|Although DVT commonly occurs in the leg, it may occur in the upper body and extremities as well.|
Venous thromboembolism (VTE), including deep venous thrombosis (DVT)—also known as deep vein thrombosis—and pulmonary embolism (PE), are potential complications of plastic surgery procedures. Often presenting with subtle signs and symptoms, the recognition and diagnosis of DVT and PE may be delayed, thereby leading to significant morbidity and mortality.
It is estimated that PE accounts for 100,000 to 200,000 deaths annually in the United States.1 Approximately 5% of all perioperative deaths are attributable to PE.2 In plastic surgery procedures, PE is the leading cause of death following liposuction,3 and it is estimated that the incidence of DVT following abdominoplasty is as high as 1.2%.4 Interestingly, rhytidectomy is also associated with a 0.35% incidence of DVT and a 0.14% incidence of PE.5
It is important for the surgeon to realize that DVT is commonly asymptomatic,6 and that the majority of fatal PEs are not suspected prior to death.7 In addition, the rate of PE in patients with untreated proximal (above-knee) DVT approaches 50%. Fortunately, this rate may be reduced to less than 5% with current treatment algorithms.4
According to Chicago-based, board-certified plastic surgeon Loren S. Schechter, MD, FACS, it is of utmost importance for physicians to listen very carefully to the subtleties and signs in patients’ complaints after surgery in order to avoid a potential PE.
PSP spoke with Schechter, who is assistant professor of surgery at Chicago Medical School and chief of plastic surgery at Rosalind Franklin University. He is also the chairman of the Patient Safety Committee for the American Society of Plastic Surgeons (ASPS).
PSP: What is DVT?
Schechter: It is basically a blood clot that forms in the deep veins of the body, as opposed to the clot forming in more superficial veins.
PSP: What is the difference between DVT and PE?
Schechter: Both come under the heading of venous thromboembolism, but a PE occurs when the clot breaks off and travels to the lungs. Generally, the more concerning clots are those that may form in the deep veins of the legs and thighs. This may occur in the perioperative period. The concern is if that blood clot breaks off and travels to the lungs, it could be life-threatening. This may occur several days after surgery. In fact, surgery is one of the predisposing factors in the formation of the clot. DVTs typically occur after surgery. It is at this time that the clot can break off and travel to the lungs.
PSP: What particular procedures should you watch more carefully for DVT?
Schechter: In plastic surgery, abdominoplasty carries the highest risk of DVT, followed by the facelift. There are any number of hypotheses as to why. We do know certain conditions that predispose to clot formation. These include general anesthesia, immobility, and certain genetic conditions, such as hypercoagulable states.
Among plastic surgeons, the ASPS has done a good job of increasing awareness about the risks of these procedures.
PSP: What are the signs of DVT?
Schechter: Some signs that may be of concern include sudden onset swelling or pain in the leg, or feeling a lump or a bump in the leg. Signs of PE can also be variable and nonspecific, and may range from shortness of breath to chest pain, a fast heart rate, and fever. However, some of these signs and symptoms may occur after surgery and are not necessarily indicative of a PE. This can be confusing for a patient. For example, a fast heart rate may be related to pain or dehydration. Other potential causes are infection or a heart attack.
Furthermore, DVTs do not occur only in the leg. Although the leg is more common, DVTs may also occur in the upper extremities. These clots are oftentimes associated with indwelling catheters such as central venous lines or peripherally inserted central catheters (PICC lines).
PSP: What is the risk of death for PE from plastic surgery?
Schechter: The rate of DVT following abdominoplasty can be as high as 1.2%. Following a facelift, the rate may be .35%. The risk of death with an untreated proximal DVT may be as high as 50%.
PSP: What are the risk factors for DVT?
Schechter: The risk factors, known as Virchaud’s Triad, include stasis, hypercoagulability, and vascular injury. Other things, such as immobilization as a result of surgery or other trauma, obesity, smoking, oral contraceptives, previous history of a DVT, cancer, pregnancy, certain genetic states like hypercoagulable states, protein C or S deficiency, and other medical conditions, can also be issues.
