From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery

Venous Thromboembolism in Plastic Surgery: Where Are We Now?

As the obesity epidemic continues to grow, symptomatic macromastia at earlier ages has become increasingly common. The present study aims to explore trends, risk factors, and postoperative complications in adolescent reduction mammaplasty (ARM) over an 11-year period. The American College of Surgeons National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) was queried to identify ARM cases between 2012-2022 in patients 18 years or younger. Patient demographics, procedure details, and postoperative outcomes were collected. Trend analysis and predictors for postoperative complications were performed via linear regression and multivariable logistic regression, respectively. Between 2012 and 2022, 3158 patients underwent ARM. The overall complication rate was 4.4%, with superficial surgical site infections at 3.0%. Among those who underwent ARM, elevated body mass index (adjusted odds ratio 1.04, P < 0.001) and higher American Society of Anesthesiologists (ASA) class predicted complications (ASA1: adjusted odds ratio 0.34, P = 0.01). The prevalence of ARM increased by 482%, while overall obesity rates increased by 58% over the years. Total operation time ( P = 0.005), anesthesia duration ( P = 0.02), and length of stay ( P < 0.001) decreased throughout the years, while superficial surgical site infections increased ( P = 0.04). As obesity rates rise, the prevalence of ARM has increased even more rapidly, with elevated body mass index and higher ASA individuals at an increased risk for complications. Operative time, anesthesia duration, and length of stay decreased over time, with low overall complication rates. Plastic surgeons should note these trends to provide adequate care for patients requesting ARM.

An elevated body mass index (BMI) is suggested to be a risk factor for a poor outcome after intracranial aneurysm rupture and is considered to be associated with cerebral infarction in patients with aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to analyze the association between permorbid BMI and neurological outcome. In this retrospective study, the patients' BMI at the time of their admission to hospital was correlated to their neurological outcome as measured by the Glasgow outcome score after two weeks and two months of treatment. In contrast to other studies, there were no significant correlations between premorbid BMI and neurological outcome, shunt requirement, tracheotomy requirement and duration of stay on the intensive care unit (ICU). Overweight patients have no higher risk of a poor neurological outcome after aneurysmal SAH if premorbid risk factors such as hypertension and hyperglycemia are carefully modified throughout the period of critical care.

Historically, there has been broad adoption of body mass index (BMI) as a gold-standard predictor of postoperative complications, yet the lack of consensus on clear BMI cutoffs suggests other factors involved. This study sought to evaluate how comorbidities modify the relationship between BMI and postoperative complications across different surgical locations and define a safe BMI threshold for those with and without comorbidities. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was filtered for the most common plastic surgery procedures, which were organized by surgical site location. A multivariate logistic regression model was created, which incorporated comorbid status, BMI, and body location as predictors. Simple slopes analysis was performed to assess how the marginal effect of BMI on complication risk varied by comorbidity status within each body location. A total of 239,676 patients were identified, with 7.1% (n = 17,107) having at least 1 comorbidity and 0.8% (n = 1818) developing postoperative complications. Both BMI and comorbidity were significantly associated with complication development ( P < 0.01).We noted a significant interaction between the presence of comorbidities and increasing BMI. The combination of comorbidities and elevated BMI is particularly high risk in patients undergoing trunk, breast, and extremity procedures. For patients without comorbidities, BMI <35 kg/m 2 does not significantly increase the risk of complications. In contrast, in patients with comorbid disease, risk of complications begins to increase in patients with a BMI of 30 kg/m 2 . Through logistic regression analysis of the ACS-NSQIP database, this study demonstrates that elevated BMI alone may not lead to serious postoperative complications until reaching values above 35 or 40 kg/m 2 . Nevertheless, when a comorbidity is present, a BMI of 30 kg/m 2 may be associated with increased risk of complications. This study also shows that BMI-related risks varied by surgical site, with more pronounced complication risk in adipose-rich surgical sites such as the abdomen. It is essential to take a more individualized risk-stratified approach to preoperative patient evaluation with careful consideration of a patient's comorbidities and overall health status.

