Unknown15,336 (2.5)4348 (0.7)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.03
Comorbidities (n, %)
 Tobacco use32,510 (5.3)29,177 (4.7)<0.01
 Substance abuse19,628 (3.2)3104 (0.5)<0.01
 Diabetes51,525 (8.4)42,836 (6.9)<0.01
 Immunodeficiency3680 (0.6)621 (0.1)<0.01
 Autoimmune disease1226 (0.2)1862 (0.3)<0.01
Procedure class (n, %)
  Nasal235,487 (38.3)216,950 (34.9)<0.01
  Oculoplastic59,312 (9.7)67,902 (10.9)<0.01
  Breast101,987 (16.6)97,573 (15.7)<0.01
  Abdomen37,476 (6.1)23,150 (3.7)<0.01
  Soft tissue reconstruction179,138 (29.2)215,231 (34.8)<0.01
Psychiatric diagnosis class (n,%)a
  Anxiety371,107 (60.5)—
  Depression264,988 (43.2)—
 Body dysmorphic disorder2453 (0.4)—
  Eating disorder28,216 (4.6)—
  Other77,901 (12.7)—
CharacteristicWith psychiatric diagnosesMinus psychiatric diagnosesP
Number613,400 (49.7)620,806 (50.3)-
Male (n, %)206,102 (33.6)277,500 (44.7)<0.01
Age (years, [standard deviation])37.1 [16.3]42.1 [17.0]<0.01
Region (n, %)<0.01
 Northeast125,747 (20.5)61,459 (9.9)
 North central146,602 (23.9)170,721 (27.5)
 South216,530 (35.3)294,882 (47.5)
 West109,185 (17.8)89,396 (14.4)
 Unknown15,336 (2.5)4348 (0.7)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.03
Comorbidities (n, %)
 Tobacco use32,510 (5.3)29,177 (4.7)<0.01
 Substance abuse19,628 (3.2)3104 (0.5)<0.01
 Diabetes51,525 (8.4)42,836 (6.9)<0.01
 Immunodeficiency3680 (0.6)621 (0.1)<0.01
 Autoimmune disease1226 (0.2)1862 (0.3)<0.01
Procedure class (n, %)
  Nasal235,487 (38.3)216,950 (34.9)<0.01
  Oculoplastic59,312 (9.7)67,902 (10.9)<0.01
  Breast101,987 (16.6)97,573 (15.7)<0.01
  Abdomen37,476 (6.1)23,150 (3.7)<0.01
  Soft tissue reconstruction179,138 (29.2)215,231 (34.8)<0.01
Psychiatric diagnosis class (n,%)a
  Anxiety371,107 (60.5)—
  Depression264,988 (43.2)—
 Body dysmorphic disorder2453 (0.4)—
  Eating disorder28,216 (4.6)—
  Other77,901 (12.7)—

IQR, interquartile range. *P < 0.01. aSum of percentages adds up to >100% as some patients had psychiatric diagnoses from >1 class

Table 3.
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Thirty-Day Postoperative Complications Study Population Characteristics

