Aesth Plast Surg (2014) 38:25–26 DOI 10.1007/s00266-013-0229-7
EDITOR’S INVITED COMMENTARY
AESTHETIC
Commentary on ‘‘Venous Thromboembolism After Face-Lift Surgery Using Local Anesthesia: Results of a Multicenter Survey’’ Foad Nahai
Received: 20 September 2013 / Accepted: 23 September 2013 / Published online: 23 October 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. When asked to review and write a commentary on this article, I readily accepted. Having written on patient safety [1] and the risk of venous thromboembolism (VTE) in facial rejuvenation [2, 3], I immediately began my review in anticipation of new information. The literature on the topic is rather scant, and any new information will improve safety for those undergoing facial rejuvenation. After my first read through, I felt the article had very little new information but rather affirmation of known information. I read and reread the paper, each time confirming my initial impression that the paper, although adding very little if anything new, merited publication and discussion of this serious and important issue. Although our discussions of VTE have almost always focused on abdominoplasty, body contouring after massive weight loss, and combined lengthy procedures as the techniques most commonly associated with VTE, facelifts, especially face-lifts combined with other procedures, have been second in incidence only to abdominoplasty [4]. Before I discuss in detail the confirmatory data presented, I evaluate the methodology of the reported survey. This was ‘‘an anonymous online-based survey through survey monkey,’’ and ‘‘the survey was kept as brief as possible in order to maximize participation and survey completion.’’ A total of 24 questions were asked. Regrettably, the questionnaire is not reproduced in the article. F. Nahai (&) Emory Aesthtric Center, Atlanta, GA, USA e-mail: [email protected]
Although a large number of patients from multiple centers were included, the method of data collection renders the study an EBM level 4 investigation. Did the respondents conduct a chart review before responding to the survey, or did they reply based on their recollection? The article does not mention how the respondents collected their data. The report by Reinsch et al. [5] also described a retrospective survey through a questionnaire, whereas the report by Abboushi et al. [3], although retrospective, was based on a chart review. Although the methodology was not flawless, the conclusions confirmed previously published data [4, 6, 7], showing that the risk of VTE is lower with the patient under local, regional, or epidural anesthesia; that the shorter the procedure, the lower the risk; and that combined procedures increase the risk. They also confirmed that more experienced surgeons perform a similar procedure in less time. The authors do not comment on whether the patients underwent any VTE risk assessment, and the VTE prophylaxis was neither universal nor standardized in this series. Of the surgeons surveyed, 15 % reported occasional use of thromboembolic disease (TED) hose and/or intermittent compression devices (ICDs), 4 % reported frequent use of TED hose and/or ICD, and 81 % reported that they never use either. In the series reported by Reinsch et al. [5] 19.7 % of the surgeons reported using ICDs, 19.6 % reported using TED hose or ace wraps, and 60.7 % reported using no prophylaxis. They also reported that prophylaxis with a sequential compression device was associated with a significantly lower incidence of thromboembolic complications and that ace wraps and TED hose afforded no protection. In the Abboushi et al. [3] series, all the patients had VTE prophylaxis with an ICD. Without preoperative Caprini
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risk assessments and reports of significant differences in VTE prophylaxis, comparison of these three studies is neither possible nor valid. Nevertheless, enough evidence is provided to support the observation that shorter procedures using local anesthesia carry a lower risk. With no preoperative risk assessment, the question arises whether patients suitable for outpatient facial rejuvenation under local anesthesia are preselected as low-risk individuals. The authors further emphasize that the surgeons reporting the largest number of procedures during the study period were the more experienced surgeons. They had shorter operative times and the lowest incidences of VTE. Although we accept that a shorter procedure reduces risk, we wonder whether more experienced surgeons also exercise more discretion in selecting patients for outpatient face-lifts using local anesthesia. The authors point out that no combined or additional procedures were performed in their series. This is an important and critical observation that must be emphasized because it confirms previous reports. The large series based on American Association for Accreditation of Ambulatory Surgical Facilities data demonstrated that the largest number of reported VTEs was seen with abdominoplasty, a combination of abdominoplasty and other procedures, and face-lift combined with other procedures. Both patients with DVT in the Abboushi et al. [3] series underwent additional procedures. The lower VTE risk with local anesthesia is not the only advantage, although this is not discussed by the authors. Local anesthesia offers a significant cost savings compared with general anesthesia. Typically, the surgeon or a nurse who has supervision of the patient administers sedation and monitors the patient. This results in a significant saving compared with the cost of having an anesthetist or anesthesiologist in the room to administer sedation or full anesthesia. Whereas local anesthesia and sedation for relatively short procedures may work well for most patients and surgeons, it may not be the case for prolonged procedures. Despite adequate sedation, after awhile some patients may become restless and may wish to stretch their limbs or turn their neck. They may even complain about a full bladder!