PSP: Are there any treatments/medications that a patient can do/take prior to surgery to prepare for and prevent DVT?
Schechter: There are many things you can do to minimize the risk, such as compression boots, medications, and ambulation. If the patient is high risk, or has a history of DVT or a hypercoagulable state, then he or she may also benefit from a consultation with a hematologist.
PSP: Many plastic surgery patients are over 40, and many also are overweight—two known risk factors of DVT. How does that play into how you evaluate a patient for surgery?
Schechter: There are many factors to consider when evaluating a patient. How many of the risk factors are present is an issue. What is the nature of the surgery? What is the most appropriate prophylaxis? But every decision between the patient and the surgeon requires an understanding of the risks of surgery.
PSP: What are some of the other things a surgeon can do to help prevent DVT complications?
Schechter: Knee positioning on the operating table. I prefer to have the knees flexed and bent a bit. Depending on the patient, I may use compression boots alone or boots and medication. After surgery we like to get the patient up and moving as soon as possible. However, this is not always possible, especially in the trauma population. In these instances, we may have interventional radiology place a vena cava filter. The filter doesn’t prevent a clot. It prevents the clot from migrating to the lungs.
PSP: What about tried-and-true techniques versus newer techniques for the treatment of DVT and PE?
Schechter: There is nothing guaranteed. Any surgery carries risk. Most of what we are using today is fairly well-known methodologies. From what I understand, there are medications on the horizon, but what we are discussing today is mechanical compression, chemoprophylaxis, early ambulation, and hydration.
Another aspect is travel, such as the concept of medical tourism. This is something patients have to be careful about. Air travel is a potential independent risk factor for DVT. Because of sitting for long periods, it is important to get up and walk, stay well hydrated, and avoid alcohol.
PSP: Do you have any thoughts for residents or new surgeons who may encounter a DVT incident after surgery?
Schechter: The most important thing is to understand what your patients’ complaints are. If you are called by a patient who has sudden onset unilateral leg pain, chest pain, or shortness of breath, she needs to get to the emergency room right away.
The problem isn’t so much the DVT, the problem is if the clot breaks off and becomes a PE. The goal in the treatment of the DVT is the prevention of the PE. The signs or symptoms of the PE could be very nonspecific and may be consistent with pain after surgery, infection or a heart problem. You must be vigilant and get the patient to the hospital right away so therapy can be initiated.
Specifically, for the more high-risk procedures, patients need to be informed. Surgeons need to be informed about the appropriate prophylactic techniques and should have a high index of suspicion for the complaints we discussed. You always have to understand the risks and the trade-offs of surgery. There are also risks that exist with the medications. Because the medicines to help prevent clots are blood thinners, there is a risk of bleeding.
As the physician, we have to balance the risk between clotting and bleeding.
Amy Di Leo is a contributing writer for PSP. She can be reached at .
- Dalen JE. Pulmonary embolism: What have we learned since Virchow? Natural history, pathophysiology, and diagnosis. Chest. 2002;122:1440-1456.
- Anderson FA, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates for deep vein thrombosis and pulmonary embolism. The Worcester DVT study. Arch Intern Med. 1991;151:933-938.
- De Jong RH, Grazer FM. Perioperative management of cosmetic liposuction. Plast Reconstr Surg. 2001;107:1039-1044.
- Most D, Kozlow J, Heller J, Shermak M. Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005;115:20e-30e.
- Reinisch JF, Bresnick SD, Walker JWT, Rosso RF. Deep venous thrombosis and pulmonary embolus after facelift: A study of incidence and prophylaxis. Plast Reconstr Surg. 2001;107:1570-1575.
- Tapson VF. The diagnosis of acute venous thromboembolism. Dis Mon. 2005;182: 569-574.
- Stein PD, Henry JW. Prevalence of acute pulmonary embolism among patients in a general hospital and at autopsy. Chest. 1995;108: 978-981.