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9. Safety Considerations in Aesthetic Surgery
Adam Jacoby, Anmol Chattha
See Essentials of Aesthetic Surger y, pp. 119–141
ANTIBIOTICS
1. What is the ideal timing of administration of prophylactic antibiotics prior to surgery?
A. At the time of incision.
B. <30 minutes before incision.
C. 30 to 59 minutes of incision.
D. 60 to 120 minutes before incision.
E. >120 minutes before incision.
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
2. A 59-year-old female is undergoing 5-hour body contouring surgery with concomitant mastopexy. Her past
medical history consists of preexisting coronary artery disease, obstructive sleep apnea, body mass index of
34, and high cholesterol. Which of the following is a biggest risk factor for developing deep vein thrombosis
(DVT) for this patient?
A. BMI >30.
B. Coronary artery disease.
C. Patient's age.
D. Undergoing concomitant breast surgery during body contouring.
E. 5 hours of surgery.
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
3. Using the Caprini score, which of the following is the greatest risk factor for developing a DVT?
A. Age >60.
B. Pregnancy.
C. Oral contraceptive use.
D. Genetic hypercoagulable disorder.
E. BMI >30.
COMPLICATIONS
4. After liposuction, what is the most common cause of death?
A. Anesthesia-related complications.
B. Thromboembolism.
C. Fat embolism.
D. Gastrointestinal perforations.
E. Massive infection.
COMPLICATIONS
5. What is the most common cause of patient dissatisfaction after aesthetic plastic surgery procedures?
A. Postoperative hematoma.
B. Surgical site infection.
C. Irregular body contour.
D. Postoperative nausea and vomiting (PONV).
E. Reoccurring seromas.
50 Part III&Safety
ANTIBIOTICS
6. Prior to which of the following surgical procedures is administration of prophylactic antibiotics suggested?
A. Carpal tunnel release.
B. Breast reduction.
C. Liposuction.
D. Blepharoplasty.
E. Lipoma excision.
PREOPERATIVE MANAGEMENT
7. In the postbariatric body contouring patient population, what is the most common vitamin or mineral defi-
ciency seen preoperatively?
A. Vitamin B12.
B. Folate.
C. Iron.
D. Calcium.
E. Magnesium.
COMPLICATION MANAGEMENT
8. What is most effective strategy to decrease infection rates?
A. Shave patient's hair to remove hair before prepping patient.
B. Giving preoperative prophylactic antibiotics at the time incision is made.
C. Double gloving instead of single gloving.
D. Use betadine instead of chlorhexidine/alcohol for skin prep.
E. Have the patient take a multivitamin daily a week before surgery.
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
9. Hormone replacement therapy increases DVT risk through which of the following mechanisms?
A. Decreased levels of protein S.
B. Decreased levels of protein C.
C. Inducing factor V Leiden deficiency.
D. Binds to antithrombin III.
E. Activating plasminogen.
Chapter 9&Safety Considerations in Aesthetic Surgery 51
Answers
ANTIBIOTICS
1. What is the ideal timing of administration of prophylactic antibiotics prior to surgery?
C. 30 to 59 minutes of incision.
Several trials have found this to be the optimal window of administering prophylactic antibiotics for
preventing surgical site infections (SSIs). Time frames outside of this window are associated with a higher
risk of developing a surgical site infection (Table 9.1).
Table 9.1 Relationship to SSI Rates: European Data
Time Administered RR OR p Value
<30 minutes before incision 2.0 2.0 0.02
30–59 minutes before incision 1.0 1.0 *
60–120 minutes before incision 1.8 1.7 0.05
Abbreviations: OR, odds ratio; RR, relative risk.
Note: * No p value is listed for antibiotic infusion times from 59 to
30 minutes before incision because that timing had the lowest risk
of SSI and therefore serves as the reference or standard to which all
other infusion times are compared.
REFERENCE
1. Steinberg JP, Braun BI, Hellinger WC, et al; Trial to Reduce Antimicrobial Prophylaxis Errors (TRAPE) Study
Group. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to
Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009;250:10
1
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
2. A 59-year-old female is undergoing 5-hour body contouring surgery with concomitant mastopexy. Her past
medical history consists of preexisting coronary artery disease, obstructive sleep apnea, body mass index of
34, and high cholesterol. Which of the following is a biggest risk factor for developing deep vein thrombosis
(DVT) for this patient?
A. BMI >30.
The answer is A, BMI >30, which is a statistically signif icant risk factor for developing DVT. Other risk factors
include increased operative time (>6 hours), increased pain, large excisional procedures, and hormone
replacement/birth control. Coronary artery disease, age, and breast surgery are not risk factors for postoperative DVT.
