Should I be concerned about my Dr not using blood thinners post op from tummy tuck and Smart Lipo?

Question

I am 46 yo. I am 5'6. 148lb and run 3 miles several days a week. I am concerned..my surgeon doesn't feel it is a benefit to use exparel, and doesn't feel I need to have lovenox or a blood thinner post surg to prevent DVT/PE. I love the surgeon I picked but am disappointed that these are not what I was expecting for my tummy tuck, smart lipo of abdomen and flanks, and removal of saline breast implants under the muscle. I had 2 kids by c section no pain meds, but not sure if tummy tuck compares?

Kenneth Hughes, MD · Answer

This depends upon your individual risk factors according to the Caprini index.   This will help determine your relative risk and the need for chemoprophylaxis.

Camille Cash, MD · Answer

The use of blood thinners after surgery varies by surgeon preference and each patient's medical history.  I encourage you to discuss your concerns with your surgeon in more detail.  Be sure to know signs and symptoms of issues to watch for and when to contact your surgeon.  It is important that you feel comfortable and confident as you prepare for surgery.

Joseph L. Grzeskiewicz, MD, FACS · Answer

First I want to say that I think that your concern is valid, and I congratulate you on being so knowledgeable about these issues; most lay people aren't.  Second, I want to state that these things you are bringing up are still, for lack of a better word, debatable in the plastic surgery community.  That is to say that I don't believe there currently are any established standards for the routine use of things like Exparel and "blood thinners," or so-called "chemoprophylaxis" agents for DVT/PE, like Lovenox, or Fragmin (the one that I personally use the most) for body contouring procedures.  Although there is certainly evidence that they are both very beneficial.  Having said that, we must acknowledge that at the present time we are venturing more into a conversation about medical judgment, style of risk management, and methods of patient care, and those things are largely discretionary among doctors.  In every day terms this means that "there is more than one way to skin a cat" as it were, and each doctor has the latitude to base their management decisions on their own experience, their education and training, and any other valid sources of information that they find useful.  I would never be able to criticize your surgeon in those management decisions, although as a surgeon myself I might respectfully disagree with him.

Personally, I think we are entering a new era in the care of surgical patients, and this will also include plastic surgery patient care too, at some point.  The concept of "ERAS," or "Enhanced Recovery After Surgery," is something that has its origins in Europe and Canada in many other surgical specialties, and it is now gaining momentum in the US.  While it is still a new idea, and most plastic surgeons have never even heard of ERAS, or enhanced recovery (ER), let alone practice it as a dedicated protocol or method, many of us have actually been using some of the techniques and methods comprising a rigorous ER protocol for years.  I just attended a course about this topic at our most recent annual plastic surgery society meeting in LA, as I have been on board with the ER movement for about 3 years now, and I am myself now a member of the American Society for Enhanced Recovery (ASER), so it's definitely a real thing and it's becoming more mainstream in the US.  Basically, ER is a way to not necessarily shorten a patient's recovery from surgery - although this may certainly also be one of the benefits, but to ENHANCE it, which means that safety is enhanced, risk is reduced, comfort is enhanced, return to normal diet and activity is enhanced, and generally the overall experience of surgery is enhanced.  This is not to imply that doing things the "old fashioned way" without practicing any or all of the principles of an ER protocol is "bad" or in any way "ineffective," rather we're finding that there is a newer and better way to manage our patients.  However, we will never accomplish this goal unless we are aware of those measures that are available to enhance recovery, we are familiar with the medical research on the safety and effectiveness of those measures (we don't want to do things just to be doing them if they haven't been shown to be useful, and conversely, we WANT to do those things that have been scientifically proven to be effective and published in the medical literature), and we make a dedicated effort to actually sit down and structure a program and incorporate those measures into our practice of medicine.  While I wouldn't go so far as to say right now that those surgeons who do not follow these principles are "cutting corners," I would say that I believe that it's only a matter of time before that indictment will probably stick.  Doctors are scientists, and as such we should commit ourselves to adhering to an evidence-based practice of medicine.  As time goes on, and more and more scientific literature is accumulated demonstrating the efficacy of these measures, and more and more plastic surgeons learn about enhanced recovery (ER) and how to develop and incorporate ER protocols into their practices, these things will become more standard, and those people who do not adhere will be viewed as "cutting corners."

