SPECIAL TOPIC

The Effect of Sequential Compression Devices

on Fibrinolysis in Plastic Surgery Outpatients:
A Randomized Trial
Eric Swanson, M.D.
Leawood, Kan.
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVE5wmW8EcRnj5uOVvkzKvz5LRdTTdJUNv0S+R+UGETsZ on 02/13/2020
Background: Sequential compression devices are often considered a main-
stay of prophylaxis against deep venous thromboses in surgical patients.
The devices are believed to produce a milking action on the deep veins to
prevent venous stasis. A systemic fibrinolytic effect has also been proposed,
adding a second mechanism of action. The plasma levels of tissue plas-
minogen activator and plasminogen activator inhibitor-1 reflect fibrinolytic
activity.

Methods: A randomized trial was conducted among 50 consecutive plastic

surgery outpatients undergoing cosmetic surgery performed by the author
under total intravenous anesthesia and without paralysis. Patients were ran-
domized to receive calf-length sequential compression devices or no sequen-
tial compression devices during surgery. Blood samples were obtained from
the upper extremity preoperatively and at hourly intervals until the patient
was discharged from the postanesthesia care unit. Tissue plasminogen ac-
tivator and plasminogen activator inhibitor-1 levels were measured. Ultra-
sound surveillance was used in all patients. There was no outside funding
for the study.
Results: All patients agreed to participate (inclusion rate, 100 percent).
No patient developed clinical signs or ultrasound evidence of a deep ve-
nous thrombosis. There were no significant changes in tissue plasmino-
gen activator levels or plasminogen activator inhibitor-1 levels from the
preoperative measurements at any hourly interval and no differences in
levels comparing patients treated with or without sequential compression
devices.
Conclusions: No significant change in systemic fibrinolytic activity occurs dur-
ing outpatient plastic surgery under total intravenous anesthesia. Sequential
compression devices do not affect tissue plasminogen activator or plasminogen
activator inhibitor-1 levels, suggesting no fibrinolytic benefit.  (Plast. Reconstr.
Surg. 145: 392, 2020.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

S
equential compression devices, also called
intermittent pneumatic compression devices,
are widely recommended to reduce the risk of
deep venous thrombosis.1–10 Plastic surgery review
articles frequently describe their use as essential,6,7
From private practice.
Received for publication January 31, 2019; accepted June
6, 2019.
This trial is registered under the name “Sequential Compres-
sion Devices Effect on Fibrinolysis in Plastic Surgery Out-
patients: A Randomized Trial,” ClinicalTrials.gov identifi-
cation number NCT03821597 (https://clinicaltrials.gov/
show/NCT03821597).
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006464
although a 2012 American Society of Plastic Sur-
geons task force found insufficient data on which
to make a recommendation.11 Limited data sup-
port their efficacy in plastic surgery patients.12
In addition to a possible mechanical effect,
early investigators believed that sequential com-
pression devices altered the fibrinolytic bal-
ance toward fibrinolysis.13–20 For this reason,
some surgeons recommend applying sequential
Disclosure: Dr. Swanson receives royalties from
Springer Nature (Cham, Switzerland). The author
received no financial support for the research,
authorship, and publication of this article.

