Hello everyone, I am Dr. Brandon Claytor and will be the moderator for tonight for ASPS Global Partners webinar series, March 20th, 2025. This is safety in abdominoplasty. And tonight we're going to hear from two esteemed surgeons, Dr. Joseph Richie and Dr. Eric Swanson. There's going to be the opportunity to view this later, and you're going to be getting an email from Romina Valadez, and her email is on there, but this will be available to everyone on the ASPS EdNet, and she will be sending you a link so that you can get to that. The next slide, please, is the introduction to the session, and you can click on that little QR code right there to have a link to signing up for coming to Plastic Surgery the meeting in New Orleans, which is going to be October 9th through the 12th, and should be absolutely fantastic. So we're thrilled that you can be part of this webinar series, but we certainly hope and encourage you to come to that meeting. So with no further ado, I'd like to introduce Dr. Joseph Richie, who will speak first, speaking about his version of safety in abdominoplasty current recommendations. Dr. Richie is a graduate of the Harvard Combined Plastic Surgery Residency Program. He then completed a microsurgery fellowship at NYU. He currently holds the rank of Associate Professor of Surgery and is the Associate Residency Program Director at the Hofstra Northwell Plastic Surgery Residency Program. He performs a wide variety of complex adult reconstruction services for patients with oncologic and trauma defects. So with no further ado, here is Dr. Richie. Thank you very much. Let me just share my screen here, let me full screen this. So thanks everybody for attending. This is the webinar series on abdominoplasty safety and abdominoplasty, and I'm going to just speak for a few minutes here and then turn it over to Dr. Eric Swanson afterwards. So the question that I want to discuss is, does surgical technique increase the risk of VTE and abdominoplasty contouring? And I don't have any conflicts of interest to disclose. So abdominoplasty, as everybody knows, obviously there's a lot of participants on this call. This is something that is commonly performed in the United States and around the world. It's one of the most common cosmetic procedures performed. And based on ASPS statistics, about 100,000 abdominoplasties were performed annually in the United States before 2020. So we're looking at before the COVID pandemic with nearly 161,000 reported in 2022 alone. This represents approximately a 37% increase in the past four or five years and about a 56% increase since 2000 overall. And as I just mentioned, it's one of the most commonly performed plastic surgery procedures, as we all know. This is from the ASPS website, and this actually is showing the top cosmetic surgical procedures, both pre-pandemic and as I mentioned in 2022, which is what some of these recent statistics are for with the percentage change. And you can see that abdominoplasty rates as one of the absolute most common just behind liposuction in terms of body procedures with perhaps the greatest increase except for buttock lift, but the numbers are smaller, but with perhaps one of the greatest increases change. So a lot of interest in people for abdominoplasty with regard to cosmetic procedures, and you can see that highlighted right there. So what about VTE, menis thromboembolism? Well, this is obviously a devastating complication that everybody is concerned about. The VTE risk is reported to be approximately 0.2% to 1.5% in all abdominal body contour procedures. This is what's reported in the literature. We do know for sure that this is higher than that of other aesthetic procedures. In fact, abdominoplasty itself is a risk for VTE procedures, which I think we're going to hear about a little bit later from Dr. Swanson. Many people, there's been considerable effort employed in terms of decreasing incidence of VTE and understanding risk factors, methods of prevention, and there's been a lot of recent discussion on whether we need to employ chemoprophylaxis or mechanical prophylaxis, or whether we should do things like surveillance. Risk factors, chemoprophylactic regimens, and other procedural recommendations have previously been characterized in many areas of many surgical fields, many surgical areas with guidelines by the American College of Chest Physicians. So this is the standard guidelines that a lot of hospitals, operating rooms, physicians would follow. These guidelines have yet to reach consensus in plastic surgery, and this is because they contain minimal evidence from plastic surgery literature, and really no plastic surgery procedures are specifically included in these recommendations. With regard to abdominoplasty directly, there are many well-known risk factors, including things like smoking, BMI, etc. But there are, with regard to abdominoplasty specifically, there are many unique additional concerns that are related to surgical technique that is not necessarily present in other aesthetic cases that we might perform. And so this, specifically in this case, we're talking about rectus placation. So placation of the rectus muscles occurring during your abdominal, during your abdominoplasty as a standard, a standard step, a standard portion of the procedure has been associated with increased intra-abdominal pressures. And theoretically, this could increase the risk for venous thromboembolism. Increased intra-abdominal pressure, IAP, via placation or even via compression garments post-operatively may lead to lower extremity venous stasis. This can persist for up to 48 hours after surgery. And we know that lower extremity stasis has been demonstrated with real-time ultrasound in two, sorry, this lower extremity stasis has been demonstrated with real-time ultrasound to identify common femoral stasis with tight abdominal wall fascial closures, irrespective of intraoperative hydration. So regardless of fluid status or amount of fluid administered, we do see with fascial placation that there is, that there can be lower extremity stasis. And we know from back from medical school that venous stasis is a key component of Virchow's triad stasis, hypercoagulability or vessel injury. And this is one of the proposed mechanisms for thrombus formation in patients specifically undergoing abdominal placation in abdominoplasty. Many surgeons believe this risk to be just theoretical. Patients with vessel dilation and venous stasis have no increased VTE risk. And there's examples of this, which is just like epidural anesthesia or paraplegia. These patients are not necessarily at increased VTE risk, but they do demonstrate vessel dilation and they do demonstrate venous stasis. So how do we bridge this gap? How do we bridge