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Page 6 of 11 Leach et al. Plast Aesthet Res 2023;10:39 https://dx.doi.org/10.20517/2347-9264.2023.32

microsurgical free flap reconstruction in 2008 and found that intravenous heparin administration prior to
anastomosis did not lead to increased rates of hematoma or bleeding, but also did not decrease the rate of
[50]
microvascular thrombosis .

In addition to requiring transfusions, bleeding may lead to hematoma formation and the need to return to
the OR for evacuation. In order to try to reduce bleeding complications, the use of tranexamic acid (TXA)
has been evaluated. In 2018, a meta-analysis of surgical trials evaluated the safety and effectiveness of TXA.
The study showed the risk for transfusion was reduced by 38% in the TXA groups with no significant
[51]
differences in mortality or thrombotic events . Lardi et al. evaluated the use of TXA in microsurgical
breast reconstruction . The study compared patients who received up to 3 g of intravenous TXA
[52]
intraoperatively and postoperatively to those that received no TXA. The use of TXA was determined by
intraoperative and postoperative blood loss. Analysis of the two groups showed decreased blood loss in the
TXA group (158.4 mL) versus control (231.5 mL) (P < 0.001) and a trend towards decreased hematoma of
the breast (10.0% TXA versus 18.2% control), but this was not statistically significant (P = 0.332). There was
no statistical difference in blood transfusions, deep venous thrombosis, or thrombosis of anastomosis .
[52]
Hematoma of the chest recipient site can be related to venous congestion. Chu et al. discussed the results of
a retrospective review of reoperation for hematoma and/or venous congestion in head and neck
reconstruction and breast reconstruction patients . Of the 15 patients who developed both, 8 were separate
[53]
occurrences, while 4 patients developed compression of the pedicle vein from the hematoma, and in the
remaining 3 patients, it was believed that the venous congestion was the cause of the hematoma. For breast
reconstruction, venous congestion leading to hematoma was more common than hematoma preceding
venous congestion .
[53]

Meticulous hemostasis at the time of free flap reconstruction is vital to minimize hematoma formation or
bleeding complications requiring transfusion. We have not adopted the routine use of TXA in microsurgical
breast reconstruction. We administer a preoperative dose of aspirin, which is continued daily for 30 days, in
addition to low-molecular-weight heparin while inpatient. The combination may contribute to bleeding in
some patients. While hematomas do occur, in our experience, this seems to be most common in the setting
of continuous heparin infusion following microsurgical thrombosis, anastomotic redo, or deep venous
thrombosis/pulmonary embolism. Prompt identification and treatment of hematomas is important as it
may be related to another issue, such as venous congestion or compression of the pedicle.

PNEUMOTHORAX
Dissection of the internal mammary vessels as recipients of autologous breast reconstruction poses a risk of
injury to the parietal pleura and subsequent development of pneumothorax (PTX). The rate is overall low in
autologous reconstruction, with literature primarily composed of case reports and case series [54-56] .
Darcy et al. reported one pneumothorax in a series of 463 rib-sparing free flap reconstructions . Clinical
[14]
symptoms of pneumothorax can include decreased oxygen saturation, tachycardia, tachypnea, dyspnea, and
difficulty ventilating the patient. Progression to tension pneumothorax will result in hypotension.
Reekie et al. reported a case of tension pneumothorax after an extended latissimus dorsi flap with noted
venous congestion of the flap in combination with progressive hypotension, tachycardia, low pulse oximeter
[54]
readings, and increased ventilatory pressures . The patient was treated with needle decompression and
subsequent chest tube placement with noted rapid improvement in the flap venous congestion concurrent
with physiologic improvement .
[54]