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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_612_Библиотеки_им_академика_М_И_Перельмана
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surgery, including reduction mammoplasty, mastopexy, and breast augmentation, obesity increases
the odds of postoperative complications 12-fold.
4
Because of these risks, many plastic surgeons use BMI cutoffs and will decline to perform elective
operations on high BMI patients. However, BMI is not a perfect measure of health, and in many cases,
such as breast reduction, quality-of-life benefits may exceed the surgical risks, and even help the
patient lose weight over the long term. Obese patients should be informed of the increased surgical
risk associated with their BMI during the preoperative consultation. Quality-of-life benefits should be
weighed carefully with the risks of proceeding with surgery, and shared decision-making between the
patient and plastic surgeon should be used to optimize both patient safety and satisfaction.
Nutritional Optimization
Malnutrition, loosely defined as a state of inadequate intake of nutrients to meet one’s needs,
increases the risk of wound healing complications, SSIs, and postoperative mortality.3 Geriatric
patients, hospitalized patients, and bariatric surgery patients are at significantly increased risk for
postoperative complications as a result of malnutrition. Even in the United States where obesity is
epidemic, it is estimated that up to 80% of elderly hospitalized and nursing home patients are
malnourished. Patients with chronic wounds should be considered malnourished until proven
otherwise. High-risk patients should be formally evaluated for malnutrition and treated prior to surgery
whenever possible.
While there is no one specific diagnostic test to determine whether a patient is malnourished, a
careful patient history and clinical exam, in addition to trends in laboratory markers, can help assess
overall nutritional status. Laboratory markers such as albumin and prealbumin are useful predictors of
poor healing after surgery. However, their use as markers of malnutrition remains controversial
because of their lack of specificity. Serum albumin concentrations do not specifically reflect nutritional
status, and can be decreased secondary to inflammatory cytokines, hepatic insufficiency, and renal or
gastrointestinal protein losses.7 Prealbumin may be decreased in settings of stress, infection, and liver
dysfunction, and elevated in patients with renal dysfunction or taking corticosteroids. Prealbumin has a
shorter half-life (approximately 2 days), and thus more accurately reflects acute changes in nutritional
status than albumin, which has a longer half-life of approximately 20 days.
7
Numerous studies have shown that albumin levels < 3 g/dL and prealbumin levels < 10 mg/dL are
strong prognostic indicators of poor healing, surgical complications, and mortality postoperatively.
Thus, regardless of whether albumin and prealbumin levels reflect chronic illness or poor nutritional
status alone, efforts should be made to normalize these values preoperatively.
Diabetes
Diabetes is associated with increased risk of postoperative complications, including SSIs, wound
dehiscence, and increased length of hospital stay for inpatient procedures.8 In outpatient plastic
surgery procedures, diabetes has been shown to be an independent risk factor for wound dehiscence
following panniculectomy and reduction mammoplasty.9 Patients with diabetic foot disease have an
increased risk of lower extremity amputation and premature mortality.
The mechanism by which diabetes increases perioperative complications is multifactorial, and the
effects of microvascular sequelae of long-standing diabetes are unfortunately irreversible. However,
perioperative hyperglycemia (blood glucose >200 mg/dL) and HgbA1C levels > 7.5% have been
shown to independently increase risk of SSIs.8 Risk is further increased in patients with insulindependent diabetes, compared to diabetic patients controlled on noninsulin regimens.9 Therefore,
referring patients with poorly controlled diabetes to their primary care physician or endocrinologist for
preoperative diabetes optimization is an intervention that may reduce postoperative complications and
improve outcomes for this high-risk patient population.
Frailty
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Historically, age has been associated with increased risk of postoperative complications. This is
largely because of the accumulation of chronic diseases over the life span, rather than chronologic
age itself. Frailty, commonly defined as a condition that increases a patient’s risk for adverse healthrelated effects or death following exposure to stressors, has emerged as a more effective proxy for
predicting postoperative morbidity and mortality than age alone.
10
The 5-factor modified frailty index is an easy-to-use risk assessment tool that has been validated
across multiple subspecialties, including orthopedic and plastic surgery.
