The Timing of Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction

Abstract

Background: Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction. Methods: A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed. Results: A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups. Conclusions: This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction

“…In terms of VTE prophylaxis agents investigated, six studies administered enoxaparin to at least one of their experimental groups, four studies involved unfractionated heparin, and four studies investigated low-molecular-weight heparin. Bassiri-Tehrani et al 28 also administered aspirin (81 mg) to “certain” patients in both the control and experimental groups based on senior author experiments. It was unclear how many of the studies also incorporated adjunct VTE prophylaxis measures, such as sequential compression device boots, in their protocols, as most of the studies did not explicitly state they were utilized.…”

“…(See figure, Supplemental Digital Content 3, which displays the summary of articles in systematic review. 10,21,[24][25][26][27][28][29][30][31]…”

“…After manual review of each of these studies by two individuals, 10 studies were identified to be included in this systematic review. 10,21,[24][25][26][27][28][29][30][31] common methodology of these studies was retrospective review (n = 8) with the remaining studies being prospective cohorts (n = 2). One of the retrospective cohort studies also featured a meta-analysis, the data from which were excluded in this systematic review.…”

Prolonged Venous Thromboembolism Prophylaxis May Not Be Necessary for DIEP Flap Breast Reconstruction: A Tertiary Center's 10-Year Experience

“…Our hematoma rate is in line with rates found in literature, which reported a 0.8 to 7.5% incidence of breast hematoma following free flap breast reconstruction. 10,20,24,25 In 2010, Caprini et al updated the model by adding more risk factors and granting more weight to several others including BMI, operative duration, and malignancy. A major surgery lasting more than 3 hours, such as DIEP flap reconstruction, would grant 5 points in the 2010 model.…”

“…Our hematoma rate is in line with rates found in literature, which reported a 0.8 to 7.5% incidence of breast hematoma following free flap breast reconstruction. 10 20 24 25…”