Commentary on: Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice Trends

Commentary on: Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice... In this survey of 220 board-certified plastic surgeons, the majority of surgeons reported not routinely recommending cessation of oral contraceptive pills (OCPs) before or after aesthetic procedures.1 Although the incidence of venous thromboembolism (VTE) following aesthetic surgery is low (estimated between 0% and 3%), OCPs are an established risk factor for VTE and account for one point in validated Caprini risk assessment models for the perioperative setting.2-10 Despite the markedly low response rate for this study (11.9%), we have no reason to believe that these findings do not reflect actual practice patterns. Nonetheless, the variability in perioperative management of OCPs raises important questions that many of us navigate while counseling patients in our clinical practices. This issue is highly relevant not only to surgical patients taking OCPs, but also for women receiving perioperative hormone replacement therapy and for transgender patients undergoing gender-affirming surgeries while on estrogen therapies. The VTE risk reduction that occurs from cessation of OCPs is small, but likely still significant and clinically relevant. The overwhelming majority of data on VTE risk are based on predefined Caprini risk categories of 3 to 4, 5 to 6, 7 to 8, and >8. Therefore, it is not clear how VTE risk changes if a patient’s Caprini score decreases from 4 to 3, but remains within the same risk category. The duration of cessation needed to reduce risk for postoperative VTE in the preoperative and postoperative periods for aesthetic surgery is also currently not clear. An older study assessing thrombosis at varying time points after discontinuing OCPs in middle-aged women found that thrombosis returned to normal after at least 4 weeks of cessation.11 There are a number of factors that likely contribute to variations in perioperative management of OCPs for aesthetic surgery, most of which have been discussed by the authors. The majority of patients undergoing aesthetic procedures are at low risk for postoperative VTE, and therefore, many surgeons may feel that the additional risk associated with OCPs in the perioperative period is negligible or outweighed by the potential for unwanted pregnancy associated with stopping these medications. Discontinuing OCPs is certainly inconvenient for patients, and requires alternative forms of birth control in the perioperative period, as well as a preoperative pregnancy test before undergoing surgical procedures. Some surgeons may not feel comfortable discussing alternative forms of birth control with their patients. Additionally, perioperative management of medications may be performed by midlevel providers and other nursing staff in some clinical settings, and thus not accurately captured by the survey. Professional societies in the United States have not as yet published guidelines for perioperative management of OCPs. By contrast, our colleagues in Western Europe appear to have taken a more proactive stance on this issue. The British National Formulary recommends discontinuing OCPs four to six weeks prior to major surgery in the United Kingdom.12 A similar survey of consultant plastic surgeons in the United Kingdom found that more than half of the respondents recommended cessation of OCPs prior to surgery.13 Differences in the perioperative management of OCPs between the plastic surgeons in the United States and the United Kingdom are likely due, in part, to the presence of guidelines. Due to a lack of data and consensus on this issue in the United States, there are also variations in protocols for managing OCPs in the perioperative setting at academic hospitals. The University of Michigan Health System recommends that patients continue taking OCPs preoperatively.14 In contrast, guidelines from the Ohio State University Wexner Medical Center suggest that OCPs be held four to six weeks prior to certain operations and for patients at high risk for developing VTE.15 Despite little to no research on this topic in the aesthetic surgery literature, professional societies for plastic surgery in the United States should consider developing clinical practice guidelines for management of OCPs in the perioperative setting from a broad review of available evidence. At the very least, plastic surgeons should discuss the added risk of VTE associated with taking these medications while counseling patients undergoing aesthetic procedures. For