I have given you all of that background because it is important to understanding why I am going to answer your question the way I am.  With regard to your questions about Exparel and Lovenox, you can see that those might be very important components of a well structured ER protocol.  They are designed to enhance the recovery of a body contouring patient and reduce risk.  They themselves carry their own risks, just as any intervention that a doctor might prescribe, but we have to assess risks accurately - the risk of doing something like using Exparel or Lovenox, versus not using it and having the complications they were designed to prevent - and then making appropriate judgements.  Personally, I find the use of both agents vital in my own ER protocol in caring for my body contouring patients.  With regard to Exparel, it is a very unique medication.  It is a long acting form of a local anesthetic agent called bupivicaine, or Marcaine.  It will last over 72 hours when injected properly into the tissues during surgery.  This is very important to the overall recovery of tummy tuck patients, and it is much more than a "foo foo" comfort measure.  It is also not exactly cheap, but the cost isn't prohibitive, and on balance it is worth every penny when used properly.  Injection with local anesthetic agents is a fundamental tenet of any ER protocol because it is part of an overall strategy to cut down on or eliminate narcotic pain medications.  The more "numb" your tissues are through proper anesthetic use intraoperatively, the less narcotics you will need postoperatively.  This translates to less nausea and vomiting (very important after tummy tuck), less constipation (very important after tummy tuck), less "dopeyness" and sedation (very important after tummy tuck), better ability to move around and ambulate, thus less risk of DVT/PE (very important after tummy tuck), and less risk of urinary retention (very important after tummy tuck).  There might be even more benefits, but you get the point - I've just listed about half a dozen ways in which a single simple intervention like Exparel can significantly enhance your recovery and reduce risk.  With respect to Lovenox, there is ample literature to support the use of low molecular weight heparins, like Lovenox for several days or a week postoperatively to prevent DVT/PE after surgery lasting longer than 1 hour.  In fact, there is even a scoring method, called the "Caprini Score," which is widely recognized and used to assess DVT/PE risk and recommend methods for prevention.  There is no question that there are some risks associated with using these medications in postoperative patients, however, dosed properly and given in the proper time course, those risks are very small, and they are well worth it for the benefit of largely preventing the catastrophic and potentially fatal complications of DVT and PE.  My own thinking on the subject is that if I have a measure like this that I have used essentially complication free for almost 15 years which has had the track record of prevention of a serious complication that it has for me, I am going to err on the side of using it, especially in elective surgery on young, healthy patients.  I am a big believer in using these agents, I believe that the literature strongly supports their use and most people will achieve a high enough Caprini Score to justify it if scored properly anyhow, and my own anecdotal experience over hundreds of these cases over many years has shown that it is of benefit.  This is also an important component of surgical risk reduction, and thus it has its place in any well thought out ER protocol.

So, to summarize, you certainly can do the surgery without using these things.  Surgeons have proved this over many years, and many still do to this day on a daily basis.  However, that doesn't mean that these things aren't important and won't make the overall care of their patients better.  I tend to lean toward the latter side of the spectrum, and I personally use these, and many other, measures to enhance the overall experience of my own patients during and after surgery.  The question for you now is what is important to you?  You say you love your current surgeon, yet he does not believe in these measures.  Is your love for him enough to allow you to go forward with him as your surgeon?  While I have no doubt he can pull off a good result without using these things, as he probably does so routinely, you have to decide if that's good enough for you.  A "B" is still a pretty good, passing grade, but at the end of the day, it's not an "A+."  Would you rather have someone who pays attention to these other details as well, optimizes your risk avoidance strategies, maximizes your ability to come through the surgery safely and with the best recovery, and gets a good result for you in the end?  That is the big question, and only you can answer that.

Should I be concerned about my Dr not using blood thinners post op from tummy tuck and Smart Lipo?

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Should I be concerned about my Dr not using blood thinners post op from tummy tuck and Smart Lipo?

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