Selective Serotonin Reuptake Inhibitors (SSRIs) and Surgical Bleeding in Plastic Surgery: A Systematic Review

Abstract

Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacotherapy for various psychiatric disorders. These medications adversely affect hemostasis by limiting serotonin reuptake crucial for platelet aggregation. Increased bleeding risk vs SSRI discontinuation syndrome may have important clinical considerations for plastic and reconstructive surgeries (PRSs). With the increasing use of SSRIs, understanding the associated risk of bleeding in soft-tissue surgeries is crucial for optimizing patient outcomes and ensuring safety. In this systematic review, the National Center for Biotechnology Information (NCBI) and Embase databases were searched for publications addressing SSRI consumption and bleeding outcomes in PRS and soft-tissue procedures. Five retrospective cohort studies on SSRIs and bleeding were identified, differing in surgical types, study designs, and reporting of bleeding outcomes, precluding meta-analysis. Post-operative bleeding rates ranged from 1.9% to 2.6%. A U.S. study on breast cosmetic procedures reported a 4.14-fold increase in hematoma reoperations (odds ratio (OR) 4.14; 95% CI 1.90-9.04), while a Danish study on breast oncologic procedures showed a 2.7-fold increased risk (OR 2.7; 95% CI 1.6-4.4). Another Danish study found no increased risk of post-operative blood transfusion (OR 1.2; 95% CI 0.7-1.9). Two U.S. studies on facial procedures found no significant differences in bleeding events, though both had low statistical power. Overall, the risk of significant bleeding complications in breast and facial PRS procedures appears low, with SSRI use increasing hematoma reoperation risk for breast procedures to less than 5%, without evidence of life-threatening bleeding. Conclusions regarding SSRI-related bleeding in facial plastic surgery are limited due to the overall quality of existing studies, which often rely on case reports rather than higher-quality research designs, such as cohort or prospective analyses. Therefore, further high-level evaluations of SSRI-related bleeding are necessary, particularly focusing on procedures involving the face, extremities, and flap surgeries.