1,2
REFERENCES
1. McDevitt NB. Deep vein thrombosis prophylaxis. Plast Reconstr Surg 1999;104:1923
2. Seruya M, Baker SB. MOC-PS CME article: venous thromboembolism prophylaxis in plastic surgery patients.
Plast Reconstr Surg 2008;122:1
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
3. Using the Caprini score, which of the following is the greatest risk factor for developing a DVT?
D. Genetic hypercoagulable disorder.
The answer is D, genetic hypercoagulable disorder, which represents 3 risk scores on the Davison-Caprini
risk assessment. Age >40, pregnancy, and malignancy are all risk factors described in the Davison-Caprini
risk assessment but carry less of a weight than genetic hypercoagulable disorder. Fractures of the hip,
stroke, and spinal cord injuries are other factors that place patients at the highest risk of developing DVT
(Table 9.2).
1
52 Part III&Safety
Table 9.2 Exposing and Predisposing Risk Factors (Davison-Caprini)
Exposing Risk Factors Predisposing Risk Factors
1 Risk Factor
(each item represents one risk score)
Minor surgery Age 40–60
2 Risk Factors
(each item represents two risk scores)
Major surgery Age >60
Immobilization Malignancy
Patients confined to bed for more than 72 hours
Central venous access
3–4 Risk Factors
(each item represents three risk scores)
Previous myocardial infarction History of DVT/PE
Congestive heart failure Any genetic hypercoagulable disorder
Severe sepsis Lupus anticoagulant
Free flap Antiphospholipid antibodies
5 Risk Factors
(each item represents five risk scores)
Fracture of the hip, pelvis, or leg
Stroke
Multiple trauma
Acute spinal cord injury
Abbreviations: DVT/PE, deep vein thrombosis/pulmonary embolism; IBW, ideal body weight.
1 Risk Factor
Obesity >20% IBW
Pregnancy or <10 months postpartum
Oral contraceptive/hormone replacement therapy
2 Risk Factors
3 Risk Factors
Myeloproliferative disorders
Heparin-induced thrombocytopenia
Hyperviscosity
Homocystinemia
REFERENCE
1. Davison SP,Venturi ML, Attinger CE, et al. Prevention of venous thromboembolism in the plastic surgery patient.
Plast Reconstr Surg 2004;114:43e
COMPLICATIONS
4. After liposuction, what is the most common cause of death?
B. Thromboembolism.
The answer is B, thromboembolism, which can lead to pulmonary embolism and death. After
thromboembolism, gastrointestinal perforation is the second most common cause of fatality, followed by
anesthesia-related complications, and finally fat embolism (Table 9.3).
1,2
Chapter 9&Safety Considerations in Aesthetic Surgery 53
Table 9.3 Fatal Outcomes from Liposuction
Cause of Death Number of Deaths Percentage
Fat embolism 11 8.5
Anesthesia-related complications 13 10.0
Hemorrhage 6 4.6
Thromboembolism 30 23.1
Cardiorespiratory failure 7 5.4
Gastrointestinal perforations 19 14.6
Massive infection 7 5.4
Unknown or confidential 37 28.5
Total 130 ∼100
REFERENCES
1. Grazer FM, DeJong R. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg
2000;105:436
2. Hughes CE III. Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthet Surg J 2001;21:120
COMPLICATIONS
5. What is the most common cause of patient dissatisfaction after aesthetic plastic surgery procedures?
D. Postoperative nausea and vomiting (PONV).
The answer is D, postoperative nausea and vomiting, which is also a major factor in delayed discharge and
unplanned postoperative hospital admissions. Upwards of 10% of patients experience postoperative nausea
and vomiting in the recovery room. Multimodal pain management, avoiding long-acting narcotics, and
inhalational anesthetics are the best ways of preventing and treating nausea and vomiting after surgery.
1,2
REFERENCES
1. Iverson RE, Lynch DJ. Practice advisory on pain management and prevention of postoperative nausea and
vomiting. Plast Reconstr Surg 2006;118:1060
2. Watcha MF. Postoperative nausea and emesis. Anesthesiol Clin North Am 2002;20:709
ANTIBIOTICS
6. Prior to which of the following surgical procedures is administration of prophylactic antibiotics suggested?
B. Breast reduction.
The answer is B, breast reduction, as surgery crosses the ductal architecture of the breast which contains
bacteria. Carpal tunnel release, standard liposuction, lipoma excision, and blepharoplasty are clean cases
and evidence does not support the use of prophylactic antibiotics. Antibiotics are also recommended for
contaminated cases, clean contaminated cases where the aerodigestive track is entered, and cases that
may involve an implant.
