Venous thromboembolism (VTE) is an important patient safety issue and potentially a life or limb threatening complication that can occur following plastic surgery. Patients are at different levels of VTE risk, based on patient-centric and procedure-specific risks. The following review discusses the paradigms of risk identification, risk modification and risk reduction for VTE risk in plastic surgery, with an ultimate goal of reducing VTE risk and improving patient safety.
HenkePKKahnSRPannucciCJ, et al.Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association. Circulation. 2020;141(24):e914‐e931. doi:10.1161/CIR.0000000000000769
2.
GouldMKGarciaDAWrenSM, et al.Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S‐e277S. doi:10.1378/chest.11-2297; 10.1378/chest.11-2297
3.
MurphyRXAldermanAGutowskiK, et al.Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130(1):168e‐175e. doi:10.1097/PRS.0b013e318254b4ee
4.
PannucciCJMacDonaldJKAriyanS, et al.Benefits and risks of prophylaxis for deep venous thrombosis and pulmonary embolus in plastic surgery: a systematic review and meta-analysis of controlled trials and consensus conference. Plast Reconstr Surg. 2016;137(2):709‐730. doi:10.1097/01.prs.0000475790.54231.28
5.
Cuenca-PardoJRamos-GallardoGMorales-OliveraM, et al.How to stratify the risk of thrombosis for esthetic plastic surgery? The proposal of a new scale. J Plast Reconstr Aesthet Surg. 2023;83:361‐372. doi:10.1016/j.bjps.2023.03.005
6.
DavisonSPVenturiMLAttingerCE, et al.Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg.2004;114(3):43E‐51E.
7.
PannucciCJShanksAMooteMJ, et al.Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery. Ann Surg.2012;255(6):1093‐1099. doi:10.1097/SLA.0b013e3182519ccf
8.
RogersSOJr.KilaruRKHosokawaP, et al.Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg.2007;204(6):1211‐1221. doi:10.1016/j.jamcollsurg.2007.02.072
9.
CapriniJA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon.2005;51(2-3):70‐78. doi:10.1016/j.disamonth.2005.02.003
10.
LobastovKUrbanekTStepanovE, et al.The thresholds of Caprini score associated with increased risk of venous thromboembolism across different specialties: a systematic review. Ann Surg. 2023;277(6):929-937. doi:10.1097/SLA.0000000000005843
11.
ObiATPannucciCJNackashiA, et al.Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941‐948. doi:10.1001/jamasurg.2015.1841
12.
ShumanAGHuHMPannucciCJ, et al.Stratifying the risk of venous thromboembolism in otolaryngology. Otolaryngol Head Neck Surg. 2012;146(5):719‐724. doi:10.1177/0194599811434383
13.
SunHXueSHuangY, et al.Stratifying the risks of venous thromboembolism in the lateral skull base surgery using Caprini risk assessment model. Eur Arch Otorhinolaryngol. 2023;280(7):3219‐3228. doi:10.1007/s00405-023-07984-0
14.
BahlVHuHMHenkePK, et al.A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2):344‐350. doi:10.1097/SLA.0b013e3181b7fca6
15.
StroudWWhitworthJMMiklicM, et al.Validation of a venous thromboembolism risk assessment model in gynecologic oncology. Gynecol Oncol. 2014;134(1):160‐163. doi:10.1016/j.ygyno.2014.04.051
16.
PannucciCJBaileySHDreszerG, et al.Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg.2011;212(1):105‐112. doi:10.1016/j.jamcollsurg.2010.08.018
17.
PannucciCJSwistunLMacDonaldJK, et al.Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis. Ann Surg. 2017;265(6):1094‐1103. doi:10.1097/SLA.0000000000002126
18.
YagoHYamakiTSasakiY, et al.Application of the Caprini risk assessment model for evaluating postoperative deep vein thrombosis in patients undergoing plastic and reconstructive surgery. Ann Vasc Surg. 2020;65:82‐89. doi:10.1016/j.avsg.2019.10.082
19.
PannucciCJDreszerGWachtmanCF, et al.Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk plastic surgery patients. Plast Reconstr Surg.2011;128(5):1093‐1103. doi:10.1097/PRS.0b013e31822b6817
20.
PoredosPKozakMAntignaniPL, et al.From varicose veins to venous thromboembolic events. Int Angiol. 2023;42(3):254‐259. doi:10.23736/S0392-9590.23.04948-9
21.
SrivastavaSGargIBansalA, et al.COVID-19 infection and thrombosis. Clin Chim Acta. 2020;510:344‐346. doi:10.1016/j.cca.2020.07.046
22.