these diverging theories on the presence of venous stasis, the possibility of increased intra-abdominal pressure from venous, from rectus placation, and how can we characterize that effect on surgical technique and placation events? Well, we decided to actually study this. So we reviewed all patients who underwent abdominal body contouring at our procedure for a 10 year span. So between 2010 and 2020, so to make sure they had adequate time for follow-up. Demographic data, operative details, medical comorbidities were collected, and these included things like the Caprini risk score, whether or not rectus placation was performed. And we also evaluated the patients using something called the Charleston Comorbidity Index, which I'm going to get into in a second. The Charleston Comorbidity Index, or CCI, is a validated score that is associated with post-operative complications, mortality, and readmission in patients undergoing surgery. It's validated to predict the one-year mortality risk for patients with specific comorbid conditions. And I have 19 of them there. The CCI is scored by compiling a list of medical comorbidities from 19 different categories and assigning them a risk factor score, giving the patients a total score. The Charleston Comorbidity Index has utility in matching patients together because it is accurately associated with morbidity and mortality for patients undergoing surgery in a variety of fields, and that's been validated. So this is something we can actually use to compare different patients from different groups of different ages to try to standardize their medical comorbidities. Many of the research projects that we do, we'd look at one or two factors. Did they have diabetes? Did they have coronary artery disease? Did they have a history of XYZ thing? In this situation, even if somebody with diabetes would get a score of one, somebody with a history of a prior myocardial infarction would get a score of one. Those patients would actually be equivalent when scored by the Charleston Comorbidity Index. Both of them would have the same sort of total score if those were their only medical issues, and they would be comparable patients based on medical history in this validated tool. Essentially, what we did was we evaluated all these patients, collected all this medical data on them, and then looked at identified VTE events and whether the event status was confirmed via imaging studies or not. So cases were matched to controls who did not. So cases with VTE, patients with VTE were matched to controls who did not in a one to four fashion. So we matched four patients with no VTE to one patient with VTE, and then controlled for potential confounders. The case control match here were done on variables including age, body mass index, Charleston Comorbidity Index, which we just discussed, of which BMI is not one of the factors. So it can be scored. It can be evaluated separately. Preoperative Caprini score and duration of chemoprophylaxis. The performance of rectal splication or not was compared between the two groups along with complications as an independent variable. This is our overall cohort. You can see here the average age of these patients, as you might imagine, was fairly young, approximately 44. They were all relatively healthy. The Charleston Comorbidity Index on average was one with a range from one to three, with the median range of one to three and an interquartile range, and low Caprini scores, low but not extremely BMIs. And I think this makes sense with the group of patients who would be coming in seeking body contouring. We do see that about an equal number of these patients underwent plication and did not, 54% and 45%, predominance of female, which again, not unusual for patients undergoing abdominoplasty. When we look at our patients, when we just look at the match comparison results here, so if we split them based on venous thromboinsulin, venous VTE events and no VTE events, you can see that there's no significant difference between patients with regard to age, BMI, Charleston Comorbidity Index, baseline Caprini score, operative time, or duration of chemoprophylaxis. And that's by design, obviously, we match the patients to try to minimize these differences so we could look at plication as an independent risk factor. When we look at the complications all told from these surgeries in our VTE group, our event group, and our matched no VTE group, we see that there is no difference here with regard to the vast majority of complications. And when we run a multivariate analysis, we actually find that there's no difference between patients. We actually find each line here represents a separate multivariate analysis, a multivariate logistic regression analysis. And when we evaluate this, we find that rectus placation was not independently associated with the incidence of the onset of VTE when all these other factors are taken into consideration. So in summary, even though bivariate analysis does demonstrate that cases with VTE were more likely to experience concurrent complications, including things like delayed wound healing, seromal formation, and fat necrosis, maybe related to a pro-inflammatory state. We find that these findings do not transfer over to a multivariate models. And we did identify that rectus placation was not associated with venous thromboembolism outcomes. Overall, we did find that the VTE incidence of this cohort, of this approximately 1,000 patient cohort, was about 1.59%, which is right at what has been reported roughly in the literature in alliance with the general trends. We hope that given the large cohort here and the large amount of matching that was performed with regard to medical data, that these results are generalizable to other practices and other situations. And we hope that the results are generalizable, you know, most importantly to other surgeons in other locations, whether that's in the U.S. or abroad performing these procedures. So in conclusion, you know, there's very sparse literature examining the role of surgical techniques, specifically rectus placation in VTE development in abdominal body contouring procedures. The literature demonstrates, as we have said, and I think we're going to hear a little bit about in a few minutes here, conflicting opinions on whether rectus placation actually precipitates stasis and thus could be a triggering factor for venous thromboembolism. The results of our research here would support the idea that VTE events were not associated with rectus placation, meaning rectus placation did not increase the risk of VTE events. I would just like to thank everybody for their attention and I would turn it back over to our moderator, Dr. Kleder. Thank you so very much, Dr. Ricci. I just