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Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines

Authors:

Abstract

Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.
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Disclosure: Dr. Janis receives royalties from Thieme and
Springer Publishing. The other authors have no nancial
interest to declare.
Business
From the Department of Plastic and Reconstructive Surgery, The
Ohio State University Medical Center, Columbus, Ohio.
Received for publication June 30, 2022; accepted September 8,
2022.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
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DOI: 10.1097/GOX.0000000000004634
INTRODUCTION
Outpatient procedures remain a popular trend in
recent years. In 2020, 82% of cosmetic procedures and
41% of reconstructive procedures were performed in the
outpatient setting, compared with 81% and 62% in 2007,
respectively.1,2 Internationally, 56% of cosmetic proce-
dures were performed in the outpatient setting in 2020.3
Improved convenience, comfort, and costs benet both
patients and surgeons when compared with the hospital
setting.4–6 It is, therefore, reasonable to expect the preva-
lence of outpatient procedures to continue, or even rise,
into the future. Despite such momentum, regulations have
been slow to keep pace; fewer than 30 states have laws gov-
erning ofce-based surgery (OBS), and even fewer states
require accreditation.7,8 Among those that do, there is a
lack of standardization over accreditation.9
Conicting evidence exists regarding the complica-
tion rate in OBS compared with other surgical settings.10–12
Regardless, patient safety remains paramount.4 Given the
lack of safety regulations for OBS, organizations, such as
the American College of Surgeons, the American Society
of Plastic Surgeons (ASPS), the Aesthetic Society (formerly
ASAPS), and the American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF), have released
practice advisories to guide surgeons.13–16 As such, the
onus of patient safety lies on the shoulders of surgeons.
This article will summarize and consolidate contem-
porary, evidence-based practice guidelines to help plas-
tic surgeons understand topics guiding patient safety in
OBS. The principles outlined herein are not exhaustive,
nor are they hard and fast rules. They also should not be
interpreted as the legal standard of medical care. Rather,
physicians should use these guidelines to inform their own
understanding of the evidence and supplement their best
clinical judgment within individual circumstances.
PRINCIPLES GOVERNING OFFICE SAFETY
Accreditation
Accreditation provides validation of safe practices,
compares performance against other accredited facili-
ties, and standardizes practice guidelines.12,17 This dem-
onstrates that the practice meets a nationally accepted
standard and is committed to patient safety and qual-
ity care.17 Current accreditation organizations include
AAAASF, the Accreditation Association for Ambulatory
Health Care, and the Joint Commission.14,17,18 With
expanding medical tourism, reciprocal demand for
patient safety has increased international outreach from
these organizations.19 AAAASF has modied domestic
accreditation standards to accommodate cultural and
social differences internationally and been endorsed by
the International Society for Aesthetic Plastic Surgery.
Kevin K. Zhang, BA
Nihaal Reddy, BS
Jeffrey E. Janis, MD, FACS
Summary: Outpatient procedures are extremely prevalent in plastic surgery, with
an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that
patient safety is paramount, this practical review summarizes major contemporary,
evidence-based recommendations regarding ofce-based plastic surgery. These
recommendations not only outline clinical aspects of patient safety guidelines,
but administrative, as well, which in combination will provide the reader/prac-
tice with a structure and culture that is conducive to the commitment to patient
safety. Proper protocols to address potential issues and emergencies that can arise
in ofce-based surgery, and staff familiarity with thereof, are also necessary to be
best prepared for such situations. (Plast Reconstr Surg Glob Open 2022;10:e4634; doi:
10.1097/GOX.0000000000004634; Published online 9 November 2022.)
Ofce-based Plastic Surgery—Evidence-based
Clinical and Administrative Guidelines
Lww
REVIEW ARTICLE
PRS Global Open 2022
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All accredited facilities are reevaluated yearly via self-
survey and every 3 years by an onsite inspector.19 While
each agency has their own process, they share the goal
of ensuring quality health care and patient safety.17
Membership to plastic surgery societies also demon-
strates a commitment to patient safety; ASPS and the
Aesthetic Society mandate members operate in accred-
ited outpatient facilities.20
Culture of Safety
The Institute of Medicine denes safety culture as “indi-
vidual and organizational behavior, based upon shared
beliefs and values that continuously seek to minimize
patient harm.”21 This culture is a foundational element
of outpatient surgery. Administering surveys can evaluate
perception of safety culture in the ofce.22 Physicians and
staff are responsible for maintaining and honoring the
ofce culture to ensure a collective commitment to qual-
ity improvement and patient safety.23
Personnel and Training
Physicians should maintain certication as recog-
nized by the American Board of Medical Specialties, the
American Osteopathic Association, or a state-approved
board with equivalent standards.4,14,24,25 Ofce-based phy-
sicians are generally subject to less-detailed credential
review, predisposing them to “practice drift”; that is, they
are more susceptible to providing care outside the scope
of their training.26–30 Physicians must work within the
scope of their licensing, experience level, and the facility’s
accreditation guidelines.4,14,28,29 This also applies to anes-
thesiologists, who may receive less ambulatory training in
residency, as well as nursing and support staff.18,23,31,32
Informed Consent
Informed consent is the acknowledgement of a discus-
sion between the provider and patient about the proposed
procedure, including indications, expectations, risks, and
benets along with alternative options.25,32 This includes
a corresponding discussion with the anesthesiologist
regarding the anesthetic plan.26 Discussions should consist
of nonmedical jargon, with communication performed at
a fth-grade level and translated into the patient’s pre-
ferred language.32–35 Supplemental use of visual aids can
improve understanding and retention of information.33
Patients should demonstrate their understanding of the
discussion and proposed treatment using the teach-back
method before signing their consent.32,33 Consent should
also be thoroughly obtained for legal purposes.34
In 2021, the US Food and Drug Administration
updated informed consent protocols tying breast implant
manufacturers and plastic surgeons to a comprehensive
decision-making process with patients. These involve
a device-specic label consisting of ve components
(Table 1), including an additional checklist created by
implant manufacturers for obtaining informed consent.
This checklist aims to conrm understanding of the risks
associated with the operation and implant, and it must be
signed by both the patient and implanting plastic surgeon
after review. Implant manufacturers are prohibited from
selling breast implants to surgeons until they attest in writ-
ing their agreement to using the checklist while obtaining
informed consent.36,37
ASPS encourages plastic surgeons to become famil-
iar with these new Food and Drug Administration guide-
lines.36 For this purpose, both organizations have released
examples of implant labels.38,39 These examples are not
ofcial manufacturer labels and should only be used as
reference—not for patient care.
