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Khubrani AM, Alobaidi HA, Alzahrani IA, Alelyani RH, Wani MS, AlThubaiti GA. Microvascular Thrombosis in Celiac Disease: Is Free Flap an Option? Case Presentation and Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5890. [PMID: 38859805 PMCID: PMC11164015 DOI: 10.1097/gox.0000000000005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/24/2024] [Indexed: 06/12/2024]
Abstract
Celiac disease is an autoimmune disease that occurs due to gluten intolerance. The prevalence of breast cancer among celiac disease patients is the same as in the general population. It is of note that breast cancer is the most common type of cancer in women. Following mastectomy, these patients visit plastic surgeons for breast reconstruction. Based on various factors, autologous reconstruction using abdominal-based flaps is the best option. Patients with celiac disease have a high incidence of thromboembolic disorders, which may prevent plastic surgeons from doing breast reconstruction with free flaps. We present a case of a patient with celiac disease who underwent a free flap for breast reconstruction with an uneventful course after using our routine postoperative protocol. This case report highlights that patients with celiac disease cannot be denied the option of breast reconstruction with free flaps.
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Affiliation(s)
- Abdullah Mohammed Khubrani
- From the Department of Plastic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Department of Scholarship, Ministry of Health, Riyadh, Saudi Arabia
| | - Hussain Amin Alobaidi
- Department of Plastic Surgery and Burns, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Rakan H. Alelyani
- Department of Plastic Surgery and Burns, King Saud Medical City, Riyadh, Saudi Arabia
| | - Musaib Shabeer Wani
- Department of Plastic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ghazi A. AlThubaiti
- Department of Plastic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
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Knoedler S, Kauke-Navarro M, Knoedler L, Friedrich S, Ayyala HS, Haug V, Didzun O, Hundeshagen G, Bigdeli A, Kneser U, Machens HG, Pomahac B, Orgill DP, Broer PN, Panayi AC. The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis. J Plast Reconstr Aesthet Surg 2024; 89:40-50. [PMID: 38134626 DOI: 10.1016/j.bjps.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg, Germany
| | - Haripriya S Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Oliver Didzun
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany.
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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Wu SS, Raymer C, Schafer R, Culbert A, Bernard S, Djohan R, Schwarz G, Bishop SN, Gurunian R. Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction. J Reconstr Microsurg 2023; 39:705-714. [PMID: 36809785 DOI: 10.1055/a-2040-1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
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.
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Affiliation(s)
- Shannon S Wu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Charles Raymer
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Rachel Schafer
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - August Culbert
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven Bernard
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Graham Schwarz
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sarah N Bishop
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Raffi Gurunian
- Department of Plastic Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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Mahrhofer M, Reichert R, Siegwart LC, Russe E, Schoeller T, Wechselberger G, Weitgasser L. Risk of perioperative hormonal breast cancer therapy for microvascular flap complications in breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 85:143-148. [PMID: 37487260 DOI: 10.1016/j.bjps.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 06/11/2023] [Accepted: 07/02/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Hormone therapy with selective estrogen modulators (tamoxifen) and aromatase inhibitors is commonly used in the treatment of breast cancer. While the increased risk for thromboembolic events has been known since their early application, the potential risk in microsurgical breast reconstruction is still debated. This study aimed to evaluate the risk for microvascular flap complications in patients with perioperative hormone therapy. METHODS All patients who underwent microsurgical breast reconstruction with a deep inferior epigastric perforator (DIEP) or transverse myocutaneous gracilis flap at our institution between March 2010 and November 2020 were retrospectively identified in our records. Patients were grouped according to the type and use of perioperative hormone therapy. Flap-related thromboembolic events, flap loss, and revision procedures were compared and analyzed between groups. Risk factors associated with postoperative microsurgical complications were determined. RESULTS A total of 560 patients (656 flaps) were included in our analysis. One hundred ninety-eight patients (224 flaps) received perioperative hormone therapy (35.4%) and 50 (8.9%) postoperative microsurgical events occurred. Tamoxifen and aromatase inhibitors were not associated with postoperative microsurgical events (p = 0.254), full flap loss (p = 0.702), or partial flap loss (p = 0.916). Patients receiving DIEP flaps had a higher risk for postoperative microsurgical complications (OR 2.36, p = 0.004) and partial flap loss (OR 14.66, p < 0.001). A BMI > 30 was associated with an increased risk for partial flap loss (OR 4.2; p < 0.001) CONCLUSION: This article presents one of the largest single-center datasets for the risks of hormone therapy in microsurgical breast reconstruction. Our results show that perioperative hormone therapy does not increase the risk for microsurgical complications. The findings of our study do challenge the common practice of discontinued hormone therapy before microsurgical breast reconstruction.
