Eric Swanson

Ultrasound Screening for Deep Venous Thrombosis Detection: A Prospective Evaluation of 200 Plastic Surgery Outpatients

Background: Our understanding of the pathophysiology of venous thromboembolism is largely based on the experience of orthopedic patients undergoing total joint replacement. Little is known regarding the natural history of venous thromboembolism in plastic surgery outpatients. Today, ultrasound screening, including compression and Doppler color flow imaging, represents the standard for detecting deep venous thromboses. Methods: Ultrasound screening was offered to 200 consecutive plastic surgery outpatients undergoing 205 operations. Patients were scanned before surgery, on the day after surgery, and approximately 1 week after surgery. No patient declined to participate (inclusion rate, 100%). Spontaneous breathing, Avoid gas, Face up, Extremities mobile anesthesia was used, with no chemoprophylaxis. Patient surveys were administered. Results: Six hundred ultrasound screening tests were performed. All scans performed the day after surgery were negative. Only one examination was positive, 8 days after a lipoabdominoplasty. Subsequent scans revealed complete resolution of the thrombosis with anticoagulation. Ninety percent of surveyed patients would choose to have ultrasound screening in the future. Conclusions: The natural history of thromboembolism in plastic surgery outpatients differs from orthopedic patients. The risk of a deep venous thrombosis in a patient treated with Spontaneous breathing, Avoid gas, Face up, Extremities mobile anesthesia is approximately 0.5%. Thromboses are unlikely to develop intraoperatively. In the single affected patient, the thrombosis was located distally, in a location that is less prone to embolism and highly susceptible to anticoagulation. Ultrasound screening is an effective and highly feasible method to identify affected patients for treatment.

Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination.

Background: Despite the popularity of these procedures, there are limited published prospective studies evaluating liposuction and abdominoplasty. Lipoabdominoplasty is a subject of recent attention. Several investigators have recommended alternative techniques that preserve the Scarpa fascia in an effort to reduce complications, particularly the risk of seromas. Methods: Over a 5-year period, 551 consecutive patients were treated with ultrasonic liposuction alone (n = 384), liposuction/abdominoplasty (n = 150), or abdominoplasty alone (n = 17). In lipoabdominoplasties, the abdomen and flanks were first treated with liposuction. A traditional flap dissection was used for all abdominoplasties. Scalpel dissection was used rather than electrodissection. A supine “jackknife” position was used in surgery to provide maximum hip flexion, allowing a secure deep fascial repair. Results: The complication rate after liposuction was 4.2% vs 50% for patients treated with an abdominoplasty. Approximately half of the abdominoplasty complications were minor scar deformities, including widened umbilical scars (17.3%) that were revised. The seroma rate after abdominoplasties was 5.4%; there were no seromas after liposuction alone. Conclusions: Lipoabdominoplasty may be performed safely, so that patients may benefit from both modalities. The seroma rate is reduced by avoiding electrodissection, making Scarpa fascia preservation a moot point. A deep fascial repair keeps the abdominoplasty scar within the bikini line. Deep venous thrombosis and other complications may be minimized with precautions that do not include anticoagulation.

The Case against Chemoprophylaxis for Venous Thromboembolism Prevention and the Rationale for SAFE Anesthesia.

Summary: The Venous Thromboembolism Prevention study concludes that anticoagulation is effective in reducing the risk of thromboembolism in patients who are identified as higher risk by Caprini scores. This report critically assesses the statistics used in the Venous Thromboembolism Prevention study, its method of data presentation, and its conclusions. The usefulness of risk stratification and the value of anticoagulation—both prevailing concepts in risk reduction today—are challenged. Actual data show that chemoprophylaxis has no proven benefit in plastic surgery. Complications of anticoagulation predictably include excessive bleeding and hematomas, which may be serious and life-threatening. Several large published series of patients undergoing elective plastic surgery under total intravenous anesthesia have shown a much reduced risk of thromboembolism. A SAFE (Spontaneous breathing, Avoid gas, Face up, Extremities mobile) anesthesia method is discussed as a safer and more effective alternative to traditional general endotracheal anesthesia and anticoagulation. The choice for plastic surgeons is not between a venous thromboembolism and a hematoma. The choice is between a thromboembolism and adjusting our anesthesia and surgery habits to reduce the risk to a baseline level.

