Chapter 1 Patient safety in body contouring
• Complications of tobacco use are avoidable with a concerted effort by both the patient and the surgeon. Preoperative and postoperative urine cotinine testing make detection of tobacco use straightforward and not reliant on patient self-respect.
• A thorough preoperative assessment should be performed well in advance of the surgical date to allow adequate time for necessary behavior modification (i.e., tobacco cessation), medical modification (improved glycemic control in a diabetic patient), preoperative tests (i.e., sleep study for undiagnosed sleep apnea), and preoperative consultation with appropriate specialists (i.e., hematologist for family history of thrombophilia). Rushing to the operating table can impede a meticulous and safe preoperative investigation.
• Hypothermia is a common preventable condition with straightforward preoperative and intraoperative measures such as warm irrigation and preoperative warming blankets. These measures are essential in long body contouring cases with wide exposure.
• Surgical site infections should be prevented at every step, with appropriate preoperative disinfection, perioperative antibiotics, and close glycemic control.
• Thromboembolic events are largely preventable with comprehensive preoperative evaluation and appropriate consultation, mechanical and chemical prophylaxis, patient education, and high levels of alertness and suspicion in the postoperative period.
Introduction
In the end the science of human factors (HF) should be foremost in our minds in designing a system of checks and balances in a given clinical situation.1 A group of well-trained surgeons and health care professionals can still miss a step or two among the hundreds we take from the time the patient enters the clinic for preoperative consultation to the time the patient exits the clinic from the final postoperative visit. In every scenario: the initial consultation, the preoperative assessment, the preop holding area, the operating room, the postoperative care on the wards and in the office, a detail missed can lead to grave consequences. While this chapter is in no way comprehensive, it should aid a surgeon in developing his or her own standardized model for safe clinical practice.
Preoperative Assessment and Patient Selection
Medical Assessment
Cardiac clearance is often a nebulous concept that may get glossed over. Cardiac tests are doled out according to patient age and prior history, and too often, according to institutional guideline. Often a “normal” electrocardiogram tells us very little about the patient. The patient’s functional status should be assessed using exercise tolerance, stress tests, and if deemed appropriate, a cardiology consultation with further noninvasive and invasive studies. All too often, patients are deemed “cleared for surgery” by a physician who is both unfamiliar with the surgical procedure, as well as the duration of recovery and rehabilitation afterwards. Family history is crucially important when a seemingly healthy patient presents to us, since a patient with no apparent cardiac history in the family is a different beast from the patient with three close relatives suffering an early cardiac event. Hypertensive patients should be carefully monitored in the perioperative period because their antihypertensive regimen may have to be changed during periods of fluid shifts, body weight change, and postoperative anemia.2
Patients with significant cardiovascular history deserve special attention. Elective surgery should be delayed until adequate preoperative clearance and tests are attained. If a patient has undergone cardiac intervention, the timing of elective surgery is crucial. Perioperative stent thrombosis is associated with high mortality and morbidity and should not be taken lightly. Patients undergoing noncardiac surgery within 1–2 weeks after placement of a bare-metal stent are at high risk of stent thrombosis and death even if perioperative antiplatelet therapy is continued. Perioperative thrombosis of drug-eluting stents has been reported as late as 21 months after stent implantation. A cardiologist should be consulted to determine both the appropriate surgery date and the appropriate stop date for antiplatelet agents. If elective surgery is pursued too quickly, patients are at risk for stent thrombosis because of increased thrombotic state parlayed by surgery and by the therapeutic absence of antiplatelet agents. In general, elective surgery should be delayed until 6 weeks after balloon angioplasty or bare metal stents, and a year after drug-eluting stents. Patients should be continued on their preoperative beta blockers throughout and post surgery, barring unexpected hypotension.3
Close attention must be paid to the patient’s personal and family history of coagulopathy4 (Tables 1.1 and 1.2). Hereditary thrombophilia is surprisingly common – with approximately 5% of patients displaying factor V Leiden mutation and 2–4% of the population testing positive for antiphospholipid syndrome. Recent data suggest that the family history of a thrombotic event even in the absence of hereditary thrombophilia significantly increases the likelihood that the patient will have a postoperative thromboembolism. In women who smoke, hormone therapies (including oral contraceptives) should ring warning bells, as should a history of multiple miscarriages. Bleeding disorders are rarely life-threatening, but a 2% incidence of Von Willebrand’s in the general population is no small figure. The risk of bleeding should be carefully considered, especially if the patient is about to undergo multiple procedures over large anatomic areas.