392 www.PRSJournal.com
Volume 145, Number 2 • Effect of Sequential Compression Devices
compression devices to the upper extremities in
the event of trauma or other circumstances pre-
cluding lower limb application.1–5,14,21
Plasminogen is converted to plasmin by tis-
sue plasminogen activator,19,22–24 which is released
from endothelial cells.22 Plasmin is a protease
that degrades fibrin.22,23 This activation sequence
is inhibited by plasminogen activator inhibi-
tor-1,19,22,24 which is also released from endothe-
lial cells22,23 and forms a 1:1 complex with tissue
plasminogen activator.24 Increases in serum tissue
plasminogen activator and decreases in plasmino-
gen activator inhibitor-1 are considered primary
markers of systemic fibrinolysis.24,25
This investigation was undertaken to evaluate
any possible effect of sequential compression devices
on fibrinolytic activity in plastic surgery patients.
The author does not routinely use sequential com-
pression devices, but does use ultrasound surveil-
lance to provide early detection and treatment of
any postoperative deep venous thromboses.26–28
Chemoprophylaxis is not prescribed.29,30 Anticoag-
ulation is reserved for patients who develop deep
venous thromboses detected by ultrasound.
PATIENTS AND METHODS
This Level 1, prospective, controlled, ran-
domized trial31 was undertaken among con-
secutive plastic surgery outpatients treated at a
state-licensed ambulatory surgery center during
November and December of 2018. Institutional
review board approval was obtained from Advarra
Institutional Review Board Services, Inc. Exclu-
sion criteria included lymphedema, infection,
an existing deep venous thrombosis of the lower
extremity, and congestive heart failure.1,32
An online computer random number genera-
tor33 was used to randomize 50 patients into two
groups of 25 patients by the off-site statistician. An
e-mail was sent by the statistician to the circulating
nurse directing her to either apply or not apply
sequential compression devices. This instruc-
tion was revealed after the patient had entered
the operating room, ensuring concealment of
allotment.34
Sequential Compression Devices
The Triple-Play-VT Vascular Therapy System
was used with EZ-FIT VT (Compression Solutions,
Tulsa, Okla.) compression sleeves.32
Blood Samples
Two milliliters of blood was obtained immedi-
ately preoperatively. Sequential compression devices
were applied before induction of anesthesia and
were removed after surgery. Samples were drawn
each hour in the operating room. The sampling
continued in the postanesthesia care unit hourly
until the patient was discharged. A saline lock was
used for blood sampling, and the first 5 ml was dis-
carded.35 Samples were obtained from the contra-
lateral extremity to avoid any dilutional effect from
the intravenous catheter used to administer fluids
during surgery. A tourniquet was not used.35 Each
patient served as his or her own control to minimize
the effect of diurnal variations in blood levels.23,35
The blood sample was centrifuged for 15
minutes at 1500 rpm (128 g). The plasma was
transferred to a separate tube containing 3.2%
sodium citrate. Plasma specimens were frozen
and submitted to the Quest Diagnostics (Secau-
cus, N.J.) laboratory for analysis of tissue plas-
minogen activator and plasminogen activator
inhibitor-1 levels by enzyme-linked immunosor-
bent assay. The cost of the laboratory testing,
sequential compression devices, and all other
costs associated with the study were paid for by
the author, with no outside funding or insurance
billing.
Ultrasound Surveillance
Ultrasound scans were obtained at three
times: before surgery, 1 day after surgery (except
in four patients who were scanned postoperatively
on the day of surgery), and approximately 1 week
after surgery (range, 5 to 13 days).26–28
Surgery
All operations were performed by the author.
Total intravenous anesthesia was administered,
with no muscle relaxation. SAFE principles (Spon-
taneous breathing, Avoid gas, Face up, Extremi-
ties mobile) were observed.30
Statistical Analysis
Statistical analyses were performed using
SPSS for Mac version 25.0 (SPSS, Inc., Chicago,
Ill.). An a priori power analysis was performed.
To achieve 80 percent power, with an alpha level
of 0.05, sufficient to detect a large treatment
effect (d = 0.80)36 with a one-sided test, 21 sub-
jects would be needed in each group.37 Indepen-
dent t tests were used to compare mean plasma
levels between two groups, and chi-square tests
were used to compare frequencies for categori-
cal variables. Change scores were computed by
subtracting the preoperative value from the val-
ues obtained at later times.
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 Plastic and Reconstructive Surgery • February 2020