women who are willing and able to use alternative forms of birth control, it seems appropriate to recommend cessation of OCPs in the perioperative setting, in accordance with manufacturer guidelines and in line with our European counterparts. Currently, manufacturers recommend discontinuing OCPs four weeks prior to and two weeks after elective surgery.16 Clearly, additional research is needed on this issue. Given the rarity of postoperative VTEs in the outpatient surgery setting, a randomized controlled trial assessing the effect of OCP cessation on VTE risk is likely not feasible. Alternatively, a well-designed case-control study might be more appropriate, but would still require considerable resources and case volumes to control for the multitude of other clinical variables that contribute to VTE risk. Based upon data from the Venous Thromboembolism Prevention Study, the 60-day postoperative VTE risk for patients who receive inpatient enoxaparin with Caprini scores of 5 to 6 and 3 to 4 is 1.20% and 0.61%, respectively.9 A study with adequate power to detect a statistical difference between these two groups would require approximately 8752 patients total (4376 patients per group). It would not be feasible to design and conduct a prospective study of this size. Despite the inherent challenges of these studies, additional research is needed to facilitate the development of evidence-based clinical practice guidelines. Disclosures The 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. Chattha A, Brown E, Slavin S, Lin S. Oral contraceptive management in aesthetic surgery: a survey of current practice trends. Aesthet Surg J . 2017. doi: 10.1093/asj/sjx234. [Epub ahead of print] 2. 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  3. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast Reconstr Surg . 2001; 107( 6): 1570- 1575; discussion 1576. Google Scholar CrossRef Search ADS PubMed  4. Moubayed SP, Akdagli S, Most SP. Incidence of Venous Thromboembolism in Rhinoplasty. Aesthet Surg J . 2017; 37( 3): NP34- NP35. Google Scholar CrossRef Search ADS PubMed  5. Shaikh MA, Jeong HS, Mastro A, Davis K, Lysikowski J, Kenkel JM. Analysis of the American society of anesthesiologists physical status classification system and caprini risk assessment model in predicting venous thromboembolic outcomes in plastic surgery patients. Aesthet Surg J . 2016; 36( 4): 497- 505. Google Scholar CrossRef Search ADS PubMed  6. Gravante G, Araco A, Sorge Ret al.   Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed. Ann Plast Surg . 2008; 60( 6): 604- 608. Google Scholar CrossRef Search ADS PubMed  7. de Bastos M, Stegeman BH, Rosendaal FRet al.   Combined oral contraceptives: venous thrombosis. Cochrane Database Syst Rev . 2014( 3): CD010813. 8. Vandenbroucke JP, Rosing J, Bloemenkamp KWet al.   Oral contraceptives and the risk of venous thrombosis. N Engl J Med . 2001; 344( 20): 1527- 1535. Google Scholar CrossRef Search ADS PubMed  9. Pannucci CJ, Bailey SH, Dreszer Get al.   Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg . 2011; 212( 1): 105- 112. Google Scholar CrossRef Search ADS PubMed  10. Murphy RXJr, Alderman A, Gutowski Ket al.   Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg . 2012; 130( 1): 168e- 175e. Google Scholar CrossRef Search ADS PubMed  11. Robinson GE, Burren T, Mackie IJet al.   Changes in haemostasis after stopping the combined contraceptive pill: implications for major surgery. BMJ . 1991; 302( 6771): 269- 271. Google Scholar CrossRef Search ADS PubMed  12. Britain BMAaRPSoG. British National Formulary . 70th edn. London: BMJ Publishing Group and RPSD Publishing; , 2015. 13. Johnson RL, Hemington-Gorse SJ, Dhital SK. Do cosmetic surgeons consider estrogen-containing drugs to be of significant risk in the development of thromboembolism? Aesthetic Plast Surg . 2008; 32( 5): 743- 747. Google Scholar CrossRef Search ADS PubMed  14. Perioperative Management of Chronic Medications. The University of Michigan Health System, 2017. https://www.med.umich.edu/preopclinic/guidelines/meds_to_stop1.pdf. Accessed December 1, 2017. 15. Preoperative Testing and Medication Management. The Ohio State University Wexner Medical Center, 2017. https://evidencebasedpractice.osumc.edu/Documents/Guidelines/Preoperative.pdf. Accessed December 1, 2017. 16. Merck and Co I. DETAILED PATIENT PACKAGE INSERT - DESOGEN® Tablets 28 Day Regimen . Whitehouse Station, NJ. © 2018 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: Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice Trends