11,12
The index assigns one
point for the presence of each of the following conditions: hypertension, diabetes mellitus, chronic
obstructive pulmonary disease, congestive heart failure, and functional dependence. The minimum
score is 0 and the maximum score is 5, with higher scores predicting greater postoperative
complication risk.
Psychiatric Conditions and Disorders
Human beliefs and behaviors are driven by a complex interaction between genetic predisposition and
the environment in which one is socialized. From an evolutionary standpoint, the need to fit into the
norms of society are critical to survival. Therefore, the importance of having one’s physical
characteristics be accepted by society simply cannot be underestimated.
Body image is a complex psychological abstraction that develops over the lifetime in response to
the value one’s social community ascribes to their physical characteristics. Whether or not individuals
feel their physical characteristics are adequate and valued within their societal norms greatly
influences their overall self-worth, and can result in either feelings of confidence, or feelings of anxiety.
These feelings of either confidence or anxiety affect behavior, and ultimately can impact one’s overall
success in establishing a career, relationships, and a safe living environment.
The profound impact of body image is the primary rationale for early reconstruction in children with
craniofacial anomalies. Children who undergo reconstruction earlier have improved socialization,
behavior, and self-esteem compared to children who undergo reconstruction later.13 These effects are
so profound that often the measure of whether pediatric craniofacial surgery has been successful is
whether or not the children are able to meaningfully participate in society without ridicule, and develop
meaningful friendships and relationships.
Some patients seeking plastic surgery are aiming to correct a flaw that has resulted in significant
distress, and ridicule or rejection from their peers. Others seek reconstruction following a difficult
cancer diagnosis. It is not surprising then, that plastic surgery patients have higher rates of mood
disorders, including anxiety and depression, than the general population.
A diagnosis of anxiety or depression alone is not a reason to turn away a patient. These diagnoses
are incredibly common in the general population, and numerous studies have shown that plastic
surgery can improve depression and anxiety scores, perception of body image, self-confidence, and
overall quality of life.14 However, it is important that symptoms be well-controlled with psychoactive
medications, therapy, or a combination thereof, and for patients to have specific and realistic
expectations about their postoperative outcomes. Patients with poorly controlled mood disorders, or
other major psychiatric illnesses, are at significantly increased risk for postoperative dissatisfaction,
and the results can be detrimental: patients may pursue litigation against the physician, or even
engage in suicidal or homicidal behaviors. Therefore, a critical step in establishing operative
candidacy is determining whether or not a patient has realistic expectations, and the ability to cope
with imperfect results or surgical complications.
Establishing whether a patient has realistic expectations is especially critical because of the high
rates of body dysmorphic disorder (BDD) present in patients seeking plastic surgery. BDD is a
psychiatric condition characterized by excessive concern with perceived physical flaws that results in
social or occupational impairment.15 Individuals with BDD have an obsessive concern with either a
minimal or imagined bodily defect. Their preoccupation with their appearance frequently results in the
pursuit of esthetic surgery to fix the perceived defect. What differentiates BDD is an overexaggerated
negative response to a physical defect that is either within the range of normal variations, or with a
minimal defect. For example, a patient who has had multiple cosmetic rhinoplasties and has a
proportional nose relative to their facial esthetics may consider their nose huge and bulbous, and
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avoid taking photos or attending parties because of fear of ridicule over the imagined defect. This
disorder is often undiagnosed or unknown to the patient at the time of presentation.
Behaviors that should raise concern for BDD include avoiding social situations because of the
perceived defect, history of multiple previous cosmetic procedures in the area of concern, and an
unrealistic expectation that cosmetic surgery will solve all of their problems. Many of these patients
have a history of psychological trauma and adverse childhood experiences such as emotional abuse,
emotional neglect, family substance abuse, and family mental illness. These patients often suffer from
body shame and increased rate of revisional surgery. Patients who meet Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition criteria for BDD should not undergo cosmetic surgical
procedures, and should instead be referred for psychological assessment and treatment.
VENOUS THROMBOEMBOLISM
VTE, which includes both deep vein thrombosis and pulmonary embolism (PE), is a leading cause of
preventable death in the postoperative period. PE carries a high mortality rate, and may result in
devastating long-term consequences including pulmonary hypertension and right heart strain.