CollaborativeC. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27‐38. doi:10.1016/S0140-6736(20)31182-X
23.
CollaborativeCCollaborativeG. SARS-CoV-2 infection and venous thromboembolism after surgery: an international prospective cohort study. Anaesthesia. 2022;77(1):28‐39. doi:10.1111/anae.15563
24.
CollaborativeCCollaborativeG. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. 2021;76(6):748‐758. doi:10.1111/anae.15458
ParesiRJMyersRSMatarassoA. Contraceptive vaginal rings: do they pose an increased risk of venous thromboembolism in aesthetic surgery?Aesthet Surg J. 2015;35(6):721‐727. doi:10.1093/asj/sju166
27.
JohnsonRLHemington-GorseSJDhitalSK. Do cosmetic surgeons consider estrogen-containing drugs to be of significant risk in the development of thromboembolism?Aesthetic Plast Surg. 2008;32(5):743‐747. doi:10.1007/s00266-008-9156-4
28.
HennessySBerlinJAKinmanJL, et al.Risk of venous thromboembolism from oral contraceptives containing gestodene and desogestrel versus levonorgestrel: a meta-analysis and formal sensitivity analysis. Contraception. 2001;64(2):125‐133. doi:10.1016/s0010-7824(01)00234-7
GradyDWengerNKHerringtonD, et al.Postmenopausal hormone therapy increases risk for venous thromboembolic disease. the Heart and Estrogen/progestin Replacement Study. Ann Intern Med. 2000;132(9):689‐696. doi:10.7326/0003-4819-132-9-200005020-00002
31.
ValenteDSCarvalhoLAZanellaRK, et al.Venous thromboembolism following elective aesthetic plastic surgery: a longitudinal prospective study in 1254 patients. Plast Surg Int. 2020;510:344-346. doi:10.1155/2014/565793
32.
Bulletins—Gynecology ACoOaGCoP. Prevention of venous thromboembolism in gynecologic surgery: ACOG practice bulletin, number 232. Obstet Gynecol. 2021;138(1):e1‐e15. doi:10.1097/AOG.0000000000004445
33.
ChatthaABrownESlavinS, et al.Oral contraceptive management in aesthetic surgery: a survey of current practice trends. Aesthet Surg J. 2018;38(3):NP56‐NP60. doi:10.1093/asj/sjx234
34.
WinocourJGuptaVKaoutzanisC, et al.Venous thromboembolism in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J. 2016;37(3):337‐349. doi:10.1093/asj/sjw173
35.
Arrington-SandersRConnellNTCoonD, et al.Assessing and addressing the risk of venous thromboembolism across the spectrum of gender affirming care: a review. Endocr Pract. 2023;29(4):272‐278. doi:10.1016/j.eprac.2022.12.008
36.
HavelesCSWangMMArjunA, et al.Effect of cross-sex hormone therapy on venous thromboembolism risk in male-to-female gender-affirming surgery. Ann Plast Surg. 2021;86(1):109‐114. doi:10.1097/SAP.0000000000002300
37.
RobinsonGEBurrenTMackieIJ, et al.Changes in haemostasis after stopping the combined contraceptive pill: implications for major surgery. Br Med J.1991;302(6771):269‐271. doi:10.1136/bmj.302.6771.269
38.
WhiteheadEMWhiteheadMI. The pill, HRT and postoperative thromboembolism: cause for concern?Anaesthesia. 1991;46(7):521‐522. doi:10.1111/j.1365-2044.1991.tb09646.x
39.
GoldhaberSZSavageDDGarrisonRJ, et al.Risk factors for pulmonary embolism. The Framingham Study. Am J Med. 1983;74(6):1023‐1028. doi:10.1016/0002-9343(83)90805-7
40.
TsaiAWCushmanMRosamondWD, et al.Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med.2002;162(10):1182‐1189.
41.
GlynnRJRosnerB. Comparison of risk factors for the competing risks of coronary heart disease, stroke, and venous thromboembolism. Am J Epidemiol.2005;162(10):975‐982. doi:10.1093/aje/kwi309
42.
MahmoodiBKCushmanMAnne NæssI, et al.Association of traditional cardiovascular risk factors with venous thromboembolism: an individual participant data meta-analysis of prospective studies. Circulation. 2017;135(1):7‐16. doi:10.1161/CIRCULATIONAHA.116.024507
43.
