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significant increase in postoperative bleeding with perioperative enoxaparin.19 Re-operative hematoma is significantly increased in breast surgery or post-bariatric body contouring surgery patients who receive postoperative enoxaparin prophylaxis.4 Ultimately, these data provide further support for judicious, as opposed to widespread, use of chemical prophylaxis. The author advocates that the decision to provide chemical prophylaxis be made based on the surgeon’s estimate of VTE risk and also the surgeon’s estimate of risk for bleeding. Current American College of Chest Physicians guidelines explicitly recommend against aspirin as a single-agent chemical prophylaxis strategy against VTE in non-orthopedic surgical patients.48 Abdominoplasty patients routinely prescribed 7 days of rivaroxaban, an oral Factor Xa inhibitor, for postoperative VTE prevention had low rates of re-operative hematoma (2.3%) and symptomatic VTE (0.8%).63 A retrospective cohort study examined routine postoperative anticoagulation using low molecular weight heparin and oral Factor Xa inhibitors after body contouring procedures and showed no substantial differences in rates of bleeding or VTE between the 2 chemical prophylaxis strategies.64 There are no data available to examine the role of routine administration of chemical prophylaxis after aesthetic surgical procedures; thus, current data do not support this practice. In the author’s opinion, routine chemical prophylaxis among aesthetic patients would likely have an unfavorable risk/benefit relationship—this opinion is supported by existing knowledge that shows the majority of aesthetics patients are known to be at low VTE risk33,34 and that low-risk (Caprini ≤ 6) plastic surgery inpatients2 or surgical patients as a whole32 do not benefit from chemical prophylaxis. Existing recommendations from the American Association of Plastic Surgeons explicitly recommend against providing chemical prophylaxis to all plastic surgery inpatients, as this practice has an unfavorable risk/benefit relationship.7 Both the American Society of Plastic Surgeons and the American Association of Plastic Surgeons recommend individualized VTE risk stratification with provision of prophylaxis based on Caprini score, as opposed to explicit reliance on procedure type.6,7 Screening Duplex Ultrasound Current guidelines from the American College of Chest Physicians explicitly recommend against screening duplex ultrasound (eg ultrasound performed in the absence of Figure 2. Preoperative, intraoperative, and postoperative opportunities for VTE risk modification. Downloaded from https://academic.oup.com/asj/article-abstract/39/2/209/5017390 by guest on 20 February 2020 216 Aesthetic Surgery Journal 39(2) clinical symptoms).48 This is because the clinical relevance and natural history of asymptomatic DVT is unknown—a fact made clear by the LONFLIT in-flight DVT data discussed above.44 One study specific to the aesthetic population performed postoperative screening duplex ultrasound on 200 consecutive patients and showed that the rate of asymptomatic DVT was 0.5%.65 The author disagrees with screening duplex ultrasound for any population because, as noted in the 2012 American College of Chest Physicians guidelines, the clinical significance and appropriate management of asymptomatic VTE remains unclear. The author does not agree with screening duplex ultrasound as a replacement for individualized VTE risk assessment, VTE risk modification strategies, or provision of mechanical or pharmacologic means of VTE prevention. A visual summary of opportunities for VTE risk identification and modification is provided in Figure 2. CURRENT GUIDELINES AND RECOMMENDATIONS The American Society of Plastic Surgeons’ “Pathway to Preventing Adverse Events in Ambulatory Surgery” makes explicit recommendations that surgeons 1) consider VTE risk reduction strategies, and 2) consider chemical prophylaxis for patients who have breast reconstruction, body contouring procedures, and abdominoplasty under general anesthesia when the patient’s Caprini score is ≥7.66 Moubayed and colleagues confirm for us that this recommendation likely applies to only a small fraction (approximately 2%) of the aesthetic population.33 The American Society of Plastic Surgeons published the findings of its VTE Task Force in 2011, and the American Association of Plastic Surgeons published the findings of its meta-analysis driven Consensus Panel in 2016. Both organizations agree upon the following tenets of VTE risk stratification and prevention: 1) individualized VTE risk assessment to understand baseline VTE risk, 2) utilization of the 2005 Caprini score as an individualized VTE risk stratification tool, and 3) incorporation of patientand procedure-specific VTE risk into the patient-specific VTE prevention plan. These documents are referenced for readers, who are strongly encouraged by the author to review the source literature.6,7 Direct quotes that are relevant to the aesthetic population are provided here. American Society of Plastic Surgeons VTE Task Force Recommendations (2011)6 1. Risk stratification: “Should consider completing a 2005 Caprini RAM…to stratify patients into a VTE risk category based on their individual risk factors.” 2. For elective surgery
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