Patient safety in plastic surgery: a systematic review
Segurança do paciente em cirurgia plástica: revisão sistemática

Preoperative period category

Surgery always begins with the patient in the office when the benefits and risks of the procedure to be performed are explained. In this sense, it is necessary to use the term of informed consent (ICT). Doncatto, in 2012¹², performed a retrospective analysis on 100 judgments of the Courts of Justice of 5 Brazilian states, from July 2010 to August 2012, in cases related to cosmetic plastic surgery, excluding cases of restorative plastic surgery. The last 20 trials of each state were considered, covering a total of approximately 3,427 active plastic surgeons, where the most frequent causes of the actions and the main evidentiary elements that led to the conviction or acquittal of the cases were evaluated. The author noted that in cases of medical process, in addition to a favorable expert opinion, the appropriate use of the consent form was the most relevant aspect in cases in which there was absolution.

Therefore, the Informed Consent Form represents safety for the plastic surgeon and the patient, since it equals and consolidates the relationship of trust and transparency between the two, fulfilling the obligation of the doctor to inform the patient and in turn that this patient declares that understood and that he/she agrees to submit to the proposed treatment, allowing the doctor legal certainty, unless the term has been obtained irregularly.

Many lawyers have considered plastic surgery to be a result-binding specialty. Therefore, there is a condemnation without any malpractice, imprudence or negligence, disregarding the biological, technical and specific aspects of the patient. Doncatto, in 201212, (p. 353) still notes that:

The required result obligation of cosmetic plastic surgery has generated uneasiness in the medical profession, as many judges have not yet understood that it is impossible to guarantee results in all types of surgery, as organic tissues react differently to the will of both the physician and the patient. In this perspective, the author considers that the consent form leaves the doctor-patient relationship in addition to being transparent, respectful in the sense of the patient’s autonomy for his body, aware of the advantages and disadvantages, risks, and possible results. He says: “in turn, the plastic surgeon, when using the ICT properly, demonstrates suitability, good intentions, good principles and honesty, a fact that becomes an attenuator¹².

The consent form must provide adequate and sufficient information, containing the nature and purpose of the treatment, the probable risks and benefits, the alternative treatments, in addition to the risks of failing to perform the proposed treatment or the alternatives. Doncatto, in 2012¹², observed that in cases of medical process, in addition to a favorable expert opinion, the proper use of the consent form was the most relevant aspect in cases in which there was an acquittal.

The article called “Anesthetic complications in plastic surgery and the importance of pre-anesthetic consultation as a safety instrument” already points to the aspect of patient safety according to the pillars of the Federal Council of Medicine, which says it has been mandatory since 2006, the pre-anesthetic consultation (CFM, in 2016X). Schwartzman et al., In 2011¹³, in a retrospective and analytical cohort study of hospital patients, discussed the anesthetic complications of surgical procedures in a given hospital in Brazilia. In the preoperative periods, pre-anesthetic consultations were carried out with clinical evaluation and description of the anesthetic plan.

The authors, in agreement with Doncatto, in 2012¹², previously presented, also state that the informed consent form was signed, which is kept confidential, attached to the medical record. The focus of this study was the main information obtained in the pre-anesthetic consultation and the classification of the patient’s physical state.

As a result of this study, it was found that 6365 anesthetic procedures were performed between April 2006 and December 2007, and of these, 2.74% had an anesthesia-related complication rate. Several specialties have been researched, and concerning plastic surgery, even with complex procedures for reconstruction of the upper limb (neurotendinous lesions and tumors), lower limb, injuries to the trunk (pressure ulcers, myelomeningocele and ostemilielitis), there was a complication in 8%, compared to orthopedics, with 46.25% and neurosurgery with 24.6%. Regardless of surgical specialty, the authors identified hypotension with 22.8% of cases as an anesthesia-related complication, followed by vomiting and arrhythmias with 13.7% and perforation of the dura mater and laryngospasm with 6.3%.

