The initial consultation and shared decision making

The initial consultation is oftentimes the most critical. Unlike the typical medical patient, cosmetic patients are paying their own money toward a procedure, that isn’t always medically necessary, so from the moment a patient enters your office, or even calls to make an appointment, you should presume they are critiquing the practice. By the time the patient arrives at the initial consultation, he/she/they have typically gone through a preliminary decision-making process whereby they have likely considered the different surgical and non-surgical options available to address their concerns. The relationship that begins in this first visit will span across the entirety of the perioperative period, and years beyond. It is important to realize that the office staff and ancillary medical personnel are all important influencers that can enhance a surgeon-patient relationship and can contribute to a patient’s decision to move forward with a surgery.

Whether a patient has sought you out specifically because of your expertise or he or she is physician “shopping,” one must be very respectful of the patient’s ideas, concerns, and preconceptions. It is important to keep an open mind, and first and foremost, actively listen to the patient. By doing so, you will have initiated a process of shared decision making.

Shared decision making refers to the collaborative process between a patient and surgeon, leading to a mutual agreement on a treatment plan. To practice this effectively, a strong relationship between a patient and physician must be developed to allow the patient to express their personal values in addition to explicit treatment expectations and goals. With that understanding of the patient’s goals and preferences, the surgeon can share their clinical knowledge and medical evidence in such a way that provides a path for the patient to make an educated decision and be involved in their own treatment. Shared decision making has been recently incorporated into the health care policy including the Patient Protection and Affordable Care Act (PPACA) as a means of providing guideline-based surgical practices that reduce the grey area of unnecessary surgical procedures. ^, Cosmetic surgical procedures are by definition elective, which makes the process of shared decision making that much more important.

Boss et al. conducted a systematic review looking at studies that used shared decision-making tools for patients undergoing elective surgery. The findings indicate that shared decision making has the potential to decrease the likelihood of patients opting for elective surgery. However, it can enhance the quality of decision-making and alleviate decision conflict in such cases.​

Part of shared decision making for cosmetic surgery involves defining a successful outcome based on open communication with the patient. To prevent situations where the outcome of an intervention is technically satisfactory but does not align with the patient’s desires, it is essential for the surgeon to empathetically understand and address the concerns of the patient from their perspective. The patient’s concerns should serve as a guiding factor for the surgeon to ensure that their viewpoint is taken into account. The most successful surgeon puts the interests of the patient before self-interest, which is of utmost importance.

As a surgeon, one of the most difficult challenges is to inform the patient of the different treatment options, that may help the patient achieve their ultimate goal, so the patient may make a truly informed choice. A collaborative patient physician relationship can guide the patient to the best possible treatment plan and the use of shared decision-making tools will help in this process. Verbal, graphical, and written decision aids are all viable options in presenting evidence-based information to a patient. These tactics will help elicit the best possible absorption of information by the patient. Creating a collaborative and open forum for patients to express their concerns and goals through the use of these modules are the first step in improving a patient’s health literacy and determining the best steps toward their treatment goals and recovery. ^,

Additionally, physicians have a responsibility to communicate realistic expectations and potential complications that can arise from surgical procedures and ensure the patient has an understanding of all the risks involved. In cosmetic surgical procedures, where the postoperative period can often be long and burdensome, it is important to ensure the patient understands that healing is a fluid process and typically not an overnight conclusion. Wound healing, scar contracture, fading, edema, and ecchymosis are all natural components of the healing process that require time to fully resolve.

Body image and psychosocial evaluation

During the initial evaluation, it is crucial for the surgeon to gather the patient’s medical history. However, it is equally important to evaluate the patient’s psychological well-being. This includes obtaining—with meticulous detail—their motivation(s) for surgery and their expectations after the procedure.

One of the main aspects of psychological well-being that has been assessed is that of the patient’s body image. The concept of body image can be defined as an individual’s perception of their physical self and the associated emotions it evokes. It is a dynamic aspect that evolves throughout life and is influenced by factors such as age and personal experiences. Plastic surgery procedures modify and alter the physical aspect of a person and can have an everlasting effect on body image, whether positive or negative. The psychological qualities that coincide with the desire to alter a body image has been a centerpiece for research interests among plastic surgeons and psychologists alike.