CharacteristicWith psychiatric diagnosesMinus psychiatric diagnosesP
Number613,400 (49.7)620,806 (50.3)-
Male (n, %)206,102 (33.6)277,500 (44.7)<0.01
Age (years, [standard deviation])37.1 [16.3]42.1 [17.0]<0.01
Region (n, %)<0.01
 Northeast125,747 (20.5)61,459 (9.9)
 North central146,602 (23.9)170,721 (27.5)
 South216,530 (35.3)294,882 (47.5)
 West109,185 (17.8)89,396 (14.4)
 Unknown15,336 (2.5)4348 (0.7)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.03
Comorbidities (n, %)
 Tobacco use32,510 (5.3)29,177 (4.7)<0.01
 Substance abuse19,628 (3.2)3104 (0.5)<0.01
 Diabetes51,525 (8.4)42,836 (6.9)<0.01
 Immunodeficiency3680 (0.6)621 (0.1)<0.01
 Autoimmune disease1226 (0.2)1862 (0.3)<0.01
Procedure class (n, %)
  Nasal235,487 (38.3)216,950 (34.9)<0.01
  Oculoplastic59,312 (9.7)67,902 (10.9)<0.01
  Breast101,987 (16.6)97,573 (15.7)<0.01
  Abdomen37,476 (6.1)23,150 (3.7)<0.01
  Soft tissue reconstruction179,138 (29.2)215,231 (34.8)<0.01
Psychiatric diagnosis class (n,%)a
  Anxiety371,107 (60.5)—
  Depression264,988 (43.2)—
 Body dysmorphic disorder2453 (0.4)—
  Eating disorder28,216 (4.6)—
  Other77,901 (12.7)—
CharacteristicWith psychiatric diagnosesMinus psychiatric diagnosesP
Number613,400 (49.7)620,806 (50.3)-
Male (n, %)206,102 (33.6)277,500 (44.7)<0.01
Age (years, [standard deviation])37.1 [16.3]42.1 [17.0]<0.01
Region (n, %)<0.01
 Northeast125,747 (20.5)61,459 (9.9)
 North central146,602 (23.9)170,721 (27.5)
 South216,530 (35.3)294,882 (47.5)
 West109,185 (17.8)89,396 (14.4)
 Unknown15,336 (2.5)4348 (0.7)
Van Walraven index (median, IQR)0.0 (0.0-5.0)0.0 (0.0-3.0)0.03
Comorbidities (n, %)
 Tobacco use32,510 (5.3)29,177 (4.7)<0.01
 Substance abuse19,628 (3.2)3104 (0.5)<0.01
 Diabetes51,525 (8.4)42,836 (6.9)<0.01
 Immunodeficiency3680 (0.6)621 (0.1)<0.01
 Autoimmune disease1226 (0.2)1862 (0.3)<0.01
Procedure class (n, %)
  Nasal235,487 (38.3)216,950 (34.9)<0.01
  Oculoplastic59,312 (9.7)67,902 (10.9)<0.01
  Breast101,987 (16.6)97,573 (15.7)<0.01
  Abdomen37,476 (6.1)23,150 (3.7)<0.01
  Soft tissue reconstruction179,138 (29.2)215,231 (34.8)<0.01
Psychiatric diagnosis class (n,%)a
  Anxiety371,107 (60.5)—
  Depression264,988 (43.2)—
 Body dysmorphic disorder2453 (0.4)—
  Eating disorder28,216 (4.6)—
  Other77,901 (12.7)—

IQR, interquartile range. *P < 0.01. aSum of percentages adds up to >100% as some patients had psychiatric diagnoses from >1 class

Table 4 displays differences in both specific and overall complication rates between the 2 groups after multivariable analysis. The most common complication in both cohorts was SSI, occurring in 4.6% of the psychiatric diagnoses cohort and in 1.2% of the cohort without psychiatric diagnoses, corresponding to an aOR of 2.29 (95% CI, 1.34-3.63). Thirty-day hospital admission resulted in the greatest difference between the 2 groups: 2.7% of patients with psychiatric diagnoses were readmitted, compared with 0.67% of those without psychiatric diagnoses (aOR, 3.15; 95% CI, 1.22-5.76). The rate of any complication was 5.5% in the group with psychiatric diagnoses, and 2.0% in the group without psychiatric diagnoses (aOR, 2.00; 95% CI, 1.28-3.11). Patients with psychiatric diagnoses also had greater rates of postoperative bleeding and hematoma formation (0.66% vs 0.34%; aOR, 1.21; 95% CI, 1.05-1.97). Rates of wound-healing complications (such as wound dehiscence) were not significantly increased among patients with psychiatric diagnoses (0.06% vs 0.03%; aOR, 1.03; 95% CI, 0.59-1.78).

