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postoperative pain control regimen. Which of the following interventions is associated with
reduced perioperative opioid requirements?
a. Patient education on expected levels of postoperative pain
b. Ketorolac administration prior to extubation and for the first 3 days postoperatively
c. TAP block
d. Postoperative multimodal pain control regimen consisting of acetaminophen, NSAIDs,
gabapentin, and opioids
e. All of the above
ANSWERS AND EXPLANATIONS
Answer: c. This patient with obesity (1 point) and oral contraceptive pills (1 point) has a Caprini
score of 2, which is considered low risk for VTE. Her VTE risk can be managed with patient
education, intraoperative mechanical prophylaxis with sequential compression devices, and early
postoperative ambulation. Pharmacologic prophylaxis is not indicated in low-risk patients
undergoing low-risk surgical procedures for VTE. In an already low-risk patient, there is no need
to stop oral contraceptive pills prior to surgery. While obesity is a risk factor for VTE, this patient is
otherwise low risk, and preoperative weight loss is not required.
Answer: a. Antibiotic prophylaxis is indicated in clean procedures of the breast; therefore, this
patient undergoing mastopexy requires perioperative prophylaxis. The duration of antibiotics
should be limited to a single perioperative dose of cefazolin administered within 30 to 60 minutes
of incision time. Current literature does not provide any evidence that postoperative systemic
antibiotics can lower the incidence of SSI. However, increased duration of antibiotics has been
shown to increase bacterial diversity, rates of gram-negative infections, allergic reactions, and
Clostridium difficile colitis.
Answer: e. Opioid dependency is one of the most common complications of elective surgery.
Surgeons should strive to reduce the quantity and duration of opioid consumption following
surgery. Current literature suggests that opioid consumption may be reduced through patient
education and multimodal pain regimens. Pain regimens should use a variety of oral nonopioid
medications, in addition to local anesthetic blocks and IV ketorolac.
REFERENCES
1. Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status—historical perspectives
and modern developments. Anaesthesia. 2019;74(3):373-379.
2. Fu RH, Toyoda Y, Li L, Baser O, Rohde CH, Oerburn DM. Smoking and postoperative
complications in plastic and general surgical procedures: a propensity score-matched analysis of
294,903 patients from the national surgical quality improvement program database from 2005 to
2014. Plast Reconstr Surg. 2018;142(6):1633-1643.
3. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce postoperative complications in
plastic surgery. Plast Reconstr Surg. 2016;138(3 suppl l):51S-60S.
4. Chen CL, Shore AD, Johns R, Clark JM, Manahan M, Makary MA. The impact of obesity on breast
surgery complications. Plast Reconstr Surg. 2011;128(5):395e-402e.
5. Sieffert MR, Fox JP, Abbo LE, Johnson RM. Obesity is associated with increased health care
charges in patients undergoing outpatient plastic surgery. Plast Reconstr Surg. 2015;135(5):1396-
1404.
https://t.me/med1917
6. Srinivasa DR, Clemens MW, Qi J , et al. Obesity and breast reconstruction: complications and
patient-reported outcomes in a multicenter, prospective study. Plast Reconstr Surg.
2020;145(3):481e-490e.
7. Keller U. Nutritional laboratory markers in malnutrition. J Clin Med Res. 2019;8:775.
8. Reich MS, Fernandez I, Mishra A, Kafchinski L, Adler A, Nguyen MP. Diabetic control predicts
surgical site infection risk in orthopaedic trauma patients. J Orthop Trauma. 2019;33(10):514-517.
9. Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic
surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open.
2017;5(8):e1461.
American College of Surgeons NSQIP data. J Am Coll Surg. 2018;226(2):173-181.e8.
postoperative complications: a retrospective cohort analysis. Plast Reconstr Surg. 2022;150:82S-94S.
following panniculectomy in the elderly. Plast Reconstr Surg Glob Open. 2020;8(7):e2987.
psychosocial function of children with craniofacial anomalies. Plast Reconstr Surg. 2017;140(4):776-
784.
cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229-1237.
