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ACS Case Reviews

Deep Venous Thrombosis After Repair of Abdominal Bulge with Fascial Plication and Onlay Mesh Placement

January 31, 2024

Abstract

Background

A 70-year-old female patient developed deep vein thrombosis (DVT) after undergoing abdominal bulge repair with fascial plication and placement of onlay mesh.

Summary

Abdominal bulge after abdomen-based autologous breast reconstruction is a well-known complication that contributes to donor site morbidity. Our patient presented with a symptomatic abdominal bulge and contour deformity after a pedicled left transverse rectus abdominis muscle (TRAM) flap for right breast reconstruction. She underwent abdominal bulge repair via fascial plication with onlay mesh placement for reinforcement. On postoperative day (POD) 6, she developed bilateral lower extremity swelling. Bilateral lower extremity DVTs were confirmed via venous duplex ultrasound imaging on POD 18, and she required three months of oral anticoagulation. Abdominal wall plication-associated increased intra-abdominal pressure is thought to be the main contributing factor in the increased risk of venous thromboembolism (VTE) associated with abdominoplasty by causing lower extremity venous stasis. High-tension abdominal wall closures, bed position, binder placement, and general anesthesia have also been implicated as risk factors. These abdominoplasty techniques are frequently used in abdominal bulge repair surgery. This case report demonstrates that patients undergoing abdominal bulge repair operations might warrant increased utilization of risk-stratifying measures and a heightened level of awareness for DVT.

Conclusion

Risk factors for VTE in abdominoplasty patients, particularly fascial plication, are well-recognized. The risk of DVT in patients undergoing abdominal bulge repair with similar techniques is not well studied and may be underreported. This reported case should encourage plastic surgeons to be more cognizant of VTE risk and consider performing risk stratification in patients undergoing repair of abdominal wall bulge.

Key Words

deep vein thrombosis; venous thromboembolism; fascial plication; abdominal wall bulge; autologous breast reconstruction

Case Description

Autologous breast reconstruction with abdomen-based flaps is recognized as the gold standard for breast reconstruction.1 While improvements in surgical flap harvesting techniques have reduced donor site morbidity overall, 52% of women still experience clinically important worsening of physical well-being of the abdomen after abdomen-based free flap for breast reconstruction.2 Among donor site complications, abdominal bulge/hernia rate ranges from 4.2% to 16.6%, depending on flap type, and up to 3.1% to 10% of bulges require surgical intervention.3

Maximizing donor-site aesthetic outcomes has become an important component of autologous breast reconstruction. Hernia repair techniques and abdominoplasty techniques, such as abdominal wall plication, are frequently implemented to improve abdominal donor site contour and prevent or correct an abdominal bulge.4-12 Abdominal wall plication-associated increased intra-abdominal pressure is also thought to be the main contributing factor in the increased risk of deep vein thrombosis (DVT) associated with abdominoplasty by causing lower extremity venous stasis.13

We hypothesize that the use of abdominoplasty techniques, such as abdominal wall plication, to address the complication of abdominal bulge after abdominal-based autologous breast reconstruction puts these patients at increased risk for perioperative venous thromboembolism (VTE). To our knowledge, deep vein thrombosis after abdominal bulge repair has not been previously reported in the literature. Thromboembolic disease, its management, and its prevention have recently become an important topic of discussion in plastic surgery.14 We present a case demonstrating that the risk of perioperative DVT might deserve an increased level of awareness.

A 70-year-old female presented to our clinic with a symptomatic abdominal bulge and contour deformity after a pedicled left transverse rectus abdominis muscle (TRAM) flap for right breast reconstruction. The patient underwent right breast-conserving therapy in 2016 for invasive ductal carcinoma. She developed severe radiation-induced contracture of the right breast, for which she underwent reconstruction with a pedicled left TRAM flap in 2019. From records available to us from the prior surgeon who performed the rectus abdominis flap harvest, the abdominal donor site was reinforced with a 30 × 30 cm piece of Prolene mesh doubled up on itself and inset in an inlay position encompassing the entire rectus sheath up to the costal margin.

