Venous thromboembolism following microsurgical breast reconstruction: an objective analysis in 225 consecutive patients using low-molecular-weight heparin prophylaxis

A standardized anesthesiology and surgical protocol leads to zero VTE events: A retrospective study in 502 autologous breast reconstructions

BACKGROUND

Autologous breast reconstruction carries an inherent risk of developing venous thromboembolism (VTE), a complication with potentially severe outcomes. This study evaluated the incidence of VTE events in a large cohort of 502 autologous breast reconstructions, achieved through a standardized surgical, anesthesiologic, and thromboprophylaxis protocol. Our primary aim was to evaluate the effectiveness of this comprehensive approach in preventing VTE events.

METHODS

We conducted a retrospective analysis of 370 patients who underwent autologous breast reconstruction between December 2007 and February 2023, employing a uniform surgical and anesthesiology protocol designed around the enhanced recovery after surgery (ERAS) protocol. The incidence of VTE and flap-related complications was documented, alongside an evaluation of the potential risk factors and Caprini scores.

RESULTS

None of the patients in this cohort developed deep vein thrombosis or pulmonary embolism. Hematomas were noted in 5.4% of the cases. The mean Caprini score observed was 6.67, ranging from 3 to 9. Incidences of total and partial flap necrosis were recorded in 7 (1.4%) and 9 (1.8%) cases, respectively. Analysis revealed no significant disparity in the complication rates between patients categorized as being at low risk (Caprini score ≤6), at 5.4%, and those deemed to have the highest risk and super high risk together (Caprini score ≥7), at 3.8%.

CONCLUSIONS

Our cohort study is the first, to our knowledge, to demonstrate a zero percent incidence of clinical VTE events following autologous breast reconstruction, attributed to the rigorous application of a standardized surgical, anesthesiology, and thromboprophylaxis protocol. This result highlights the potential of a well-implemented pre- and intra-operative management, combined with the ERAS protocol, to significantly reduce the VTE risk in this group of patients.

LEVEL OF EVIDENCE

IV.

Abdominal Fascial Plication and the Risk of Venous Thromboembolism in Abdominoplasty Patients: A Systematic Review of the Literature

BACKGROUND

Repair of the abdominal fascia at the time of abdominoplasty is a valuable method to improve the contour of the abdomen. However, this maneuver has been linked to an increased risk of venous thromboembolism (VTE). This review was undertaken to evaluate the evidence.

METHODS

An electronic literature review was conducted to identify publications on the subject of abdominal fascial repair during abdominoplasty and VTE risk. Key words included abdominoplasty, fascial plication, intra-abdominal pressure, and venous thrombosis.

RESULTS

Three large clinical studies were identified. One retrospective study using matched comparisons reported nearly identical VTE rates for patients treated with and without abdominal fascial plication (1.5% vs 1.7%). Another retrospective study reported significantly more VTEs (2.3%) in abdominoplasty patients undergoing fascial repair compared with panniculectomy patients who did not undergo fascial plication (0.36%). The author also recommended a modified Caprini score, adding fascial repair as a risk factor. Only 1 prospective study reported a large number of consecutive plastic surgery outpatients evaluated with Doppler ultrasound. This group included 188 abdominoplasty patients, all treated with fascial plication and without muscle paralysis. Only 1 VTE was diagnosed on the day after abdominoplasty (0.5%).

DISCUSSION

Retrospective studies are susceptible to confounders and confirmation bias. Caprini scores do not have a scientific foundation. Chemoprophylaxis increases the risk of bleeding without reducing the risk of VTE.

CONCLUSIONS

The best available evidence supports performing a fascial repair. An effective and safe alternative to Caprini scores and chemoprophylaxis is avoidance of muscle paralysis and early detection of VTEs using ultrasound screening.

Impact of COVID-19 on Thrombotic Complications in Microsurgery: Deep Inferior Epigastric Perforator Flap Outcomes Amid Pandemic

Background

Emerging research underscores the heightened risk of vasculitis and microvascular thrombosis in COVID-19 patients, alongside concerns about prothrombotic events post-severe acute respiratory syndrome coronavirus 2 vaccination. Following the pandemic's end, we sought a comprehensive analysis to elucidate its impact on microsurgical thrombosis rates, informed by empirical and anecdotal evidence.

