National survey of thromboprophylaxis management and tranexamic acid utilization in patients undergoing non-free flap breast surgery.

Abstract

Patients undergoing breast surgery are at risk of venous thromboembolism (VTE), but most literature examining thromboprophylaxis management in breast surgery focuses on free flap reconstruction. We evaluated thromboprophylaxis and tranexamic acid (TXA) practices among Canadian plastic surgeons for non-free flap breast surgeries. An anonymous online survey was distributed to Canadian plastic surgeons in 2025. Data collected included demographics, VTE prophylaxis strategies, and TXA use across nine commonly-performed non-free flap breast procedures. Predictors of thromboprophylaxis and TXA use were identified. Sixty-five surgeons nationwide (34% response rate) completed the survey; 43% had completed a breast fellowship. Although 79% reported regular use of VTE risk tools, prophylaxis practices varied widely. The most common threshold for initiating prophylaxis was 2-3 h of operative duration (35%). Mechanical prophylaxis was the least common in breast augmentation (38%), and chemical prophylaxis was the most common in pedicled flap reconstruction (46%). Fellowship-trained surgeons initiated thromboprophylaxis at earlier operative times (OR 5.8, 95% CI 1.8-19.1), whereas those with more than 10 years of experience delayed initiation (OR 8.2, 95% CI 1.8-38.0). Self-reported "guideline-adherent" surgeons were more likely to use mechanical prophylaxis than surgeons who did not report guideline usage. TXA use correlated with chemical thromboprophylaxis usage (OR 8.0, 95% CI 1.8-86.0) and earlier prophylaxis initiation (OR 27.2, 95% CI 2.7-273.1). Thromboprophylaxis management is inconsistent in non-free flap breast surgery. Fellowship training, TXA utilization, and guideline usage predicted proactive prophylaxis approaches, whereas more clinical experience predicted conservative behaviors. Prophylaxis consensus is needed to support consistent, evidence-based care.