The patient complained of persistent pain in the abdomen with distention, a bulge in the upper abdomen, difficulty standing upright, and difficulty taking a deep breath since the time of her breast reconstruction surgery. On physical exam, an abdominal bulge was apparent on stress testing in the epigastrium and left hemi-abdomen. CT scan of the abdomen and pelvis demonstrated asymmetric abdominal wall musculature consistent with her previous TRAM flap but no evidence of a hernia (Figure 1).

Figure 1. Abdominopelvic CT Scan. Published with Permission

Left rectus abdominal musculature smaller than right consistent with left pedicled transverse rectus abdominis muscle (TRAM) flap surgery. No anterior abdominal wall hernia or mass
Left rectus abdominal musculature smaller than right consistent with left pedicled transverse rectus abdominis muscle (TRAM) flap surgery. No anterior abdominal wall hernia or mass

She elected to undergo abdominal wall reconstruction with onlay Prolene mesh for correction of the abdominal bulge and improvement in abdominal wall contour in 2021. Sequential compression devices were placed on the bilateral lower extremities prior to initiation of general anesthesia. Intraoperatively, she was noted to have an abdominal bulge and weak fascia, especially on the left side. The abdominal wall bulge was marked on both sides and in the midline and was then serially plicated with 0-PDS sutures. A 15 × 15 cm Prolene Bard soft mesh was placed over the abdominal wall repair and sutured in place with 0-PDS to reinforce the repair. The abdominal wall flap was re-draped with the excision of excess infraumbilical skin, and the umbilicus was brought out through a U incision at the level of the iliac crests. The patient was flexed at the hips for closure of the abdominal wall. Of note, flank liposuction for fat grafting to the breast was also performed. She was placed in an abdominal binder at the completion of the case.

On POD 6, the patient started complaining of fatigue, hypotension, and lower extremity swelling. A bilateral lower extremity venous duplex was ordered. The imaging demonstrated acute deep vein thromboses of the right popliteal, right peroneal, and left posterior tibial veins. Her risk factors included recent surgery and a sedentary position with neuropathy limiting ambulation. She was treated with a single dose of subcutaneous enoxaparin and started on oral systemic anticoagulation with apixaban. Repeat bilateral lower extremity venous duplex at three months revealed the resolution of DVTs, and the patient's anticoagulation was discontinued. Her abdominal pain and discomfort with ambulation resolved, and her bulge was absent on follow-up examination.

Discussion

The venous thromboembolism (VTE) rate in autologous breast reconstruction ranges from 0.1%-4%,15-18 comparable to the VTE rate in abdominoplasty of 0.35%-5%.14,18,19 Similarly, the VTE rate in patients undergoing simultaneous ventral hernia repair and panniculectomy is 1.2%.20 Techniques used in these surgeries have significant similarities to abdominal bulge repair following abdomen-based autologous breast reconstruction.

The 2005 modification of the Caprini Risk Assessment Model has been validated in plastic surgery patients.18 In the plastic surgery population, a significantly increased risk of VTE with a rate of 11.3% exists for patients with a modified Caprini score >8 who do not receive chemoprophylaxis. Additionally, there is a significantly increased risk of VTE in patients with a score of 7-8 compared to a score of 3-4.18 Significant differences in VTE incidence have been seen between patients with Caprini scores of 5 to 6, 7 to 8, and >8.21

Patients with a score >8 are recognized as "super high risk" and should be considered for chemoprophylaxis on a case-by-case basis.18,22 It has also been recommended that in addition to considering chemoprophylaxis, surgeons should consider risk factor modification or avoiding surgery in patients with a Caprini score of 8 or higher.18,23 Additionally, 30 days of postoperative chemoprophylaxis is recommended for a score of >8.18

In plastic surgery patients with a Caprini score of 7 to 8, 2.7% had a symptomatic VTE event between 0 and 60 days postoperatively.18 Our patient had a modified Caprini score of 7 (BMI>25, age 60-74 years, previous or present malignancy, major surgery >45 minutes), placing her at a relatively high risk of VTE but not reaching the threshold score of 8 or higher where recommendations state there should be consideration for chemoprophylaxis.18,22 However, the patient admitted that her history of significant neuropathy limited her ambulation at baseline. It could be argued that the patient's Caprini score was 1 to 2 points higher, given her baseline sedentary lifestyle and postoperative status, further limiting ambulation.