WattanakitKLutseyPLBellEJ, et al.Association between cardiovascular disease risk factors and occurrence of venous thromboembolism. A time-dependent analysis. Thromb Haemost. 2012;108(3):508‐515. doi:10.1160/TH11-10-0726
44.
ChengYJLiuZHYaoFJ, et al.Current and former smoking and risk for venous thromboembolism: a systematic review and meta-analysis. PLoS Med. 2013;10(9):e1001515. doi:10.1371/journal.pmed.1001515
45.
JeongHSMillerTJDavisK, et al.Application of the Caprini risk assessment model in evaluation of non-venous thromboembolism complications in plastic and reconstructive surgery patients. Aesthet Surg J. 2014;34(1):87‐95. doi:10.1177/1090820X13514077
46.
GuptaVWinocourJRodriguez-FeoC, et al.Safety of aesthetic surgery in the overweight patient: analysis of 127,961 patients. Aesthet Surg J. 2016;36(6):718‐729. doi:10.1093/asj/sjv268
47.
KimJYKhavaninNRambachanA, et al.Surgical duration and risk of venous thromboembolism. JAMA Surg. 2015;150(2):110‐117. doi:10.1001/jamasurg.2014.1841
48.
QiuCSJordanSWDorfmanRG, et al.Surgical duration impacts venous thromboembolism risk in microsurgical breast reconstruction. J Reconstr Microsurg. 2018;34(1):47‐58. doi:10.1055/s-0037-1606339
49.
BelcaroGGeroulakosGNicolaidesAN, et al.Venous thromboembolism from air travel: the LONFLIT study. Angiology. 2001;52(6):369‐374.
50.
BitarGMullisWJacobsW, et al.Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures. Plast Reconstr Surg. 2003;111(1):150‐156; discussion 157-8. doi:10.1097/01.PRS.0000037756.88297.BC
51.
ErsekRA. Dissociative anesthesia for safety’s sake: ketamine and diazepam—a 35-year personal experience. Plast Reconstr Surg. 2004;113(7):1955‐1959.
52.
ErsekRA. General anesthesia gases are a common denominator in cases of thromboembolism. Aesthetic Surg J.2009;29(4):340‐341. doi:10.1016/j.asj.2009.02.004
53.
SwansonE. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open. 2014;2(6):e160. doi:10.1097/GOX.0000000000000116
54.
SwansonE. Doppler Ultrasound imaging for detection of deep vein thrombosis in plastic surgery outpatients: a prospective controlled study. Aesthet Surg J. 2015;35(2):204‐214. doi:10.1093/asj/sju052
55.
SwansonE. Prospective study of Doppler ultrasound surveillance for deep venous thromboses in 1000 plastic surgery outpatients. Plast Reconstr Surg. 2020;145(1):85‐96. doi:10.1097/PRS.0000000000006343
56.
BenköTCookeEAMcNallyMA, et al.Graduated compression stockings: knee length or thigh length. Clin Orthop Relat Res. 2001;383(383):197‐203.
57.
SachdevaADaltonMAmaragiriSVLeesT. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2010;7:CD001484. doi:10.1002/14651858.CD001484.pub2
58.
ComerotaAJStewartGJAlburgerPDSmalleyKWhiteJV. Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis. Surgery. 1989;106(2):301‐308; discussion 308-9.
59.
ComerotaAJChouhanVHaradaRN, et al.The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis. Ann Surg. 1997;226(3):306‐313; discussion 313-4.
60.
KnightMTDawsonR. Effect of intermittent compression of the arms on deep venous thrombosis in the legs. Lancet. 1976;2(7998):1265‐1268. doi:10.1016/S0140-6736(76)92029-8
61.
SwansonE. The effect of sequential compression devices on fibrinolysis in plastic surgery outpatients: a randomized trial. Plast Reconstr Surg. 2020;145(2):392‐401. doi:10.1097/PRS.0000000000006464
62.
HoKMTanJA. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Circulation. 2013;128(9):1003‐1020. doi:10.1161/CIRCULATIONAHA.113.002690
63.
UrbankovaJQuirozRKucherN, et al.Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost. 2005;94(6):1181‐1185. doi:10.1160/TH05-04-0222
64.
HaeckPCSwansonJAIversonRE, et al.Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Plast Reconstr Surg. Oct 2009;124(4 Suppl):6S‐27S. doi:10.1097/PRS.0b013e3181b8e880
65.
YoungVLWatsonME. Continuing medical education article—patient safety: the need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthetic Surg J.2006;26(2):157‐175. doi:10.1016/j.asj.2006.02.001
66.