Malignancy is a strong risk factor for venous thromboembolism (VTE), either from the malignancy itself or from other factors such as cancer treatments.1 VTE can lead to morbidity and mortality, delay cancer treatments, and increase hospitalisations and healthcare utility. Multiple myeloma (MM) is associated with a 4- to 7·5-fold increased risk of VTE compared with age- and sex-matched controls, with highest risk observed in the year following MM diagnosis, and in patients exposed to immunomodulatory drugs.2 Therefore, effective VTE prevention strategies are crucial in this patient population. International guidelines have recommended thromboprophylaxis with aspirin or low-molecular-weight heparin (LMWH) in patients with MM receiving immunomodulatory agents.3 However, aspirin poorly prevents VTE, and LMWH has not been adopted routinely as primary thromboprophylaxis given the burden and cost of daily injections. In recent years, two large randomised controlled trials, the AVERT and CASSINI studies, established the role of apixaban and rivaroxaban respectively, as primary thromboprophylaxis in ambulatory cancer patients with Khorana score ≥ 2 starting chemotherapy.4, 5 However, patients with MM were underrepresented in these studies, with only 15 out of 574 (2·6%) patients in the AVERT study and none in the CASSINI study. The applicability of Khorana score to patients with MM has also been challenged,6 and they were not included in the initial population from which Khorana score was derived.7 Therefore, whether direct oral anticoagulants (DOACs) can be effective and safe thromboprophylactic options in patients with MM remains unclear. Cornell and colleagues report their results of a single arm pilot study of using apixaban 2·5 mg orally twice daily as primary thromboprophylaxis in 50 patients with MM receiving immunomodulatory agents. Over the study period of six months, no patients developed VTE (the primary efficacy outcome) nor major bleeding complications (part of the composite primary safety outcome), and only three developed clinically relevant non-major bleeding events (another part of the composite primary safety outcome). In addition, no arterial thrombotic events were observed. The results are encouraging, although this may be a relatively ‘lower risk’ group, given that 40% of patients were on maintenance therapy with a low disease burden and a low dose of immunomodulatory agents with or without dexamethasone. Recently two risk stratification models, the SAVED and IMPEDE VTE scores, have been developed in the MM population.8, 9 Li et al. identified a high-risk group representing 30% of MM patients, with a six-month cumulative VTE incidence of 11–12%, while Sanfilippo et al. identified 10% of MM patients in the highest risk group with a six-month cumulative incidence of VTE of >15%.8, 9 These unacceptable rates of thrombosis urge evaluation of new tailored thromboprophylaxis strategies using DOACs to achieve an optimal risk:benefit ratio. This pilot study is important because it establishes the feasibility of larger trials investigating thromboprophylaxis in patients with MM. It also opens ways to further important trials assessing thromboprophylaxis in high-risk patients with other haematological malignancies. Specific VTE risk assessment models have already been developed for acute leukaemia (Al-Ani risk score), myeloproliferative diseases (IPSET-thrombosis), or lymphoma (ThroLy score).10-12 However, to date, only one randomised pilot trial assessing a DOAC for thrombosis prevention in adult patients with malignant haematologic conditions has been registered with ClinicalTrials.gov. This pilot study will assess the feasibility of a full-scale trial comparing a prophylactic dose of apixaban to aspirin in addition to cytoreductive therapy in patients with JAK2-positive myeloproliferative neoplasm (NCT04243122). In light of the AVERT and CASSINI studies, evaluation of the potential benefits of DOACs for the prevention of thrombosis in patients with haematological malignancies is urgently needed.

e18526 Background: Cancer is a severe public health problem in Brazil, and prevention and screening measures are uneven throughout the country, despite universal guidelines of the NCI/Sistema Único de Saúde (SUS). The non-governmental and multidisciplinary expedition “Alma Pantaneira” is one of the few health programs in the Pantanal region, state of Mato Grosso do Sul, inland Brazil, with a rural population of 45,000 inhabitants. The expedition takes place regularly for over ten years on a pre-established route. Methods: This is a observational study involving data collection through questionnaires from the Alma Pantaneira Expedition, previously submitted and approved by the Local Ethics Committee. The questionnaire was distributed to six physicians who volunteered to apply. Patients of both sexes and over 18 years old were included. The study sample was defined by convenience, including all patients treated by the program in the period established between 11/18/21 to 11/30/21. Results: The collection involved 156 patients, with a mean age of 41.25 ± 13.95 years of which 63.5% were men and 36.5% were women. We observed that among the study population, 70.5% declared themselves brown, 10.9% black, and 15.4% white. More than half of the population, 25.6%, and 32.1%, were classified as overweight and having grade 1 obesity, respectively. The most prevalent comorbidity was systemic arterial hypertension (SAH) at 23.7%, followed by diabetes mellitus (DM) at 3.2%. When we analyze other risk factors, 38.5% of the population are active smokers, 3.2% are former smokers, and 51.3% are frequent alcohol consumers. When it comes to population screening for cancer, 65.9% of women over 25 years of age underwent the Papanicolaou Test in the last two years; 42.9% of men over 45 years old had performed a PSA test, and only 5.8% of the population underwent a colonoscopy over 45 years of age. Regarding the family history of cancer, it was identified that 12.3% of the population had a first- and second-degree relative with a positive history of cancer; 7.7% of the population had a first- or second-degree relative with a history of breast cancer before age 50, and 5.1% with a history of bowel cancer before age 50. In addition, 4.5% of the population had three or more first- or second-degree relatives with a history of cancer before age 50. Conclusions: The present study generated epidemiological data hitherto unavailable in the Pantanal region, inland Brazil, on the prevalence of the main risk factors for the development of malignant neoplasms, as well as secondary prevention measures. Population screening for cancer is below the target set by the WHO for the most prevalent types of cancer. Risk factors such as smoking, alcohol consumption, and being overweight are above the average for the Brazilian population. The need to adopt public policies in the study population and increase access to prevention, screening, diagnosis and early cancer treatment is urgent.

