Does testosterone replacement therapy increase the risk of Deep Vein Thrombosis (DVT) in a patient undergoing a 4-hour abdominoplasty procedure with a CAPRINI (Cardiovascular and Pulmonary Risk Index) score of 4, and what are the post-operative management guidelines for Venous Thromboembolism (VTE) prophylaxis?

VTE Prophylaxis for Abdominoplasty with Caprini Score 4

For this patient undergoing a 4-hour abdominoplasty with a Caprini score of 4, you should provide pharmacologic prophylaxis with either LMWH (enoxaparin 40 mg subcutaneously once daily) or low-dose unfractionated heparin (5000 U subcutaneously twice or three times daily) in addition to the sequential compression devices already planned, continuing for 10-14 days postoperatively. 1

Testosterone Replacement Therapy and DVT Risk

While testosterone replacement therapy is not specifically listed as a risk factor in the Caprini scoring system, it does not appear to significantly alter your VTE prophylaxis strategy in this surgical context. 1 The patient's Caprini score of 4 already places them in the moderate-risk category (3% VTE risk), and the surgical factors (4-hour procedure duration, abdominoplasty) are the primary drivers of thrombotic risk. 1

Risk Stratification Analysis

Your patient falls into the moderate-risk category with a Caprini score of 4, corresponding to approximately 3% VTE risk. 1 The American College of Chest Physicians guidelines specifically address this risk level for general and abdominal-pelvic surgery patients. 1

• A 4-hour operative time is a significant risk factor that contributes to the Caprini score (major open surgery >45 minutes = 2 points). 1
• In plastic surgery populations specifically, a Caprini score of 3-4 may correspond to a slightly lower absolute risk (0.6-1.5%) compared to general abdominal surgery, but prophylaxis recommendations remain the same. 1

Recommended Prophylaxis Strategy

Intraoperative Management

• Continue sequential compression devices throughout the procedure and postoperatively as already planned. 1
• Maintain perioperative normothermia to reduce VTE risk. 2

Pharmacologic Prophylaxis Options

For moderate-risk patients (Caprini 3-4) without high bleeding risk, the ACCP recommends LMWH, low-dose UFH, or mechanical prophylaxis. 1 Given the 4-hour operative duration and general anesthesia, pharmacologic prophylaxis is strongly advisable:

• Enoxaparin 40 mg subcutaneously once daily, starting 12 hours before or after surgery, continued for 10-14 days. 1
• Alternatively, unfractionated heparin 5000 U subcutaneously twice or three times daily, continued for 10-14 days. 1
• Fondaparinux 2.5 mg subcutaneously once daily is another option if heparins cannot be used. 1

Duration of Prophylaxis

Standard duration is 10-14 days for non-cancer abdominopelvic surgery. 1 Extended prophylaxis up to 28-35 days is reserved for:

• High-risk patients (Caprini ≥5) undergoing major cancer surgery in the abdomen. 1
• This patient does not meet criteria for extended prophylaxis unless additional high-risk features emerge. 3

Critical Considerations for Abdominoplasty

Abdominoplasty has unique bleeding considerations due to the extensive undermining and potential for wound complications. 2 However:

• The consequences of bleeding in abdominoplasty (hematoma, seroma) are generally less severe than in procedures involving free flaps or neurosurgery. 1
• If you assess this patient as having high bleeding risk, use mechanical prophylaxis alone (IPC) until bleeding risk diminishes, then add pharmacologic prophylaxis. 1
• Early ambulation (planned for day of surgery) is excellent and should be maintained. 2

Postoperative Management Algorithm

1. Continue sequential compression devices until patient is fully ambulatory. 1
2. Initiate pharmacologic prophylaxis (if not started preoperatively) within 12-24 hours postoperatively once hemostasis is secure. 1
3. Ensure early and frequent ambulation as planned. 3, 2
4. Continue prophylaxis for 10-14 days or until fully ambulatory, whichever is longer. 1
5. Do not use IVC filters for primary prophylaxis. 1
6. Do not perform routine surveillance duplex ultrasound. 1

Common Pitfalls to Avoid

• Do not withhold pharmacologic prophylaxis based solely on plastic surgery specialty—the Caprini score and procedure duration dictate risk. 1, 4
• Do not rely on mechanical prophylaxis alone in moderate-risk patients unless bleeding risk is prohibitive. 1
• Do not extend prophylaxis to 4 weeks unless this is cancer surgery with Caprini ≥5. 1
• Ensure compression devices are properly fitted and used for at least 18 hours daily when relying on mechanical prophylaxis. 1