| Healthy Subjects | First VTE Episode | |
|---|---|---|
| Antithrombin deficiency | 0.02 | 1 |
| Protein C deficiency | 0.3 | 3 |
| Protein S deficiency | ? | 1–2 |
| Factor V Leiden | 5 | 20–40 |
| Prothrombin gene mutation | 1–2 | 6 |
| Fasting homocysteine >95th % | 5 | 23 |
| Anti-phospholipid antibodies | 3 | 16 |
TABLE 1.2 Indications for a Laboratory Workup for Thrombophilia
Connective tissue diseases are frequently under good medical control when a patient is cleared for surgery. However, connective tissue disorders are independent predictors of thromboembolic events and patients should be informed of this risk factor. Steroids and other immunosuppressants are frequently used in medical management of connective tissue disorders and can place a patient at risk for wound healing complications.5
Obstructive sleep apnea (OSA) is a frequently underdiagnosed condition that affects 24% of men and 9% of women. OSA diagnosis can pose a challenge in the preoperative interview because, very frequently, the patients are unaware of the symptoms. Physiologically, the parapharyngeal fat pads narrow the airway, causing restrictive ventilation defects, and resulting in measurable decreases of functional residual capacity and total lung capacity. Of note, over 80% of patients with OSA are undiagnosed, and up to 80% of elderly patients may be affected. Periodic apnea/hypopnea can result in hypertension, arrhythmias, increased intrathoracic negative pressure, and decreased restorative sleep.6
Close preoperative monitoring is especially important in patients with diabetes.7 While the presence of diabetes itself should not preclude surgery, poorly controlled diabetes should halt surgery until better medical management is achieved. HgbA1C is a useful screening tool to check for patient compliance and an index of overall glycemic control, and should be included in the preoperative workup. Even patients who are no longer on insulin will frequently require perioperative insulin to compensate for the stress of surgery as well as diet fluctuations in the postoperative period.
Psychiatric and Behavioral
Second, tobacco impacts wound healing in numerous pathways. Tobacco use reduces cutaneous blood flow in a significant and meaningful way even in light smokers by impairing microvascular vasodilation. Wound healing, immune, and inflammatory responses are blunted in smokers, and collagen deposition and remodeling are decreased. Smoking has been associated with increased wound complications in both aesthetic and reconstructive patients. There is no consensus as to when patients should quit smoking prior to surgery, as benefits of quitting have been found whether a patient quit for 3 weeks, 4–8 weeks, or greater than 2 months. There is no definitive consensus that quitting for a longer period necessarily improves outcome, but the current CDC recommendation is to halt tobacco for 30 days prior to surgery. Self-report of smoking cessation is notoriously unreliable, especially when a patient is incentivized to lie in order to attain the go-ahead for plastic surgery. Objective tests of smoking cessation, such as urine cotinine, may be warranted in order to ensure patient safety.8–14
While tobacco use is a behavior that can be monitored objectively, the plastic surgeon is often faced with a patient who is medically stable, but displays poor judgment, immaturity, unrealistic expectations, or psychiatric illness. Body dysmorphic disorder (BDD) is a DSM diagnosis marked by obsession over a perceived defect that results in compulsive behavior and illogical methods to hide or transform the perceived defect. This is most commonly seen in rhinoplasty patients, but is seen with greater frequency than in the general population among cosmetic patients. BDD is a clear psychiatric contraindication for plastic surgery and patients who are suspected of this condition should receive a psychiatric evaluation, not surgery.15
One specific concern for body contouring patients can be the high incidence of maladaptive eating patterns, especially binge eating disorder. In concert with nutritional difficulties presented by the physiology of weight loss, this can lead to poor perioperative nutritional status or weight fluctuations. Psychiatric history should include eating and dieting patterns. Patients with a history of binge eating disorder, in particular, should be carefully assessed to make sure that they have not recently engaged in pathologic eating behaviors.16