Metabolic Syndrome, Obstructive Sleep Apnea, and Continuous Positive Airway Pressure: A Weighty Issue

Background: Excessive scarring remains a frequent complication in plastic surgery, yet standardized preventive strategies are lacking. Type I collagen-based biomaterials may support regenerative processes and improve scar outcomes. Methods: This case series includes six female patients (ages 24–52) undergoing wound management after trauma and procedures including blepharoplasty, abdominoplasty, and revision mammaplasty. Native collagen type I (7% or 15%) was injected along wound margins or into hypertrophic scars at 3–4 week intervals. Outcomes were assessed through patient-reported symptoms and Antera 3D imaging (vascularity, pigmentation, surface topography). Results: Patients reported reduced tightness, pruritus, and scar stiffness after initial sessions. Antera 3D imaging showed decreased vascular and pigment indices, and a reduction in surface elevation over follow-up (up to 14 months). No adverse effects such as atrophy or infection were observed. Conclusions: Native type I collagen was well tolerated and may be a useful adjunct for wound healing and scar modulation following plastic surgery.

Because patients with scar contracture of the neck are at a high risk of loss of the airway control after anesthesia induction, awake intubation is usually recommended. This retrospective clinical study was designed to evaluate the possibility, safety and efficacy of airway management and tracheal intubation under general anesthesia in such patients. This retrospective study included 1683 patients from January 1994 to December 2006 with scar contracture of the neck, aged 1.5 - 67.0 years, who were scheduled for elective plastic surgery under general anesthesia in Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. Based on the results of the preoperative airway assessment, the patients were classified into group 1 (including 1375 patients with the atlanto-occipital extension of > 20 degrees and the Mallampatti's grade I or II) and group 2 (containing 308 patients with the atlanto-occipital extension of < 20 degrees and the Mallampatti's grade III or IV. In group 1, the intravenous induction and maintenance of anesthesia and succinylcholine for muscle relaxation were used. The intubation was done using a modified Macintosh technique. In group 2, the total intravenous anesthesia (TIVA) or the sevoflurane inhalation anesthesia was chosen and the spontaneous breathing was reserved during anesthesia. The intubation was performed by a fiberoptic stylet laryngoscope (FOSL). The number of intubation attempts, intubation time and relative complications were observed and recorded in all patients. In group 1, the intubation was accomplished during the first attempt in 1279 cases (93%) and the intubation time was < 3 minutes in 1304 cases (95%). In group 2, the intubation was completed by the first attempt in 114 patients (37%) and 123 patients had an intubation time of < 3 minutes (40%). Tracheal intubation was successful by the second or third attempt in 96 patients in group 1 and 156 patients in group 2. Thirty-eight patients required four or more attempts which only occurred in group 2. The incidence of traumatic complication was 2.6% and 9.7% with one intubation attempt in groups 1 and 2, respectively, 12.5% and 17.0% with multiple intubation attempts (one vs multiple attempts in both groups, P < 0.001). All non-traumatic complications occurred in group 2 and laryngospasm and hypoxemia were more common in patients using the TIVA compared to those using the sevoflurane inhalational anesthesia (P < 0.001). This study demonstrated that with a precise airway evaluation, an adequate preoperative preparation and a pre-planned failed intubation strategy, the anesthetist who was experienced in the difficult airway management could safely perform airway control and tracheal intubation under general anesthesia in patients with scar contracture of the neck. We believe that this technique may be very valuable for the management of a known difficult airway because it is comfortable for the patient and saves time for the anesthetist.