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Publisher
Oxford University Press
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/sjx260
Publisher site
See Article on Publisher Site

Abstract

In this survey of 220 board-certified plastic surgeons, the majority of surgeons reported not routinely recommending cessation of oral contraceptive pills (OCPs) before or after aesthetic procedures.1 Although the incidence of venous thromboembolism (VTE) following aesthetic surgery is low (estimated between 0% and 3%), OCPs are an established risk factor for VTE and account for one point in validated Caprini risk assessment models for the perioperative setting.2-10 Despite the markedly low response rate for this study (11.9%), we have no reason to believe that these findings do not reflect actual practice patterns. Nonetheless, the variability in perioperative management of OCPs raises important questions that many of us navigate while counseling patients in our clinical practices. This issue is highly relevant not only to surgical patients taking OCPs, but also for women receiving perioperative hormone replacement therapy and for transgender patients undergoing gender-affirming surgeries while on estrogen therapies. The VTE risk reduction that occurs from cessation of OCPs is small, but likely still significant and clinically relevant. The overwhelming majority of data on VTE risk are based on predefined Caprini risk categories of 3 to 4, 5 to 6, 7 to 8, and >8. Therefore, it is not clear how VTE risk changes if a patient’s Caprini score decreases from 4 to 3, but remains within the same risk category. The duration of cessation needed to reduce risk for postoperative VTE in the preoperative and postoperative periods for aesthetic surgery is also currently not clear. An older study assessing thrombosis at varying time points after discontinuing OCPs in middle-aged women found that thrombosis returned to normal after at least 4 weeks of cessation.11 There are a number of factors that likely contribute to variations in perioperative management of OCPs for aesthetic surgery, most of which have been discussed by the authors. The majority of patients undergoing aesthetic procedures are at low risk for postoperative VTE, and therefore, many surgeons may feel that the additional risk associated with OCPs in the perioperative period is negligible or outweighed by the potential for unwanted pregnancy associated with stopping these medications. Discontinuing OCPs is certainly inconvenient for patients, and requires alternative forms of birth control in the perioperative period, as well as a preoperative pregnancy test before undergoing surgical procedures. Some surgeons may not feel comfortable discussing alternative forms of birth control with their patients. Additionally, perioperative management of medications may be performed by midlevel providers and other nursing staff in some clinical settings, and thus not accurately captured by the survey. Professional societies in the United States have not as yet published guidelines for perioperative management of OCPs. By contrast, our colleagues in Western Europe appear to have taken a more proactive stance on this issue. The British National Formulary recommends discontinuing OCPs four to six weeks prior to major surgery in the United Kingdom.12 A similar survey of consultant plastic surgeons in the United Kingdom found that more than half of the respondents recommended cessation of OCPs prior to surgery.13 Differences in the perioperative management of OCPs between the plastic surgeons in the United States and the United Kingdom are likely due, in part, to the presence of guidelines. Due to a lack of data and consensus on this issue in the United States, there are also variations in protocols for managing OCPs in the perioperative setting at academic hospitals. The University of Michigan Health System recommends that patients continue taking OCPs preoperatively.14 In contrast, guidelines from the Ohio State University Wexner Medical Center suggest that OCPs be held four to six weeks prior to certain operations and for patients at high risk for developing VTE.15 Despite little to no research on this topic in the aesthetic surgery literature, professional societies for plastic surgery in the United States should consider developing clinical practice guidelines for management of OCPs in the perioperative setting from a broad review of available evidence. At the very least, plastic surgeons should discuss the added risk of VTE associated with taking these medications while counseling patients undergoing