In the 1940s and 1950s, the literature first captured the use of psychiatric evaluations for patients undergoing cosmetic procedures, and generally classified patients seeking these procedures as highly narcissistic or neurotic. Despite over generalizations made about patients’ psychological well-being at the time, surgery was rarely ruled out on these grounds, and the majority of surgical and psychological outcomes were described as positive. ^, Recent literature continues to support the idea of in improved psychological well-being as a result of cosmetic surgery. For example, Castle et al. conducted a systematic review looking at the psychosocial outcomes of cosmetic surgery and found that the majority of patients were satisfied with their results and felt better about themselves and their self-worth. Similarly, Margraf performed a large comparison control study in which 544 patients who underwent aesthetic surgery and 264 participants who were interested in aesthetic surgery but did not undergo were compared at 3, 6, and 12 months after their surgery or clinic visit. It was found when looking at different measures of psychological health including anxiety, social phobia, depression, body dysmorphia, goal attainment, quality of life, life satisfaction, attractiveness, mental and physical health, well-being, self-efficacy, and self-esteem that across all measures patients who underwent aesthetic surgery had statistically positive results. Overall, the majority of medical literature from the facial plastic surgery community highlights clinical and empirical evidence that supports a high rate of satisfaction among patients undergoing cosmetic procedures.

However, it is important to acknowledge that not all patients experience satisfaction and psychological advantages from cosmetic surgery. Therefore, it is crucial to accurately identify the factors that put patients at risk of experiencing negative psychosocial outcomes after undergoing cosmetic surgery. Research suggests that being young, male, having anxiety or depression, or having a personality disorder may be among the factors associated with such risks. Other characteristics that may raise concern for poor outcome include :

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  Convoluted medical history

  
  
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  Patients with numerous cosmetic procedures

  
  
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  A history of noncompliance to treatment plans

  
  
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  Patients with multiple complaints about previous procedures or providers

  
  
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  Patients who are not responsive to the informed consent process or educative initiatives

  
  
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  Patients spending money on procedures that are beyond their financial means

The extent of the surgical change has also been cited as an important predictor of positive outcomes. More extensive procedures that directly affect a person’s appearance, such as rhinoplasty, have been shown to have more psychological effects on body image than those that are restorative such as rhytidectomy and botulinum toxin injections. The type of procedure and extent of change that it may have on a person’s physical appearance is equally important to account for in high-risk individuals.

The medical literature regarding specific psychiatric disorders and cosmetic surgery is quite inconsistent. Jang et al. conducted a retrospective review study of 1,000 adult patients seeking elective plastic surgery at a single institution and found 44.1% of patients had an underlying psychiatric disorder. Ishigooka et al. conducted a study to explore the demographic characteristics of 415 patients seeking cosmetic surgery from a psychological standpoint. Their findings revealed that a similar pattern emerged, with approximately 198 patients (47.7%) meeting the diagnostic criteria for psychiatric disorders according to the ICD-10 classification. In the cosmetic surgery literature, the prevalence of psychiatric disorders, with the majority focusing on body dysmorphic disorder (BDD), was found to be between 7% and 15% of all patients. This discrepancy in the percentage of patients diagnosed with a psychiatric disorder among the plastic surgery and psychiatry literature is likely a result of under and over reporting, respectively. ^,

Screening tools such as the body dysmorphic disorder examination (BDDE), the multidimensional body self-relations questionnaire-appearance scales (MBSRQ-AS), and the Rosenberg self-esteem scale (RSE-S) are reliable measures of body image that may be useful in screening borderline patients for surgery. Dey et al. performed a prospective prevalence and instrument validation study, using the body dysmorphic disorder questionnaire (BDDQ), and found the surveillance tool to be an accurate, sensitive, and specific screening instrument for BDD (please refer to Chapter 2 for the BDD questionnaire).

An ideal candidate for cosmetic surgery is a focused and compliant patient with realistic goals and expectations who establishes a healthy relationship with their surgeon. Therefore, surgeons must develop a keen sense for identifying suitable candidates for surgery and being humble at times to decline those who are not, which may be quite difficult. When a patient expresses realistic expectations and genuine concerns about a noticeable flaw, it is worth noting that surgery has the potential to enhance self-image, boost self-esteem, and instill confidence, and the experienced cosmetic surgeon should be able to make this distinction at the initial patient encounter. The following sections will further discuss specific challenges in managing patients seeking cosmetic surgery and the medical literature that guides our commentary.

