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Commentary on: Incidence and Predictors of Venous Thromboembolism in Abdominoplasty

Commentary on: Incidence and Predictors of Venous Thromboembolism in Abdominoplasty Among healthcare providers, we all agree that collecting data is essential to document our current approach to patient care and learn how to optimize and improve this. However, if data are merely collected and never analyzed, it serves no real purpose. We congratulate the authors of this excellent paper1 for “looking into the box” and uncovering some interesting observations through analysis of the Internet Based Quality Assurance Program (IBQAP) database that lends insight into the enigma of venous thromboembolism (VTE) occurring in patients undergoing abdominoplasty. We, too, have been interested in this topic and have been analyzing the CosmetAssure database with the goal of understanding complication rates and risk factors in aesthetic surgery and learn how we might optimize outcomes. Specifically, we have looked at the safety of abdominoplasty, and further, the incidence of VTE among all different aesthetic procedures.2-4 We have found some supportive parallels to the current study as well as some differences. The CosmetAssure database is generated from a large group of board eligible or certified plastic surgeons who enter patient data prospectively as a requirement for participation in the complications insurance program. The insurance covers each patient for major complications which may occur following aesthetic surgical procedures performed under general anesthesia or local anesthesia with IV sedation. It currently reimburses patients for uncovered expenses incurred within 45 days following surgery (30 days prior to 2017). Several important conclusions were found in this study, which concur with findings from our previously published work. The patient characteristics (age, body mass index [BMI], gender) in the IBQAP database were similar to the CosmetAssure database. Equally, the authors of this study found age and BMI to be significant risk factors for VTE risk following abdominoplasty, which is similar to our analysis. They found that 58% of all VTEs in the IBQAP database were associated with abdominoplasties, compared to 52.9% found in the CosmetAssure database. Both studies agree that limitations exist with the Caprini Risk Assessment Module (RAM) in the specific subset of cosmetic patients. Most importantly, we recommended considering body region in risk assessment of patients, which we have previously shown to be the most significant risk factor for VTE (relative risk [RR], 13.47).2,4 The incidence of VTE in the IBQAP database following abdominoplasty was found to be 0.07%, lower than in the CosmetAssure database (0.2%).2 We suspect that this is due to estimation of denominator in this study and possible surgeon self-selection of cases for peer review. This study found that abdominoplasty combined with liposuction had a higher rate of VTE compared to abdominoplasty without liposuction (the authors’ Table 7), however, when combined procedures were looked at as a whole the authors concluded that combined procedures have no effect on VTE rate. Nevertheless, we feel that it is important to emphasize that a difference in VTE rate was seen with the addition of liposuction.5 This was a consistent finding in the CosmetAssure database, where combined procedure/number of procedures was found to be a significant risk factor for VTE (RR, 2.40).4 In our previous study, VTE risk steadily increased with the number of procedures (0.04% for 1 procedure to 0.53% for 4 procedures). Also, it is mentioned in this study that “abdominoplasty is the aesthetic procedure most likely to be responsible for a VTE,” however, we found that other body contouring operations, such as thighlift and lower body lift have a higher incidence of VTE (0.25%) than abdominoplasty (0.2%).6 A limitation of this paper, as acknowledged by the study authors, is that the denominator used to determine the incidence of VTE in abdominoplasty is an extrapolation from the peer-reviewed