A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery

Nikhil A. Agrawal, M.D.; Kirsty Hillier, M.D.; Riten Kumar, M.D., M.Sc.; Shayan A. Izaddoost, M.D., Ph.D.; Rod J. Rohrich, M.D.


Plast Reconstr Surg. 2022;149(1):121e-129e. 

In This Article

Venous Thromboembolism Risk Stratification: What the Caprini Score Gets Right

Risk stratification scores help surgeons determine the venous thromboembolism risk and an appropriate prophylaxis regimen. The most pertinent components to the plastic surgery patient population of the 2005 modification Caprini score include prior venous thromboembolism history, family history of venous thromboembolism, age, body mass index, length of surgery, past medical history, oral estrogen use, hospital admission, immobility, spinal cord injury, recent trauma, and presence of cancer (Table 1 and Table 2).

The Caprini score has been validated specifically in plastic surgery. In 2011, Pannucci et al. published the midterm analysis of the control group of the Venous Thromboembolism Prevention Study. This multi-institutional study evaluated over 1100 plastic surgery patients who did not receive pharmacologic prophylaxis and estimated a venous thromboembolism rate of 11.3 percent in patients with a 2005 modification Caprini score greater than 8. This is statistically significant even when compared to patients with a score of 7 to 8 (OR, 4.6). [See Figure, Supplemental Digital Content 1, which shows rates of venous thromboembolism in the first 60 postoperative days by stratified Caprini score (n = 1126),[7,15]http://links.lww.com/PRS/E804.] Longer total operative time has been associated with increased risk of venous thromboembolism, although Pannucci's study did not find this to be a statistically significant factor. However, given the literature, this should be considered in further studies.[16,17] The 2010 modification to the Caprini score has also been studied in plastic surgery. This modification included four major data-driven changes to the 2005 version, including more specific body mass index ranges, active versus history of cancer, history of superficial venous thromboembolism, and operative time. Interestingly, when compared to the 2005 model in the same patients who were in the Venous Thromboembolism Prevention Study, the 2005 model remained a better predictor of venous thromboembolism in adult plastic surgery patients.[18]

The Davison worksheet was proposed in 2015 in an attempt to improve the Caprini score and make it more relevant to plastic surgery. While it will require vigorous validation before being recommended for widespread use, attempts to develop a plastic surgery–specific score should be encouraged.[19,20]

Fortunately, the Caprini Risk Assessment Model corroborates our clinical suspicion that most elective surgery patients are low risk and do not require pharmacologic prophylaxis.[21] Evaluation of more than 400 rhinoplasty patients demonstrated an average Caprini score of 3, and venous thromboembolism risk was similar to that of the general population.[22] Winocour et al. utilized the CosmetAssure database to evaluate almost 130,000 cosmetic surgery patients, and the incidence of venous thromboembolism was less than 0.1 percent.[23] Yet, for the small number of patients who do meet "high risk" criteria, these risk scores and preventative recommendations could improve mortality.