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Affiliation(s)
- Maximilian Mahrhofer
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Germany.
| | - Raphael Reichert
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Germany
| | - Laura Cosima Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Elisabeth Russe
- Department of Plastic and Reconstructive Surgery, Hospital of the Brothers of St. John of God, Paracelsus Medical University Salzburg, Austria
| | - Thomas Schoeller
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Germany
| | - Gottfried Wechselberger
- Department of Plastic and Reconstructive Surgery, Hospital of the Brothers of St. John of God, Paracelsus Medical University Salzburg, Austria
| | - Laurenz Weitgasser
- Department of Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Teaching Hospital of the Eberhard Karls University Tuebingen, Germany
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A UK consensus statement on thromboprophylaxis for autologous breast reconstruction ,. J Plast Reconstr Aesthet Surg 2023; 81:138-148. [PMID: 37141788 DOI: 10.1016/j.bjps.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
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.
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Mrad MA, Al Qurashi AA, Shah Mardan QNM, Alqarni MD, Alhenaki GA, Alghamdi MS, Fathi AB, Alobaidi HA, Alnamlah AA, Aljehani SK, Daghistani G, Alsharif TH. Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4693. [PMID: 36583164 PMCID: PMC9750533 DOI: 10.1097/gox.0000000000004693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/06/2022] [Indexed: 12/15/2022]
Abstract
Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications. Methods We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model. Results Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission. Conclusion This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.
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Affiliation(s)
- Mohamed Amir Mrad
- Plastic and Reconstructive Surgery Section, Department of Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Abdullah A Al Qurashi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | | | - Mohammed D Alqarni
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | | | | | - Abdulaziz B Fathi
- Plastic and Reconstructive Surgery Section, Department of Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Hussain A Alobaidi
- Plastic and Reconstructive Surgery Section, Department of Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman A Alnamlah
- Plastic and Reconstructive Surgery Section, Department of Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Saif K Aljehani
- Plastic and Reconstructive Surgery Section, Department of Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Webster TK, Roth SC, Yu D, Baltodano PA, Araya S, Elmer NA, Kaplunov BS, Massada KE, Talemal L, Hackley M, Patel SA. Safe perioperative tamoxifen use in autologous breast free flap reconstruction: systematic review and meta-analysis. Breast Cancer Res Treat 2022; 193:241-251. [PMID: 35286525 DOI: 10.1007/s10549-022-06558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/24/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Theresa K Webster
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Stephanie C Roth
- Biomedical and Research Services, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daohai Yu
- Biostatistics and Bioinformatics Facility, Temple University Health System, Philadelphia, PA, USA
| | - Pablo A Baltodano
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Sthefano Araya
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Nicholas A Elmer
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Briana S Kaplunov
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Karen E Massada
- Department of General Surgery, Mercy Catholic Medical Center, Philadelphia, PA, USA
| | - Lindsay Talemal
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Madison Hackley
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA
| | - Sameer A Patel
- Fox Chase Cancer Center/Temple University Division of Plastic and Reconstructive Surgery, Philadelphia, PA, USA.
- Department of Surgical Oncology, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
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Microvascular breast reconstruction and thromboembolic events in patients on hormone therapy: Audit of practice from a tertiary referral centre. J Plast Reconstr Aesthet Surg 2020; 74:957-965. [PMID: 33221183 DOI: 10.1016/j.bjps.2020.10.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/20/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Hormonal therapy with tamoxifen and aromatase inhibitors reduces breast cancer recurrence and mortality but represents a risk factor for thromboembolic events. Therefore, most surgeons discontinue hormonal agents before microvascular surgery and for a variable period thereafter. There are no guidelines regarding when therapy should be stopped (preoperatively) or when it should be resumed (post-operatively). We, therefore, audited our hospital practice with the objective of making recommendations for microvascular breast reconstruction patients. PATIENTS AND METHODS A review was performed of all free flap breast reconstructions between 2014 and 2019. Patients were classified according to hormone medication status at operation. Timings of drug cessation and recommencement were recorded. Thrombotic events, namely flap microvascular thrombosis, deep vein thrombosis, superficial vein thrombosis and pulmonary embolism, were compared. RESULTS A total of 240 patients had 275 free flaps over five years with 36 receiving hormone therapy within one month prior to surgery, which was discontinued 8.5 days (range: 0-28 days) before surgery. Intraoperative microvascular thromboses (HT 2.0%, NHT 0%, and p = 0.869) and post-operative microvascular complications/flap re-explorations (HT 6.6%, NHT 0%, and p = 0.234) were comparable between the two groups. Systemic venous thromboembolic events were also similar (HT 8.3%, NHT 6.1%, and p = 0.893). Age, BMI, smoking status and preoperative chemotherapy did not influence the incidence of thrombotic complications. CONCLUSION Hormone therapy did not significantly increase the risk of thromboembolic events. Despite the widespread practice of withholding it for 2 weeks prior to reconstructive surgery, this study does not support such practice being beneficial in terms of thromboembolic events and flap viability. Large-scale trials are needed to establish definitive protocols.
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Reply: Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction? Plast Reconstr Surg 2019; 143:658e. [PMID: 30817671 DOI: 10.1097/prs.0000000000005331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction? Plast Reconstr Surg 2019; 143:657e-658e. [PMID: 30601298 DOI: 10.1097/prs.0000000000005330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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