In the most recent issue of the Aesthetic Surgery Journal (ASJ), there is an interesting article on postoperative hematoma formation in plastic surgery patients. We have long been aware of the correlation of postoperative hematomas and blood pressure. (BP) Most of these studies have been done in face lift patients. In 1973, Straith showed that patients with elevated BP (greater than 150/100 mm Hg) on admission had a 2.6 times greater incidence of postop hematoma formation. Berner suggested that the patient should be medically protected against uncontrolled postop elevated BP's to reduce the incidence of postop hematomas. Postoperative "reactive hypertension" can be caused by coughing, retching or vomiting, postoperative pain, and anxiety. For facial and head/neck procedures, we ask patients to avoid bending over with their head down. We ask them to squat to pick up dropped items or ask someone else to pick them up. Baker used a strict antihypertensive and perioperative blood pressure control regimen of chlorpromazine, valium, and clonidine which reduced his incidence of postop hematomas from 8.7% to 3.97% in his face lift patients.
The ASJ article (see first reference below) was done in patients undergoing body contouring surgery (abdominoplasty, thigh lifts, etc). Many of these patients were placed on antithrombotic therapy, because most of them were massive weight loss patients, the surgery was of increased length, and the current (rightfully so) interest in preventing pulmonary embolus in surgery patients. The incidence of hematoma formation in abdominoplasty surgery ranges from 1%-10%. This study looked at blood pressure and antithrombotic therapy as risk factors in the formation of postop hematomas.
Plastic surgeons have long asked the anesthesiologist to keep the patient's blood pressure low (hypotensive anesthesia) for many of our procedures. This does result in lower pressures within the small vessels and capillaries, which helps keep the surgical field "dry". However, once the patient has returned to their normal blood pressure, these small vessels and capillaries may open (ones that weren't cauterized because they weren't bleeding and therefore missed), and bleeding may ensue. This may lead to a postop hematoma.
So it may be time to give up hypotensive anesthesia, as we begin to use more antithrombotic therapy. Of their 360 patients, 137 received enoxaparin (Lovenox). There were 11 (3.1%) hematomas among the 360 patients. Ten of the 11 (90.9%) occurred in patients receiving Lovenox. These patients were then evaluated for perioperative blood pressures and compared to similar patients without hematoma formation. Mean preoperative MAP's were similar (97.4 mm Hg in the hematoma patients, 95.8 mm Hg in the non-hematoma patients). The mean intraoperative blood pressures (within the last 2 hours of each case) differed significantly. In the hematoma patients, the MAP was 66.7 mm Hg and 82.4 mm Hg in the non-hematoma patients. Postoperative MAP's were 96.3 mm Hg in the hematoma patients and 88.5 mm Hg in the non-hematoma patients.
Though the risk of pulmonary embolus is small (0.1%-0.3%), they can be fatal. So currently, most surgeons feel that the increased risk of hematoma formation from use of antithrombotic prophylaxis is worth it. The things we can do to reduce the risk of hematoma formation are try to keep blood pressure more even between pre-, intra-, and postoperative periods. Then the small capillaries and veins that might get missed by hypotensive anesthesia can be seen and cauterized and the ones that might be missed would be less likely to bleed if the "hyper"tension postoperatively didn't occur.
- Patients who are taking antihypertensive medication should be well maintained until the time of surgery and reinstated as soon as possible postoperatively.
- Patients should adhere to the restrictions given them postoperatively. It is good to get up and move, but do so in a way as to not raise your blood pressure. No heavy lifting means that. No speed walking or jogging means that. Squat rather than bending over.
The Effect of Blood Pressure on Hematoma Formation with Perioperative Lovenox in Excisional Body Contouring Surgery; Aesthetic Surgery Journal, Vol 27, No 6, pp 589-593; Jordan P. Farkas, Jeffrey M. Kenkel, Daniel A. Hatef, Gabrielle Davis, Tuan Truong, Rod J. Rohrich, Spencer A. Brown
The Study of Hematomas in 500 Consecutive Face Lifts; Plastic & Reconstructive Surgery. 59(5):694-698, May 1977; Straith, Richard E. M.D.; Raju, D. Raghava M.D.; Hipps, Chauncey J. M.D.
Postoperative Hypertension as an Etiological Factor in Hematoma after Rhytidectomy; Plastic & Reconstructive Surgery, 57(3):314-319, March 1976; Berner, Robert E. M.D.; Morian, William D. M.D.; Noe, Joel M. M.
Reducing the Incidence of Hematoma requiring Surgical Evacuation following Male Rhytidectomy: a 30-year Review of 985 Cases; Plastic & Reconstructive Surgery. 116(7):1973-1985, December 2005; Baker, Daniel C. M.D.; Stefani, William A. M.D.; Chiu, Ernest S. M.D.
Aggressive pharmacologic protocols may be associated with TJR complications: To guide orthopedists in selecting prophylaxes, AAOS has issued new recommendations. By Susan M. Rapp ORTHOPEDICS TODAY 2007; 27:18