By Abby Van Voorhees, MD, October 01, 2015
In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Max Yeslev, MD, about his recent Aesthetic Surgery Journal article, “Safety of Cosmetic Procedures in Elderly and Octogenarian Patients.”
Dr. Van Voorhees: How often are the elderly getting cosmetic procedures in your plastic surgery data registry? Is this a common request amongst the elderly? Do they tend to get one type of procedure over others?
Dr. Yeslev: The number of elderly patients undergoing cosmetic surgery is significant and increases annually. Among the 129,000 cosmetic surgery patients reviewed in our study (from 2008 – 2013), over 6,700 patients were over the age of 65. We identified a trend of increasing proportion of elderly patients among the entire cosmetic cohort, which almost doubled (from 3.4 percent to 6.4 percent) over the reviewed time period of five years. This consisted of mostly face procedures (63.2 percent) in the elderly cohort, compared to younger patients who more commonly underwent body and breast procedures.
Dr. Van Voorhees: What database did you use to study the question of complication rates?
Dr. Yeslev: For our analysis we used the CosmetAssure patients’ registry. This is a private insurance company that specifically insures cosmetic procedures. Compared to other available clinical databanks, the CosmetAssure database collects information on patients’ risk factors and clinical outcomes after cosmetic procedures restricted to only those which are performed by board-certified plastic surgeons across the country. Our research team at Vanderbilt University, which included Drs. J. Winocour, V. Gupta, and K. Higdon, performed systematic review of the database and statistical analysis of the incidence of major postoperative complications in relation to patient’s age.
Dr. Van Voorhees: What types of risks does it identify? What does it not look at? How are patients included in this registry? What comorbid diseases are also screened for in this database?
Dr. Yeslev: The database we looked at captures only major postoperative complications, which are defined as those that required admission to hospital, re-operation, or visit to emergency room. It did not contain information on minor complications such as minor infections, wound healing problems, etc. These are dealt with in the clinic setting for the most part. Although both types of complications are important for both practitioners and patients, it is the incidence of major life-threatening adverse effects after surgery that is critical for evaluation of patient safety and therefore was analyzed in our study.
The pre-existing comorbid conditions that were registered in the database were obesity, diabetes mellitus, and active tobacco use. The database equally included demographic patient details, including gender and age.
All patients who participate in the CosmetAssure insurance program are entered into the prospectively maintained database and complications encountered are filed as a claim by either patient or operating surgeon. Because the expenses incurred would have otherwise been “out of pocket” by the patient or surgeon, the capture rate of the database is very high.
Dr. Van Voorhees: What did you find in your study? Were there differences in the types of cosmetic procedures chosen by the elderly vs. the younger age groups? How about the kinds of procedures chosen by the very old such as those over 80?
Dr. Yeslev: According to our study, the type of cosmetic procedures differs between elderly and young patients. The majority of younger patients undergo breast- or body-related procedures, whereas patients of older age tend to undergo mostly facial aesthetic procedures. Similarly, cosmetic surgical procedures on the face comprised the majority of aesthetic procedures in patients over age 80. [pagebreak]
Dr. Van Voorhees: Let’s talk about what you found about the risks associated with cosmetic procedures for the elderly. Were they increased? How about for the very old? What were the risks that were seen? What were the most common complications?
Dr. Yeslev: The key finding of our study is that elderly patients demonstrated similar incidence of major postoperative complications after cosmetic procedures compared to younger patients. The average incidence of major adverse outcomes in older patients was 1.8 percent, compared to 1.9 percent in younger patients. This was not a statistically significant difference.
What is also interesting is that the risk of major complications among octogenarian patients was only slightly elevated (2.2 percent) compared to younger cohort and the difference again was not statistically significant. Among all reviewed types of complications, hematoma, wound healing problems, and surgical site infections were the most commonly encountered.
Dr. Van Voorhees: When you looked at patients with diabetes or those who smoked were their risks increased?
Dr. Yeslev: Diabetes and smoking are well-known risk factors for postoperative complications in plastic surgery. Interestingly, in our study preexisting diabetes mellitus or active tobacco use were not associated with increased incidence of major complications. These findings may partly be explained by the fact these risk factors likely play a more significant role in the development of minor surgical complications, such as delayed wound healing and minor wound infection, and have less impact on major adverse events such as acute bleeding, pulmonary embolism or major postoperative infection.
Dr. Van Voorhees: What are the practical take-aways for dermatologists doing cosmetic procedures?
Dr. Yeslev: Firstly, the number of elderly individuals who seek cosmetic surgery increases annually and we all will see more patients of advanced age in our practice. Secondly, the safety of aesthetic procedures in elderly patients was clearly demonstrated in our study. However, careful selection of appropriate surgical candidates is paramount in minimizing the risk of complications and promoting safe cosmetic surgery.
Dr. Van Voorhees: Are there limits to your study that would be important to highlight for dermatologists?
Dr. Yeslev: Our study has several limitations and one of the most important ones is the existing selection bias. The analyzed cohort of patients consists of carefully selected healthy elderly individuals by operating surgeons. This fact again highlights the need for careful preoperative evaluation and selection of appropriate surgical candidates in order to archive safe outcomes.
Dr. Yeslev is a plastic surgery fellow at Vanderbilt University Medical Center. His article appeared in Aesthetic Surgery Journal, 2015 Apr 24. pii: sjv053. [Epub ahead of print]. doi: 10.1093/asj/sjv053.