Thromboembolism risk and tummy tucks

There's a good review article on the risk of blood clotting problems known as "VTE's" and their relationship to abdominoplasty surgery in this months issue of Plastic and Reconstructive Surgery. VTE is the abbreviation for venous thrombo-embolism, and it includes such problems as deep vein thrombosis of the leg and pulmonary embolism.

Although this topic may sound obscure, pulmonary embolism can be fatal, and it can sneak up and strike suddenly after major surgery, without warning symptoms. My friend, Dr. Paul Vanek, once described VTE's as a "scud missile striking randomly in the middle of the night" - and that's a good way to think about it. So, anything we can learn to understand and prevent this problem better is really very important.

The authors reviewed the plastic surgery literature on VTE's, and their analysis revealed some findings that should make surgeons sit up and take notice.

In particular:

Risk of VTE with standard tummy tuck: 0.34% (= 1 / 300)

Risk of VTE when tummy tuck is combined with an intra-abdominal procedure (e.g. hysterectomy) 2.17% = 6 x risk

Risk of VTE when tummy tuck is combined with lower body lift (circumferential tummy tuck) 3.40% = 10 x risk.


Both of these findings were highly statistically significant.

Of course, wise surgeons do everything possible to prevent this problem. Using pneumatic compression leggings, which massage the calf area, keeping blood moving during surgery helps. Giving Lovenox, the medication which treats blood clots, helps significantly. And getting people moving as soon as possible after surgery helps too. But the risk of developing a VTE is still not eliminated.

So, what can we learn from this paper?

Personally, I think surgeons should give up doing the procedures that are high risk for these complications, until a proven strategy to prevent these potentially life-threatening problems can be developed and tested.

That mean no "circumferential" tummy tucks, and not doing tummy tucks at the same time as other operations inside the abdomen.

Just my two cents.

New simpler rules for cholesterol testing

I had an interesting conversation with a patient this week, who strenuously asserted that the link between cholesterol levels and heart disease remains "unproven". As it happens, this month's issue of the Journal of the American Medical Association (JAMA) has a major new study reviewing the link between cholesterol, heart disease and stroke, so I was able to show him the data.

The study group came up with some new findings, and re-confirmed some older findings:

1. HDL levels (high density lipoprotein) - aka "the good cholesterol" - is clearly protective for heart disease. Higher levels are strongly correlated with a reduced rate of coronary heart disease. We knew this already.

2. Everything else (other than HDL) in the cholesterol family is "bad", with the risk of cardiac disease increasing significantly for non-HDL levels above 135 mg/ml. "Non-HDL cholesterol" is certainly simpler to remember than LDL's, VLDL's, chylomicrons and all the rest.

3. Triglyceride levels had no relation to heart disease risk in this study. Before you start celebrating, remember that excess triglyceride levels have been linked to pancreatitis.

4. Interestingly, there was no significant linkage between non-HDL (bad) cholesterol and stroke rates. That finding was unexpected.

5. Also new, Cholesterol levels did not vary significantly from the fasting and non-fasting states. Therefore, next time you go to have your cholesterol blood test, you will no longer need to skip breakfast.

Essentially, this study simplifies assessment of the lipid risk profile for cardio-vascular disease. Measure your total cholesterol and your HDL cholesterol, and don't worry too much about the other cholesterol groups. And don't worry about getting fasting lab work, unless the fasting state is needed for some other lab test, like glucose levels.

Ripples and breast augmentation

One of the frustrating problems that can sometimes occur after breast implant surgery is known as "rippling" - an irregular wavy look or feel to the breast. This is caused by a combination of factors, related to the physical properties of the implant, the patient's own soft tissue and how it may have changed over time, and the choice of implant pocket design ("over vs. under").

Plastic surgeons generally divide these problems into 2 main categories, based on why they've happened.
1. Shell rippling
2. Traction rippling

Shell rippling is the most common problem of this kind I see, and is the topic for today. (I'll discuss traction ripples in a later blog.) The classic scenario is with a subglandular ("over") saline-filled implant in a slender woman who doesn't have very much tissue coverage over the implant. Typically, the breasts looked OK for a period of time, and then, ripples started to show up later.

The usual way to improve this situation is to operate, and get more tissue coverage over the implant, by converting it to a sub-pectoral position. This move significantly improves ripples in the upper portion of the breast - which is the area most exposed by low neckline fashions. The other solution is to change the saline implant to a silicone gel implant, which has been shown in studies to have a ripple rate of approximately 1%, as opposed to the ripple rate of saline implants, at about 10%. I usually prefer to use both methods - getting muscle coverage over a gel implant. It works well to fix this problem.