Therefore, understanding the pathophysiology, identifying patient risk factors, and providing effective
VTE prophylaxis is a critical component of patient safety.
Pathophysiology
The pathophysiology of VTE begins with Virchow triad; the risk of VTE increases in conditions with
venous stasis, endothelial damage, and hypercoagulable states. During surgery, general anesthesia
induces lower extremity venous stasis through the halting of the physiologic venous pumping
mechanism. Therefore, all surgery in which general anesthesia is used increases risk of VTE. This risk
is highest during the first 6 weeks after inpatient surgery and remains increased for up to 12 weeks
postoperatively.
16
VTE Prophylaxis
VTE prophylaxis can be divided into two categories: mechanical prophylaxis (compression stockings
and sequential compression devices) and pharmacologic prophylaxis (unfractionated heparin, lowmolecular-weight heparin).
Compression stockings reduce venous stasis by shunting blood from the superficial to deep venous
system. Sequential compression devices (SCDs), or intermittent pneumatic compression, re-create
the calf muscle pump to minimize stasis, and simultaneously stimulate fibrinolysis, reducing
hypercoagulability. It is recommended that SCDs be used for all plastic surgery procedures performed
under general anesthesia.17 The devices should be applied and activated prior to induction.
Unfractionated heparin and low-molecular-weight heparin are the most well-studied agents for
pharmacologic chemoprophylaxis in plastic surgery patients. Preoperative administration of
unfractionated heparin reduces intraoperative VTE, and its short half-life of roughly 90 minutes limits
the duration of action and corresponding bleeding risk to the immediate perioperative period.
Enoxaparin, a low-molecular-weight heparin, has a longer elimination half-life of 270 minutes, and is
commonly used for postoperative VTE prophylaxis. Multiple high-quality studies have shown that
enoxaparin is effective in the reduction of postoperative VTE in high-risk patients.
18
Risk Assessment
A patient’s risk of VTE must be carefully weighed against their risk of bleeding from pharmacologic
prophylaxis. Chemoprophylaxis may not be necessary in the overall plastic surgery population;
however, patients should be stratified based on individual risk assessment. The 2005 Caprini Risk
Assessment Model is the most extensively used and validated postoperative VTE risk assessment
tool, and assigns scores to both patient and operation-specific risk factors and provides an estimated
VTE risk. In general, plastic surgery patients with Caprini scores <7 are considered low risk, and
require only mechanical prophylaxis for low-risk procedures.19 Patients with Caprini scores of ≥ 7 are
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at higher risk of VTE, and should be considered for both mechanical and pharmacologic
prophylaxis.
17,19
Smoking, obesity, oral contraceptive use, and recent trauma are highly prevalent VTE risk factors in
the plastic surgery population. For a full list of risk factors and associated Caprini scores, see Table
13.2. Personal or family history of VTE, or history of multiple miscarriages, should raise concern for an
underlying hematologic disorder, and prompt a referral for hematology evaluation prior to surgery.
TABLE 13.2. THE 2005 MODIFICATION OF THE CAPRINI SCORE
1 Point 2 Points 3 Points 5 Points
Age 41-60
Minor surgery
History of
recent major
surgery
(<1 mo)
Varicose veins
inflammatory
bowel disease
Swollen legs
(current)
BMI > 25
Acute MI
CHF
Sepsis
(<1 mo)
Pneumonia
(<1 mo)
COPD
Temporary
bed rest
Oral
contraceptives
Hormone
replacement
therapy
Pregnancy or
up to 1 mo
postpartum
History of
unexplained
stillbirth, three
or more
spontaneous
abortions, or
Premature
birth with
toxemia or
growth-
Age 60-74
Arthroscopic
surgery
Malignancy
Major
surgery (>45
min)
Laparoscopic
surgery (>45
min)
Patient
confined to
bed >72 h
Immobilizing
plaster cast
Central
venous
access
Age > 75
History of VTE
Family history of
thrombosis
Positive factor V
Leiden
Positive
prothrombin
20210A
Elevated serum
homocysteine
Positive lupus
anticoagulant
Elevated
anticardiolipin
antibodies
Heparin-induced
thrombocytopenia
Any other
congenital or
acquired
thrombophilia
Elective major
lower
extremity
arthroplasty
Any of the
following
within the last
month:
Hip,
pelvis,
or leg
fracture
Stroke
Multiple
trauma
Acute
spinal
cord
injury
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restricted
infant
BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; MI, myocardial
infarction; VTE, venous thromboembolism
In addition to patient-level risk factors, operation-specific risks should also inform decision-making
on whether to initiate pharmacologic prophylaxis. Procedures that require prolonged operative times
and significant blood loss or fluid shifts or result in increased intra-abdominal pressure carry increased
VTE risk, and pharmacologic prophylaxis should be highly considered. High-risk procedures in plastic
surgery include free flaps, body contouring, abdominoplasty, breast reconstruction, lower extremity
procedures, head and neck cancer procedures, and combined procedures, such as “mommy
makeovers.”