Schwartzman et al., In 2011¹³, point out that the team of health professionals, composed of anesthetists and nurses, is of paramount importance for the realization of pre-anesthetic consultation in the context of patient safety in plastic surgery, “as it can reduce complications intra and postoperative periods and avoid unfavorable outcomes ”(p. 226).

Also, in this category, we can point out the study by Rezaeian et al. in 2013¹⁴, a German publication, which sought to develop, implement and evaluate a new concept of teaching and training in aesthetic plastic surgeries. Although this research was carried out with residents, a fact that will be discussed in another category of analysis, the central point is the training program carried out in 304 aesthetic surgeries of body, breast and facial contour. The responsible physicians used these surgeries to teach residents the best techniques and recorded cases where complications occurred as an indicator of patient safety. It emerged from the study that training was effective, considering that the incidence of complications from educational surgeries and those that did not compose the research sample, that is, that were not for teaching the residents, had practically the same percentage of complications, being 4.4% for elective surgeries and 4.9% for educational ones.

Transoperative period category

For this category, some articles dealt with issues related to the transoperative period, such as a checklist, surgical evolution, iatrogeny, adverse events, and communication.

Prates et al., in 2018¹⁵, demonstrate that the checklist can also be used to reduce rates of surgical infection. According to the authors, surgical infections are recognized worldwide as a serious public health problem because they are associated with high morbidity and mortality, increased length of stay, and hospital costs. They are one of the main targets of epidemiological surveillance in health institutions. In underdeveloped and developing countries, the authors claim that it can affect up to a third of patients undergoing surgical procedures. Monitoring and implementing effective strategies to prevent them in health facilities have been stimulated and driven by worldwide movements for patient safety. Surgical site infections are, for the authors, preventable adverse events and markers of low quality of care, requiring efforts by health professionals and institutions to reduce them.

Also related to the checklist, the study by Sucupira et al., In 2016¹⁶, describes authors who recall in their work “Aesthetic Plastic Surgery Checklist: A Safety Tool” that about 10% of patients have iatrogenic events and that more than half of them occur in the perioperative environment. The research aimed to develop a complete and functional checklist for cosmetic plastic surgery and to test it in patients undergoing elective plastic surgery. It was developed a complete checklist to improve patient safety in cosmetic plastic surgery.

Although the authors marked the level of evidence in this study as IV, the results point to the use of data from 486 patients, 430 of whom were female, and 56 of whom were male, with the most commonly performed liposuction in 305 cases and anesthesia plus sedation. As for complications, the authors identified seromas with 7%, other complications not related to the wound with 3%, and the group that most adhered to the use of the checklist was the group of residents.

In the paper, it was demonstrated that the use of the checklist allows the collection of data and the identification of potential risks, promoted favorable changes in the attitudes of some professionals, and generated interest in patient safety and the team labor.

Another article that is classified in the category related to the transoperatory period is the one that discusses the safety of the technique itself. Amorim et al., in 2012¹⁷, in their work on lipoabdominoplasty, demonstrates that surgical techniques undergo evolution over time, resulting in greater safety for the patient. The author demonstrates that the evolution of the technique has made lipoabdominoplasty a more elaborate surgery, enabling the achievement of good results by knowing the safety limits of the surgery.

A retrospective study was carried out using 162 medical records of patients who underwent lipoabdominoplasty over five years, and the results show a significant reduction in cutaneous-adipose tissue, with a significant decrease in abdominal flaccidity and an improvement in body contour.

The author reports that the safety of this procedure is modernly based on decreased detachment of the abdominal flap. On the other hand, it is undeniable the greater viability and safety of a less detached flap, which preserves its vascular and sensitive source. This safety for flap irrigation is described in studies with Doppler, as shown by the authors. That is, the lipoabdominoplasty technique is a safe procedure, with a low rate of complications, as long as the safety criteria described by the authors are respected. This proceeding allows obtaining a well-vascularized flap, with preservation of perforating arteries. Amorim et al., In 2012¹⁷, stated that the postoperative complications found in the medical record review are low and meet the incidences reported in the literature.

