Julian Winocour

Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients

BACKGROUND Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies. OBJECTIVES This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures. METHODS A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥ 25 (relative risk 2.8) increased infection risk. CONCLUSIONS Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥ 25, and combined procedures are independent risk factors. LEVEL OF EVIDENCE 2: Risk.

Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures.

Background: Among aesthetic surgery procedures, abdominoplasty is associated with a higher complication rate, but previous studies are limited by small sample sizes or single-institution experience. Methods: A cohort of patients who underwent abdominoplasty between 2008 and 2013 was identified from the CosmetAssure database. Major complications were recorded. Univariate and multivariate analysis was performed evaluating risk factors, including age, smoking, body mass index, sex, diabetes, type of surgical facility, and combined procedures. Results: The authors identified 25,478 abdominoplasties from 183,914 procedures in the database. Of these, 8,975 patients had abdominoplasty alone and 16,503 underwent additional procedures. The number of complications recorded was 1,012 (4.0 percent overall rate versus 1.4 percent in other aesthetic surgery procedures). Of these, 31.5 percent were hematomas, 27.2 percent were infections and 20.2 percent were suspected or confirmed venous thromboembolism. On multivariate analysis, significant risk factors (p < 0.05) included male sex (relative risk, 1.8), age 55 years or older (1.4), body mass index greater than or equal to 30 (1.3), multiple procedures (1.5), and procedure performance in a hospital or surgical center versus office-based surgical suite (1.6). Combined procedures increased the risk of complication (abdominoplasty alone, 3.1 percent; with liposuction, 3.8 percent; breast procedure, 4.3 percent; liposuction and breast procedure, 4.6 percent; body-contouring procedure, 6.8 percent; liposuction and body-contouring procedure, 10.4 percent). Conclusions: Abdominoplasty is associated with a higher complication rate compared with other aesthetic procedures. Combined procedures can significantly increase complication rates and should be considered carefully in higher risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Safety of Cosmetic Procedures in Elderly and Octogenarian Patients

BACKGROUND The proportion of elderly patients in North America is increasing. This has resulted in an increased number of elderly patients undergoing cosmetic procedures. OBJECTIVES The purpose of this study was to determine the incidence of postoperative complications in elderly patients (age ≥65) undergoing elective aesthetic plastic surgical procedures compared with younger patients. METHODS A total of 183,914 cosmetic surgical procedures were reviewed using the prospectively enrolled cohort of patients in the CosmetAssure database. Comorbidities and postoperative complications in elderly and younger patient groups were recorded and compared. A separate analysis of postoperative complications was performed in the octogenarian subgroup (age ≥80). RESULTS A total of 6786 elderly patients who underwent cosmetic procedures were included in the study. Mean ages (±standard deviation) in elderly and younger patients were 69.1 ± 4.1 and 39.2 ± 12.5 years, respectively. The elderly patient population had more men, a higher mean body mass index (BMI), a higher prevalence of diabetes mellitus (DM), and fewer smokers compared with the younger patients. The overall postoperative complication rate was not significantly different between elderly and younger patients. When stratified by type of cosmetic procedure, only abdominoplasty was associated with a higher postoperative complication rate in elderly compared with younger patients. The most common postoperative complications in elderly patients were hematoma and infection. The overall postoperative complication rate in octogenarians was 2.2%, which was not significantly different from the younger population. CONCLUSIONS Cosmetic procedures in elderly patients, including octogenarians, remain safe with an acceptable complication rate compared to younger patients.

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients

BACKGROUND Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results. OBJECTIVES This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database. METHODS A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56). CONCLUSIONS Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients

Background Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties. Objectives This study analyzed the risk factors for VTE in cosmetic surgical procedures. Methods A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%). Conclusions The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases

Background: Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging. Objectives: To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures. Methods: A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated. Results: Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation‐mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation‐mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03). Conclusions: Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications. Level of Evidence: 2 Figure. No caption available.

Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures

Background Liposuction is among the most commonly performed aesthetic procedures, and is being performed increasingly as an adjunct to other procedures. Objectives To report the incidence and risk factors of significant complications after liposuction, and to determine whether adding liposuction to other cosmetic surgical procedures impacts the complication risk. Methods A prospective cohort of patients who underwent liposuction between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the operation. Univariate and multivariate analysis evaluated risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. Results Of the 31,010 liposuction procedures, only 11,490 (37.1%) were performed as a solitary procedure. Liposuction alone had a major complication rate of 0.7% with hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and confirmed venous thromboembolism (VTE) (0.06%) being the most common. Independent predictors of major complications included combined procedures (Relative Risk (RR) 4.81), age (RR 1.01), BMI (RR 1.05), and procedures performed in hospitals (RR 1.36). When examining specifically other aesthetic procedures performed alone or with liposuction, combined procedures had a higher risk of confirmed VTE (RR 5.65), pulmonary complications (RR 2.72), and infection (RR 2.41), but paradoxically lower hematoma risk (RR 0.77) than solitary procedures. Conclusions Liposuction performed alone is a safe procedure with a low risk of major complications. Combined procedures, especially on obese or older individuals, can significantly increase complication rates. The impact of liposuction on the risk of hematoma in combined procedures needs further investigation. Level of Evidence 2

Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients.

Background: Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts. Objectives: The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study. Methods: A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. Results: A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications. Conclusions: The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries. Level of Evidence: 2 Figure. No caption available.

Incidence and Risk Factors for Major Hematomas in Aesthetic Surgery: Analysis of 129,007 Patients

Background Postoperative hematomas are one of the most frequent complications following aesthetic surgery. Identifying risk factors for hematoma has been limited by underpowered studies from single institution experiences. Objectives To examine the incidence and identify independent risk factors for postoperative hematomas following cosmetic surgery utilizing a prospective, multicenter database. Methods A prospectively enrolled cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major hematomas requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis was used to identify potential risk factors for hematomas including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results Of 129,007 patients, 1180 (0.91%) had a major hematoma. Mean age (42.0 ± 13.0 years vs 40.9 ± 13.9 years, P < 0.01) and BMI (24.5 ± 5.0 kg/m2 vs 24.3 ± 4.6 kg/m2, P < 0.01) were higher in patients with hematomas. Males suffered more hematomas than females (1.4% vs 0.9%, P < 0.01). Hematoma rates were higher in patients undergoing combined procedures compared to single procedures (1.1% vs 0.8%, P < 0.01), and breast procedures compared to body/extremity or face procedures (1.0% vs 0.8% vs 0.7%, P < 0.01). On multivariate analysis, independent predictors of hematoma included age (Relative Risk [RR] 1.01), male gender (RR 1.98), the procedure being performed in a hospital setting rather than an office-based setting (RR 1.68), combined procedures (RR 1.35), and breast procedures rather than the body/extremity and face procedures (RR 1.81). Conclusions Major hematoma is the most common complication following aesthetic surgery. Male patients and those undergoing breast or combined procedures have a significantly higher risk of developing hematomas. Level of Evidence 2.

Venous Thromboembolism in the Cosmetic Patient.

PURPOSE: Venous thromboembolism (VTE) is one of the most feared post-operative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown and current ASPS recommendations for prophylaxis are partially extrapolated from Orthopedic and General Surgery literature. Furthermore, although there are provider surveys suggesting a high incidence of deep venous thromboses in certain plastic surgeon communities in the United States, there still is a dearth of data establishing the number of these complications on a population level and quantifying concrete risk factors. This study analyzed the risk factors for VTE in cosmetic surgical procedures, alone and in combined procedures.