Perioperative Use of Antiestrogen Therapies in Breast Reconstruction

Abstract

Background Patients with hormone receptor-positive breast tumors receive hormonal therapy with either selective estrogen receptor modulators (SERMs) (eg, tamoxifen) or aromatase inhibitors (AIs) (eg, anastrozole) for 5 to 10 years. Patients are using these therapies frequently during breast reconstruction. Literature investigating the effects of hormonal modulators on breast reconstruction outcomes demonstrates conflicting results. We sought to perform a systematic evaluation to assess the effects of hormonal therapy on breast reconstruction outcomes and to guide perioperative management of antiestrogen therapies. Methods A MEDLINE, PubMed, and EBSCO Host search of articles regarding the effects of SERMs and AIs on breast reconstruction was performed. Outcomes evaluated included wound complications, total or partial flap loss, and thromboembolic events. Included studies were assigned Methodological Index for Nonrandomized Studies quality scores. Results A total of 2581 flaps were analyzed for complete loss: patients taking SERMs at the time of reconstruction had higher rates of flap loss compared with patients not taking hormone modulators (P < 0.001). Flap loss was not affected by concurrent AI use (P = 0.11). Both SERMs and AIs had an increased risk of donor site complications (P = 0.0021 and P < 0.0001, respectively). Neither hormone modulator had an effect on flap wound complications or venous thromboembolic event rates. Conclusions Evidence indicates patients using SERMs at the time of operation are at an increased risk of flap loss and those taking either SERMs or AIs have higher rates of donor site complications. These findings support holding these medications for 1 to 2 half lives (tamoxifen, 14–28 days; AIs, 2–4 days) preoperatively.

The False Positive Rate of Transcutaneous Tissue Oximetry Alarms in Microvascular Breast Reconstruction Rises after 24 Hours

“…While there are recognized preoperative patient-related factors that can affect flap outcomes, tissue oximetry monitoring can decrease free flap loss and improve salvage rate in the postoperative setting. 4,[11][12][13] A survey found that microsurgeons were more likely to immediately return to the operating room for a concerning tissue oximetry reading than an abnormal Doppler signal. 3 Other investigators have shown benefits of incorporating tissue oximetry in flap monitoring protocols as well.…”

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…50,51 When evaluating impact of antiestrogen therapies on VTE, a systematic review concluded that continuation of antiestrogen therapies at time of surgery did not increase risk of VTE. 52,53 Our findings show no statistically significant difference in VTE rate based on tamoxifen or aromatase inhibitor use, Protocols to reduce the tamoxifen cessation period may be feasible without compromising safety but was outside the scope of this study. 54 Caprini score was the only factor predictive of VTE.…”

Prevention of Venous Thromboembolism in Gynecologic Surgery

“…Although selective estrogen receptor modulators (SERMs), such as tamoxifen, are associated with an increased risk of VTE (15) (Box 1), there currently are no universally accepted guidelines for the use of SERMs in patients undergoing surgical procedures (16). Most of the available data on perioperative SERM use are from breast reconstruction studies that do not include VTE or PE incidence as a primary outcome (17).…”