Hematomas in Aesthetic Surgery

Hematomas in Aesthetic Surgery Abstract Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon’s ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery. Learning Objectives Discuss the incidence and epidemiology of hematomas following aesthetic surgical procedures. Identify potential risk factors and preoperative considerations for hematoma development following aesthetic surgery. Understand the key perioperative prevention measures to decrease the incidence of hematomas in aesthetic surgery. Diagnose and treat hematomas after aesthetic surgery. Be able to identify and manage postoperative complications associated with hematoma formation after aesthetic surgery. Hematomas are a frequently reported complication in aesthetic surgery. They can range in size, and may present with a variety of nonspecific signs and symptoms including erythema, warmth, edema, pain or tenderness, and in some instances hemodynamic changes. While smaller hematomas may resolve without incident, larger hematomas, if left untreated, can have untoward consequences for the patient including pain, poor cosmesis, scarring, skin and tissue ischemia leading to necrosis and infection. Thus, prompt identification and management of hematomas is crucial in the aesthetic surgery patient. The incidence of hematomas in aesthetic surgical procedures varies, and is influenced by a myriad of factors. These include patient factors such as hypertension and medication intake such as blood thinners, surgical factors such as operative technique, as well as perioperative and postoperative care. Consequently, the reported hematoma rates vary significantly and range from an estimated 0% to 15% across several aesthetic procedures including brachioplasty, thighplasty, body contouring, facelifts, breast surgery, and abdominoplasty.1-11 These numbers, however, may not reflect the true incidence of hematomas as studies differ with regards to how hematomas are accounted for, taking into consideration factors such as need for medical and surgical management and the postoperative follow-up period. As a result, while many authors may report low rates of hematomas, given the ever-increasing number of cosmetic procedures being performed with more than 13 million in 2016 according to the American Society of Aesthetic Plastic Surgeons (ASAPS) Statistics Report,12 the significance of these rates cannot be ignored. Rhytidectomy is one of the most well studied aesthetic procedures with regards to hematoma rates that range between approximately 0% and12%.5,13-18 This complication can lead to longer recovery times, increased risk for skin sloughing, and urgent return to the operating room.19 Several large cohorts have been studied with varying incidence rates influenced by operative technique. Imber and Silich report an incidence of 0.6% (6 cases) in a series of 1000 patients undergoing a limited-incision facelift technique.20 In a large retrospective study of 8788 facial rejuvenation cases, Pitanguy and Machado reported the most frequent complication to be hematoma with an incidence of 3% (264 cases).21 In a cohort of 383 patients, Neto et al reported a relatively higher incidence of hematomas at 7.05% (27 cases)6 (Table 1). Table 1. Reported Hematoma Incidence After Rhytidectomy Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  View Large Table 1. Reported Hematoma Incidence After Rhytidectomy Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  View Large The incidence of hematoma among rhinoplasties has also been studied, and is attributed to bleeding from incision sites or traumatized mucosa.22 One of the largest retrospective reviews of patients undergoing rhinoplasties reported a complication rate of 0.2% among 4978 patients.23 In another large retrospective study by Chuangsuwanich et al, looking at augmentation rhinoplasties among 548 Asian patients, hematomas occurred in 0.5% of the patients.24 The lower rate noted among rhinoplasties could be attributed to steps taken towards controlling postoperative bleeding such as 60 degree head elevation, gentle nostril pressure, and use of topical decongestant nasal sprays including oxymetazoline or phenylephrine.22 Further, in instances of refractory bleeding not responsive to these techniques or nasal packing, administration of desmopressin has been shown to be effective through a mechanism that involves increased coagulation by elevated plasma concentrations of Factor VIII.25 In a study examining 268 nasal operations, Faber et al reported 9 patients with excessive postoperative bleeding that responded to the use of 0.3 μg/kg of intravenous desmopressin over 30 minutes.26 While epistaxis and hematoma formation are two entirely different entities, they share a similar mechanism and have some overlap as far as treatment modalities and prevention.25 Another well-studied cohort with regards to hematoma formation is the patient population undergoing aesthetic breast surgery. This is a particularly important area given the sustained growth in cosmetic breast surgery; breast augmentation was one of the the most common surgical procedure at 310,444 as reported by the ASAPS 2016 Statistics Report.12 In the studies reviewed hematoma incidence ranged from 0.62% to 8.27%.27-30 In a retrospective study by Araco et al looking at primary breast augmentations in 3002 patients, hematomas were the most frequent complication reported in 1.5% (46 patients).27 Their analysis found both the technique for creating a pocket and implant placement to be significantly associated with complications. A more recent study by Codner et al evaluated 812 patients undergoing breast augmentation with saline (482 patients) and silicone implants (330 patients).28 Hematoma was reported as an uncommon complication and occurred in only 2%, (16 patients). Interestingly, developing a hematoma was a risk factor for the subsequent development of capsular contracture, with 25% of hematoma patients (4 of 16 patients) developing capsular contracture compared to a statistically significant lower proportion (P = 0.038) of 8% in the nonhematoma group (64 of 796 patients). Hematoma rates have also been studied in other breast surgery procedures. Carpelan et al studied 110 consecutive patients undergoing bilateral reduction mammaplasties with resections of at least 200 grams per breast and found 5% (5 patients) requiring hematoma evacuation.30 In a larger cohort of 444 patients undergoing 884 reduction mammaplasties, Stevens et al reported 4 hematomas.31 The mean resection of breast tissue weight was 1228 grams in this study. Hematoma rates seem to be lesser in breast surgeries compared to other body regions with a retrospective study by Gupta et al looking at 73,608 breast surgery cases and finding an overall major hematoma rate of 0.99%.29 Overall, reduction breast surgery had the lowest rate of hematoma formation with 27 hematomas after 3288 surgeries (0.82%) compared to augmentation-mastopexy procedures that had the highest with 89 hematomas after 8125 surgeries (1.1%) (Table 2). Table 2. Reported Hematoma Incidence After Aesthetic Breast Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  View Large Table 2. Reported Hematoma Incidence After Aesthetic Breast Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  View Large The reported rates of hematoma vary significantly in body contouring surgery depending on the region of the procedure, weight of the patient, and intraoperative interventions and techniques. In looking at medial thigh lifts in the massive weight loss population, Gusenoff et al reported a hematoma rate of 6% among 106 patients.3 In a larger cohort of 1493 patients, Afshari et al reported a lesser rate of 2.1% hematomas.32 The authors attributed the lower rates to a more specific definition for major hematomas (requiring Emergency Room visits, hospital readmissions, or reoperations within 30 days of the initial operation) and the multicenter nature of the cohort. In contrast to thighplasties, hematoma rates for brachioplasties appear to be slightly lower. In a study by Nguyen examining 2294 patients undergoing brachioplasties, using definitions similar to the study by Afshari et al, the authors reported hematomas in 1.1% of patients.33 Other smaller cohorts studying hematoma following brachioplasties reported rates ranging from approximately 0% to 3%.34–36 In a retrospective review of 25,478 abdominoplasties, Winocour et al found a major hematoma rate of 1.26%.37 Interestingly, male sex was a significant risk factor for complications in that study with a relative risk of 1.8. A similar trend was also noted by Chong et al in a study involving 48 males undergoing body contouring after weight loss.38 They found male gender to be associated with a 14.6% incidence of postoperative hematoma and an independent risk factor with an odds ratio of 3.76. The effect of technique in affecting hematoma rates also seems to be significant. In a recent study, Bertheuil et al reported no major complications (including hematoma) in a series of 25 abdominal body-contouring reconstructions where the presurgery body mass index was 26.71 and postsurgery body mass index was 20.92.39 The authors advocated the use of a novel and less-invasive circumferential lipo-body lift technique compared to traditional lower body-lifting methods (Table 3). Table 3. Reported Hematoma Incidence After Abdominoplasty and Body Contouring Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  View Large Table 3. Reported Hematoma Incidence After Abdominoplasty and Body Contouring Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  View Large Overall, across all body regions, hematoma rates are affected by the procedure type and patient comorbidities. Different patient factors influence hematoma rates to varying degrees depending on the procedure being performed. A better understanding of these risk factors could lead to better preoperative planning, patient selection, patient education, and intraoperative and postoperative management. Such steps will better facilitate the patient-physician relationship, and could lead to better outcomes and higher patient satisfaction following surgery. RISK FACTORS/PREOPERATIVE CONSIDERATIONS Age The number of cosmetic procedures continues to increase at a significant rate in particularly in older populations.12 As a result, the impact of age as a risk factor in cosmetic procedures has been investigated. Abboushi et al, in looking at 630 patients undergoing facelift, found age greater than 55 to be a significant risk factor for postoperative hematoma.15 In contrast, Marten et al reviewed 216 patients undergoing facelifts in patients younger and older than 65 years of age, and found no significant difference in major (2.9% to 2.0%, P = 0.65) or minor (5.9% to 6.1%, P = 0.99) complications between the 2 groups.40 Similar findings were noted by Becker and Castellano in their review evaluating the safety of facelifts in patients younger and older than 75 years of age.41 While Becker’s study matched patients for American Society of Anesthesiologists (ASA) class, Marten’s elderly patient group had a higher ASA class compared to the younger group. As a result, Becker’s group recommended preoperative health status as an important counseling topic with patients. In perhaps one of the largest cohorts in the literature examining the safety of cosmetic procedures in the elderly, Yeslev et al reported a significantly higher number of hematomas in the younger patient population group (younger than 65 years) compared to the older group.42 However, the younger group also underwent more procedures than the older group. In a different study using the same database, age was found to be a significant risk factor for hematomas (relative risk of 1.01, P < 0.01) in a cohort of patients undergoing aesthetic breast surgery.29 Similarly, in a cohort of 132 patients, Richard et al found age to be a risk factor for hematoma formation after primary breast augmentation on univariate analysis; however, it was not found as an independent risk factor on multivariate analysis.43 Older age (greater than 55 years) was found as a significant risk factor for complications (relative risk of 1.4) in a cohort of 25,478 abdominoplasties, with approximately a third of the overall complication rate (4%) attributed to hematomas.37 These findings suggest that while age is an important factor in patient selection, there may be other confounding variables that occur with aging (eg, medication intake, hypertension, ASA class). As previously stated by Becker et al, optimizing preoperative health status is perhaps of more importance than using age cut-offs alone.41 Gender Male gender has been advocated to be more prone to postoperative hematomas after rhytidectomy secondary to the thicker and more vascular nature of male facial skin.18 Rohrich et al, in a retrospective review of 83 consecutive male rhytidectomies over a 20 year period that was age matched