Aesth Plast Surg

https://doi.org/10.1007/s00266-019-01576-2

REVIEW BODY CONTOURING

Venous Thromboembolism (VTE) Prophylaxis After

Abdominoplasty and Liposuction: A Review of the Literature
Prerna Mittal1 • Tobias Heuft2 • Dirk F. Richter2 • Maria Wiedner2

Received: 30 August 2019 / Accepted: 4 December 2019

 Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Abstract please refer to the Table of Contents or the online

Background The aim of this review article was to study Instructions to Authors www.springer.com/00266.
recent articles and summarise the guidelines, indications,
risks and benefits of using VTE prophylaxis in patients Keywords Venous thromboembolism (VTE)

undergoing abdominoplasty and liposuction. Abdominoplasty
Liposuction
Lipo-abdominoplasty

Methods A search of PubMed was performed using Chemoprophylaxis
selected keywords related to the topic. Based on the
inclusion and exclusion criteria, a total of 25 articles were
included in the review. Introduction
Results Abdominoplasty has the highest occurrence of
VTE among aesthetic procedures. A higher incidence of VTE is the most dreaded and immediately life-threatening
VTE was noted when abdominoplasty was combined with complication of any surgical procedure. Although there are
liposuction. Circumferential procedures, obesity and HRT well-formulated protocols in orthopaedic surgery and
(hormone replacement therapy) were found to be inde- general surgery for VTE prophylaxis, its usage in plastic
pendent risk factors for VTE. The 2005 Caprini/Davison surgery, particularly aesthetic surgery, is still not well
risk assessment model is the most appropriate model for understood or standardised.
risk stratification in plastic surgery patients. Newer oral In the most recently published articles [1, 2],
anticoagulants hold promise. abdominoplasty is one of the most common aesthetic
Conclusions Preoperative risk stratification should be procedures and is the procedure most frequently associated
performed for all patients. Chemoprophylaxis should be with VTE. Earlier, Spring and Gutowski et al. [3] also
considered in cases with a Caprini RAM score [ 7 or in indicated that abdominoplasty with or without another
those with independent risk factors. Administering regional procedure has the highest risk of VTE in plastic surgery.
blocks for anaesthesia and avoiding full muscle paralysis Numerous studies have provided clear guidelines for
help reduce the risk of VTE. VTE prophylaxis in non-plastic surgery patient
Level of Evidence III This journal requires that authors populations.
assign a level of evidence to each article. For a full There is a paucity of evidence and surveys in the liter-
description of these Evidence-Based Medicine ratings, ature regarding the true overall incidence of VTE in cos-
metic surgery. Clear guidelines regarding identifying at-
risk patients and suitable protocols for prophylaxis against
& Prerna Mittal VTE are missing.
[email protected]
This literature review aimed to analyse and summarise
1
Refine Aesthetic Clinic, 68 A/2, Club Road, Ludhiana, recently published articles related to VTE prophylaxis in
Punjab 141001, India abdominoplasty and liposuction. It will help improve
2
Dreifaltigkeits-Krankenhaus, Bonner Str. 84, 50389 understanding of the scope of and need for VTE prophy-
Wesseling, Germany laxis and the risks and benefits involved; this study will

123
 Aesth Plast Surg

also help improve knowledge about new drugs and treat- Table 1 Number and type of studies included
ment methods. This study demonstrated the need to have a Type of study Number of articles
comprehensive approach to VTE prophylaxis for cosmetic
surgery patients undergoing abdominoplasty or lipo- Retrospective 14
abdominoplasty. Prospective 4
Literature review 3
CME articles 4
Materials and Methods

