The incidence of Venous Thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are undoubtedly increased by surgical procedures and these events can be life threatening.
Factors that increase risk include congenital or inherited blood clotting disorders, a family history, of DVT/PE, high BMI, previous medical conditions such as heart failure and inflammatory bowel disease and age.
In Aesthetic Surgery patients should also be aware that incidence is increased by prolonged bed rest and sitting for long periods postoperatively. Patients should only consider surgery when they are fit and well, weight stable and have given up smoking for 6 weeks. Preoperative assessment of patients has enabled clinicians to identify patients at high risk and in Mr Ross’s practice all patients undergo a preoperative assessment that includes an assessment of thromboembolic risk.
The treatments proposed to reduce DVT / PE risks include: –
- Non-pharmacological treatments include graduated compression stockings (GCS) and intermittent pneumatic compression (IPC) devices which are classified as Mechanical thromboprophylaxis devices
- Pharmacological agents
Although mechanical prophylaxis devices have been evaluated extensively in clinical studies, their efficacy in Venous Thromboembolic (VTE) prevention remains unclear. These studies have often failed to define exactly what device was used. Frequently the devices were used in combination with other prophylaxis methods, making it difficult to demonstrate their efficacy.
Mr. Ross does recommend the use of Mechanical thromboprophylaxis devices in his practice. Mr. Ross has never encountered a problem with a patient using these and believes that they do no harm. He accepts that there is limited evidence to support this practice and it is very rare for patients not to consent to having Mechanical thromboprophylaxis.
The recommended use of pharmacological venous chemoprophylaxis remains controversial. Dr Swanson who has written extensively on the prevention of venous chemoprophylaxis in plastic surgery has recently published his thoughts.
As Dr Swanson describes there may be an increased risk of bleeding for patients taking VTE prophylaxis and there is still a risk of developing a DVT / PE even in patients that take pharmacological agents. Mr Ross like Dr Swanson is concerned about the potential effect of bleeding in aesthetic and cosmetic surgery. Increased bruising and bleeding can lead to additional wound healing issues and complications. In aesthetic surgery where downtime is affected by increased bruising, patients need to weigh up this possible complication when opting to reduce the risk of DVT / PE by choosing pharmacological agents.
As Dr Swanson maintains the key to prevention is early mobilisation of patients postoperatively. This is a key aspect of Mr Ross’s practice and every patient is mobilised immediately after surgery. In patients that are unable to mobilise postoperatively Mr Ross recommends pharmacological agents until mobilising and in Mr Ross’ practice this is given on the evening following surgery.
Currently however in Mr Ross’s practice over 95% of patients have aesthetic surgery as day cases, 23hr or short stay surgery due to improved aesthetic surgery techniques that have allowed immediate postop mobilisation. It is extremely rare for patients not to be able to mobilise immediately.
The question for patients that are mobilising on the day of surgery is whether pharmacological agents are necessary. With no specific evidence to support this decision, patients need to weigh up the risks of the pros and cons of using pharmacological agents to reduce the risks of thromboembolism. Mr Ross visits all his patients postoperatively and for patients who are unsure whether to have pharmacological agents this decision can be made on the afternoon / evening of surgery.
Regardless of treatment method chosen by the patient all patients in Mr. Ross’s practice are advised regarding the need for mobilization and educated regarding VTE risk and the signs and symptoms of DVT/PE on discharge. Mr. Ross operates at a facility where patients can be seen 24/7 and can be investigated / treated as soon as possible.
Swanson E.A Rebuttal of Published Recommendations for Venous Thromboembolism Prophylaxis in Plastic Surgery. Plast Reconstr Surg. 2016 Nov;138(5):951e-952e.