Methods

An institutional review board-approved retrospective review analyzed autologous breast reconstruction cases in women from January 2019 to March 2022. Data on patient history, COVID-19 infection, vaccination status, and postoperative complications were collected. Patients were categorized as prepandemic and pandemic, and based on COVID-19 influence (infection or vaccination) for statistical evaluation.

Results

Among 527 patients, 216 underwent surgery prepandemic and 311 during the pandemic, revealing thrombotic event rates of 3.2% and 5.4%, respectively. Further comparative analysis showed no significant difference in thrombotic events among patients affected by COVID-19 through infection or vaccination during the pandemic.

Conclusions

Contrary to concerns, COVID-19 infection or vaccination status does not significantly increase thrombotic event rates in deep inferior epigastric perforator flap breast reconstructions. This study offers vital insights, affirming the safety and efficacy of microsurgical procedures amid the pandemic, thereby guiding microsurgeons in optimizing patient care in the post-COVID-19 era.

Perioperative Venous Thromboembolism Chemoprophylaxis Does Not Increase Risk of Complications in Free Flap Breast Reconstruction

BACKGROUND

Patients undergoing abdominal-based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation.

METHODS

A retrospective review was conducted on patients who underwent abdominal-based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010-2015 patients were pre-ERAS and 2015-2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation.

RESULTS

2317 patients were included: 679 were pre-ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre-ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre-ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre-ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05).

CONCLUSIONS

A standardized perioperative anticoagulation protocol for abdominal-based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.

Short-term versus extended chemoprophylaxis against venous thromboembolism in DIEP flap breast reconstruction: A retrospective study of 424 patients

BACKGROUND

Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction.

METHODS

This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates.

RESULTS

Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8.

CONCLUSION

In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals.

METHODS

This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed.

RESULTS

Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE.

CONCLUSION

The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

Awareness and associated factors of venous thromboembolism in breast cancer surgical patients: a cross-sectional study

BACKGROUND

Venous thromboembolism (VTE) is a major complication of breast cancer surgical patients. Assessing VTE awareness enables medical staff to tailor educational programs that improve patient self-management and reduce VTE risk. Therefore, this study aimed to assess VTE awareness among breast cancer surgical patients and identify factors influencing their awareness level.

METHODS

A multicenter cross-sectional study was conducted on breast cancer patients scheduled for surgery from May 2023 to November 2023. Data were collected using a general information form and a validated self-assessment questionnaire on VTE awareness for breast cancer surgical patients. Univariate analysis and multiple linear regression analysis were used to analyze the data.

RESULTS

Of 1969 patients included, the term awareness rates for deep vein thrombosis and pulmonary embolism were 42.5% and 26.1%, respectively. Information about VTE was primarily obtained from doctors (30.4%), nurses (24.0%), and social media (23.3%). The overall average VTE awareness score was 1.55 ± 0.53, with the dimension of VTE preventive measures scoring highest, and VTE clinical symptoms/signs scoring lowest. Multivariate analysis identified education level, personal VTE history, chemotherapy and surgical history, and the hospital's regional location as significant factors associated with VTE awareness level (p < 0.05).

CONCLUSION

This study highlights a critical need for improved VTE awareness among breast cancer surgical patients, particularly regarding clinical symptoms/signs. Health education programs are recommended especially tailored for patients with lower education levels, no history of VTE, or without prior surgery or chemotherapy, to improve their understanding of VTE.

An Effective Protocol for Perioperative Venous Thromboembolism Prophylaxis in DIEP Flap Breast Reconstruction: A Single Institution Retrospective Review

Background

Deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction is one of the most highly used procedures for autologous breast reconstruction. Many venous thromboembolism (VTE) risk assessment models have been proposed in breast reconstructive surgery, including the widely used Caprini score. However, a paucity of data suggests an effective standardized VTE protocol. The purpose of this study was to determine the rate of VTE in our DIEP flap patients who were treated with this protocol.