with 83 female patients who underwent rhytidectomy during the same time period, showed a hematoma rate of 6% (5 patients) in males compared to 0% in females (P = 0.0587).18 The predilection of males to hematoma formation is further confirmed by a laser Doppler flow study by Mayrovitz et al, where males had higher facial skin blood flow than women due to a higher number of perfused microvessels.44 Males also have larger and coarser hair with more blood supply compared to women who have finer vellus facial hair that have fewer capillaries. Baker et al evaluated 985 male rhytidectomies over three periods spanning 30 years, and reported a downward trend in hematoma rate from 8.70% to 3.97%.45 They attribute this to a strict antihypertensive medication and blood pressure monitoring regimen. Other studies have also shown this trend in rhytidectomies with males demonstrating higher rates (11.7% to 12.9%) than females (3.9% to 4.2%).5,15 Males are also more susceptible towards hematoma formation in body contouring surgery. Chong et al examined 418 patients undergoing body contouring after weight loss of which 48 were males, and found male gender to be associated with a 14.6% incidence of postoperative hematoma compared to 3.5% in females.38 In another cohort of 129,007 patients where 0.91% (1180 patients) developed a major hematoma, male gender was noted to be an independent predictor for hematoma formation with the highest relative risk at 1.98 (P < 0.01)46 (Table 4). Table 4. Risk Factors for Hematoma Development in Aesthetic Surgery Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  View Large Table 4. Risk Factors for Hematoma Development in Aesthetic Surgery Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  View Large Body Mass Index The impact of patient’s body mass index (BMI) has been investigated in various aesthetic procedures.47 Numerous studies have examined complications associated with aesthetic surgery, of which hematomas represent a significant percentage. In a study of 31,010 cosmetic liposuction procedures, Kaoutzanis et al demonstrated BMI > 25 kg/m2 to be an independent predictor of major complications.48 Similarly, Nguyen et al evaluated 2294 patients undergoing brachioplasty, and found BMI ≥ 30 kg/m2 to be a significant risk factor for the occurrence of complications with a relative risk of 1.92.33 In a recent meta-analysis looking at the impact of obesity on complications after reduction mammaplasty, 26 studies were identified exploring the association between surgical complications and body weight; 11 of these studies found obesity not to be a risk factor, whereas 15 studies showed an increase in surgical risk with higher BMIs.49 Their pooled risk for overall complications increased with an increase in BMI, and was 1.71 for BMI > 35 kg/m2 and 2.05 for BMI > 40 kg/m2. Abboushi et al also found a BMI > 25 kg/m2 to be a significant (P = 0.024) risk factor for developing postoperative hematoma after facelifts.15 Furthermore, in a review of major postoperative hematoma formation in 129,007 patients undergoing cosmetic surgery, the authors found a BMI ≥ 40 kg/m2 to have a higher incidence of hematomas.46 Hypertension Hypertension has been well established as a risk factor for hematomas in facelifts.50 Several studies have looked into blood pressure monitoring intraoperatively and in the postoperative period. Grover et al found a systolic pressure of greater than 150 mmHg to be a significant independent risk factor (P = 0.02) for postoperative hematoma with a relative risk of 3.6.5 The authors recommended blood pressure control to lower the hematoma rates, with continuing medications taken the day of surgery. They also recommended ensuring adequate analgesia and sedation with agents such as benzodiazepine to reduce the effects of reactive hypertension. Similarly, in a rhytidectomy series by Abboushi et al, patients with a history of hypertension had a hematoma rate of 8.2% compared to 3.5% in patients with no prior history, making history of hypertension a significant risk factor.15 In order to control the incidence of postoperative hematoma, Berner et al recommended timely administration of chlorpromazine in order to keep reactive hypertension in check.51 In a more recent study of 1089 patients undergoing rhytidectomy, Ramanadham et al implemented a preoperative routine involving transdermal clonidine with a target systolic blood pressure of less than 140 mmHg.52 The effects of hypertension on postoperative hematoma has also been looked at in body contouring surgery. Farkas et al examined patients receiving perioperative lovenox who developed hematoma after excisional body contouring surgery.53 The mean MAP for the last 2 hours of each case was significantly lower in the hematoma group (66.7 mm Hg vs 82.4 mm Hg; P < 0.0001), and a higher mean postoperative MAP reached significance in the hematoma group (96.3 mm Hg vs 88.5 mm Hg; P = 0.05). Both the difference between intraoperative and preoperative blood pressure (30.7 mm Hg vs 13.4 mm Hg; P < 0.0001) and between intraoperative and postoperative blood pressure (29.6 mm Hg vs 7.0 mm Hg; P < 0.0001) were increased in the hematoma group vs the nonhematoma group. Medications Many medications, including supplements taken by patients, have been identified as significant risk factors for bleeding and postoperative hematoma. In the study by Abboushi et al, on multivariate analysis, aspirin use was found to be an independent predictive factor for formation of postoperative hematomas (P = 0.028).15 In fact, in that study, while all patients stopped aspirin a week prior to surgery, the overall incidence of postoperative complications was significantly higher for patients who took aspirin regularly preoperatively compared to those who did not (27.2% vs 5.2%). In another study by Grover et al, multivariate analysis revealed aspirin or nonsteroidal anti-inflammatory drug (NSAID) intake to be associated with postoperative hematoma after rhytidectomy with a relative risk of 2.3 (P = 0.043).5 Nine of the 14 patients that had a history of aspirin or NSAID use and developed a postoperative hematoma, reported discontinuing the medications less than 2 weeks prior to surgery. On the contrary, of the 31 patients with a history of aspirin and NSAID intake who did not develop postoperative hematoma, 26 had discontinued the medication more than 2 weeks prior to surgery. As a result, the authors stressed the importance of discontinuing aspirin and NSAID intake at least 2 weeks prior to surgery to lower the incidence of hematoma formation. The use of other medications, such as antidepressants, have also been studied given their influence on hemostasis and bleeding risks.54 In a study of 250 patients undergoing facelift surgery, it was reported that the total hematoma rate was 1.95% for selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) users compared to 1.72% for SSRI/SNRI users.55 The authors concluded that there was no strong evidence to recommend discontinuing SSRI use perioperatively. In another study looking at SSRI use in cosmetic breast surgery, Basile et al examined 2285 patients who were divided into a no-use group and active-use group.56 Of the 196 patients in the active-use group, 4.59% (9 patients) had a bleeding event while only 1.15% (24 patients) had a bleeding event in the no-use group (2089 patients). Patients using SSRIs had a significantly higher rate of hematomas needing intervention with an odds ratio of 4.14. Further, logistic regression analysis showed that regardless of the type of procedure, body mass index, or patient age group, bleeding events were more common among SSRI users. They advocated discontinuing SSRI use 2 weeks prior to surgery and resuming 2 weeks after based on the drug pharmacology and its interactions with platelets. They emphasized the need to consider appropriate options with the patient and psychiatrist to ensure patient safety during and after cosmetic procedures. The plastic surgeon needs to be on contact with the patient’s psychiatrist or prescriber of these medications, but more importantly needs to have a preoperative discussion with the patient regarding their greater potential for postoperative complications.57 By better preparing patients for the physical and emotional stress a surgery puts them through, hospital admissions and emergency room visits may be reduced among this most vulnerable group. Type of Facility As more procedures and surgeries are being done outside a hospital setting in ambulatory surgery centers and office-based settings, there has been growing interest in the safety of such settings. In a study of over 129,000 patients undergoing aesthetic surgery low hematoma rates in office-based settings (0.6%) and surgical centers (1.0%) were reported.46 The authors do note that appropriate surgeon training and certification and patient selection for office-based settings and surgical centers may be reflected in the lower rates. Byrd et al supported this finding for over 5300 cases performed by board certified surgeons in accredited outpatient surgical facilities.58 In their cohort of cases that included procedures across the body, 35 (0.7%) required return to the operating room with hematoma being the most common in 27 cases. They stress that low complication rates are possible in outpatient settings however it involves prioritizing patient safety through up to date equipment, thorough physical exams and preoperative evaluations, adequately trained staff, and individualized patient care. As Gupta et al emphasize in their study, where they found a lower risk of developing a complication in an office-based suite compared to an ambulatory surgery center (RR = 0.67, 95% P < 0.01) or a hospital (RR = 0.59, P < 0.01), office-based settings can be safe alternatives to perform aesthetic surgery however the onus is on the plastic surgeon to carefully evaluate the patient on variables such as ASA class and medical comorbidities.59 Thus, while outpatient settings can be safe for cosmetic procedures and surgeries, thorough preoperative evaluation and patient selection is important in determining the appropriate facility for the patient and critical in lowering hematoma and complication rates. Combined Procedures There appears to be an increased rate of hematomas in patients undergoing combined procedures. In the large retrospective study combined procedures were found to be an independent risk factor for hematoma (RR = 1.35, P < 0.01).46 The authors suggest a plausible reason for this to be increased operative times leading to possible surgeon fatigue. An overwhelming increase in hematoma formation was found by Nguyen et al, looking at 2294 patients undergoing brachioplasty.33 Combined procedures had a relative risk of 12.42 in increasing the risk of hematoma formation in that study. Other studies have also found increased complication rates with combining procedures for facelifts and abdominoplasties.14,37 Care must be taken by the surgeon to ensure patients are aware of increased risk with additional procedures and it may be prudent to stage a patient’s surgeries to achieve a their aesthetic goals while minimizing complication rates. PERIOPERATIVE PREVENTION MEASURES A variety of techniques have been described and continue to be widely used to prevent hematoma formation in the perioperative period for aesthetic surgery. Depending on the procedure or procedures being performed and their anatomic locations, different preventive techniques are utilized. Drains are used in the head and neck, the breasts, the extremities, and the abdomen/body. Tissue sealants have gained significant popularity, particularly in conjunction with a rhytidectomy. Proper perioperative venous thromboprophylaxis is essential for any surgery, including aesthetic surgery, and understanding its role in hematoma formation is crucial. Lastly, the use of perioperative compression in prevention of hematoma formation continues to play a vital role for various aesthetic procedures. Hematoma is one of the most common complications in patients undergoing a rhytidectomy, with incidences up to 9%, which may require surgical evacuation.13-18 Previous studies showed several possible risk factors including high BMI, hypertension, perioperative nausea/vomiting, and heparin prophylaxis.15,47 As described above, male patients experience this complication almost three times more than female patients. This difference may be related to hormonal factors, facial follicle differences, and thicker or more vascularized facial flaps, which are prominent in males. In head and neck aesthetic surgery, the lack of major hematomas and low rate of minor hematomas is aided by meticulous hemostasis and careful placement of pressure dressings. Fibrin glue is not a replacement for meticulous hemostasis. In a previous review of the use of tissue glue without drains in short scar facelift, the authors experienced small fluid collections requiring aspiration, but