Is It Necessary to Stop Tamoxifen Therapy in Microvascular Flap Breast Reconstruction?
With great interest, we read the article entitled “The effects of perioperative tamoxifen therapy on microvascular flap complications in transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap breast reconstruction” by Salibian et al.1 In their article, Salibian et al concluded that tamoxifen does not increase trombothic complications in transverse rectus abdominis myocutaneous/deep inferior epigastric perforator microvascular flap when taken at the time of reconstruction and therefore may not need to be stopped before these procedures.
We absolutely do agree with this action, and in our practice, we do not stop tamoxifen before the microvascular breast reconstruction with DIEP flap, and in the postoperative time, we introduce tamoxifen as soon as the patient can tolerate feeding.
In delayed breast reconstruction, there are several factors related with potential vascular thrombosis: radiation, chemotherapy, hormone therapy, obesity and maybe for us the most important is the preoperative radiation which directly affects the state of the vessels.
Our perioperative anticoagulation protocol is washing the flap in a heparinized saline 5000 units in 500 ml for 5 minutes, before doing the anastomoses and continued to receive subcutaneous heparin every 24 hours until discharge to home. Same with Mirzabeigi et al,2 we also use bilateral intermittent compression devices throughout first 24 hours and compression socks throughout their hospital course.
Kelley et al3 published a study in 670 patients comparing rates of microvascular flap complication and pulmonary emboli between patients who underwent delayed microsurgical breast reconstruction, and the results indicated that tamoxifen using at the time of the delayed microsurgical reconstruction may increase the risk of flap failure or other microvascular flap complications. However, thrombosis is a demonstration of often multiple contributing factors, and in the tamoxifen group, preoperative irradiation is significantly higher, so maybe the effect of preoperative tamoxifen may have been previously overestimated.