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CHAPTER 13 Patient Safety in Plastic Surgery
Emily A. Long, Helen Xun, and Bernard T. Lee
KEY POINTS
Plastic surgeons have a duty to keep their patients, their staff, and the general public safe.
When possible, elective surgery should be deferred until modifiable patient risk factors
have been optimized.
Prescribe opioids and antibiotics only when indicated, and for the shortest effective
duration possible.
All patients should be provided preoperative risk assessment and appropriate prophylaxis
for venous thromboembolism.
A diverse and inclusive environment that promotes a culture of psychological safety
improves patient safety outcomes.
INTRODUCTION
First, do no harm.
Patient safety is the practice of preventing adverse outcomes that may arise as a result of
healthcare interventions. Plastic and reconstructive surgery is a unique surgical discipline in that it
offers patients a chance to gain, or regain, quality of life. Whereas other surgery specialties often
focus on quantity of life, in plastic surgery, improvement in quality of life is important. It is, therefore,
critical to ensure that any operative or nonoperative interventions be performed in such a way that
minimizes harm to the patient.
Plastic surgeons must take responsibility for the safety of their patients by keeping up to date on
continuing medical education, reading current literature, and most importantly, applying evidencebased measures from the literature into their own practice. Though old habits are comfortable, it is in
all likelihood that at some point during our careers, a practice we learned in training will simply be
proven to be outdated or even harmful to our patients. It is up to each surgeon to continuously strive to
improve the quality of care they provide and adjust their practice accordingly. Common modern
examples in plastic surgery include prescribing antibiotics to patients for the duration of the time they
have surgical drains (this does not decrease surgical site infections [SSIs]) or overprescribing
oxycodone because the surgeon fears ibuprofen increases postoperative hematomas (it does not).
These and other evidence-based ways to improve patient safety in plastic surgery are detailed in this
chapter.
Patient safety also requires the creation of a culture of safety among all members of the healthcare
team. Surgeons who rely solely on their own experiences without incorporating input from residents,
medical students, nursing staff, anesthesia, national societies, and most importantly, patients
themselves will inevitably cause harm. Surgical practice is built upon tradition and hierarchy; however,
it is only in the willingness to collaborate and look ahead that innovation and improvement can be
made.
PREOPERATIVE ASSESSMENT
There are generally two groups of plastic and reconstructive surgery patients: relatively young, healthy
patients who present in-office seeking elective surgery, and medically complex patients healing from
cancer or trauma who require skilled reconstruction to complete their recovery. In either case, it is vital
that no harm result from plastic surgery procedures and operations. Therefore, establishing whether a
patient is an operative candidate is perhaps the most critical aspect of patient safety in plastic surgery.
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For all patients, a thorough history and physical exam is critical. Patients presenting for elective
operations should be screened for modifiable risk factors and should be informed of the risks of
proceeding with surgery without taking the time to optimize any factors that put the patient at risk of
operative complications. Evidence-based clinical decision-making should be used to determine
whether to proceed with an operation on a high-risk patient or defer surgery until modifiable risk
factors have been appropriately managed.
Hospitalized patients in need of reconstruction or emergent procedures may not have time or the
physical capacity to reduce their risk profile. However, whenever possible, a multidisciplinary approach
to optimize nutritional status and glucose control and ensure postoperative social supports are in
place should be used.
Cardiac Risk Assessment
The goal of preoperative cardiac risk assessment is to identify patients at risk for perioperative
adverse cardiovascular events including myocardial infarction, nonfatal cardiac arrest, and cardiac
death. Estimation of risk can help inform the surgical planning process, including whether or not the
risk of surgery outweighs any predicted benefits. There are numerous cardiac risk assessment tools
and calculators available, though they all generally assess whether recent cardiac events or current
cardiac symptoms are present, and provide an understanding of a patient’s functional capacity. Very
high-risk patients (history of recent myocardial infarction, unstable angina, decompensated heart
failure, high-grade arrhythmia, or severe aortic stenosis) should be referred to a cardiologist for further
evaluation and treatment and should not undergo elective surgical procedures. For patients with
known cardiac disease or significant risk factors (diabetes mellitus requiring insulin, creatinine >2
mg/dL), pre-operative screening for diminished functional capacity (assessed by whether the patient is
able to climb two flights of stairs without becoming short of breath) can help determine whether a
patient should be referred for further cardiac evaluation prior to surgery.