no major hematomas were observed.60 Perkins et al did not find a significant difference in hematoma rates in 222 patients who underwent facelift surgery with or without the placement of drains.61 Another retrospective study also found that drainage alone does not reduce the incidence of postoperative hematomas.7 Their study included 50 patients undergoing rhytidectomy, and involved drain placement on one side of the face with the other nondrain side serving as each patient’s own control. The results showed no difference in postoperative complications between the two sides of the face including hematoma, seroma, or edema; however, there was found to be a significant reduction in ecchymosis on the side where a drain was placed.7 Drain placement can be undesirable for both the surgeon and the patient. For the patient, it is unsightly and may necessitate an extra incision in addition to causing more pain. Drains often malfunction by plugging, leaking, and slipping out. However, many surgeons are uncomfortable with the omission of drains despite the evidence that they do not prevent hematoma formation. It has also been described that a preoperative blood pressure over 150/100 mmHg was associated with a 2.6-fold greater incidence of hematoma.17 Maintaining a normal or slightly low blood pressure in the perioperative period is essential for hematoma prevention during rhytidectomy. Tissue sealants appear to be effective in preventing hematoma occurrence and reducing the amount of postoperative drainage in patients undergoing rhytidectomy independent of the technique used, as shown in a recent meta-analysis.62 However, the use of tissue sealant did not significantly prevent the incidence of ecchymosis, seroma, skin necrosis, or hypertrophic scarring. Fibrin sealants were beneficial independent of the dissection amount and plane used. Moreover, for deeper plane techniques, fibrin sealants may improve superficial muscular aponeurotic system (SMAS) fixation after repositioning with sutures, thus reducing the overall tension. A previous meta-analysis on this topic, including only prospective randomized studies, failed to show significant benefits, but it reported a trend towards diminished postoperative drainage and ecchymosis.63 More recently, another meta-analysis including seven trials demonstrated a significant reduction of hematoma incidence with the use of fibrin glue.64 While these meta-analyses provide good evidence that tissue sealants reduce hematoma formation during rhytidectomy, they are limited by confounding elements, such as patients’ age, the plane of dissection, the type of sealant used, and control treatment. Hence, it can be concluded that the current scientific evidence on the benefit of tissue sealants is still limited and inconsistent, and bias effect should be considered. Tissue sealants comprise two natural materials, thrombin and fibrinogen, forming the final common pathway of the coagulation cascade. However, as several products are available in the market, a major limitation of these studies is due to the heterogeneity and variety of the tissue sealants used. In general, tissue sealants can be divided into several subgroups: fibrin glue products (Artiss, Tisseel, Evicel, Beriplast P), thrombin and gelatin matrix compounds (Floseal, Surgiflo), bovine serum albumin and glutaraldehyde mixes (BSAG, BioGlue), polyethylene glycol hydrogels (DuraSeal), and even starch powder (4DryField, Perclot). Cost and usage of these products is extremely variable making definitive conclusions difficult. However, there are enough data to support the use of perioperative tissue sealants to reduce hematoma incidence during rhytidectomy. Compression dressings are another method of hematoma prevention commonly employed after facelift surgery; however, there exists wide variation in clinical practice in terms of dressing composition, tightness, and duration of use, making evidence-based evaluation difficult. In Jones’ series of over 900 patients undergoing rhytidectomy, the rate of hematoma formation with and without the use of postoperative compression dressings was around 4%; however, the presence of other potentially confounding factors precludes independent analysis.7 The authors also mention that tight, restrictive dressings may be uncomfortable and compromise skin flap circulation, and should therefore be avoided. Interestingly, they also looked at the application of tumescent solution prepared with and without epinephrine. Although the use of tumescent infiltration itself did not impact the incidence of postoperative complications, results demonstrated a significant reduction in hematoma rate with the omission of epinephrine from the injection solution. The authors proposed that its vasoconstrictive effects, while serving to enhance intraoperative hemostasis and facilitate dissection, may mask smaller bleeding vessels that can contribute to postoperative hematoma formation. Additional factors purported to increase the risk of hematoma are postoperative hypertension, pain and agitation, and the incidence of nausea and vomiting. Interestingly, in the review by Zoumalan and Rizk, almost one third of hematomas occurred in patients with postoperative emesis.16 Because most hematomas develop within the first 24 hours of surgery, optimizing overall patient management during this time period would seem of critical importance to ensuring a favorable surgical outcome. With this in mind, Beer et al sought to evaluate the impact of these medical and physiologic factors on the incidence of hematoma formation after facelift surgery by reviewing a series of patients treated in two distinct postoperative environments.13 The first group received medications upon request or in a “reactionary” fashion after surgery, whereas the second group was administered several pharmacologic interventions prophylactically. These included analgesics, sedatives, antihypertensives, and antiemetics while all other variables were held constant. The authors ultimately found a significant reduction in hematoma rate for the group receiving medications in a prophylactic manner, emphasizing the importance of controlling these parameters in the early postoperative setting. The use of drains in aesthetic breast surgery is controversial. However, the location of implant placement and dissection technique is an important consideration in hematoma formation. In a series reported by Araco et al, there was a fivefold increase in the risk of infection after augmentation mammaplasty if drains had been used.65 In their study of over 3000 patients, hematomas were found in 46 patients (1.5%), which is consistent with the literature. Most patients who experienced hematomas had received a submuscular placement, using both classic and dual-plane approaches (34 patients, 74%) and less the subglandular approach (12 patients, 26%). Pocket creation was performed using the manual technique for 26 patients (56.5%) and diathermy for 20 patients (43.5%). There was no particular distribution for implant size, drains, or antibiotics used to wash pockets. Their univariate analysis showed a significant association of hematomas with the submuscular/dual-plane approach and the manual type of pocket creation. No association between hematomas and capsular contractures was found at either the univariate or the multivariate analysis. Compression garments or surgical bras were recommended to reduce the incidence of seroma and hematoma formation, as well as provide perioperative support of the prostheses. Abdominoplasty and body contouring procedures continue to have significant complication rates. Part of the perioperative patient assessment is their risk of potential venous thromboembolism (VTE), specifically when performing an abdominoplasty as this procedure carries a high risk for VTE. In addition to the increase of intra-abdominal pressure caused by different maneuvers used to correct myoaponeurotic laxity, there is also the effect of abdominal flap traction, which can be transferred to the abdominal cavity. Therefore, there is possibly some interference in the venous drainage of the lower limbs and pelvis after the procedure. In a recent study, the use of enoxaparin demonstrated a trend toward decreased rates of venous thromboembolism when used in patients at highest risk under the revised Davison-Caprini risk-assessment model.66 Circumferential abdominoplasty patients who received enoxaparin had a statistically significant decrease in VTE events. However, perioperative enoxaparin administration was associated with an increased rate of hematoma and postoperative bleeding requiring transfusion. It was suggested that patients in the highest risk group, and any patient undergoing circumferential abdominoplasty, be given perioperative chemoprophylaxis with a low-molecular-weight heparin. Plastic surgeons should also use discretion in considering other patients for low-molecular-weight heparin chemoprophylaxis, such as patients in the high-risk group, those who are obese (body mass index > 30), those on over-the-counter progesterone/hormone replacement therapy, and perhaps patients undergoing abdominoplasty combined with other procedures. The risk of VTE should be balanced against the increased risk for bleeding with the use of low-molecular-weight heparin, keeping in mind that bleeding is an expected, manageable complication, whereas pulmonary embolism can be a fatal and unacceptable sequela in the setting of elective surgery. Prevention of VTE and its role in possible hematoma formation after aesthetic surgery is a critical relationship the plastic surgeon must be cognizant of. In a recent meta-analysis comparing operative techniques and hematoma formation no statistical difference was identified in patients undergoing a “conventional” abdominoplasty vs various preventative techniques.67 These preventative measures included the use progressive tension sutures, Scarpa’s fascia preservation, and use of tissue sealants or abdominal flap dissection method. Consequently, the odds of seroma in patients undergoing abdominoplasty using one of the surgical prevention measures were, on average, four times lower than for those receiving conventional abdominoplasty. Subgroup analysis was performed to analyze the effect of each method on seroma rate. Scarpa’s fascial preservation and tissue sealants both showed a statistical advantage in seroma rates and borderline differences for the use of progressive tension sutures were detected. No difference between methods of abdominal flap dissection was revealed. However, these methods did not impact hematoma prevention or formation. The use of compression after abdominoplasty or other body contouring procedures is almost universal. Compression garments are used to reduce seroma formation, promote flap adherence, and minimize hematoma risk. However, compression garments must be used with some caution after abdominoplasty because their use can contribute to a higher intra-abdominal pressure and subsequent VTE incidence.66 Compression garments are still widely used and recommended after abdominoplasty and body contouring procedures.67 POSTOPERATIVE DIAGNOSIS An analysis of a prospective, multicenter, national database examined the incidence of major hematomas following cosmetic surgical procedures in 129,007 patients, and found the overall incidence of major hematomas to be 0.91% (Table 5).46 Despite its low incidence, hematoma was still the most commonly observed major complication in the database and needs to be in the back of every plastic surgeon’s mind. The diagnosis of and urgent treatment of major hematomas after aesthetic surgery is critical to superior patient care and ultimate patient satisfaction. Clinical evaluation and diagnosis is the mainstay of major postoperative hematoma management, and cannot be replaced by any imaging modality. While some subclinical or minor hematomas may be detected by ultrasound or computed tomography, patient assessment and clinical judgement are at the core of diagnosing a patient with a major postoperative hematoma. The vast majority of major postoperative hematomas occur within the first 48 hours after surgery, so during this time period is when clinical suspicion should be at its peak.46 While there is no standardization of return visits after surgery, many surgeons will evaluate their patients after aesthetic surgery within the first 24 to 48 hours, either as an outpatient or in a hospital setting, to ensure proper patient care. Table 5. Hematoma Incidence in Aesthetic Surgery Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  View Large Table 5. Hematoma Incidence in Aesthetic Surgery Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  View Large TREATMENT After the diagnosis of hematoma has been made, the gold standard of treatment is evacuation. This can be accomplished in the operating room, in the outpatient clinic, or a variety of other locations depending on the presentation