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.

TABLE 1.1 Prevalence of Molecular Abnormalities

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

Pulmonary disease, especially when undiagnosed and undertreated, can have grave consequences in the postoperative period. In patients with pre-existing pulmonary conditions such as chronic obstructive pulmonary disease (COPD) or asthma, their medical management should be optimized well before the patient is placed on the surgical schedule. Perioperatively, these patients require a more aggressive pulmonary toilet and often pharmacotherapy, regardless of whether they took any at home.

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

During the consultation, it is often more useful to ask a patient’s significant other about the sleep habits, as patients themselves may be unaware. Male, obese, hypertensive patients are at an elevated risk. When sleep apnea is suspected, the symptom checklist should include choking, restless sleep, impaired sleep maintenance, daytime sleepiness, frequent awakening, hypersomnia, depressed mood or mood swings, fatigue, gasping, gastroesophageal reflux disease, and snort arousals. Sixty to 90% of people with OSA are obese and frequently have a neck circumference measuring >40 cm. While weight loss improves OSA symptoms, many patients may have incomplete symptom relief and still require continuous positive airways pressure (CPAP) postoperatively. There is no effective pharmacologic therapy for sleep apnea.

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.

Clinical obesity is common in the body contouring population even after massive weight loss. Many clinicians employ a BMI “cutoff” in their practice, but in reality many patients will end up on the operating room table while still obese. Obesity increases every type of surgical complication especially pulmonary, thromboembolic, and wound complications. Undiagnosed obstructive sleep apnea is frequent in obese patients and should be carefully assessed. Medication doses should sometimes be adjusted as well to compensate for obesity. There is some indication that obese patients should be treated with a higher dose of Lovenox when used as a chemoprophylactic agent.

Nutritional Assessment

In the bariatric population, preoperative screening should include nutritional screening. Protein malnutrition is possible even in weight stable patients, and routine screening of protein malnutrition is reasonable. Due to physiologic changes and changes in their GI tract and their dietary patterns, anemia can result from deficiencies in iron and vitamin B12. All massive weight loss patients need a preoperative complete blood count prior to undergoing surgery.

Psychiatric and Behavioral

Tobacco use is an independent risk factor for wound complications and cessation should be the rule in body contouring surgery. According to CDC data as of November 2007, 20.8% of adults in the United States smoke cigarettes. The health risks of habitual tobacco use are profound, but in the plastic surgery population, the risk immediately impacts postsurgical outcome.

First and foremost, smokers are prone to pulmonary complications due to chronic airway inflammation and decreased pulmonary function. Smokers are more prone to postoperative atelectasis and hypoxia, even in the absence of a diagnosis of COPD.

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

Psychiatric history should be a routine part of the history and physical examination. Body contouring patients are at an increased risk for depression and anxiety disorders compared to the general population. These patients are often labeled as having BDD, when in fact their concern is realistic based on the extreme deformity after massive weight loss. These patients are often former over-eaters who have a psychological barrier against self-discipline and equilibrium. Occasionally, massive weight loss patients have difficulty forming a marriage of their former self image and the new image in the mirror before them. The plastic surgeon should learn basic psychiatric assessment and ascertain that any prior psychiatric illness is stabilized prior to embarking on surgical treatment.

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

Patients who have undergone massive weight loss are also at an increased likelihood of having personality disorders compared to the general population. These are difficult to diagnose and can prevent optimizing the postoperative course. Personality disorders are often insidious and, unlike AXIS I disorders, are pharmacologically untreatable. When faced with a particularly difficult patient, surgeons should beware that a patient with personality disorder may be particularly threatening to his/her reputation and office morale, and that these patients’ disorders are at best slightly ameliorated by preoperative psychiatric intervention.