Low-Molecular-Weight Heparin and Postoperative Bleeding in Rhytidectomy

Sir: We read with great interest the editorial by Dr. Davison and Dr. Massoumi1 entitled “Our Complication, Your Problem,” in which our article “Low-Molecular- Weight Heparin and Postoperative Bleeding in Rhytidectomy”2 is cited and discussed. Dr. Davison's editorial gives the impression that we do not use any prophylaxis against thromboembolism. We can explain that we do use prophylaxis, having in mind that thromboembolism is a serious or even deadly complication. Our clear and strict algorithm for selective prophylaxis and perioperative regimen, as described in our article, is the following: An important fact in our regimen is the patient's history. Patients with a positive history of predisposing risk factors such as known genetic defects or thrombotic events receive prophylaxis with low-molecular-weight heparin. Further predisposing risk factors taken into consideration are use of oral contraceptives or hormone replacement therapy, age, obesity, pregnancy, gender, and nicotine abuse. If there is no risk for a thrombotic event, our perioperative regimen consists of the use of compressive stockings postoperatively and immediate mobilization on the day of operation. With regard to the article by Dr. Davison entitled “Prevention of Venous Thromboembolism in the Plastic Surgery Patient,”3 and taking the regimen described there into account, a rhytidectomy patient without predisposing risk factors would not receive low-molecular-weight heparin on the basis of Dr. Davidson's regimen or on the basis of our regimen, which is in fact similar. Probably the most important point of our regimen is the exclusive use of sedoanalgesia, which is one of the known prophylactic measures.1 Using this type of anesthesia, patients move their legs while they are on the operating table, and thus the muscle pump works. Thromboembolism is related to perioperative stasis. Administration of low-molecular-weight heparin 12 hours after surgery means that our patients are already mobilized, wearing their compressive stockings. What if thromboembolism occurs on the operating table, where the greatest part of stasis occurs? When taking a look at the number of thromboembolisms, Stuzin reported no thromboembolic events in 600 rhytidectomies under sedoanalgesia.4 In our series, we can report more than 700 rhytidectomies in the past 16 years and have observed no thromboembolic events. Despite a very high acuity for deep venous thrombosis risk and prophylaxis, Dr. Davison experienced three thromboembolic complications in 570 operations last year. He also quoted a study in which 7.8 percent of surgeons experienced an episode of deep venous thrombosis in a 3-month period. Extrapolated over a period of 12 months, the incidence rate would be 31.2 percent per surgeon.5 In accordance with the percentage estimated, one could expect more than 10 patients with a thromboembolic complication when adding the numbers of Stuzin and ourselves, but this is not the case. Good perioperative risk management includes risk management for both bleeding and thromboembolic complications. We showed in our study2 that our risk management method represents a good tool with which to avoid both. With our risk regimen, we consider the patient's complication our problem. Peter Durnig, M.D. Walther Jungwirth, M.D. Department of Plastic, Aesthetic and Reconstructive Surgery EMCO Private Hospital Salzburg, Austria