Evidence-Based Body Contouring Surgery and VTE Prevention

Evidence-Based Body Contouring Surgery and VTE Prevention View largeDownload slide View largeDownload slide In Evidence-Based Body Contouring Surgery and VTE Prevention, Eric Swanson provides a broad overview of technical aspects and perioperative care for body surgery. He begins by explaining that his purpose for writing this book is not to recite the mainstream view of surgical management for these procedures, but to challenge it. The preface outlines his goal of defining body contouring surgery from an evidence-based viewpoint. He adheres to this approach in each of the chapters. Swanson points out that “almost everything plastic surgeons ‘know’ about body contouring surgery is based on clinical impressions.” To this point, he begins by listing 40 “Things we ‘know’ that are wrong” in the first table. The book consists of 13 chapters, 6 of which are directed at specific surgical procedures: Liposuction Abdominoplasty Thigh Lift and Surgery After Massive Weight Loss Brachioplasty and Hand Rejuvenation Buttock Fat Transfer Calf Augmentation In these procedure-specific chapters, Swanson provides insight into his surgical techniques with attention to thoughts on safe surgical care. Each procedure discussion includes currently accepted practices, laced with scientific literature references, as a prelude to the author’s favorite approach. His technique suggestions are supported by patient surveys and studies that he has conducted in his practice. Surgical results are presented with preoperative and postoperative photographs with comparable aspect ratios. The first chapter, “Evidence-Based Medicine and Conflict of Interest,” discusses conflict of interest in plastic surgery, highlighting issues related to financial disclosure, FDA financial clearance, and financial conflict. He feels that “the investigator should find that publication of his or her research in a highly respected peer-reviewed journal and the accolades that come with it are more than adequate compensation” and that “Expert testimony can create a particularly insidious conflict of interest.” Pointing to the need for adherence to scientific method, he says that it begins with consecutive patients, a reasonable inclusion rate, and an objective measuring device. Concerning the importance of data for outcomes analysis, he quotes Deming: “Without data, you are just another person with an opinion.” The remaining 6 chapters delve into the author’s viewpoint on: The Myth of Fat Redistribution Metabolic Effects of Liposuction SAFE Anesthesia and Minimizing Blood Loss Evaluating New Technologies The Fallacy of Individual Risk Stratification of Chemoprophylaxis Ultrasound for VTE Surveillance and Other Plastic Surgery Applications Throughout the text, he continually challenges many current concepts related to operative care and outcomes because, in his opinion, there is insufficient data to support them. His mantra is that there is no substitute for data. With respect to evidence-based medicine, he opines that it might be considered measurement-based medicine, referring to the old adage, “What we measure we improve, and vice versa.” He writes that measurements are the missing link in objective analysis. Measuring outcomes leads to improved results and provides the underpinning of evidence-based medicine. In Chapter 5, he recommends the use of SAFE (spontaneous breathing, avoid gas, face up, and extremities mobile) anesthesia as a technique to maintain mean arterial blood pressure and avoid paralysis, preserving the calf muscle pump. Other advantages derive from avoiding anesthetic gas, such as reducing the risk of postoperative nausea. Recovery times are quicker. Prone positioning, which adds unnecessary risks and operating time for patient positioning, may be eliminated. In addition, it should lower the incidence of venous thromboembolism (VTE). This approach has merit and should be studied with a large series of patients. Interestingly, a recent article written by this reviewer and colleagues analyzing data collected from facilities accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) reported the incidence of VTE in abdominoplasty associated with intravenous sedation and general anesthesia. Anesthesia information was reviewed for 290,498 cases, of which 235,274 (81%) were performed under general anesthesia and 49,699 (17%) under monitored IV sedation. The remaining surgeries (2%) were performed under epidural with monitored IV anesthesia, spinal anesthesia, tumescent anesthesia, or were unspecified. Only general anesthesia and monitored IV sedation were analyzed in this study. VTE occurred in 201 patients (0.09%) undergoing general anesthesia and 30 patients (0.06%) undergoing monitored IV sedation. Additional analysis found no statistically significant increase in the risk of VTE by anesthesia type (OR 1.421, 95% CI 0.96 to 2.08).1 Swanson is direct and unforgiving in his arguments against risk assessment models and their use for determining whether to use chemoprophylaxis. In Chapter 12, “The Fallacy of Individual Risk Stratification and Chemoprophylaxis,” he writes that the use of risk stratification models for determining whether or not to use chemoprophylaxis is without merit. His arguments are concise, using statistical analysis of the current literature to make his points. Regardless of one’s personal opinion of the issues that he debates, his point-counterpoint discussion is of great value to understanding and assessing contemporary thought concerning VTE. The problem of VTE is a major concern for plastic surgeons and is well viewed from many perspectives. In the previously referenced article by the reviewer, analyzing the AAAASF data, it was found that in 2,295,901 performed in their accredited facilities from 2001 to 2011, 414 resulted in VTE. This represents a VTE incidence of 0.02%. Of these VTE, 240 (58%) occurred in abdominoplasty cases. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which, according to current recommendations, would not be an indication for the use of chemoprophylaxis.1 Chapter 13 discusses the use of ultrasound for VTE surveillance. Current guidelines from the American College of Chest Physicians explicitly recommend against screening duplex ultrasound performed in the absence of clinical symptoms. This recommendation is based on the fact that the clinical relevance and natural history of asymptomatic deep vein thrombosis is unknown.2 However, Swanson states that ultrasound scans are highly accurate, noninvasive, and well tolerated by patients. Unlike the routine administration of anticoagulation, there is no added risk. The diagnosis is made before treatment rather than the reverse. Early detection of thromboses allows the surgeon to initiate treatment before the thrombosis propagates and becomes dangerous. Importantly, it avoids unnecessary bleeding and hematomas. He has performed ultrasound on over 1,000 patients and presents data on the first 200. STRENGTHS Swanson takes “the emperor has no clothes approach” to analysis. The book is well written and filled with valuable information and thoughtful commentary. The graphs, tables, and artwork are of high quality, helping to provide clear understanding of the author’s approach. Each topic was sufficiently covered, and controversies between the author and the literature were reviewed in detail. The overview of surgical procedures discusses perioperative patient management with a goal of limiting unanticipated sequelae. All plastic surgeons performing body contouring procedures should benefit from reading this book. WEAKNESSES Swanson admits that this single-author volume is open to criticism, representing the experience and prejudices of one surgeon. However, these experiences and prejudices are well thought out, and by all measures, the author would welcome contrary arguments, provided they are data based and scientifically presented. SUMMARY Overall, this is an excellent book. On a scale of 1 to 5, I would give it a 5 rating. RATING: 5 OF 5 To purchase: https://www.springer.com/us/book/9783319712185 View largeDownload slide View largeDownload slide Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Keyes GR , Singer R , Iverson RE , Nahai F . Incidence and predictors of venous thromboembolism in abdominoplasty . Aesthet Surg J . 2018 ; 38 ( 2 ): 162 - 173 . Google Scholar CrossRef Search ADS PubMed 2. Gould MK , Garcia DA , Wren SM , et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines . Chest . 2012 ; 141 ( 2 Suppl ): e227S - e277S . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Evidence-Based Body Contouring Surgery and VTE Prevention