cases and known total number of cases performed. Therefore, it is possible that this is not a true “random” sample that can be extrapolated to the general population. It would have been helpful for the authors of this study to have reported a separate analysis of the peer-reviewed cases only, which was still a substantial number of 276,378 patients, including 5.55% (15,339) abdominoplasties. This could have been used as a “sensitivity analysis” to validate the analysis of the extrapolated dataset. Furthermore, it is not mentioned how many of the peer-reviewed abdominoplasty cases had VTE, which we believe would also be useful to validate their analysis. One of the disadvantages of the IBQAP database is that it relies on retrospective review of a surgeon’s cases to see their outcomes and reported complications, which could suffer from recall bias. The database also reports a seemingly high death rate related to VTE (11.25%; 27 deaths within 30 days of surgery / 240 VTE), which needs to be further discussed. Equally, one of the interesting findings in this study is the higher rate of VTE seen in black patients. It is unclear if black patients had a higher rate of significant risk factors (namely higher age and/or BMI) and it is not mentioned if race was included in their multivariate model, however, it was found to be a significant factor on univariate analysis. Neither the current study nor our study were able to analyze data from different types of abdominoplasty, so we still cannot draw any conclusions as to whether one type of procedure is safer than another. Nevertheless, we have consistently shown by multivariate analysis that the addition of one or two additional procedures does significantly increase the risk of complications of certain types in contradistinction to the current study and the others mentioned. Despite the issues that we have raised, we wish to emphasize the strength of the large numbers in trying to answer questions about the safety of procedures we perform in plastic surgery. Both of our data sets are similar in demographics and we have come to similar conclusions regarding the overall safety of aesthetic plastic surgery. With the data from both studies we can clearly conclude that abdominoplasty does, in fact, carry a higher risk of VTE and that measures should always be taken to assess risk in every patient to determine the indications for preventative interventions. We congratulate the current study authors for using their collected data over many years to add insight into this important issue. Disclosures Dr Grotting is a founder and shareholder of CosmetAssure (Birmingham, AL). He also receives book royalties from Quality Medical Publishing (St. Louis, MO) and Elsevier (New York, NY), and is a shareholder of Ideal Implant, Inc. (Dallas, TX). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. 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. Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC, Higdon KK. Abdominoplasty: risk factors, complication rates, and safety of combined procedures. Plast Reconstr Surg . 2015; 136( 5): 597e- 606e. Google Scholar CrossRef Search ADS PubMed  3. Gupta V, Parikh R, Nguyen Let al.   Is office-based surgery safe? Comparing outcomes of 183,914 aesthetic surgical procedures across different types of accredited facilities. Aesthet Surg J . 2017; 37( 2): 226- 235. Google Scholar CrossRef Search ADS PubMed  4. Winocour J, Gupta V, Kaoutzanis Cet al.   Venous thromboembolism in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J . 2017; 37( 3): 337- 349. Google Scholar PubMed  5. Kaoutzanis C, Gupta V, Winocour Jet al.   Cosmetic liposuction: preoperative risk factors, major complication rates, and safety of combined procedures. Aesthet Surg J . 2017; 37( 6): 680- 694. Google Scholar CrossRef Search ADS PubMed  6. Afshari A, Gupta V, Nguyen L, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates of thighplasty: analysis of 1493 patients. Aesthet Surg J . 2016; 36( 8): 897- 907. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Incidence and Predictors of Venous Thromboembolism in Abdominoplasty