and severity of the hematoma. Postoperative hematomas can be classified as either minor or major. The smaller collections generally do not compromise skin flap viability in the case of a rhytidectomy and are difficult to identify at all in other aesthetic procedure. These collections can usually be treated with simple needle aspiration, which may need to be repeated. These minor hematomas tend to resolve without significant morbidity to the patient. Major hematomas are much more urgent and clinically relevant. The true treatment for postoperative major hematomas is prevention at the time of the initial surgery. In the event of a major postoperative hematoma immediate treatment is essential. As the hematoma expands it can produce tissue destruction and impact flap viability. In extreme cases in the head and neck expanding hematomas can even result in airway compromise. A witnessed postoperative hematoma can be initially treated with aspiration and pressure, but if this does not resolve the bleeding the incisions must be opened and the surgical sites explored. More commonly, hematomas are insidious and progress more slowly. They typically present within the first 24 to 48 hours after surgery. After a rhytidectomy, hematomas frequently manifest as severe, unilateral stabbing facial pain. Occasionally, patients are unable to place their teeth in occlusion because of buccal swelling. After breast and body procedures hematoma presentation can be more subtle, but the hallmark features of any hematoma is swelling and pain. Distinguishing normal postoperative pain and an underlying hematoma relies upon the clinical evaluation and acumen of the surgeon. The patient should be evaluated in the clinic or in the hospital setting, and if the hematoma in clinically significant and warrants evacuation the surgeon has several options. Percutaneous aspiration can be attempted either by the surgeon or interventionalists if they are available. The success of aspiration depends on the type of surgery the patient had, the accessibility of the hematoma, and the chronicity of the collection. Obviously, the larger-bore needles will make aspiration easier and more successful. If the hematoma cannot be aspirated then the incision should be opened and the hematoma evacuated in a controlled setting where patient comfort and care is paramount. Whether this occurs in the operating room or as a procedure in the clinic again depends on what is best for the patient and what the surgeon feels would be the most effective. Regardless of the location, the incision(s) should be partially or completely opened, the hematoma evacuated, and the surgical site thoroughly inspected for signs of bleeding. The site should be copiously irrigated after ensuring hemostasis, a drain may or may not be left depending on surgeon preference, and the incision reclosed. The patient should be closely monitored either in the hospital setting or with a return visit to the clinic the following day. ASSOCIATED COMPLICATIONS Complications that arise as a result of hematoma formation and the subsequent treatment vary depending on the type of surgery and the severity. Hematoma development can be associated with increased wound healing problems. The most feared of all complication after rhytidectomy is flap necrosis and skin sloughing, with a reported incidence of 0 to 3%.68 Flap necrosis results from vascular compromise in the forms of decreased arterial perfusion, venous congestion, or small vessel disease. Hematoma is a major risk factor for the development of these postoperative changes to the skin flaps. Even if flap necrosis does not occur, hematomas can lead to prolonged facial edema and skin necrosis after rhytidectomy. Hematoma development after aesthetic breast surgery can also result in a variety of negative long-term sequelae. Wound healing issues and flap compromise can also occur in aesthetic breast surgery after hematoma formation. This complication could potentially lead to implant exposure and subsequent loss. Hematomas are significantly associated with the development of capsular contracture and chronic seromas after aesthetic breast surgery.69 Although the cause of capsular contracture continues to be examined, the results of a large prospective clinical study indicate that implant placement (submuscular/subglandular), implant surface (smooth/textured), incision site, hematoma/seroma development, device size, and surgical bra appear to play important roles. As our knowledge of capsular contracture risk factors grows, as well as its link to implant-associated anaplastic large cell lymphoma, the plastic surgeon must be aware how hematoma formation plays a role. As previously stated, submuscular implant placement has a higher hematoma incidence compared with the subglandular position.46 If the surgeon attempts to mitigate the risk of capsular contracture by choosing to place the implant in the submuscular plane, he/she must be more vigilant with hemostasis to prevent hematoma formation. Revisionary surgery, while not always described as complication, can be associated with hematoma formation and treatment. Whether the patient experienced wound dehiscence or healing problems, seroma development, a chronic infection, capsular contracture of an implant, or skin/flap loss, these problems arise from hematoma formation and frequently require revisionary surgery. To deliver the best patient satisfaction and care, complications must be acknowledged and addressed. CONCLUSIONS A review of the literature revealed a wide range of hematoma rates for some of the most frequently performed aesthetic surgeries. Major hematoma was found to be the most common complication after cosmetic surgical procedures, although the overall incidence was low at 0.91%. Identifying the risk factors for hematoma development and taking appropriate steps to prevent their occurrence are vital to providing the best care to the aesthetic patient. Despite the infrequency with which they occur, diagnosing and properly managing a postoperative hematoma must be second nature to a plastic surgeon. Even after the initial treatment, the short and long term sequelae of a hematoma must also be identified and managed. A thorough knowledge of risk factors for the most commonly encountered major complications following aesthetic surgical procedures allows providers to better educate patients, be more cognizant of high-risk patients and provide overall better patient care. 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. Footnotes American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. REFERENCES 1. Gusenoff JA, Coon D, Rubin JP. 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An outcome analysis of brachioplasty techniques following massive weight loss. Ann Plast Surg . 2010; 64( 5): 588- 591. Google Scholar PubMed  35. Bossert RP, Dreifuss S, Coon Det al.   Liposuction of the arm concurrent with brachioplasty in the massive weight loss patient: is it safe? Plast Reconstr Surg . 2013; 131( 2): 357- 365. Google Scholar CrossRef Search ADS PubMed  36. Zomerlei TA, Neaman KC, Armstrong SDet al.   Brachioplasty outcomes: a review of a multipractice cohort. Plast Reconstr Surg . 2013; 131( 4): 883- 889. Google Scholar CrossRef Search ADS PubMed  37. 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  38. Chong T, Coon D, Toy J, Purnell C, Michaels J, Rubin JP. Body contouring in the male weight loss population: assessing gender as a factor in outcomes. Plast Reconstr Surg . 2012; 130( 2): 325e- 330e. Google Scholar CrossRef Search ADS PubMed  39. Bertheuil N, Chaput B, De Runz A, Girard P, Carloni R, Watier E. The lipo-body lift: a new circumferential body-contouring technique useful after bariatric surgery. Plast Reconstr Surg . 2017; 139( 1): 38e- 49e. Google Scholar CrossRef Search ADS PubMed  40. Martén E, Langevin CJ, Kaswan S, Zins JE. The safety of rhytidectomy in the elderly. Plast Reconstr Surg . 2011; 127( 6): 2455- 2463. Google Scholar CrossRef Search ADS PubMed  41. Becker FF, Castellano RD. Safety of face-lifts in the older patient. Arch Facial Plast Surg . 2004; 6( 5): 311- 314. Google Scholar CrossRef Search ADS PubMed  42. Yeslev M, Gupta V, Winocour J, Shack RB, Grotting JC, Higdon KK. Safety of cosmetic procedures in elderly and octogenarian patients. Aesthet Surg J . 2015; 35( 7): 864- 873. Google Scholar CrossRef Search ADS PubMed  43. Richard P, Huesler R, Banic A, Erni D, Plock JA. Perioperative risk factors for haematoma after breast augmentation. J Plast Surg Hand Surg . 2013; 47( 2): 130- 134. Google Scholar CrossRef Search ADS PubMed  44. Mayrovitz HN, Regan MB. Gender differences in facial skin blood perfusion during basal and heated conditions determined by laser Doppler flowmetry. Microvasc Res . 1993; 45( 2): 211- 218. Google Scholar CrossRef Search ADS PubMed  45. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg . 2005; 116( 7): 1973- 1985; discussion 1986. Google Scholar CrossRef Search ADS PubMed  46. Kaoutzanis C, Winocour J, Gupta Vet al.   Incidence and risk factors for major hematomas in aesthetic surgery: analysis of 129,007 patients. Aesthet Surg J . 2017; 37( 10): 1175- 1185. Google Scholar CrossRef Search ADS PubMed  47. Gupta V, Winocour J, Rodriguez-Feo Cet al.   Safety of aesthetic surgery in the overweight patient: analysis of 127,961 patients. Aesthet Surg J . 2016; 36( 6): 718- 729. Google Scholar CrossRef Search ADS PubMed  48. 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  49. Myung Y, Heo CY. Relationship between obesity and surgical complications after reduction mammaplasty: a systematic literature review and meta-analysis. Aesthet Surg J . 2017; 37( 3): 308- 315. Google Scholar PubMed  50. Derby BM, Codner MA. Evidence-based medicine: face lift. Plast Reconstr Surg . 2017; 139( 1): 151e- 167e. Google Scholar CrossRef Search ADS PubMed  51. Berner RE, Morain WD, Noe JM. Postoperative hypertension as an etiological factor in hematoma after rhytidectomy. Prevention with chlorpromazine. Plast Reconstr Surg . 1976; 57( 3): 314- 319. Google Scholar CrossRef Search ADS PubMed  52. Ramanadham SR, Mapula S, Costa C, Narasimhan K, Coleman JE, Rohrich RJ. Evolution of hypertension management in face lifting in 1089 patients: optimizing safety and outcomes. Plast Reconstr Surg . 2015; 135( 4): 1037- 1043. Google Scholar CrossRef Search ADS PubMed  53. Farkas JP, Kenkel JM, Hatef DAet al.   The effect of blood pressure on hematoma formation with perioperative Lovenox in excisional body contouring surgery. Aesthet Surg J . 2007; 27( 6): 589- 593. Google Scholar CrossRef Search ADS PubMed  54. Halperin D, Reber G. Influence of antidepressants on hemostasis. Dialogues Clin Neurosci . 2007; 9( 1): 47- 59. Google Scholar PubMed  55. Harirchian S, Zoumalan RA, Rosenberg DB. Antidepressants and bleeding risk after face-lift surgery. Arch Facial Plast Surg . 2012; 14( 4): 248- 252. Google Scholar CrossRef Search ADS PubMed  56. Basile FV, Basile AR, Basile VV. Use of selective serotonin reuptake inhibitors antidepressants and bleeding risk in breast cosmetic surgery. Aesthetic Plast Surg . 2013; 37( 3): 561- 566. Google Scholar CrossRef Search ADS PubMed  57. Nahai F. Evaluating the cosmetic patient on antidepressants. Aesthet Surg J . 2014; 34( 2): 326- 327. Google Scholar CrossRef Search ADS PubMed  58. Byrd HS, Barton FE, Orenstein HHet al.   Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases. Plast Reconstr Surg . 2003; 112( 2): 636- 641; discussion 642. Google Scholar CrossRef Search ADS PubMed  59. 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  60. Matarasso A, Rizk SS, Markowitz J. Short scar face-lift with the use of fibrin sealant. Dermatol Clin . 2005; 23( 3): 495- 504, vii. Google Scholar CrossRef Search ADS PubMed  61. Perkins SW, Williams JD, Macdonald K, Robinson EB. Prevention of seromas and hematomas after face-lift surgery with the use of postoperative vacuum drains. Arch Otolaryngol Head Neck Surg . 1997; 123( 7): 743- 745. Google Scholar CrossRef Search ADS PubMed  62. Giordano S, Koskivuo I, Suominen E, Veräjänkorva E. Tissue sealants may reduce haematoma and complications in face-lifts: A meta-analysis of comparative studies. J Plast Reconstr Aesthet Surg . 2017; 70( 3): 297- 306. Google Scholar CrossRef Search ADS PubMed  63. Por YC, Shi L, Samuel M, Song C, Yeow VK. Use of tissue sealants in face-lifts: a metaanalysis. Aesthetic Plast Surg . 2009; 33( 3): 336- 339. Google Scholar CrossRef Search ADS PubMed  64. Killion EA, Hyman CH, Hatef DA, Hollier LHJr, Reisman NR. A systematic examination of the effect of tissue glues on rhytidectomy complications. Aesthet Surg J . 2015; 35( 3): 229- 234. Google Scholar CrossRef Search ADS PubMed  65. Araco A, Gravante G, Araco F, Delogu D, Cervelli V, Walgenbach K. Infections of breast implants in aesthetic breast augmentations: a single-center review of 3,002 patients. Aesthetic Plast Surg . 2007; 31( 4): 325- 329. Google Scholar CrossRef Search ADS PubMed  66. Hatef DA, Kenkel JM, Nguyen MQet al.   Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg . 2008; 122( 1): 269- 279. Google Scholar CrossRef Search ADS PubMed  67. Seretis K, Goulis D, Demiri EC, Lykoudis EG. Prevention of seroma formation following abdominoplasty: a systematic review and meta-analysis. Aesthet Surg J . 2017; 37( 3): 316- 323. Google Scholar CrossRef Search ADS PubMed  68. Griffin JE, Jo C. Complications after superficial plane cervicofacial rhytidectomy: a retrospective analysis of 178 consecutive facelifts and review of the literature. J Oral Maxillofac Surg . 2007; 65( 11): 2227- 2234. Google Scholar CrossRef Search ADS PubMed  69. Stevens WG, Nahabedian MY, Calobrace MBet al.   Risk factor analysis for capsular contracture: a 5-year Sientra study analysis using round, smooth, and textured implants for breast augmentation. Plast Reconstr Surg . 2013; 132( 5): 1115- 1123. Google Scholar CrossRef Search ADS PubMed  70. Lawson W, Naidu RK. The male facelift. An analysis of 115 cases. Arch Otolaryngol Head Neck Surg . 1993; 119( 5): 535- 539; discussion 540. Google Scholar CrossRef Search ADS PubMed  71. Costa CR, Ramanadham SR, O’Reilly E, Coleman JE, Rohrich RJ. The role of the superwet technique in face lift: an analysis of 1089 patients over 23 years. Plast Reconstr Surg . 2015; 135( 6): 1566- 1572. Google Scholar CrossRef Search ADS PubMed  72. O’Grady KF, Thoma A, Dal Cin A. A comparison of complication rates in large and small inferior pedicle reduction mammaplasty. Plast Reconstr Surg . 2005; 115( 3): 736- 742. Google Scholar CrossRef Search ADS PubMed  73. Hvilsom GB, Hölmich LR, Henriksen TF, Lipworth L, McLaughlin JK, Friis S. Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the breast. Plast Reconstr Surg . 2009; 124( 3): 919- 925. Google Scholar PubMed  74. Alderman AK, Collins ED, Streu R, Grotting JCet al.   Benchmarking outcomes in plastic surgery: national complication rates for abdominoplasty and breast augmentation. Plast Reconstr Surg . 2009; 124( 6): 2127- 2133. Google Scholar CrossRef Search ADS PubMed  75. Chun YS, Schwartz MA, Gu X, Lipsitz SR, Carty MJ. Body mass index as a predictor of postoperative complications in reduction mammaplasty. Plast Reconstr Surg . 2012; 129( 2): 228e- 233e. Google Scholar CrossRef Search ADS PubMed  76. Rusciani A, Pietramaggiori G, Troccola A, Santoprete S, Rotondo A, Curinga G. The outcome of primary subglandular breast augmentation using tumescent local Anesthesia. Ann Plast Surg . 2016; 76( 1): 13- 17. Google Scholar CrossRef Search ADS PubMed  77. Savage RC. Abdominoplasty combined with other surgical procedures. Plast Reconstr Surg . 1982; 70( 4): 437- 443. Google Scholar CrossRef Search ADS PubMed  78. Stevens WG, Vath SD, Stoker DA. “Extreme” cosmetic surgery: a retrospective study of morbidity in patients undergoing combined procedures. Aesthet Surg J . 2004; 24( 4): 314- 318. Google Scholar CrossRef Search ADS PubMed  79. Momeni A, Torio-Padron N, Bannasch H, Borges J, Stark GB. A new method for reducing postoperative complications and scar length in abdominoplasty. Plast Reconstr Surg . 2008; 121( 4): 227e- 228e. 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

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Abstract

Abstract Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon’s ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery. Learning Objectives Discuss the incidence and epidemiology of hematomas following aesthetic surgical procedures. Identify potential risk factors and preoperative considerations for hematoma development following aesthetic surgery. Understand the key perioperative prevention measures to decrease the incidence of hematomas in aesthetic surgery. Diagnose and treat hematomas after aesthetic surgery. Be able to identify and manage postoperative complications associated with hematoma formation after aesthetic surgery. Hematomas are a frequently reported complication in aesthetic surgery. They can range in size, and may present with a variety of nonspecific signs and symptoms including erythema, warmth, edema, pain or tenderness, and in some instances hemodynamic changes. While smaller hematomas may resolve without incident, larger hematomas, if left untreated, can have untoward consequences for the patient including pain, poor cosmesis, scarring, skin and tissue ischemia leading to necrosis and infection. Thus, prompt identification and management of hematomas is crucial in the aesthetic surgery patient. The incidence of hematomas in aesthetic surgical procedures varies, and is influenced by a myriad of factors. These include patient factors such as hypertension and medication intake such as blood thinners, surgical factors such as operative technique, as well as perioperative and postoperative care. Consequently, the reported hematoma rates vary significantly and range from an estimated 0% to 15% across several aesthetic procedures including brachioplasty, thighplasty, body contouring, facelifts, breast surgery, and abdominoplasty.1-11 These numbers, however, may not reflect the true incidence of hematomas as studies differ with regards to how hematomas are accounted for, taking into consideration factors such as need for medical and surgical management and the postoperative follow-up period. As a result, while many authors may report low rates of hematomas, given the ever-increasing number of cosmetic procedures being performed with more than 13 million in 2016 according to the American Society of Aesthetic Plastic Surgeons (ASAPS) Statistics Report,12 the significance of these rates cannot be ignored. Rhytidectomy is one of the most well studied aesthetic procedures with regards to hematoma rates that range between approximately 0% and12%.5,13-18 This complication can lead to longer recovery times, increased risk for skin sloughing, and urgent return to the operating room.19 Several large cohorts have been studied with varying incidence rates influenced by operative technique. Imber and Silich report an incidence of 0.6% (6 cases) in a series of 1000 patients undergoing a limited-incision facelift technique.20 In a large retrospective study of 8788 facial rejuvenation cases, Pitanguy and Machado reported the most frequent complication to be hematoma with an incidence of 3% (264 cases).21 In a cohort of 383 patients, Neto et al reported a relatively higher incidence of hematomas at 7.05% (27 cases)6 (Table 1). Table 1. Reported Hematoma Incidence After Rhytidectomy Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  View Large Table 1. Reported Hematoma Incidence After Rhytidectomy Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Lawson and Naidu70  1993  Arch Otolaryngol Head Neck Surg  115  11  9.57  Rees et al4  1994  Plast Reconstr Surg  1236  23  1.86  Grover et al5  2001  Br J Plast Surg  1078  45  4.17  Jones and Grover7  2004  Plast Reconstr Surg  678  30  4.42  Baker et al45  2005  Plast Reconstr Surg  985  36  3.65  Pitanguy and Machado21  2012  Aesthet Surg J  8788  264  3.00  Abboushi et al15  2012  Aesthet Surg J  630  29  4.60  Neto et al6  2013  Aesthetic Plast Surg  383  27  7.05  Costa et al71  2015  Plast Reconstr Surg  1042  10  0.96  TOTAL      14,935  475  3.18  View Large The incidence of hematoma among rhinoplasties has also been studied, and is attributed to bleeding from incision sites or traumatized mucosa.22 One of the largest retrospective reviews of patients undergoing rhinoplasties reported a complication rate of 0.2% among 4978 patients.23 In another large retrospective study by Chuangsuwanich et al, looking at augmentation rhinoplasties among 548 Asian patients, hematomas occurred in 0.5% of the patients.24 The lower rate noted among rhinoplasties could be attributed to steps taken towards controlling postoperative bleeding such as 60 degree head elevation, gentle nostril pressure, and use of topical decongestant nasal sprays including oxymetazoline or phenylephrine.22 Further, in instances of refractory bleeding not responsive to these techniques or nasal packing, administration of desmopressin has been shown to be effective through a mechanism that involves increased coagulation by elevated plasma concentrations of Factor VIII.25 In a study examining 268 nasal operations, Faber et al reported 9 patients with excessive postoperative bleeding that responded to the use of 0.3 μg/kg of intravenous desmopressin over 30 minutes.26 While epistaxis and hematoma formation are two entirely different entities, they share a similar mechanism and have some overlap as far as treatment modalities and prevention.25 Another well-studied cohort with regards to hematoma formation is the patient population undergoing aesthetic breast surgery. This is a particularly important area given the sustained growth in cosmetic breast surgery; breast augmentation was one of the the most common surgical procedure at 310,444 as reported by the ASAPS 2016 Statistics Report.12 In the studies reviewed hematoma incidence ranged from 0.62% to 8.27%.27-30 In a retrospective study by Araco et al looking at primary breast augmentations in 3002 patients, hematomas were the most frequent complication reported in 1.5% (46 patients).27 Their analysis found both the technique for creating a pocket and implant placement to be significantly associated with complications. A more recent study by Codner et al evaluated 812 patients undergoing breast augmentation with saline (482 patients) and silicone implants (330 patients).28 Hematoma was reported as an uncommon complication and occurred in only 2%, (16 patients). Interestingly, developing a hematoma was a risk factor for the subsequent development of capsular contracture, with 25% of hematoma patients (4 of 16 patients) developing capsular contracture compared to a statistically significant lower proportion (P = 0.038) of 8% in the nonhematoma group (64 of 796 patients). Hematoma rates have also been studied in other breast surgery procedures. Carpelan et al studied 110 consecutive patients undergoing bilateral reduction mammaplasties with resections of at least 200 grams per breast and found 5% (5 patients) requiring hematoma evacuation.30 In a larger cohort of 444 patients undergoing 884 reduction mammaplasties, Stevens et al reported 4 hematomas.31 The mean resection of breast tissue weight was 1228 grams in this study. Hematoma rates seem to be lesser in breast surgeries compared to other body regions with a retrospective study by Gupta et al looking at 73,608 breast surgery cases and finding an overall major hematoma rate of 0.99%.29 Overall, reduction breast surgery had the lowest rate of hematoma formation with 27 hematomas after 3288 surgeries (0.82%) compared to augmentation-mastopexy procedures that had the highest with 89 hematomas after 8125 surgeries (1.1%) (Table 2). Table 2. Reported Hematoma Incidence After Aesthetic Breast Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  View Large Table 2. Reported Hematoma Incidence After Aesthetic Breast Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Gabriel et al8  1997  N Engl J Med  749  43  5.74  O’Grady et al72  2005  Plast Reconstr Surg  133  11  8.27  Hvilsom et al73  2007  Plast Reconstr Surg  5373  65  1.21  Alderman et al74  2009  Plast Reconstr Surg  70,749  443  0.63  Codner et al28  2011  Plast Reconstr Surg  812  16  1.97  Collins and Verheyden9  2012  Plast Reconstr Surg  903  13  1.44  Chun et al75  2012  Plast Reconstr Surg  675  7  1.04  Richard et al43  2013  J Plast Surg Hand Surg  132  9  6.82  Basile et al56  2013  Aesthetic Plast Surg  2285  33  1.44  Rusciani et al76  2016  Aesthetic Plast Surg  150  0  0.00  TOTAL      81,961  640  0.78  View Large The reported rates of hematoma vary significantly in body contouring surgery depending on the region of the procedure, weight of the patient, and intraoperative interventions and techniques. In looking at medial thigh lifts in the massive weight loss population, Gusenoff et al reported a hematoma rate of 6% among 106 patients.3 In a larger cohort of 1493 patients, Afshari et al reported a lesser rate of 2.1% hematomas.32 The authors attributed the lower rates to a more specific definition for major hematomas (requiring Emergency Room visits, hospital readmissions, or reoperations within 30 days of the initial operation) and the multicenter nature of the cohort. In contrast to thighplasties, hematoma rates for brachioplasties appear to be slightly lower. In a study by Nguyen examining 2294 patients undergoing brachioplasties, using definitions similar to the study by Afshari et al, the authors reported hematomas in 1.1% of patients.33 Other smaller cohorts studying hematoma following brachioplasties reported rates ranging from approximately 0% to 3%.34–36 In a retrospective review of 25,478 abdominoplasties, Winocour et al found a major hematoma rate of 1.26%.37 Interestingly, male sex was a significant risk factor for complications in that study with a relative risk of 1.8. A