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stasis. Increased venous dilation during surgery is associated with later development of DVT,52 likely through the production of intimal microtears that act as a clot nidus. Elastic compression shunts the blood from the superficial to deep systems in order to minimize venous stasis. Prior studies have shown that use of stockings is more effective than non-use in prevention of VTE.53 IPCs physically pump blood out of the legs, re-creating the action of the calf muscle pump and minimizing stasis and operative venous dilation. Via a separate mechanism, IPCs also stimulate bloodborne fibrinolytic activity, meaning that IPCs have both a local and systemic effect.54 Potentially because they impact multiple limbs of Virchow’s Triad, IPCs have been shown to be superior to elastic compression for DVT prevention.55 A meta-analysis performed by the American Association of Plastic Surgeons could not produce data to support whether the combination of elastic compression plus IPCs was superior to IPCs alone. The American Association of Plastic Surgeons makes an explicit recommendation for use of IPCs.7 Among aesthetic patients, those having abdominoplasty are known to be at increased VTE risk.20,21 This population has several distinct risk factors for VTE in the intraoperative and postoperative setting. Increased intraabdominal pressure places pressure on the inferior vena cava and can cause femoral vein stasis with resultant venous dilation, intimal microtears, and DVT formation.52 Abdominal wall plication, which decreases intraabdominal volume, is known to increase intraabdominal pressure.56,57 Similarly, fascial harvest and primary closure for abdominal-based breast reconstruction has been associated with common femoral vein dilation and decreased common femoral vein flow that persists for several days after surgery.58,59 Bed flexion to achieve abdominal closure is also known to increase intraabdominal pressure.56 These data do not necessitate that surgeons abandon plication (which is a critical component of the abdominoplasty operation). However, surgeons should be aware that plication and bed flexion for abdomen closure promote conditions conducive to lower extremity venous stasis and DVT formation. In addition, plication as a “matter of course” should not be performed—this recommendation would be particularly relevant to the panniculectomy population. POSTOPERATIVE VTE RISK REDUCTION Dehydration and immobility promote venous stasis through increased blood viscosity and lack of calf muscle pump action, respectively. As a result, early ambulation and adequate hydration are critical after any surgical procedure. Common femoral vein stasis as a risk factor for DVT has previously been discussed in relation to abdominal wall plication. However, worth noting is that postoperative abdominal binders and compression garments can externally compress and constrict the common femoral vein in the thigh—these garments may require modification to allow their safe use.56,60,61 Mechanical prophylaxis can be used after aesthetic procedures. Elastic compression stockings help to shunt blood between the superficial and deep systems, which will minimize stasis and venous dilation and theoretically decrease intimal microtears as a nidus for clot formation.52,53 IPCs can be used to mimic the calf muscle pump after surgical procedures, at least until the patient’s own calf muscle pump is active.7,55 For most aesthetic patients, this would involve continuation of IPCs in the recovery area until patients are ambulatory. To the author’s knowledge, there are no data specific to the aesthetic population on VTE risk reduction with post-discharge mechanical prophylaxis. Chemical prophylaxis has been shown to decrease 60-day VTE risk in high-risk plastic surgery inpatients when provided for the duration of inpatient stay. Specifically, enoxaparin prophylaxis at 40 mg once daily provided for the duration of inpatient stay reduced VTE risk among high-risk patients (Caprini scores of 7-8 and >8), but not lower risk patients (Caprini scores of 3-4 and 5-6).2 This same study demonstrated a non-significant increase in postoperative bleeding (3.4% vs 2.7%, P = 0.17) when postoperative enoxaparin prophylaxis was or was not provided to plastic surgery inpatients.4 There is no recognized association between Caprini score and bleeding risk.32 Among the aesthetic population, there are no large controlled studies that examine the impact of chemical prophylaxis as opposed to no chemical prophylaxis for VTE prevention. However, when considered, surgeons must understand that wide areas of dissection coupled with highly vascular regions of the body predispose patients to bleeding—this risk is Downloaded from https://academic.oup.com/asj/article-abstract/39/2/209/5017390 by guest on 20 February 2020 Pannucci 215 increased based on the timing of chemical prophylaxis provision. Studies have shown that preoperative or intraoperative initiation of chemical prophylaxis in body contouring19 or facelift62 have very high rates of postoperative hemorrhage, up to 7.3% and 16.2%, respectively. Perioperative enoxaparin prophylaxis has been shown in 1 small subgroup analysis (n = 65) to significantly decrease postoperative DVT in circumferential abdominoplasty patients. However, that same series showed
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