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BACKGROUND: The American College of Chest Physicians recommends perioperative chemoprophylaxis for patients with malignancy undergoing major surgery to reduce the risk of thromboembolic complications (TEC). Most clinical studies supporting this policy describe initiation of chemoprophylaxis preoperatively with postoperative continuation. However, while surgeons recognize the importance of TEC prophylaxis, many are reluctant to use preoperative low molecular weight heparin (LMWH) for fear of bleeding complications. This study evaluates the use of preoperative LMWH chemoprophylaxis in patients undergoing mastectomy with tissue expander-based breast reconstruction. Furthermore, it looks at outcome differences when comparing tissue expander pockets created using muscle-only, Allomax, and Alloderm techniques.
METHODS: A single-surgeon, retrospective analysis was performed for patients undergoing prosthetic-based breast reconstruction over a 5 year period. Patient data was recorded, including demographics, treatments, comorbidities, surgical techinique, and complications. Univariate analysis was performed to determine risk factors for complications.
RESULTS: 154 patients (244 breasts) underwent mastectomy and prosthetic-based breast reconstruction, most of which (96.8%) were immediate reconstructions. Average follow-up was 22 months (range 1 - 54 months). Seven (4.5%) patients developed hematomas. Preoperative enoxaparin was given to 90 (58.4%) patients; five hematomas developed in this group (5.6%). Two hematomas occurred in the 60 patients who did not receive preoperative DVT prophylaxis (3.1%). However, these differences were not statistically significant (p=0.704). Tissue expander pockets were created with muscle-only in 31 (20.3%), Allomax in 33 (21.6%), or Alloderm in 89 (58.2%) patients. There were no differences in hematoma rates among patients that received enoxaparin for any of the three pocket types. Other complications included infections (7 patients, 4.5%), seromas (15 patients, 9.7%), and minor mastectomy flap problems (22 patients, 15%). The major complications were evaluated for each pocket-type (Table 1). There were no significant differences in complication rates between the 3 pocket types: hematomas (p=0.444), infections (p=0.731), and seromas (p=0.421). Additionally, no other patient comorbidities were found to be predictive of complications.
CONCLUSIONS: Preoperative TEC chemoprophylaxis in this high risk population is safe and is not associated with higher bleeding complications.
The overall incidence of postoperative complications after tissue expander-based breast reconstruction remains low. In this study, pocket type did not significantly affect complication rates.

Complications by Tissue Expander Pocket Type

Complications	Muscle-Only	Allomax	Alloderm	Total	p value
Hematoma	2(6.5%)	0(0%)	5(6.0%)	7(4.5%)	p=0.444
Infection	0(0%)	1(3.6%)	6(6.8%)	7(4.5%)	p=0.731
Seroma	1(4.5%)	2(6.9%)	12(14.1%)	15(9.7%)	p=0.421