Patients with multiple comorbidities

Patients with multiple comorbidities, such as those with uncontrolled diabetes or hypertension, obesity, bleeding/coagulopathic disorders, and autoimmune disorders can present a challenge for elective cosmetic procedures. Although minor surgical procedures may be well tolerated within an office setting, patients going to the operating room with multiple comorbidities may need surgical clearance and inpatient hospital admission depending on their need for postoperative monitoring. Abboushi et al. looked at the overall complication rate in patients undergoing rhytidectomy in a single-center series to identify risk factors for complications. Risks for venous thromboembolism were significantly higher in patients who were obese, whereas hematoma complications were higher in patients who had hypertension . A 2011 National Surgical Quality Improvement Program database was reviewed to determine predictors of readmission for plastic surgery, and found obesity, wound infection, and American Society of Anesthesiologists class 3 or 4 physical status, which are determined based on a patient’s medical comorbidities, are independent predictors of readmission. Patients with multiple comorbidities are at a higher risk for postoperative complications and should be carefully considered before proceeding with surgery. Thorough and straightforward communication regarding their understanding of operative risks and management of possible complications is required for these patients. Establishing a secure perioperative period is crucial as it lays the foundation for achieving the anticipated outcomes.

Patients with unrealistic expectations

Communication is key in determining the appropriate patient for facial plastic surgery. Surgeons must have good listening skills to hear and understand the concerns of the patient and the goals they wish to achieve with surgery. It is important to set realistic expectations with patients. When prospective patients come in with pictures of celebrities they want to transform into, it is important to guide their focus back to their own concerns and break down into key points what encompasses their aesthetic goals. Computer imaging in facial plastics has become a fantastic asset at preoperative consultations. It allows the surgeon to show the patient, using their own image, what can realistically be accomplished. Educating the patient on the postoperative period, what to except, and their role in their recovery is exceedingly important as these procedures work on a spectrum of healing and time. If prospective patients have unrealistic expectations that are not congruent with the surgeon, or the surgeon does not feel comfortable performing the procedure the patient desires, surgery should be politely refused.

Patients who have undergone multiple plastic surgery procedures

Patients who have undergone multiple prior cosmetic procedures, prior to seeking consultation, can often be difficult patients, usually dissatisfied with results. It is crucial to inquire about the motivations behind their visits to other facial plastic surgeons before coming to your clinic (moved from the area versus dislike for other doctors in the area). These patients may have extensive knowledge of facial plastic surgery procedures and an agenda to what they are looking for in precise detail. They are informed on the latest trends in the field and will challenge their surgeons to perform exactly what they want. However, medicine is not one size fits all, especially in the world of facial plastics. It is important that the surgeon educate these patients appropriately as the wealth of information available to patients today can often leave them confused and misinformed. Determining their expectations is critical to establishing a relationship with these patients and foreseeing whether you can provide them with services that will give them their desired result. Speaking with the prior surgeons who did their procedures and obtaining their past medical record can also provide insight into what had been done to allow surgical mapping for their next procedure should they be a candidate. Straightforward discussion with these prospects with multiple prior procedures and the ability to refuse surgery is an important part of their consultation.

Patients motivated for surgery by outside influences

During the initial consultation, it is essential to inquire about the patients’ motivations for seeking surgery and the duration of time they have contemplated surgical intervention to address their concerns. It is important to take the time, at the initial visit, to get to know the patient and take a comprehensive social history. Did they recently have emotional trauma in their life? Do they have healthy relationships with their immediate family, friends, and loved ones? How strongly does the opinion of others influence their decision to go forth with surgical correction? The patient’s reasoning for undergoing facial plastic surgery should be a personal choice, not influenced by outside factors. A detailed history is therefore crucial to get to know the patient and the motivation for obtaining the surgical consultation.

Patients with body dysmorphic disorder and other psychiatric disorders

Patients with psychiatric illness are a delicate subset of the population. They represent a broad spectrum of patients and often the most important subset to screen for surgical adequacy. Patients who have severe psychiatric illness will often not elicit great detail about their condition, so it is even more important for the surgeon to be transparent with the patient. It is crucial to ask about their mental health, their reasoning for surgery, and a list of medications the patient may be taking. Surgeons should also take responsibility for reaching out to the patient’s psychiatrist or primary doctor who manages their mental health to determine if the patient is well controlled and if any discrepancies in their treatment have arose in the recent past. Psychiatric illnesses do not eliminate the patient as a candidate but their psychological well-being and stability is extremely important to establish before undergoing a surgical procedure that can change their image.