PROTOCOLS TO ENSURE SAFETY
Organization is essential to maintaining a safe and suc-
cessful ambulatory practice. Perioperative patient safety
checklists are simple tools that promote safety culture and
have helped decrease complication rates.40–42 The World
Health Organization Surgical Safety Checklist is one
example that can be tailored to its user’s needs, such as
for outpatient plastic surgery. (See gure, Supplemental
Digital Content 1, which displays an example of a 28-ele-
ment, perioperative checklist template for use in the
ofce-based setting developed by Rosenberg et al 2012,
http://links.lww.com/PRSGO/C236.)40,43 However, emer-
gencies may arise, and equipment and established policies
should be familiar to all staff to handle both routine and
emergency care.26,44
Fire Safety
Fires in the OR involve three components: an oxidizer,
often oxygen or nitrous oxide; an ignition source, such
as cautery; and fuel, which includes sponges and alco-
hol-based solutions.45–48 Proper management of fuel and
ignition sources in the OR and perioperative areas is pri-
ority.24,45–47 It is crucial to observe proper safety technique
of potential ignition devices, allow preparation solution to
completely dry to disperse ammable fumes, keep gauze
and sponges moist, and minimize oxygen concentration
as appropriate (ideally <50% FiO2).45–48
The major factor behind re litigation is lack of discus-
sion among the surgical team regarding the risk of re.45
As such, re-safety training and teamwork are necessary.
If a re occurs, the procedure must be stopped, and re
protocols should be executed.45,47
Table 1. The Five Components of Breast Implant Manufacturer Labeling
Components of Breast Implant Manufacturer Labeling
1.A “black box” warning regarding potential short-term, long-term, and life-threatening consequences associated with implant
use.
2.A patient decision checklist to help conrm patient understanding of the benets, aforementioned risks, and other information about the implant.
3.Updated recommendations about silicone gel-lled implant rupture-screening protocols.
4.A device description with a list of materials that compose the implant.
5.A patient device card to full medical device tracking requirements.
Zhang et al. Outpatient Plastic Surgery Safety
3
EQUIPMENT AND STERILITY
Properly functioning equipment and sharps and ster-
ile technique are crucial for OR safety. For any OBS using
sedation, the America Society of Anesthesiologists (ASA)
and AAAASF recommend monitoring pulse oximetry,
electrocardiogram, blood pressure, capnography, and
temperature.4,24,25 Equipment must be frequently main-
tained, sanitized, inspected, and sterilized with an auto-
clave, as appropriate.5,24 Intraoperative events, such as
hypothermia or bleeding, increase postoperative morbid-
ity, and equipment should be ready to prevent and treat
such incidents.16,24,49–52 The CDC establishes sterility and
disinfection protocols adopted by many hospitals; ofce-
based practitioners should use such a model as well.53
Ultimately, meticulous adherence to proper sharps and
sterile technique is best for ensuring surgical safety.41,54
Despite this, sharps and needlestick injuries remain
among the most common injuries sustained by surgeons.
In the event of a sharps injury or exposure to blood-borne
infection, staff must wash the area, report the injury, obtain
patient samples for source testing, and receive proper and
punctual prophylaxis to HIV and hepatitis B or C viruses,
as applicable.54,55
Documentation and Quality Improvement
For every procedure, documentation should include
indications, procedure-specic information, ndings,
specimens, complications, and patient tolerance. A pro-
cedure should be documented immediately after its com-
pletion. Inclusion of all pertinent points is important for
continuity of care, protecting patient safety and privacy,
and potential legal ramications.32 Such medical records
must be stored within the facility.24
Thorough documentation can also help with quality
improvement. Monthly audits of random cases and opera-
tive sequalae should be performed, and adverse events
must be analyzed and used to improve systems and pre-
vent reoccurrences.24,56,57 The National Surgical Quality
Improvement Program allows practices to collect and
compare patient data with other participating facilities. It
also uses data sharing to develop and update best practice
guidelines to its member practices.58 Indeed, adherence
to National Surgical Quality Improvement Program pro-
tocols has decreased the risk of surgical complications and
increased patient satisfaction ratings.59–61 More specic to
plastic surgery, the Tracking Operations and Outcomes
for Plastic Surgeons and ASPS Qualied Clinical Data
Registry help plastic surgeons identify areas for improve-
ment and compare quality improvement efforts with their
peers. All ASPS members are encouraged to participate
in the Tracking Operations and Outcomes for Plastic
Surgeons program, and AAAASF requires its member
practices to engage in quality improvement programs.57,62
Within the effort to improve patient care, many plastic
surgeons have turned to standardized risk stratication
during patient evaluations. Postoperative scoring tools
such as the LACE+ index and TIME-H objectively evalu-
ate patient characteristics and comorbidities to stratify
patients on their risk for developing complications. This
information helps providers reallocate resources and
attention to better monitor those deemed high risk and
avoid excessive care to patients who may not require
it.63,64
Postoperative Care
After surgery, minimizing complications should be a
priority. Postoperative nausea and vomiting (PONV) leads
to multiple morbidities, including dehydration, electro-
lyte imbalances, aspiration, wound complications, and
anorexia. Furthermore, PONV can delay discharge and is
a leading cause of unanticipated hospital admission.4,7,65
PONV may be reduced by modifying anesthesia, using
pharmacologic prophylaxis, and managing pain. Long-
term monitoring of patients at high risk for postoperative
complications should be performed.
At discharge, patients should be handed off to an
adult who can understand and adhere to postoperative
directives. The use of durable materials with basic illus-
trations is a valuable resource in assisting with this goal.67
Follow-up visits allow physicians to monitor for compli-
cations and manage wound care devices such as closed-
suction drains.41,67 The timing of follow-up is important
too; appointments within a week of discharge can reduce
readmission rates in inpatients.68 Clinic staff may help
improve adherence by emphasizing the importance of
follow-up appointments, providing resources that amelio-
rate socioeconomic barriers, and sending appointment
reminders.69,70
EMERGENCY AND TRANSFER PROTOCOLS
Detailed protocols for handling medical and situ-
ational emergencies (eg, inclement weather and re)
should be available for reference at any time.26,32,44 Facility
premises should be spacious and organized to enable
lifesaving interventions and retrieval of equipment.4,24 A
source of emergency power must be present and immedi-
ately available.24 At least one physician who is credentialed
in the resuscitative techniques advanced trauma life sup-
port, advanced cardiovascular life support, or pediatric
advanced life support must be present until the patient is
ready for transfer. Medical personnel with direct patient
contact should be trained in basic life support.14,18 For
emergent anaphylaxis, epinephrine or alternative vasoac-
tive drugs should be administered intravenously. Steroids
and antihistamines may be used as adjuncts or for mild
reactions, and glucagon should be available for rescue
treatment for epinephrine nonresponders (eg, due to
β-blocker use).71 Physicians should also have admitting
privileges or maintain an emergency transfer agreement
with a nearby hospital.4,13,14
Periodic inventory checks and simulations are recom-
mended to keep members of the clinical team familiar
and coordinated with their roles.4,32,56 These can be done
via walk-throughs, role-playing, or practice on manne-
quins. Debrief sessions provide an opportunity to discuss
strengths and areas of improvement to better prepare for
the next drill or a real situation.56
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PERIPROCEDURAL SAFETY PRINCIPLES
Periprocedural evaluations, including histories and
physical examinations, are crucial for determining out-
patient surgical eligibility and identifying and plan-
ning for potential complications.24,32,51,72 Information to
elicit includes patient allergies, adverse drug reactions,
medications and drug history, nutritional status, and
comorbidities, such as obesity, cardiovascular disease, pul-
monary disease, diabetes mellitus, and obstructive sleep
apnea.4,5,25,32,41,51,72,73 Preoperative laboratory testing is not
recommended.72
Obesity and Procedure Characteristics
Patient BMI must be considered when planning out-
patient plastic surgery, as BMI is directly correlated with
the risk of perioperative complications.51,74–81 The British
National Health Service recommends patients undergo-
ing body contouring surgery who have a BMI less than or
equal to 28; however, no further clinical guidelines exist
for setting BMI limits or contraindicating plastic surgery
due to obesity.79,80,82 Instead, clinical judgment should
account for the combination of procedures to be per-
formed, procedure indication, and the overall health of
the patient.80–82
Procedure length is known to impact postoperative
morbidity.51 Administration of anesthesia for more than
1 hour and operations ending after 3  are signicant,
independent predictors of unanticipated admission fol-
lowing surgery.83 Although a procedure duration of less
than 6 hours was accepted as a safe cutoff, those lasting
more than 4 hours, as well as combined procedures (in
particular with abdominoplasty), are signicant risk factors
for developing venous thromboembolism (VTE).51,75,82–85
Similarly, specic to liposuction, a lipoaspirate volume less
than 5 L was considered safe.82 Two recent reviews found
an increased risk of VTE in those with a lipoaspirate more
than 3 L,85 and an increased risk of VTE and other com-
plications in those with a lipoaspirate more than 3.5 L.86
Therefore, further postoperative monitoring can be
considered for patients with a BMI more than 30 kg/m2,
liposuction volume more than 3 L, operative time more
than 4 hours, and those undergoing combined proce-
dures.51,85 Postoperative monitoring must be supervised by
a health care provider with documentation of a course of
events.24,85 Finally, longer procedures should be scheduled
earlier in the day.