Table 4.
Open in new tab

Psychiatric Diagnoses and Odds of 30-Day Complications

With psychiatric diagnosisWithout psychiatric diagnosis
Surgical site infection
  Percent4.631.21
  OR (95% CI)4.08 (1.81-8.81)*Reference
  aOR (95% CI)a2.29 (1.34-3.63)*Reference
Wound-healing complication
  Percent0.060.03
  OR (95% CI)2.25 (0.93-5.41)Reference
  aOR (95% CI)a1.03 (0.59-1.78)Reference
Bleed/hematoma
  Percent0.660.34
  OR (95% CI)1.69 (1.16-2.47)*Reference
  aOR (95% CI)a1.21 (1.05-1.97)*Reference
Hospital admission
  Percent2.740.67
  OR (95% CI)4.46 (2.84-7.01)*Reference
  aOR (95% CI)a3.15 (1.22-5.76)*Reference
Any complication
  Percent5.532.03
  OR (95% CI)2.77 (2.36-3.24)*Reference
  aOR (95% CI)a2.00 (1.28-3.11)*Reference
With psychiatric diagnosisWithout psychiatric diagnosis
Surgical site infection
  Percent4.631.21
  OR (95% CI)4.08 (1.81-8.81)*Reference
  aOR (95% CI)a2.29 (1.34-3.63)*Reference
Wound-healing complication
  Percent0.060.03
  OR (95% CI)2.25 (0.93-5.41)Reference
  aOR (95% CI)a1.03 (0.59-1.78)Reference
Bleed/hematoma
  Percent0.660.34
  OR (95% CI)1.69 (1.16-2.47)*Reference
  aOR (95% CI)a1.21 (1.05-1.97)*Reference
Hospital admission
  Percent2.740.67
  OR (95% CI)4.46 (2.84-7.01)*Reference
  aOR (95% CI)a3.15 (1.22-5.76)*Reference
Any complication
  Percent5.532.03
  OR (95% CI)2.77 (2.36-3.24)*Reference
  aOR (95% CI)a2.00 (1.28-3.11)*Reference

Odds ratios represent the odds of developing a complication in patients with a history of psychiatric diagnoses vs those without. aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01. aAdjusted for age, sex, region, van Walraven index, procedure class, and past-year comorbidities (tobacco use, substance abuse, diabetes, immunodeficiency, autoimmune disorders).

Table 4.
Open in new tab

Psychiatric Diagnoses and Odds of 30-Day Complications

With psychiatric diagnosisWithout psychiatric diagnosis
Surgical site infection
  Percent4.631.21
  OR (95% CI)4.08 (1.81-8.81)*Reference
  aOR (95% CI)a2.29 (1.34-3.63)*Reference
Wound-healing complication
  Percent0.060.03
  OR (95% CI)2.25 (0.93-5.41)Reference
  aOR (95% CI)a1.03 (0.59-1.78)Reference
Bleed/hematoma
  Percent0.660.34
  OR (95% CI)1.69 (1.16-2.47)*Reference
  aOR (95% CI)a1.21 (1.05-1.97)*Reference
Hospital admission
  Percent2.740.67
  OR (95% CI)4.46 (2.84-7.01)*Reference
  aOR (95% CI)a3.15 (1.22-5.76)*Reference
Any complication
  Percent5.532.03
  OR (95% CI)2.77 (2.36-3.24)*Reference
  aOR (95% CI)a2.00 (1.28-3.11)*Reference
With psychiatric diagnosisWithout psychiatric diagnosis
Surgical site infection
  Percent4.631.21
  OR (95% CI)4.08 (1.81-8.81)*Reference
  aOR (95% CI)a2.29 (1.34-3.63)*Reference
Wound-healing complication
  Percent0.060.03
  OR (95% CI)2.25 (0.93-5.41)Reference
  aOR (95% CI)a1.03 (0.59-1.78)Reference
Bleed/hematoma
  Percent0.660.34
  OR (95% CI)1.69 (1.16-2.47)*Reference
  aOR (95% CI)a1.21 (1.05-1.97)*Reference
Hospital admission
  Percent2.740.67
  OR (95% CI)4.46 (2.84-7.01)*Reference
  aOR (95% CI)a3.15 (1.22-5.76)*Reference
Any complication
  Percent5.532.03
  OR (95% CI)2.77 (2.36-3.24)*Reference
  aOR (95% CI)a2.00 (1.28-3.11)*Reference