Table 1.  Patient Data for 50 Plastic Surgery Table 2.  Procedures in 50 Consecutive Plastic
Outpatients Treated with and without Sequential Surgery Operations
Compression Devices
No. (%)
SCDs No SCDs All Patients p Total 112
No. of patients 25 25 50 Body
Age, yr  Liposuction 14 (12.5)
 Mean 45.3 38.7 42.0  Liposuction/abdominoplasty 6 (5.4)
 SD 15.2 15.0 15.3  Buttock fat injection 5 (4.5)
 Range 21.6–69.9 19.2–77.8 19.2–77.8 NS  Liposuction of chest (male or transgender) 5 (4.5)
Sex  Brachioplasty 3 (2.7)
 Female 23 20 43  Inner thigh lift 1 (0.9)
 Male 2 5 7  Labiaplasty 1 (0.9)
Follow-up time, days  Lower body lift 1 (0.9)
 Mean 34.6 36.1 35.3  Abdominoplasty alone 1 (0.9)
 SD 20.1 17.8 18.8  Other body 9 (8.0)
 Range 1–90 1–82 1–90 NS Breast
Smoking status  Breast augmentation 7 (6.3)
 Nonsmoker 23 22 45  Augmentation/mastopexy* 7 (6.3)
 Smoker 2 3 5 NS  Mastopexy or breast reduction 6 (5.4)
Body mass index,  Open capsulotomy 4 (3.6)
kg/m2  Subcutaneous mastectomies (male or
 Mean 26.7 26.7 26.7 transgender) 3 (2.7)
 SD 5.4 4.7 5.0  Other breast 2 (1.8)
 Range 19.4–38.1 17.2–37.1 17.2–38.1 NS Face
Operating time, min  Submental lipectomy 9 (8.0)
 Mean 114.5 114.3 114.4  Fat injection 8 (7.1)
 SD 75.2 83.0 78.4  Blepharoplasty 5 (4.5)
 Range 15–276 18–359 15–359 NS  Rhinoplasty 4 (3.6)
SCD time, min  Laser skin resurfacing 3 (2.7)
 Mean 116.9 — —  Face lift 2 (1.8)
 SD 74.9 — —  Endoscopic forehead lift 2 (1.8)
 Range 18–278 — —  Chin augmentation 1 (0.9)
NS  Other face 3 (2.7)
SCDs, sequential compression devices; NS, not significant.
*Includes breast reduction plus implants.

RESULTS for any variables when comparing the change

Fifty consecutive patients were included in
the study (Table 1). No patient had a contrain-
dication to sequential compression devices. All
patients were class I or II, using the American
Society of Anesthesiologists physical status classi-
fication. All patients participated, for an inclusion
rate of 100 percent. The mean patient age was 42
years (range, 19 to 78 years). The mean operat-
ing time was 114 minutes (range, 15 minutes to 6
hours). Twenty-nine patients (58 percent) under-
went combined procedures (Table 2).
None of the patients developed clinical signs
of a deep venous thrombosis or pulmonary embo-
lism. All ultrasound scans were negative. No
patient had a systemic complication. Two local
complications were encountered. One woman
developed a hematoma after breast augmentation
that was evacuated. One male patient required
aspiration of a seroma in the office after an inner
thigh lift.
There were no significant differences between
the sequential compression device group and the
control group comparing age, sex, follow-up time,
smoking history, body mass index, and operating
time. Therefore, no attempt was made to control
scores.
All 50 patients had preoperative test results
and at least one set of postoperative results. Those
patients undergoing short operations (<1 hour)
frequently had only two blood specimens because
they were discharged from the postanesthesia
care unit before they were due for the next hourly
blood test. One hundred sixty-nine plasma speci-
mens were analyzed. A preoperative plasminogen
activator inhibitor-1 level in one patient was not
measured because of inadequate plasma volume.
There were no significant differences in plasma
levels of the two markers after surgery and no sig-
nificant differences in levels between the sequen-
tial compression device group and the control
group at any postoperative time (Figs. 1 and 2 and
Tables 3 and 4).
Some of the measurements exceeded the lab-
oratory reference ranges. Among patients wear-
ing sequential compression devices, there were
six tissue plasminogen activator values exceeding
the normal range and eight high plasminogen
activator inhibitor-1 levels; among controls, there
were 12 tissue plasminogen activator values above
the normal range and five elevated plasminogen

