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for risk factor modification. In contrast, aesthetic surgery is completely elective. Surgeons will commonly delay a proposed aesthetic procedure to allow patient optimization, and this practice is directly relevant to VTE risk. Preoperative optimization requires a reliable tool to quantify baseline status, with an expected and demonstrable change after an intervention. Some examples include testing smoking cessation with urine cotinine levels, nutrition with serum prealbumin levels, or cardiac ejection fraction with an echocardiogram. Similarly, perioperative risk for VTE can be conceptualized using individualized VTE risk stratification. As part of a full preoperative history and physical exam, the author recommends completion of an individualized VTE risk assessment tool such as the 2005 Caprini score (Figure 1).22 The practice of individualized VTE risk stratification, and specific utilization of the 2005 Caprini score, is explicitly advocated for by the American Society of Plastic Surgeons and American Association of Plastic Surgeons.6,7 The 2005 Caprini scoring system is a weighted risk assessment tool. This means that individual risk factors receive a different number of points, with point levels related to their relative importance in VTE risk. When summed, the aggregate risk score correlates with a percentage risk for VTE. This tool also acts as a checklist-style guide to promote surgeon inquiry into family history of VTE and history of multiple lost pregnancies (the most commonly missed risk factor22,27), personal history of VTE, genetic hypercoagulability, and current estrogen usage, among others. The 2005 Caprini score has been extensively validated among individual surgical populations, including plastic surgery,3 general, vascular, and urology surgery,28 otolaryngology head and neck,29 gynecology oncology,30 and surgical ICU patients,31 to predict postoperative VTE risk among patients who receive no chemical prophylaxis. Data from plastic surgery inpatients who receive no chemoprophylaxis clearly demonstrate that a wide variation in VTE risk is present among the overall population of plastic surgery patients. Specifically, these data showed that 60-day VTE rates for inpatients not provided with chemical prophylaxis included 0.6% in Caprini 3-4 patients, 1.3% in Caprini 5-6 patients, 2.7% in Caprini 7-8 patients, and 11.3% in Caprini >8 patients.3 These data support that an 18-fold variation in baseline VTE risk exists among plastic surgery patients. Similarly, the score has been validated for surgical patients as a whole,32 meaning that pooled data for all surgical patients showed similar variation in VTE risk without chemical prophylaxis. Individualized VTE risk stratification allows surgeons to conceptualize and quantify this risk. Using the 2005 Caprini score, one study33 showed that the minority (2%) of rhinoplasty patients were at high risk for postoperative VTE (Caprini score ≥ 7). A similar study34 among the overall ambulatory aesthetic population showed that less than 1% were at high risk. These studies demonstrate that the majority of aesthetic surgery patients are at low VTE risk, but also provides evidence that there is a small, nested population of high-risk individuals within the overall low-risk group. Preoperative identification of both of these groups can be performed using individualized VTE risk assessment. The 2005 Caprini score has been used to identify highrisk populations that specifically benefit from chemical prophylaxis in plastic surgery2 and urologic surgery.35 Similarly, a meta-analysis using data from the overall surgical population clearly demonstrates that surgical patients with Caprini scores of 7-8 or >8 have significant VTE risk Figure 1. The 2005 Caprini thrombosis risk factor assessment form. Reprinted with permission.22 Downloaded from https://academic.oup.com/asj/article-abstract/39/2/209/5017390 by guest on 20 February 2020 212 Aesthetic Surgery Journal 39(2) reduction when postoperative chemical prophylaxis is provided.32 To date, no study has shown that ambulatory or outpatient surgery patients classified as high risk using the 2005 Caprini score benefit from chemical prophylaxis. This study is unlikely to be performed, due to unreasonable sample size. If we assume that 2% of the aesthetics population is at high VTE risk (Caprini score ≥ 7),33 that the postoperative VTE risk among Caprini ≥ 7 patients is 3%, and that chemical prophylaxis will decrease VTE risk by 50%,2 then a study powered at 90% to identify significant VTE risk reduction with chemical prophylaxis would have to screen 218,400 patients (98% of whom would have a Caprini score ≤ 6) and enroll 4368 patients into 1 of 2 arms (chemical prophylaxis or no chemical prophylaxis). This sample size calculation highlights the importance of considering risk at the individual level, which will allow surgeons to identify high-risk patients and selectively intervene as below. In the absence of data specific to the ambulatory aesthetic population, surgeons are forced to use indirect high-quality evidence, including data from plastic surgery inpatients or surgical patients as a whole.2,3,32 The author recommends using the 2005 Caprini score as a “jumping-off” point for surgeons to consider and conceptualize VTE risk among the aesthetic population. The score can identify existing risk factors that are
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