Although certain procedures carry increased risk of postoperative hematoma, multiple metaanalyses have found that chemoprophylaxis does not significantly increase bleeding complications
and is estimated to result in hematoma requiring reoperation in < 1% of plastic surgery procedures.
20
Hematomas are certainly inconvenient, but rarely do they result in death. In contrast, up to 10% of
acute PE cases result in sudden death.21 Therefore, concerns for bleeding should not preclude
adequate VTE prophylaxis.
In addition to mechanical and pharmacologic prophylaxis, patient education and modification of VTE
risk factors, including obesity and smoking, should be optimized prior to surgery. Postoperatively,
encouragement of early ambulation can further reduce risk of VTE. Finally, in high-risk patients, the
decision may be made to refer the patient for hematologic evaluation preoperatively or avoid high-risk
procedures altogether.
Hormonal Therapy
Many plastic surgery patients routinely take exogenous hormone therapy, including combined
estrogen-progesterone oral contraceptive pills (OCP), and estrogen and testosterone hormone
replacement therapies.
Estrogen increases the risk of VTE by increasing the activity of procoagulant factors II, VII, X, and
XII and fibrinogen, and decreasing the activity of anticoagulant factors antithrombin, protein C, and
protein S. Exogenous testosterone can be aromatized to estradiol peripherally, and therefore similarly
increase hypercoagulability risk.
Despite the increased risk, there remains a lack of evidence supporting whether preoperative
cessation of estrogen- and testosterone-containing pharmaceuticals in otherwise low-risk patients
results in a clinically significant decreased VTE incidence. For oral contraceptives in particular, there is
no high-quality evidence available to support that preoperative cessation decreases postoperative
development of VTE.18 However, stopping these medications does increase the risk of unintended
pregnancy, increased acne, abdominal pain, withdrawal bleeding, weight gain, and mood changes.
22
Because it can take several months for both the prothrombotic risk to decline after OCP cessation,
and several months for contraceptive and systemic benefits of OCP therapy to resume after
reinitiation, the harms associated with medication cessation outweigh benefits for VTE risk reduction
in otherwise healthy, low-risk patients who are able to ambulate postoperatively.
22
Data in the gender affirmation population are similarly limited; however, current evidence does not
support the idea that patients taking exogenous testosterone have increased VTE incidence. A 2023
study found no difference in VTE complication rates between patients who held testosterone therapy
compared to those who continued these medications prior to gender-affirming mastectomy.
23
Furthermore, cessation of hormone therapy may exacerbate symptoms of gender dysphoria.
24
In conclusion, though hormone therapies may increase VTE risk, the harms associated with
cessation of these therapies in otherwise low-risk patients may outweigh any theoretical benefits.
Rather than universally stopping therapy, the risks of hormone therapy should be taken into account
as a risk factor, along with any other patient risk factors, such as smoking and obesity, when
determining each patient’s risk via the Caprini score. The need for pharmacologic prophylaxis and
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hormonal therapy cessation should be determined on a case-by-case basis in light of each patient’s
overall VTE risk.
