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An Analysis of Bleeding Complications in Plastic Surgery
Analise Thomas, M.D., Ronnie Shammas, B.S., Adam Glener, B.S., Eugenia Cho, B.S., Scott Hollenbeck, M.D., F.A.C.S..
Duke University Medical Center, Durham, NC, USA.

PURPOSE: Our aim was to identify patient characteristics and procedures associated with bleeding complications during plastic surgery.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify all primary plastic surgery procedures from 2008 to 2013. Patients with bleeding complications as defined by NSQIP were identified. Patients who had a documented bleeding disorder were separately identified. Procedure CPT Codes, patient characteristics, and surgical outcomes were abstracted and analyzed to determine those procedures and conditions associated with bleeding complications. An analysis of co-morbidities, peri-operative characteristics, and post-operative complications between bleeding and non-bleeding cohorts was performed using a non-paired, 2-tailed t-test and a chi-squared test with Yates correction.
RESULTS: Of 59,184 cases identified, 1261 (2.1%) experienced bleeding complications. Regarding co-morbid conditions, 18.2% of patients had diabetes, 41.8% had hypertension, and 6.7% had bleeding disorders in the bleeding group compared with 7.4%, 25.9%, and 1.5% in the group without bleeding complications (p<0.0001). The most common primary procedures associated with bleeding complications were breast reconstruction with a free flap (20.7%) and myocutaneous trunk flaps (13.1%). The most common concurrent procedures associated with bleeding complications were breast oncology procedures (35.3%) and enterolysis (1.9%). The most common non-bleeding complication was difficulty weaning the patient off the ventilator. Twenty-five patients (2.0%) with bleeding complications died within 30 days of the procedure.
Of the primary plastic surgery procedures identified, 953 (1.6%) patients carried a pre-existing diagnosis of bleeding disorder. The two most common primary procedures performed in this group were myocutaneous trunk flaps and reduction mammaplasty. The rate of bleeding complications in the group with a pre-existing bleeding disorder was more than four times the rate of bleeding complications for those without a bleeding disorder (8.9% vs. 2.0%, p<0.01). In addition, the rate of other non-bleeding complications was significantly higher in the cohort with a bleeding condition (1.29% vs. 0.35%; p<0.01). The most common non-bleeding complications in this cohort were prolonged ventilation requirement (2.9%) and septic shock (2.9%).
CONCLUSIONS: Plastic surgery procedures have an overall low rate of post-op bleeding (2.1%). Bleeding most commonly occurs with flap reconstruction, specifically breast and trunk flaps. A pre-operative diagnosis of hypertension, diabetes, or bleeding disorder was associated with increased incidence of post-operative bleeding complications. Two percent of patients undergoing plastic surgery procedures during our period of study had known pre-operative bleeding disorders. As these patients exhibit a significantly higher rate of post-operative bleeding as well as overall post-operative complications, recognition and appropriate management pre-operatively, potentially including risk stratification and a multi-disciplinary approach, may represent a realistic method for reducing complications in this cohort when undergoing plastic surgery procedures.


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