Clinical Outcomes After Hematoma Development

Abstract

Background Hematomas after tissue expander immediate breast reconstruction (TE-IBR) pose a significant challenge during the recovery period. In this study, we aim to evaluate whether hematoma formation leads to subsequent complications and how management can impact final reconstructive goals. Methods A single-institution retrospective review of TE-IBRs from 2001 to 2018 was performed using an established breast reconstruction database. Demographics, medications, comorbidities, and complications were identified. Implant loss was defined as removal of the tissue expander/implant without immediate reimplantation during that operation. Hematoma size, management, transfusion requirement, reoperations, and final outcome were recorded. Reconstructive failure was defined as an implant loss that was not replaced with another implant or required secondary autologous reconstruction. Results Six hundred twenty-seven TE-IBR patients were analyzed. Postoperative hematoma (group 1) occurred in 4.1% (n = 26) of TE-IBRs and did not develop in 95.9% (group 2: n = 601). Group 2 had a higher mean body mass index (24.5 vs 27.3 kg/m2, P = 0.018); however, there were no significant differences in smoking status, preoperative/postoperative radiation/chemotherapy, or other comorbidities. Group 1 was found to have increased rates of implant loss (15.4% vs 3.7%, P = 0.0033) and reconstructive failure (11.5% vs 2.8%, P = 0.0133) compared with group 2. Eighteen hematomas (69.2%) underwent surgical intervention (group 1a) compared with 30.8% (n = 8) that were clinically managed (group 1b). Group 1a had statistically significant lower rates of subsequent complications (22.2% vs 62.5%, P = 0.046) and reoperations (5.6% vs 27.5%, P = 0.037) than did group 1b, respectively. Lastly, 23.1% (n = 6) of patients who developed a hematoma were on home antithrombotics (group 1c) compared with 76.9% (n = 20) of patients with no antithrombotics (group 1d). There were statistically significant differences in transfusion rates (50% vs 0%, P = 0.001) between groups 1c and 1d, respectively. Differences in hematoma volume (330 vs 169.3 mL, P = 0.078) and reconstructive failure (33.3% vs 5%, P = 0.057) approached significance between both groups. Conclusions Hematoma after TE-IBR should be monitored closely, as it may play a role in jeopardizing reconstruction success. Patients on home antithrombotic medication may be at increased risk of larger-volume hematomas and reconstruction failure. Plastic surgeons should consider aggressive surgical evacuation of postoperative TE-IBR hematomas to reduce subsequent complications and reoperations, thus optimizing reconstructive outcomes.

Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction

“…The incidence of hematomas after alloplastic breast reconstruction has been reported to range from 1% to 5% 15,16 . For TE-IBR patients who develop postoperative hematomas, the outcomes after the complication can be potentially devastating, as hematomas significantly increase the risk of other complications such as capsular contracture, infections, implant loss, and reconstructive failure 16–18 . Therefore, surgeons may be hesitant to discharge their patients home the day of surgery because of the risk of forming a hematoma in the immediate postoperative period and delaying treatment.…”

“…15,16 For TE-IBR patients who develop postoperative hematomas, the outcomes after the complication can be potentially devastating, as hematomas significantly increase the risk of other complications such as capsular contracture, infections, implant loss, and reconstructive failure. [16][17][18] Therefore, surgeons may be hesitant to discharge their patients home the day of surgery because of the risk of forming a hematoma in the immediate postoperative period and delaying treatment. A recent systematic review with a total of 285 same-day discharge patients found that ERAS protocols after immediate alloplastic breast reconstruction had no difference in overall complication rates, including hematomas, between same-day discharge and overnight admission patients.…”