want to remind everyone that, I don't know if you can see me or you see Dr. Ricci at the moment, but... We see you. Oh, okay. I can see you. I just want to remind everybody that if you scroll down or look at the bottom, you have the ability to put in a question and so we will go over all these at the end and so please put in your questions now and I'll be looking through them and be able to ask them when we finish the next section. So that was an excellent presentation and very stimulating and I'm looking forward to having our discussion afterwards after Dr. Swanson presents. So Dr. Swanson is an outspoken proponent of evidence-based medicine. Dr. Swanson disputes chemoprophylaxis for VTE prevention and proposing safe and effective alternatives supported by his own clinical research. In 2020, Dr. Swanson published the first large 1,000 patients prospective study of VTE and plastic surgery outpatients using ultrasound screening. In 2020, he also published a level one randomized trial evaluating the effect of sequential compression devices on fibrinolysis. Dr. Swanson has authored over 220 publications in peer-reviewed plastic surgery journals, published two textbooks, evidence-based cosmetic breast surgery in 2017 and evidence-based body contouring surgery and VTE prevention in 2018. Dr. Swanson is in private practice in Kansas City. So with that introduction, Dr. Swanson, we await your presentation. Thank you. Well, thank you, Brandon. So I'll talk about VTE risk after abdominoplasty without chemoprophylaxis. So these are my only disclosures are these two textbooks that I wrote and royalties on those. You know, I like this quote from Mark Twain. It's easier to fool people than to convince them that they have been fooled, but that's my job. So I wrote this provocative piece in Annals of Plastic Surgery. It was published a couple of years ago and I'm calling, you know, I'm calling for abandoning Caprini scores and chemoprophylaxis. And you know, I referred to this as bloodletting 2.0, which when I, when I first called bloodletting 2.0, I was a little tongue in cheek, but I'm not anymore. You know, my interest in this started with a VTEP study, which was published in 2011. And my concern reading this study was that, you know, here in the abstract, it's got the P values and they don't seem to support the title and the conclusion. So that's a problem. And also throughout, you know, I read it very carefully. I could not find the numbers of VTEs in the control and treatment or anticoagulant patients reported anywhere in the study. So we do get this graphic that, you know, it's, it's kind of puzzling. I had to look at it for a long time. It appears to show that more VTEs are happening in patients that are not anticoagulated, which are the blue ones than the red ones. And it also appears to show that more VTEs are occurring in patients with higher Caprini scores and that the treatment is particularly effective in patients with high Caprini scores. But if you, if you believe that, you'd actually be wrong because this, this graphic is affected by if you have very small sample sizes, it'll exaggerate the differences. So if you actually look at the data and take the data and look at it in a proper histogram where the percentages add up to 100, you know, the results look very different. The blue and red, it looks like a very similar amount of blue and red in the graphic. And you can see that VTEs are happening in patients with a range of Caprini scores. Doesn't seem to be much advantage in the patients with the highest Caprini scores. So, you know, what's going on with this? So the total number of study patients was over 3,000. The ones in red are the Lovenox treated ones. The ones in blue, that's the historical control study. And, you know, the proportion of patients with VTE was very similar. It was actually the same as it turns out, 1.2% for both treated and untreated patients. So how do you get that and then take it and find that there's a significant difference? Well, what the authors did was they adjusted their data analysis for Caprini scores because the Caprini scores were lower in the historical group. So they thought, well, the prospective group, maybe they're sicker. So we'll make an adjustment for that. But that doesn't recognize the fact that chart reviews underrate Caprini scores. And then they adjusted their data analysis for the length of hospitalization. But, you know, Caprini doesn't regard the length of hospitalization as a risk factor. And you would think these patients are anticoagulated for a little longer if they're staying in hospital longer. So the problem is you're adjusting the data to fit your theory rather than adjusting your theory to fit the data. So let's get back to that bloodletting idea. You know, bloodletting was done for a couple thousand years. The startling thing is this is an actual photograph. This is not a painting from 1860. And it shows a surgeon dutifully doing his bloodletting, following, you know, whatever guidelines were, you know, existed at the time that this was the, you know, the recommended practice, but it was almost always harmful. It's amazing that we were doing it hundreds of years after the scientific method was developed. And if you look at bloodletting versus chemoprophylaxis, you know, there are a disturbing number of parallels, but, you know, the difference is we should know better. You know, hematomas, they're often caused by chemoprophylaxis, and this is not surprising because hemorrhage is the most common adverse reaction associated with lovinods, between one and 10%. So this group in Brazil, Dini et al, they actually had to discontinue their prospective randomized, actually did a randomized study of Xarelto because of excessive bleeding, and they had to break their code. Then there was this study from France, 1,128 abdominoplasty patients who received lovinods, 5.7% had hematomas, you know, that's high. I recently published my series, consecutive abdominoplasty. I don't use any chemoprophylaxis. I didn't have any hematomas. So, you know, that's a hugely significant difference. Now, sometimes people will say, well, hematomas are just inconveniences. You know, VTE can kill you. Well, they're not just inconveniences. You can't have this happening on a regular basis in your practice. It completely changes the patient-physician relationship. You know, they're serious. They might need a blood transfusion. You know, they're going to blame their physician. You know, maybe he wasn't good enough about hemostasis. They affect the quality. You know, they get skin necrosis. So these are very serious. You know, I get emails from time to time and people come up to me at meetings and they talk to me about having used anticoagulation and had