The Safety of Preoperative Versus Postoperative Enoxaparin Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction
Brian Bassiri-Tehrani, M.D.1, Irena Karanetz, M.D.2, Stephanie F. Bernik, M.D.1, Wojciech Dec, M.D.1, Oren Z. Lerman, M.D.1.
1Lenox Hill Hospital, New York, NY, USA, 2Hofstra Northwell School of Medicine, New Hyde Park, NY, USA.
PURPOSE: Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events (VTE). The efficacy of chemoprophylaxis in decreasing VTE is well established but the timing of chemoprophylaxis remains controversial. Many surgeons are reluctant to initiate preoperative chemoprophylaxis due to concerns of bleeding. We compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction.
METHODS: Patients undergoing autologous breast reconstruction from August 2010-July 2016 were reviewed. 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 (mean age 51.4, SD 4.9; mean BMI 26). A total of 105 patients(166 flaps) received preoperative enoxaparin 40mg while 91 patients(145 flaps) received postoperative chemoprophylaxis. A total of four patients required hematoma evacuation, overall incidence of 2.04%. Of these, no hematomas (0%) occurred in the preoperative chemoprophylaxis group (p=0.045). Six patients received blood transfusions; two in the preoperative group, and four in the postoperative group (1.9% vs 4.4%, p=0.419). There was a total of one flap failure and no documented VTE in all groups.
CONCLUSION: This study demonstrates that preoperative chemoprophylaxis can safely be used 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 4-6 hours, which allows for intraoperative hemostasis in the preoperative group while possibly potentiating postoperative oozing when administered postoperatively.
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