Commentary on: An In-Depth Analysis of 1370 Consecutive Abdominoplasties: Fascial Plication Increases Risk of Venous Thromboembolism, and Scoring for Plication Improves the Caprini Risk Assessment Model
Year: 2024
Type: editorial
Abstract: See the Original Article here. In his article “An In-depth Analysis of 1370 Consecutive Abdominoplasties: Fascial Plication Increases Risk of Venous Thromboembolism, and Scoring for Plication Improves the Caprini Risk Assessment Model,”1 Dr Restifo provides compelling evidence of the link between abdominal wall plication and increased venous thromboembolism (VTE) risk after cosmetic abdominoplasty. Plication is a necessary component of many cosmetic abdominoplasties, as the desired surgical result cannot be achieved by other means. This manuscript adds to an increasing volume of literature helping surgeons (and patients!) to understand the risks and benefits of plication. Notably, this manuscript is the first I am aware of that uses a “real world,” private practice cosmetic abdominoplasty population (as opposed to a university-based massive-weight-loss population2) to correlate plication with the symptomatic deep vein thrombosis/pulmonary embolism (DVT/PE) endpoint, as opposed to a marker for DVT/PE risk. Thus, the findings of this manuscript are very important as surgeons and patients discuss the safety of aesthetic surgery. These concepts are discussed below, and in the accompanying video commentary (Video). Watch now at http://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjae183 Cosmetic abdominoplasty patients have a 2-fold greater risk for DVT/PE than the overall cosmetic surgery population (0.2% vs 0.09%).3 A disproportionate number of deaths after cosmetic surgery occur in the abdominoplasty population.4,5 Importantly, survey data support that 92% of tummy tuck surgeons routinely plicate the abdomen.6 Why are abdominoplasty patients different? The thought process is this: plication forces the intra-abdominal contents into a smaller volume, with a commensurate increase in intra-abdominal pressure (IAP). IAP elevation compresses the inferior vena cava, producing common femoral vein (CFV) stasis with resultant CFV dilation. Venous stasis and dilation are known to correlate with elevated DVT risk.7,8 There are substantial data to support this thought process. Plication is known to increase IAP in abdominoplasty9,10 and muscle sparing-TRAM breast reconstruction,11 as measured via bladder pressure. Extent of tightening matters: in breast reconstruction, bridged mesh (looser) closure of fascial defects results in lower IAP elevation compared with primary (tighter) closure,12,13 and pedicled TRAM patients have more IAP elevation than free TRAM patients.14 In free flap breast reconstruction, IAP elevation has demonstrable clinical impact; ultrasound studies have shown increased CFV diameter13 and decreased CFV flow.11,13 CFV stasis persists for at least 2 days after surgery.11,15 Notably, Momeni et al13 concurrently scanned the internal jugular vein, confirming that CFV dilation was not the result of fluid hydration status.13 Bed flexion,9,13 a necessary component of abdomen closure, and postoperative compression garments6,9,16 can further promote CFV stasis. Stasis and resultant venous dilation can produce intimal microtears, which serve as a nidus for DVT formation.7,8 The study utilized a large (N = 1370), single-surgeon sample with a uniform technique; this design inherently controls for some surgeon-level confounders. The directionality of the result (eg, plication predisposes to postoperative VTE) is shown by means of multiple analyses, including bivariate analysis, case-control, and a logistic regression. The case-control analysis, performed to match for identified baseline differences in the plication and nonplication groups, is particularly appropriate, given that the plication and nonplication groups were inherently different for risk factors known to impact VTE risk, including BMI, baseline VTE risk quantified by 2005 Caprini score,17 receipt of postoperative anticoagulation, and multiple procedures. When matching for baseline differences, the plication group had significantly elevated postoperative VTE (2.3% vs 0.36%, P = .028). This is the manuscript's key finding. The multivariable logistic regression is more challenging to interpret because the model may be overfit (with only 25 outcome events in the whole data set, addition of multiple variables/degrees of freedom into the model may be statistically incorrect). The author notes that “the odds ratio suggesting a 17-fold VTE risk increase from plication seems persuasive,” and I both agree and disagree. A thoughtful look at the Table 2 data shows that the 95% CI is quite wide (2.13-140.54), suggesting uncertainty in the point estimate. I agree with the author that the regression analysis supports the directionality of the association (eg, plication results in increased symptomatic VTE risk), but the magnitude remains in question. Of note, the case-control data supported a 6.4-fold, not 17-fold, increased risk. The author