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Thromboembolism & body sculpting

Article-Thromboembolism & body sculpting

Orlando, Fla. — A plastic surgeon in Houston, reports no pulmonary embolism (PE) or deep vein thrombosis (DVT) cases in a series of more than 400 at-risk female patients undergoing large volume liposuction or abdominoplasty combined with liposuction. The secret, according to study author German Newall, M.D., is adding low molecular weight heparin, or enoxaparin (Lovenox, Sanofi-Aventis), to a comprehensive DVT prevention regimen.

Thromboembolism is one of the most feared and serious complications in body contouring, according to Dr. Newall.

"The incidence in the U.S. of deep vein thrombosis, which is a precursor to pulmonary embolism, is 1.2 percent. Over half of those patients that get a DVT will get a pulmonary embolism," he says.

Study, prevention particulars

Dr. Newall decided to conduct the study because despite using every possible American Society for Aesthetic Plastic Surgery (ASAPS) recommendation, short of a blood thinner, to avoid DVT or PE after extensive liposuction or body contouring, his patients continued to experience a 1.2 to 1.5 percent DVT incidence. The study regimen, which he continues to use today but in combination with enoxaparin, is:

  • maintaining core temperature at 36.5 degrees centigrade or higher
  • using heating pads on the operating table
  • using humidified oxygen
  • constant changing of body positioning during the procedure
  • using positional aid pillows and wedges
  • using upper and lower Bair Huggers (Actamed)
  • using intermittent compression stockings
  • a Foley catheter for strict fluid monitoring
  • IV perioperative antibiotics
  • encouraging early ambulation.

"Given the continued high incidence of DVT, I decided to study the literature and came up with information from the orthopedic literature, where orthopedic surgeons were using Lovenox after most of their procedures. Orthopedics has an extremely high incidence of pulmonary embolism," Dr. Newall says.

The average age of women in the study was 39 years old, with an average body mass index (BMI) of 30. Of the study participants, 14 percent had normal BMI; 54 percent were overweight (with BMI between 25 and 29.9); and 31 percent were obese (BMI of 30 or greater).

Dr. Newall notes that 16 percent of his patients had been using estrogen, which increases blood clot incidence.

"I tell all my patients to stop estrogen a few weeks before, if they are using estrogen, but still I think there is an inherently higher chance for them to have a problem clotting," he says.

From theory to practice

Dr. Newall assessed patient risk for DVT according to guidelines published by the division of plastic surgery at Georgetown Medical Center. All patients in the series have undergone general anesthesia in an accredited outpatient facility, and all had been discharged after 23 hours of observation. A registered nurse followed up with patients the day after surgery and the plastic surgeon saw them a week post -surgery in his office.

Dr. Newall uses traditional tumescent liposuction (the super-wet technique), with 5 mm blunt cannulas for deep tissues and 3 mm cannulas for liposculpting. He leaves incisions open for drainage. He uses a lateral tension abdominoplasty, regional infusion pain pumps and compression garments for four to six weeks.

"The average length of my surgery has been two hours and 24 minutes. I like to keep my combined surgeries to less than five hours because it has been my experience that you lower complications by keeping it within that time frame," Dr. Newall tells Cosmetic Surgery Times.

Post-surgical paradigm

Dr. Newall starts patients on 30 mg (of Lovenox) twice a day, but moves up to 40 mg once a day for first 72 hours after surgery. He starts the medication one hour after surgery.

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