Methods

A retrospective single-center review of DIEP flap breast reconstruction from 2016 to 2021 was performed. Data were collected on 554 patients and 893 flaps including demographics, intraoperative and perioperative details, and postoperative course. Patients who were not treated with our standard protocol were excluded. Data were analyzed with alpha = 0.05.

Results

The average age was 50.4 ± 9.9 years, and the total follow-up time was 16.9 ± 12.6 months. The average body mass index for the cohort was 30.1 ± 5.2. During the 90 postoperative days, the mean length of hospital stay was 4.3 days. There were six cases of postoperative VTE: five patients presented with pulmonary embolism (0.9%) and one patient (0.2%) had deep venous thrombosis with an overall VTE prevalence of 1.1%. No specific single factor could be attributed to VTE occurrence.

Conclusions

Using our standardized VTE prophylaxis protocol, our institution was effective at keeping VTE rates low. Additional studies would be beneficial to determine optimal VTE prophylaxis protocols in higher-risk patients, such as those with known clotting disorders.

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

BACKGROUND

 Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction.

METHODS

 This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE.

RESULTS

 This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001).

CONCLUSION

 In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

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

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes.

Methods

The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis.

Results

In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk.

Conclusions

This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery

This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.

A UK consensus statement on thromboprophylaxis for autologous breast reconstruction ,

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base.

METHODS

Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached.

RESULTS

The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis.

CONCLUSION

To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction

BACKGROUND

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction.

METHODS

A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered.

RESULTS

Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps.

CONCLUSIONS

Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients

INTRODUCTION

 Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications.

METHODS

 Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria.

RESULTS

 Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R ² = 0.47, p < 0.0001).

CONCLUSION

 Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.

Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation

Background  Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.

Methods  A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.

Results  From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m ² (SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%, p  = 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%, p  = 0.63), thromboembolism (5% vs. 0%, p  = 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2], p  = 0.85).

Conclusion  Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.

Safe perioperative tamoxifen use in autologous breast free flap reconstruction: systematic review and meta-analysis

BACKGROUND

Perioperative tamoxifen remains a valuable therapeutic modality for breast cancer patients. Studies in the existing literature have suggested a potential increased risk of thrombotic complications in autologous breast free flap reconstruction patients exposed to tamoxifen perioperatively. However, several recent publications have questioned the validity of these associations. Therefore, we aim to perform a systematic appraisal of the existing literature to determine if perioperative tamoxifen exposure increases the risk of flap complications in autologous breast-free flap reconstruction patients.

METHODS

A systematic literature search was performed using: PubMed, EMBASE, Cochrane Central, Web of Science, EBSCOHost, ClinicalTrials.gov, and TRIP databases from their inception up to April 2021. Articles analyzing the impact of perioperative tamoxifen in autologous breast free flap patients were included. The outcomes assessed were total flap loss, overall flap complications, thrombotic flap complications, which was defined as the sum of arterial and venous flap thrombi, and systemic venous thromboembolism (VTE). Pooled estimates and relative risk were calculated using a random effects model.

RESULTS

9294 Articles were screened and 7 were selected for analysis, which included 3669 flaps in 2759 patients. Compared to patients who did not receive tamoxifen perioperatively, those who received tamoxifen did not have an increased risk of thrombotic flap complications (pooled RR 1.06; 95% CI 0.61-1.84), total flap loss (pooled RR 2.17; 95% CI 0.79-5.95), overall flap complications (pooled RR 1.04; 95% CI 0.76-1.41), or systemic VTE (pooled RR 1.93; 95% CI 0.72-5.13). The heterogeneity of the studies was not significant for any of the outcomes.

CONCLUSIONS

The purpose of this study was to update the current understanding of the impact of perioperative tamoxifen on autologous breast free flap reconstruction outcomes. The existing literature supports that the perioperative continuation of tamoxifen in breast free flap patients is not associated with an increased risk of thrombotic flap complications, total flap loss, overall flap complications, or systemic VTE.