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Publisher
Oxford University Press
Copyright
© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
DOI
10.1093/asj/sjx196
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Abstract

Among healthcare providers, we all agree that collecting data is essential to document our current approach to patient care and learn how to optimize and improve this. However, if data are merely collected and never analyzed, it serves no real purpose. We congratulate the authors of this excellent paper1 for “looking into the box” and uncovering some interesting observations through analysis of the Internet Based Quality Assurance Program (IBQAP) database that lends insight into the enigma of venous thromboembolism (VTE) occurring in patients undergoing abdominoplasty. We, too, have been interested in this topic and have been analyzing the CosmetAssure database with the goal of understanding complication rates and risk factors in aesthetic surgery and learn how we might optimize outcomes. Specifically, we have looked at the safety of abdominoplasty, and further, the incidence of VTE among all different aesthetic procedures.2-4 We have found some supportive parallels to the current study as well as some differences. The CosmetAssure database is generated from a large group of board eligible or certified plastic surgeons who enter patient data prospectively as a requirement for participation in the complications insurance program. The insurance covers each patient for major complications which may occur following aesthetic surgical procedures performed under general anesthesia or local anesthesia with IV sedation. It currently reimburses patients for uncovered expenses incurred within 45 days following surgery (30 days prior to 2017). Several important conclusions were found in this study, which concur with findings from our previously published work. The patient characteristics (age, body mass index [BMI], gender) in the IBQAP database were similar to the CosmetAssure database. Equally, the authors of this study found age and BMI to be significant risk factors for VTE risk following abdominoplasty, which is similar to our analysis. They found that 58% of all VTEs in the IBQAP database were associated with abdominoplasties, compared to 52.9% found in the CosmetAssure database. Both studies agree that limitations exist with the Caprini Risk Assessment Module (RAM) in the specific subset of cosmetic patients. Most importantly, we recommended considering body region in risk assessment of patients, which we have previously shown to be the most significant risk factor for VTE (relative risk [RR], 13.47).2,4 The incidence of VTE in the IBQAP database following abdominoplasty was found to be 0.07%, lower than in the CosmetAssure database (0.2%).2 We suspect that this is due to estimation of denominator in this study and possible surgeon self-selection of cases for peer review. This study found that abdominoplasty combined with liposuction had a higher rate of VTE compared to abdominoplasty without liposuction (the authors’ Table 7), however, when combined procedures were looked at as a whole the authors concluded that combined procedures have no effect on VTE rate. Nevertheless, we feel that it is important to emphasize that a difference in VTE rate was seen with the addition of liposuction.5 This was a consistent finding in the CosmetAssure database, where combined procedure/number of procedures was found to be a significant risk factor for VTE (RR, 2.40).4 In our previous study, VTE risk steadily increased with the number of procedures (0.04% for 1 procedure to 0.53% for 4 procedures). Also, it is mentioned in this study that “abdominoplasty is the aesthetic procedure most likely to be responsible for a VTE,” however, we found that other body contouring operations, such as thighlift and lower body lift have a higher incidence of VTE (0.25%) than abdominoplasty (0.2%).6 A limitation of this paper, as acknowledged by the study authors, is that the denominator used to determine the incidence of VTE in abdominoplasty is an extrapolation from the peer-reviewed cases and known total number of cases performed. Therefore, it is possible that this is not a true “random” sample that can be extrapolated to the general population. It would have been helpful for the authors of this study to have reported a separate analysis of the peer-reviewed cases only, which was still a substantial number of 276,378 patients, including 5.55% (15,339) abdominoplasties. This could have been used as a “sensitivity analysis” to validate the analysis of the extrapolated dataset. Furthermore, it is not mentioned how many of the peer-reviewed abdominoplasty cases had VTE, which we believe would also be useful to validate their analysis. One of the disadvantages of the IBQAP database is that it relies on retrospective review of a surgeon’s cases to see their outcomes and reported complications, which could suffer from recall bias. The database also reports a seemingly high death rate related to VTE (11.25%; 27 deaths within 30 days of surgery / 240 VTE), which needs to be further discussed. Equally, one of the interesting findings in this study is the higher rate of VTE seen in black patients. It is unclear if black patients had a higher rate of significant risk factors (namely higher age and/or BMI) and it is not mentioned if race was included in their multivariate model, however, it was found to be a significant factor on univariate analysis. Neither the current study nor our study were able to analyze data from different types of abdominoplasty, so we still cannot draw any conclusions as to whether one type of procedure is safer than another. Nevertheless, we have consistently shown by multivariate analysis that the addition of one or two additional procedures does significantly increase the risk of complications of certain types in contradistinction to the current study and the others mentioned. Despite the issues that we have raised, we wish to emphasize the strength of the large numbers in trying to answer questions about the safety of procedures we perform in plastic surgery. Both of our data sets are similar in demographics and we have come to similar conclusions regarding the overall safety of aesthetic plastic surgery. With the data from both studies we can clearly conclude that abdominoplasty does, in fact, carry a higher risk of VTE and that measures should always be taken to assess risk in every patient to determine the indications for preventative interventions. We congratulate the current study authors for using their collected data over many years to add insight into this important issue. Disclosures Dr Grotting is a founder and shareholder of CosmetAssure (Birmingham, AL). He also receives book royalties from Quality Medical Publishing (St. Louis, MO) and Elsevier (New York, NY), and is a shareholder of Ideal Implant, Inc. (Dallas, TX). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. 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. Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC, Higdon KK. Abdominoplasty: risk factors, complication rates, and safety of combined procedures. Plast Reconstr Surg . 2015; 136( 5): 597e- 606e. Google Scholar CrossRef Search ADS PubMed  3. Gupta V, Parikh R, Nguyen Let al.   Is office-based surgery safe? Comparing outcomes of 183,914 aesthetic surgical procedures across different types of accredited facilities. Aesthet Surg J . 2017; 37( 2): 226- 235. Google Scholar CrossRef Search ADS PubMed  4. Winocour J, Gupta V, Kaoutzanis Cet al.   Venous thromboembolism in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J . 2017; 37( 3): 337- 349. Google Scholar PubMed  5. Kaoutzanis C, Gupta V, Winocour Jet al.   Cosmetic liposuction: preoperative risk factors, major complication rates, and safety of combined procedures. Aesthet Surg J . 2017; 37( 6): 680- 694. Google Scholar CrossRef Search ADS PubMed  6. Afshari A, Gupta V, Nguyen L, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates of thighplasty: analysis of 1493 patients. Aesthet Surg J . 2016; 36( 8): 897- 907. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery Journal – Oxford University Press

Published: Feb 1, 2018

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