very serious problems with it. There is this cautionary tale. This was published in Plastic Surgery News a long time ago, but it talked about a plastic surgeon's patient died of a massive PE three days after a mommy makeover. Competitors rallied against him. He was accused of failing to perform a proper risk assessment and perioperative care to prevent this, like he should have been able to prevent it. So really adding a second victim, that the surgeon lost his hospital privileges, his practice, his wife, and he attempted suicide. I mean, this is very serious. And it's a very serious thing with regard to medical malpractice liability because, you know, today's surgeons, they may believe that they will be exposed to med mal risk if they do not record the Caprini scores. And some plastic surgeons, and this is really sad, but they've got a side hustle going, acting as paid plaintiff's experts to testify against their plastic surgeon colleagues. You know, once you do that, that's a very potent form of COI. You can never go back and say, you know, I was wrong about that. You know, I mean, this is very, very serious. I defended a doctor in California last year, who's, you know, they were trying to take his medical license away. He had a patient who had an abdominoplasty, died of a PE the next day. The plastic surgery expert testified that no anticoagulation was negligent. Her Caprini score was five, by the way. I also, there was a surgeon, he was accused of negligence because he did not use SCDs in a conscious sedation facelift patient, defended him. Two plastic surgeons, board certified, testifying that he violated the standard of care. Problem is surgeons may decide to settle for insurance limits rather than risk a jury verdict exceeding their coverage. And this drives up the cost of our medical, you know, malpractice insurance. This is actual deposition testimony from one of these plastic surgeons. I think it is a deviation of the standard of care that this patient didn't get anticoagulated. And if she had, more likely than not, it would have prevented her death. This is, you know, I told you about that surgeon in California. This is from that, the plastic surgeon plaintiff's expert noted that the patient had a Caprini score of five, and this was an extreme departure from the standard of care not anticoagulating this patient. You know, the surgeon's looking at having his license taken away. You know, I like this quote, the greater the ignorance, the greater the dogmatism, and there's no better example than VTE, the issue of VTE. So where did this start? Well, this is Caprini's paper. Now, I think very few plastic surgeons have actually read this paper, even though they're using Caprini scores, they haven't read the paper. It was a low impact primary care journal. It had 24 references. None of the references supported the relative risk data, and he based his conclusions on logic, emotion, experience, and his intuition. And he didn't disclose all of his various financial conflicts with anticoagulant manufacturers. So I actually looked at Caprini scores, and then I pulled data from the literature, you know, medical literature, and looked at them to see if there was a correlation. There wasn't a correlation. In fact, the correlation was slightly the other way, although not significantly. So this should concern anybody who's using Caprini scores, just the scientific validity of these scores. So, you know, I think it's not surprising that risk assessment models have, you know, they've been failures. I mean, there are these three large studies, the false positive rate was 97%. In other words, let's say you use a Caprini score of seven and over to, you know, identify which patients are at high risk, you'll be wrong 97% of the time. There's a study of Team Southwestern, all 36 patients with super high Caprini scores had no VTE. And, you know, I'm not the first person to look at consecutive patients with ultrasound screening. This group in Memorial Sloan-Kettering, they found that 97% of microsurgical breast reconstruction patients with the highest Caprini scores had no ultrasound evidence of DVTs. In fact, this was interesting because they found that clinical evaluation alone is grossly inadequate. In nine suspected cases, clinical cases where it was suspected, ultrasound showed no DVT, but they did pick up four DVTs in patients with no clinical signs. So that really shows us that we really need to be using ultrasound to properly identify this problem. This is a meta-analysis of plastic surgery patients. It actually really went against the VTEP study because there was no significant difference in VTE rates looking at pool data, and there was increased bleeding in anticoagulated patients. I mean, no surprise there. This other meta-analysis, Dr. Panucci was talking about this just a few weeks ago at the ASPS spring meeting. In fact, they weren't all surgery patients, but the study reported a 2.45% VTE risk for patients not receiving chemoprophylaxis, but it did not report the 4.37% risk for patients who did receive it. So kind of a counterintuitive finding. And in fact, the patients with Caprini scores of five or more, VTE risk was greater for anticoagulated patients. They actually did not enter in the data properly for this study out of U of T Southwestern, where this group, a very large study, again, they found more VTEs in patients who received anticoagulation than those that did not, highly significant. And of course, bleeding risk is increased. What about this study by, you know, this is quadruple ASF data, Keys et al reported it in 2017, a huge number of abdominoplasties, 240 VTEs, 200 of them had Caprini scores, 89% of the VTEs occurred in patients with quotes, low risk Caprini scores equal to or less than six. So what about doubling down on the Lovenox dose? The idea being that, well, maybe we're just not using an adequate dose of Lovenox. Now this was a study, the sample size was only 94, which is, you know, way too small to be studying VTE risk. And the authors included three patients who actually had upper extremity thrombosis from central lines. I mean, a totally different etiology. These should not have been included in the study, but by doing so, they were able to get a P value just under 0.05. And in fact, the findings did not support extra dosing. All of the DVTs occurred in patients who received extra doses. So, you know, comparing bleeding risk, there's a study that talks about twice daily dosing, but what they really mean is doubling the daily dosing from 40 milligrams daily to 80 milligrams daily. Now we have to keep in mind that number one, this practice is off-label in plastic surgery. It's really for general surgery and orthopedic surgery, you know, joint replacement