Articles related to VTE prophylaxis after abdominoplasty

and liposuction were searched for in PubMed. The most widely used risk stratification and risk
The keywords used were ‘‘VTE prophylaxis after assessment model was the 2005 Caprini/Davison risk
abdominoplasty and liposuction’’ and ‘‘VTE prophylaxis assessment model.
after body contouring’’. The 2005 Caprini/Davison RAM adapted specifically
All abstracts related to the topic were reviewed. Full- for plastic surgery is described in Tables 3, 4 and 5.
text articles were accessed on the respective websites and The 2005 Caprini/Davison RAM is divided into ‘‘ex-
studied. The reference lists of the selected studies were posing risk factors’’ (the risk imposed by the surgery itself)
reviewed, and related articles were handpicked; those and ‘‘predisposing risk factors’’ (the patient’s biological
meeting the inclusion criteria were accessed and included. risk).
Only articles less than 15 years old (2004–2019) were The patient-related variables that were significantly and
included. consistently associated with an increased risk of VTE are
The inclusion criteria were articles written in English shown in Table 6. There were eight studies that showed
and articles related to VTE prophylaxis after abdomino- statistical significance for these variables.
plasty and liposuction, including articles on newer oral Two articles identified circumferential abdominoplasty
anticoagulants. All retrospective, prospective and CME as the procedure most commonly associated with VTE.
articles were included. Another article associated body procedures with the high-
The articles were studied and classified under the fol- est incidence of VTE. Table 7 shows the details.
lowing headings: Five studies found concurrent liposuction with
• Incidence and extent of the problem. abdominoplasty to be associated with a higher risk of VTE.
• Risk assessment models (RAMs), their limitations with In one study, which was a prospective study, a correlation
regard to plastic surgery patients and additional criteria between the amount of fat removed and the risk of VTE
for abdominoplasty and body contouring procedures. was found. Removal of more than 1500 g of fat was con-
• Procedure-specific risk. cluded to be a risk factor.
• Measures of prophylaxis for VTE, including the One study did not find any association between the risk
efficacy of chemoprophylaxis with low-molecular- of VTE and the addition of liposuction with
weight heparin (LMWH). abdominoplasty.
• Newer oral anticoagulants and their efficacy. Table 8 gives an overview of the above-mentioned
• Role of anaesthesia in the prevention of VTE. studies.
A prolonged operative time is considered a risk factor
for deep vein thrombosis (DVT) in the surgical population
because of the effects of anaesthesia medications, muscle
Results relaxation and the drop in body temperature leading to
venous stasis and coagulation. A description of the evi-
There were a total of 25 articles studied that were directly dence is beyond the scope of this article.
related to the topic. Two studies [2, 4] concluded that the length of anaes-
Table 1 shows the distribution of CME articles, litera- thesia or the duration of surgery had no relationship with
ture reviews, retrospective studies and prospective studies. the risk of developing VTE after abdominoplasty, nor was
Abdominoplasty was the most common procedure the risk increased when abdominoplasty was combined
associated with VTE among cases of VTE in plastic sur- with other aesthetic procedures.
gery. Two studies confirmed this finding, with abdomino- Factors that have been recognised as independently
plasty accounting for more than 50% of the VTE cases. increasing the risk of VTE, irrespective of the RAM score,
Table 2 shows the details of this outcome. are obesity, hormone replacement therapy (HRT)/over-the-

123
Aesth Plast Surg

Table 2 Incidence of VTE in abdominoplasty procedures

S No. Journals Percentage of abdominoplasty among VTE cases

1. Keyes et al., 2018, Aesthetic Surgery Journal 58

2. Winocour et al., 2017, Aesthetic Surgery Journal 52.9
3. Gutowski et al., Aesthetic Surgery Journal, 2006 36 per 10,000

Table 3 Caprini/Davison risk

1 Factor 2 Factors 3 Factors 5 Factors
assessment model: exposing
risk factors Minor surgery Major surgery Previous MI/CHF Hip, pelvis, leg fracture
Immobilisation Severe sepsis Stroke
Central venous access Free flap Multiple trauma
MI myocardial infarction, CHF congestive heart failure

Table 4 Caprini/Davison risk assessment model: predisposing risk counter progesterone (OCP) use, circumferential proce-
factors dures and family history of DVT.
Factor The review of various articles analysing risk stratifica-
tion and assignment, along with the recommendations
Age 40–60 years 1 according to risk score, is summarised in Table 9.
Age [ 60 years 2 Table 10 provides details for studies suggesting that
History of VTE 3 post-operative LMWH (enoxaparin) is beneficial in
Current pregnancy 1 reducing the incidence of DVT in body contouring
Current malignancy 2 procedures.
Obesity 1 The significance of the reduction of VTE after chemo-
OCP/HRT 1 prophylaxis has been found to be directly proportional to
Hypercoagulable disorder 3 the Caprini RAM score; there is a greater reduction in
VTE venous thromboembolism, OCP over-the-counter progesterone, incidence in patients with higher scores.
HRT hormone replacement therapy The studies showing the safety and efficacy of novel oral
anticoagulants (NOAC) compared to low-molecular-
weight heparin (LMWH) are detailed in Table 11.
The results of studies showing an increased risk of post-
Table 5 Caprini/Davison risk assessment model: risk assignment operative haematoma, blood transfusions and drain output
1 Factor 2 Factors 3–4 Factors [ 4 Factors after chemoprophylaxis are detailed in Table 12. Two
studies showed a significant risk of haematoma, blood
Low risk Moderate risk High risk Highest risk
transfusion and increased drain output after
chemoprophylaxis.

Table 6 Independent risk

Patient variables associated with increased risk of VTE Journals
factors/patient variables for
VTE Age [ 40 years 1. Keyes et al., ASJ, 2018
Obesity/BMI [ 25 kg/m2 2. Winocour et al., ASJ, 2017
Oral contraceptives 3. Pannucci et al., PRS Journal, 2017
Hormone replacement therapy 4. Hunstad et al., ASJ, 2016
5. Somogyi et al., ASJ 2012
6. Hatef et al., PRS Journal, 2008
7. Newall et al., ASJ, 2006
8. Most et al., PRS Journal, 2005

123
 Aesth Plast Surg

Table 7 Incidence of VTE in circumferential procedures

S No. Journals Procedure with the highest incidence of VTE

1. Winocour et al., 2017, Aesthetic Surgery Journal Body procedures/combined procedures

2. Hatef et al., 2010, Plastic and Reconstructive Surgery Journal Circumferential abdominoplasty/abdominoplasty
combined with intraabdominal procedure
3. Hatef et al., 2008, Plastic and Reconstructive Surgery Journal Circumferential abdominoplasty