Homeopathic Supplements
The increasing popularity of alternative and homeo-
pathic medicine without regulation of product labeling
poses potential health risks for surgical patients.41,87,88
Screening for these supplements should be part of the
preprocedure evaluation.88 For homeopathic medica-
tions lacking pharmacokinetic data, ASA recommends
they be discontinued 2–3 weeks preoperatively and not
be resumed for another 1–2 weeks postoperatively.41,88,89
Ultimately, an empathetic surgeon can counsel on
homeopathic therapies while maintaining cultural
respect and patient compliance in preparation for
surgery.90
Anesthesia
Preoperative evaluations are necessary to maintain
patient safety when administering sedatives, local, or
general anesthesia.24,92 The chosen anesthetic technique
should be appropriate for both the patient’s overall health
and the procedure.26 The ASA Patient Selection Physical
Status Classication System places patients into four cat-
egories of health and ability to tolerate anesthesia.14,32,51
Categories 1–3 are able to undergo OBS, whereas those in
category 4 are not.26,41,51,72
Conscious sedation, characterized by the patient’s
ability to self-maintain spontaneous respirations and air-
way protection, and local anesthesia can be considered in
the OBS setting, including for facial and breast surgery
and body contouring.92–94 These techniques offer multiple
advantages over general anesthesia, including shorter
recovery, less PONV, improved cost effectiveness, and less
equipment and personnel required for administration.
Low-dose propofol is a good sedative in OBS because of
its anxiolytic and amnestic properties and its manage-
able pharmacodynamics and side effects. Adjuvants, such
as ketamine, fentanyl, and benzodiazepines, may also be
used. Oral sedation offers some advantages over intrave-
nous administration, such as relative vital sign stability, but
it also lengthens drug onset and duration, which could
complicate management.92
Targeted techniques and nerve blocks can also be
applied in certain operations. Inltration of anesthesia
between the internal oblique and transversus abdominis
(TAP blocks) can reduce the need for postoperative anal-
gesia in abdominal surgery.95,96 Pectoralis and intercostal
nerve blocks are a strong rst choice for local anesthesia
in breast procedures, with serratus anterior plane and
erector spinae plane blocks as reasonable alternatives or
adjuncts.23,96–98
Ropivacaine is commonly used as the local agent.96
Liposomal bupivacaine has a duration of action of approx-
imately 72 hours and can, therefore, be effective in reduc-
ing postoperative pain.99 The aforementioned blocks
are similar in efcacy and safety, so surgeons should
use whichever block they are most comfortable with.96
Surgeons should also be aware of signs of anesthetic toxic-
ity, including agitation, confusion, dizziness, drowsiness,
tinnitus, perioral numbness, metallic taste, and dysarthria.
Antidotes should be available for administration as neces-
sary, including benzodiazepines in the event of seizures or
epinephrine for cardiac arrest.100
Patients considered for conscious sedation should be
ASA 1 or 2 and emotionally stable to reduce the risk of
intraoperative agitation. Given the nature of conscious
sedation and local anesthesia, it is the surgeon’s responsi-
bility to be aware of the patient’s comfort level and be in
communication with the anesthesiologist.92
Antibiotic Prophylaxis
Surgical site infections are a risk ubiquitous to all set-
tings. The Surgical Care Improvement Project recommends
IV antibiotic prophylaxis between 30 and 59 minutes of inci-
sion (2 hours for vancomycin and uoroquinolones).101–103
Preoperative antibiotics should be tailored to the patient;
Zhang et al. Outpatient Plastic Surgery Safety
5
cefazolin, or clindamycin in those with beta-lactam aller-
gies, is commonly used. If the surgery lasts over 4 hours,
repeat dosing is indicated.99 Antibiotics are unnecessary 24
hours postoperatively in clean cases except with placing a
foreign object or for head and neck oncologic reconstruc-
tion.41,101,103–106 Antibiotic administration and discontinu-
ation time, and incision time, should be documented.105
While no guidelines exist for antibiotic prophylaxis based
on procedural characteristics in plastic surgery, surgeons
can refer to the standards recommended by other surgical
specialties in combination with their own judgment.101
Venous Thromboembolism
Plastic surgeons must assess for VTE risk by record-
ing predisposing conditions and lifestyle factors
(Table 2).23,51,84,107 The Caprini Score uses this informa-
tion to stratify patients into low-, moderate-, and high-risk
categories, allowing systematic administration of VTE
prophylaxis based on risk prole.16,108–112 The American
Association of Plastic Surgeons released recommenda-
tions in 2015 regarding deep vein thrombosis and pulmo-
nary embolism (DVT/PE) prevention in plastic surgery
(Table 3).110,113 However, there remains no all-encom-
passing recommendation regarding VTE chemoprophy-
laxis based on Caprini stratication, and surgeons should
use clinical judgment when evaluating patients for VTE
management.108,109,114 An exception may be noted for
abdominoplasty, which is associated with a higher risk of
developing VTE; studies have shown benet in using VTE
chemoprophylaxis in abdominoplasty patients.23,99,112,115
Hypothermia
Hypothermia is an intraoperative event associated
with increased risks of surgical site infections, myocardial
events, and blood loss due to disruption of the coagulation
cascade24,50,116,117; a 1 °C decrease in core body temperature
increases blood loss by as much as 20%, in turn increas-
ing the likelihood of a transfusion.16,49–51 Hypothermia
can also potentiate the effects of anesthesia and prolong
the duration of postoperative recovery and the hospital
stay.50,116–118 Therefore, measures to prevent hypothermia
should be available, including but not limited to, ambi-
ent temperature optimization, forced air warming blan-
kets (bair huggers), warmed intravenous uids, and blood
products.16,24,51,117 Strict monitoring of patients’ vitals and
temperature is necessary in all practices.4
Malignant Hyperthermia
Malignant hyperthermia (MH) is a life-threatening,
anesthetic emergency that must be investigated during
the preprocedure evaluation. A query of personal and
family history of adverse anesthesia reactions, such as
intraoperative trismus, unexplained fevers, or deaths dur-
ing anesthesia, should be performed.119,120 If a patient is
deemed susceptible to hyperthermia or has history of
muscular pathology, he/she may still undergo outpa-
tient surgery with proper precautions.120,121 This includes
obtaining a baseline serum creatine kinase, potassium,
and myoglobin level.120 Nontriggering anesthetics such as
propofol and vecuronium should be used for all suscep-
tible patients, while volatile anesthetics and succinylcho-
line must be avoided.119,120,122 Early recognition of MH is
crucial, with common indicators being end-tidal hypercar-
bia, sinus tachycardia, and masseter spasm.117 In the event
of a hyperthermic crisis, dantrolene and active cooling
methods, such as ice packs and cold IV uids, should be
ready until the patient can be transferred to a hospital.51,117
Failure to monitor temperature is associated with mortal-
ity in MH, further highlighting the importance of moni-
toring vitals during and up to 2.5 hours after surgery.50,51
Multimodal Analgesia (MMA)
The use of local anesthesia and adjunctive MMA can
provide many benets pertaining to operative and post-
operative anesthesia. Improved comfort and PONV man-
agement reduce unanticipated postoperative admissions
and promote recovery with increased patient satisfac-
tion.23,51,96,97,99,123,124 Importantly, use of local anesthesia and
MMA could reduce the need for opioids and, thus, reduce
the risk of new persistent opioid use.96,97,99,124–126 Appropriate
supplementation with NSAIDs, acetaminophen, gabapen-
tinoids, and steroids is, therefore, recommended.98,123
CONCLUSIONS
As physicians, patient safety is the foremost priority.