A population of psychiatric patients who should be approached with caution in facial plastic surgery are those with BDD. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition describe four diagnostic criteria for BDD: (1) a preoccupation with an imagined or slight defect in appearance where the person’s degree of concern is extreme and not visible to others; (2) marked distress or impairment in social, occupational, or other areas of functioning resulting from the appearance preoccupation; (3) the preoccupation is not attributable to the presence of another psychiatric disorder (e.g., anorexia nervosa); and (4) repetitive behaviors such as frequently looking in the mirror, skin picking, excessive grooming, or comparing his/her appearance to others.

Insight of the individual is also important to take into account which the DSM V recognizes and scales from good/fair insight, poor insight, absent/delusional insight, and muscle dysmorphia (individual is consumed that their physique is too small or inadequately muscular). Based on some of the characteristics of BDD, many patients presenting for cosmetic surgery may appear to meet one or more of these criteria, as they are concerned about a feature that in their view is bothersome. This explains why the surgeon must have a keen eye and ask appropriate questions at the initial evaluation to determine if they are suitable for surgery and if favorable results will bring them psychological satisfaction. Patients often will not have an official diagnosis, given by a mental health professional when they present, which is why the time should be taken to complete appropriate screening and interviewing to protect the surgeon from a difficult perioperative period and possible legal action. Although it is normal for cosmetic patients to be concerned with an aspect of their appearance, the greatest indicator is the degree of distress and functional impairment they have in relation to their concern. Concerning signs include: outlandish requests for cosmetic procedures, dissatisfaction with prior surgeries that don’t correlate with the outcome, disrespectful or demanding behavior, dictating their surgical plan and demanding a specific surgical technique, attempts at camouflaging a defect not apparent to others, unrealistic expectations, belief that surgery will help other aspects of their life, and pursuing surgery because of a preoccupation of what others think of them.

Within the field of psychiatry, it has been observed that the prevalence of Body Dysmorphic Disorder (BDD) is significantly higher among individuals seeking cosmetic surgery compared to the general population.

Patient with Axis II type personality disorders should also be screened prior to interventional cosmetic surgery. The medical literature has shown an association between 57% and 100% between BDD and comorbid Axis II disorders, with avoidant personality disorder being the most common. Other personality disorders linked with BDD include paranoid, obsessive-compulsive, and borderline or dependent personality disorders. ^, Similar traits exist among all these disorders that must be kept in mind while evaluating a patient’s candidacy for cosmetic surgery. Borderline personality disorder patients, such as those with BDD, are fixated on self-image but also show impulsive behavior and instability of emotions, with poor interpersonal relationships leading to fearfulness of abandonment. This subset of patients will often request multiple procedures to continue their relationship with their surgeon despite little evidence for needing a surgical procedure. Surgeons should carefully consider refraining from operating on patients with Axis II disorders and instead, offer them access to mental health resources that can address their underlying psychiatric conditions.

Patients with whom the surgeon is incompatible

Trust and mutual respect are important aspects of a healthy doctor-patient relationship. The ability to see and discuss concerns on an equal playing field is essential to obtaining successful surgical results. Surgeons should exercise caution when dealing with patients with whom they do not share a mutual understanding or rapport. Patients who exhibit the following characteristics should be regarded as poor candidates for surgery: demanding a guaranteed result, expressing a desire to resemble a specific celebrity, complaining or attempting to negotiate fees, displaying impulsive behavior, or insisting on particular surgical techniques without considering the professional opinion of the surgeon. A trusting relationship with open communication will set the tone for a successful perioperative period. Patients who have established good relationships with their surgeons tend to have a positive outlook, which can directly impact their surgical results. If a patient expresses genuine dissatisfaction during the initial consultation, it suggests that they may have difficulty finding satisfaction even after undergoing aesthetic surgery. Therefore, such individuals should be carefully assessed before considering them as suitable candidates for the procedure.

An operation that sets forth to change the physical aspect of the human body is with the intent of improving the patient’s quality of life. Patient selection in facial plastic surgery is extremely important as the process doesn’t end when the surgery is completed, but rather encompasses the entirety of the perioperative and follow up visit process. In the author’s experience, patient satisfaction goes hand in hand with patient selection, as those with a strong doctor-patient relationship and ability to communicate will prosper. Preoperative psychosocial assessments translate into successful facial plastic surgery outcomes and surgeons should spend the time on developing these interpersonal relationships and interviewing skills with patients to develop strong compatible relationships. Great surgeons know when and when not to operate, and the art of refusing a patient is one that can make for a long lasting and fruitful career. The decision to proceed with cosmetic surgery should be grounded in honesty, proper motivation, and careful patient selection.