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

BACKGROUND

 Based on the 2005 Caprini Risk Assessment Model for venous thromboembolism, the American Society of Plastic Surgeons prevention guidelines would result in prolonged chemoprophylaxis (1 week or more) for the majority of patients undergoing deep inferior epigastric perforator flap breast reconstruction. We aim to assess the necessity of prolonged prophylaxis by describing our institutional experience in thromboembolism prevention and evaluating the incidence of symptomatic VTE in our patient cohort.

METHODS

 Women who underwent DIEP flap reconstruction from August 2011 to March 2020 at a tertiary care center were included. Charts were retrospectively reviewed for patient characteristics, VTE prophylaxis regimens, and development of deep vein thrombosis and pulmonary embolism within 60 days of surgery. Caprini scores were calculated for all patients.

RESULTS

 Out of the 249 patients included in the study, 245 patients received chemoprophylaxis only during hospitalization, while four patients additionally received anticoagulant for at least 2 weeks after discharge for prophylactic or therapeutic indications. The cohort's average Caprini score was 6.0, with 72.7% of scores between 3 and 6 and 26.5% at 7 or higher. One patient (0.4%), who scored a 7 and received prophylaxis only while hospitalized, developed deep vein thrombosis. There were no cases of pulmonary embolism. There was no significant difference in VTE rate between patients who received chemoprophylaxis consistent with ASPS guidelines and those who did not (p = 1.000).

CONCLUSION

 Despite our limited chemoprophylaxis use in DIEP flap patients, our VTE incidence is low. This current work suggests that the blanket application of prolonged prophylaxis is not warranted, and it further serves as impetus to re-evaluate the 2005 Caprini RAM in this patient population.

Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations

Background and Objective

Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery.

Evidence

We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review.

Conclusion

A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.

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

Background:

Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment.

Methods:

Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma.

Results:

Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001).

Conclusions:

Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Evaluation of an Extended-duration Chemoprophylaxis Regimen for Venous Thromboembolism after Microsurgical Breast Reconstruction

Patients undergoing free flap breast reconstruction are at a high risk for venous thromboembolism based upon Caprini scores. Guidelines for venous thromboembolism prophylaxis recommend high-risk groups receive extended chemoprophylaxis for several weeks after gynecological, orthopedic, and surgical oncology cases. Extended prophylaxis has not been studied in free flap breast reconstruction. The purpose of this study was to compare outcomes of free flap breast reconstruction patients who received extended venous thromboembolism (VTE) prophylaxis with those who received standard inpatient-only prophylaxis.

Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: A case series

BACKGROUND

Venous thromboembolism (VTE) is a potentially devastating complication following abdominally based microsurgical breast reconstruction, with a reported incidence of 0.08-4%. The authors aim to describe disease presentation and clinical course following VTE diagnosis in patients within their practice.

METHODS

A retrospective chart review identified patients who underwent microsurgical breast reconstruction from January 2007 through December 2018. Patients with VTE diagnosed within 90 days of surgery were included. Demographics, co-morbidities, signs and symptoms, and characteristics of oncologic, surgical, and post-operative care were analyzed.

RESULTS

Seven hundred one patients underwent microsurgical breast reconstruction. Eleven patients with pulmonary embolism (PE) and four with deep vein thrombosis (DVT) were identified, resulting in VTE incidence of 2.1% (0.57% DVT, 1.6% PE). Patients were on average 51 years old and had an average body mass index (BMI) of 31.7 kg/m2. Two had a history of VTE, and none had a known hypercoagulable disorder. Using the 2005 Caprini model, all were high risk and seven were highest risk. Among those with PE, the most common symptom was shortness of breath, and the most common signs were desaturation or supplemental oxygen requirements. VTE was diagnosed on average 14.2 days post-operatively (range 2-52 days).

CONCLUSION

VTE is an infrequent complication following abdominally based microsurgical breast reconstruction. We recommend a high index of suspicion in women reporting shortness of breath or having desaturation, especially in those with high BMI, high Caprini scores, post-operative complications, or early return to the operating room.

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction

BACKGROUND

 Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series.

METHODS

 A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications.

RESULTS

 Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I ² = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I ² = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication.