In an ever-evolving landscape that favors decentraliza-
tion, this means the institution, adherence, and con-
tinual improvement of culture and protocols to secure
high-level patient care. For the plastic surgeon, it also
Table 2. Common Risk Factors for Venous Thromboembolism
Common Risk Factors for Venous Thromboembolism
Personal or family history of clotting disorders (eg, factor V Leiden)
History of more than three pregnancies
Current pregnancy
Contraception use
Venous insufciency
Chronic heart failure
Infectious disease
Recent muscular trauma
Connement to a bed and/or armchair
Long-distance travel
Use of general anesthesia during surgery
Standing >6 hours per day
Performance of combined procedures
Performance of abdominoplasty
Table 3. American Association of Plastic Surgeons 2015 Recommendations for DVT/PE Prevention in Plastic Surgery
Recommendations for Prevention of Deep Vein Thrombosis and Pulmonary Embolism in Plastic Surgery
1. Use nongeneral anesthesia when appropriate.
2. All patients should have intermittent pneumatic compression.
3. All patients should have preoperative Caprini risk stratication performed.
4. Chemoprophylaxis for Caprini scores >8 should be considered on an individualized basis.
PRS Global Open 2022
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means assessing whether the patient is suitable for out-
patient surgery and knowing and preparing for adverse
events that may occur in the facility or after discharge.
This article represents a starting point for the outpatient
plastic surgeon to reference with the goal of promot-
ing consistent understanding and awareness for patient
safety. Indeed, a conscientious physician who exercises
prudent clinical judgment goes a long way in ensuring
patient safety. (See table, Supplemental Digital Content
2, which displays the main takeaways of each topic sec-
tion discussed in this article, http://links.lww.com/
PRSGO/C237.)
Jeffrey E. Janis, MD, FACS
Department of Plastic and Reconstructive Surgery
Ohio State University Wexner Medical Center
915 Olentangy River Road, Suite 2140
Columbus, OH 43212
E-mail: jeffrey.janis@osumc.edu
REFERENCES
1. American Society of Plastics Surgeons. 2020 Plastic Surgery
Statistics Report. Am Soc Plast Surg. 1–23. 2020. Available at http://
scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Plasti
c+Surgery+Statistics+Report#1. Accessed October 5, 2021.
2. American Society of Plastic Surgeons. 2008 Report of the
2007 National Clearinghouse of Plastic Surgery Statistics.
Available at https://www.plasticsurgery.org/documents/News/
Statistics/2008/plastic-surgery-statistics-full-report-2008.pdf.
2008. Accessed October 5, 2021.
3. International Society of Aesthetic Plastic Surgery. Aesthetic/
Cosmetic Procedures Global Survey. 1–60. 2020. Available at
www.isaps.org. Accessed October 5, 2021.
4. Urman RD, Punwani N, Shapiro FE. Ofce-based surgi-
cal and medical procedures: educational gaps. Ochsner J.
2012;12:383–388.
5. Schmalbach CE. Patient safety and anesthesia considerations for
ofce-based otolaryngology procedures. Otolaryngol Clin North
Am. 2019;52:379–390.
6. DeFrancesco MS. Patient safety in outpatient procedures. Obstet
Gynecol Clin North Am. 2019;46:379–387.
7. Kurrek MM, Twersky RS. Ofce-based anesthesia: how to start an
ofce-based practice. Anesthesiol Clin. 2010;28:353–367.
8. O’Donnell J. States lax in regulating cosmetic surgery. ABC
News. Published December 28, 2011. Available at https://abc-
news.go.com/Business/states-lax-regulating-cosmetic-surgery/
story?id=15243751. Accessed October 12, 2022.
9. Conor Murphy YS. Medical malpractice and asset protection
part 7-real risks in today’s headlines. Published 2018. Available
at https://www.physicianspractice.com/view/medical-malprac-
tice-and-asset-protection-part-7-real-risks-in-today-s-headlines.
Accessed October 5, 2021.
10. Vila H Jr, Soto R, Cantor AB, et al. Comparative outcomes analy-
sis of procedures performed in physician ofces and ambulatory
surgery centers. Arch Surg. 2003;138:991–995.
11. Gupta V, Parikh R, Nguyen L, et al. Is ofce-based surgery safe?
Comparing outcomes of 183,914 aesthetic surgical procedures
across different types of accredited facilities. Aesthet Surg J.
2017;37:226–235.
12. Ohsfeldt RL, Li P, Schneider JE, et al. Outcomes of surgeries per-
formed in physician ofces compared with ambulatory surgery
centers and hospital outpatient departments in Florida. Health
Serv Insights. 2017;10:1178632917701025.
13. Berglas NF, Battistelli MF, Nicholson WK, et al. The effect of
facility characteristics on patient safety, patient experience, and
service availability for procedures in non-hospital-afliated out-
patient settings: a systematic review. PLoS One. 2018;13:e0190975.
14. ACS National Surgical Quality Improvement Program. Available
at https://www.facs.org/education/patient-education/patient-
safety/ofce-based-surgery. Accessed October 10, 2021.
15. Patient Safety. The Aesthetic Society. Available at https://www.
surgery.org/professionals/patient-safety. Accessed October 10,
2021.