Table 8 Incidence of VTE in lipo-abdominoplasty

S. no. Risk of VTE when abdominoplasty is combined with liposuction Journals

1. Increased Keyes et al., ASJ, 2018

2. Increased Hatef et al., PRS Journal, 2010
3. Increased Hatef et al., PRS Journal, 2008
4. Increased (fat removed [ 1500 g) Gravante et al., Ann Plast Surg, 2008
5. Increased Broughton et al., PRS Journal, 2006
6. Not affected Most et al., PRS Journal, 2005

The circumferential procedures were associated with though they are not specifically designed for plastic surgery
both increased rates of haematoma and VTE. The risk is patients.
individualised for each patient depending on their BMI, A modified version of the 2005 Caprini/Davison RAM,
Caprini RAM score, the type and duration of procedure. which was developed to accommodate plastic surgery
The timing of the administration of chemoprophylaxis, procedures in particular, is the most widely used model for
whether 2 h preoperatively, intra- or immediately post- risk stratification [8, 9].
operatively, did not affect the haematoma rate. All plastic surgery patients should undergo preoperative
There are articles recommending SAFE anaesthesia/ risk stratification as suggested by Pannucci et al. [10]. They
anaesthesia without full muscle paralysis/IV sedation/re- also commented that 70–80% of the plastic surgery popu-
gional blocks as a non-chemoprophylactic measure for lation falls into the low-risk category.
lowering the risk of post-operative VTE after abdomino- The use of LMWHs has proven to reduce the risk of
plasty/body contouring (Table 13). VTE in other abdominal, pelvis, orthopaedic and cancer
One study demonstrated the efficacy of epidural anaes- surgeries. However, the safety and justification of LMWHs
thesia and differential nerve blocks in preventing post-op- in aesthetic surgery procedures have yet to be fully estab-
erative VTE. lished. Estimates of VTE risk reduction were more precise
among higher risk patients [11].
The debate on identifying at-risk patients is ongoing in
Conclusion the literature.
Obesity (BMI [ 30), HRT/OCP use and circumferential
Abdominoplasty accounts for the highest percentage of procedures are independent high risk factors [2, 4, 12–15].
VTE cases among all VTE cases in aesthetic procedures. A significant percentage of plastic surgeons performing
Circumferential procedures are considered to have one these procedures still do not implement chemoprophylaxis.
of the highest rates of thromboembolic complications as Broughton et al. [7] surveyed members of the American
are procedures where abdominoplasty is combined with Society of Plastic Surgeons (ASPS) and found that only
liposuction and other intraabdominal procedures [2, 4–6]. 43–60% provided some form of VTE prophylaxis due to a
Despite this, a significant percentage of plastic surgeons fear of post-operative bleeding and haematoma. In the
performing these procedures still do not implement Venous Thromboembolism Prevention Study (VTEPS) and
chemoprophylaxis [7]. The reason is fear of post-operative other studies, the risk was not clinically significant
bleeding and haematoma. [16–18].
Risk assessment models such as the Caprini RAM have
been developed to identify patients at high risk of bleeding,

123
Aesth Plast Surg

Table 9 Risk stratification and recommendations in various studies

S. Journals Risk factors/assessment mostly found in Recommendations/suggestions
no. the study

1. Keyes et al., ASJ Caprini RAM 2–8 [ 8 chemoprophylaxis

2018
2. Pannucci, PRS 2005 Caprini/Davison score of 7–8, [ 8 Chemoprophylaxis
Journal, 2017
3. Morales et al., ASJ, Caprini RAM 3–4 and 5–6 NOACs have promise
2016
4. Kenkel et al., ASJ, Caprini RAM score [ 5, high risk Mechanoprophylaxis and chemoprophylaxis
2019
5. Pannucci et al., PRS Caprini scores [ 7, especially Chemoprophylaxis
Journal, 2016 circumferential abdominoplasty
6. Gould et al., Chest, Caprini RAM score:
2012 1–2 Mechanical prophylaxis
3–4 Mechanical prophylaxis, preferably IPC/chemoprophylaxis if no major
risk of bleeding
[5 Chemoprophylaxis (if no increased risk of bleeding) plus IPC/stockings
7. Somogyi et al., ASJ, 3–4 risk factors (high risk) Comprehensive approach like TED stockings, IPC devices, early
2012 ambulation, shortened operative time, normothermia, pain control
8. Pannucci et al., Caprini RAM score [ 8 Chemoprophylaxis
JACS, 2011
9. Hatef et al., PRS Caprini RAM classification: high-risk Chemoprophylaxis
Journal, 2008 group and highest risk group
Circumferential procedures
10. Most et al., PRS Low risk Comfortable positioning in OR/avoid constricting garments
Journal, 2005 Moderate risk Above measures plus IPC devices plus graded stockings
High risk Above measures plus prophylactic anticoagulation