Shell ripples occur for several reasons: they have to do with the tendency of the elastomeric implant shell to want to fold in on itself, the amount of fill in the implant, the viscosity of the fill material in the implant, and the pressure applied by the surrounding soft tissue. They are disguised by the amount of soft tissue thickness over the implant. Often, with the passage of time, there is thinning out of the breast tissue adjacent to the implant, and implants that were adequately covered early post-op may become more obviously rippled over time.

Saline implants, having the lowest viscosity filler, will ripple the most. Currently available silicone gel implants, having a moderate viscosity filler, ripple a lot less. The "form stable" gummy bear implants, with their high viscosity silicone filler, should ripple even less than the current generation of gel implants. Early data from Europe seems to support this concept.

Women interested in saline implants often ask about the concept of "over-filling", which is just adding more saline solution in the implant bag, beyond the manufacturer's recommended range. There are pro's and con's to this approach. Certainly, more fluid will reduce some of the emptiness and collapse of the implant shell seen when the saline implant is in the vertical position. It also makes the implant larger, rounder, less natural looking, and a little more firm. It also potentially voids the manufacturer's warranty. If you over-do the over-filling, you start to see a new type of wrinkling - tension bands around the equator of the implant. So overfilling is only partially helpful- and as we've discussed, it only addresses one of the multiple factors that are involved with ripple formation.

The soft tissue pocket is also important. If there is a significant amount of capsular contracture, the soft tissue envelope may actually distort the shape of the implant, and cause it to fold on itself. This can cause a knuckle-like point to occur in the implant, which patients may be able to feel through the skin. Implant folds can lead to early implant failure. So, when you are fixing ripple issues, any capsule issues will need to be addressed surgically as well.

Take home message: ripples are related to the combination of thin soft tissue coverage, combined with the engineering limitations of the current generation of breast implant devices. If you are slender up top, and can feel or see your ribs on the side of your rib cage, you should give some thought to sub-pectoral implant placement of a gel implant, if you want to do everything currently possible to minimize your risk of ripple issues post-op.

For some ultra-skinny women, even sub-pectoral gel implants will have some ripples. While weight gain would help, very few women want to hear that they should gain a few pounds! Here, our treatment options are limited - placement of a layer of alloderm or strattice (very expensive), fat grafting to the breast (technically difficult), or perhaps injections of commercially available fillers. It remains to be seen whether the new generation of form-stable breast implants will be a good answer or not for this group of patients.

Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries - say, a tummy tuck with a breast operation.

To answer this, we have to look at things from 2 different angles:
1) legal - what do the Florida regulations permit, and
2) medical - what do the studies looking at surgical complications find.

First of all, the applicable Florida regulations for office-based surgery state that the "maximum combined duration of anesthesia shall not exceed 8 hours."
Longer procedures can be performed - in a hospital.

From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, somewhat of a mixed picture, when it comes to plastic surgery operations for healthy people.

Data against long surgeries:

- increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.

- increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT's.

- increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions.

- increased rate of surgical site (wound) infections with longer surgeries.


Data supporting combination surgeries

- no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.

- no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this study, all surgeries were less than 6 hours in length.

The bottom line: Combination surgeries can be performed safely, but that doesn't mean we should throw caution to the winds and have a marathon surgical make-over. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating.

I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients. I feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this number.

So, going back to the original question: I will combine a breast augmentation (approx. 1 hour procedure) with a major abdominoplasty (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a big tummy tuck, as I feel the lengthy anesthesia / surgery time is worrisome.

As always - safety first.

Risks of Body Contouring Surgery Rise with Increased BMI

We've long suspected this, but now a recent study confirms the link between increased body mass index (BMI) and complications of body contouring surgery, such as tummy tucks, thigh lifts, breast reduction, and other similar procedures. The study, published in the July/August 2008 issue of the Aesthetic Surgery Journal, showed an increase in the complication rate with increasing obesity.

A statistically significant association was found between increasing BMI and an increased number of complications and poorer outcomes. Specifically, the percentage of complication increased as weight category increased. Major complications increased progressively from 6.6% in the ideal weight group to a shockingly high 43.7% in the severely morbidly obese group (BMI>40). Major risks were defined as wound breakdown, need for hospital readmission, re-operation, or death.

In particular, risks seemed to increase substantially with any BMI above 30-34.

Patients and surgeons alike need to be aware of these findings. In addition to making wound healing and anesthesia more complicated, many secondary medical conditions, including high blood pressure, diabetes, sleep apnea, and cardiovascular disease, are more common in patients with an increased BMI.