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Table 1.  
Perioperative Details of Patients Who Underwent Abdominoplastya
Perioperative Details of Patients Who Underwent Abdominoplastya
Table 2.  
Risk-Adjusted Multivariate Logistic Regression Models for Outcomes Following Abdominoplasty Based on Autoimmune Connective Tissue Disease Statusa
Risk-Adjusted Multivariate Logistic Regression Models for Outcomes Following Abdominoplasty Based on Autoimmune Connective Tissue Disease Statusa
1.
Winocour  J, Gupta  V, Ramirez  JR, Shack  RB, Grotting  JC, Higdon  KK.  Abdominoplasty: risk factors, complication rates, and safety of combined procedures.  Plast Reconstr Surg. 2015;136(5):597e-606e.PubMedGoogle ScholarCrossref
2.
Tsai  DM, Borah  GL.  Implications of rheumatic disease and biological response-modifying agents in plastic surgery.  Plast Reconstr Surg. 2015;136(6):1327-1336.PubMedGoogle ScholarCrossref
3.
Zöller  B, Li  X, Sundquist  J, Sundquist  K.  Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden.  Lancet. 2012;379(9812):244-249.PubMedGoogle ScholarCrossref
4.
Wong  LE, Bass  AR.  Postoperative risk of venous thromboembolism in rheumatic disease patients.  Curr Rheumatol Rep. 2015;17(2):11.PubMedGoogle ScholarCrossref
5.
Familusi  OT, Doscher  M, Manrique  OJ, Shin  J, Benacquista  T.  Abdominal contouring: can the American Society of Anesthesiologists classification system help determine when to say no?  Plast Reconstr Surg. 2016;138(6):1211-1220.PubMedGoogle ScholarCrossref
6.
Pannucci  CJ, Swistun  L, MacDonald  JK, Henke  PK, Brooke  BS.  Individualized venous thromboembolism risk stratification using the 2005 caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis.  Ann Surg. 2017;265(6):1094-1103.PubMedGoogle ScholarCrossref
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Research Letter
Association of VA Surgeons
February 2018

Association of Autoimmune Connective Tissue Disease With Abdominoplasty Outcomes: A Nationwide Analysis of Outcomes

Author Affiliations
  • 1DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
  • 2University of Miami Leonard M. Miller School of Medicine, Miami, Florida
  • 3Division of Plastic, Aesthetic, and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
JAMA Surg. 2018;153(2):186-188. doi:10.1001/jamasurg.2017.3796

Abdominoplasty is generally associated with favorable outcomes and high levels of patient satisfaction. Nonetheless, abdominoplasties have one of the highest complication rates among aesthetic procedures.1 Patient selection and risk stratification is paramount to preventing postoperative complications. Patients with autoimmune connective tissue diseases (CTDs) may have associated systemic and soft tissue manifestations that increase their risk of complications.2 To date, the association of CTDs with abdominoplasty outcomes has not been reported. The purpose of this study was to evaluate whether patients with autoimmune CTDs undergoing abdominoplasties are at an increased risk of complications.

Methods

Patients who underwent abdominoplasty as a primary procedure from January 2006 to December 2011 were identified in the Nationwide Inpatient Sample by International Classification of Diseases, 9th Revision, Clinical Modification code 86.83 in combination with a primary diagnoses of diastasis recti (728.84) or umbilical/ventral hernia without obstruction (553.1-553.29). Patients with concurrent autoimmune CTD diagnoses were also identified, including rheumatoid arthritis, systemic lupus erythematosus, Raynaud phenomenon, scleroderma, Sjögren syndrome, psoriatic arthritis, and mixed CTD. Demographic characteristics, comorbidities, and in-hospital postoperative complications were compared among groups. Outcomes included in-hospital wound complications, venous thromboembolism (VTE), blood transfusion, medical adverse events (myocardial infarction, stroke, pulmonary, and/or renal complications), and length of stay. Multivariable logistic regression models for each outcome included primary predictor group (CTD status, with non-CTD as reference), in addition to cofactors including age, sex, race, insurance type, and medical comorbidities. This study using publicly available deidentified patient data was exempt from full review by the institutional review board at the University of Miami Miller School of Medicine. P values of less than .05 were considered statistically significant.