16. Singer R, Keyes GR, Nahai F. American Association for
Accreditation of Ambulatory Surgical Facilities (AAAASF) his-
tory: its role in plastic surgery safety. Aesthet Surg J Open Forum.
2019;1:ojz008.
17. Urman RD, Philip BK. Accreditation of ambulatory facilities.
Anesthesiol Clin. 2014;32:551–557.
18. Levy BS, Ness DL, Weinberger SE. Consensus guidelines for facil-
ities performing outpatient procedures: evidence over ideology.
Obstet Gynecol. 2019;133:255–260.
19. McGuire MF. International accreditation of ambulatory surgical
centers and medical tourism. Clin Plast Surg. 2013;40:493–498.
20. Pearcy J, Terranova T. Mandate for accreditation in plastic surgery
ambulatory/outpatient clinics. Clin Plast Surg. 2013;40:489–492.
21. Aspden P, Corrigan JM, Wolcott J, et al. Patient Safety: Achieving a
New Standard for Care Editors. Committee on Data Standards for
Patient Safety. 2004:550. Available at http://www.nap.edu/cata-
log/10863.html.
22. Diagnostic safety and quality. Published 2021. Available at
http://www.ahrq.gov/professionals/quality-patient-safety/diag-
nostic-safety/index.html. Accessed October 12, 2021.
23. Bogan V. Anesthesia and safety considerations for ofce-based
cosmetic surgery practice. AANA J. 2012;80:223.
24. Brownstein GM, Baker PA. Outpatient facility standards:
what is necessary for satisfactory outcomes? Clin Plast Surg.
2013;40:363–370.
25. Horton JB, Reece EM, Broughton G II, et al. Patient safety in the
ofce-based setting. Plast Reconstr Surg. 2006;117:61e–80e.
26. Evron S, Ezri T. Organizational prerequisites for anesthesia out-
side the operating room. Curr Opin Anaesthesiol. 2009;22:514–518.
27. Gupta R, Pyati S. Controversies in ofce-based anesthesia:
obstructive sleep apnea considerations. Minerva Anestesiol.
2018;84:1102–1107.
28. Long EA, Gabrick K, Janis JE, et al. Board certication in cos-
metic surgery: an evaluation of training backgrounds and scope
of practice. Plast Reconstr Surg. 2020;146:1017–1023.
29. Gabrick K, Makhoul AT, Riccelli V, et al. Board certication in
cosmetic surgery: an analysis of punitive actions. Plast Reconstr
Surg. 2022;150:713–717.
30. Chen S, Makhoul AT, Janis JE, et al. Board certication in cos-
metic surgery: an examination of online advertising practices.
Ann Plast Surg. 2022;88(suppl 5):S461–S465.
31. Hausman LM, Levine AI, Rosenblatt MA. A survey evaluating the
training of anesthesiology residents in ofce-based anesthesia. J
Clin Anesth. 2006;18:499–503.
32. Shah PD. Patient safety and quality for ofce-based procedures
in otolaryngology. Otolaryngol Clin North Am. 2019;52:89–102.
33. Barton N, Janis JE. Missing the mark: the state of health care liter-
acy in plastic surgery. Plast Reconstr Surg Glob Open. 2020;8:e2856.
34. Morton R. Informed consent: substance and signature. Available
at https://www.thedoctors.com/articles/informed-consent-sub-
stance-and-signature/.Accessed November 1, 2021.
35. Tiourin E, Barton N, Janis JE. Health literacy in plastic surgery: a
scoping review. Plast Reconstr Surg Glob Open. 2022;10:e4247.
36. American Society of Plastics Surgeons. Breast implant check-
list requirement: what you need to know. Available at https://
Zhang et al. Outpatient Plastic Surgery Safety
7
www.plasticsurgery.org/for-medical-professionals/publications/
psn-extra/news/breast-implant-checklist-requirement-what-you-
need-to-know. 2021. Accessed January 3, 2022.
37. Food and Drug Administration. Breast implants. https://www.
fda.gov/medical-devices/implants-and-prosthetics/breast-
implants. 2021. Accessed January 3, 2022.
38. Breast implant patient decision checklist example. The American
Society of Plastic Surgeons. Published 2021. Available at https://
www.plasticsurgery.org/documents/Patient-Safety/Breast-
Implant-Patient-Decision-Checklist-Example.pdf. Accessed
January 11, 2022.
39. Breast implants—certain labeling recommendations to improve
patient communication. Guidance for industry and food and
drug administration staff. Food and Drug Administration.
2020;1–22. Available at https://www.fda.gov/media/131885/
download. Accessed January 11, 2022.
40. Rosenberg NM, Urman RD, Gallagher S, et al. Effect of an
ofce-based surgical safety system on patient outcomes. Eplasty.
2012;12:e59.
41. Harrison B, Khansa I, Janis JE. Evidence-based strategies to
reduce postoperative complications in plastic surgery. Plast
Reconstr Surg. 2016;137:351–360.
42. Newkirk JD. Preventing surgical mishaps: using surgical check-
lists. Clin Plast Surg. 2013;40:475–487.
43. Schroeder SD. Surgical safety checklist. S D Med. 2009;62:209.
44. Ahmad S. Ofce based—is my anesthetic care any different?
Assessment and management. Anesthesiol Clin. 2010;28:369–384.
45. Roy S, Smith LP. Preventing and managing operating room res
in otolaryngology-head and neck surgery. Otolaryngol Clin North
Am. 2019;52:163–171.
46. Bansal VK, Dobie KH, Brock EJ. Emergency response in the
ambulatory surgery center. Anesthesiol Clin. 2019;37:239–250.
47. Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for
the prevention and management of operating room res.
Anesthesiology. 2008;108:786–801.
48. Luba K, Apfelbaum JL, Cutter TW. Airway management in the
outpatient setting. Clin Plast Surg. 2013;40:405–417.
49. Rajagopalan S, Mascha E, Na J, et al. The effects of mild periop-
erative hypothermia on blood loss and transfusion requirement.
Anesthesiology. 2008;108:71–77.
50. Sessler DI. Perioperative thermoregulation and heat balance.
Lancet. 2016;387:2655–2664.
51. Haeck PC, Swanson JA, Schechter LS, et al; ASPS Patient Safety
Committee. Evidence-based patient safety advisory: blood dyscra-
sias. Plast Reconstr Surg. 2009;124(4 suppl):82S–95S.
52. Tiourin E, Barton N, Janis JE. Methods for minimizing bleeding
in facelift surgery: an evidence-based review. Plast Reconstr Surg
Glob Open. 2021;9:e3765.
53. Centers for Disease Control and Prevention. Guideline for disinfec-
tion and sterilization in healthcare facilities, 2008; miscellaneous
inactivating agents. CDC website. 2013:9–13. Available at http://
www.cdc.gov/hicpac/Disinfection_Sterilization/10_0MiscAgents.
html. Accessed December 10, 2021.
54. Waljee JF, Malay S, Chung KC. Sharps injuries: the risks and rel-
evance to plastic surgeons. Plast Reconstr Surg. 2013;131:784–791.