patients. And there the dose is 40 milligrams for prophylactic is 40 milligrams daily. So you're increasing, you're going above the guidelines, even though it's off-label, you're going above the guidelines that are for orthopedic patients to 80 milligrams daily. So you're exceeding those guidelines. The authors found a non-significant increase in clinically relevant bleeding to 6.8%, but they found that wasn't significant. But, you know, if you're getting 6.8% clinically relevant bleeding, that's a problem. You know, I'm in private practice. I could never have this high degree of bleeding in my patients. And very concerning thing, 28% of the patients had overdoses. So the ethics are very questionable. There was this five trial randomized dosing. There were more bleeding, returns to the OR, blood transfusion, and death. This is from the clinical website that was labeled, ironically, minimization of bleeding. This report included, didn't indicate the number of blood transfusions, but there were two patients that died. You know, I don't know what the cause of death. Again, the P-value just under 0.05. So there's an irony here because Dr. Bonucci believes that what he's doing is within the standard of care. And in fact, what I'm doing, which is ultrasound screening, which is FDA approved, and prescribing anticoagulation for people who have DVTs, that's FDA approved. So, and then I was, you know, it was interesting to find this clinical trial that was registered. And it was looking at the proposed study would pilot a randomized double-blind placebo-controlled trial to examine de-implementing current guidelines for anticoagulants. Now, if you're really confident about chemoprophylaxis, why would you even propose such a study? It was withdrawn. Okay, so let's, we just talked a little bit about P-hacking. This is the practice of adjusting your eligibility criteria or controlling for other study factors to force a P-value below 0.05. And we see examples of this. I like this quote from Greg Yesterbrook, "'Torture numbers and they won't confess to anything.'" So what about the bleeding risk? Well, these authors reported no increased bleeding risk. This was in ASJ in 2021, but, you know, they left out a couple of studies. They left out that study, that Brazilian study that I was showing you earlier where they stopped the study because they had so much bleeding. They treated that as an outlier. So, you know, they didn't include that. And they didn't include that big French study I told you about. So if you include these other studies that were excluded, it's a very highly, you know, significantly increased risk of bleeding in anticoagulated patients. So let's get to my study. It's a five-year prospective study. Look at, you know, I used ultrasound scans on a thousand patients, total IV anesthesia, no chemoprophylaxis. There were nine DVTs, one PE, no deaths. And the affected patients were then anticoagulated. Interestingly, the mean time to resolution was five weeks. And the only independent risk factor on regression analysis was age, which was kind of a surprising finding. The next month in 2020, I had a paper published in PRS. This was a randomized controlled study of SCDs in 50 plastic surgery outpatients. You're familiar with this idea that SCDs is not only a mechanical benefit, but it can cause fibrinolysis. So I looked at TPA levels and PAI-1 levels in my patients. These are the results. There was no fibrinolytic benefit. So I think we can put that concept aside. And, you know, if you look at existing studies on SCDs, there's this large one frequently quoted from 2005. They actually found more pulmonary emboli, although not significantly, in the patients that had SCDs. And they detected publication bias. This other study was not in surgical patients. So you have to be critical. These are not in plastic surgery patients. A number of studies are funded by SCD manufacturers. Anesthesia is important. On the left, we have general endotracheal anesthesia. On the right, total IV. So there seems to be, you know, and this is the same horizontal scale on either side. So that type of anesthesia is important. And what about traditional VT prevention models and risk mitigation? They require patient sacrifices. Patients have to have more, pay more for cost of injections. You know, women have to ask, answer questions about miscarriages and stillbirths, you know, and they might be with a different husband or partner than they had before. These are very sensitive questions. They have to, you know, stop taking their hormones. They might have an unplanned pregnancy. You know, they're likely to bleed more because they're taking anticoagulation. And they, you know, they're asked to compromise the result. You know, let's not placate your fascia. Let's not do combined surgery. Let's do two operations rather than one. So let's look again at, you know, risk mitigation, just like risk stratification and chemoprophylaxis. It's a euphemism, it's a blind alley. I found in my studies, there's no increased risk from either of these, from these things, flexing the OR table, repairing the diastasis, combining procedures, hormones or the compression garment. And, you know, I think we all agree that we have to be truthful in what we say. We shouldn't say there's a significant reduction in VTE risk for patients with higher caprinosis if it isn't significant. We shouldn't say that we absolutely know that anticoagulation is appropriate and effective, or that it's VTE risk calculation is like identifying the needle in the haystack. And we all need to get IRBs. I'm in private practice. I always get IRBs. And we have to mention that chemoprophylaxis is not FDA approved. If we're not saying it on our presentations and papers, we're probably not saying it to patients. So why calculate a Caprini score? In fact, if you just look at age as a single variable, you'll do better than if you calculate a Caprini score, but there's still not, you know, we're just talking about a 3% risk. So that's, that's inadequate. This is a controlled study of intra-abdominal pressures and abdominoplasty patients. And the authors, it was a great study. They used a group of breast reduction patients as a control. It was actually a controlled study. The pressures were not significant. You know, they were not high enough to be clinically important and no significant differences comparing with controls. So this is my paper. This is the paper that Dr. Ritchie was involved with. And then this paper by Dr. Restifo. Dr. Ritchie's paper, my paper came to the same conclusion, no difference in VTE risk for placation. Restifo found there was an increased risk, but you know, he had a lot of problems. I mean, he had bleeding issues. And in fact, there were more