No validated VTE risk model exists specifically for the outpatient surgery population, and practice varies regarding the use of anticoagulation in the immediate postoperative period.24,25 Current guidelines state that routinely administering chemoprophylaxis for all plastic surgery patients is not recommended nor recommended for TRAM flaps and body contouring surgeries. Additionally, chemoprophylaxis for patients with a Caprini score >8 is recommended only individually.22 Our patient did have mechanical prophylaxis in accordance with current practice recommendations.22 In our practice, we typically administer perioperative subcutaneous heparin only for patients with a Caprini score of 8 and above. We will endeavor to revise this practice as more evidence becomes available.

Agrawal et al.23 propose the need for closer evaluation of the role of the following factors on VTE risk in plastic surgery patients: the effects of muscle relaxation, long flights immediately after surgery, estrogen use, the type of surgery, and the use of tranexamic acid. Abdominal wall plication-associated increased intra-abdominal pressure is thought to be the main contributing factor in the increased risk of deep vein thrombosis (DVT) associated with abdominoplasty by causing lower extremity venous stasis.13 However, plication of the musculoaponeurotic system is also a core technique for improving abdominal wall contour24 in cosmetic abdominoplasty and transverse rectus abdominis muscle (TRAM) flap patients.25-28

Abdominal wall plication has been shown to cause deep venous stasis in the proximal femoral vein, indicated by decreased flow and increased proximal femoral vein diameter.13 In addition to high-tension abdominal closures and rectus plication, tight compression garments have been implicated in decreasing venous return and may be involved in lower extremity DVT formation. Ultrasound has demonstrated proximal vessel dilation, decreased flow, and loss of normal venous flow within the popliteal vein with compression garments in place. Additionally, 92% of surgeons use rectus plication with their abdominoplasties, and 95% of surgeons use postoperative compression garments for patients getting liposuction and/or abdominal binder with abdominoplasties.29 Another study that demonstrated rectus plication increases intraabdominal pressures also exposes bed position, binder placement, and general anesthesia as risk factors for DVT.27

While some studies have suggested that plastic surgeons may underutilize chemoprophylaxis in high-risk patients, miss risk factors when present, and/or fail to modify risk factors prior to surgery,18,30-32 the risk of venous thromboembolism in abdominal bulge repair operations may be underreported. This reported case and available evidence should encourage plastic surgeons to consider performing risk stratification and have heightened vigilance for VTE in patients undergoing repair of abdominal wall bulge after abdomen-based autologous breast reconstruction.

Conclusion

Risk factors for venous thromboembolism (VTE) in abdominoplasty patients, particularly fascial plication, are well-recognized. While abdominoplasty techniques are commonly implemented in abdominal bulge repair, the risk of DVT in this patient population is not well studied and may be underreported. This reported case should compel plastic surgeons to be more cognizant of VTE threat and consider performing risk stratification in patients undergoing repair of abdominal wall bulge after abdomen-based autologous breast reconstruction.

Lessons Learned

Fascial plication is one of several technical factors that increase VTE risk in abdominoplasty. Surgeons should recognize these abdominoplasty techniques similarly increase VTE risk when utilized in abdominal wall bulge repair after abdominal-based autologous breast reconstruction. Enhanced surveillance and risk stratification in this patient population should be amply considered.

Authors

Kapsalis C; Ogunleye A

Author Affiliations

Department of Surgery, University of North Carolina, Chapel Hill, NC 27514

Corresponding Author

Christina Kapsalis, MD
Department of Surgery
4001 Burnett-Womack Building
CB #7050
Chapel Hill, NC 27599
Email: christina.kapsalis@unchealth.unc.edu

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding/Support

The authors have no relevant financial relationships or in-kind support to disclose.

Received: March 20, 2022
Revision received: May 3, 2022
Accepted: May 25, 2022

References

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