Hernandes-Boussard et al., In 2015¹⁸, remember that adverse events are not rare, 3.7% of all hospital admissions experience an adverse event, and most of these events are considered preventable. In addition to the impact on the patient and his family, adverse events increase the use of hospital resources and the costs of hospitalization.

Given the wide-ranging impact of these events, there has been global prioritization in patient safety and associated hospital performance. The authors say that plastic surgery is a surgical discipline with its particularities, that there are essentially two groups of patients who need reconstructive plastic surgery: elective patients, who are generally young and healthy adults; and, complex patients, who need reconstructive surgery due to other conditions, such as the closure of exposed wounds, reconstruction after tumor removal or injury repair such as burns. It was observed in their work that patients undergoing reconstructive plastic surgery, in general, had lower rates of complications than other surgical specialties, but adverse effects were not uncommon. Over five years, a total of 16,635 patients experienced at least one potentially preventable adverse event during hospitalization. These events led to more than twice the patient’s hospital stay time and increased hospital expenses.

Sidhoum et al., In 2016¹⁹, discuss, in their work, the relatively modern concern in patient safety that has been the use of social media such as Whatsapp. The author recalls that concerns such as the dissemination of data and images of patients that would be protected by medical confidentiality are considered, but the safety of this data in new media and mobile devices is questioned. Instant messaging can be used as a valuable tool to coordinate surgical teams or for simpler patient guidance. It is a valuable approach to simplify communication.

The authors present the experience and results of the plastic surgery team at Centro Hospitalar Universitário Amiens, using instant messaging as part of medical communication for almost three years. In terms of daily time spent writing messages, the statistics are quite favorable and show no detrimental time wasted with using WhatsApp. The use of this tool seems to keep the medical team in a continuous call throughout the day, favoring the treatment of patients. Regarding the technical characteristics involving security in 2014, the Electronic Frontier Foundation, an independent American institution that defends civil liberties in the world, assessed the vulnerability of WhatsApp messages to measure their security by a complex analysis of their encryption. This institution concluded that WhatsApp has a good level of security and confidentiality, guaranteeing the security of the data and communications exchanged. A disadvantage would be the medical record. Undeniably, medical information shared through WhatsApp during the patient’s hospitalization does not appear in his medical record. However, even so, instant messaging is an effective, inexpensive, and safe tool for professional communication. It does not seem to harm oral communication and brings better communication from the surgical team.

Tadisina et al., In 2015²⁰, raised another interesting question regarding patient safety in plastic surgery in the transoperative category. The authors question whether the procedures performed during the week would have any difference in terms of safety concerning those performed at the weekend. The authors point out that several studies demonstrate greater complications on weekends. This situation would be attributed to the lack of availability of personnel, services, and worse access to diagnostic tests. It can also be seen that the surgeon is without his usual team at the weekend. However, the authors remember that these studies do not take into account the particularities of plastic surgery patients, who are generally healthier. Even so, there are the factors mentioned that are independent of the health of the surgical patient, such as the decrease in hospital resources on weekends, including the team and access to diagnostic tests.

Besides, Tadisina et al., in 2015²⁰, reported that plastic surgeons often end up operating on weekends due to the lack of an operating room during the week, as these are used for emergency cases, which can result in more operative cases being performed on weekends. The authors were the first to investigate whether there is a relationship between patient safety and plastic surgery on weekends. They consider that although it seems to be negative, this subject needs further investigation.

Perioperative period category

This category was the one with the highest number of selected articles. It is believed that since many subjects are related to various times that involve surgery in its different aspects, this category covers most of the studies in this review.

It will begin with different investigations that inform the participation of residents in the surgical act, such as Koulaxouzidis et al. in 2014²¹, in their work, they performed 273 aesthetic procedures in 206 patients. They demonstrated that cosmetic surgery performed by plastic surgery residents, under the supervision of medical assistants is safe and provides high levels of postoperative patient satisfaction. Furthermore, offering these services can bridge the gap between providing training in high-quality cosmetic plastic surgery and, at the same time, allowing an increasing number of patients who can perform procedures less cheaply.