Odds ratios represent the odds of developing a complication in patients with a history of psychiatric diagnoses vs those without. aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01. aAdjusted for age, sex, region, van Walraven index, procedure class, and past-year comorbidities (tobacco use, substance abuse, diabetes, immunodeficiency, autoimmune disorders).

To assess the relative independent strength of all assessed sociodemographic, comorbid, and procedural factors contributing to 30-day postoperative complications of the entire reconstructive plastic surgery cohort, a multivariable logistic regression was conducted (see Table 5). Diagnosis of an eating disorder was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by undergoing a nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89) and BDD (aOR, 3.16; 95% CI, 1.76-5.67). Patients with psychiatric diagnoses were at significantly increased risk of postoperative complications compared with those without; as previously indicated, eating disorders and BDD carried the greatest odds of a complication, but patients with anxiety (aOR, 2.02; 95% CI, 1.75-2.32) and depression (aOR, 1.76, 95% CI, 1.25-2.04) were also associated with increased risk. Whereas procedural-based complication risk was greatest with nasal surgery, breast surgery (aOR, 2.16; 95% CI, 1.95-2.39) and abdominal surgery (aOR, 1.85; 95% CI, 1.59-2.18) also were associated with increased risk of postoperative complications compared with those undergoing soft tissue reconstructions. Other independent risk factors associated with increased postoperative complications included tobacco use (aOR, 2.10; 95% CI, 1.22-3.12), autoimmune disease (aOR, 2.00; 95% CI, 1.14-3.50), substance abuse (aOR, 1.52; 95% CI, 1.07-1.23), immunodeficiency (aOR, 1.24; 95% CI, 1.10-1.37), and age (aOR, 1.01; 95% CI, 1.01-1.02), whereas postoperative antibiotic use (aOR, 0.85; 95% CI, 0.71-0.98) and male sex (aOR, 0.86; 95% CI, 0.74-0.99) were associated with decreased odds of postoperative complications.

Table 5.
Open in new tab

Multivariable Logistic Regression Models for 30-Day Postoperative Complications

Model variableaOR (95% CI)
Age1.01 (1.01-1.02)*
Male sex0.856(0.74-0.99)*
Postoperative antibiotic prescription0.85 (0.71-0.98)*
Past-year comorbidities
 Autoimmune disease2.00 (1.14-3.50)*
 Immunodeficiency1.24 (1.10-1.36)*
 Diabetes1.02 (0.79-1.33)
 Tobacco use2.10 (1.22-3.12)*
 Substance abuse1.52 (1.07-2.16)*
van Walraven index1.05 (0.89-1.23)
Procedure class
 Nasal3.65 (2.74-4.89)*
 Eye0.84 (0.79-0.90)*
 Breast2.16 (1.95-2.39)*
 Abdomen1.85 (1.59-2.17)*
 Recon1 (reference)
Psychiatric diagnoses
 Depression1.76 (1.25-2.04)*
 Anxiety2.02 (1.75-2.32)*
 Body dysmorphic disorder3.16 (1.76-5.67)*
 Eating disorder4.17 (3.59-4.86)*
 Other1 (reference)
Model variableaOR (95% CI)
Age1.01 (1.01-1.02)*
Male sex0.856(0.74-0.99)*
Postoperative antibiotic prescription0.85 (0.71-0.98)*
Past-year comorbidities
 Autoimmune disease2.00 (1.14-3.50)*
 Immunodeficiency1.24 (1.10-1.36)*
 Diabetes1.02 (0.79-1.33)
 Tobacco use2.10 (1.22-3.12)*
 Substance abuse1.52 (1.07-2.16)*
van Walraven index1.05 (0.89-1.23)
Procedure class
 Nasal3.65 (2.74-4.89)*
 Eye0.84 (0.79-0.90)*
 Breast2.16 (1.95-2.39)*
 Abdomen1.85 (1.59-2.17)*
 Recon1 (reference)
Psychiatric diagnoses
 Depression1.76 (1.25-2.04)*
 Anxiety2.02 (1.75-2.32)*
 Body dysmorphic disorder3.16 (1.76-5.67)*
 Eating disorder4.17 (3.59-4.86)*
 Other1 (reference)