similar trend was also noted by Chong et al in a study involving 48 males undergoing body contouring after weight loss.38 They found male gender to be associated with a 14.6% incidence of postoperative hematoma and an independent risk factor with an odds ratio of 3.76. The effect of technique in affecting hematoma rates also seems to be significant. In a recent study, Bertheuil et al reported no major complications (including hematoma) in a series of 25 abdominal body-contouring reconstructions where the presurgery body mass index was 26.71 and postsurgery body mass index was 20.92.39 The authors advocated the use of a novel and less-invasive circumferential lipo-body lift technique compared to traditional lower body-lifting methods (Table 3). Table 3. Reported Hematoma Incidence After Abdominoplasty and Body Contouring Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  View Large Table 3. Reported Hematoma Incidence After Abdominoplasty and Body Contouring Surgery Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  Study  Year  Journal  No. patients  Hematomas reported  Incidence  Abdominoplasty            Savage77  1982  Plast Reconstr Surg  33  0  0.00  Stevens et al78  2004  Aesthet Surg J  248  2  0.81  Momeni et al79  2008  Plast Reconstr Surg  139  4  2.88  Alderman et al74  2009  Plast Reconstr Surg  31,630  245  0.77  Quaba et al11  2015  Plast Reconstr Surg  271  5  1.85  TOTAL      32,321  256  0.79  Body contouring            Gusenoff et al1  2008  Plast Reconstr Surg  101  3  2.97  Bossert et al35  2013  Plast Reconstr Surg  144  2  1.39  Gusenoff2  2015  Plast Reconstr Surg  106  6  5.66  Nguyen et al33  2016  Aesthet Surg J  2294  25  1.09  TOTAL      2645  36  1.36  View Large Overall, across all body regions, hematoma rates are affected by the procedure type and patient comorbidities. Different patient factors influence hematoma rates to varying degrees depending on the procedure being performed. A better understanding of these risk factors could lead to better preoperative planning, patient selection, patient education, and intraoperative and postoperative management. Such steps will better facilitate the patient-physician relationship, and could lead to better outcomes and higher patient satisfaction following surgery. RISK FACTORS/PREOPERATIVE CONSIDERATIONS Age The number of cosmetic procedures continues to increase at a significant rate in particularly in older populations.12 As a result, the impact of age as a risk factor in cosmetic procedures has been investigated. Abboushi et al, in looking at 630 patients undergoing facelift, found age greater than 55 to be a significant risk factor for postoperative hematoma.15 In contrast, Marten et al reviewed 216 patients undergoing facelifts in patients younger and older than 65 years of age, and found no significant difference in major (2.9% to 2.0%, P = 0.65) or minor (5.9% to 6.1%, P = 0.99) complications between the 2 groups.40 Similar findings were noted by Becker and Castellano in their review evaluating the safety of facelifts in patients younger and older than 75 years of age.41 While Becker’s study matched patients for American Society of Anesthesiologists (ASA) class, Marten’s elderly patient group had a higher ASA class compared to the younger group. As a result, Becker’s group recommended preoperative health status as an important counseling topic with patients. In perhaps one of the largest cohorts in the literature examining the safety of cosmetic procedures in the elderly, Yeslev et al reported a significantly higher number of hematomas in the younger patient population group (younger than 65 years) compared to the older group.42 However, the younger group also underwent more procedures than the older group. In a different study using the same database, age was found to be a significant risk factor for hematomas (relative risk of 1.01, P < 0.01) in a cohort of patients undergoing aesthetic breast surgery.29 Similarly, in a cohort of 132 patients, Richard et al found age to be a risk factor for hematoma formation after primary breast augmentation on univariate analysis; however, it was not found as an independent risk factor on multivariate analysis.43 Older age (greater than 55 years) was found as a significant risk factor for complications (relative risk of 1.4) in a cohort of 25,478 abdominoplasties, with approximately a third of the overall complication rate (4%) attributed to hematomas.37 These findings suggest that while age is an important factor in patient selection, there may be other confounding variables that occur with aging (eg, medication intake, hypertension, ASA class). As previously stated by Becker et al, optimizing preoperative health status is perhaps of more importance than using age cut-offs alone.41 Gender Male gender has been advocated to be more prone to postoperative hematomas after rhytidectomy secondary to the thicker and more vascular nature of male facial skin.18 Rohrich et al, in a retrospective review of 83 consecutive male rhytidectomies over a 20 year period that was age matched with 83 female patients who underwent rhytidectomy during the same time period, showed a hematoma rate of 6% (5 patients) in males compared to 0% in females (P = 0.0587).18 The predilection of males to hematoma formation is further confirmed by a laser Doppler flow study by Mayrovitz et al, where males had higher facial skin blood flow than women due to a higher number of perfused microvessels.44 Males also have larger and coarser hair with more blood supply compared to women who have finer vellus facial hair that have fewer capillaries. Baker et al evaluated 985 male rhytidectomies over three periods spanning 30 years, and reported a downward trend in hematoma rate from 8.70% to 3.97%.45 They attribute this to a strict antihypertensive medication and blood pressure monitoring regimen. Other studies have also shown this trend in rhytidectomies with males demonstrating higher rates (11.7% to 12.9%) than females (3.9% to 4.2%).5,15 Males are also more susceptible towards hematoma formation in body contouring surgery. Chong et al examined 418 patients undergoing body contouring after weight loss of which 48 were males, and found male gender to be associated with a 14.6% incidence of postoperative hematoma compared to 3.5% in females.38 In another cohort of 129,007 patients where 0.91% (1180 patients) developed a major hematoma, male gender was noted to be an independent predictor for hematoma formation with the highest relative risk at 1.98 (P < 0.01)46 (Table 4). Table 4. Risk Factors for Hematoma Development in Aesthetic Surgery Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  View Large Table 4. Risk Factors for Hematoma Development in Aesthetic Surgery Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  Risk factor  Relative risk  95% CI  P-value  Age  1.011  1.007-1.016  <0.01  Body mass index  1.01  0.99-1.02  0.33  Breast procedures  1.81  1.58-2.07  <0.01  Combined procedures  1.35  1.20-1.52  <0.01  Diabetes mellitus  1.31  0.90-1.91  0.16  Hospital or ASC-based procedures  1.68  1.37-2.04  <0.01  Male gender  1.98  1.62-2.41  <0.01  Smoking  1.12  0.91-1.36  0.29  View Large Body Mass Index The impact of patient’s body mass index (BMI) has been investigated in various aesthetic procedures.47 Numerous studies have examined complications associated with aesthetic surgery, of which hematomas represent a significant percentage. In a study of 31,010 cosmetic liposuction procedures, Kaoutzanis et al demonstrated BMI > 25 kg/m2 to be an independent predictor of major complications.48 Similarly, Nguyen et al evaluated 2294 patients undergoing brachioplasty, and found BMI ≥ 30 kg/m2 to be a significant risk factor for the occurrence of complications with a relative risk of 1.92.33 In a recent meta-analysis looking at the impact of obesity on complications after reduction mammaplasty, 26 studies were identified exploring the association between surgical complications and body weight; 11 of these studies found obesity not to be a risk factor, whereas 15 studies showed an increase in surgical risk with higher BMIs.49 Their pooled risk for overall complications increased with an increase in BMI, and was 1.71 for BMI > 35 kg/m2 and 2.05 for BMI > 40 kg/m2. Abboushi et al also found a BMI > 25 kg/m2 to be a significant (P = 0.024) risk factor for developing postoperative hematoma after facelifts.15 Furthermore, in a review of major postoperative hematoma formation in 129,007 patients undergoing cosmetic surgery, the authors found a BMI ≥ 40 kg/m2 to have a higher incidence of hematomas.46 Hypertension Hypertension has been well established as a risk factor for hematomas in facelifts.50 Several studies have looked into blood pressure monitoring intraoperatively and in the postoperative period. Grover et al found a systolic pressure of greater than 150 mmHg to be a significant independent risk factor (P = 0.02) for postoperative hematoma with a relative risk of 3.6.5 The authors recommended blood pressure control to lower the hematoma rates, with continuing medications taken the day of surgery. They also recommended ensuring adequate analgesia and sedation with agents such as benzodiazepine to reduce the effects of reactive hypertension. Similarly, in a rhytidectomy series by Abboushi et al, patients with a history of hypertension had a hematoma rate of 8.2% compared to 3.5% in patients with no prior history, making history of hypertension a significant risk factor.15 In order to control the incidence of postoperative hematoma, Berner et al recommended timely administration of chlorpromazine in order to keep reactive hypertension in check.51 In a more recent study of 1089 patients undergoing rhytidectomy, Ramanadham et al implemented a preoperative routine involving transdermal clonidine with a target systolic blood pressure of less than 140 mmHg.52 The effects of hypertension on postoperative hematoma has also been looked at in body contouring surgery. Farkas et al examined patients receiving perioperative lovenox who developed hematoma after excisional body contouring surgery.53 The mean MAP for the last 2 hours of each case was significantly lower in the hematoma group (66.7 mm Hg vs 82.4 mm Hg; P < 0.0001), and a higher mean postoperative MAP reached significance in the hematoma group (96.3 mm Hg vs 88.5 mm Hg; P = 0.05). Both the difference between intraoperative and preoperative blood pressure (30.7 mm Hg vs 13.4 mm Hg; P < 0.0001) and between intraoperative and postoperative blood pressure (29.6 mm Hg vs 7.0 mm Hg; P < 0.0001) were increased in the hematoma group vs the nonhematoma group. Medications Many medications, including supplements taken by patients, have been identified as significant risk factors for bleeding and postoperative hematoma. In the study by Abboushi et al, on multivariate analysis, aspirin use was found to be an independent predictive factor for formation of postoperative hematomas (P = 0.028).15 In fact, in that study, while all patients stopped aspirin a week prior to surgery, the overall incidence of postoperative complications was significantly higher for patients who took aspirin regularly preoperatively compared to those who did not (27.2% vs 5.2%). In another study by Grover et al, multivariate analysis revealed aspirin or nonsteroidal anti-inflammatory drug (NSAID) intake to be associated with postoperative hematoma after rhytidectomy with a relative risk of 2.3 (P = 0.043).5 Nine of the 14 patients that had a history of aspirin or NSAID use and developed a postoperative hematoma, reported discontinuing the medications less than 2 weeks prior to surgery. On the contrary, of the 31 patients with a history of aspirin and NSAID intake who did not develop postoperative hematoma, 26 had discontinued the medication more than 2 weeks prior to surgery. As a result, the authors stressed the importance of discontinuing aspirin and NSAID intake at least 2 weeks prior to surgery to lower the incidence of hematoma formation. The use of other medications, such as antidepressants, have also been studied given their influence on hemostasis and bleeding risks.54 In a study of 250 patients undergoing facelift surgery, it was reported that the total hematoma rate was 1.95% for selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) users compared to 1.72% for SSRI/SNRI users.55 The authors concluded that there was no strong evidence to recommend discontinuing SSRI use perioperatively. In another study looking at SSRI use in cosmetic breast surgery, Basile et al examined 2285 patients who were divided into a no-use group and active-use group.56 Of the 196 patients in the active-use group, 4.59% (9 patients) had a bleeding event while only 1.15% (24 patients) had a bleeding event in the no-use group (2089 patients). Patients using SSRIs had a significantly higher rate of hematomas needing intervention with an odds ratio of 4.14. Further, logistic regression analysis showed that