Antiplatelet therapy

Platelets are produced in the bone marrow, from megakaryocytes, and represent the smallest of the blood cells. After production and entrance into the circulation, platelets have an average lifespan between 7 and 10 days before removal by the reticuloendothelial system. They play a large role in responding to vessel damage and compromise by aggregating together and initiating the clotting cascade thereby avoiding persistent bleeding. Antiplatelet therapy has been developed over the last century to prevent catastrophic cardiovascular and thromboembolic events, which occur from intravascular vessel injury. Different categories of anti-platelet medications have been developed and they will be discussed in the following sections.

Aspirin

For many decades the use of daily aspirin had been ingrained in the minds of individuals in the United States as a means of preventing cardiovascular events or stroke. The U.S. Preventive Services Task Force, which is comprised of an independent panel of national experts in disease prevention, recommends a low-dose aspirin regimen for adults 50 to 59 whose 10-year risk of developing cardiovascular disease is greater than 10%. Since then, new recommendations developed by the American Heart Association and American College of Cardiology have argued against using aspirin in low- and intermediate-risk patients unless recommended by a physician. ^{, ,}

Aspirin is a noncompetitive irreversible antagonist of cyclooxygenase activity, which prevents the release of prostaglandins and thromboxane A ₂ synthesis from arachidonic acid, thereby decreasing platelet synthesis. It is rapidly absorbed by the stomach with plasma levels peaking 30 to 40 minutes after ingestion and inhibition of platelet function starting within an hour. Despite its prompt clearance from the circulation, with an average half-life of about 15 to 20 minutes, its effects last 7 to 10 days in congruence with the lifespan of a platelet. Partial platelet aggregation is restored between 4 and 5 days after aspirin discontinuation. Therefore, the current recommendation for discontinuation prior to surgery, to prevent perioperative bleeding, is variable with recommendations falling between 5 and 10 days depending on the procedure. Optimal timing of aspirin discontinuation before noncardiac surgery was found to be between 4 and 5 days based on platelet aggregometry tests in one study without an increased risk of bleeding. This would safely decrease the amount of time patients are off the medication with an average perioperative cessation period of about 5 days.

Kraft et al. conducted a study at the University of Michigan that examined the incidence of complications in 430 surgical procedures among 320 patients who underwent facial plastic surgery while using antiplatelet or anticoagulation medications like aspirin, clopidogrel, or warfarin during the perioperative period. The study compared these results to a control group consisting of individuals who did not take any antiplatelet or anticoagulation medications. Complications were categorized into wound healing (dehiscence or necrosis), infection, hematoma, or ecchymosis, and return to the operating room. The use of aspirin in high-risk patients was found to be safe throughout the perioperative period without significantly increased risk of complications as compared to controls. These results have sparked a shift against aspirin discontinuation in high-risk patients in recent years by many physicians. ^, Although there are multiple recommendations in the literature that highlight the management of preoperative aspirin therapy based on risk stratification, the effects of cessation or continuation in a wide variety of facial plastic procedures remain lacking. Many studies have observed high risk patients on aspirin and analyzed post operative morbidities and concluded that there was no significant rise in complications. ^{, ,} Therefore, current evidence supports the continuation of aspirin use in high-risk patients when undergoing minor cutaneous surgeries. Larger procedures where excessive bleeding can be catastrophic, such as rhytidectomy, have continued to follow current recommendations on cessation of aspirin until further studies have been conducted.