Table 10 Effectiveness of LMWH in VTE prevention

S. no. Journals Effect of LMWH on DVT

1. Pannucci et al., PRS Journal, 2011 Reduces DVT in highest risk patients (Caprini 7–8 and Caprini [ 8)
2. Hatef et al., PRS Journal, 2008 Reduces DVT in circumferential procedures
3. Newall et al., Aesth Plast Surg, 2006 Reduces DVT

Table 11 NOAC versus LMWH the Caprini RAM score, type of procedure, BMI and his-
S. no. Journals Result of NOAC versus LMWH
tory of VTE since circumferential procedures are associ-
ated with the highest incidence of both VTE and post-
1. Hunstad et al., ASJ, 2016 Comparable operative bleeding.
2. Morales et al., ASJ, 2016 Comparable The rate of post-operative haematoma is less than 1%
[17, 18].
Newer oral anticoagulants hold promise but need more
studies to establish their safety [19].
The risk of post-operative haematoma is higher in pro- Comprehensive measures such as non-general anaes-
cedures involving large areas of dissection and in circum- thesia, elastic stockings, IPC (intermittent pneumatic
ferential procedures [11, 19]. compression) devices, normothermia, early ambulation and
Hence, the risk of VTE and post-operative bleeding shortened operative times all help in reducing the risk of
must be assessed on a case-to-case basis depending upon

123
 Aesth Plast Surg

Table 12 Incidence of post-

S. no. Journals Complication rate after chemoprophylaxis
operative bleeding after
chemoprophylaxis 1. Hunstad et al., ASJ, 2016 Not significant
2. Morales et al., ASJ. 2016 Not significant
3. Pannucci et al., PRS, 2012 Not significant
4. Dinni et al., PRS Journal, 2012 Significantly increased
5. Hatef et al., PRS Journal, 2008 Significantly increased

Table 13 Choice of
S. no. Journals Type of anaesthesia recommended
anaesthesia in VTE prevention
1. Aly et al., ASJ, 2018 Non-general anaesthesia/epidural anaesthesia
2. Pannucci, PRS Journal, 2017 Non-general anaesthesia
3. Pannucci et al., PRS Journal, 2016 Non-general anaesthesia
4. Somogyi et al., ASJ, 2012 Non-general anaesthesia
5. Hafezi et al., ASJ, 2011 Epidural anaesthesia

post-operative VTE in patients undergoing abdominoplasty • All attempts to keep the patient pain-free post-opera-
and liposuction [1, 2, 10, 11]. tively, in the form of pain pumps, epidural top-ups, etc.,
should be made.
Our Recommendations • Ambulation should be encouraged within 1 h of
surgery, and, if possible, patients should be discharged
Preoperatively, home the same day.
• Every patient should receive mechanical prophylaxis.
• All patients should be risk stratified, and VTE risk
Patients with Caprini scores of 7–8 and [ 8, those with
factors should be scored with the Caprini/Davison
a BMI [ 30, those using HRT/OCP and those who are
RAM.
undergoing circumferential procedures may benefit
• Particular attention should be paid to patients with a
from chemoprophylaxis, beginning 6–8 h following
family history of VTE, BMI greater than 30, age older
surgery and continued for the duration of inpatient stay
than 40, previous history of VTE; patients on HRT/
or 7 days post-operatively [1, 19].
OCP; and patients who have undergone bariatric and
circumferential procedures. The risk of venous thromboembolism should be bal-
• Haematology consults/workups should be performed anced against the increased risk of bleeding with the use of
when indicated (in patients with a family or previous LMWH, keeping in mind that bleeding is an expected,
history of VTE or of either known or clinically manageable complication, whereas pulmonary embolism
suspected haematological disorders). can be a fatal and unacceptable sequela in the setting of
elective surgery.
Intraoperatively,
• Warming of the patient, IV fluids and the room should
be strictly performed. Discussion
• Graded compression stockings and intermittent pneu-
matic compression devices should be placed on all Extent of the Problem
patients.
• Attempts should be made to reduce the operative time Abdominoplasty is one of the most common aesthetic
and concurrent procedures, as an increased length of procedures performed. It can be combined with liposuction
surgery is a risk factor. or other procedures. During the past 13 years, its frequency
• SAFE anaesthesia/non-general anaesthesia should be has increased by 79%. Over the past two decades, there
considered where applicable and feasible. have been many advances in terms of technical approaches
• Epidural anaesthesia where possible. and perioperative patient management [1].
In a study performed by Keyes et al. [2], abdomino-
Post-operatively,
plasty accounted for 58% of the total cases of VTE among
outpatient aesthetic surgery cases.

