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J Reconstr Microsurg
DOI: 10.1055/a-2717-4751
Original Article

Postoperative Prophylactic Anticoagulation in Flap Surgery: A Review of the Evidence and Challenging Common Beliefs

Authors

  • Hamid Malekzadeh 

    1   Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Jude Kluemper

    1   Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Abdulaziz Elemosho

    1   Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

  • Jeffrey E. Janis

    1   Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

Funding Information None.
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Abstract

Background

Postoperative anticoagulation is widely used in microsurgical flap reconstruction to reduce the risk of thrombosis and flap complications. However, their effectiveness and safety in relation to flap outcomes remain uncertain. This systematic review and meta-analysis evaluate the existing evidence on postoperative anticoagulant use in microsurgical flap reconstruction.

Methods

A literature search was performed in the PubMed database for studies published from 1995 until January 2025 that compared flap outcomes with postoperative prophylactic anticoagulation regimens in microsurgical flap procedures. Outcomes of interest included hematoma, complete flap failure, and reoperation. Relevant data were extracted and analyzed using meta-analytic techniques.

Results

In total, 11 studies were included in the final review and meta-analysis. Seven studies comparing patients who received postoperative anticoagulation with those who did not demonstrated a significantly higher rate of hematoma in the anticoagulated group (5.0% vs. 3.0%; p = 0.03). However, there were no significant differences in flap failure or reoperation rates. In subgroup analyses, only studies using unfractionated heparin showed increased hematoma risk, whereas low-molecular-weight heparin (LMWH) showed no significant effect. Four studies compared patients receiving postoperative anticoagulation plus aspirin with those receiving anticoagulation alone and found a higher reoperation rate when aspirin was added (17.5% vs. 10.0%; p < 0.01), with no significant differences in flap failure rates.

Conclusion

Postoperative heparin increases the risk of hematoma without improving flap survival. Additionally, combining aspirin with LMWH may increase reoperation rates. These results suggest that routine anticoagulation may not benefit all patients and support a risk-based approach to postoperative management in microsurgical reconstruction.

Keywords

microsurgery - surgical flaps - evidence-based medicine - anticoagulants

All authors have read and approved the final manuscript.




Publication History

Received: 27 May 2025

Accepted: 20 September 2025

Accepted Manuscript online:
10 October 2025

Article published online:
27 October 2025

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