Reconstr Surg. 2013;132(6):1759-1762.
thromboembolism in middle aged women: prospective cohort study. BMJ. 2009;339:b4583.
guide. Plast Reconstr Surg. 2017;139(2):520e-532e.
risk assessment and prophylaxis in plastic surgery. Plast Reconstr Surg. 2022;149(1):121e-129e.
thromboembolism prophylaxis. Mayo Clin Proc. 2020;95(12):2775-2798.
reoperative hematoma. Plast Reconstr Surg. 2012;129(1):160-168.
stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary
embolism. Exp Clin Cardiol. 2013;18(2):129-138.
NEJM Evidence. 2022;1:EVID2100050.
mastectomy: is stopping testosterone before top surgery really necessary? Plast Reconstr Surg.
2023;151(2):421-427.
venous thromboembolism and other complications. Plast Reconstr Surg. 2021;147(4):1008-1017.
https://t.me/med1917
consumption paerns for plastic and reconstructive surgery patients. Plast Reconstr Surg.
2021;147(4):669e-679e.
hospital consumer assessment of healthcare providers and systems survey. JAMA.
2017;317(19):2013-2015.
expectations for postoperative opioid prescriptions. Ann Plast Surg. 2020;84(6S suppl 5):S437-S440.
ambulatory plastic surgery with an opioid-restrictive pain protocol. Ann Plast Surg. 2020;84(6S
suppl 5):S431-S436.
the perioperative period. Plast Reconstr Surg. 2017;140(4):613e-619e.
surgery: a systematic review and meta-analysis. Plast Reconstr Surg. 2016;137(4):1309-1316.
nonsteroidal antiinflammatory drugs for postoperative analgesia in outpatient rhinoplasty. Plast
Reconstr Surg. 2021;147(1):56-62.
procedures: a nationwide Claims analysis. Plast Reconstr Surg. 2018;142(4):472e-480e.
plastic surgery: an evidence-based consensus conference statement from the American Association
of Plastic Surgeons. Plast Reconstr Surg. 2015;135(6):1723-1739.
immediate prosthetic breast reconstruction: evidence from 683 consecutive reconstructions without
prophylaxis. Plast Reconstr Surg. 2023;151(5):730e-738e. doi:10.1097/PRS.0000000000010073
placement postmastectomy does not improve outcome. Ann Plast Surg. 2021;87(1s suppl 1):S28-S30.
operation. J Am Coll Surg. 2008;207(3):326-335.
and intended use: a systematic review and meta-meta-analysis. J Am Coll Surg. 2021;233(6):794-
809.e8.
motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ
Med. 2000;57(10):649-655.
American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2020;16(5):803-805.
between patient safety culture and adverse events—a scoping review. BMC Health Serv Res.
2023;23(1):300.
383.
https://t.me/med1917
in the healthcare seing: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773.
choice. Aesthet Surg J. 2017;37(4):466-471.
with care? J Health Soc Behav. 2002;43(3):296-306.
minority representation among applicants and residents. Plast Reconstr Surg. 2019;143(3):940-949.
CIRS data analysis to identify problem areas and competency requirements of professionals in
healthcare institutions. GMS J Med Educ. 2020;37(2):Doc14.
systematic scoping review. Plast Reconstr Surg. 2018;141(6):1561-1577.
safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA
Intern Med. 2018;178(10):1317-1331.
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CHAPTER 14 Ethics of Plastic Surgery
Loree K. Kalliainen
KEY POINTS
Cultural differences need to be taken into account when
discussing treatment options.
Practical application of codes of ethics includes valuing
dignity, confidentiality, informed consent, competent
practice, scientific justification, and appropriate
advertising.
Open disclosure of relationships with industry and
conflicts of interest in academic forums maintains
integrity of the field of plastic surgery.
INTRODUCTION
Plastic surgery has traditionally valued novelty and innovation and, in
doing so, routinely faces ethical questions regarding appropriate and
optimal application of our skills. We work with patients who are
healthy but wish to present themselves to the world in a new way as
well as patients with life-altering injuries, birth differences, or
acquired conditions. People of all cultures have modified their bodies
for cultural and personal purposes through recorded history, but the
speed and variety of change has increased over the past several
decades. Our techniques have likewise continuously improved,
facilitating evermore complex and elegant solutions to our patients’
concerns, needs, and desires. This chapter will review principles of
ethics and discuss the many ways in which ethical questions are
related to our practices as plastic surgeons.