regardless of the type of procedure, body mass index, or patient age group, bleeding events were more common among SSRI users. They advocated discontinuing SSRI use 2 weeks prior to surgery and resuming 2 weeks after based on the drug pharmacology and its interactions with platelets. They emphasized the need to consider appropriate options with the patient and psychiatrist to ensure patient safety during and after cosmetic procedures. The plastic surgeon needs to be on contact with the patient’s psychiatrist or prescriber of these medications, but more importantly needs to have a preoperative discussion with the patient regarding their greater potential for postoperative complications.57 By better preparing patients for the physical and emotional stress a surgery puts them through, hospital admissions and emergency room visits may be reduced among this most vulnerable group. Type of Facility As more procedures and surgeries are being done outside a hospital setting in ambulatory surgery centers and office-based settings, there has been growing interest in the safety of such settings. In a study of over 129,000 patients undergoing aesthetic surgery low hematoma rates in office-based settings (0.6%) and surgical centers (1.0%) were reported.46 The authors do note that appropriate surgeon training and certification and patient selection for office-based settings and surgical centers may be reflected in the lower rates. Byrd et al supported this finding for over 5300 cases performed by board certified surgeons in accredited outpatient surgical facilities.58 In their cohort of cases that included procedures across the body, 35 (0.7%) required return to the operating room with hematoma being the most common in 27 cases. They stress that low complication rates are possible in outpatient settings however it involves prioritizing patient safety through up to date equipment, thorough physical exams and preoperative evaluations, adequately trained staff, and individualized patient care. As Gupta et al emphasize in their study, where they found a lower risk of developing a complication in an office-based suite compared to an ambulatory surgery center (RR = 0.67, 95% P < 0.01) or a hospital (RR = 0.59, P < 0.01), office-based settings can be safe alternatives to perform aesthetic surgery however the onus is on the plastic surgeon to carefully evaluate the patient on variables such as ASA class and medical comorbidities.59 Thus, while outpatient settings can be safe for cosmetic procedures and surgeries, thorough preoperative evaluation and patient selection is important in determining the appropriate facility for the patient and critical in lowering hematoma and complication rates. Combined Procedures There appears to be an increased rate of hematomas in patients undergoing combined procedures. In the large retrospective study combined procedures were found to be an independent risk factor for hematoma (RR = 1.35, P < 0.01).46 The authors suggest a plausible reason for this to be increased operative times leading to possible surgeon fatigue. An overwhelming increase in hematoma formation was found by Nguyen et al, looking at 2294 patients undergoing brachioplasty.33 Combined procedures had a relative risk of 12.42 in increasing the risk of hematoma formation in that study. Other studies have also found increased complication rates with combining procedures for facelifts and abdominoplasties.14,37 Care must be taken by the surgeon to ensure patients are aware of increased risk with additional procedures and it may be prudent to stage a patient’s surgeries to achieve a their aesthetic goals while minimizing complication rates. PERIOPERATIVE PREVENTION MEASURES A variety of techniques have been described and continue to be widely used to prevent hematoma formation in the perioperative period for aesthetic surgery. Depending on the procedure or procedures being performed and their anatomic locations, different preventive techniques are utilized. Drains are used in the head and neck, the breasts, the extremities, and the abdomen/body. Tissue sealants have gained significant popularity, particularly in conjunction with a rhytidectomy. Proper perioperative venous thromboprophylaxis is essential for any surgery, including aesthetic surgery, and understanding its role in hematoma formation is crucial. Lastly, the use of perioperative compression in prevention of hematoma formation continues to play a vital role for various aesthetic procedures. Hematoma is one of the most common complications in patients undergoing a rhytidectomy, with incidences up to 9%, which may require surgical evacuation.13-18 Previous studies showed several possible risk factors including high BMI, hypertension, perioperative nausea/vomiting, and heparin prophylaxis.15,47 As described above, male patients experience this complication almost three times more than female patients. This difference may be related to hormonal factors, facial follicle differences, and thicker or more vascularized facial flaps, which are prominent in males. In head and neck aesthetic surgery, the lack of major hematomas and low rate of minor hematomas is aided by meticulous hemostasis and careful placement of pressure dressings. Fibrin glue is not a replacement for meticulous hemostasis. In a previous review of the use of tissue glue without drains in short scar facelift, the authors experienced small fluid collections requiring aspiration, but no major hematomas were observed.60 Perkins et al did not find a significant difference in hematoma rates in 222 patients who underwent facelift surgery with or without the placement of drains.61 Another retrospective study also found that drainage alone does not reduce the incidence of postoperative hematomas.7 Their study included 50 patients undergoing rhytidectomy, and involved drain placement on one side of the face with the other nondrain side serving as each patient’s own control. The results showed no difference in postoperative complications between the two sides of the face including hematoma, seroma, or edema; however, there was found to be a significant reduction in ecchymosis on the side where a drain was placed.7 Drain placement can be undesirable for both the surgeon and the patient. For the patient, it is unsightly and may necessitate an extra incision in addition to causing more pain. Drains often malfunction by plugging, leaking, and slipping out. However, many surgeons are uncomfortable with the omission of drains despite the evidence that they do not prevent hematoma formation. It has also been described that a preoperative blood pressure over 150/100 mmHg was associated with a 2.6-fold greater incidence of hematoma.17 Maintaining a normal or slightly low blood pressure in the perioperative period is essential for hematoma prevention during rhytidectomy. Tissue sealants appear to be effective in preventing hematoma occurrence and reducing the amount of postoperative drainage in patients undergoing rhytidectomy independent of the technique used, as shown in a recent meta-analysis.62 However, the use of tissue sealant did not significantly prevent the incidence of ecchymosis, seroma, skin necrosis, or hypertrophic scarring. Fibrin sealants were beneficial independent of the dissection amount and plane used. Moreover, for deeper plane techniques, fibrin sealants may improve superficial muscular aponeurotic system (SMAS) fixation after repositioning with sutures, thus reducing the overall tension. A previous meta-analysis on this topic, including only prospective randomized studies, failed to show significant benefits, but it reported a trend towards diminished postoperative drainage and ecchymosis.63 More recently, another meta-analysis including seven trials demonstrated a significant reduction of hematoma incidence with the use of fibrin glue.64 While these meta-analyses provide good evidence that tissue sealants reduce hematoma formation during rhytidectomy, they are limited by confounding elements, such as patients’ age, the plane of dissection, the type of sealant used, and control treatment. Hence, it can be concluded that the current scientific evidence on the benefit of tissue sealants is still limited and inconsistent, and bias effect should be considered. Tissue sealants comprise two natural materials, thrombin and fibrinogen, forming the final common pathway of the coagulation cascade. However, as several products are available in the market, a major limitation of these studies is due to the heterogeneity and variety of the tissue sealants used. In general, tissue sealants can be divided into several subgroups: fibrin glue products (Artiss, Tisseel, Evicel, Beriplast P), thrombin and gelatin matrix compounds (Floseal, Surgiflo), bovine serum albumin and glutaraldehyde mixes (BSAG, BioGlue), polyethylene glycol hydrogels (DuraSeal), and even starch powder (4DryField, Perclot). Cost and usage of these products is extremely variable making definitive conclusions difficult. However, there are enough data to support the use of perioperative tissue sealants to reduce hematoma incidence during rhytidectomy. Compression dressings are another method of hematoma prevention commonly employed after facelift surgery; however, there exists wide variation in clinical practice in terms of dressing composition, tightness, and duration of use, making evidence-based evaluation difficult. In Jones’ series of over 900 patients undergoing rhytidectomy, the rate of hematoma formation with and without the use of postoperative compression dressings was around 4%; however, the presence of other potentially confounding factors precludes independent analysis.7 The authors also mention that tight, restrictive dressings may be uncomfortable and compromise skin flap circulation, and should therefore be avoided. Interestingly, they also looked at the application of tumescent solution prepared with and without epinephrine. Although the use of tumescent infiltration itself did not impact the incidence of postoperative complications, results demonstrated a significant reduction in hematoma rate with the omission of epinephrine from the injection solution. The authors proposed that its vasoconstrictive effects, while serving to enhance intraoperative hemostasis and facilitate dissection, may mask smaller bleeding vessels that can contribute to postoperative hematoma formation. Additional factors purported to increase the risk of hematoma are postoperative hypertension, pain and agitation, and the incidence of nausea and vomiting. Interestingly, in the review by Zoumalan and Rizk, almost one third of hematomas occurred in patients with postoperative emesis.16 Because most hematomas develop within the first 24 hours of surgery, optimizing overall patient management during this time period would seem of critical importance to ensuring a favorable surgical outcome. With this in mind, Beer et al sought to evaluate the impact of these medical and physiologic factors on the incidence of hematoma formation after facelift surgery by reviewing a series of patients treated in two distinct postoperative environments.13 The first group received medications upon request or in a “reactionary” fashion after surgery, whereas the second group was administered several pharmacologic interventions prophylactically. These included analgesics, sedatives, antihypertensives, and antiemetics while all other variables were held constant. The authors ultimately found a significant reduction in hematoma rate for the group receiving medications in a prophylactic manner, emphasizing the importance of controlling these parameters in the early postoperative setting. The use of drains in aesthetic breast surgery is controversial. However, the location of implant placement and dissection technique is an important consideration in hematoma formation. In a series reported by Araco et al, there was a fivefold increase in the risk of infection after augmentation mammaplasty if drains had been used.65 In their study of over 3000 patients, hematomas were found in 46 patients (1.5%), which is consistent with the literature. Most patients who experienced hematomas had received a submuscular placement, using both classic and dual-plane approaches (34 patients, 74%) and less the subglandular approach (12 patients, 26%). Pocket creation was performed using the manual technique for 26 patients (56.5%) and diathermy for 20 patients (43.5%). There was no particular distribution for implant size, drains, or antibiotics used to wash pockets. Their univariate analysis showed a significant association of hematomas with the submuscular/dual-plane approach and the manual type of pocket creation. No association between hematomas and capsular contractures was found at either the univariate or the multivariate analysis. Compression garments or surgical bras were recommended to reduce the incidence of seroma and hematoma formation, as well as provide perioperative support of the