Identifying transfusion criteria and risk factors after deep inferior epigastric artery perforator flap breast reconstruction.

[BACKGROUND] Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction depends on perfusion and outflow through microvascular anastomoses. Preoperative anemia is predictive of transfusion and increased complications; however, transfusion is also linked to thrombosis. Moreover, guidelines for transfusion after DIEP flaps are not established. We aimed to identify a safe hemoglobin level after DIEP flaps and identify risk factors and complications associated with transfusion.

[METHODS] A retrospective study was performed for DIEP flap breast reconstruction patients over 5 years. Patient characteristics and postoperative variables were gathered. Outcomes included 30-day complications, surgical takebacks, microvascular thrombosis, and flap loss. Descriptive statistics and receiver operating characteristic curve were used to determine the lowest hemoglobin (Hb) cutoff where complications increased.

[RESULTS] Overall, 156 patients (239 flaps) underwent DIEP flap reconstruction. Transfused patients were younger, had lower preoperative Hb, longer surgery, higher blood loss, immediate reconstruction, bilateral reconstruction, and lower postoperative Hb. They had increased 30-day complications and more surgical takebacks, and higher rates of microvascular thromboses, though no increased flap loss. Receiver operating characteristic curve identified an Hb of 8.3, below which more complications were seen.

[CONCLUSION] Among patients with high-risk characteristics undergoing DIEP flap reconstruction, there is the possibility for transfusion and associated complications. Withholding transfusion for hemodynamically stable patients with Hb >8.3 appears to be safe. Lower Hb is associated with increased transfusion and complications; however, when managed appropriately, it does not increase flap loss.