Data presented as aOR (95% CI) unless otherwise noted. aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01.

Table 5.
Open in new tab

Multivariable Logistic Regression Models for 30-Day Postoperative Complications

Model variableaOR (95% CI)
Age1.01 (1.01-1.02)*
Male sex0.856(0.74-0.99)*
Postoperative antibiotic prescription0.85 (0.71-0.98)*
Past-year comorbidities
 Autoimmune disease2.00 (1.14-3.50)*
 Immunodeficiency1.24 (1.10-1.36)*
 Diabetes1.02 (0.79-1.33)
 Tobacco use2.10 (1.22-3.12)*
 Substance abuse1.52 (1.07-2.16)*
van Walraven index1.05 (0.89-1.23)
Procedure class
 Nasal3.65 (2.74-4.89)*
 Eye0.84 (0.79-0.90)*
 Breast2.16 (1.95-2.39)*
 Abdomen1.85 (1.59-2.17)*
 Recon1 (reference)
Psychiatric diagnoses
 Depression1.76 (1.25-2.04)*
 Anxiety2.02 (1.75-2.32)*
 Body dysmorphic disorder3.16 (1.76-5.67)*
 Eating disorder4.17 (3.59-4.86)*
 Other1 (reference)
Model variableaOR (95% CI)
Age1.01 (1.01-1.02)*
Male sex0.856(0.74-0.99)*
Postoperative antibiotic prescription0.85 (0.71-0.98)*
Past-year comorbidities
 Autoimmune disease2.00 (1.14-3.50)*
 Immunodeficiency1.24 (1.10-1.36)*
 Diabetes1.02 (0.79-1.33)
 Tobacco use2.10 (1.22-3.12)*
 Substance abuse1.52 (1.07-2.16)*
van Walraven index1.05 (0.89-1.23)
Procedure class
 Nasal3.65 (2.74-4.89)*
 Eye0.84 (0.79-0.90)*
 Breast2.16 (1.95-2.39)*
 Abdomen1.85 (1.59-2.17)*
 Recon1 (reference)
Psychiatric diagnoses
 Depression1.76 (1.25-2.04)*
 Anxiety2.02 (1.75-2.32)*
 Body dysmorphic disorder3.16 (1.76-5.67)*
 Eating disorder4.17 (3.59-4.86)*
 Other1 (reference)

Data presented as aOR (95% CI) unless otherwise noted. aOR, adjusted odds ratio; CI, confidence interval. *P < 0.01.

Discussion

Patients with psychiatric diagnoses were found to undergo reconstructive plastic surgery at a greater rate than those without these diagnoses, and in particular, patients with BDD and anxiety had 3 times greater odds of undergoing reconstructive plastic surgery. As reflected in the literature from other surgical specialties, psychiatric comorbidity is also associated with greater 30-day postoperative complications for patients undergoing reconstructive plastic surgery. A 2-fold greater risk of any 30-day postoperative complication was found among patients with psychiatric diagnoses after controlling for other relevant variables. Of specific complications, hospital readmission was associated with the greatest difference, with over 3 times increased risk in patients with psychiatric diagnoses. Assessing psychiatric diagnoses individually found that those with a diagnosis of an eating disorder or BDD had the greatest risk of any 30-day postoperative complication.