123
Aesth Plast Surg

Spring and Gutowski et al. [3] and Most et al. [5] stated where a patient’s personal characteristics (e.g., age, body
that abdominoplasty has one of the highest rates of DVT mass index and personal or family history of venous
and VTE in plastic surgery populations. thromboembolism) are used to conceptualise and quantify
In a study conducted by Hatef et al. [20], abdomino- their venous thromboembolism risk. The recommendations
plasty was associated with a 5.03% overall rate of VTE, were based on risk stratification using the 2005 Caprini
with the incidence being higher when it was combined with RAM. Levels of probability based on a variety of risk
other procedures. In the same study, circumferential factors were established, and patients at a level 4 were
abdominoplasty was associated with a significantly higher considered to be at high risk and those at a level 5 or
rate of DVT (8.33%) when compared with all other pro- greater were considered to be in the highest risk category.
cedures (1.73%). A study by Pannucci et al. [13] validated the use of the
In a review of the literature by Hatef et al. [12], cir- Caprini model for identifying patients at increased risk of
cumferential abdominoplasty was associated with the the occurrence of DVT among plastic surgery patients. It
highest VTE rate (3.40%). This was statistically higher showed that patients with Caprini scores of 7 who were not
than the thromboembolic rate of abdominoplasty (0.35%, receiving chemoprophylaxis were at high risk of VTE, and
p \ 0.0001) and abdominoplasty with concomitant plastic patients with scores C 8 were at the highest risk. The
surgery (0.79%, p \ 0.0001). Abdominoplasty combined authors suggested that the patients previously considered
with an intraabdominal procedure was associated with the ‘‘high’’ or ‘‘highest’’ risk by the Caprini/Davison RAM did
second highest rate of thromboembolism (2.17%). not have a significantly higher VTE incidence compared
Winocour et al. [5] found that body procedures and with those considered ‘‘low’’ and ‘‘moderate’’ risk and may
combined procedures compared to solitary procedures have not require chemoprophylaxis if their composite scores
the highest incidence of VTE. were less than eight.
A prospective study was conducted on patients who Pannucci [9] also concluded that risk factors and pro-
underwent abdominoplasty and flank liposuction to deter- tective factors that may be relevant but are not included in
mine the influence of the amount of fat removed on the the 2005 Caprini score include recent air or car travel
occurrence of pulmonary embolism [21]. In this study, the (including plastic surgery tourism), rectus plication,
relative risk conferred when the amount of fat removed was anaesthetic type, timing and extent of early ambulation,
greater than 1500 g was 7.4. An association was also found and inpatient versus outpatient surgery.
with the duration of surgery: all embolisms occurred in Hence, the Caprini/Davison RAM [14] was adapted
patients who underwent long operations ([ 140 min; 8.8%; specifically for plastic surgery. It is divided into ‘‘exposing
3/34), with a relative risk of 3.0. risk factors’’ (the risk imposed by the surgery itself) and
As described in Table 8, the majority of the relevant ‘‘predisposing risk factors’’ (the patient’s biological risk).
studies suggest that the risk of VTE is increased when Each factor in both categories is scored, and a composite
liposuction is combined with abdominoplasty. risk assignment of ‘‘low’’ (one factor), ‘‘moderate’’ (two
factors), ‘‘high’’ (three or four factors) and ‘‘highest’’ (more
Risk Stratification and Risk Assessment Models than four factors) is assigned. Each of these categories has
a proposed prophylaxis regimen, ranging from ‘‘ambulate
Risk assessment models provide a point system relative to three times per day’’ (for low risk) to graduated compres-
individual factors believed to increase the likelihood of the sion stockings (GCS) and use of an intermittent pneumatic
development of a VTE. The patient’s score is calculated compression device (IPC) (moderate risk) to ‘‘GCS with
and then used to help determine if chemoprophylaxis IPC ± chemoprophylaxis’’ (high/highest risk).
should be considered during and after surgery. Based on the Caprini/Davison RAM, chemoprophylaxis
Current RAMs were created with the hope that quanti- with LMWH can be ‘‘considered’’ for patients who score
tation of a variety of data points might facilitate analysis of three or four points (high risk), whereas those with scores
a patient’s risk of developing a VTE and aid in the decision of five points or more (highest risk) should be given
to use chemoprophylaxis. Risk assessment models are LMWH. Lista et al. [22] mentioned that the effectiveness
valuable because they focus the evaluation of patients on of stratification into high and highest risk is yet to be
VTE and provide a means of communicating potential risks established, as giving chemoprophylaxis to patients with
with patients. However, when performing abdominoplasty, three to four points might result in overtreatment.
risk assessment models do not seem to provide a broad- The analysis of the data collected by Hatef et al. [20]
spectrum approach to making the decision for showed three risk factors that may enable a plastic surgeon
chemoprophylaxis. to more accurately risk-stratify potential body contouring
The most recent American College of Chest Physicians patients: circumferential abdominoplasty, body mass index
guidelines [8] support individualised risk stratification, and hormone therapy use. Patients with BMI [ 30, those