Perioperative Travel
In the general population, long-haul travel (car or air travel >4 hours) is associated with 2 to 4 times
increased risk of VTE.18 High-risk patients should avoid long-haul travel for at least 6 weeks following
surgery. These considerations are particularly important when considering operative candidacy in
patients who do not live in close proximity to the surgical center. When unavoidable, patients traveling
in the perioperative period should reduce risk by staying hydrated, wearing compression stockings,
and moving and stretching during each hour of travel.
PAIN MANAGEMENT
Effective, evidence-based perioperative pain management is a critical aspect of patient safety. Opioid
overprescribing has led to a national health crisis in the United States; therefore, careful prescribing of
narcotics during the perioperative period is important. This does not mean plastic surgeons should
ignore or undertreat surgical pain; rather, surgeons should educate both themselves and their patients
on the role of opioid medications in the treatment of postoperative pain, and incorporate multimodal
pain control regimens into their practice.
Opioid Stewardship
Drug overdose is the leading cause of accidental death for adults in the United States. The vast
overprescribing of opioid medications in the perioperative period has substantially contributed to this
crisis. Surgeons are responsible for nearly 37% of all opioid prescriptions, and it is estimated that
plastic surgeons specifically tend to overprescribe over 50% more narcotics than patients require for
postoperative pain.25 Overprescribing of narcotic pain medications in the perioperative period
increases the risk of patients developing opioid dependence, and increases the community supply of
narcotics available for nonmedical use. Up to 6% of all opioid-naïve patients develop persistent opioid
use postoperatively, making opioid dependence one of the most common complications of elective
surgery.
25
Despite these risks, plastic surgeons continue to overprescribe opioid pain medications for
postoperative pain control. Commonly cited reasons for doing so include increasing patient
satisfaction with their surgeon, and avoiding phone calls to the office for refills during the postoperative
period. However, current literature has demonstrated that increased opioid prescribing is not
associated with increased patient satisfaction.26 In fact, the majority of plastic surgery patients do not
anticipate needing to take opioid medications for postoperative pain control, and only consume
roughly half the number of opioids prescribed to them after outpatient plastic surgery.25-27 Reduced
opioid prescribing in conjunction with the implementation of multimodal pain control regimens leads to
a decrease in patient narcotic consumption, and does not increase refill requests.
28
The solution to patient satisfaction with postoperative pain control is not to prescribe more opioids at
the time of surgery, but instead, to take a preventive approach through patient education at the time of
the initial consultation. It should be communicated to the patient that a degree of postoperative pain is
unavoidable, but that it will be managed in the safest, evidence-based way possible with a multimodal
pain control regimen. Patients should be informed about expected postoperative pain, and the risks
and side effects of opioid pain medications including drug dependence, nausea, vomiting, drowsiness,
and constipation. Special care should be taken to screen patients for a history of previous or current
substance use disorders, chronic pain syndromes, and untreated anxiety and depression, as these
conditions are associated with increased risk of postoperative opioid dependency.
29
Multimodal Pain Control Regimens
Multimodal anesthesia uses two or more drugs with different mechanisms of action to provide
synergistic pain control. The use of such regimens has been shown to effectively minimize
postoperative pain scores and opioid use and improve patient satisfaction.
29
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Common multimodal regimens incorporate oral medications including acetaminophen, nonsteroidal
anti-inflammatory drugs (NSAIDs), gabapentin, and low doses of opioids when needed for severe
pain. Local anesthetics are another important adjunct and long-acting local anesthetics can further
reduce postoperative opioid requirements. The decision of whether or not to prescribe narcotics
should be tailored based on the expected pain associated with the procedure, patient history of opioid
use, and patient contraindications to any of the other therapy modalities. Baseline pain control should
be managed with nonopioid medications taken at scheduled intervals. Opioids should only be
prescribed for severe, breakthrough pain, and for the shortest duration possible (no more than
3 days). In opioid-naïve patients, weaker opioid-like medications, such as tramadol, should be
considered over oxycodone. In addition to oral medications, the use of local and regional anesthesia is
effective in reducing opioid requirements both intraoperatively and postoperatively.
