Perioperative Venous Thromboembolism Chemoprophylaxis Does Not Increase Risk of Complications in Free Flap Breast Reconstruction

ABSTRACT Background Patients undergoing abdominal‐based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation. Methods A retrospective review was conducted on patients who underwent abdominal‐based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010–2015 patients were pre‐ERAS and 2015–2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation. Results 2317 patients were included: 679 were pre‐ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre‐ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre‐ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre‐ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05). Conclusions A standardized perioperative anticoagulation protocol for abdominal‐based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.