Results

Overall, 41 030 patients were identified. Of these, 537 (1.3%) had autoimmune CTD. The most common autoimmune CTDs were rheumatoid arthritis (n = 315 [58.7%]) and systemic lupus erythematosus (n = 124 [23.1%]), followed by Raynaud phenomenon (n = 44 [8.2%]), psoriatic arthritis (n = 30 [5.6%]), Sjögren syndrome (n = 14 [2.6%]), and scleroderma (n = 10 [1.9%]). Mean (SD) age of patients with CTD was 54.1 (11.6) years compared with 49.7 (12.0) years in patients without CTD (Table 1). As expected, the CTD group had higher rates of medical comorbidities than the non-CTD group. Postoperatively, the overall in-hospital complication rate was 14.9%, which was not significantly different among groups. However, the CTD group experienced higher rates of hematoma (4.5% vs 3.0%; P < .05), VTE (1.9% vs 0.9%; P < .05), and need for blood transfusion (13.0% vs 7.7%; P < .01) than the non-CTD group, respectively. Median (interquartile range [IQR]) length of stay was longer for the CTD group compared with the non-CTD group (4 [2-6] vs 3 [2-5] days; P < .001). On risk-adjusted multivariate analysis, CTD status was associated with increased risk of VTE (adjusted odds ratio, 2.12; 95% CI, 1.11-4.05) and perioperative blood transfusion (adjusted odds ratio 1.75; 95% CI, 1.32-2.31) (Table 2).

Discussion

Autoimmune CTDs can be associated with several features that may increase risk of postoperative adverse events. These include chronic anemia, hypercoagulable states, soft tissue inflammation, chronic immunosuppressive therapy, as well as cardiac, pulmonary, and renal disease.2-4

In this study, patients with autoimmune CTDs experienced similar overall in-hospital complication rates following abdominoplasty compared with patients without CTD. However, results highlight an increased risk of VTE events and need for blood transfusions in these patients. Incidence of these complications are also higher than have been reported in large cohorts of patients who have undergone abdominoplasty.1,5 Plastic surgeons should be aware of these elevated risks for appropriate patient counseling and informed consent. We recommend plastic surgeons work in a multidisciplinary fashion to optimize perioperative management. Strategies for VTE prophylaxis should be implemented.6

Limitations of the Nationwide Inpatient Sample database include lack of postdischarge data; therefore, complication rates may be underestimated. Furthermore, this study was not able to evaluate the relationship between individual CTD diagnoses, disease severity, immunosuppressive regimen, and VTE prophylaxis on postoperative complication rates. Future studies should focus on further evaluating these relationships in order establish evidence-based recommendations.

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Article Information

Corresponding Author: Seth R. Thaller, MD, DMD, Division of Plastic, Aesthetic, and Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, 1120 NW 14th St, Clinical Research Bldg, Room 410, Miami, FL 33136 (sthaller@med.miami.edu).

Accepted for Publication: July 2, 2017.

Published Online: November 1, 2017. doi:10.1001/jamasurg.2017.3796

Author Contributions: Drs Rubio and Thaller had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rubio, Mundra.

Critical revision of the manuscript for important intellectual content: Mundra, Thaller.

Statistical analysis: Rubio, Mundra.

Study supervision: Thaller.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the Association of Veterans Affairs Surgeons Annual Meeting; May 8, 2017; Houston, Texas.

References
1.
Winocour  J, Gupta  V, Ramirez  JR, Shack  RB, Grotting  JC, Higdon  KK.  Abdominoplasty: risk factors, complication rates, and safety of combined procedures.  Plast Reconstr Surg. 2015;136(5):597e-606e.PubMedGoogle ScholarCrossref
2.
Tsai  DM, Borah  GL.  Implications of rheumatic disease and biological response-modifying agents in plastic surgery.  Plast Reconstr Surg. 2015;136(6):1327-1336.PubMedGoogle ScholarCrossref
3.
Zöller  B, Li  X, Sundquist  J, Sundquist  K.  Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden.  Lancet. 2012;379(9812):244-249.PubMedGoogle ScholarCrossref
4.
Wong  LE, Bass  AR.  Postoperative risk of venous thromboembolism in rheumatic disease patients.  Curr Rheumatol Rep. 2015;17(2):11.PubMedGoogle ScholarCrossref
5.
Familusi  OT, Doscher  M, Manrique  OJ, Shin  J, Benacquista  T.  Abdominal contouring: can the American Society of Anesthesiologists classification system help determine when to say no?  Plast Reconstr Surg. 2016;138(6):1211-1220.PubMedGoogle ScholarCrossref
6.
Pannucci  CJ, Swistun  L, MacDonald  JK, Henke  PK, Brooke  BS.  Individualized venous thromboembolism risk stratification using the 2005 caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis.  Ann Surg. 2017;265(6):1094-1103.PubMedGoogle ScholarCrossref
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