55. Rizk C, Monroe H, Orengo I, et al. Needlestick and sharps
injuries in dermatologic surgery: a review of preventative tech-
niques and post-exposure protocols. J Clin Aesthet Dermatol.
2016;9:41–49.
56. Gardner R. Ofce patient safety. Obstet Gynecol Clin North Am.
2019;46:339–351.
57. Soltani AM, Keyes GR, Singer R, et al. Outpatient surgery and
sequelae: an analysis of the AAAASF internet-based quality assur-
ance and peer review database. Clin Plast Surg. 2013;40:465–473.
58. ACS National Surgical Quality Improvement Program. Published
2004. Available at https://www.facs.org/quality-programs/acs-
nsqip. Accessed December 10, 2021.
59. Castaldi M, George G, Turner P, et al. NSQIP impacts patient
experience. J Patient Exp. 2020;7:89–95.
60. Welling SE, Katz CB, Goldberg MJ, et al. NSQIP versus insti-
tutional morbidity and mortality conference: complementary
complication reporting in pediatric spine fusion. Spine Deform.
2021;9:113–118.
61. Keyes GR, Nahai F, Iverson RE, et al. Evidence-based medicine
and data sharing in outpatient plastic surgery. Clin Plast Surg.
2013;40:453–463.
62. American Society of Plastic Surgeons. Plastic Surgery Registries
Network. Published 2022. Available at https://www.plasticsurgery.
org/for-medical-professionals/registries. Accessed March 15, 2022.
63. Winter E, Glauser G, Caplan IF, et al. The LACE+ index as
a predictor of 30-day patient outcomes in a plastic surgery
population: a coarsened exact match study. Plast Reconstr Surg.
2020;146:296e–305e.
64. Guarro G, Cozzani F, Rossini M, et al. Wounds morphologic
assessment: application and reproducibility of a virtual measur-
ing system, pilot study. Acta Biomed. 2021;92:e2021227.
65. Keyes M. Management of postoperative nausea and vomiting
in ambulatory surgery: the big little problem. Clin Plast Surg.
2013;40:447–452.
66. Krasnoryadtseva A, Dalbeth N, Petrie KJ. The effect of different
styles of medical illustration on information comprehension, the
perception of educational material and illness beliefs. Patient
Educ Couns. 2020;103:556–562.
67. Khansa I, Khansa L, Meyerson J, et al. Optimal use of sur-
gical drains: evidence-based strategies. Plast Reconstr Surg.
2018;141:1542–1549.
68. Coppa K, Kim EJ, Oppenheim MI, et al. Examination of post-
discharge follow-up appointment status and 30-day readmission.
J Gen Intern Med. 2021;36:1214–1221.
69. Gurol-Urganci I, Vodopivec-Jamsek V, Atun R, et al. Mobile
phone messaging reminders for attendance at healthcare
appointments. Cochrane Database Syst Rev. 2013;2013:CD007458.
70. Aaland MO, Marose K, Zhu TH. The lost to trauma patient fol-
low-up: a system or patient problem. J Trauma Acute Care Surg.
2012;73:1507–1511.
71. Laguna JJ, Archilla J, Doña I, et al. Practical guidelines for
perioperative hypersensitivity reactions. J Investig Allergol Clin
Immunol. 2018;28:216–232.
72. Kataria T, Cutter TW, Apfelbaum JL. Patient selection in outpa-
tient surgery. Clin Plast Surg. 2013;40:371–382.
73. Janis JE, Teotia SS, Bowen JB, et al. Safety considerations in aes-
thetic surgery. Essentials of Aesthetic Surgery. New York, NY: Thieme
Medical Publishers, Inc.; 2018:119–142.
74. Haeck PC, Swanson JA, Gutowski KA, et al. Evidence-based
patient safety advisory: liposuction. Plast Reconstr Surg. 2009;124(4
suppl):28S–44S.
75. Kaoutzanis C, Gupta V, Winocour J, et al. Cosmetic liposuction:
preoperative risk factors, major complication rates, and safety of
combined procedures. Aesthet Surg J. 2017;37:680–694.
76. Winocour J, Gupta V, Ramirez JR, et al. Abdominoplasty: risk
factors, complication rates, and safety of combined procedures.
Plast Reconstr Surg. 2015;136:597e–606e.
77. van der Beek ES, van der Molen AM, van Ramshorst B. Complications
after body contouring surgery in post-bariatric patients: the impor-
tance of a stable weight close to normal. Obes Facts. 2011;4:61–66.
78. Mioton LM, Buck DW II, Rambachan A, et al. Predictors of
readmission after outpatient plastic surgery. Plast Reconstr Surg.
2014;133:173–180.
PRS Global Open 2022
8
79. Soldin M, Mughal M, Al-Hadithy N; Department of Health;
British Association of Plastic, Reconstructive and Aesthetic
Surgeons; Royal College of Surgeons England. National com-
missioning guidelines: body contouring surgery after massive
weight loss. J Plast Reconstr Aesthet Surg. 2014;67:1076–1081.
80. Crane DP, Inglesby D, Lauzon S, et al. The effects of obesity
on plastic and reconstructive surgical outcomes. J Plast Reconstr
Aesthet Surg. 2020;73:783–808.
81. Bigarella LG, Ballardin AC, Couto LS, et al. The impact of obe-
sity on plastic surgery outcomes: a systematic review and meta-
analysis. Aesthetic Surg J. 2021;42:795–807.
82. Schechter L. Letter from the patient safety committee chair. In
Pathways to Preventing Adverse Events in Ambulatory Surgery. The
American Society of Plastic Surgeons. Published 2011. Available
at https://www.plasticsurgery.org/Documents/Health-Policy/
Patient-Safety/patient-safety-2011-adverse-events-ambulatory-
surgery.pdf. Accessed October 12, 2022.
83. Halk AB, Habbema L, Genders RE, et al. Safety studies in
the eld of liposuction: a systematic review. Dermatol Surg.
2019;45:171–182.
84. Winocour J, Gupta V, Kaoutzanis C, et al. Venous thromboem-
bolism in the cosmetic patient: analysis of 129,007 patients.
Aesthet Surg J. 2017;37:337–349.
85. Rohrich RJ, Mendez BM, Afrooz PN. An update on the safety
and efcacy of outpatient plastic surgery: a review of 26,032
consecutive cases. Plast Reconstr Surg. 2018;141:902–908.
86. Kanapathy M, Pacico M, Yassin AM, et al. Safety of large-vol-
ume liposuction in aesthetic surgery: a systematic review and
meta-analysis. Aesthet Surg J. 2021;41:1040–1053.
87. Winslow LC, Kroll DJ. Herbs as medicines. Arch Intern Med.
1998;158:2192–2199.
88. Wong WW, Gabriel A, Maxwell GP, et al. Bleeding risks of
herbal, homeopathic, and dietary supplements: a hidden night-
mare for plastic surgeons? Aesthet Surg J. 2012;32:332–346.
89. Leak JA. Perioperative considerations in the management of
the patient taking herbal medicines. Curr Opin Anaesthesiol.
2000;13:321–325.
90. Ruan QZ, Chen AD, Tran BNG, et al. Integrative medicine in
plastic surgery. Physiol Behav. 2016;176:139–148.
