An Assessment of Bleeding Complications Necessitating Blood Transfusion Across Inpatient Plastic Surgery Procedures

A Nationwide Analysis Using the National Surgical Quality Improvement Program Database

Analise B. Thomas, M.D.; Ronnie L. Shammas, M.D.; Jonah Orr, B.S.; Tracy Truong, M.S.; Maragatha Kuchibhatla, Ph.D.; Amanda R. Sergesketter, B.S.; Scott T. Hollenbeck, M.D.


Plast Reconstr Surg. 2019;143(5):1109e-1117e. 

In This Article

Abstract and Introduction


Background: This study described the prevalence of bleeding complications necessitating blood transfusion across plastic surgery procedures and identified those procedures that may be associated with higher rates of bleeding.

Methods: The authors retrospectively identified patients who suffered from postoperative bleeding complications from 2010 to 2015 using the National Surgical Quality Improvement Program database. This is defined by the National Surgical Quality Improvement Program as the need for transfusion of at least one unit of packed or whole red blood cells. Patient characteristics were described using summary statistics, and National Surgical Quality Improvement Program and univariate analysis of patient characteristics and bleeding complications was performed.

Results: Overall, 1955 of 95,687 patients experienced bleeding complications. Patients with bleeding complications were more likely to be diagnosed with hypertension, have a longer total operative time, and have a previously diagnosed bleeding disorder. The most common primary plastic surgery procedure associated with bleeding complications was breast reconstruction with a free flap, and breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap had the highest rate of bleeding. A return to the operating room was required in 539 patients (27.6 percent) who suffered a postoperative bleeding complication. Patients with a preexisting bleeding disorder [n = 1407 (1.5 percent)] were more likely to be diabetic, have a lower preoperative hematocrit, and have a longer operative time. In addition, these patients were more likely to suffer from other nonbleeding complications (1.29 percent versus 0.35 percent; p < 0.01).

Conclusions: Complex procedures (i.e., free flap breast reconstruction) have a higher prevalence of bleeding requiring a transfusion. Furthermore, patients undergoing combined procedures—specifically, breast oncologic and reconstructive cases—may be at a higher risk for experiencing bleeding-related complications.

Clinical Question/Level of Evidence: Therapeutic, III.


Improving patient safety has become a priority for health care systems and physicians across all subspecialties. Plastic surgery represents a unique field, as it is composed primarily of both elective procedures, which encompass a relatively young and healthy patient demographic, and reconstructive procedures, which may include patients with significant comorbidities. This distinct patient population necessitates separate consideration for plastic surgery with respect to patient safety and quality improvement measures. Before establishing guidelines to reduce the risk of adverse perioperative events, it is important to delineate the national prevalence and rates of certain postoperative complications.

Although bleeding complications represent a small subset of intraoperative and postoperative complications in plastic surgery, the effects of these complications are substantial. Unanticipated surgical bleeding has been associated with increased operative time, unplanned return to the operating room, and significantly increased health care costs.[1–3] Patients who have a need for transfusion of even one unit of packed red blood cells following procedure-related blood loss experience significantly higher rates of pulmonary, wound, septic, and thromboembolic complications, and overall mortality.[4,5] These patients also have an average longer postoperative length of stay, further increasing the burden of health care costs.[3,5] Although the prevalence and effect of bleeding complications have been explored within the surgical literature,[2,6,7] this topic has yet to be thoroughly investigated with regard to its impact in plastic surgery.

Plastic surgery procedures are relatively safe overall, with mortality rates of less than 1 percent; however, bleeding-related complications including failure to rescue (i.e., death caused by treatable complications), hemorrhage, and hematoma occur at similar rates as for other inpatient operations.[8,9] Previous studies have examined this topic within the scope of breast reconstruction, reporting that the rates of bleeding complications are between 0.9 and 5.0 percent for breast implant reconstruction and between 2.9 and 9.0 percent for autologous breast reconstruction.[10–12] A nationwide investigation into the rates of postoperative bleeding complications across all inpatient plastic surgery procedures has yet to be conducted.

Using a large national population database, we sought to determine the prevalence of bleeding complications that necessitate a blood transfusion across all inpatient plastic surgery procedures, and to identify those primary and concurrent plastic surgery procedures with the highest prevalence and rate of bleeding complications. The findings of this study will help identify which procedures and patient characteristics may be associated with an increased risk for postoperative bleeding that requires a transfusion, with the aim of reducing postoperative morbidity and improving overall clinical care.