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Volume 145, Number 2 • Effect of Sequential Compression Devices

Fig. 1. Tissue plasminogen activator (tPA) levels versus time after induction of anesthesia. In patients treated
with sequential compression devices (green), the devices were applied immediately before induction of anes-
thesia using a propofol infusion. Laboratory values less than 3.5 ng/ml are plotted as 3.5 ng/ml. The normal
reference range provided by the laboratory is less than or equal to 12.8 ng/ml. SCDs, sequential compression
devices.

Fig. 2. Plasminogen activator inhibitor-1 (PAI-1) levels versus time after induction of anesthesia. In patients
treated with sequential compression devices (green), the devices were applied immediately before induction
of anesthesia using a propofol infusion. One laboratory value that was reported less than 2 ng/ml is plotted as
2 ng/ml. The normal reference range provided by the laboratory is 4 to 43 ng/ml. SCDs, sequential compression
devices.

activator inhibitor-1 levels (Figs. 1 and 2). The dif-
ferences between groups were not significant.
DISCUSSION
Principles of Sequential Compression
Device Use
Pneumatic compression devices have been
used routinely in surgical patients since the
early 1970s.13,38–40 The cuffs can cover the feet,41
the calves, or both the calves and thighs.42 The
concept is highly intuitive.12 The cuffs provide
a milking action,9,42 simulating the calf-muscle
pump in patients whose pump mechanism is
compromised by muscle paralysis during surgery,
which is believed to cause venous stasis, leading
to thrombus formation.43 Surgeons welcomed an
alternative to anticoagulation, which increases the
risk of bleeding and may therefore be unsafe,41,44
particularly in head injury45 and neurosurgery
cases.46 Most guidelines call for application of
sequential compression devices before induction

395
 Plastic and Reconstructive Surgery • February 2020

Table 3.  Comparison of Changes in Tissue Plasminogen Activator Levels during Surgery and in the
Postanesthesia Care Unit between Control Patients and Patients Wearing Sequential Compression Devices*
No SCDs SCDs
Mean (SD) Mean (SD)
Change from Change from
Time after Induction Mean (SD) Preoperatively Mean (SD) Preoperatively
of Anesthesia (hr) No. (ng/ml) (ng/ml) No. (ng/ml) (ng/ml) p
0 (preoperatively) 25 7.74 (3.85) — 25 6.21 (4.03) — —
1 25 6.96 (3.46) −0.77 (1.97) 25 5.57 (3.04) −0.64 (1.51) NS
2 16 6.32 (3.96) −1.16 (1.87) 16 5.38 (3.56) −1.91 (1.99) NS
3 10 8.30 (7.73) 0.63 (5.43) 12 5.66 (3.86) −1.27 (1.78) NS
4 4 8.32 (3.90) −1.42 (3.18) 5 6.24 (3.42) 1.10 (2.31) NS
5 2 9.05 (7.85) −0.50 (0.57) 1 10.20 1.90 NS
6 1 16.60 1.90 0 — — —
7 1 14.10 −0.60 0 — — —
8† 1 13.50 −1.20 0 — — —
tPA, tissue plasminogen activator; PACU, postanesthesia care unit; SCDs, sequential compression devices; NS, not significant.
*Independent t tests are used for comparisons.
†One control patient had a longer procedure (operating room time, 6 hr) and time in the PACU (2 hr), allowing a total of nine blood tests.
The maximum for the patients wearing SCDs was six tests (operating time, 4 hr 36 min).

