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intraoperative, and postoperative settings. Editorial Decision date: May 22, 2018; online publish-ahead-of-print May 28, 2018. Learning Objectives After reviewing this article, readers are expected to: 1. Understand the basic concepts of individualized venous thromboembolism risk stratification. 2. Understand how to minimize venous thromboembolism risk in the preoperative, intraoperative, and postoperative settings. 3. Recognize that risk for venous thromboembolism can be minimized, but not necessarily eliminated, in the aesthetic and ambulatory populations. Physicians may earn 1 hour of AMA PRA Category 1 Credit™ by successfully completing the examination based on this article. American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ’s website (https://asjcme.oxfordjournals.org/) and then searching for the examination by subject or publication date. Venous thromboembolism (VTE), which encompasses both deep venous thrombosis (DVT) and pulmonary embolus, is among the most devastating of all complications in aesthetic surgery. The United States Surgeon General1 has previously identified VTE as a public health crisis. The Plastic Surgery Foundation has funded multiple clinical trials to examine the impact of VTE among plastic surgery patients.2-5 The American Society of Plastic Surgeons released an evidence-based practice summary for VTE prevention in 2011,6 and maintains an ongoing public VTE Awareness Campaign. The American Association of Plastic Surgeons recently convened an expert consensus panel and published a systematic review Dr Pannucci is an Assistant Professor, Division of Plastic Surgery, Division of Health Services Research, at the University of Utah, Salt Lake City, UT. Corresponding Author: Dr Christopher J. Pannucci, 30 North 1900 East 3B400, Salt Lake City, UT 84132, USA E-mail: Christopher.Pannucci@hsc.utah.edu; Twitter: @PannucciMD Downloaded from https://academic.oup.com/asj/article-abstract/39/2/209/5017390 by guest on 20 February 2020 210 Aesthetic Surgery Journal 39(2) and meta-analysis to provide data-driven VTE prevention recommendations.7 The American Society for Aesthetic Plastic Surgery’s Patient Safety Committee has published a “Common Sense” protocol for VTE prevention.8 The great interest and effort among all plastic surgery societies to identify at-risk patients and prevent VTE is not misguided. Postoperative VTE can be a life- or limb-threatening event that presents suddenly and can be difficult, sometimes impossible, to treat.1,9-14 Thus, prevention is the dominant initial strategy for VTE risk mitigation. The majority of aesthetics patients are at low risk for VTE—and fortunately VTE is a rare complication among the overall aesthetic population. However, when these events occur, they can be devastating. Unlike many complex and comorbid plastic surgery inpatients, the elective aesthetic population is typically younger and healthier. While VTE is rare among these individuals, a fatal pulmonary embolus in a 35-year-old mother of three is devastating in multiple paradigms. The overall rate of 30-day symptomatic VTE among aesthetic surgery patients is 0.09%, based on data from 129,007 CosmetAssure patients.15 Although rare, VTE remains important: a recent review of American Association for Accreditation of Ambulatory Surgery Facilities data showed that pulmonary embolus (PE) accounted for the majority of unexpected deaths after ambulatory surgical procedures,16,17 and that patients who died of PE had high rates of inaccurate VTE risk stratification.17 Certain procedures are known to carry increased or decreased risk when compared to the overall population. This may be due to procedure-specific risk factors, or patient-centric risk factors more common among those patients who elect to have these procedures. Published VTE rates for breast augmentation and facial rhytidectomy are as low as 0.02% and circumferential abdominoplasty as high as 3.4%. Abdominoplasty alone carries a VTE risk of 0.34%, but this nearly doubles (to 0.67%) with concomitant procedures and increases over 6-fold (to 2.1%) when combined with an intraabdominal procedure.15,18-21 VTE risk quantification using procedure type alone ignores the important contributions of patient-centric factors such as body mass index, personal or family history of VTE, and genetic hypercoagulability.2,15,22-26 Patient and procedure-centric factors, including increased age, body procedures, and combined procedures, are known to be independent predictors of 30-day VTE risk.15 The purpose of this CME article is to provide a framework for practicing surgeons to conceptualize and quantify VTE risk among the aesthetic and ambulatory surgery population. In support of this goal, sections highlight existing knowledge and concepts for preoperative, intraoperative, and postoperative VTE risk identification and modification. PREOPERATIVE VTE RISK STRATIFICATION Surgical procedures in the inpatient realm are often time sensitive and cannot be delayed. This means that surgeons must accept a patient’s baseline status (eg, actively smoking, taking anti-platelet agents, or not nutritionally optimized) without the opportunity
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