Breast free flap complications related to haematoma formation – do the risks of multiple antithrombotics outweigh the benefits today?

Abstract

Background Free flap reconstruction is today a common operation for many breast cancer patients, but local protocols for microsurgery still predict the use of antithrombotic agents. Reduced operation times and complication rates together with faster mobilisation, after introduction of perforator flaps, call for less comprehensive antithrombotic regimens. It was hypothesised that multiple antithrombotics was a risk factor for bleeding-related flap complications. Methods A retrospective cohort study was conducted to study the association between reoperation for haematoma and flap-related complications after free flap breast reconstruction. A combination of heparin, low-molecular-weight heparin and dextran were used as antithrombotics. A sub-analysis was performed to compare non-dextran to dextran treated patients. Results One hundred and thirty-nine patients were identified, reconstructed with 150 consecutive perforator free flaps to the breast. Reoperation for breast haematoma (13%) was associated with concomitant re-operation for venous congestion (8.6%) (p < 0.001), but also for flap thrombosis (2.9%) (p = 0.007), highlighting haematoma as a risk factor for flap-related complications. An increased rate of haematoma re-operations of the breast was noted among the flap-related complications in the dextran (n = 79), compared to the non-dextran group (p = 0.011). Conclusion The current study highlights the use of multiple antithrombotics as a risk factor for haematoma reoperation. Liberal use of drains and evacuation of breast haematomas are, therefore, indicated together with limitation of antithrombotic agents. The highly variable use of antithrombotic agents worldwide call for evidence-based guidelines in standardised free flap breast reconstruction.

A randomised controlled feasibility trial to evaluate local heat preconditioning on wound healing after reconstructive breast surgery: the preHEAT trial

“…This was scrutinised by the Trial Steering Committee mid-way through the trial and concluded to be surgery-related. A literature search indicated that the rate of haematoma requiring surgical intervention was in line with other studies and therefore is not likely to be increased by the heating process [14, 21, 22]. No other complications, SAEs, SARs or ARs were attributable to the heating procedure; therefore, we can conclude that this is a safe intervention.…”

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

“…Dextran was omitted from the standard treatment at our department in 2011 since there was evolving evidence showing no beneficial effect with dextran used in head and neck free flaps, but rather an increased risk for systemic complications. 13 Over the last decade, most centers have abandoned the use of dextran because several studies have confirmed that it does not decrease the risk for thrombosis and flap failure 7 , 14 – 16 …”

The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability

“…The lower rates found in our institutional data are supported by a previous review article outlining URO for hematomas in microvascular free tissue transfers, noting rates ranging from 0.2% to 9%. 44 Halle et al 45 reported a 13% incidence of reoperations for hematomas in breast free flaps, highlighting the potential risk of antithrombotic use and importance of using drains. A study assessing risk factors for hematoma formation in 883 patients who underwent mastectomy and immediate reconstruction found no measurable preoperative, operative, or oncologic risk factors, citing that meticulous hemostasis may be 1 of the factors.…”