I am scheduled for abdominoplasty with liposuction. I recently had a friends sister pass away 2 days post op from a PE. I still want to proceed and my PS recommended lovenox the night before surgery and also the next night after surgery to help relieve my fears. I have no known risk factors that are associated with blood clots. I am now worried about bleeding risk if I were to do the Lovenox. I don't want to avoid one problem and put myself at risk for another. What are your recommendations?
Safety of Lovenox with Abdominoplasty Procedure?
Doctor Answers 8
Anticoagulation and Abdominoplasty
The American Society of Plastic Surgeons(ASPS) formed a task force to develop recommendations for prevention of Deep Venous Thrombosis(DVT) and Pulmonary Emboli(PE). These are complications of surgery that can be life threatening and should be treated aggressively. Using the guidelines issued by the task force, most patients who undergo an abdominoplasty are candidates for anticoagulation. In our office, instead of using Lovenox, we use Arixtra which can be administered 8 hours after surgery. Studies performed and published in peer reviewed journals demonstrated decreased incidences of DVT/PE in Arixtra treated patients without significant increased bleeding risks. Of course, all patient should be treated with sequential compression hose, early ambulation, hydration, and appropriate pain control.
Medicine is always changing and one of the new priorities is avoiding of complications, not just treating them. The new guidelines are a step in this direction. Please discuss them with your plastic surgeon who can best advise you on how to proceed.
Safety of Lovenox with Abdominoplasty Procedure
I used Lovenox for five days after surgery for a series of patients and did have one patient with bleeding between the flap and abdominal wall that required treatment and was resolved with no long term effect on the patient or the surgical outcome. However, I have since cut back to two days. Answering the question of how long to give a blood thinner will require accumulation of more data with randomized, controlled trials, something that is difficult to do in cosmetic surgery.
Personally, I would rather take the risk of some bleeding, which occurs very rarely, than the risk of a pulmonary embolism, even with the uncertainty discussed above.
During the history taking process, if a risk factor in the personal or family history is identified, then specific blood tests to check for clotting tendency is done. In the absence of such a history, a patient would be considered to have the risk of the general population and no specific blood testing would be done in my practice. I do feel that the benefit of Lovenox post-op outweighs the risks, so after many years of using serial compression devices alone, I have added Lovenox.
Caprini scores which show an increased risk for procedures lasting over two hours, and the ongoing discussion of DVT risks in the literature and in our meetings have influenced my decision to add Lovenox to tummy tuck patients. Every patient and plastic surgeon will come to their own decisions based on their understanding of the risks, benefits and trade-offs.
Risk of blood clots vs. risk of bleeding with Lovenox treatment with tummy tuck
My condolences on the loss of your friend's sister. You ask a very understandable question in the light of this information, but let me put another question to you. If your friend's sister were killed in a motor vehicle accident, would you start using a motorcycle to avoid that MVA risk? Perhaps a bad example, but you wisely understand that trading a very minimal risk (truly) of a fatal blood clot after tummy tuck surgery for a perhaps slightly-higher risk of post-operative bleeding--perhaps requiring re-operation--with Lovenox (injectable anticoagulant) treatment may not be a good bet.
Another factor is that even bleeding that requires re-operation is very rarely life-threatening, whereas a blood clot can be (though most clots are both rare, and non-fatal).
As others have stated, use of Lovenox with uncomplicated tummy tuck and lipo, in the absence of other risk factors (smoking, hormone usage, certain genetic conditions, etc.), is NOT the routine standard of care for most plastic surgeons who frequently perform this operation. Anxiety is not a good reason to prescribe Lovenox. Unless your surgeon is one of the minority who use Lovenox on a regular basis for similar patients with similar operations, then it should NOT be prescribed to allay this concern. Minority decisions are not always automatically "wrong," but you should have a risks vs. benefits discussion with your plastic surgeon before requesting Lovenox, or letting your fears induce a medical/surgical decision that would not be otherwise made. Good for you for asking, and best wishes! Dr. Tholen
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Use of Lovenox for Tummy Tuck
The use of Lovenox, or any medicine (chemoprophylaxis) should be done on an individual basis and based on the patient's individual risk factors. Intra-operative sequential compression stockings (SCDs), good hydration and early ambulation should be standard of care in order to reduce the chance of DVT and PE. Make sure you discuss your complete medical history with your surgeon so that you can come up with the right plan. You are right to be concerned about the possible side effects of bleeding with the use of Lovenox.
Chemoprophylaxis with Lovenox and tummy yucks
While chemoprophylaxis is not commonly used for a straightforward tummy tuck, it is used in high risk patients commonly and those with other conditions that increase the risk of DVT( Clot in the leg) formation. It does however have a slight increase risk of hematoma formation.
Lovenox for abdominoplasty
Lovenox and abdominoplasty
The use of Lovenox for trying to prevent deep venous thrombosis is not the routine for most plastic surgeons performing tummy tucks, unless there is a medical reason for doing so (I.e. need for anticoagulation, previous history of DVT). The use of sequential compression devices, keeping well hydrated before, during and after surgery and ambulating regularly after surgery will help decrease the risk of DVT.
With a family history of DVT/ PE it might be prudent for you to see a Hematologist before your Lipo-Abdominoplasty. A work-up could determine if you at increased risk for DVT/ PE possible due to a blood disorder. However, there is really only one clotting disorder that requires pre-operative Lovenox-Factor V Lyden Deficiency. According to several Hematology colleges all other disorders would require Lovenox 12 hours post-operatively. This is the standard in our surgical practice.
So, yes you most likely that you will require Lovenox with your Lipo-Abdominoplasty. You are not have just a Tummy Tuck. Your Surgeon is performing Liposuction with your Abdominoplasty. This represents a combined procedure and places you at increased risk for peri-operative DVT/ PE. It could be administered 12 hours post-operativliy if you do not have a Factor V Lyden Deficiency.
I disagree with Dr.’s Kraft., Case & Tholen. As Dr. Lund expressed great strives have been made in the prevention of DVT/ PE in Plastic Surgery. One area of extreme interest is the procedure we perform monthly- Lipo-Abdominoplasty. We have done over 50 LipoAbdominoplasty’s utilizing Lovenox without any post operative cases of bleeding and no DVT/ PE’s. Feel free to have your surgeon give us a call. Best,
Gary R Culbertson, MD, FACS
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.