Body Mass Index Trajectory during Triplet Induction Therapy: Clinical Implications in Newly Diagnosed Multiple Myeloma

Robotic microsurgery is rapidly changing the surgical landscape by mitigating conventional hand-surgical limitations such as physiological tremor while promoting increased precision in confined spaces through the provision of high-depth microoptics and motion-scaling. The innovation of specialized "super" microsurgical robotic platforms such as Medical Microinstruments' Symani and Microsure's MUSA-2 has further bolstered microsurgical toolkits by enabling high-precision microvascular anastomoses in vessels with a diameter of 0.8 mm of less. Our team conducted a systematic literature review of the global uses of robotic-assisted supermicrosurgery in plastic and reconstructive surgery. Using Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 flow guidelines, our search yielded 107 articles, of which 16 were eligible based on our inclusion criteria. Our results showed that lymphaticovenous anastomoses represent 37% of reported plastic and reconstructive surgery supermicrosurgery robot clinical uses, whereas free flaps and nerve repairs comprised just 14% and 2%, respectively. These procedures were found to correspond with significant but short learning curves. Across studies, mean operating times were found to be up to 1.5 times greater than manual techniques and showed a downward trend in time spent. Our analysis revealed that robotic-assisted techniques decreased rates of microtrauma, with anastomotic patency rates of 99.38%. Although robotic technology represents a significant financial investment and includes training needs, current literature supports evidence of potential long-term net savings due to reliably high patency rates; decreased in-hospital recovery times; the promise of new, expanded surgical options and capabilities; and enhanced career longevity for surgeons.

Marked Variation in Venous Thromboprophylaxis Management for Abdominal Aortic Aneurysm Repair; Results of Survey Amongst Vascular Surgeons in the United Kingdom

Cigarette smoking has been well demonstrated to be associated with adverse outcomes and increased complications in surgical patients in the operative and postoperative periods. There is general agreement that smoking cessation decreases such risks; however, much debate still exists regarding the most effective modalities for risk mitigation, especially concerning modalities involving nicotine replacement in some form. This article reviews the discussion regarding smoking cessation therapies, in particular those involving nicotine replacement, in the context of mitigating risk in plastic surgery procedures. The recent rise in popularity of electronic cigarettes poses further challenges for clinicians in minimizing risk and optimizing outcomes for patients. Prospective studies including high-level evidence such as randomized controlled clinical trials will be required to help plastic surgeons develop guidelines that will enable optimization of patient safety and clinical outcomes.

Journal Article Breast Cancer Epidemiology: Summary and Future Directions Get access Jennifer L. Kelsey Jennifer L. Kelsey Stanford University School of MedicineStanford, CA Search for other works by this author on: Oxford Academic PubMed Google Scholar Epidemiologic Reviews, Volume 15, Issue 1, 1993, Pages 256–263, https://doi.org/10.1093/oxfordjournals.epirev.a036112 Published: 01 March 1993 Article history Published: 01 March 1993 Received: 28 April 1993

Class 3 (severe) obesity is defined as a body mass index (BMI) greater than 40 kg/m2 . Obesity is common and an independent risk factor for breast cancer. The plastic surgeon will be tasked with providing reconstruction for obese patients after mastectomy. This presents a surgical dilemma because patients with elevated BMI are known to have greater rates of morbidity when undergoing free flap reconstruction, however free flap reconstruction is associated with greater functional and aesthetic outcomes. This study quantifies complication rates in a cohort of patients with class 3 obesity that underwent abdominally based free flap breast reconstruction. This study may be able answer whether this surgery is feasible or safe. Patients with a class 3 obesity who underwent abdominally-based free flap breast reconstruction between January 1, 2011 and February 28, 2020 at the authors' institution were identified. A retrospective chart review was performed to record patient demographics and peri-operative data. Twenty-six patients met inclusion criteria. Eighty percent of patients had at least one minor complication including infection (42%), fat necrosis (31%), seroma (15%), abdominal bulge (8%), and hernia (8%). Thirty-eight percent of patients had at least one major complication (requiring readmission (23%) and/or a return to the operating room (38%)). No flaps failed. Abdominally based free flap breast reconstruction in patients with class 3 obesity is associated with great morbidity, however, no patients experienced flap loss or failure which may imply that this population can safely undergo surgery so long as the surgeon is prepared for complications and takes steps to mitigate risk.