VTEs again, kind of a counterintuitive thing among anticoagulated patients. I talked about this. This was just published this month, actually, in Annals. But the bottom line is placating the fascia, like Dr. Ritchie said, it doesn't increase risk. And it's such a wonderful patient, you know, thing to do for patients. I mean, it really improves the quality of the result. This was a study finding, again, more VTEs among patients receiving anoxaparin. So my approach, we have to recognize it's really a conceit that we can predict affected patients. We need to give that up. Avoid muscle paralysis if you can. I do it on all patients. We do all total IV anesthesia, no chemoprophylax, no SCDs. We use ultrasound surveillance and patients that are detected early and treated with oral anticoagulation. Now there's this idea, you know, well, plastic surgeons are not radiologists. Should we be doing this? Well, keep in mind, you know, a lot of plastic surgeons are already doing ultrasound in their offices. We, you know, we read EKGs without getting a cardiologist and consider many plastic surgeons, you know, I would be unthinkable 20 years ago, they're prescribing potent anticoagulants that may cause hemorrhage and thrombocytopenia without being hematologists, without being experts and reversal agents. So, you know, important advances are made by those who challenge the status quo. And, you know, I've said it's better to diagnose a DVT on ultrasound screening than an autopsy. So this is actually a video, it's on YouTube, and I'm just amazed. It's got 290,000 views now, which, you know, there are less than 8,000 board certified plastic surgeons. So that's where you can read about, you can see how to do it if you're interested in doing it. And, you know, patient safety is good for business. You know, you can show your patients that you place their safety and their comfort first. Just ending with a quote, the reasonable man adapts, you might've heard this, adapts himself to the world. The unreasonable one persists to adapt the world to himself. Therefore, all progress depends on the unreasonable man. Thank you. That was unbelievable. A great review of the literature. I know that Dr. Panucci has been a member of this in the past and has contributed significantly to the literature that we all use as a resource. And it's nice to look at it in a balanced way. I just want to ask a couple of quick questions. My first one is to Dr. Ricci, and that is, and you may have said it, so I apologize if you had said this, but did you look at the chemoprophylaxis that was being used? And if you did, was there a trend one way or another? Thank you. We did. I just want to say great, great talk, Eric. I mean, I agree with so much of what you're saying there. I think that just to answer your question, we did look at chemoprophylaxis use. We looked at sort of whether they were getting it and the duration of it. Many of the procedures that were performed were done ambulatory. So most of the patients got no days of it, zero doses or one dose. So it was very little, but it didn't show itself to be a risk factor for, it didn't show itself to be preventative or harmful in terms of VTE development. Okay, so to recap, there was very little usage of chemoprophylaxis or was it just so random that it didn't match up to anything? I think the latter. You know, we had a lot of surgeons that were involved in this study over time. We're talking about 10 years, different practice patterns. Some people use it all the time. Some people use it none of the time. Some people score Caprini's and decide to use it. So there was very variable data, but it did not show itself to be an independent, independently preventative of VTE or in the duration of it either. All right. Dr. Swanson, can you share with us, do you remember off the top of your head, the nine patients that had VTEs, were they within the first week? What was their clinical? It sounds like they didn't have a clinical presentation. You picked it up. Can you speak to the timing of when they were discovered? Right, well, there was one abdominoplasty patient who we discovered the day after surgery. And it turns out that she had May-Therner syndrome because we referred her to the hospital right away. The radiologist determined that she had compression of her left iliac vein from this vascular anomaly. So she was actually kind of a setup for a DVT, but that was the only abdominoplasty patient that was diagnosed with a DVT the day after surgery. So in that period of five years, there were nine patients that we detected VTEs. I believe two of them were the day after and seven were at the one week. So we detected more at the one week follow-up than at the day after surgery. And the interesting thing was, I expected to get a lot of DVTs diagnosed, subclinical DVTs the day after surgery, but that's not what I found. And that reassures me because I routinely repair the rectus diastasis. So that reaffirms to me that my repair of the rectus diastasis is not precipitating a DVT in my abdominoplasty patients. So just as a quick clarification, how many of those 1000 patients were abdominoplasty patients? Well, I don't remember off hand, but it might've been a couple of hundred. I don't remember exactly, but- So just to compare apples to apples. So, because I think that that's the big question that we're looking at here is, is it the abdominoplasty patient that is at higher risk with this operation? And I think classically, what we are all taught in medical school is that it's the induction of general anesthesia that starts the cascade. And again, it's again, something that is taught in medical school. And again, going back to bloodletting, it may be something that is changed, but at the moment, it tends to be some conventional wisdom to get these sequential compression devices on before the patient undergoes a general anesthetic. But my point that I'm really trying to ask you to follow up on, Dr. Swanson, is do you feel that it is a significant mediator of your incidence, of your very low incidence, that your patients are having TIVA rather than general anesthesia? Well, yes, I do. I think that is an important factor. And most people who study this, I think Dr. Panucci agrees that anesthesia is an important thing. And if you can do your cases without paralyzing your patients and paralyzing the calf muscle pump, you're probably, you're gonna be in a, you're gonna reduce your VTE risk. And when I did the study, I found that 1,000 patients, I found that an abdominoplasty, increased OR time, combining procedures, and age were all associated with VTE. But here's the interesting thing. Somebody, actually, one of the, I think it was a reviewer who said, can you look at that a little bit more and