The greater rate of reconstructive plastic surgery among patients with psychiatric diagnosis in this study reflects both prior plastic surgery literature, as well as the overall surgery literature in general.1-4 In one study of noncardiac surgery, the prevalence of anxiety and depression medication use was analyzed, and found to be 2 times higher (30%) than in the general population.3 Not surprisingly, the top 3 procedures with the greatest rates of anxiety or depression medication use were abdominoplasty, breast reduction, and breast reconstruction, as compared to other procedures such as abdominal or bowel procedures.3

In particular, rates of BDD are high in the cosmetic surgery population, with an estimated prevalence of 5% to 20%, compared with 0.7% to 2.4% in the general population, and as high as 32% in septorhinoplasty patients.44-58 Similarly, in this study, patients with BDD were associated with the greatest odds of undergoing reconstructive plastic surgery, at 3 times the odds of those without psychiatric diagnoses. Although this study reflects patients undergoing insurance-based, presumably noncosmetic procedures, the inherent nature of most of these procedures (abdominoplasty, rhinoplasty, breast surgery, eye surgery) addresses highly aesthetic, body-conscious areas, similar to cosmetic procedures. The increased rate of reconstructive plastic surgery among patients with psychiatric diagnoses suggests, that like cosmetic surgery, patients should be screened and appropriately treated before undergoing medically necessary reconstructive plastic surgery as well.

A 2-fold greater risk of 30-day postoperative complications after reconstructive plastic surgery procedures in patients with psychiatric diagnoses corresponds with literature from other surgical specialties. From the general surgery literature, an assessment of common abdominal procedures (cholecystectomy, appendectomy, other bowel surgery), found 1.18 greater odds of any complication among patients with psychiatric diagnoses and 1.4 greater odds of prolonged hospitalization.21 In another study, the use of anxiety medication was associated with greater duration of hospital stay, infection rate, wound-healing problems, and cardiovascular events after noncardiac surgery.3 For burn patients, mortality was 3 times higher in patients with pre-existing psychiatric disorders.12 They were also more likely to present with greater severity of burn, experience in-hospital complications, and less likely to be discharged home, with greater difficult regarding placement at a facility at the time of discharge.12 In the spine surgery literature, the presence of psychiatric diagnoses was associated with 1.17 greater odds for any complication, 1.32 greater odds for readmission, and was the strongest predictor of revision surgery with an aOR of 1.56.23 Similar findings were also found for bariatric, cardiac, urologic, orthopedic, and breast oncology surgery.24-30

Explanations for these higher complications rates are related to the physiology of the psychiatric disease itself, as well as related comorbid and social factors, as the type of complications collected (bleeding, infection, hospital readmission) are unlikely to reflect cosmetic dissatisfaction with results. For instance, depression is associated with increased proinflammatory cytokines and altered immune response which can accelerate cardiovascular disease and inhibit wound healing.36-38 Additionally, changes were observed in myocardial perfusion, autonomic nervous system regulation, platelet activation, and the hypothalmo-pituitary-adrenal axis activity.38-41 These physiologic effects may be compounded by the direct influence of related behaviors, such as substance abuse, poor diet, poor compliance with treatment or postoperative wound care instructions, and inactive lifestyles with grater rates of obesity, hypertension, and hyperlipidemia as a result.9-12,32-35,41,42 Postoperative care is further complicated by social issues such as homelessness, lack of access to follow-up care, or placement issues on discharge.11,12

Hospital readmission was the complication with the greatest difference between the psychiatric diagnosis and nonpsychiatric diagnosis cohorts, with 3-fold greater odds of readmission. Explanations for this difference include potential difference in access to care, poor pain control, or seeking care at greater severity or duration of postoperative complication onset.9-12,20,21,31,59-63 For instance, in the general surgery literature, patients with psychiatric diagnoses were more likely to present urgently or emergently for procedures, with a longer time from symptom onset to treatment, which likely resulted in higher complication rates and hospital duration.20-22 Burn patients with pre-existing psychiatric diagnoses were more likely to present at greater extent of burn injury.12 Differences in ability to control pain between those with psychiatric diagnoses has also been described, which may lead to higher rates of 30-day postoperative hospital readmission.59