Thienopyridines

The thienopyridines are all structurally related medications that include Ticlopidine (Ticlid-Sanofi/Hoffmann-La Roche Ltd., New York, United States), clopidogrel (Plavix-Bristol-Myers Squibb Pharmaceuticals Ltd.), and prasugrel (Effient-Eli Lilly and Company, Indiana, United States). All are considered prodrugs as they require metabolism by a cytochrome p450 hepatic enzyme to become their active forms. The first-generation medication ticlopidine has been discontinued in the US and replaced by clopidogrel due to its bone marrow toxicity. These medications decrease platelet aggregation through inhibition of the adenosine diphosphate (ADP) receptor P2Y12 on platelets. Newer ADP receptor antagonists such as prasugrel, an irreversible inhibitor, have faster onset and are stronger, as compared to clopidogrel, with more reliable antiplatelet activity. Compared with clopidogrel, it has also shown an overall higher risk of bleeding which increases with the duration of therapy, making it second-line therapy to clopidogrel. Ex vivo studies have shown that clopidogrel reaches its maximum efficacy on platelet inhibition after 3 to 7 days, and its effects on platelet aggregation and bleeding time are dose dependent. The half-life of clopidogrel is 6 hours, with full antiplatelet activity occurring within 2 to 3 hours. The active metabolite in clopidogrel can last up to 5 days. Therefore, clopidogrel should be stopped similarly to aspirin, 7 to 10 days prior to surgery with studies suggesting a minimum of 5 days .

Cook-Norris et al. examined the use of clopidogrel on 363 Moh’s reconstructive surgical procedures and found that patients using the medication were 28 times more likely to have severe complications than those with no anticoagulation and six times more likely than those on aspirin monotherapy. These complications included considerable intraoperative or postoperative hemorrhage, wound bleeding unresponsive to pressure, acute hematoma, necrosis, or dehiscence. This may suggest that more complicated facial plastic surgery procedures that require extensive undermining, and therefore intrinsically higher risk of bleeding complications, may require cessation of the antiplatelet therapy prior to surgery. Clopidogrel complements the action of aspirin and therefore may be used for dual antiplatelet therapy in high-risk patients such as those with cardiac stents. Although there remains a paucity of literature in the field of facial plastics on the use of dual antiplatelet therapy in the perioperative period, studies that have been done are seen to increase postoperative bleeding risk.

Neither thienopyridine medications nor aspirin can be reversed pharmacologically due to their respective irreversible inhibition at the site of action. In the setting of hemorrhage, patients on aspirin may respond to platelet transfusions given the rapid clearance of aspirin from the circulation. However, because the active metabolite of thienopyridine remains active for a few days after cessation, platelet transfusion may not be beneficial and variations in data exist. Reversal of thienopyridines may require multiple platelet transfusions over the course of a few days to achieve appropriate hemostasis.

In high-risk patients who have undergone percutaneous coronary intervention (PCI) with either a bare metal or drug eluting stent, a general consensus has been derived from the American College of Cardiology. Stent thrombosis and myocardial infarction is directly correlated with discontinuation of antiplatelet therapy with the risk being inversely proportional to the timing of surgery after PCI.

Although there may be a risk of surgical bleeding associated with antiplatelet therapy, the risk of cardiovascular events has been shown to be greater and more severe, warranting careful perioperative management. In patients without cardiac stents, the risks and benefits of antiplatelet cessation preoperatively should be discussed with their cardiologist.

Warfarin

First approved for use as an oral anticoagulation medication in 1954, warfarin (Coumadin-Bristol-Myers Squibb Pharmaceuticals Ltd.) was widely used for decades as the only option for outpatient anticoagulation and was proven, in the 1980s, to be highly effective at preventing strokes. ^, Warfarin is a vitamin K antagonist that acts by blocking the enzyme vitamin K epoxide reductase (VKER), which acts on the gamma carboxylation of procoagulant factors II, VII, IX, and X and anticoagulant proteins C, S, and Z. It is used as an anticoagulation medication for patients with significant hypercoagulability risk such as those with cardiac prosthetic valves, stroke, AF, and valvular heart disease. The decision to discontinue warfarin in the preoperative period should not be taken lightly, as patients on warfarin typically have a higher risk profile than those on aspirin alone. It should also be noted that the discontinuation of warfarin can induce a hypercoagulable state due to a rebound increase in clotting factors.

Warfarin-associated hemorrhages are the cause of admission to Emergency Departments in the United States for an estimated 65,000 patients annually. Kraft et al. found patients taking warfarin were seven times more likely to have complications from bleeding and four times more likely to have postoperative infections but severe complications such as graft loss, dehiscence, or return to the operating room were not any more likely to occur than controls. In many studies on minor cutaneous surgical procedures, the continuation of warfarin has been shown to be safe, without an increased rate of complications. ^{, , ,} Nevertheless, a large meta-analysis of 1,373 patients, undergoing cutaneous surgery while on anticoagulant medications (aspirin, non steroidal antiinflammatory drugs [NSAIDs], warfarin, clopidogrel), showed that while the overall risks are low, anticoagulated patients did have an increased risk of bleeding. More specifically those on warfarin were nearly seven times more likely to have a moderate-to-severe complication compared to controls. In larger procedures such as facelifts, neck lifts, and rhinoplasty, where the bleeding risk is significantly increased, the comfort level of surgeons continuing such a high-risk drug is low. Bleeding risks among these surgical procedures can also be devastating when compared to minor cutaneous procedures.