91. Rollert MK, Busaidy K, Krishnan D, et al. Anesthesia in outpa-
tient facilities. J Oral Maxillofac Surg. 2017;75:e34–e49.
92. Pollock H, Forman S, Pollock T, et al. Conscious sedation/local
anesthesia in the ofce-based surgical and procedural facility.
Clin Plast Surg. 2013;40:383–388.
93. Ma X, Wu L, Ouyang T, et al. Safety and efcacy of facial fat graft-
ing under local anesthesia. Aesthetic Plast Surg. 2018;42:151–158.
94. Shapiro FE. Anesthesia for outpatient cosmetic surgery. Curr
Opin Anaesthesiol. 2008;21:704–710.
95. Araco A, Pooney J, Araco F, et al. Transversus abdominis plane
block reduces the analgesic requirements after abdominoplasty
with ank liposuction. Ann Plast Surg. 2010;65:385–388.
96. ElHawary H, Joshi GP, Janis JE. Practical review of abdominal
and breast regional analgesia for plastic surgeons: evidence and
techniques. Plast Reconstr Surg Glob Open. 2020;8:e3224.
97. Barker JC, DiBartola K, Wee C, et al. Preoperative multimodal
analgesia decreases postanesthesia care unit narcotic use and
pain scores in outpatient breast surgery. Plast Reconstr Surg.
2018;142:443e–450e.
98. Schoenbrunner AR, Janis JE. Pain management in plastic sur-
gery. Clin Plast Surg. 2020;47:191–201.
99. Shestak KC, Rios L, Pollock TA, et al. Evidenced-based approach
to abdominoplasty update. Aesthet Surg J. 2019;39:628–642.
100. Mahajan A, Derian, A. Local anesthetic toxicity. In StatPearls.
Treasure Island, FL: StatPearls Publishing. Published January
2022. Available at https://www.ncbi.nlm.nih.gov/books/
NBK499964/.
101. Anigian KT, Miller T, Constantine RS, et al. Effectiveness of pro-
phylactic antibiotics in outpatient plastic surgery. Aesthet Surg J.
2014;34:1252–1258.
102. LaBove G, Davison SP, Jackson M. Compliance of perioperative
antibiotic dosing and surgical site infection rate in ofce-based
elective surgery. Plast Reconstr Surg Glob Open. 2016;4:e710.
103. Nazarian Mobin SS, Keyes GR, Singer R, et al. Infections in out-
patient surgery. Clin Plast Surg. 2013;40:439–446.
104. Bratzler DW, Houck PM; Surgical Infection Prevention
Guideline Writers Workgroup. Antimicrobial prophylaxis for
surgery: an advisory statement from the National Surgical
Infection Prevention Project. Am J Surg. 2005;189:395–404.
105. Surgical Care Improvement Project (SCIP). Published 2010.
Available at https://manual.jointcommission.org/releases/
archive/TJC2010B/SurgicalCareImprovementProject.html.
Accessed January 17, 2022.
106. ElHawary H, Hintermayer MA, Alam P, et al. Decreasing surgical
site infections in plastic surgery: a systematic review and meta-
analysis of level 1 evidence. Aesthet Surg J. 2021;41:NP948–NP958.
107. Hernandez S, Valdes J, Salama M. Venous thromboembolism
prophylaxis in plastic surgery: a literature review. AANA J.
2016;84:167–172. Available at https://www.aana.com/docs/
default-source/aana-journal-web-documents-1/venous-throm-
boembolism-0616-pp167-172.pdf?sfvrsn=6c948b1_6.
108. Iverson RE, Gomez JL. Deep venous thrombosis: prevention
and management. Clin Plast Surg. 2013;40:389–398.
109. Gold A. Deep vein thrombosis chemoprophylaxis in plastic sur-
gery. Clin Plast Surg. 2013;40:399–404.
110. Pannucci CJ, MacDonald JK, Ariyan S, et al. Benets and risks
of prophylaxis for deep venous thrombosis and pulmonary
embolus in plastic surgery: a systematic review and meta-analysis
of controlled trials and consensus conference. Plast Reconstr
Surg. 2016;137:709–730.
111. Cronin MA, Dengler N, Krauss ES, et al. Completion of the
updated caprini risk assessment model (2013 Version). Clin
Appl Thromb. 2019;25:1076029619838052.
112. Kraft CT, Janis JE. Deep venous thrombosis prophylaxis. Clin
Plast Surg. 2020;47:409–414.
113. Iorio ML, Venturi ML, Davison SP. Practical guidelines for
venous thromboembolism chemoprophylaxis in elective plastic
surgery. Plast Reconstr Surg. 2015;135:413–423.
114. Murphy RX, Schmitz D, Rosolowski K. Evidence-based prac-
tices for thromboembolism prevention: a report from the ASPS
venous thromboembolism task force approved by ASPS Executive
Committee: July 2011. Plast Reconstr Surg. 2012;130:168e–175e.
115. Gray S, Gittleman E, Moliver CL. Safety in ofce-based full
abdominoplasty. Aesthet Surg J. 2012;32:200–206.
116. Kurz A, Sessler D, Lenhardt R. Perioperative normothermia to
reduce the incidence of surgical wound infection and shorten
hospitalization. J Neurosurg Anesthesiol. 1996;8:314–315.
117. Hernandez M, Cutter TW, Apfelbaum JL. Hypothermia and
hyperthermia in the ambulatory surgical patient. Clin Plast
Surg. 2013;40:429–438.
118. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative
hypothermia prolongs postanesthetic recovery. Anesthesiology.
1997;87:1318–1323.
119. Gurunluoglu R, Swanson JA, Haeck PC; ASPS Patient Safety
Committee. Evidence-based patient safety advisory: malignant
hyperthermia. Plast Reconstr Surg. 2009;124:68S–81S.
120. Rüffert H, Bastian B, Bendixen D, et al; European Malignant
Hyperthermia Group. Consensus guidelines on perioperative
management of malignant hyperthermia suspected or suscep-
tible patients from the European Malignant Hyperthermia
Group. Br J Anaesth. 2021;126:120–130.
121. Urman RD, Rajan N, Belani K, et al. Malignant hyperther-
mia-susceptible adult patient and ambulatory surgery center:
Zhang et al. Outpatient Plastic Surgery Safety
9
Society for Ambulatory Anesthesia and Ambulatory Surgical
Care Committee of the American Society of Anesthesiologists
position statement. Anesth Analg. 2019;129:347–349.
122. Litman RS, Joshi GP. Malignant hyperthermia in the ambula-
tory surgery center: how should we prepare? Anesthesiology.
2014;120:1306–1308.
123. Barker JC, Joshi GP, Janis JE. Basics and best practices of multi-
modal pain management for the plastic surgeon. Plast Reconstr
Surg Glob Open. 2020;8:e2833.
124. Chu JJ, Janis JE, Skoracki R, et al. Opioid overprescribing and pro-
cedure-specic opioid consumption patterns for plastic and recon-
structive surgery patients. Plast Reconstr Surg. 2021;147:669e–679e.
125. Brummett CM, Waljee JF, Goesling J, et al. New persistent opi-
oid use after minor and major surgical procedures in US adults.
JAMA Surg. 2017;152:e170504.