Similarly, in the article “The Impact of Resident Participation in Outpatient Plastic Surgical Procedures,” Massenburg et al., in 2015²², observed all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the database of the National Health Improvement Program American College of Surgeons Surgical Quality. The authors assessed the impact of residents’ participation in the surgery of 6,227 patients and the results demonstrate that initially, the resident’s presence may appear to increase the levels of complication, however, in conclusion, a more careful analysis shows that the levels of safety and complications are the same as those of more experienced surgeons. It is reiterated that this study has a level of evidence II.

Qureshi et al., in 2016²³, remember that plastic surgery procedures tend to be costly for patients. The authors, considering the American health care system, remember that services that have medical residency in general, imply less expensive procedures. They exemplify through patients that after bariatric surgery, they lose much weight. Health insurance only covers expenses for abdominal surgery, but these patients generally require other procedures such as brachioplasty or cruroplasty.

The authors report that surgery services where there is teaching, health institutions that are references in teaching, could enable these procedures to be performed with the same levels of complication and safety as clinics with trained surgeons at a lower cost to patients. In this study, the authors assessed the safety of procedures performed at a school clinic and statistically compared it with the results of national cosmetic surgery, concluding that in 175 cosmetic procedures, there was a general complication rate of 1.7%, compared with 2,0% for patients in the Cosmet Assure database.

When talking about event notification by residents, Parikh et al., 2017²⁴, demonstrated that an intervention using an online event notification system, developed by the head of the plastic surgery department, in conjunction with Patient safety experts have led to significant improvements in the reporting of complications by plastic surgery residents at an academic hospital.

The proportion of complications reported in the pre-intervention group of the notification system was 28.1%; after the intervention, this increased significantly to 91.4% (p <0.001). Therefore, the authors demonstrated that the implementation of this system could improve learning and safety in plastic surgery by improving reports of complications. Also, the authors point out that the involvement of residents in quality improvement initiatives is essential to train physicians for clinical practice in a complex health system.

Also, in this category, there is the issue of documentation that involves all surgical procedures. Within this context of medical documentation, Kittinger et al., 2016²⁵, proposed a project to improve the quality and safety of care performed at the Plastic Surgery Division of Scott & White Memorial Hospital. The main focus of the project involved improving the clinical documentation of inpatients. This interaction between doctors and specialists, in documentation in the health area, allowed the doctors to write down in the medical record all the diagnoses relevant to the treatments that were provided during hospitalizations. The plastic surgery service was able to improve its documentation and, in doing so, improved the recognition of the complexity of the patients it was treating. It has been shown that an effort to improve documentation has proved fruitful in terms of quality of care and cost management for the hospital.

To finalize this category, we can mention Swanson, in 2016²⁶, who cites thromboembolism as a feared complication in plastic surgery. The author reports that the procedures are associated several times, increasing the surgical time and the risk of thrombosis. The author also recalls that many doubts arise in the transposition of protocols idealized for surgeries of other specialties, without taking into account the particularities of plastic surgery. The author exemplifies with breast prosthesis surgery. The patients are at low risk because it is a quick surgery, usually performed on young and thin patients. This fact makes it seems that the opposite, overweight male patients in long surgeries, would have a higher risk, but the correlation, according to the author, is not necessarily true.

In 2016, Swanson²⁶ recalled that the pneumatic boot for intermittent compression of the lower limbs presents conflicting studies. Although it appears that it reduces the appearance of deep vein thrombosis (DVT) by up to 60%, it would increase cases of pulmonary embolism by 12% with its use. Another question that the author raises would be related to the combined procedures. It seems that the combination of surgical times would increase the risk of thrombosis, however, if we consider the sum of the two surgical procedures performed individually, the author says that the patient would have a higher risk of thromboembolic events. Caprini’s own score, widely used in risk stratification of surgical patients for thrombotic events, according to the author, is questionable, as it is an uncontrolled and randomized study with a 2C degree of recommendation. The author also points out that the clotting tests, Prothrombin Activation Time (PAT) and Thromboplastin Partial Activation Time (PTT), which are routinely ordered and do not diagnose various genetic disorders that interfere with coagulation.