Levels of Evidence in Cosmetic Surgery: Analysis and Recommendations Using a New CLEAR Classification

Background: The Level of Evidence rating was introduced in 2011 to grade the quality of publications. This system evaluates study design but does not assess several other quality indicators. This study introduces a new “Cosmetic Level of Evidence And Recommendation” (CLEAR) classification that includes additional methodological criteria and compares this new classification with the existing system. Methods: All rated publications in the Cosmetic Section of Plastic and Reconstructive Surgery, July 2011 through June 2013, were evaluated. The published Level of Evidence rating (1–5) and criteria relevant to study design and methodology for each study were tabulated. A new CLEAR rating was assigned to each article, including a recommendation grade (A–D). The published Level of Evidence rating (1–5) was compared with the recommendation grade determined using the CLEAR classification. Results: Among the 87 cosmetic articles, 48 studies (55%) were designated as level 4. Three articles were assigned a level 1, but they contained deficiencies sufficient to undermine the conclusions. The correlation between the published Level of Evidence classification (1–5) and CLEAR Grade (A–D) was weak (&rgr; = 0.11, not significant). Only 41 studies (48%) evaluated consecutive patients or consecutive patients meeting inclusion criteria. Conclusions: The CLEAR classification considers methodological factors in evaluating study reliability. A prospective study among consecutive patients meeting eligibility criteria, with a reported inclusion rate, the use of contemporaneous controls when indicated, and consideration of confounders is a realistic goal. Such measures are likely to improve study quality.

Comparison of Vertical and Inverted-T Mammaplasties Using Photographic Measurements

Background: Surgeons have long debated the relative merits of vertical and inverted-T mammaplasties. These debates have centered on surgeons’ opinions. Without measurements, this controversy is unlikely to be resolved. This study compares these common techniques using a recently published measurement system. Such a study using measurements on photographs matched for size and orientation has not been previously published. Methods: A prospective group of women undergoing primary vertical mastopexies, augmentation/mastopexies, and reductions (n = 78) was compared with a retrospective group of women treated with inverted-T mastopexies, augmentation/mastopexies, and reductions (n = 35). Consecutive patients with photographs at least 3 months after surgery and no subsequent procedures were evaluated. Results: All patient groups demonstrated a significant elevation (P < 0.001) of the breast mound. Vertical mastopexy, but not inverted-T mastopexy, increased breast projection and upper pole projection (P < 0.008). Neither vertical nor inverted-T breast reduction significantly increased breast projection. Vertical breast reduction better preserved breast projection (P < 0.017) than the inverted-T technique. Vertical reduction significantly increased upper pole projection (P < 0.008), but inverted-T reduction did not. The inverted-T breast reduction caused greater breast constriction (reduced lower pole distance) than the vertical technique. Lower pole ratios were significantly higher for inverted-T patients (P < 0.01), indicating boxier lower poles. Conclusions: Photographic measurements of relevant breast parameters favor the vertical technique over the inverted-T technique and are consistent with anatomical considerations and clinical experience.

Validity, reliability, and the questionable role of psychometrics in plastic surgery.

Summary: This report examines the meaning of validity and reliability and the role of psychometrics in plastic surgery. Study titles increasingly include the word “valid” to support the authors’ claims. Studies by other investigators may be labeled “not validated.” Validity simply refers to the ability of a device to measure what it intends to measure. Validity is not an intrinsic test property. It is a relative term most credibly assigned by the independent user. Similarly, the word “reliable” is subject to interpretation. In psychometrics, its meaning is synonymous with “reproducible.” The definitions of valid and reliable are analogous to accuracy and precision. Reliability (both the reliability of the data and the consistency of measurements) is a prerequisite for validity. Outcome measures in plastic surgery are intended to be surveys, not tests. The role of psychometric modeling in plastic surgery is unclear, and this discipline introduces difficult jargon that can discourage investigators. Standard statistical tests suffice. The unambiguous term “reproducible” is preferred when discussing data consistency. Study design and methodology are essential considerations when assessing a study’s validity.