Table 4.  Comparison of Changes in Plasminogen Activator Inhibitor-1 Levels during Surgery and in the
Postanesthesia Care Unit between Control Patients and Patients Wearing Sequential Compression Devices*
No SCDs SCDs
Mean (SD) Mean (SD)
Change from Change from
Time after Induction Mean (SD) Preoperatively Mean (SD) Preoperatively
of Anesthesia (hr) No. (ng/ml) (ng/ml) No. (ng/ml) (ng/ml) p
0 (preoperatively) 24 23.29 (15.10) — 25 19.72 (14.67) — —
1 25 18.88 (14.78) −5.38 (14.67) 25 15.80 (13.10) −3.92 (17.70) NS
2 16 24.63 (18.32) −0.75 (17.30) 16 25.31 (27.58) 4.94 (24.14) NS
3 10 25.30 (11.19) −2.20 (13.39) 12 18.75 (18.94) 2.25 (18.53) NS
4 4 46.50 (40.04) 6.75 (52.69) 5 16.00 (11.14) 2.00 (9.03) NS
5 2 21.50 (19.09) −31.00 (12.73) 1 24.00 4.00 NS
6 1 36.00 −39.00 0 — — —
7 1 29.00 −46.00 0 — — —
8† 1 25.00 −50.00 0 — — —
PAI-1, plasminogen activator inhibitor-1; PACU, postanesthesia care unit; SCDs, sequential compression devices; NS, not significant.
*Independent t tests are used for comparisons.
†One control patient had a longer procedure (operating room time, 6 hr) and time in the PACU (2 hr), allowing a total of nine blood tests.
The maximum for the patients wearing SCDs was six tests (operating time, 4 hr 36 min).

of anesthesia1–5 and removal when the patient
resumes ambulation.1–3,5,9 Their use for elective
plastic surgery cases more than 1 hour in duration
is recommended.5
Logically, systems that optimize the milking
action should be more effective in reducing the
risk of deep venous thromboses. Devices that com-
press sequentially from distal to proximal using
multiple chambers were designed in the 1970s and
remain in widespread use today. However, clinical
experience has not substantiated the theoretical
advantages of sequential compression.42,46 A pro-
spective randomized trial among 136 neurosur-
gical patients compared sequential compression
devices with uniform compression devices. There
was no significant difference in deep venous
thrombosis rates (9 percent overall).46 Another
study found no difference in venous thromboem-
bolism rates comparing compression of the foot
alone with graded sequential calf compression
despite much smaller blood volumes of the foot
compared with the calf.44
Efficient vein emptying would also seem to
be advantageous. However, rapid inflation, high
pressures, and sequential compression have not
been shown to improve efficacy.42 Counterintui-
tively, higher deep venous thrombosis rates are
associated with devices that produce higher peak
velocities.47 Surprisingly, more compliant patients
and patients with longer periods of sequential
compression device use experience more deep
venous thromboses, not less.47 A greater number
of proximal deep venous thromboses occur using
thigh-length sleeves compared with calf-length