123
 Aesth Plast Surg

undergoing circumferential procedures and patients who for patients with a 2005 Caprini score of greater than 8 and
are on oral contraceptives or hormone replacement therapy 1.4% for patients with a 2005 Caprini score of 7–8.
have an increased risk of venous thromboembolism. In their study comparing the efficacy of enoxaparin in
Table 9 shows that higher Caprini RAM scores are DVT prophylaxis, Hatef et al. [20] concluded that enoxa-
associated with higher rates of DVT, the risk being highest parin administration was associated with a statistically
in patients with a score [ 8, patients with obesity, patients significant decrease in the incidence of deep venous
using HRT and patients undergoing circumferential thrombosis in circumferential abdominoplasty patients.
procedures. Enoxaparin use was associated with a non-significant trend
towards a decreased rate of overall venous
Procedure-Specific Risk thromboembolism.
The inconvenience of daily injections of LMWH is a
Abdominoplasty is a procedure that is associated with a common complaint among patients. The relatively new
high risk of VTE, independent of RAM score. novel oral anticoagulants (NOACs) are medications that
Pannucci et al. [13] mentioned in his review that may prove to be a safe alternative for post-operative
abdominal wall plication in abdominoplasty [23, 24] can chemoprophylaxis.
increase intraabdominal pressure. Increased intraabdominal Morales et al. [18] conducted a study comparing novel
pressure (IAP) is known to create lower extremity venous oral anticoagulants (rivaroxaban and apixaban) to LMWH
stasis and venous dilation [25, 26], which can in turn create for chemical prophylaxis after body contouring procedures
intimal microtears that provide a nidus for clot formation and concluded that they have similar rates of drug-related
[27]. In addition to plication, bed flexion to facilitate complications. Further investigation is warranted with
Scarpa fascia and skin closure may provide an additional more clinical cases to recommend the use of this medica-
increase in IAP [23]. Post-operative abdominal binders tion for routine post-operative chemical prophylaxis after
may further increase IAP [23, 26], and compression gar- body contouring procedures.
ments and binders [28] can create a tourniquet effect on the Hunstad et al. [19] also concluded that oral rivaroxaban
upper thighs, further decreasing lower extremity venous administration for chemoprophylaxis in abdominoplasty
outflow. However, a study conducted by Rodrigues et al. patients is safe and has low rates of symptomatic VTE and
[15] concluded that diastasis width does not interfere with haematoma formation. The authors continue routine use of
the increase of IAP when a plication of the anterior the medication for patients at increased risk of VTE events.
aponeurosis is performed to correct rectus diastasis in Aly et al. [1] state that reluctance to adopt chemopro-
patients with BMI \ 28. All such factors plus post-opera- phylaxis is due to the risk of haematoma and the lack of
tive pain, prolonged bed rest, length of surgery and general solid evidence in the plastic surgery literature supporting a
anaesthesia contribute to the increased risk. Hence, the particular protocol.
recent trend is towards early ambulation, drainless proce- Table 12 summarises the results of studies on the clin-
dures, epidural top-ups for pain relief and a preference for ically significant rate of haematoma after VTE prophylaxis.
non-general anaesthesia [1, 13]. In their prospective trial, Dini et al. [11] found a rate as
high as 29.6% in the study group receiving chemopro-
Chemoprophylaxis for VTE Prophylaxis phylaxis in the form of rivaroxaban (10 mg), once a day,
beginning 6–8 h after abdominoplasty. They concluded
Low-molecular-weight heparin (e.g., enoxaparin) remains that for procedures in which a large detachment is planned
the most widely used drug for VTE prophylaxis. Newall in patients with a moderate risk of deep venous thrombosis,
et al. [16] presented an 18-month experience with the use patients should be evaluated with regard to the risk and
of this therapy for 291 consecutive patients. All the patients benefit of thromboembolism prophylaxis.
fell into the categories of high risk and highest risk of the The efficacy and safety of oral anticoagulants need to be
development of deep vein thrombosis, embolism or both. established with more studies.
No patient experienced DVT and/or PE when using Hatef et al. [20] noted a statistically significant increase
enoxaparin as a prophylaxis after major body contouring in the mean drain output for the first 24 h post-operatively
surgery in their study. This study is the first report that and clinically significant bleeding requiring blood trans-
describes the use of enoxaparin in aesthetic surgery for fusion in the group of patients who received their first dose
high-risk patients. of enoxaparin intraoperatively or post-operatively. How-
Pannucci et al. [17, 29], in the Venous Thromboem- ever, there was no statistically increased rate of
bolism Prevention Study (n = 3334), demonstrated a 50% haematoma.
relative risk reduction and absolute risk reductions of 4.5%