126. Bohnert AS, Valenstein M, Bair MJ, et al. Association between
opioid prescribing patterns and opioid overdose-related
deaths. JAMA. 2011;305:1315–1321.
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Background: Aesthetic surgery patients commonly use online resources to select a surgeon. The American Board of Plastic Surgery is the American Board of Medical Specialties member board that certifies plastic surgeons. The American Board of Cosmetic Surgery (ABCS) provides aesthetic surgery credentials through a non-American Board of Medical Specialties-recognized process. This study examines use of the phrases "plastic surgery" and "plastic surgeon" by ABCS-certified surgeons when advertising online. Methods: Diplomates of the ABCS were identified from the ABCS Web site. Professional Web sites, Facebook business pages, and Instagram profiles were located by online search. Use of the descriptor "plastic" and ABCS board certification on practice Web sites, Facebook business page categorization, and plastic surgery-related hashtag use on Instagram were recorded. Results: A total of 298 non-American Board of Plastic Surgery-certified ABCS diplomates were included. One hundred eighty-nine (69.5%) categorized their Facebook business page as "plastic surgeon." Within Instagram posts, 123 (57.2%) used #plasticsurgeon, and 172 (80.0%) used #plasticsurgery. On professional Web sites, 90 (30.4%) identified themselves as a "plastic surgeon," 123 (41.6%) characterized their practice as "plastic surgery," and 196 (68.5%) used their ABCS credential to identify as a "board-certified" cosmetic surgeon. Conclusions: Diplomates of the ABCS frequently use "plastic surgeon" and "plastic surgery" in online advertisements despite a lack of accredited plastic surgery training or board certification. Furthermore, most ABCS diplomates use their ABCS credentials to market themselves as "board-certified" cosmetic surgeons, potentially violating American Medical Association-supported truth in advertising laws in some states and increasing public confusion regarding different board certifications.
Article
Background Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory. Objectives The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures. Methods We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes. Results Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction. Conclusions Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast. Level of Evidence: 2
Article
Background and aims: Assessment of wounds morphology can be considered, in the everyday medical activity, the first step for the correct pathway of diagnosis. Authors present a pilot study focused on the statistical analysis of 32 cases of wounds measurements conducted by both the traditional method (paper ruler) both the digital smartphone analysis. Materials and methods: 32 lesions were morphologically evaluated. All the enrolled patients were evaluated by both the traditional method (paper ruler) both a digital smartphone analysis based on the app imitoMeasure. The extracted data were compared to the traditional measurements and a statistical analysis was based on intraclass correlation coefficients (ICC). Results: Three morphological parameters were evaluated: width (expressed in cm), length (expressed in cm) and area (expressed in cm2). The area (expressed in cm2) was found to be the less comparable, but the data were close in this case, too. Conclusion: The present study shows that the digital measuring systems should be easily addressed as versatile tools that could be applied in daily clinical practice in the future.
Article
Background: Opioid prescribing practices contribute to opioid misuse, dependency, and diversion. There are currently no comprehensive and quantitative evidence-based guidelines that give procedure-specific recommendations regarding opioid prescribing in plastic surgery. Methods: A retrospective review of 479 plastic surgery patients encompassing 23 different plastic surgery procedure categories was performed. Opioid prescribing patterns and patient-reported opioid use at 1 and 3 months postoperatively are reported. Results: Opioid overprescribing was common, averaging an excess of 13 pills per patient across all procedure categories (prescribed versus consumed, 25.4 ± 23.1 versus 12.1 ± 19.7; p = 3.0 × 10-19), with a total excess of 5895 pills (30,967 oral morphine equivalents) for the study's sample. Fifty-two percent of all opioid pills prescribed went unused. Opioid consumption ranged between four and 37 pills across procedure categories. A greater proportion of patients who reported a history of preoperative opioid use were still using opioids at the time of their 1-month and 3-month follow-up appointments (62 percent versus 9 percent at 1 month, and 31 percent versus 1 percent at 3 months). Most patients (83 percent) did not store opioids in a locked location, and 64 percent did not dispose of opioids at 1 month. Conclusions: Opioids are commonly overprescribed by plastic surgery providers. This study determined procedure-specific opioid consumption patterns, which can help providers reduce opioid waste. In addition, patients do not properly store or dispose of opioids, demonstrating the need for better patient education.
Article
Background Although many interventions are implemented to prevent surgical site infections (SSIs) in plastic surgery, their supporting evidence is inconsistent. Objectives The goal of this study is to assess the efficacy of methods for decreasing SSIs in plastic surgery. Methods A systematic review and meta-analysis were preformed comparing the effects of SSI prevention methods. All the studies were assessed for quality of evidence using the GRADE assessment. Results Fifty Level-1 randomized controlled trials were included. The most common interventions for preventing SSIs were antibiotic prophylaxis, showering, prepping, draping, and the use of dressings. Current evidence suggests that antibiotic prophylaxis is largely unnecessary and overused in many plastic surgical procedures, with the exception of head and neck oncologic, oral craniofacial, and traumatic hand surgeries. Conclusions Efficacy of antibiotic prophylaxis in plastic surgery is dependent on surgery type. There is a lack evidence that showering and prepping with chlorohexidine and povidone reduces SSIs.
Article
Background Post-hospital discharge follow-up appointments are intended to evaluate patients’ recovery following a hospitalization, but it is unclear how appointment statuses are associated with readmissions.Objective To examine the association between post-discharge ambulatory follow-up status, (1) having a scheduled appointment and (2) arriving to said appointment, and 30-day readmission.Design and SettingA retrospective cohort study of patients hospitalized at 12 hospitals in an Integrated Delivery Network and their ambulatory appointments in that same network.Patients and Main MeasuresWe included 50,772 patients who had an ambulatory appointment within 18 months of an inpatient admission in 2018. Primary outcome was readmission within 30 days post-discharge.Key ResultsThere were 32,108 (63.2%) patients with scheduled follow-up appointments and 18,664 (36.8%) patients with no follow-up; 28,313 (88.2%) patients arrived, 3149 (9.8%) missed, and 646 (2.0%) were readmitted prior to their scheduled appointments. Overall 30-day readmission rate was 7.3%; 6.0% [5.75–6.31] for those who arrived, 8.8% [8.44–9.25] for those without follow-up, and 10.3% [9.28–11.40] for those who missed a scheduled appointment (p < 0.001). After adjusting for covariates, patients who arrived at their appointment in the first week following discharge were significantly less likely to be readmitted than those not having any follow-up scheduled (medical adjusted hazard ratio (aHR) 0.57 [0.47–0.69], p < 0.001; surgical aHR 0.58 [0.44–0.75], p < 0.001) There was an increased risk at weeks 3 and 4 for medical patients who arrived at a follow-up compared to those with no follow-up scheduled (week 3 aHR 1.29 [1.10–1.51], p = 0.001; week 4 aHR 1.46 [1.26–1.70], p < 0.001).Conclusions The benefit of patients arriving to their post-discharge appointments compared with patients who missed their follow-up visits or had no follow-up scheduled, is only significant during first week post-discharge, suggesting that coordination within 1 week of discharge is critical in reducing 30-day readmissions.