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Volume 145, Number 2 • Effect of Sequential Compression Devices
devices.47 Sequential compression devices may in
some cases impede venous return by causing dis-
tal venous trapping, with an increase in flow on
deflation of the cuff42—the opposite of what is
expected.
Deep Venous Thrombosis Risk after Surgery
A “fibrinolytic shutdown,” the body’s response
to limit blood loss after trauma,25 is widely believed
to be responsible for an increased risk of deep
venous thromboses after surgery.13,16–18,24,25,35,39,40,46
Early studies reported deep venous thrombosis
rates in the range of 30 to 60 percent in orthope-
dic and general surgery patients.39,48,49 The need
for a remedy was considered “urgent.”39
Unlike orthopedic and general surgery
patients,39,48,49 patients undergoing elective outpa-
tient plastic surgery under total intravenous anes-
thesia rarely develop deep venous thromboses
within 24 hours after surgery.26–28 Only two plastic
surgery outpatients among 1000 patients (0.2 per-
cent) were found to have a deep venous thrombo-
sis on an ultrasound scan the day after surgery.28
If deep venous thromboses rarely develop dur-
ing surgery, there would seem to be no benefit in
applying sequential compression devices in the
operating room. Indeed, in the referenced study
of 1000 plastic surgery outpatients, sequential
compression devices provided no significant risk
reduction.28 The absence of a significant change
in tissue plasminogen activator or plasminogen
activator inhibitor-1 levels suggests that outpa-
tient plastic surgery patients undergoing total
intravenous anesthesia do not experience either
a decrease or an increase in systemic fibrino-
lytic activity during surgery or immediately after
surgery.
Possible Systemic Fibrinolytic Effect of
Sequential Compression Devices
The vascular endothelium regulates fibrinoly-
sis. It is hypothesized, although not conclusively
proven,25 that sequential compression devices
mechanically stimulate endothelial cells to release
tissue plasminogen activator.46 Proponents claim
that increased fibrinolytic activity adds a second
treatment arm—reduced blood coagulability in
addition to avoiding venous stasis,4,6,8,9,13–17,19,45,46,50
thereby treating two of the three limbs of Vir-
chow’s triad (the third being vascular injury).51
Increased fibrinolytic activity is believed to occur
within 3 hours of application of sequential com-
pression devices for 2 hours (i.e., within 1 hour of
their removal).19 Therefore, the study parameters
are expected to capture any change in tissue plas-
minogen activator and plasminogen activator
inhibitor-1 levels during this short time frame.
The mean sequential compression device applica-
tion time in this study was approximately 2 hours
(117 minutes).
A 1976 study reported a reduction in deep
venous thromboses among surgical patients
treated with sequential compression devices
applied to both upper extremities.14 This extraordi-
nary finding has not been reproduced.25 A widely
cited 1997 study evaluated fibrinolytic activity in
12 volunteers.19 Six of the volunteers were normal
subjects. The other six subjects had a history of
a treated proximal deep venous thrombosis. The
patients were treated with five different pneumatic
devices applied randomly once per week over 5
weeks. The devices were applied for 2 hours, and
blood samples were drawn before application,
and at 1 hour, 2 hours, and 3 hours. The authors
reported an increase in tissue plasminogen activa-
tor activity and a decrease in plasminogen activa-
tor inhibitor-1 activity. These investigators do not
believe that sequential compression devices stim-
ulate the release of tissue plasminogen activator
from endothelial cells. Rather, they postulate that
sequential compression devices cause a decline in
plasminogen activator inhibitor-1 levels.19 Limita-
tions of the study included a very small sample size
(six healthy volunteers), five different devices, and
no surgery. Financial compensation was provided
by two of the device manufacturers.19
An increasing number of studies challenge
sequential compression device–induced fibrino-
lysis.18,24,25,35,40 A study using euglobulin clot lysis
times found no benefit from intermittent calf
compression in surgical patients.40 A study of four
volunteers wearing thigh-length sequential com-
pression devices found no significant increase in
tissue plasminogen activator levels.18
Early investigators used primitive means to
evaluate fibrinolytic activity,13–15,17,40 such as the
nonspecific euglobulin clot lysis time.24 More
