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potentially modifiable in the preoperative setting, and can be used in concert with clinical judgment and consideration of other VTE risk factors, such as prolonged operative time, combined procedures, abdominal wall tightening, and anesthesia type, to determine a patient-centric VTE risk reduction plan. This paradigm is extensively discussed below. PREOPERATIVE VTE RISK OPTIMIZATION Risk Modification Through Caprini Score Reduction Individualized VTE risk stratification can be utilized as a jumping off point to conceptualize and quantify perioperative risk for VTE. Review of the individual components that comprise the 2005 Caprini score shows that many patient-level risk factors are potentially modifiable prior to surgery.22 Some examples of these include patient weight or body mass index,36 the presence of a central line or chemotherapy port, recent operative procedure, or use of exogenous sources of estrogen, including oral contraceptives37,38 and vaginal estrogen supplementation.39,40 Once identified in the elective population, surgeons can encourage patients to lose weight, have a chemotherapy port removed if no longer needed, wait at least 30 days before an additional procedure, and/or hold estrogen products and Tamoxifen for 3 to 4 weeks prior to (and after) surgery—all of these interventions will decrease a patient’s Caprini score at the time of surgery. Existing validation studies of the 2005 Caprini score in plastic surgery patients have shown a rapid decrease in VTE risk as risk score decreases; a 1 to 2 point decrease could decrease patient’s VTE risk by 2- to 4-fold.3 VTE risk reduction through any means is desirable. However, as noted above, individualized VTE risk stratification is a jumping off point for surgeons to begin thinking about VTE risk, and also to begin discussing VTE risk with patients. A common scenario concerns oral contraceptives—cessation of exogenous estrogen would decrease a patient’s Caprini score by one point, but might have the unintended side effect of pregnancy. An aesthetics patient with a baseline 2005 Caprini score of 3 has a predicted 60-day VTE risk of 0.32% based on best available data,3 which could be decreased by a fraction of 1% with oral contraceptive cessation. This knowledge helps surgeons to quantify VTE risk but also initiate a discussion with patients about an individualized VTE prevention strategy that also optimizes other paradigms (such as pregnancy avoidance). Surgery-Specific Factors Some surgery-specific factors are poorly characterized by existing risk stratification tools but have been shown to contribute to VTE risk. Studies have associated an increased number of surgical procedures and longer surgical duration with higher risk for VTE.15,41 The 2 are related, and which is the driving force is unknown. However, with this knowledge, surgeons can consider limiting the number of concurrent procedures, which will by nature limit operative time, in order to decrease VTE risk. Aesthetic surgeons combine procedures frequently due to patient convenience (single recovery), expedited patient gratification, competitive market forces, and a desire to minimize patient costs. The American Society of Plastic Surgeons recommends 6 hours or less as the targeted length of aesthetic surgery, specifically stating that “ideally, office procedures should be completed within six hours….this might involve staging multiple procedures into more than one case.”42 Concurrent procedures are known to increase 30-day VTE risk, as shown by CosmetAssure data demonstrating significant increase in VTE risk with an increased number of procedures,15,21 and Internet Based Quality Assurance Data that show increased VTE risk with abdominoplasty plus additional procedures.36 Specifically, 30-day VTE risk among the overall aesthetic population by procedure number included 0.04 % (1), 0.16% (2), 0.26% (3), and 0.53% (4).15 In the preoperative setting, limiting operative time through reduction in the number of concurrent procedures performed is a potentially modifiable VTE risk factor. A discussion in which the patient is an active Downloaded from https://academic.oup.com/asj/article-abstract/39/2/209/5017390 by guest on 20 February 2020 Pannucci 213 participant can help to balance desire for concurrent procedures, patient convenience, and VTE risk. When considering concurrent procedures, the types of procedures combined have an impact as well. For example, abdominoplasty plus intraabdominal procedure has a 6-fold increased VTE risk when compared to abdominoplasty alone (0.34% vs 2.17%). Similarly, abdominoplasty plus a second procedure has a 2-fold increased risk (0.34% vs 0.67%).20 A prior TOPS and CosmetAssure analysis (2009) shows that the risk of VTE increases 5-fold (from 0.02% to 0.1%) among those having breast augmentation vs breast augmentation plus 1 or more procedures and nearly 3-fold (from 0.1% to 0.27%) for those having an abdominoplasty vs abdominoplasty plus 1 or more procedures.21 A more recent review of CosmetAssure (2017) confirmed that breast procedures plus a second procedure carried significantly increased VTE risk, when compared to a breast procedure alone.43 Plastic Surgery Tourism and Flight-Associated DVT Plastic surgery tourism is increasingly common, and the act of flying puts patients at risk for DVT. “Coach
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