Skin necrosis is another complication that should be taken into account in patients who are prescribed warfarin. While skin necrosis is a relatively rare complication, affecting approximately 1 in 10,000 patients receiving warfarin, it is believed that deficiencies in protein C and S may contribute as underlying risk factors. Amongst facial plastic surgery patients, the high-risk profile of warfarin’s side effects can lead to devastating complications and thus must be considered when managing patients on the medication.

Warfarin is monitored using the international normalized ratio (INR) or prothrombin time (PT), and has a half-life of approximately 36 to 42 hours. It typically takes about 5 to 6 days for the medication to reach its full efficacy, with the earliest changes in INR seen after 24 to 36 hours. In terms of warfarin use in the perioperative period, the limiting factor is determined by the INR that should be safely kept below 3.5 IU, with an aim of 2.5 IU . In low-risk patients, coumadin can be safely discontinued 4 to 5 days prior to surgery (the time for warfarin to be reversed) to allow the INR to fall below 1.5 IU before restarting postoperatively. In intermediate- and high-risk patients, warfarin can be stopped 4 to 5 days before surgery and bridged with low molecular weight heparin (LMWH). High-risk patients can stop coumadin 4 to 5 days prior to surgery and start on LMWH 1 mg/kg every 12 hours 3 days prior to the procedure. The LMWH is held the evening before surgery and restarted 12 hours after the procedure has completed and continued for 2 days after the warfarin is in its therapeutic range. ^{, ,} In excessive cases of severe hemorrhage where coagulopathy needs to be reversed, warfarin can be counteracted with the administration of vitamin K. In its oral form, it can take up to 24 hours to achieve a normal INR, but in emergent situations, can be given intravenously with INR decreasing effects seen after 2 hours. Full reversal to a normal INR range with intravenous vitamin K can take from 12 to 16 hours. Partial, but not always effective, reversal of INR can be attempted with fresh frozen plasma because of its composition which includes vitamin K dependent coagulation factors. The risk of bleeding in facial plastic procedures does not end once the procedure is completed but continues for up to 1 week postoperatively and those risks must be considered when continuing on these medications in the perioperative period.

Factor Xa inhibitors and direct thrombin inhibitors

Newer anticoagulation therapies have emerged over the last decade for patients with AF and increased risk of strokes. These medications include the direct thrombin inhibitors Dabigatran (Pradaxa-Boehringer Ingelheim Pharmaceuticals, Inc., Connecticut, United States) and factor Xa inhibitors Rivaroxaban (Xarelto-Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium) and Apixaban (Eliquis-Bristol-Myers Squibb Pharmaceuticals Ltd.). Their appeal for patients taking direct oral anticoagulation (DOAC) medications includes a more predictable pharmacodynamic and pharmacokinetic profile then their earlier predecessor warfarin. Consequently, they do not require routine monitoring and have a rapid onset of action (1 to 4 hours) with half-lives of approximately 12 hours. Direct thrombin inhibitors act as their name suggests, through the direct competitive inhibition of both free and clot-bound thrombin, whereas factor Xa inhibitors act on Factor Xa and thereby prevent the conversion of prothrombin to thrombin in a concentration-dependent manner. Both DOAC classes have a reduced bleeding profile risk when compared with warfarin and are reversible through their antidotes idarucizumab (Praxbind) for the direct thrombin inhibitors and Andexanet alpha (Andexxa) for the Factor Xa inhibitors. Unlike warfarin, they don’t require bridging with heparin prior to surgery in intermediate- and high-risk patient groups. Interruption for surgical procedures is often based on the bleeding risk of the surgery, but because of the relatively short half-lives of these newer anticoagulants, the duration of interruption when it is required in the perioperative period may be reduced.

Because these medications have dual hepatic and renal excretion profiles, dose adjustments need to be made in the setting of renal insufficiency. Renal function monitoring is therefore required in patients on these medications, typically at 6-month to 1-year intervals and when they are in periods where cessation of these medications is necessary. Certain thrombin inhibitors such as Dabigatran rely heavily on renal excretion and therefore must be closely monitored more so than their Factor Xa cousins.