do a regression analysis? So I have a biostatistician who I work with. She did a regression analysis, and lo and behold, the only independent risk factor was age. And then I thought about it a little more, and I thought, well, our abdominoplasty patients are older, and their OR times tend to be longer, and they're having combined procedures. And it also fits physically, because as you get older, your valves stiffen, and the risk goes way up as you go over 50. So that makes sense from a first principles basis, that age would be the most important criterion. Now, getting to SCDs, yeah, the traditional thinking is that, you put it on before you intubate, but, okay, in this study, the first half of the study, the patients got SCDs. The second half, at least the ones that had OR times over an hour. The second half, they didn't. There was no difference in VTE risk. So we determined, and there were enough patients to satisfy that this was statistically reliable, that SCDs did not appear to reduce risk. But this is in plastic surgery outpatients that are getting total IV anesthesia. All right. So some questions, and either one of you jump on this. Can I ask a question too? Let me answer a couple of questions from people who've written in. Do you think that the rate of VTE is increased or decreased with a drainless abdominoplasty? Joe, do you want to take that one? That's a good question. I know a lot of people are doing drainless abdominoplasties. I'm a chicken. I do them with drains. It's a good question. I don't know. I'm not sure if they would be increased or decreased. I don't know if you feel strongly either way about that. Eric? Well, first of all, I like the answer. I don't know, because I agree with that. I don't know either. And so, but I'm like Joe, I actually use a drain. I use one drain. I take it on three or four days, but it probably makes no difference, but I have no scientific grounds for saying that. Okay. Next question is, the study, in the study, is usage of garments an independent risk factor for VTE? So we didn't look at garments specifically, post-operative compression garments as an independent risk. We didn't look, evaluate that as a risk factor. As I mentioned a little earlier, we have multiple surgeons in our study, so not everybody used them routinely, the same type, the same even manufacturer. I think that there is research that shows that there could be associated, elevated intra-abdominal pressure associated with garment use. That, I think, has been shown on ultrasound examination in the literature. But again, I don't think that, as I was mentioning, I don't think that that necessarily translates. Increased, the theoretical increase in intra-abdominal pressure does not necessarily translate into VTEs. That's confirmed with multiple studies here and opinions. With regard to rectus placation, so I would say post-operative garment use. Again, I don't have any, I don't have the actual data to support that, but I would lean towards it. It probably does not increase the risk of VTE. Yeah, and Eric, I'm sure you feel the same way. I agree with that, yeah. I think that point is valid. Next question. Maybe dilation doesn't mean there's anesthesis. Gotcha, next question. Is it malpractice to have a VTE on an abdominoplasty patient who does not get post-op anticoagulation? I'm sure we all know the answer to this one. Well, no, because if that were the case, then I'd be committing malpractice day in and day out. And I'm sure you agree, Joe. Yeah, and I think if I'm understanding your question correctly, he asked about post-operative chemo-prophylaxis, not even preoperative or intraoperative. I actually did a deep flap today, it's a totally unrelated story, but I was talking with my co-surgeon about whether we should send the patients home with chemo-prophylaxis, and I don't even think for something like that we should. So I don't routinely send anybody home with post-operative prophylactic chemo-prophylaxis unless they have some very established clotting disorder or something else we're worried about. I think a little bit what we're touching on here is that there is no general consensus and people can have their particular opinions as long as you feel comfortable defending them. Next question is, do the speakers have any observations on the relationship between DVT-PE and ethnicity? That one I could comment on a little bit. So if you actually look at our cohort, the study, when I performed the study, I was working up a month for a medical center in the Bronx and the cohort of patients there is largely underrepresented minorities, African-American, Spanish, et cetera. Most of them are non-English speakers and that didn't actually bear. So there was a huge percentage, I don't remember off the top of my head, of patients that were non-white. It was probably two thirds of the patients in the study and that did not bear any relationship with VTE. Okay, perfect. Next is, congratulations, Dr. Swanson, exclamation, independent of Caprini score, do you recommend anaxaparin prophylaxis or not in an abdominoplasty surgery with or without placation? Well, I never recommend Lovenox as chemoprophylactically. In fact, I don't even use it in patients that have, where we detect a DVT. Most of the time, by the way, those are subclinical. So in that situation, I use oral Xarelto actually. I guess like 15 milligrams twice a day for three weeks and then 20 milligrams daily up to three months. So, you know, I'm never using Lovenox. Okay, Joe, do you agree? Yeah, I think what was just described with regard to the Xarelto, I mean, a lot of times if we have patients that have a VTE event, they're admitted to the hospital. We would engage, you know, medical providers, chematologists if needed, so they could get worked up sometimes afterwards. But I think patients actually do fairly well with Xarelto. I've had a few where they've been discharged on Coumadin as sort of an older recommendation, but I think the Xarelto is much better for patients in terms of getting a long-term, you know, steady state management of the anticoagulation. It's easy to take. It's just a small pill once or twice a day. So I think that that makes sense. Okay, next question. Has the timing of when chemoprophylaxis was begun, pre-op, day of surgery, post-op, same day, following day, or otherwise, has been studied and compared in the prevention of DVT in this setting? I don't think that either of you had a paper to address that. No. And, okay, well, let's see. We have another question over here. Rectus placation, question mark, increased failure in obese patients with visceral fat, question mark. It's a bit of a cryptic question. I guess the question is, is rectus placation appropriate for an obese patient? I don't know