Abdominoplasties and DVT Prophylaxis: “I Want It All, I Want It Now”
Deep Vein thrombus (DVT) is one of the most serious complications of abdominoplasty surgery. Plastic surgery as a speciality in general is afflicted with one of the highest incidence rates of thromboembolic events. Abdominoplasty procedures in particular are known to assimilate the greatest rates of DVT in plastic surgery. With an ever increasing number of procedures performed and rising commonality of DVT, it is now more important than ever to prevent the incidence of such complications.
Currently, major guidelines outlined by the American Society of Aesthetic Plastics Surgery (ASAPS), the American College of Chest Physicians (ACCP) and the Davison/Caprini scale advocate a risk stratification prophylaxis protocol. These risk assessment models (RAM) have proven to be useful in reducing DVT incidence in some cases. However, complete eradication is yet to be achieved. In this study we assess a new non-RAM surgical prophylaxis protocol aimed at eliminating abdominoplasty associated DVT.
Methods/Technique:
A retrospective clinical analysis of 1078 abdominoplasty cases completed over a 7-year period was performed.
All patients were enrolled onto an 8-point prophylaxis protocol with an inclusive holistic approach. A 4-week smoking, HRT and COC cessation period was imposed on all patients. In addition to which a maximum BMI score of 40 was required of all pre-operative patients. Participants were administered with compression stockings, flowtrons and enoxaparin (Clexane). Individuals with a DVT history were also required to be 1-year treatment free prior to surgery. Furthermore, the protocol necessitated post-operative deambulation of fit patients within 4 hours (figure 1).
Figure (1): 8-point DVT prophylaxis protocol
Part 1
- All patients taking HRT or COC must stop 4 weeks prior to surgery and only recommence 2 weeks postoperatively.
- All patients must stop smoking for 4 weeks prior to surgery
- All patients must have a BMI under 40 prior to surgery
- All patients with a previous history of DVT must be treatment free for over 1 year
Part 2
- Compressions socks fitted 1 hour preoperatively to all patients
- Intermittent Pneumatic Compression (flowtrons) devices applied to all patients throughout theatre
- 20mg of cleaxane to all patients with a BMI less than 30 – one dose pre and post-operatively
- 40mg of cleaxane to all patients with a BMI greater than 30 – one dose pre and post-operatively
- Ambulation within 4 hours postoperatively
*Patients with a BMI greater then 30 and/or patients who are unable to ambulate early have Intermittent Pneumatic Compression device fitted for an additional 12 hours
Surgical technique involved a transverse lower abdominal incision, wide undermining of the skin and subcutaneous tissue to the costal margins and 2 cm bellow the xiphoid appendix. Tightening of the abdominal musculature with correction of rectus muscle diastasis with Prolene 1 sutures was performed, followed by resection of redundant abdominal skin and subcutaneous tissue, umbilical repositioning according to Avelar’s technique before final skin closure. Liposuction was performed in the lateral regions of the abdomen and hips. Liposculpture was executed to improve the contouring result, but no liposculpture of the dorsum and/or abdominal flap or any other additional areas were performed in any of these cases. All Patients involved were operated on by the same surgical team under general anaesthesia. Post-operative DVT incidence was recorded in addition to other major complications.
Results/Complications:
Between 2007 and 2013 no incidence of DVT was recorded in all 1078 abdominoplasty surgery patients. In addition to which we incurred no incidence of haematoma amongst our cohort. Statistical analysis performed using the Chi squared test returned values indicative of significant association between the implementation of our protocol and DVT rates (p<0.001) Similar significant association was also found with haematoma incidence and the described protocol (p<0.001)
Conclusion:
In this study we performed a retrospective clinical analysis involving 1076 patients undergoing abdominoplasty surgery, using a new 8-point DVT prophylaxis protocol. This is the first non-criteria based inclusive protocol aimed at preventing abdominoplasty associated DVT. As a result, not a single incident of DVT was recorded over the seven-year period of this study. We therefore believe that a holistic and procedure specific approach to prophylaxis can eliminate the occurrence of DVT in abdominoplasty surgery.