Use of at-Home, Portable Sequential Compression Devices and Low Molecular Weight Heparin in Outpatient Abdominoplasty Patients
Body-contouring procedures, and specifically abdominoplasty, have a known higher incidence of venous thromboembolic events, which includes deep vein thrombosis (DVT) and pulmonary embolism(PE), compared to other plastic surgery procedures. While the true etiology is unknown, the increased risk is likely due to a combination of increased intra-abdominal pressure leading to venous dilatation and stasis as well as limited ambulation post-operatively. Sequential compression devices(SCDs) has been proven to be beneficial in preventing the formation of DVTs when used in the peri-operative period. Previous research shows that SCDs prevent DVT formation by preventing venous stasis. This is accomplished by mimicking the contraction of the calf muscles to limit venous stasis and venous dilatation. It also been shown that these devices can stimulate both local and systemic fibrinolytic activity. The American Association of Plastic surgeons recommend the use of SCDs in the peri-operative period.
There remains significant controversy over the recommendations regarding VTE prophylaxis for patients undergoing plastic surgery. The controversy arises due to a lack of generally accepted consensus regarding prophylaxis recommendations; continued concerns for post-operative bleeding and/or hematoma due to the wide operative dissection; as well as arguments about the lack of evidence specific to plastic surgery regarding the use of chemoprophylaxis. While the Caprini score is widely regarded as a template for risk assessment, there is also wide latitude on the treatment protocols for VTE prophylaxis. The trend towards performing these procedures on an outpatient basis causes more concern regarding how to properly prevent VTEs from occurring while the patient recovers at home.
The purpose of this study was to retrospectively analyze the utilization of a maximal prophylactic regimen that combines both low molecular weight heparin and at home, portable SCDs and demonstrate its safety and efficacy in preventing VTEs in abdominoplasty patients.
Methods/Technique
:A retrospective review of patient data was performed on all patients who underwent abdominoplasty over a 18 month period from March 2019, when the practice began using at-home SCDs, to September 2020 (n=34 patients). All abdominoplasty patients over this time period were provided at-home sequential compression devices to wear post-operatively for two weeks. They were also required to administer LMWH (Lovenox) to themselves beginning 24 hours after the procedure and continuing it for one week. Teaching regarding the use of both of these adjuncts was done at multiple time points by both the surgeon and clinical staff. The primary outcome analyzed was incidence of VTE and secondary outcome was incidence of hematoma formation.
Results/Complications
:Data analysis showed the average age of the patients was 44 years old (+/- 7.78 yrs) and their average BMI was 27.7 kg/m2(+/-4.5 kg/m2). The average preoperative Caprini risk score VTEs was 4 (+/- 1.2, max score of 7). There was 100% compliance based on discussions between the senior surgeon and the patients. Among this group of patients there was no clinically evident DVTs or PEs in any of the patients on the post-operative VTE prophylaxis regimen of LMWH and at-home SCD use. In addition, no patients developed post-operative bleeding complications or hematomas. One patient out of the thirty-four reviewed developed a seroma(2.9%).
Conclusion
:Venous thromboembolic events represent a serious post-operative morbidity, which can also extend to mortality. Due to the obvious concerns regarding VTEs there have been numerous studies looking at the ideal combination of both chemoprophylaxis and mechanical prophylaxis to prevent VTE in the post-surgical patient. Despite recommendations by the American Association of Plastic Surgeons and the American Society of Plastic Surgeons VTE Task Force, there has not been a standardized approach to both chemo- and mechanical prophylaxis in patients undergoing plastic surgery. This has mostly been due to concerns for bleeding and hematoma formation in the post-operative period, after leaving the operating room. In addition to concerns regarding hematomas, patients undergoing abdominoplasty surgery demonstrate a low incidence of DVT/PE which operationally translates to a low risk situation. This may be interpreted by some practitioners as acceptable risk and thus not necessitate prophylaxis.
The current retrospective review demonstrated that the post-operative use of LMWH did not cause any hematomas or bleeding complications and that the combination of LMWH and at-home SCDs led to a complete absence of clinically evident DVTs in this patient cohort. There was also a very small incidence of seroma formation in this patient cohort. For this reason, we believe that it is not only safe, but effective to use both LMWH and at-home portable SCDs on a more routine basis in plastic surgery patients. In addition, at-home portable SCDs could potentially be used as the singular modality for VTE prevention in patients with a high-risk of bleeding post-operatively.