PannucciCJHenkePKCedernaPS, et al.The effect of increased hip flexion using stirrups on lower-extremity venous flow: a prospective observational study. Am J Surg. 2011;202(4):427‐432. doi:10.1016/j.amjsurg.2011.04.002
67.
HuangGJBajajAKGuptaS, et al.Increased intraabdominal pressure in abdominoplasty: delineation of risk factors. Plast Reconstr Surg.2007;119(4):1319‐1325. doi:10.1097/01.prs.0000254529.51696.43
68.
Al-BastiHBEl-KhatibHATahaA, et al.Intraabdominal pressure after full abdominoplasty in obese multiparous patients. Plast Reconstr Surg.2004;113(7):2145‐2150; discussion 2151-5.
69.
LoskenACarlsonGWJonesGE, et al.Significance of intraabdominal compartment pressures following TRAM flap breast reconstruction and the correlation of results. Plast Reconstr Surg.2002;109(7):2257‐2264.
70.
LoskenACarlsonGWTyroneJW, et al.The significance of intraabdominal compartment pressure after free versus pedicled TRAM flap breast reconstruction. Plast Reconstr Surg.2005;115(1):261‐263.
71.
MomeniATecceMGLanniMA, et al.Increased lower extremity venous stasis may contribute to deep venous thrombosis formation after microsurgical breast reconstruction—an ultrasonographic study. J Reconstr Microsurg. 2017;33(3):173‐178. doi:10.1055/s-0036-1594297
72.
MomeniASoriceSCLiAY, et al.Breast reconstruction with free abdominal flaps is associated with persistent lower extremity venous stasis. Plast Reconstr Surg. 2019;143(6):1144e‐1150e. doi:10.1097/PRS.0000000000005613
73.
PannucciCJAldermanAKBrownSL, et al.The effect of abdominal wall plication on intra-abdominal pressure and lower extremity venous flow: a case report. J Plast Reconstr Aesthet Surg.2012;65:392‐394. doi:10.1016/j.bjps.2011.08.013
74.
WangFChemakinKShamamianP, et al.Rectus plication does not increase risk of thromboembolic events following abdominal body contouring: a matched case-control analysis. Aesthet Surg J. 2022;42(12):1435‐1444. doi:10.1093/asj/sjac195
75.
KeyesGRSingerRIversonRENahaiF. Incidence and predictors of venous thromboembolism in abdominoplasty. Aesthet Surg J. 2018;38(2):162‐173. doi:10.1093/asj/sjx154
76.
KeyesGRSingerRIversonRE, et al.Mortality in outpatient surgery. Plast Reconstr Surg.2008;122(1):245‐250; discussion 251-3. doi:10.1097/PRS.0b013e31817747fd
77.
ClaymanMAClaymanESSeagleBM, et al.The pathophysiology of venous thromboembolism: implications with compression garments. Ann Plast Surg.2009;62(5):468‐472. doi:10.1097/SAP.0b013e31818cd08c
78.
BerjeautRHNahasFXDos SantosLK, et al.Does the use of compression garments increase venous stasis in the common femoral vein?Plast Reconstr Surg. 2015;135(1):85e‐91e. doi:10.1097/PRS.0000000000000770
79.
RodriguesMANahasFXGomesHC, et al.Ventilatory function and intra-abdominal pressure in patients who underwent abdominoplasty with plication of the external oblique aponeurosis. Aesthetic Plast Surg. 2013;37(5):993‐999. doi:10.1007/s00266-013-0158-5
80.
KeiterJEJohnsDRockwellWB. Importance of postoperative hydration and lower extremity elevation in preventing deep venous thrombosis in full abdominoplasty: a report on 450 consecutive cases over a 37-year period. Aesthet Surg J. Sep 2015;35(7):839‐841. doi:10.1093/asj/sjv070
81.
Del VecchioDSteinMJDayanE, et al.Nanotechnology and artificial intelligence: an emerging paradigm for postoperative patient care. Aesthet Surg J. 2023;43(7):748‐757. doi:10.1093/asj/sjad071
82.
HenkePK. Discussion: prospective study of Doppler ultrasound surveillance for deep venous thromboses in 1000 plastic surgery outpatients. Plast Reconstr Surg. 2020;145(1):97‐98. doi:10.1097/PRS.0000000000006407
83.
KahnSRShbakloHLampingDL, et al.Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J Thromb Haemostasis.2008;6(7):1105‐1112. doi:10.1111/j.1538-7836.2008.03002.x
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