123
Aesth Plast Surg

Pannucci et al. [14, 18] also concluded that post-oper- In their meta-analysis, Pannucci et al. [10] suggest that
ative enoxaparin did not significantly increase the rate of non-general anaesthesia should be preferred where
re-operative haematoma in the post-operative period. possible.
Increased bleeding has been demonstrated in operations Epidural anaesthesia (EA) is known to reduce post-op-
with large areas of dissection, such as post-bariatric body erative thromboembolic complications, but the mecha-
contouring, and in surgery in highly vascular areas, such as nisms are poorly understood.
the face [13, 19]. Hafezi et al. [6] performed a retrospective study
As stated by Pannucci et al. [10], there are minimal data between two groups of patients undergoing abdomino-
to give evidence-based recommendations for the duration plasty with or without concurrent liposuction. One throm-
of chemoprophylaxis. The Venous Thromboembolism boembolic event (pulmonary embolism [PE]) occurred in
Prevention Study adopted a uniform protocol for giving Group 1 (4%), in which the procedure was performed
chemoprophylaxis for the duration of the inpatient stay under general anaesthesia. No cases of DVT or PE occur-
only. red among Group 2 patients, who received EA. The authors
The timing of administration of chemoprophylaxis, concluded that EA with a differential nerve block, which
whether 2 h preoperatively, intra- or immediately post- has less of an effect on motor function, improves perfusion
operatively does not affect the haematoma rate, and of the lower limbs by active muscle contraction.
chemoprophylaxis can be safely started 6–8 h after surgery Therefore, more frequent use of EA for abdominoplasty
[4, 11, 16]. and lipo-aspiration may reduce the rate of thromboembolic
events.
Comprehensive Measures and Choice
of Anaesthesia
Funding No intramural or extramural funding supported any aspect
of this work.
Lista et al. [22] performed a retrospective review in which
404 consecutive abdominoplasty patients who were treated Compliance with Ethical Standards
at a single outpatient surgery centre between 2000 and
2010 were studied. Graded compression stockings and Conflict of interest The authors declare that they have no conflicts of
interest to disclose. None of the authors have a financial interest in
intermittent pneumatic compression devices were placed any of the products, devices or drugs mentioned in the manuscript.
on all patients, and perioperative and intraoperative
warming was strictly applied. A progressive tension Ethical Approval This article does not contain any studies with
suturing technique was performed in all cases, and drains human participants or animals performed by any of the authors.
were eliminated. All patients received pain pumps, ambu-
Informed Consent For this type of study, informed consent is not
lated within 1 h of surgery and were discharged home the required.
same day. Patient VTE risk factors were scored with the
Caprini/Davison RAM. Perioperative and intraoperative
measures were taken to reduce factors that may increase References
VTE risk in abdominoplasty. They concluded that a com-
prehensive approach to perioperative and intraoperative 1. Shestak KC, Rios L, Pollock TA, Aly A (2018) Evidenced-based
approach to abdominoplasty update. Aesthet Surg J 39:628–642
patient care allows outpatient abdominoplasty to be safely
2. GutowskiGR Singer R, Iverson RE, Nahai F (2018) Incidence
performed without VTE chemoprophylaxis in patients with and predictors of venous thromboembolism in abdominoplasty.
fewer than six risk factors. Aesthet Surg J 38:162–173
Specifically, this series demonstrates an exceedingly low 3. Spring MA, Gutowski KA (2006) Venous thromboembolism in
plastic surgery patients: survey results of plastic surgeons. Aes-
incidence of VTE without chemoprophylaxis.
thet Surg J 26:522–529
Swanson has written about the potential benefits of 4. Most D, Kozlow J, Heller J, Shermak MA (2005) Thromboem-
using ‘‘SAFE’’ anaesthesia [30]. The acronym SAFE stands bolism in plastic surgery. Plast Reconstr Surg 115:20e–30e
for Spontaneous breathing using propofol or other IV 5. Winocour J, Gupta V, Kaoutzanis C, Shi H, Shack RB, Grotting
JC, Higdon KK (2017) Venous thromboembolism in the cosmetic
medication, Avoidance of the use of gas, maintenance of a
patient: analysis of 129,007 patients. Aesthet Surg J 37:337–349
supine position with the patient Face up, and allowing for 6. Hafezi F, Naghibzadeh B, Nouhi AH, Salimi A, Naghibzadeh G,
mobility of the Extremities. By titrating the amount of Mousavi SJ (2011) Epidural anesthesia as a thromboembolic
sedation, intubation is not necessary, and the calf muscle prophylaxis modality in plastic surgery. Aesthet Surg J
31:821–824
pump remains active. Conversely, when inhalation agents
7. Broughton G 2nd, Rios JL, Rohrich RJ, Brown SA (2007) Deep
are used, there is increased cardiovascular and respiratory venous thrombosis prophylaxis practice and treatment strategies
depression leading to increased rates of VTE [20]. among plastic surgeons: survey results. Plast Reconstr Surg
119:157–174