prostheses. Abdominoplasty and body contouring procedures continue to have significant complication rates. Part of the perioperative patient assessment is their risk of potential venous thromboembolism (VTE), specifically when performing an abdominoplasty as this procedure carries a high risk for VTE. In addition to the increase of intra-abdominal pressure caused by different maneuvers used to correct myoaponeurotic laxity, there is also the effect of abdominal flap traction, which can be transferred to the abdominal cavity. Therefore, there is possibly some interference in the venous drainage of the lower limbs and pelvis after the procedure. In a recent study, the use of enoxaparin demonstrated a trend toward decreased rates of venous thromboembolism when used in patients at highest risk under the revised Davison-Caprini risk-assessment model.66 Circumferential abdominoplasty patients who received enoxaparin had a statistically significant decrease in VTE events. However, perioperative enoxaparin administration was associated with an increased rate of hematoma and postoperative bleeding requiring transfusion. It was suggested that patients in the highest risk group, and any patient undergoing circumferential abdominoplasty, be given perioperative chemoprophylaxis with a low-molecular-weight heparin. Plastic surgeons should also use discretion in considering other patients for low-molecular-weight heparin chemoprophylaxis, such as patients in the high-risk group, those who are obese (body mass index > 30), those on over-the-counter progesterone/hormone replacement therapy, and perhaps patients undergoing abdominoplasty combined with other procedures. The risk of VTE should be balanced against the increased risk for bleeding with the use of low-molecular-weight heparin, keeping in mind that bleeding is an expected, manageable complication, whereas pulmonary embolism can be a fatal and unacceptable sequela in the setting of elective surgery. Prevention of VTE and its role in possible hematoma formation after aesthetic surgery is a critical relationship the plastic surgeon must be cognizant of. In a recent meta-analysis comparing operative techniques and hematoma formation no statistical difference was identified in patients undergoing a “conventional” abdominoplasty vs various preventative techniques.67 These preventative measures included the use progressive tension sutures, Scarpa’s fascia preservation, and use of tissue sealants or abdominal flap dissection method. Consequently, the odds of seroma in patients undergoing abdominoplasty using one of the surgical prevention measures were, on average, four times lower than for those receiving conventional abdominoplasty. Subgroup analysis was performed to analyze the effect of each method on seroma rate. Scarpa’s fascial preservation and tissue sealants both showed a statistical advantage in seroma rates and borderline differences for the use of progressive tension sutures were detected. No difference between methods of abdominal flap dissection was revealed. However, these methods did not impact hematoma prevention or formation. The use of compression after abdominoplasty or other body contouring procedures is almost universal. Compression garments are used to reduce seroma formation, promote flap adherence, and minimize hematoma risk. However, compression garments must be used with some caution after abdominoplasty because their use can contribute to a higher intra-abdominal pressure and subsequent VTE incidence.66 Compression garments are still widely used and recommended after abdominoplasty and body contouring procedures.67 POSTOPERATIVE DIAGNOSIS An analysis of a prospective, multicenter, national database examined the incidence of major hematomas following cosmetic surgical procedures in 129,007 patients, and found the overall incidence of major hematomas to be 0.91% (Table 5).46 Despite its low incidence, hematoma was still the most commonly observed major complication in the database and needs to be in the back of every plastic surgeon’s mind. The diagnosis of and urgent treatment of major hematomas after aesthetic surgery is critical to superior patient care and ultimate patient satisfaction. Clinical evaluation and diagnosis is the mainstay of major postoperative hematoma management, and cannot be replaced by any imaging modality. While some subclinical or minor hematomas may be detected by ultrasound or computed tomography, patient assessment and clinical judgement are at the core of diagnosing a patient with a major postoperative hematoma. The vast majority of major postoperative hematomas occur within the first 48 hours after surgery, so during this time period is when clinical suspicion should be at its peak.46 While there is no standardization of return visits after surgery, many surgeons will evaluate their patients after aesthetic surgery within the first 24 to 48 hours, either as an outpatient or in a hospital setting, to ensure proper patient care. Table 5. Hematoma Incidence in Aesthetic Surgery Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  View Large Table 5. Hematoma Incidence in Aesthetic Surgery Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  Procedure  Procedure performed  Hematoma incidence, N (%)  Face       Blepharoplasty  4879  9 (0.2%)   Brow lift  441  2 (0.5%)   Cheek implants  33  0 (0%)   Chin augmentation  157  1 (0.6%)   Rhinoplasty  3608  5 (0.1%)   Rhytidectomy  4809  50 (1.0%)  Breast       Breast augmentation  41651  422 (1.0%)    Male breast surgery  2498  44 (1.8%)   Mastopexy  3383  22 (0.6%)   Reduction mammaplasty  3288  27 (0.8%)  Body       Abdominoplasty  8975  96 (1.1%)   Brachioplasty  762  1 (0.1%)   Buttock lift  407  3 (0.7%)   Liposuction  11490  17 (0.1%)   Lower body lift  426  17 (4.0%)   Thigh lift  405  8 (2.0%)  View Large TREATMENT After the diagnosis of hematoma has been made, the gold standard of treatment is evacuation. This can be accomplished in the operating room, in the outpatient clinic, or a variety of other locations depending on the presentation and severity of the hematoma. Postoperative hematomas can be classified as either minor or major. The smaller collections generally do not compromise skin flap viability in the case of a rhytidectomy and are difficult to identify at all in other aesthetic procedure. These collections can usually be treated with simple needle aspiration, which may need to be repeated. These minor hematomas tend to resolve without significant morbidity to the patient. Major hematomas are much more urgent and clinically relevant. The true treatment for postoperative major hematomas is prevention at the time of the initial surgery. In the event of a major postoperative hematoma immediate treatment is essential. As the hematoma expands it can produce tissue destruction and impact flap viability. In extreme cases in the head and neck expanding hematomas can even result in airway compromise. A witnessed postoperative hematoma can be initially treated with aspiration and pressure, but if this does not resolve the bleeding the incisions must be opened and the surgical sites explored. More commonly, hematomas are insidious and progress more slowly. They typically present within the first 24 to 48 hours after surgery. After a rhytidectomy, hematomas frequently manifest as severe, unilateral stabbing facial pain. Occasionally, patients are unable to place their teeth in occlusion because of buccal swelling. After breast and body procedures hematoma presentation can be more subtle, but the hallmark features of any hematoma is swelling and pain. Distinguishing normal postoperative pain and an underlying hematoma relies upon the clinical evaluation and acumen of the surgeon. The patient should be evaluated in the clinic or in the hospital setting, and if the hematoma in clinically significant and warrants evacuation the surgeon has several options. Percutaneous aspiration can be attempted either by the surgeon or interventionalists if they are available. The success of aspiration depends on the type of surgery the patient had, the accessibility of the hematoma, and the chronicity of the collection. Obviously, the larger-bore needles will make aspiration easier and more successful. If the hematoma cannot be aspirated then the incision should be opened and the hematoma evacuated in a controlled setting where patient comfort and care is paramount. Whether this occurs in the operating room or as a procedure in the clinic again depends on what is best for the patient and what the surgeon feels would be the most effective. Regardless of the location, the incision(s) should be partially or completely opened, the hematoma evacuated, and the surgical site thoroughly inspected for signs of bleeding. The site should be copiously irrigated after ensuring hemostasis, a drain may or may not be left depending on surgeon preference, and the incision reclosed. The patient should be closely monitored either in the hospital setting or with a return visit to the clinic the following day. ASSOCIATED COMPLICATIONS Complications that arise as a result of hematoma formation and the subsequent treatment vary depending on the type of surgery and the severity. Hematoma development can be associated with increased wound healing problems. The most feared of all complication after rhytidectomy is flap necrosis and skin sloughing, with a reported incidence of 0 to 3%.68 Flap necrosis results from vascular compromise in the forms of decreased arterial perfusion, venous congestion, or small vessel disease. Hematoma is a major risk factor for the development of these postoperative changes to the skin flaps. Even if flap necrosis does not occur, hematomas can lead to prolonged facial edema and skin necrosis after rhytidectomy. Hematoma development after aesthetic breast surgery can also result in a variety of negative long-term sequelae. Wound healing issues and flap compromise can also occur in aesthetic breast surgery after hematoma formation. This complication could potentially lead to implant exposure and subsequent loss. Hematomas are significantly associated with the development of capsular contracture and chronic seromas after aesthetic breast surgery.69 Although the cause of capsular contracture continues to be examined, the results of a large prospective clinical study indicate that implant placement (submuscular/subglandular), implant surface (smooth/textured), incision site, hematoma/seroma development, device size, and surgical bra appear to play important roles. As our knowledge of capsular contracture risk factors grows, as well as its link to implant-associated anaplastic large cell lymphoma, the plastic surgeon must be aware how hematoma formation plays a role. As previously stated, submuscular implant placement has a higher hematoma incidence compared with the subglandular position.46 If the surgeon attempts to mitigate the risk of capsular contracture by choosing to place the implant in the submuscular plane, he/she must be more vigilant with hemostasis to prevent hematoma formation. Revisionary surgery, while not always described as complication, can be associated with hematoma formation and treatment. Whether the patient experienced wound dehiscence or healing problems, seroma development, a chronic infection, capsular contracture of an implant, or skin/flap loss, these problems arise from hematoma formation and frequently require revisionary surgery. To deliver the best patient satisfaction and care, complications must be acknowledged and addressed. CONCLUSIONS A review of the literature revealed a wide range of hematoma rates for some of the most frequently performed aesthetic surgeries. Major hematoma was found to be the most common complication after cosmetic surgical procedures, although the overall incidence was low at 0.91%. Identifying the risk factors for hematoma development and taking appropriate steps to prevent their occurrence are vital to providing the best care to the aesthetic patient. Despite the infrequency with which they occur, diagnosing and properly managing a postoperative hematoma must be second nature to a plastic surgeon. Even after the initial treatment, the short and long term sequelae of a hematoma must also be identified and managed. A thorough knowledge of risk factors for the most commonly encountered major complications following aesthetic surgical procedures allows providers to better educate patients, be more cognizant of high-risk patients and provide overall better patient care. 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. Footnotes American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. REFERENCES 1. Gusenoff JA, Coon D, Rubin JP. 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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)

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Aesthetic Surgery JournalOxford University Press

Published: Feb 21, 2018

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