A crucial aspect in the implementation of multimodal anesthesia is eliminating the outdated notion
that NSAIDs increase bleeding risk. Numerous studies, including a 2018 meta-analysis, have found
that ibuprofen provides equivalent postoperative pain control to narcotics, and is not associated with
increased bleeding risk in plastic surgery patients.
30,31
Ketorolac, a potent intravenous NSAID, is
likewise often withheld because of concern for bleeding risk, despite its long-proven efficacy in
postoperative pain control across a wide variety of surgical specialties. Current high-quality evidence
controlling for confounding variables has found no correlation between ketorolac use and hematoma
in plastic surgery patients.32 Ketorolac use has, however, been shown to reduce postoperative
duration of hospital stay and readmission rates.32 Additionally, studies also show that regular use of
ketorolac lowers the need for perioperative opioids and also decreases postoperative nausea and
vomiting. Patients with normal kidney function are good candidates for such perioperative painreducing therapies.
ANTIBIOTIC STEWARDSHIP
Antibiotic overprescribing causes antibiotic resistance, thereby reducing future efficacy. Despite this,
plastic surgeons have increasingly prescribed perioperative antibiotics for prophylaxis over the last
2 decades, with the intention of preventing SSIs. However, bad decisions made with good intentions
are still bad decisions, and continued antibiotic overprescribing causes harm to both current and future
patients.
Several factors are important to determine the risk of SSIs including the grade of wound
contamination: clean, clean-contaminated, contaminated, and dirty. Current evidence has shown that
the use of antibiotic prophylaxis is beneficial in the reduction of SSI in clean surgery of the breast, and
clean-contaminated, contaminated, and dirty plastic surgery procedures.33 With the exception of
breast surgery, systemic antibiotic prophylaxis is not recommended for prevention of SSI in clean
plastic surgery procedures.
The duration of antibiotics should be limited to a single perioperative dose administered within 30 to
60 minutes of incision time. There is no evidence to suggest that prolonged antibiotic use reduces
SSIs or implant explantation rates.34 However, increased duration of antibiotics has been shown to
increase bacterial diversity, rates of gram-negative infections, allergic reactions, and Clostridium
difficile colitis.
34
Current literature does not provide any evidence that postoperative systemic antibiotics effectively
lowers the incidence of SSI associated with drains.35 Maintaining sterility near the drain insertion site is
more effective than systemic antibiotics for prevention of drain-associated SSIs. Regardless, drainassociated infection rates are low, and the presence of surgical drains is not an indication for
postoperative antibiotics.
The most common cause of SSI in plastic surgery patients is Staphylococcus aureus, which is
adequately covered by cefazolin. For patients with beta-lactam allergies, clindamycin may be
substituted. Vancomycin should only be used in patients with a history of methicillin-resistant S.
aureus (MRSA) infection.
INTRAOPERATIVE SAFETY
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Operative Positioning
Improper positioning on the operative table may result in pressure injuries and neuropathies. Pressure
injuries can be avoided by adequately padding all points of pressure and minimizing sites of external
compression. The most common nerve injury is ulnar nerve neuropathy. This can be prevented by
properly positioning the patient with arms either tucked at the sides or abducted on arm boards. The
arms should be placed in either a neutral or supinated position and abducted no more than 90° to
prevent stretch injury to the brachial plexus.
Concurrent and Overlapping Surgery
In a busy operative practice, scheduling overlap between noncritical portions of surgical cases
increases timely access to surgical care, facility utilization, and educational opportunities for residents
and fellows. For example, an attending surgeon may scrub out to start their next case while a resident
finishes closing the incision. Overlapping surgery differs from concurrent surgery, in which a single
surgeon is responsible for critical portions of an operation on different patients during the same period
of time. Concurrent surgery carries inherent safety risks and is associated with increased operative
complications, as it is not possible to adequately provide skilled attention to two patients in two places
at the same time. Thus, concurrent surgery should be avoided whenever possible, and reserved for
true emergencies where no other alternatives are available.
Infection Prevention
SSIs result in significant patient morbidity and mortality, prolonged hospital stays, and increased
healthcare costs.