CONCLUSION

 A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options

The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.

Implementing Our Microsurgical Breast Reconstruction Enhanced Recovery after Surgery Pathway: Consensus Obstacles and Recommendations

Enhanced recovery after surgery pathways are well established in other surgical specialties but are relatively new in plastic surgery. These guidelines focus on improving patient care by incorporating evidence-based recommendations. Length of stay is shorter, and overall hospital costs are lower without compromising patient satisfaction. When care is standardized, ambiguity is removed and physician acceptance is improved. Yet, implementation can be challenging on an institutional level. The Johns Hopkins microsurgical breast reconstruction team identified areas of dogmatic dissonance during 3 focus groups to formalize an enhanced recovery pathway for microsurgical breast reconstruction. Six microsurgeons used nominal group technique to reach consensus. Four discussion points were identified: multidisciplinary buy-in, venous thromboembolism (VTE) chemophylaxis, early feeding, and dietary restrictions. Evidence-based recommendations and our enhanced recovery after surgery protocol are provided.

The Timing of Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction

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.

Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis

BACKGROUND

The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery.

METHODS

We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE.

RESULTS

Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1-2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9-18.2) and lung cancer (8.1%, 95% CI 3.7-12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40-0.53; I² = 93.8%), radiation (OR 1.29, 95% CI 1.03-1.62; I² = 34.6%), transfusion (OR 1.96, 95% CI 1.48-2.59; I² = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07-1.16; I² = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07-30.56; I² = 92.0%).

CONCLUSIONS

The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.

The Expanding Role of Diagnostic Ultrasound in Plastic Surgery

Supplemental Digital Content is available in the text.

Background:

Ultrasound in plastic surgery is quickly finding new applications. Ultrasound surveillance may replace ineffective individual risk stratification and chemoprophylaxis for deep venous thromboses. Abdominal penetration can be a catastrophic complication of liposuction. Preoperative screening for fascial defects may reduce risk. Limiting buttock fat injections to the subcutaneous plane is critical for patient safety, but it is difficult to know one’s injection plane.

Methods:

The author’s use of diagnostic ultrasound was evaluated from May 2017 to May 2018. Ultrasound scans were used routinely to detect deep venous thromboses. Patients undergoing abdominal liposuction and/or abdominoplasty were scanned for possible hernias. Other common applications included the evaluation of breast implants, breast masses, and seroma management. The device was used in surgery in 3 patients to assess the plane of buttock fat injection.

Results:

One thousand ultrasound scans were performed during the 1-year study period. A distal deep venous thrombosis was detected in 2 patients. In both cases, the thrombosis resolved within 1 month, confirmed by follow-up ultrasound scans. A lateral (tangential) fat injection method was shown to safely deposit fat above the gluteus maximus fascia.

Conclusions:

Ultrasound scans are highly accurate, noninvasive, and well-tolerated by patients. Some of these applications are likely to improve patient safety. Early detection of deep venous thromboses is possible. Unnecessary anticoagulation may be avoided. Subclinical abdominal defects may be detected. Ultrasound may be used in the office to evaluate breast implants, masses, and seromas. In surgery, this device confirms the level of buttock fat injection.

Thromboprophylaxis in Head and Neck Microvascular Reconstruction

Head and neck patients undergoing microvascular reconstruction are at high risk for thromboembolism. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The aim of this review was to evaluate the risks and benefits of prophylactic agents for thromboprophylaxis. A literature search was conducted in MEDLINE, Cochrane Library, and PubMed/NCBI databases. Articles discussing thromboprophylaxis in otolaryngology, head and neck surgery, or microvascular reconstruction were considered in the review from the past 30 years. The majority of patients undergoing microvascular surgery have multiple risk factors for thrombus formation. Several consensus guidelines exist for the prophylaxis in patients who are critically ill, undergoing surgery, or with malignancy. Significant evidence supports the routine use of mechanical means, such as early mobilization and pneumatic compression along with subcutaneous heparin. Low-molecular-weight heparin is also frequently utilized, although results are largely divided. Data on aspirin remain equivocal. Studies on microvascular failure and flap loss have demonstrated little to no association with chemoprophylaxis. The evidence for postoperative thromboprophylaxis regimens in patients undergoing head and neck free tissue transfer is variable. Multiple studies have supported the use of unfractionated heparin or low-molecular-weight heparin. There appears to be an expert consensus for the combined use of mechanical prophylactic methods and chemical prophylaxis. Prospective randomized trials are required to validate the most effective combination of chemoprophylaxis agents.

Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.

METHODS

A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.

RESULTS

High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.

CONCLUSION

Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Evidence for Extending the Duration of Chemoprophylaxis following Free Flap Harvest from the Lower Extremity: Prospective Screening for Deep Venous Thrombosis

BACKGROUND

The purpose of this study was to investigate the incidence of symptomatic and asymptomatic deep venous thrombosis in patients undergoing harvest of a free flap from the lower extremity who were receiving standard chemoprophylaxis while hospitalized.

METHODS

A retrospective review of 65 consecutive patients undergoing surgery between 2011 and 2013 was performed to determine the incidence of symptomatic deep venous thrombosis. These patients were screened for deep venous thrombosis based on development of symptoms. Prospective evaluation of a similar consecutive population of 37 patients between 2014 and 2015 was then performed to determine the incidence of asymptomatic deep venous thrombosis. These patients underwent routine duplex ultrasonography of both legs at postoperative weeks 1 and 4.

RESULTS

Symptomatic deep venous thrombosis occurred in 2.9 percent of all patients. In the prospective cohort, 8.1 percent of the patients were found to have an acute deep venous thrombosis by postoperative week 1. At postoperative week 4, 16.7 percent of the patients developed a new, acute deep venous thrombosis. The estimated costs of screening and treating deep venous thrombosis in the retrospective group and the prospective group were $222 and $2259, respectively. The cost of routine chemoprophylaxis without duplex screening for an additional 14 days after discharge was $125 per patient.

CONCLUSIONS

The rate of asymptomatic deep venous thrombosis may be much higher than previously appreciated in this population of very high-risk patients, especially during the 2 weeks after discharge. Extending the duration of chemoprophylaxis to 4 weeks after surgery may be warranted.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Coagulation Changes following Combined Ablative and Reconstructive Breast Surgery

BACKGROUND

This study assessed hemostatic function in cancer patients at high risk for venous thromboembolism.

METHODS

Thirty-eight female patients (age, 53 ± 9 years) undergoing immediate postmastectomy reconstruction were prospectively studied with informed consent. Blood was sampled preoperatively, on postoperative day 1, and at 1 week follow-up. Rotational thromboelastography clotting time, α-angle (clot kinetics), clot formation time, and maximum clot firmness were studied with three different activating agents: intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D. Thromboprophylaxis was unfractionated heparin plus sequential compression devices if not contraindicated. Hypercoagulability was defined by one or more parameters outside the reference range.

RESULTS

Preoperatively, 29 percent of patients were hypercoagulable, increasing to 67 percent by week 1 (p = 0.017). Clotting time, clot formation time, and α-angle remained relatively constant over time, but maximum clot formation increased in intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (all p < 0.05). Body mass index was 28 ± 5 kg/m, 23 percent received preoperative chemotherapy, and 15 percent had a history of tobacco use, but there was no association between these risk factors and hypercoagulability.

CONCLUSIONS

Despite perioperative thromboprophylaxis, two-thirds of patients undergoing combined tumor resection and reconstructive surgery for breast cancer were hypercoagulable 1 week after surgery. Hypercoagulability was associated with increased clot strength mediated by changes in platelet and fibrin function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .

Legal issues related to postoperative pulmonary thromboembolism in Korea

PURPOSE

Currently, development of pulmonary thromboembolism (PTE) after surgery is frequently being followed by legal action in Korea, as consequences may be fatal. In the current study, we assessed possible countermeasures that medical teams can take when faced with conflicting opinions on responsibility for PTE.