DEFINITIONS
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Ethics is the branch of philosophy that discusses applications of the
moral ideas of right and wrong. Applied ethics is a further subdivision
of philosophy and includes discussions of practical questions of the
nature of “right actions” in the fields of medicine, science, business,
and law. This can be further divided into macro- and microethics.
Macroethics in surgery are related to big picture questions such as
societal issues of distributive justice and the nature of ethical
principles. Microethics deals with the doctor-patient relationships, the
consent process, and the individual choices made in practice.
Professional ethics are those moral principles promoted by
professional societies and expected of members, and ideally are
those personally held and practiced by professionals.1 A profession
is defined as how one masters a complex body of knowledge
requiring advanced education. Members of a profession are
autonomous, are self-regulatory, and chosen by other members of
the profession. Members are formally organized, follow a code of
ethics, and serve a useful purpose in society.2 Professionalism is an
expectation of all surgeons and, per the Accreditation Council for
Graduate Medical Education, includes commitments to “carrying out
professional responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population.”
3
ETHICAL PRINCIPLES
Following the creation of the Belmont Report which serves to protect
research subjects, Beauchamp and Childress defined the classic
four pillars of ethics widely used today in ethical situations with
patients: autonomy, beneficence, nonmaleficence, and justice.
4
Autonomy is defined as respect for another’s choices. Beneficence is
keeping the patient’s welfare in mind by respecting their choices,
protecting them from harm, and actively working toward their own
good. Nonmaleficence is the avoidance of intentional harm. Justice
considers how benefits and risks are distributed among a group
which includes the consideration of distribution of scarce resources
and of differing needs of group members for resources. Articles in
the plastic surgery literature have infrequently discussed ethics, but
inclusion of the ethical principles has increased since 2017. The
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most common practice area discussing ethics was that of esthetic
surgery followed by composite tissue allografting. Furthermore, the
most common principle discussed was autonomy/informed consent.
4
Though the four ethical pillars have been understood and applied
in research since 1979, routine, overt, adoption in daily clinical
practice is not common. A more practical method to view and apply
ethics in daily patient care was developed by Jonsen. The four
elements of his “box method” are indication, context, patient choices,
and quality of life.
4
The principalist view above is not necessarily shared by all
persons. Given the increasing diversity of backgrounds of people
living in the United States, it is important to consider that people from
other cultures have different priorities and perspectives regarding
their health, decision-making, the role of religion, acceptability of
procedures and medications, and the roles of family and community.
Efforts should be made to identify and adapt to preferences that are
important to patients from other cultures.
5,6
The American Society of Plastic Surgeons (ASPS) and the
American Board of Plastic Surgery (ABPS) both have published
codes of ethics.
7,8
Each discusses the importance of valuing our
patients’ dignity, maintaining confidentiality, operating with
competence and using techniques with scientific merit, and
maintaining the boundaries of advertising. The ASPS code also
includes a discussion of the informed consent process.7 It is the duty
of all plastic surgeons and plastic surgery trainees to familiarize
themselves with the codes and to follow them accordingly.
Informed Consent
As has been discussed broadly in the literature, informed consent is
not a paper but a process. It includes a description of the planned
procedure; discussion of why the procedure has been chosen; risks,
benefits, and alternatives (including nonoperative approaches); and
reasonable expectations of the procedure.7 When multiple options
are reasonable, each should be discussed thoroughly with the
patient who then should make the final choice. For example,
including videos of the procedure and written information from
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professional societies in the informed consent process empowers
patients to make better decisions for their health. Reviewing a
prewritten algorithm or making notes and drawings during the visit
are helpful for the patient and their family as the volume of
information can be daunting. Or, in complex situations, it is valuable
to schedule a second visit to review options. In addition, patients
must be told if the procedure is part of a research study, whether the
surgeon has conflicts of interest related to the procedure, and if any
elements of the procedure are considered off-label use. Written
information should be in the patient’s preferred language, and the
language of documents should be at a reading level appropriate for
the patient. For non–English-speaking patients, a professional
translator must be used—whether by telephone, video, or in person.