how you guys feel, but sometimes when I'm operating on an extremely obese patient, I will be much less sort of attempting to tighten the rectus because it's not gonna make that much difference. And so what's the purpose of putting them at a higher risk? And Joe, it's entirely fair to ask the question to your study. What was the level of placation in those patients? Because you were looking at that as a binary, on-off, and there's certainly a range to placation. Yeah, you know, that is a good question about the range of placation. I mean, I think most people standardly would do something from the xiphoid down to the pubis, but some people do it in two segments, right? Like an infraumbilical, supraumbilical. Some people do the whole thing as one segment. Some people do multiple rows of sutures, like an inner row and an outer row of placation. This is a hard thing to quantify because so many surgeons, so many patients, such a long time, a lot of the records, this is all retrospective data. It's just as good as we can do in a lot of situations. But a lot of the data, you're reading something and it's saying, okay, well, I elevated the abdominal skin, I encircled the umbilical stalk with a metamem scissor, and then I did a placation. But it doesn't really get into the details as a nitty gritty more than that. I do think patients with higher BMI though, just as you suggested, maybe don't do as well. They don't get as much sort of bang for your buck from a cosmetic perspective with the placation. And I think if they have a lot of intra-abdominal fat, you also would probably risk something if they had a very wide rectus diastasis, which I think you probably could cause something like, we know it increases intra-abdominal pressure, regardless of VTE. You could be looking at something more devastating, like abdominal compartment syndrome, et cetera, if you really overdid it in somebody that was heavy. Yeah, I'd like to follow up on that. Number one, I think we all know, don't operate on patients that have a beer belly. I mean, it's the type of, you know, you can have a patient with a high BMI, but if they have a very large frame, that's a different matter. I do all my abdominoplasties, patients do not get paralyzed. So when I'm repairing the rectus fascia, they're breathing spontaneously. So you know, if you're restricting their breathing, your anesthetist will tell you. So it's kind of nice to have that vital sign available, which you don't have if you're doing surgery with paralysis. Yeah, and I do all my surgery basically at a hospital, with, you know, it's a university setting. We don't, I'd be lucky, if I had an anesthesiologist that's trying to give a total intravenous anesthesia, the patients would be running down the hallway in the operating room. They'd be running halfway during the case. So a lot of times if we're doing something like that, I'll look at peak pressure for people that don't have that possibility. Peak abdominal, peak ventilatory pressure, can use it as a surrogate for peak abdominal pressure too. So you can actually trend if that's going up and your anesthesiologist can help you to tell you that while you're doing it, if you just talk to them. Yeah, you have a very good relationship and I commend that with your anesthesiologist. It can be, it hasn't been my experience, but I know that some anesthesiologists turn the monitor so that the surgeon can't even see that. Here's the next question is, I think it's for you, Joe. Why is acquired immune deficiency syndrome of so high on the CCI? I think I did see on there that I think it's a six. Is AIDS the highest risk factor? Can you comment on that, please? There are, it is one of the higher risk factors. All of the variables have different, each of the 19 categories, comorbidities has a different score. I think there's one or two factors, HIV AIDS being one of them that has a very high score, which is six. And I think the reason that it's weighted highly like that, I didn't develop the Charleston comorbidity index, but it is widely used. I think one of the reasons that it's highly scored like that is because of the associated downstream things from it. So you can imagine somebody that has a very advanced age or HIV would have other things, malignancies, they'd be at risk for infections. They have a lot of other complications that could be buried underneath that diagnosis. And so that's why I think it adds a little more, it has more sort of gravitas associated with it when we're looking at the old, because you got to remember the Charleston comorbidity index is a way to compare, is to try to equalize different medical conditions to make patients comparable to each other. Awesome, awesome. Next question, do any of you combine abdominal flap liposuction with the standard abdominoplasty? Yeah, I think maybe they're referencing like liposuction the superior abdominal skin flap as you lift it up. I think for select patients that can look good. It kind of gives you the, what they call it, liposculpting. It gives you the equivalent of like a, almost like a midline fake rectus six-pack look. So that can be done, I think, safely suctioning some of the subscarpal fat or excising some of the subscarpal fat is probably safe to do. How do you feel about liposucting with your abdominoplasty? Yes, I think if you don't do it, the patient is likely to complain that they've got this persistent fat of their upper abdomen. So I think you can safely do it. Obviously, you don't want to be too aggressive, but I do it routinely. Yeah, I agree. I do as well. And I think this will probably be the last question. Do any of the speakers have an experience using sodic beneparina in VT prophylaxis? I had to look this up. This is actually a second generation synthetic low molecular weight heparin as an anticoagulant. But I did not have experience with that, no. Yeah. All right, well, I think we can wrap this up. We've answered all the questions. And I think that this is contributing to the immense body of knowledge that's out there about safety and abdominoplasty. And I think the most important thing that we can all get out of this is that we are at least thinking about it, attentive to it, either by ultrasound or some other chemoprophylactics or mechanical prophylactic method so that we are giving our patients the best chance for an excellent outcome as well as a safe result. So I would say thank you very much to everyone and thank you to ASPS for hosting this global webinar. Thank you for having us. Thanks from everyone. Everyone in New Orleans for PTSM. See you there. Bye.

abdominoplasty

venous thromboembolism

rectus plication

surgical techniques

chemoprophylaxis

Caprini scores

total intravenous anesthesia

patient assessment

VTE prevention