recent studies use more advanced methods of
determining fibrinolysis activity.18,24 A study pub-
lished in 2000 randomized three treatments in 48
patients undergoing major intraabdominal proce-
dures—subcutaneous heparin injections, thigh-
length sequential compression devices, and both
methods. Venous samples were assayed for tissue
plasminogen activator and plasminogen activa-
tor inhibitor-1 activity. Sequential compression
devices did not enhance fibrinolysis.24 A 2002 study
randomized 50 total hip arthroplasty patients into
two groups of 25 patients treated with and without
397
 Plastic and Reconstructive Surgery • February 2020
sequential compression devices (the same sample
sizes used in the present study). Levels of tissue
plasminogen activator and plasminogen activator
inhibitor-1 were measured preoperatively, at skin
closure, and 8 hours and 22 hours after the preop-
erative sample was drawn. No statistically signifi-
cant difference was detected between treatment
and control groups.25 A randomized study of gen-
eral surgery patients documented a persistent ele-
vation of plasminogen activator inhibitor-1 levels
in patients treated with sequential compression
devices, rather than the expected reduction.35
Sequential Compression Devices and Deep
Venous Thrombosis Risk
Deep venous thromboses still occur with
disturbing regularity despite the application of
sequential compression devices—in the range
of 7 to 9 percent in orthopedic, general sur-
gery, neurosurgery, and trauma patients.16,17,44,46
Thromboembolism rates of 6 to 7.5 percent have
been reported in series of plastic surgery patients
deemed to be at higher risk, despite the use of
sequential compression devices.52,53 Nevertheless,
plastic surgery guidelines and continuing medical
education articles1–10 frequently, but not univer-
sally,11 recommend their use. Many plastic sur-
geons regard sequential compression devices as
part of the standard of care.12 Surgeons may use
sequential compression devices for medicolegal
reasons, regardless of their validity.12
Two meta-analyses supporting sequential com-
pression device use are widely cited.54,55 A 2005
meta-analysis found a significant reduction in
postoperative deep venous thromboses, with a rel-
ative risk of 0.40 in treated patients.54 Oddly, the
risk of pulmonary embolism was slightly higher
(relative risk, 1.12), not lower, in treated patients,
although the difference was not significant. A sig-
nificant publication bias was detected, meaning
that studies showing a benefit were more likely to
be reported.54 Studies of sequential compression
devices are often supported financially by manu-
facturers of the devices.19,20,25,46 Investigators have
a conflict of interest when they are compensated
by companies that manufacture antithrombotic
medications and devices.56
A more recent review supporting sequential
compression device use included a wide range
of patient groups, both surgical and nonsurgical,
and variable means of diagnosing deep venous
thromboses.55 The study was limited to hospital-
ized inpatients in whom sequential compression
devices were applied for at least 24 hours. This
398
heterogenous inpatient population and duration
of use are much different from intraoperative
sequential compression device use in plastic sur-
gery outpatients.
Downside of Sequential Compression Devices
A treatment based on first principles alone
(e.g., compression of the legs keeps the blood
moving) is not considered reliable.11,57 One might
ask, why not use sequential compression devices
anyway, out of an abundance of caution? There
are downsides to consider.12 Sequential compres-
sion devices can cause skin irritation,45 peroneal
nerve compression neuropathy,58–60 compartment
syndrome,58,61,62 and falls when patients trip on the
air hoses.63 Applying the devices compromises the
sterile field, particularly when the lower extremi-
ties are in the treatment area, such as during lipo-
suction. Valuable minutes are wasted and the cost
of surgery is increased. Sequential compression
devices worn postoperatively are cumbersome
for patients and are frequently removed for bath-
ing and patient transportation and because of
discomfort.18 Not surprisingly, noncompliance is
common.45,47 Sequential compression devices may
impart a false sense of security. The surgeon may
ignore other more effective deep venous throm-
bosis risk-reduction methods.12
Alternative Means of Deep Venous Thrombosis
Risk Reduction
The author prefers propofol infusions and
no muscle paralysis, as part of the SAFE strategy
to reduce risk (Spontaneous breathing, Avoid