In the plastic surgery literature, most studies of patients with psychiatric diagnoses focus on the impact of surgery on patients’ psychiatric or satisfaction with surgical outcomes, rather than perioperative complication rates.14-19 However, another database study assessing 30-day postoperative complications of cosmetic procedures, found that hospital admission occurred at 1.6 greater odds, and emergency department visits at 1.88 greater odds in patients with psychiatric diagnoses compared with those without.64 In another study of septorhinoplasty outcomes, anxiety and depression were both associated with a higher rate of readmission or emergency department visits 30 days postoperatively (aOR for anxiety, 1.79; aOR for depression, 1.42).65

The significantly increased rate of postoperative complications among patients with eating disorders is one that has not been described in the plastic surgery literature. This finding is of particular importance given the approximately equal rates of eating disorders compared with BDD (2%-3% of the general population).66,67 The relation between BDD and eating disorders is a subject of ongoing study; however, there is emerging evidence that BDD and eating disorders are frequently comorbid, and many patients with eating disorders have high rates of body image concerns not related to weight or body shape.68-70 Bariatric surgery literature focusing on surgical outcomes related to underlying disordered eating of patients, if not treated properly prior to surgery, found both poorer long-term and short-term outcomes, potentially related to the adverse effects of malnutrition, binge-eating, or purging on the gastrointestinal system.18 This topic deserves further inquiry given the potential for significant impact on the population of patients undergoing reconstructive plastic surgery.

Once identified, some studies have shown improvement of postoperative complication rates in patients with psychiatric diagnoses through cognitive behavioral therapy.71 Several small studies showed that early psychological management may be associated with a reduction of hospital length of stay, pain medication use, and postsurgical morbidity.72-75 In a randomized controlled trial, psychiatric counseling and relaxation exercises improved wound healing after cholecystectomy.76 A systematic review of a variety of treatment modalities to address psychological, neuroendocrine or immunologic variables found reduction in proinflammatory cytokines, and stress-related hormones in a variety of disease models; however, minimal investigation was published regarding how this affected actual disease progression or complications over time.38 Although more research is needed in this area, identifying and appropriately treating psychiatric disease preoperatively may help reduce complication rates.

The primary limitations of this study relate to its data source of an administrative insurance claims database. Thus, it will not capture cosmetic, self-pay procedures, and reflects primarily reconstructive procedures covered by insurance. Although we cannot speak to the practice habits of other physicians in the United States, it is our experience that insurance companies for rhinoplasty in particular, and likely other potentially cosmetic procedures, deny these claims unless clear evidence of medical necessity is documented in the medical record, which limits the likelihood purely cosmetic procedures are represented in this dataset. It is possible, however, that patients may have a combined functional and cosmetic surgery, and the functional part is represented in this dataset, which concurrently occurred with a cosmetic procedure, not represented here. Additionally, data assessed are reliant on the accuracy and completeness of coding practices by practitioners and healthcare ancillary staff, which often underestimates true complication rates, and reflects only those requiring more significant treatment. Thus, actual complication rates may be higher among both groups analyzed. Likewise, the inclusion of psychiatric diagnoses in the medical record is also often underreported, and therefore the patients represented in this study may have more severe presentations than the general population, potentially inflating the differences between those with and without psychiatric diagnoses. This point is particularly true among patients with BDD, who may never obtain a formal diagnosis or be incorrectly diagnosed with obsessive compulsive disorder, depression, or anxiety disorders, leading to underestimation of the relation between a BDD diagnosis and rates of surgery or postoperative complications. Therefore, correlation with prospectively collected clinical data would strengthen the conclusions of this study.

Conclusions

The presence of a psychiatric disorder is an independent risk factor contributing to 30-day postoperative reconstructive plastic surgery complications; patients with a psychiatric diagnosis have 2 times greater risk of a 30-day complication than those without this diagnosis.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

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

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