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BACKGROUND: One of the newest subspecialties in plastic surgery has emerged over the past ten years with the advent of bariatric surgery and the ensuing massive weight loss. Post-bariatric body contouring has rapidly become a routine part of many plastic surgeons’ practices. In contrast to other cosmetic plastic surgery patients, the risk of DVT is much higher with a rate reported as high as 9%. This has forced plastic surgeons to rethink their DVT prevention strategies for truncal contouring procedures and consider chemoprophylaxis in addition to the standard mechanical prophylaxis with pneumatic compression devices. Since perioperative deep vein thrombosis likely begins at the time of the operation, one strategy for DVT prevention in the highest risk patients is to give preoperative low dose unfractionated heparin (LDUH, 5000 Units). Postoperative LDUH or low molecular weight heparin (LMWH) can likewise provide some protective benefits in VTE prevention while the patient is relatively immobile. However, risk of bleeding has prevented some plastic surgeons from using LDUH or LMWH chemoprophylaxis perioperatively. We review our incidence of bleeding and thrombosis in patients undergoing truncal contouring receiving perioperative heparin.
METHODS: Retrospective review of a single surgeon’s practice was performed to identify patients who had a truncal contouring procedure including panniculectomy, abdominoplasty, or lower body lift from July 2008-December 2010 and who received perioperative heparin. Perioperative DVT prevention methods were recorded along with postoperative complications of thromboembolism and bleeding.
RESULTS: Eighty patients with an average age of 45 (range 19-69) had an abdominoplasty or panniculectomy procedure with perioperative heparin prophylaxis. Sixty-eight patients received preoperative LDUH and postoperative LDUH or LMWH and twelve patients received only postoperative heparin. A fleur-de-lys pattern was used in 23 (29%) and liposuction was performed in 53 (66%). Fifty-six (70%) patients had massive weight loss. Combined procedures were performed in 60 (75%) patients including hernia repair (20), buttock lift (12), medial thigh lift (12), brachioplasty (11), augmentation mastopexy (10), mastopexy (4), breast reduction (10), excision of gynecomastia (4), total abdominal hysterectomy (4), rectocele repair (1), implant exchange (1), and nipple reconstruction (1). The average operative time was 5 hours (range 1h 55min-11h 15min). The highest risk patients were sent home on 5 days of Lovenox 40mg once daily. Complications included one episode of bleeding (1/80) on POD#3 requiring reoperation in a patient with a complex medical history and active drug abuse that was not known at the time of surgery. There were no clinically detected DVTs. There was one superficial thrombosis in a varicose vein.
CONCLUSIONS: Venous thromboembolism is a devastating complication, which is important to consider in patients undergoing truncal contouring. Perioperative chemoprophylaxis with unfractionated heparin does not appear to significantly increase the incidence of reoperation for bleeding compared to abdominoplasty series in the literature that do not use heparin. Larger studies are warranted to validate this data and determine the optimum duration of chemoprophylaxis.