1
REFERENCE
1. Ariyan S, Martin J, Lal A, et al. Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an
evidence-based consensus conference statement from the American Association of Plastic Surgeons. Plast
Reconstr Surg 2015;135(6):1723–1739
PREOPERATIVE MANAGEMENT
7. In the postbariatric body contouring patient population, what is the most common vitamin or mineral defi-
ciency seen preoperatively?
C. Iron.
The answer is C, iron, which is associated with iron-deficiency anemia seen in up to 50% of postbariatric
patients. Vitamin B12 and folate deficiencies are commonly seen in this population after malabsorptive
54 Part III&Safety
procedures but are still not as common as iron deficiency. Hypocalcemia can be seen in this patient
population but is not as common.
1,2,3
REFERENCES
1. Rhode BM, Maclean LD. Vitamin and mineral supplementation after gastric bypass. In: Deitel M, Cowan GM Jr,
eds. Update: Surgery for the Morbidly Obese Patient: The Field of Extreme Obesity Including Laparoscopy and
Allied Care. Toronto, Ontario: FD Communications; 2000
2. Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate deficiency clinically important after roux-enY gastric bypass? J Gastrointest Surg 1998;2:436
3. Rohrich RJ. Body contouring surgery after massive weight loss. Plast Reconstr Surg 2006;117:S1
COMPLICATION MANAGEMENT
8. What is most effective strategy to decrease infection rates?
C. Double gloving instead of single gloving.
Double gloving reduces perforation of the inner glove and reduces risk of contamination. Analysis of 655
cases revealed that 31% of surgical gloves had a perforation by the end of the case. Glove perforations
raises the risk of surgical site infection (SSI) (odds ratio [OR] = 2.0). Double gloving is associated with less
perforation of the inner glove (OR = 0.10). Shaving increases the risk of infection 2.4-fold. Hypothermia is
a risk factor for worsening infection. Preoperative antibiotics should be given 30 to 59 minutes before
skin incision, but not immediately before the incision is made. Chlorhexidine/alcohol preps are more
effective than betadine in skin decontamination and SSI reduction. Vitamin supplementation in an
otherwise healthy patient does not improve wound healing or decrease infection (it is only effective in
vitamin-deficient patients).
1,2,3
REFERENCES
1. Anderson DJ. Surgical site infections. Infect Dis Clin North Am 2011;25:135
2. Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg
1971;121:251
3. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann
Surg 2011;253:1082
VENOUS THROMBOEMBOLISM (VTE) MANAGEMENT
9. Hormone replacement therapy increases DVT risk through which of the following mechanisms?
A. Decreased levels of protein S.
The answer is A, decreased levels of protein S, which is part of the anticoagulation pathway. Protein C is
not affected by exogenous estrogen. Factor V Leiden is associated with deep vein thrombosis (DVT) but is
caused by activated protein C resistance. Finally, heparin and not estrogen binds to antithrombin III,
which is part of the anticoagulation cascade. Tissue plasminogen activator (tPA) activates plasminogen
and is fibrinolytic.
1
REFERENCE
1. Seruya M, Baker SB. MOC-PS CME article: venous thromboembolism prophylaxis in plastic surgery patients.
Plast Reconstr Surg 2008;122:1
10. Decreasing Complications in Aesthetic Surgery
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 143–159
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
1. A female patient with multiple comorbidities including diabetes, chronic obstructive pulmonary disorder, hyper-
tension, and an underlying coagulopathy requires preoperative medical clearance by the patient's primary care
physician. Which of the following comorbidities places the patient at an increased risk for delayed wound
healing?
A. Diabetes.
B. Chronic obstructive pulmonary disorder.
C. Hypertension.
D. Female gender.
E. Coagulopathy.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
2. When conducting a preoperative consultation, you find out that your Caucasian female patient has had a his-
tory of multiple blood clots during unsuccessful pregnancies resulting in spontaneous abortions. Which of the
following hematologic coagulopathy is she most likely to have?
A. Factor V Leiden deficiency.
B. Von Willebrand disease.
C. Factor X deficiency.
D. Glanzman disease.
E. Hemophilia A.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
3. The use of herbal medicines and supplements is more prevalent in the aesthetic surgery patient population
than in the general population at large. How many weeks prior to and following the procedure should
patients stop taking any herbal medicines and/or supplements?
A. 2 days.
B. 1 week.
C. 2 weeks.
D. 8 weeks.
E. 12 weeks.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
4. If planning to proceed with an aesthetic procedure on a patient who is an active smoker, how long before and
after the operation should the patient refrain from smoking?