There are few guidelines for the perioperative management of this medication category for facial plastic procedures, which offer algorithms referencing either the European Heart Rhythm Association (EHRA) guidelines or The Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis, based on procedure categorization into low-, intermediate-, and high-risk stratification. ^, Extrapolation of these guidelines for use in facial plastic surgery is possible but requires the surgeon to decide what procedures fall under which risk category. Both the risk of bleeding from the procedure and the patients’ renal function are important factors in regard to stopping DOAC therapy in the perioperative period. For Factor Xa inhibitors, the current recommendation is to stop the medication for 24 hours in the setting of low bleeding risk procedures and 48 hours for high bleeding risk procedures. For the direct thrombin inhibitors, the renal function of the patient is just as important as the bleeding risk of the procedures. That is because patients with poor clearance will sustain an anticoagulated state for a longer period of time, and therefore need a longer washout period prior to surgery. Based on the EHRA guidelines, research indicates that patients with normal renal function who are on direct thrombin inhibitors and are scheduled for a low bleeding risk procedure can discontinue the medication 24 to 48 hours before the procedure. In contrast, patients undergoing a high bleeding risk procedure and/or those that have impaired renal function should stop the medication at least 96 hours preoperatively. ^,

The Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis have slightly more conservative guidelines, regarding DOAC medications with low-risk procedures, requiring a 48-hour cessation prior to surgery, and high bleeding risk procedures necessitating cessation 5 days prior. Postoperatively, the current recommendations stratify the groups into low and high postoperative bleeding risk, where DOACs can be restarted 24 h post-operatively for low-risk procedures and 48 to 72 hours in procedures with higher bleeding risk. Because there is little information and literature currently available for the use of DOACs in facial plastic surgery procedures, surgeons must educate themselves on their uses and effects, and how to appropriately manage patients on these medications that continue to gain popularity as a replacement for warfarin.

Following consideration of the surgical procedure type, the patient’s past medical history, and risk profile, it is important to consult with the provider who prescribed and manages these medications. They can shed light on the patient’s potential for thromboembolic events and guide the surgeon toward a recommendation that will assure a positive outcome. Maintaining an open mind regarding the goals of the procedure and potential patient complications is crucial. While the consulting physician will prioritize the patient’s well-being from a medical perspective, it is the surgeon’s responsibility to carefully consider these factors in conjunction with the desired surgical outcome. Close monitoring and follow up with patients on anticoagulation medication is even more important because of the increased risk of complications. With the increasing popularity of facial rejuvenation therapy among the aging population, it is becoming more likely that surgeons will encounter patients who are taking anticoagulation medications ( Table 14.1 ). The decision to hold or continue anticoagulation medication involves a thorough perioperative assessment of the qualitative and quantitative risks. Understanding the risk profile of a patient can lead to making the most appropriate choices, which leads to a safe perioperative period with favorable results.

TABLE 14.1

Antiplatelet and Anticoagulation Medications

	Aspirin	Clopidogrel (Plavix)	Warfarin (Coumadin)	Dabigatran (Pradaxa)	Rivaroxaban (Xarelto)	Apixaban (Eliquis)
Target	COX Inhibitor	ADP Receptor	Vitamin K	Thrombin	Factor Xa	Factor Xa
Dose Frequency	Daily	Daily	Individualized dosing	Twice daily	Once daily	Twice daily
Onset	∼1–2 h	∼45 min	∼5 days	∼2 h	∼2.5–4 h	∼3 h
Kidney function affects dosage	No	No	No	Yes	Yes	Yes
Routine lab monitoring	No	No	Yes-INR	No	No	No
Half life	15–20 min	6 h	20–60 h	12–17 h	5–13 h	8–15 h
Reversal agents	None	None	Vitamin K, Fresh frozen plasma, Prothrombin complex concentration	Idarucizumab (Praxbind)	Andexanet alpha (Andexxa)	Andexanet alpha (Andexxa)
When to stop preoperatively	4–5 days	4–5 days	Low risk: 4–5 days prior High risk: 4–5 days prior and start LMWH Or when INR < 1.5	Low risk: 24–48 h prior High risk/renal: 96 h	Low risk: 24–48 h prior High risk/renal: 96 h	Low risk: 24–48 h prior High risk/renal: 96 h
When to restart postoperatively	24 h	24 h	12–24 h	1–3 days	1–3 days	1–3 days

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