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Aesth Plast Surg (2014) 38:25–26
A surgeon whose patient is restless and wants to move and stretch has the difficult choice of accelerating the pace of the operation and compromising the result or not responding to the patient’s concerns, a choice the surgeon would not face with general anesthesia. Despite the limitations of this article, especially the methodology of the data collection, I commend the authors for sharing the results of this very large series of patients and focusing our attention on the important issue of VTE after face-lifts. As evidenced by their report and those by Reinsch et al. [5] and Abboushi et al. [3], no uniformity or consensus exists as to the type or even the need for VTE prophylaxis. Many questions remain. Should a Caprini score be assigned to each and every patient undergoing a face-lift? If chemoprophylaxis is indicated by that score, should it be undertaken? Will the risk of hematoma outweigh the real, albeit small, risk of VTE? More studies are needed to answer these questions. In the meantime, enough evidence exists to advocate sound judgment in the selection of patients, type of anesthesia, length of procedure, and combination of procedures.
References 1. Nahai F (2009) Minimizing risk in aesthetic surgery. Clin Risk 15:232–236 2. Nahai F (2008) Invited discussion: mortality in outpatient surgery. Plast Reconstr Surg 122:245 3. Abboushi N, Yezhelyev M, Symbas J, Nahai F (2012) Facelift complications and the risk of venous thromboembolism: a single center’s experience. Aesthet Surg J 32:413–420 4. Keyes GR, Singer R, Iverson RE et al (2008) Mortality in outpatient surgery. Plast Reconstr Surg 122:245–250 5. Reinsch JF, Bresnick SD, Walker JWT, Rosso RF (2001) Deep venous thrombosis and pulmonary embolus after facelift: a study of incidence and prophylaxis. Plast Reconstr Surg 107:1570–1577 6. Hafezi F, Naghibzadeh B, Nouhi AH, Salimi A, Naghibzadeh G, Mousavi SJ (2011) Epidural anesthesia as a thromboembolic prophylaxis modality in plastic surgery. Aesthet Surg J 31:821–824 7. Phillips BT, Wang ED, Rodman AJ et al (2012) Anesthesia duration as a marker for surgical complications in office-based plastic surgery. Ann Plast Surg 69:408–411
EDITOR’S INVITED COMMENTARY
AESTHETIC
Commentary on ‘‘Venous Thromboembolism After Face-Lift Surgery Using Local Anesthesia: Results of a Multicenter Survey’’ Foad Nahai
Received: 20 September 2013 / Accepted: 23 September 2013 / Published online: 23 October 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. When asked to review and write a commentary on this article, I readily accepted. Having written on patient safety [1] and the risk of venous thromboembolism (VTE) in facial rejuvenation [2, 3], I immediately began my review in anticipation of new information. The literature on the topic is rather scant, and any new information will improve safety for those undergoing facial rejuvenation. After my first read through, I felt the article had very little new information but rather affirmation of known information. I read and reread the paper, each time confirming my initial impression that the paper, although adding very little if anything new, merited publication and discussion of this serious and important issue. Although our discussions of VTE have almost always focused on abdominoplasty, body contouring after massive weight loss, and combined lengthy procedures as the techniques most commonly associated with VTE, facelifts, especially face-lifts combined with other procedures, have been second in incidence only to abdominoplasty [4]. Before I discuss in detail the confirmatory data presented, I evaluate the methodology of the reported survey. This was ‘‘an anonymous online-based survey through survey monkey,’’ and ‘‘the survey was kept as brief as possible in order to maximize participation and survey completion.’’ A total of 24 questions were asked. Regrettably, the questionnaire is not reproduced in the article. F. Nahai (&) Emory Aesthtric Center, Atlanta, GA, USA e-mail: [email protected]
Although a large number of patients from multiple centers were included, the method of data collection renders the study an EBM level 4 investigation. Did the respondents conduct a chart review before responding to the survey, or did they reply based on their recollection? The article does not mention how the respondents collected their data. The report by Reinsch et al. [5] also described a retrospective survey through a questionnaire, whereas the report by Abboushi et al. [3], although retrospective, was based on a chart review. Although the methodology was not flawless, the conclusions confirmed previously published data [4, 6, 7], showing that the risk of VTE is lower with the patient under local, regional, or epidural anesthesia; that the shorter the procedure, the lower the risk; and that combined procedures increase the risk. They also confirmed that more experienced surgeons perform a similar procedure in less time. The authors do not comment on whether the patients underwent any VTE risk assessment, and the VTE prophylaxis was neither universal nor standardized in this series. Of the surgeons surveyed, 15 % reported occasional use of thromboembolic disease (TED) hose and/or intermittent compression devices (ICDs), 4 % reported frequent use of TED hose and/or ICD, and 81 % reported that they never use either. In the series reported by Reinsch et al. [5] 19.7 % of the surgeons reported using ICDs, 19.6 % reported using TED hose or ace wraps, and 60.7 % reported using no prophylaxis. They also reported that prophylaxis with a sequential compression device was associated with a significantly lower incidence of thromboembolic complications and that ace wraps and TED hose afforded no protection. In the Abboushi et al. [3] series, all the patients had VTE prophylaxis with an ICD. Without preoperative Caprini
