The risk of stroke during plastic surgery

Global Courant

An unspoken concern

While most plastic surgeons will outline the risks of having an elective surgical procedure performed, few directly address the issues of safety and postoperative complications. Often, a surgeon will make a blanket statement about the risks of surgery, such as, “All surgeries carry risks, including bleeding, infection, difficulty breathing, swelling, clotting, and other disease in a small percentage of patients,” and then start talking right away about the benefits of the procedure. Patients should educate themselves about the real risks associated with cosmetic surgery procedures, especially the risk of stroke or cerebral vascular accident (CVA). As a physician, I understand that there is no point in scaring our patients for no reason. Yet I still firmly believe that patients should never rush into an elective surgical procedure without being fully aware of the potential for devastating complications.

Both patients and physicians should recognize that most patients who receive any form of cosmetic care are generally considered to be healthy individuals. Thus, neither the patient nor the doctor is necessarily ready for the occurrence of a complication. This fact alone can make a complication much more serious than if the same complication occurred during a medically necessary procedure. For example, even during routine knee surgery, doctors may not see their patients as completely healthy and are more wary of blood clots forming or other stroke risk factors.

While the estimated one to two percent of patients undergoing cosmetic surgery who have a stroke may seem like a very limited number of patients, the consequences of these strokes can be devastating

Who is at risk?

Few patients believe they are at risk for possible stroke because they associate the condition with an event that occurs in people over the age of 55. While age plays a role in some cases, it is far from being the determinant of stroke. In fact, a healthy 65-year-old woman is less likely to have a stroke than a 35-year-old woman undergoing invasive cosmetic surgery. Patients need to understand the causes of stroke in a postoperative setting to more realistically assess their risk level. However, as a physician, I can attest to the fact that sometimes there is simply no way to determine why a stroke occurred in one person and not in another person with the same health history, risk factors, and surgical procedure.

Most postoperative strokes occur when a blood clot breaks loose, which usually occurs in the lower part of the body. This blood clot then travels through the body and can lodge in the brain or more commonly in the lungs. This action of a blood clot traveling through the body post-operatively is commonly referred to as an embolism and usually results from a larger blood clot that commonly forms in the lower body, known as a deep vein thrombosis or “DVT”. DVT is a primary concern for surgeons and can be considered a precursor to stroke.

Understand the potential danger

Blood clots generally become lodged in the lungs or brain when they break free from other parts of the body. When the blood clot becomes lodged in a blood vessel in the brain, it results in a CVA or stroke. When it becomes lodged in a blood vessel in the lung, it is known as a pulmonary embolus, or PE. Both conditions are life-threatening and can have serious consequences.

While blood clots and strokes pose a significant risk to all patients undergoing invasive surgery, plastic surgeons run into a unique scenario that generally makes it a bit more difficult for our patients to get treatment and help in a short period of time. Incidents of blood clots and stroke can occur anywhere from a few hours after surgery to about ten days after surgery. Thus, these incidents rarely take place in a medical setting and usually take place at home. Patients who remain in hospital or a medical center after a medically necessary procedure are more likely to experience these in-hospital incidents.

Patients undergoing cosmetic surgery or other surgery should familiarize themselves with the general symptoms of postoperative pulmonary embolism or stroke. Symptoms such as shortness of breath, chest pain, disorientation, and sometimes even a sense of altered mental status are likely related to a pulmonary embolism or stroke. Both patients and physicians should also understand the basic risk factors for these complications and prior to any surgical procedure. While studies are still being conducted that will help determine a patient’s level of risk going forward, there are some fairly fundamental factors that point to a likely candidate.

Risk factors for patients

Women are more likely to have these types of complications than men, as are smokers. There are numerous medications that put patients at higher risk for postoperative blood clots, including but not limited to hormone replacement drugs and birth control pills. Weight plays an important role, as does the level of activity in which the patient generally participates. Patients who generally lead a sedentary lifestyle are at greater risk. Obese patients are at an even higher risk. Older age and a history of deep vein thrombosis are more likely risk factors. Patients with a current diagnosis of cancer are at particularly high risk.

Reducing risk factors for safer surgery

Whenever a patient is booked for surgery in my practice, I always insist that they have a medical clearance from an internist to help with their overall risk level for elective surgery and the possibility of medical complications, including the risk of abnormal blood clotting determine. I also take into account the type of surgery I perform on the patient. In general, surgical procedures that have a longer operative time and involve body contouring carry a higher risk than those that are minimally invasive and performed on the head and neck. The internist, like myself, will review a list of current and recent medications and verify that the patient is physically able to tolerate the desired procedure. There are still no guarantees, but knowing a patient’s medical history, their obvious risk factors, and having a second set of eyes look at the same information presented to me ensures that I take every precaution possible.

I also use something known as pneumatic compression boots on any patient undergoing surgery and I urge other doctors to do the same. These boots are able to keep the muscles of the lower extremities moving in a manner similar to walking, which can help prevent blood clots. I insist that my patients maintain an active lifestyle, to help prevent DVT formation and to assist directly with both preoperative and postoperative care. Proper positioning in the operating room also provides additional prevention of blood clot formation.

Doctors and patients need to understand that the potential for serious complications associated with cosmetic surgery can be devastating. Knowledge is power and education can help reduce the number of blood clots and such rare but devastating complications as strokes that occur after surgery. With current research and teaching practices, we should be able to reduce the number of postoperative strokes and blood clots in the coming years.

The risk of stroke during plastic surgery

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