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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Incidence of hematoma complication with heparin venous thrombosis prophylaxis after TRAM flap breast reconstruction
Eric C. Liao, M.D., Ph.D., Amir Taghinia, M.D., Lisa Nguyen, B.S., Bernard T. Lee, M.D., James W. May, Jr., M.D., Dennis P. Orgill, M.D., Ph.D..
Harvard Medical School, Boston, MA, USA.

Purpose: Numerous randomized controlled studies provide ample evidence that the use of heparin is effective in reducing the risk of thromboembolic complications. Nevertheless, plastic surgeons are often reluctant to use heparin in chemoprophylaxis for fear of post-operative hematoma complications. We conducted a retrospective study to determine if the use of heparin was associated with post-operative hematoma that required re-operation, and whether it decreased thromboembolic complications.
Methods: A multi-center retrospective review of consecutive cases utilizing abdominal tissue for breast reconstruction was carried out. We identified 820 patients that underwent immediate or delayed breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) (n = 618), free TRAM (n = 61), deep inferior epigastric perforator (DIEP) (n = 133) or superficial inferior epigastric artery (SIEA) (n = 8) flaps. The heparin-treated and the untreated control group consisted of 532 and 288 patients, respectively. Our sample sizes were adequate to detect a 5% different in hematoma rate with 89% power at an alpha of 5% (p < 0.05). Outcome measures of operative hematoma, deep vein thrombosis and pulmonary embolism were recorded. Fisher’s exact test was applied to determine statistical significance between the treatment (heparin chemoprophylaxis) and the control (no heparin) groups.
Results: Operative hematoma occurred in 1.7% of patients in the heparin-treated group and 1% of patients in the untreated group, and this difference failed to reach statistical significance (p = 0.56). When a hematoma did develop, it was found in the reconstructed breast mound site in all cases. Thromboembolic events were detected at a low rate, 0.56% in the heparin-treated group vs. 1.38% in the untreated group (p = 0.25). Thromboembolic complications occurred in cases of unilateral pedicled TRAM in 6 of the 7 cases, in one free TRAM case, but not in DIEP or SIEA cases.
Conclusion: We present one of the first studies in plastic surgery to examine the incidence of operative hematoma associated with heparin chemoprophylaxis. Our retrospective study suggests that the use of heparin for venous thrombotic prophylaxis does not increase the risk of operative hematoma after breast reconstruction with abdominal tissue. We propose a risk assessment that balances a statistical hematoma rate of 1-5% (clinically observed rate of 1.7%) with rare (clinically observed rate of 1.38%) but morbid occurrence of thromboembolic complications. Evidence based practice of venous thrombotic chemoprophylaxis in plastic surgery is clearly important, as our patients undergoing elective surgery are generally healthy and thromboembolic complications should be minimized.

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