has several additional thoughts in the Discussion, worthy of a counterpoint. Dr Restifo concludes that the 2005 Caprini score is used as a jumping-off point, not an end-all-or-be-all decision point, and that 2005 Caprini score plus surgeon judgement is paramount. The Caprini score itself does not obligate a surgeon to a specific action—the combination of Caprini score and the surgeon's interpretation of clinical scenario dictates the correct next step. I completely agree, and have stated as such.18 Dr Restifo notes that the 2005 Caprini score was able to identify clinically relevant (eg, actionable) and statistically significant differences in VTE risk among risk levels (see Supplemental Table 2 in the article1). This has previously been shown in plastic surgery data from the VTEPS study,19,20 as well as the surgical population as whole,21,22 and explains why the 2005 Caprini score is the risk stratification tool recommended by the American Society of Plastic Surgeons, the American Association of Plastic Surgeons, and the American College of Chest Physicians. Dr Restifo states “the obvious, overarching question that a RAM [Risk Assessment Model] seems designed to answer is: Who should get chemoprophylaxis?” I believe that there are missed opportunities to improve patient safety if the 2005 Caprini score is used solely to identify the yes/no decision for prophylactic anticoagulation. The 2005 Caprini score is designed to identify baseline VTE risk—used at a preoperative visit, it can help surgeons (and patients!) to rigorously identify patient-centric risk factors, providing an opportunity for risk modification prior to surgery, or risk reduction (separate from anticoagulation) during surgery. This paradigm of risk identification, risk modification, and risk reduction has previously been described in the literature.23 The 2005 Caprini score is not meant to be diagnostic test for VTE, as suggested by Dr Restifo, but rather as an identifier of baseline risk and opportunities for improvement before, during, and after the operation. Dr Restifo makes well-intentioned modifications, via addition of a plication risk factor, to the gold standard, data-driven 2005 Caprini score. Dr Restifo's use of the same dataset to both derive and validate the proposed change is incorrect. To be valid, the proposed, “admittedly ad hoc practice” of modifying the 2005 Caprini score for plication would need to be validated in an independent dataset, not the dataset from which the scores were derived. In contrast, the 2005 Caprini score's ability to identify baseline VTE risk19,21,24 and to identify high-risk patients with favorable risk/benefit from prophylactic anticoagulation20,21 has been validated in multiple independent plastic surgery and general surgery populations. Of note, Caprini's own well-intentioned 2010 modifications to the 2005 Caprini score were independently shown to have decreased ability to identify VTE risk in plastic surgery patients.25 This further supports use of the 2005 Caprini score without modification. Finally, Dr Restifo's overall VTE rate of 1.8% (25 events/1370 cases) is almost an order of magnitude higher than published 30-day VTE rates in large series of cosmetic abdominoplasty (0.20%),3 and is more in line with the inpatient plastic surgery population's rate (1.2%).19 Thus, the author's VTE rate may not be indicative of the expected VTE rate after abdominoplasty with plication nationally. No data are provided in the manuscript about peak airway pressure or bladder pressure measurements before and after plication, as markers of extent (“tightness”) of plication. Why the author's overall VTE rate is higher than most remains unclear. This important manuscript supports that abdominal wall plication performed during cosmetic abdominoplasty is an independent risk factor for postoperative, symptomatic VTE. Plication is a necessary component of many cosmetic abdominoplasties, and I am not suggesting that surgeons abandon plication as a useful operative tool. Rather, these data provide surgeons and patients with another data-driven discussion point in the ongoing and important conversation surrounding patient safety in cosmetic surgery. Dr Pannucci currently performs practice consulting and expert witness work specific to VTE in plastic surgery and currently sits on the editorial board as a clinical editor for Aesthetic Surgery Journal. Dr Pannucci previously received an honorarium to speak on VTE in breast reconstruction from Sientra (Irvine, CA); this relationship ended in fall 2022. Sientra was not involved in this publication. He previously received 2 competitive research grants from Mentor (Irvine, CA) to study breast implants and blunt traumatic injury; this relationship ended in fall 2023. Mentor was not involved in this publication. The author received no financial support for the research, authorship, and publication of this article.
Source: Aesthetic Surgery Journal
DOI: 10.1093/asj/sjae183
Author: Christopher J Pannucci
Language: English
Subfield: Internal Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4401729520