3,36
Within plastic surgery, infection may delay wound healing, increase scarring, and
lead to poor esthetic outcomes. Special consideration should be given to preventing infection of
implantable devices, including breast implants, tissue expanders, and orthopedic hardware. When
infection of implantable devices occurs, it is devastating and requires reoperation and removal of the
device, in addition to long courses of antibiotics. In rare cases, periprosthetic breast implant infection
may result in the development of breast implant–associated anaplastic large cell lymphoma. A “notouch” technique when placing implants, as well as minimizing all potential exogenous sources of
contamination, is recommended.
Steps to reduce exogenous bacteria include enforcing hand hygiene, double-gloving, and requiring
operating room personnel to dawn appropriately fitting masks and surgical caps. Traffic in and out of
the operating room should be minimized, and backpacks, white coats, and other items that may
introduce bacteria should be prohibited. SSIs are more rarely the result of endogenous bacteria, but
chlorhexidine showers preoperatively, especially in patients at high risk for MRSA colonization
(physicians, inmates, etc.), are useful at reducing bacteria native to the patient’s skin.
PREVENTING HUMAN ERROR
To err is human, a key tenet of patient safety, is anticipation of human error and systemic interventions
to reduce the likelihood of errors at both the individual and institutional level.
Cognitive Aids
Cognitive aids are tools that prompt clinicians to complete a set of tasks. The most commonly used
cognitive aid in surgical settings is the surgical safety checklist. Surgical safety checklists improve
surgical team communication and reduce morbidity, mortality, wrong-site surgery, and SSIs.37 Other
cognitive aids including mnemonics, institutional algorithms, and computerized prompts are helpful in
preventing errors of omission and enhancing clinical decision-making.
Communication
Ensuring all relevant information is communicated to all members of the patient care team in an
appropriate and timely fashion is a crucial aspect of patient safety. In the surgical setting, effective
communication includes standardizing handoffs to ensure no relevant information is excluded, and
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“talk back” or “closed-loop” communication, in which the person receiving the information repeats it
back to the giver, thereby confirming there are no misunderstandings.
Physician Fatigue
Physician fatigue is an often-overlooked patient safety issue. Studies have shown that after 24 hours
without sleep, response speeds slow by up to 50%, and accuracy on tests declines to a level
equivalent or worse than taking the test while legally intoxicated (blood alcohol concentration >
0.08%).38 Sleep deprivation among physicians results in increased incidence of near misses and
adverse events, and significantly contributes to physician burnout, especially among early-career
physicians and residents.
39
CULTURE OF SAFETY
Patient safety is the practice of applying quality improvement to reduce harm to patients through the
prevention of medical errors and adverse events. It is the principle of doing no harm and striving to
provide the highest-quality care possible to patients. Though patient safety is generally the universal
goal of healthcare systems, developing and nurturing a true culture of patient safety requires strong
leadership and complex systemic and organizational processes that cultivate buy-in from the various
parts of the healthcare team.
To this end, it is helpful to think of culture both as a noun (the customs, ideas, and behaviors of a
particular social group) and as a verb (to maintain in conditions suitable for growth). Culture does not
simply exist, it is cultivated over time, and must be thoughtfully and continuously maintained and
nourished to survive. A petri dish full of cells can only thrive and multiply when the proper
environmental conditions are present, and nourishment is provided via growth mediums. Patient
safety cultures are obviously more complex, but have the same basic requirements: healthy
organisms, an environment conducive to survival, and the nourishment needed to grow. When any of
these elements are lacking, be it a fatigued, uninformed, or uncaring surgeon, a lack of hospital
staffing or resources, or a leader who punishes mistakes and thereby discourages reporting of
adverse events, the culture’s survival, and ultimately, the patient’s survival, is at risk. Healthcare
systems with low culture of safety scores have significantly greater morbidity and mortality than
systems that effectively implement multifaceted approaches to creating a culture of patient safety.