A. 2 days.
B. 1 week.
C. 4 weeks.
D. 10 weeks.
E. 12 weeks.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
5. Which of the following is a potential effect(s) of alcohol consumption?
A. Decreased hemostasis and cardiac function.
B. Poor wound healing.
C. Risk of infection.
D. Increased blood pressure.
E. Altered mental status.
56 Part III&Safety
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
6. A patient comes to your office to request a bilateral silicone implant breast augmentation. The patient is a
good surgical candidate but works as a night float nurse at a local community hospital. How would you proceed with preoperative precautions to avoid surgical site infection in this patient?
A. Have her wash with soap and water twice daily.
B. Prescribe PO antibiotics for 5 to 7 days prior to the operation.
C. Screen for S. aureus nasal carriage.
D. Consult infectious disease specialist.
E. Advise her to switch her shifts to day time to improve circadian rhythm 2 weeks before surgery.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
7. A patient is curious about what they can do about the scars after aesthetic surgery. Which of the following is
the best option regarding postoperative early scar treatments?
A. Silicone gel ointments.
B. Cocoa butter.
C. Mederma.
D. Silicone gel sheeting.
E. Topical vitamin E.
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
8. Which of the following antimicrobial agents has been shown to be most effective?
A. 2% chlorhexidine gluconate (CHG).
B. 4% CHG (Hibiclens).
C. 70% isopropyl alcohol (IPA).
D. 2% CHG combined with IPA (ChloraPrep).
E. 4% CHG with 70% IPA.
Chapter 10&Decreasing Complications in Aesthetic Surgery 57
Answers
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
1. A female patient with multiple comorbidities including diabetes, chronic obstructive pulmonary disorder , hyperten-
sion, and an underlying coagulopathy requires preoperative medical clearance by the patient's primary care physician. Which of the following comorbidities places the patient at an increased risk for delayed wound healing?
A. Diabetes.
Poor glycemic control places diabetic patients seeking any aesthetic surgery procedure at increased risk of
surgical site infection and delayed wound healing.
medical clearance from their primar y care or medical specialist provider in order to undergo elective aesthetic surgery. The other answer choices are not risk factors for wound healing-based complications.
REFERENCES
1. Guyuron B, Raszewski R. Undetected diabetes and the plastic surgeon. Plast Reconstr Surg 1990;86:471
2. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce postoperative complications in plastic surgery.
Plast Reconstr Surg 2016;137:351
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
2. When conducting a preoperative consultation, you find out that your Caucasian female patient has had a his-
tory of multiple blood clots during unsuccessful pregnancies resulting in spontaneous abortions. Which of the
following hematologic coagulopathy is she most likely to have?
A. Factor V Leiden deficiency.
Factor V Leiden gene is found as a heterozygous mutation in 3 to 7% of white females and results in a
sixfold increase in the risk of venous thromboembolism (VTE). VTE risk is increased if combined with
cancer, travel, immobilization, use of oral contraceptives, hormone replacement therapy, and estrogen
receptor antagonists. Factor X deficiency is also a clotting disorder; however, it is rarer. Von Willebrand
disease, Glanzman disease, and hemophilia A are all abnormal clotting disorders along different
pathways where patients are more likely to bleed and have a dif ficult time forming a clot.
1,2
Patients with diabetes must obtain a preoperative
1
REFERENCE
1. Fischer JP, Shang EK, Nelson JA, et al. Patterns of preoperative laboratory testing in patients undergoing outpatient plastic surgery procedures. Aesthet Surg J 2014;34:133
PREOPERATIVE MEASURES TO REDUCE COMPLICATIONS
3. The use of herbal medicines and supplements is more prevalent in the aesthetic surgery patient population
than in the general population at large. How many weeks prior to and following the procedure should
patients stop taking any herbal medicines and/or supplements?
C. 2 weeks.
Although it has been shown that aesthetic surgery patients are more likely than the general population
to be taking herbal medicines and/or supplements,
that they use such supplements.
icines and supplements to all patients at least 2 to 3 weeks prior to and immediately following any operation, as many of these supplements are cited for adverse perioperative reactions.
2
Thus, aesthetic plastic surgeons should discuss cessation of herbal med-
1
these patients also tend to be less likely to disclose
3
REFERENCES
1. Broughton G II, Crosby MA, Coleman J, et al. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast Reconstr Surg 2007;119:48e
2. Zwiebel SJ, Michelle L, Brendan A, et al. The incidence of vitamin, mineral, herbal, and other supplement use in
facial cosmetic patients. Plast Reconstr Surg 2013;132:78
3. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and supplemental medicines used by cosmetic patients:
what the plastic surgeon needs to know. Plast Reconstr Surg 2006;117:436