123
26
risk assessments and reports of significant differences in VTE prophylaxis, comparison of these three studies is neither possible nor valid. Nevertheless, enough evidence is provided to support the observation that shorter procedures using local anesthesia carry a lower risk. With no preoperative risk assessment, the question arises whether patients suitable for outpatient facial rejuvenation under local anesthesia are preselected as low-risk individuals. The authors further emphasize that the surgeons reporting the largest number of procedures during the study period were the more experienced surgeons. They had shorter operative times and the lowest incidences of VTE. Although we accept that a shorter procedure reduces risk, we wonder whether more experienced surgeons also exercise more discretion in selecting patients for outpatient face-lifts using local anesthesia. The authors point out that no combined or additional procedures were performed in their series. This is an important and critical observation that must be emphasized because it confirms previous reports. The large series based on American Association for Accreditation of Ambulatory Surgical Facilities data demonstrated that the largest number of reported VTEs was seen with abdominoplasty, a combination of abdominoplasty and other procedures, and face-lift combined with other procedures. Both patients with DVT in the Abboushi et al. [3] series underwent additional procedures. The lower VTE risk with local anesthesia is not the only advantage, although this is not discussed by the authors. Local anesthesia offers a significant cost savings compared with general anesthesia. Typically, the surgeon or a nurse who has supervision of the patient administers sedation and monitors the patient. This results in a significant saving compared with the cost of having an anesthetist or anesthesiologist in the room to administer sedation or full anesthesia. Whereas local anesthesia and sedation for relatively short procedures may work well for most patients and surgeons, it may not be the case for prolonged procedures. Despite adequate sedation, after awhile some patients may become restless and may wish to stretch their limbs or turn their neck. They may even complain about a full bladder!
123
Aesth Plast Surg (2014) 38:25–26
A surgeon whose patient is restless and wants to move and stretch has the difficult choice of accelerating the pace of the operation and compromising the result or not responding to the patient’s concerns, a choice the surgeon would not face with general anesthesia. Despite the limitations of this article, especially the methodology of the data collection, I commend the authors for sharing the results of this very large series of patients and focusing our attention on the important issue of VTE after face-lifts. As evidenced by their report and those by Reinsch et al. [5] and Abboushi et al. [3], no uniformity or consensus exists as to the type or even the need for VTE prophylaxis. Many questions remain. Should a Caprini score be assigned to each and every patient undergoing a face-lift? If chemoprophylaxis is indicated by that score, should it be undertaken? Will the risk of hematoma outweigh the real, albeit small, risk of VTE? More studies are needed to answer these questions. In the meantime, enough evidence exists to advocate sound judgment in the selection of patients, type of anesthesia, length of procedure, and combination of procedures.
References 1. Nahai F (2009) Minimizing risk in aesthetic surgery. Clin Risk 15:232–236 2. Nahai F (2008) Invited discussion: mortality in outpatient surgery. Plast Reconstr Surg 122:245 3. Abboushi N, Yezhelyev M, Symbas J, Nahai F (2012) Facelift complications and the risk of venous thromboembolism: a single center’s experience. Aesthet Surg J 32:413–420 4. Keyes GR, Singer R, Iverson RE et al (2008) Mortality in outpatient surgery. Plast Reconstr Surg 122:245–250 5. Reinsch JF, Bresnick SD, Walker JWT, Rosso RF (2001) Deep venous thrombosis and pulmonary embolus after facelift: a study of incidence and prophylaxis. Plast Reconstr Surg 107:1570–1577 6. Hafezi F, Naghibzadeh B, Nouhi AH, Salimi A, Naghibzadeh G, Mousavi SJ (2011) Epidural anesthesia as a thromboembolic prophylaxis modality in plastic surgery. Aesthet Surg J 31:821–824 7. Phillips BT, Wang ED, Rodman AJ et al (2012) Anesthesia duration as a marker for surgical complications in office-based plastic surgery. Ann Plast Surg 69:408–411
