Cutting Through the Clot: Rethinking Venous Thromboembolism Prophylaxis in Plastic Surgery with Aspirin, Direct Oral Anticoagulants, and Low Molecular Weight Heparin

Background: Venous thromboembolism (VTE) remains a critical concern in plastic and reconstructive surgery (PRS) due to prolonged operative duration, perioperative immobility, and procedure-specific risks. While low-molecular-weight heparin (LMWH) has been the prophylactic standard, use of direct oral anticoagulants (DOACs) and aspirin (ASA) has been gaining traction. This study summarizes prophylactic practices in PRS. Methods: A systematic search of three databases was conducted. Studies evaluating ASA, DOACs, or LMWH prophylaxis in PRS with VTE, bleeding, or 30-day reoperation rates were included. Mixed anticoagulant regimens were excluded. Data on dosage, duration, and complication rates were extracted. A random-effect meta-analysis of proportions was conducted. Results: Of 884 studies screened, 7 met inclusion criteria, totaling 3,475 patients: ASA (n=402), DOACs (n=2056), and LMWH (n=802). Common regimens included ASA 325mg daily for 5 days and DOAC 10mg daily for 10 days; LMWH dosing varied. VTE rates were low across groups: 1.15% ASA, 0.3% DOACs, and 0.44% LMWH. Hematoma rates were similar for ASA (4.6%) and LMWH (4.5%), while DOACs had a higher rate (8.7%), largely influenced by an outlier. Reoperation rate was highest for ASA (16.9%), followed by DOACs (10.5%) and LMWH (8.0%). Conclusion: Despite comparable VTE rates across agents, variability in bleeding and reoperation highlights the need for procedure-specific, individualized prophylaxis. ASA and LMWH may offer more predictable safety profiles, while DOACs remain promising but warrant further investigation Level of Evidence III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.