Breast Reduction versus Breast Reduction Plus Implants: A Comparative Study with Measurements and Outcomes

Background: Breast reduction is well-known to provide an improvement in physical symptoms. However, measurements show that this procedure is less effective in restoring upper-pole fullness. Breast implants effectively augment the upper pole. This study was undertaken to determine the effectiveness and safety of this treatment combination. Methods: This retrospective study consists of 3 parts: (1) a clinical study, (2) breast measurements, and (3) an outcome study. Eighty consecutive women undergoing breast reduction (n = 56) or breast reduction plus implants (n = 24) were evaluated. All breast implants were inserted submuscularly. All patients were treated with the same vertical reduction technique, using a medially based pedicle and intraoperative nipple positioning. Measurements were compared between preoperative photographs and photographs taken at least 3 months after surgery (n = 51). Patient surveys (n= 56) were evaluated. Results: There was no significant difference in complication or reoperation rates between groups. Both procedures elevated the breast mound and lower-pole level and increased the breast parenchymal ratio (upper-pole area/lower-pole area). Breast implants significantly increased upper-pole projection (P < 0.01). All surveyed patients who had simultaneous implants reported that they were pleased with their decision. Physical symptoms were reduced in both groups. Patient satisfaction was 92.5% for breast reduction and 93.8% for breast reduction plus implants. Both groups reported an improvement in quality of life. Conclusions: Vertical breast reduction with a medial pedicle may be combined safely and effectively with breast implants in patients who desire upper-pole fullness.

Chemoprophylaxis for venous thromboembolism prevention: concerns regarding efficacy and ethics.

Summary: Chemoprophylaxis has been recommended for plastic surgery patients judged to be at increased risk for venous thromboembolism. Several investigators have encountered this complication in patients despite anticoagulation therapy. An increased rate of complications related to postoperative bleeding has been reported. This article examines the efficacy and safety of this intervention, along with ethical considerations, in an attempt to determine whether any benefits of chemoprophylaxis justify the additional risks. The statistical methods and conclusion of the Venous Thromboembolism Prevention Study are challenged. Other preventative measures that do not cause negative side effects are discussed as safer alternatives.

Caprini Scores, Risk Stratification, and Rivaroxaban in Plastic Surgery: Time to Reconsider Our Strategy.

Summary: Limited data are available regarding the pathophysiology of venous thromboembolism in plastic surgery patients. In an effort to identify patients at greater risk, some investigators promote individual risk assessment using Caprini scores. However, these scores do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false positive rate). Caprini scores make many body contouring patients candidates for chemoprophylaxis, an intervention that introduces risks related to anticoagulation. Caprini has financial conflicts with several companies that manufacture products such as enoxaparin, commonly used for chemoprophylaxis. Rivaroxaban, taken orally, has been used by some plastic surgeons as an alternative to enoxaparin injections. However, this medication is not United States Food and Drug Administration approved for venous thromboembolism prophylaxis in plastic surgery patients, and a reversal agent is unavailable. This article challenges the prevailing wisdom regarding individual risk stratification and chemoprophylaxis. Alternative methods to reduce risk for all patients include safer anesthesia methods and Doppler ultrasound surveillance. Clinical findings alone are unreliable in diagnosing deep venous thromboses. Only by using a reliable diagnostic tool such as Doppler ultrasound are we able to learn more about the natural history of this problem in our patients. Such knowledge is likely to better inform our treatment recommendations.

All Seasons Vertical Augmentation Mastopexy: A Simple Algorithm, Clinical Experience, and Patient-reported Outcomes

Background: The safety of augmentation mastopexy has been questioned. Staging has been recommended for women deemed to be at higher risk, such as women with greater degrees of ptosis. Most existing studies evaluate women treated with multiple methods, including the traditional Wise pattern. This retrospective study specifically evaluates vertical augmentation mastopexy. A simple algorithm is introduced. Methods: From 2002 to 2016, 252 women underwent consecutive vertical augmentation mastopexies performed by the author, with no staged surgery. All patients underwent a vertical mastopexy using a medially based pedicle and intraoperative nipple siting. A subset of women treated from 2012 to 2016 were surveyed to obtain outcome data; 90 patients (inclusion rate, 90%) participated. Results: The complication rate was 32.9%, including persistent ptosis, delayed wound healing, scar deformities, and asymmetry. There were no cases of nipple loss. An increased risk of complications was detected for smokers (P < 0.01), but not for combined procedures, secondary breast augmentations, or secondary mastopexies. The revision rate was 15.5%. Persistent nipple numbness was reported by 13.3% of respondents. Eighty percent of women were self-conscious about their breast appearance before surgery; 22% of respondents were self-conscious about their breasts after surgery. Seventy percent of respondents reported an improved quality of life, 94.4% would repeat the surgery, and 95.6% would recommend it. Conclusions: A simple algorithm may be used to guide treatment in women who desire correction of ptosis and upper pole fullness. An all seasons vertical augmentation mastopexy is safe and widely applicable. Staging is unnecessary.