40
Psychological Safety
A key aspect to creating a culture of safety is developing psychological safety among members of the
healthcare team. Psychological safety is a shared belief held by members of a team that one will not
be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes.41 An
environment that is psychologically safe increases individual commitment to the organization and
investment in patient care.42 Team members who feel empowered to raise concerns make better
decisions and fewer medical errors. Conversely, a lack of psychological safety both directly and
indirectly threatens patient safety. When physicians feel unsupported or afraid to speak up because of
fear of retaliation or risk to their reputation, they are more likely to make mistakes and overlook
important details.42 A lack of psychological safety additionally indirectly affects patient safety through
its negative impacts on well-being, resulting in increased healthcare worker stress, burnout, and
employee turnover.
Diversity, Equity, and Inclusion
Increasing diversity in the field of plastic surgery is a crucial patient safety need to provide equitable
access to health care. Patients frequently prefer physicians who understand their cultural
backgrounds, and seek care from surgeons who have similar gender, racial, and ethnic preferences,
especially when undergoing intimate breast, genital, and facial procedures.
43,44
A lack of cultural
congruence among available physician options often leads to patient’s foregoing care, rather than
risking uncomfortable encounters.45 Diversity among physicians additionally increases cultural
competency and sensitivity to microaggressions, thus improving patient care and safety across the
field.
46
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To increase equitable access to patient-centered care, the field of plastic surgery must take steps to
be more inclusive and make training accessible to physicians of all backgrounds. This includes
improving maternal leave and childcare options and reducing pregnancy-related stigmas that continue
to deter female physicians from pursuing plastic surgery residencies during their childbearing years.
47
It also requires acknowledging and overcoming implicit biases that negatively impact both minority
applications to residencies and promotion to leadership positions, thereby limiting mentorship
opportunities for future applicants.
Physician Burnout and Wellness
To effectively take care of our patients, we must first take care of ourselves. It is estimated that over
50% of US physicians suffer from burnout, and early retirement and suicide among physicians
continue to increase year over year.48 Loss of the physician workforce increases the burden on
remaining members, further perpetuating the cycle.
Burnout is independently associated with significantly increased risk of patient safety events, poorer
clinical care, and low patient satisfaction.48 A 2018 meta-analysis found burnt out physicians were
more than twice as likely to be involved in an adverse patient safety incident.48 Many of the factors
discussed in this chapter, including adequate sleep, psychological safety, diversity and inclusion, and
feeling like a valued member of the healthcare team, are crucial to preventing burnout. In addition, it is
crucial that physicians be able to find joy in their work, which often requires minimizing redundant
administrative tasks, including time spent documenting in the electronic medical record. It is critical
that physicians be involved in the development and implementation of any systemic patient safety
interventions. Systemic redundancies and checklists designed to improve patient safety may have
unintended negative consequences if they lack physician buy-in and inadvertently increase physician
burnout.
Patient safety is a broad and multifaceted topic fundamental to the practice of plastic surgery.
Keeping patients safe requires concerted efforts towards appropriate patient selection, risk factor
optimization, opioid and antibiotic stewardship, and physician wellness.
QUESTIONS
1. A 32-year-old woman presents for preoperative evaluation for reduction mammoplasty. History
is significant for symptomatic macromastia, depression, and obesity. Her medications include
oral contraceptive pills and an antidepressant. Optimization of VTE risk includes which of the
following?
a. Cessation of oral contraceptive pills
b. Cessation of antidepressant therapy
c. Intraoperative sequential compression devices
d. Intraoperative sequential compression devices and subcutaneous heparin
e. Deferral of surgery until BMI < 25
2. A 46-year-old woman presents for abdominoplasty and mastopexy. Appropriate antibiotic
prophylaxis for this patient includes which of the following?
a. Administration of cefazolin within 60 minutes of incision time
b. Administration of vancomycin and ceftriaxone within 60 minutes of incision time
c. Administration of cefazolin within 60 minutes of incision time plus 5 days of cefadroxil
500 mg BID postoperatively
d. Administration of cefazolin within 60 minutes of incision time plus cefadroxil 500 mg BID
postoperatively until all surgical drains have been removed
e. No antibiotic prophylaxis is indicated as this is a clean procedure
3. A 56-year-old woman with newly diagnosed breast cancer presents to the clinic for a
preoperative evaluation for DIEP flap breast reconstruction. She inquires about her
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