The American Society of Anesthesiologists Classification
The American Society of Anesthesiologists (ASA) physical status classification system assesses
patient preoperative medical comorbidities and disease burden (Table 13.1). The ASA classification
system is not designed to stratify preoperative risk independently. However, when used alongside
other operative risk factors, including length and invasiveness of the planned procedure and overall
patient frailty, the ASA classification system can be a helpful assessment tool for evaluating
preoperative risk.1 Additionally, it can be used to aid decision-making about risk-reducing techniques,
including whether or not a patient is a candidate for surgery.
TABLE 13.1. ASA CLASSIFICATION DEFINITIONS AND EXAMPLES
ASA
Classification
Definition Examples
ASA I Healthy patient
ASA II Patient with mild
systemic disease
BMI 30-40, active smoker, controlled DM or HTN,
asthma
ASA III Patient with severe
systemic disease
BMI > 40, poorly controlled DM or HTN, asthma,
COPD, implanted pacemaker, ESRD on dialysis,
history of MI, TIA, or CAD requiring stents (>3 mo)
ASA IV Patient with severe
systemic disease that
is a constant threat to
life
Recent MI, TIA, CAD/stents (<3 mo), ESRD not on
dialysis, sepsis, shock
ASA V Moribund patient not Ruptured AAA, massive trauma, intracranial bleed
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expected to survive
without the operation
with mass effect
ASA VI Brain-dead patient
AAA, abdominal aortic aneurysm; ASA, American Society of Anesthesiologists; BMI, body mass index; CAD, coronary
artery disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; ESRD, end-stage kidney disease;
HTN, hypertension; MI, myocardial infarction; TIA, transient ischemic attack
From Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status: historical perspectives and modern
developments. Anesthesia. 2019;74(3):373-379. doi: 10.1111/anae.14569. Table 13.1 and derived from Saklad M. Grading
of patients for surgical procedures. Anesthesiology. 1941;2:281-284. © Georg Thieme Verlag KG.
Modifiable Patient Risk Factors
Smoking
Smoking is a major modifiable risk factor that poses significant risk to patient safety during the
perioperative period. Smoking increases the risk of pulmonary and cardiovascular complications, and
significantly increases the risk of venous thromboembolism (VTE), especially in patients who are also
taking oral contraceptives or have other VTE risk factors.
2
In plastic surgery patients, smoking has a profoundly detrimental effect on wound healing. Nicotine
causes vasoconstriction, resulting in local tissue ischemia. This ischemia is further exacerbated by
carbon monoxide and hydrogen cyanide in cigarette smoke, which inhibit oxygen binding and
transport. Additional physiologic effects of smoking include increased platelet aggregation and
endothelial cell dysfunction, and decreased neutrophil function and oxidative burst. This results in
further ischemia and increased risk of SSI. Wound healing is disrupted because of decreased
fibroblast activity, increased matrix metalloproteinase activity, and impaired endothelial proliferation.
Plastic and reconstructive operations requiring the dissection of large flaps with significant
undermining, such as rhytidectomy and abdominoplasty, carry increased risk of flap loss in smokers.
Breast reconstruction patients who are active smokers are more likely to develop mastectomy flap and
nipple-areola complex necrosis. For patients in whom delaying surgery is not possible, an inability to
quit smoking prior to mastectomy should be taken into account during the preoperative planning
process. Patients should be counseled extensively on their increased risk of complications.
There is good evidence to suggest that wound healing complication risk is decreased with smoking
cessation 4 weeks preoperatively and postoperatively.3 It is recommended that patients who are active
smokers be referred to smoking cessation programs and required to stop smoking for a minimum of
4 weeks prior to surgery. Smoking cessation should be confirmed with cotinine testing 2 to 5 days
preoperatively, to allow time for rescheduling the operation in the case of a positive test.
Postoperatively, patients should continue to abstain from smoking for a minimum of 4 weeks, or until
wound healing is complete.
Obesity
Obesity, defined as body mass index (BMI) > 30 kg/m2, is an independent risk factor for numerous
postoperative complications including hematoma, seroma, wound dehiscence, and VTE.4 These
complications frequently require additional instances of hospital-based care within the postoperative
period, resulting in substantially higher healthcare charges for obese patients undergoing outpatient
plastic surgery.5 Likely as a result of increased complications, in conjunction with nonideal esthetic
outcomes, obese patients report lower patient-reported outcomes and decreased satisfaction
compared to nonobese patients.
Obesity increases levels of circulating estrogen and is an independent risk factor for the
development of breast cancer. Obesity is highly prevalent among the breast reconstruction population.
Obese patients are more likely than normal weight patients to develop postoperative complications
following both implant-based and autologous breast reconstruction.6 Additionally, obese patients who
undergo implant-based breast reconstruction are more likely to experience reconstructive failure, and
have significantly lower patient satisfaction scores than their normal weight peers.6 In elective breast
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