gas, Face up, Extremities mobile).30 This type of
anesthesia avoids a drop in mean arterial blood
pressure during surgery, and preserves the calf
muscle pump, so there is no need for an exter-
nal device to simulate its function.43 By contrast,
general endotracheal anesthesia with paralysis
can cause an alarming (30 percent) drop in mean
arterial blood pressure in large-volume liposuc-
tion cases.64 Local hypoxia in the venous valves
of the lower extremities is believed to trigger
thrombogenesis.65,66
Clinical signs of a deep venous thrombo-
sis are notoriously unreliable.27,39,40,45,67 When
sequential compression devices were intro-
duced, diagnostic ultrasound technology was
not yet widely available. Existing methods for
deep venous thrombosis detection—radioactive
fibrinogen uptake,15–17,39,46,50 impedance pleth-
ysmography,16,46 and venography46,48,49—were
impractical as surveillance methods.41,45 Today,
Volume 145, Number 2 • Effect of Sequential Compression Devices
high-resolution ultrasound is used for numerous
applications in the plastic surgery office, and this
method is being adopted by a growing number
of surgeons.68
Limitations
This study does not evaluate the efficacy of
sequential compression devices. The number of
patients (n = 50) is far too small for that. Total
intravenous anesthesia was used exclusively in
this homogenous group of cosmetic surgery
patients. Larger patient populations are pre-
ferred. However, the assays are expensive. The
cost of the laboratory tests for this study exceeded
$20,000. The average operating time (114 min-
utes) was short, but typical for outpatient plastic
surgery. It is possible that longer operating times
and sequential compression device applications
might allow more opportunity for a fibrinolytic
effect. However, there was no sign of any sig-
nificant benefit comparing plasma levels at all
hourly intervals up to 5 hours after induction
(Table 3).
The effect of sequential compression devices
on a urokinase-type plasminogen activator was not
studied; its importance is not well understood.22–24
Unlike tissue plasminogen activator, urokinase-
type plasminogen activator has a low affinity for
fibrinogen.18,22,23 There is little evidence of a corre-
lation between urokinase-type plasminogen acti-
vator levels and thrombosis.67 Plasminogen levels
were not measured. Plasminogen deficiency is not
believed to cause thrombosis.67 Plasminogen acti-
vator inhibitor-1 inhibits both tissue plasminogen
activator and urokinase-type plasminogen activa-
tor.67 The other plasminogen activator inhibitor,
plasminogen activator inhibitor-2, is present in
substantial amounts only during pregnancy.69
This study measured tissue plasminogen acti-
vator and plasminogen activator inhibitor-1 anti-
gen levels in nanograms per milliliter.25,35 Tissue
plasminogen antigen levels measure both free tis-
sue plasminogen activator and tissue plasminogen
activator bound to plasminogen activator inhibi-
tor-1.18 Only the free fraction of tissue plasmino-
gen activator is biologically active.18,24 Some studies
measure activity, expressed in units, rather than
antigen levels.19,24,67 However, measurement of tis-
sue plasminogen activator activity is technically
challenging and not uniformly accepted.18 The tis-
sue plasminogen activator level may be increased
with a traumatic venipuncture.70 Excessive levels
of plasminogen activator inhibitor-1 may reflect
platelet contamination of the sample.71 These
technical issues may cause erroneously high mea-
surements in some samples.
Strengths
This Level I randomized trial is adequately
powered to detect a change in tissue plasminogen
activator and plasminogen activator inhibitor-1
levels. An a priori sample size calculation reduces
the risk of a type II (false-negative) error.34 Ran-
domization immediately before surgery and allo-
cation concealment minimize selection bias.34
The inclusion rate was 100 percent.
CONCLUSIONS
No significant change in systemic fibrinolytic
activity occurs during or immediately after out-
patient plastic surgery. Sequential compression
devices do not cause significant changes in tissue
plasminogen activator or plasminogen activator
inhibitor-1 levels in plastic surgery outpatients,
suggesting no fibrinolytic benefit.
Eric Swanson, M.D.
Swanson Center
11413 Ash Street
Leawood, Kan. 66211
eswanson@swansoncenter.com
@EricSwansonMD
ACKNOWLEDGMENTS
The author thanks Lauren Arnold, R.N., and Chris-
tina Engel, R.V.T., for collecting data, Jane Zagorski,
Ph.D., for statistical analysis, and Gwendolyn Godfrey
for graphics.
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