123
 Aesth Plast Surg

8. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, thromboembolism prophylaxis in abdominoplasty: a multicenter
Heit JA, Samama CM (2012) Prevention of VTE in nonortho- experience. Aesthet Surg J 36:60–66
pedic surgical patients: antithrombotic therapy and prevention of 20. Hatef DA, Kenkel JM, Nguyen MQ, Farkas JP, Abtahi F, Rohrich
thrombosis, 9th ed: American college of chest physicians evi- RJ, Brown SA (2008) Thromboembolic risk assessment and the
dence-based clinical practice guidelines. Chest 141:e227S–e277S efficacy of enoxaparin prophylaxis in excisional body contouring
9. Pannucci CJ (2017) Evidence-based recipes for venous throm- surgery. Plast Reconstr Surg 122:269–279
boembolism prophylaxis: a practical safety guide. Plast Reconstr 21. Gravante G, Araco A, Sorge R, Araco F, Nicoli F, Caruso R,
Surg 139:520e–532e Langiano N, Cervelli V (2008) Pulmonary embolism after com-
10. Pannucci CJ, MacDonald JK, Ariyan S, Gutowski KA, Kerrigan bined abdominoplasty and flank liposuction: a correlation with
CL, Kim JY, Chung KC (2016) Benefits and risks of prophylaxis the amount of fat removed. Ann Plast Surg 60:604–608
for deep venous thrombosis and pulmonary embolus in plastic 22. Somogyi RB, Ahmad J, Shih JG, Lista F (2012) Venous throm-
surgery: a systematic review and meta-analysis of controlled boembolism in abdominoplasty: a comprehensive approach to
trials and consensus conference. Plast Reconstr Surg lower procedural risk. Aesthet Surg J 32:322–329
137:709–730 23. Al-Basti HB, El-Khatib HA, Taha A, Sattar HA, Bener A (2004)
11. Dini G, Ferreira M, Albuquerque L, Ferreira L (2012) How safe Intraabdominal pressure after full abdominoplasty in obese
is chemoprophylaxis after abdominoplasty? Plast Reconstr Surg multiparous patients. Plast Reconstr Surg 113:2145–2150
130:851e–857e 24. Huang GJ, Bajaj AK, Gupta S, Petersen F, Miles DA (2007)
12. Hatef DA, Trussler AP, Kenkel JM (2010) Procedural risk for Increased intraabdominal pressure in abdominoplasty: delineation
venous thromboembolism in abdominal contouring surgery: a of risk factors. Plast Reconstr Surg 119:1319–1325
systematic review of the literature. Plast Reconstr Surg 25. Schein M, Wittmann DH, Aprahamian CC, Condon RE (1995)
125:352–362 The abdominal compartment syndrome: the physiological and
13. Pannucci CJ, Bailey SH, Dreszer G, Fisher Wachtman C, Zum- clinical consequences of elevated intra-abdominal pressure. J Am
steg JW, Jaber RM, Hamill JB, Hume KM, Rubin JP, Neligan PC, Coll Surg 180:745–753
Kalliainen LK, Hoxworth RE, Pusic AL, Wilkins EG (2011) 26. Pannucci CJ, Alderman AK, Brown SL, Wakefield TW, Wilkins
Validation of the Caprini risk assessment model in plastic and EG (2012) The effect of abdominal wall plication on intra-ab-
reconstructive surgery patients. J Am Coll Surg 212:105–112 dominal pressure and lower extremity venous flow: a case report.
14. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL J Plast Reconstr Aesthet Surg 65:392–394
(2004) Prevention of venous thromboembolism in the plastic 27. Comerota AJ, Stewart GJ, Alburger PD, Smalley K, White JV
surgery patient. Plast Reconstr Surg 114:43e–51e (1989) Operative venodilation: a previously unsuspected factor in
15. Rodrigues MA, Nahas FX, Reis RP et al (2015) Does diastasis the cause of postoperative deep vein thrombosis. Surgery
width influence the variation of the intra -abdominal pressure 106:301–308
after correction of rectus diastasis. Aesthet Plast Surg 35:583–588 28. Clayman MA, Clayman ES, Seagle BM, Sadove R (2009) The
16. Newall G, Ruiz-Razura A, Mentz HA, Patronella CK, Ibarra FR, pathophysiology of venous thromboembolism: implications with
Zarak A (2006) A retrospective study on the use of a low- compression garments. Ann Plast Surg 62:468–472
molecular-weight heparin for thromboembolism prophylaxis in 29. Pannucci CJ, Wachtman CF, Dreszer G, Bailey SH, Portschy PR,
large-volume liposuction and body contouring procedures. Aes- Hamill JB, Hume KM, Hoxworth RE, Kalliainen LK, Rubin JP,
thet Plast Surg 30:86–95 Pusic AL, Wilkins EG (2012) The effect of postoperative
17. Pannucci CJ, Dreszer G, Wachtman CF, Bailey SH, Portschy PR, enoxaparin on risk for reoperative hematoma. Plast Reconstr Surg
Hamill JB, Hume KM, Hoxworth RE, Rubin JP, Kalliainen LK, 129:160–168
Pusic AL, Wilkins EG (2011) Postoperative enoxaparin prevents 30. Swanson E (2014) The case against chemoprophylaxis for venous
symptomatic venous thromboembolism in high-risk plastic sur- thromboembolism prevention and the rationale for SAFE anes-
gery patients. Plast Reconstr Surg 128:1093–1103 thesia. Plast Reconstr Surg Glob Open 2:e160
18. Morales R Jr, Ruff E, Patronella C, Mentz H 3rd, Newall G,
Hustak KL, Fortes P, Bush A (2016) Safety and efficacy of novel
oral anticoagulants vs low molecular weight heparin for throm- Publisher’s Note Springer Nature remains neutral with regard to
boprophylaxis in large-volume liposuction and body contouring jurisdictional claims in published maps and institutional affiliations.
procedures. Aesthet Surg J 36:440–449
19. Hunstad JP, Krochmal DJ, Flugstad NA, Kortesis BG, Augen-
stein AC, Culbertson GR (2016) Rivaroxaban for venous

123