Practical Guidelines for Venous Thromboembolism Prophylaxis in Free Tissue Transfer

Background: Venous thromboembolism encompasses a spectrum of disease, ranging from asymptomatic deep vein thrombosis to fatal pulmonary embolism. As microsurgical techniques increase in complexity, the overriding benefit from a microsurgical versus a venous thromboembolism prophylactic regimen remains unclear. This study evaluated the current recommendations and procedure-specific strategies for venous thromboembolism prophylaxis with a focus on the utility of prophylaxis in microsurgical procedures. Methods: A review was performed to identify all articles discussing the rates of venous thromboembolism in patients undergoing microsurgical procedures. Data were summarized based on body area, including hand, breast, lower extremity, and head and neck. Guidelines for venous thromboembolism prophylaxis in microsurgical cases were established. Results: The available studies demonstrate a reduction in postoperative venous thromboembolism. Unfortunately, chemoprophylaxis continues to be underused throughout plastic surgery, amid concern over the risk of bleeding complications. Based on the best available data, the use of mechanical and chemoprophylaxis should be strongly considered in all microsurgical cases. A preoperative screening algorithm based on a risk-assessment model should be used in all cases to preoperatively characterize and modify risk factors when possible, and plan for perioperative prophylaxis. Conclusions: Although not completely preventable, venous thromboembolism risks can be reduced with careful preoperative planning and medical history and the judicious use of chemoprophylaxis. Because there does not appear to be an increase in the rate of postoperative bleeding when prophylaxis is administered appropriately, the use of venous thromboembolism prophylaxis should be considered in all microsurgery patients except those at extremely high risk of bleeding.