Family members, friends, or the patient’s employer should not be
used as translators. When using a translator, it is important for the
surgeon to speak in short, declarative sentences using nontechnical
language. Patients should be asked to state back their interpretation
of the procedure. It is recommended that the consent process be
done at a time before the day of surgery (unless this is not possible,
such as in urgent trauma situations). This also serves as a cooling
off procedure to ensure that the patient is making a thoughtful and
unhurried choice after receiving educational information. Many
patients are well-educated regarding their options and many only
believe that they are. It is the surgeon’s responsibility to provide a full
and accurate picture of all key elements related to the procedure.
The procedure should be reviewed on the day of surgery and any
questions clarified. Patients should be suggested at their initial visit
or visits that they write down questions that arise after the visit. If the
patient appears to be uncertain about proceeding or has questions
demonstrating a major lack of understanding on the day of surgery,
strong consideration should be given to rescheduling the procedure.
Conflicts of Interest
The Physician Payment Sunshine Act was created in 2010 to
disclose payments from industry to physicians.9 The goal of this
program was to reveal potential sources of bias related to
relationships with industry held by physicians. Payments in the Open
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Payments Database (OPD) range from accepting lunch at a meeting
to consultations for professional opinions to creation of a technology.
It is recommended that physicians check their OPD data annually to
confirm accuracy and challenge erroneous entries.
Innovation is valuable and has been an intrinsic part of our
specialty, but it is important to be aware of the potential influence
industry has on research and practice. More than 50% of plastic
surgeons (and many presenting at national meetings) have some
relationship with industry, and more than half of all payments by
industry ($46 million) have been made to 1% of board-certified
plastic surgeons. Furthermore, almost all the surgeons were male
(95%) and in private practice (77%).10 Awareness of speakers’ and
authors’ conflicts is important in evaluating content of information
presented at meetings and in publications before deciding whether to
incorporate the proposed material into one’s practice. Reading at
least three varying opinions on any topic is a useful exercise while
attempting to triangulate your way toward an objective truth.
Given the expense of research and product development and the
diminishing funding for research, surgeon involvement in research
and collaboration with industry are important. Investigators should be
aware, though, of the specifics within contracts with industry. If
restrictions are placed on study design or dissemination of all
findings by the industry sponsor, the relationship should be
reconsidered. Research has found that published industrysponsored research is more likely to be supportive of the product
under investigation. This may be related to biases by journals
against negative findings or restriction of publication of data by the
industry sponsor. Industry has also withheld negative findings that
have only been revealed after large-scale complications related to
the medication or treatment become known.11 Even the US Food and
Drug Administration has withheld from public scrutiny over one
million reports of harm related to medical devices since 2016.
12
Disclosure of Relationships
A high percentage of speakers, moderators, panelists, and
instructors at national plastic surgery meetings have received
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industry funds related to royalties, licenses, and consulting fees.
9
Panelists, moderators, and instructors were the most common roles
of surgeons who received industry payments, and many speakers,
when stating their disclosures, will only make disclosure they feel
relevant to that session. It is incumbent upon the listener to review
complete listings of conflicts of interest to determine for themselves
the potential degree of impact of these biases.
Guidelines which may be helpful in managing conflicts include
monitoring the OPD, recusing oneself at meetings where the source
of conflict is being discussed, using a variety of products in clinical
practice to challenge personal biases, and disclosing all sources of
conflict to patients, employers, and audiences.13 Retrospective
studies have found incomplete reporting of conflicts of interest; most
are relatively small monetary sums related to food and beverage and
are infrequently associated with research.14 As even minimal
interactions with industry can create favorable conscious and
unconscious biases toward products, it is important for authors to
disclose all payments.
13,14
ETHICS AND EVIDENCE-BASED MEDICINE
Research evidence has been stratified into levels since the 1980s,
making it easier to determine the effectiveness of treatments based
on the quality of the research data. The initial goal was to attempt to
substitute true knowledge for the power-based wisdom that was the
status quo.15 Stratification is based on study design—the
randomized controlled trial (RCT) (level 1) being at the apex and the
case report (level 5) at the base. Stratification is based on the quality
of the design and likelihood of avoidance of the most common types
of bias and statistical error. Modifications of the levels of evidence
have been made depending on whether the study design is
therapeutic, prognostic, diagnostic, symptom prevalence, or
economic, whether it is a systematic review or an individual one, and
if it is prospective or retrospective. Studies are further defined by
whether they can be strongly recommended (grade A) or considered
an option (grades C and D).
16
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