aesthetic procedures. For women who are willing and able to use alternative forms of birth control, it seems appropriate to recommend cessation of OCPs in the perioperative setting, in accordance with manufacturer guidelines and in line with our European counterparts. Currently, manufacturers recommend discontinuing OCPs four weeks prior to and two weeks after elective surgery.16 Clearly, additional research is needed on this issue. Given the rarity of postoperative VTEs in the outpatient surgery setting, a randomized controlled trial assessing the effect of OCP cessation on VTE risk is likely not feasible. Alternatively, a well-designed case-control study might be more appropriate, but would still require considerable resources and case volumes to control for the multitude of other clinical variables that contribute to VTE risk. Based upon data from the Venous Thromboembolism Prevention Study, the 60-day postoperative VTE risk for patients who receive inpatient enoxaparin with Caprini scores of 5 to 6 and 3 to 4 is 1.20% and 0.61%, respectively.9 A study with adequate power to detect a statistical difference between these two groups would require approximately 8752 patients total (4376 patients per group). It would not be feasible to design and conduct a prospective study of this size. Despite the inherent challenges of these studies, additional research is needed to facilitate the development of evidence-based clinical practice guidelines. Disclosures The 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. Chattha A, Brown E, Slavin S, Lin S. Oral contraceptive management in aesthetic surgery: a survey of current practice trends. Aesthet Surg J . 2017. doi: 10.1093/asj/sjx234. [Epub ahead of print] 2. 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  3. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast Reconstr Surg . 2001; 107( 6): 1570- 1575; discussion 1576. Google Scholar CrossRef Search ADS PubMed  4. Moubayed SP, Akdagli S, Most SP. Incidence of Venous Thromboembolism in Rhinoplasty. Aesthet Surg J . 2017; 37( 3): NP34- NP35. Google Scholar CrossRef Search ADS PubMed  5. Shaikh MA, Jeong HS, Mastro A, Davis K, Lysikowski J, Kenkel JM. Analysis of the American society of anesthesiologists physical status classification system and caprini risk assessment model in predicting venous thromboembolic outcomes in plastic surgery patients. Aesthet Surg J . 2016; 36( 4): 497- 505. Google Scholar CrossRef Search ADS PubMed  6. Gravante G, Araco A, Sorge Ret al.   Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed. Ann Plast Surg . 2008; 60( 6): 604- 608. Google Scholar CrossRef Search ADS PubMed  7. de Bastos M, Stegeman BH, Rosendaal FRet al.   Combined oral contraceptives: venous thrombosis. Cochrane Database Syst Rev . 2014( 3): CD010813. 8. Vandenbroucke JP, Rosing J, Bloemenkamp KWet al.   Oral contraceptives and the risk of venous thrombosis. N Engl J Med . 2001; 344( 20): 1527- 1535. Google Scholar CrossRef Search ADS PubMed  9. Pannucci CJ, Bailey SH, Dreszer Get al.   Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg . 2011; 212( 1): 105- 112. Google Scholar CrossRef Search ADS PubMed  10. Murphy RXJr, Alderman A, Gutowski Ket al.   Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg . 2012; 130( 1): 168e- 175e. Google Scholar CrossRef Search ADS PubMed  11. Robinson GE, Burren T, Mackie IJet al.   Changes in haemostasis after stopping the combined contraceptive pill: implications for major surgery. BMJ . 1991; 302( 6771): 269- 271. Google Scholar CrossRef Search ADS PubMed  12. Britain BMAaRPSoG. British National Formulary . 70th edn. London: BMJ Publishing Group and RPSD Publishing; , 2015. 13. Johnson RL, Hemington-Gorse SJ, Dhital SK. Do cosmetic surgeons consider estrogen-containing drugs to be of significant risk in the development of thromboembolism? Aesthetic Plast Surg . 2008; 32( 5): 743- 747. Google Scholar CrossRef Search ADS PubMed  14. Perioperative Management of Chronic Medications. The University of Michigan Health System, 2017. https://www.med.umich.edu/preopclinic/guidelines/meds_to_stop1.pdf. Accessed December 1, 2017. 15. Preoperative Testing and Medication Management. The Ohio State University Wexner Medical Center, 2017. https://evidencebasedpractice.osumc.edu/Documents/Guidelines/Preoperative.pdf. Accessed December 1, 2017. 16. Merck and Co I. DETAILED PATIENT PACKAGE INSERT - DESOGEN® Tablets 28 Day Regimen . Whitehouse Station, NJ. © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Feb 14, 2018

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