METHODS

A retrospective analysis of claims handled by the Supreme Court and subordinate courts, from 1999 to 2015, was performed. We analyzed the type of procedure, associated complications, and critical legal points from the recorded judgments along with any liability limitations on surgeons.

RESULTS

After reviewing cases between 1999 and 2015, a total of 18 cases were analyzed. There were no cases in which the surgeon was held accountable between 1999 and 2002. From 2003, there were instances of the surgeon being held accountable, with a peak of cases in 2013. Legal standards applied in judicial decision-making related to appropriate use of preventive measures, operation characteristics, doctor's reaction towards symptom occurrence, obligation of postoperative medical care, and duty of explanation.

CONCLUSION

The courts in Korea have changed their position from one of denying doctors' liability to one of enforcing responsibility for PTE. Surgeons are therefore being held responsible with greater frequency, depending on the details of the case. Lessons can be learnt from precedents that can be incorporated into medical education and training programs with the aim of reducing both major PTE complication rates and litigation costs.

Incidence of deep vein thrombosis in patients undergoing breast reconstruction with autologous tissue transfer

Background Breast reconstruction is associated with multiple risk factors for venous thromboembolism. However, the incidence of deep vein thrombosis in patients undergoing breast reconstruction is uncertain. Objective The aim of this study was to prospectively evaluate the incidence of deep vein thrombosis in patients undergoing breast reconstruction using autologous tissue transfer and to identify potential risk factors for deep vein thrombosis. Methods Thirty-five patients undergoing breast reconstruction were enrolled. We measured patients' preoperative characteristics including age, body mass index (kg/m²), and risk factors for deep vein thrombosis. The preoperative diameter of each venous segment in the deep veins was measured using duplex ultrasound. All patients received intermittent pneumatic pump and elastic compression stockings for postoperative thromboprophylaxis. Results Among the 35 patients evaluated, 11 (31.4%) were found to have deep vein thrombosis postoperatively, and one patient was found to have pulmonary embolism postoperatively. All instances of deep vein thrombosis developed in the calf and were asymptomatic. Ten of 11 patients underwent free flap transfer, and the remaining one patient received a latissimus dorsi pedicled flap. Deep vein thrombosis incidence did not significantly differ between patients with a free flap or pedicled flap (P = 0.13). Documented risk factors for deep vein thrombosis demonstrated no significant differences between patients with and without deep vein thrombosis. The diameter of the common femoral vein was significantly larger in patients who developed postoperative deep vein thrombosis than in those who did not ( P < 0.05). Conclusions The morbidity of deep vein thrombosis in patients who underwent breast reconstruction using autologous tissue transfer was relatively high. Since only the diameter of the common femoral vein was predictive of developing postoperative deep vein thrombosis, postoperative pharmacological thromboprophylaxis should be considered for all patients undergoing breast reconstruction regardless of operative procedure.

Caprini Scores, Risk Stratification, and Rivaroxaban in Plastic Surgery: Time to Reconsider Our Strategy

Limited data are available regarding the pathophysiology of venous thromboembolism in plastic surgery patients. In an effort to identify patients at greater risk, some investigators promote individual risk assessment using Caprini scores. However, these scores do not correlate with relative risk values. Affected patients cannot be reliably predicted (97% false positive rate). Caprini scores make many body contouring patients candidates for chemoprophylaxis, an intervention that introduces risks related to anticoagulation. Caprini has financial conflicts with several companies that manufacture products such as enoxaparin, commonly used for chemoprophylaxis. Rivaroxaban, taken orally, has been used by some plastic surgeons as an alternative to enoxaparin injections. However, this medication is not United States Food and Drug Administration approved for venous thromboembolism prophylaxis in plastic surgery patients, and a reversal agent is unavailable. This article challenges the prevailing wisdom regarding individual risk stratification and chemoprophylaxis. Alternative methods to reduce risk for all patients include safer anesthesia methods and Doppler ultrasound surveillance. Clinical findings alone are unreliable in diagnosing deep venous thromboses. Only by using a reliable diagnostic tool such as Doppler ultrasound are we able to learn more about the natural history of this problem in our patients. Such knowledge is likely to better inform our treatment recommendations.

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

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.