2024

Question 1

A 60-year-old woman with a history of hormone-positive breast cancer presents for consultation for autologous breast reconstruction with deep inferior epigastric artery perforator flaps in a delayed fashion. She is currently taking anastrazole. To address thromboembolic risk, this drug should be held for which of the following intervals at the time of the operation?
A) O weeks before and 0 weeks after surgery
B) 2 weeks before and 0 weeks after surgery
C) 2 weeks before and 2 weeks after surgery
D) 4 weeks before and 0 weeks after surgery
E) 4 weeks before and 2 weeks after surgery

Answer 1

A
Anastrazole is an aromatase inhibitor, a type of hormonal therapy that is given for treatment of postmenopausal women diagnosed with hormone-positive breast cancer. Aromatase inhibitors are a class of drug that do not need to be stopped (feld) perioperatively for microvascular operations.
Other types of hormonal agents, like tamoxifen, have a known risk for blood clotting and therefore have historically been felt to have an increased risk for microvascular thromboses and flap loss. The data on tamoxifen, a selective estrogen receptor modulator, are mixed, with some studies finding an increased risk for microvascular compromise, while others do not. The original publication by Kronowitz in 2012 found an increase in flap loss and decrease in flap salvage in patients who had been treated with tamoxifen within 28 days of microvascular surgery, and as a result recommended holding it for 28 days prior to operation. Other papers have since reported no increased events in shorter time period (ie, 2 weeks) or no increased events without holding it at all. While the data are inconclusive on whether to hold tamoxifen, and for how long, multiple studies have demonstrated no increased microvascular risks in allowing patients to continue their aromatase inhibitors.

Question 2

• A) Bilateral prophylactic skin-sparing mastectomy with a prepectoral custom-made implant
• B) Deferring surgical management until age 21 years
• C) Left vertical mastopexy
• D) Placement of a total submuscular tissue expander in the right breast
•E) Reconstruction with a right deep inferior epigastric artery perforator free flap

Answer 2