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Publisher
Mosby Inc.
Copyright
© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjy133
Publisher site
See Article on Publisher Site

Abstract

View largeDownload slide View largeDownload slide In Evidence-Based Body Contouring Surgery and VTE Prevention, Eric Swanson provides a broad overview of technical aspects and perioperative care for body surgery. He begins by explaining that his purpose for writing this book is not to recite the mainstream view of surgical management for these procedures, but to challenge it. The preface outlines his goal of defining body contouring surgery from an evidence-based viewpoint. He adheres to this approach in each of the chapters. Swanson points out that “almost everything plastic surgeons ‘know’ about body contouring surgery is based on clinical impressions.” To this point, he begins by listing 40 “Things we ‘know’ that are wrong” in the first table. The book consists of 13 chapters, 6 of which are directed at specific surgical procedures: Liposuction Abdominoplasty Thigh Lift and Surgery After Massive Weight Loss Brachioplasty and Hand Rejuvenation Buttock Fat Transfer Calf Augmentation In these procedure-specific chapters, Swanson provides insight into his surgical techniques with attention to thoughts on safe surgical care. Each procedure discussion includes currently accepted practices, laced with scientific literature references, as a prelude to the author’s favorite approach. His technique suggestions are supported by patient surveys and studies that he has conducted in his practice. Surgical results are presented with preoperative and postoperative photographs with comparable aspect ratios. The first chapter, “Evidence-Based Medicine and Conflict of Interest,” discusses conflict of interest in plastic surgery, highlighting issues related to financial disclosure, FDA financial clearance, and financial conflict. He feels that “the investigator should find that publication of his or her research in a highly respected peer-reviewed journal and the accolades that come with it are more than adequate compensation” and that “Expert testimony can create a particularly insidious conflict of interest.” Pointing to the need for adherence to scientific method, he says that it begins with consecutive patients, a reasonable inclusion rate, and an objective measuring device. Concerning the importance of data for outcomes analysis, he quotes Deming: “Without data, you are just another person with an opinion.” The remaining 6 chapters delve into the author’s viewpoint on: The Myth of Fat Redistribution Metabolic Effects of Liposuction SAFE Anesthesia and Minimizing Blood Loss Evaluating New Technologies The Fallacy of Individual Risk Stratification of Chemoprophylaxis Ultrasound for VTE Surveillance and Other Plastic Surgery Applications Throughout the text, he continually challenges many current concepts related to operative care and outcomes because, in his opinion, there is insufficient data to support them. His mantra is that there is no substitute for data. With respect to evidence-based medicine, he opines that it might be considered measurement-based medicine, referring to the old adage, “What we measure we improve, and vice versa.” He writes that measurements are the missing link in objective analysis. Measuring outcomes leads to improved results and provides the underpinning of evidence-based medicine. In Chapter 5, he recommends the use of SAFE (spontaneous breathing, avoid gas, face up, and extremities mobile) anesthesia as a technique to maintain mean arterial blood pressure and avoid paralysis, preserving the calf muscle pump. Other advantages derive from avoiding anesthetic gas, such as reducing the risk of postoperative nausea. Recovery times are quicker. Prone positioning, which adds unnecessary risks and operating time for patient positioning, may be eliminated. In addition, it should lower the incidence of venous thromboembolism (VTE). This approach has merit and should be studied with a large series of patients. Interestingly, a recent article written by this reviewer and colleagues analyzing data collected from facilities accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) reported the incidence of VTE in abdominoplasty associated with intravenous sedation and general anesthesia. Anesthesia information was reviewed for 290,498 cases, of which 235,274 (81%) were performed under general anesthesia and 49,699 (17%) under monitored IV sedation. The remaining surgeries (2%) were performed under epidural with monitored IV anesthesia, spinal anesthesia, tumescent anesthesia, or were unspecified. Only general anesthesia and monitored IV sedation were analyzed in this study. VTE occurred in 201 patients (0.09%) undergoing general anesthesia and 30 patients (0.06%) undergoing monitored IV sedation. Additional analysis found no statistically significant increase in the risk of VTE by anesthesia type (OR 1.421, 95% CI 0.96 to 2.08).1 Swanson is direct and unforgiving in his arguments against risk assessment models and their use for determining whether to use chemoprophylaxis. In Chapter 12, “The Fallacy of Individual Risk Stratification and Chemoprophylaxis,” he writes that the use of risk stratification models for determining whether or not to use chemoprophylaxis is without merit. His arguments are concise, using statistical analysis of the current literature to make his points. Regardless of one’s personal opinion of the issues that he debates, his point-counterpoint discussion is of great value to understanding and assessing contemporary thought concerning VTE. The problem of VTE is a major concern for plastic surgeons and is well viewed from many perspectives. In the previously referenced article by the reviewer, analyzing the AAAASF data, it was found that in 2,295,901 performed in their accredited facilities from 2001 to 2011, 414 resulted in VTE. This represents a VTE incidence of 0.02%. Of these VTE, 240 (58%) occurred in abdominoplasty cases. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which, according to current recommendations, would not be an indication for the use of chemoprophylaxis.1 Chapter 13 discusses the use of ultrasound for VTE surveillance. Current guidelines from the American College of Chest Physicians explicitly recommend against screening duplex ultrasound performed in the absence of clinical symptoms. This recommendation is based on the fact that the clinical relevance and natural history of asymptomatic deep vein thrombosis is unknown.2 However, Swanson states that ultrasound scans are highly accurate, noninvasive, and well tolerated by patients. Unlike the routine administration of anticoagulation, there is no added risk. The diagnosis is made before treatment rather than the reverse. Early detection of thromboses allows the surgeon to initiate treatment before the thrombosis propagates and becomes dangerous. Importantly, it avoids unnecessary bleeding and hematomas. He has performed ultrasound on over 1,000 patients and presents data on the first 200. STRENGTHS Swanson takes “the emperor has no clothes approach” to analysis. The book is well written and filled with valuable information and thoughtful commentary. The graphs, tables, and artwork are of high quality, helping to provide clear understanding of the author’s approach. Each topic was sufficiently covered, and controversies between the author and the literature were reviewed in detail. The overview of surgical procedures discusses perioperative patient management with a goal of limiting unanticipated sequelae. All plastic surgeons performing body contouring procedures should benefit from reading this book. WEAKNESSES Swanson admits that this single-author volume is open to criticism, representing the experience and prejudices of one surgeon. However, these experiences and prejudices are well thought out, and by all measures, the author would welcome contrary arguments, provided they are data based and scientifically presented. SUMMARY Overall, this is an excellent book. On a scale of 1 to 5, I would give it a 5 rating. RATING: 5 OF 5 To purchase: https://www.springer.com/us/book/9783319712185 View largeDownload slide View largeDownload slide Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Keyes GR , Singer R , Iverson RE , Nahai F . Incidence and predictors of venous thromboembolism in abdominoplasty . Aesthet Surg J . 2018 ; 38 ( 2 ): 162 - 173 . Google Scholar CrossRef Search ADS PubMed 2. Gould MK , Garcia DA , Wren SM , et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines . Chest . 2012 ; 141 ( 2 Suppl ): e227S - e277S . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Jun 5, 2018

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