No Need to Stop Antidepressants before Plastic Surgery, Evidence Suggests

For patients undergoing plastic surgery procedures, there's no consistent evidence that taking antidepressants increases the risk of bleeding, breast cancer, or other adverse outcomes, concludes a research review in the November issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Stopping antidepressants before plastic and reconstructive surgery is unlikely to reduce complications—and might increase the risk of postoperative problems related to the patient's underlying depression, according to the report by Dr. Isabel Teo of Ninewells Hospital, Dundee, and medical student Christopher Tam Song of University of Edinburgh.

Do Antidepressants Increase Complications after Plastic Surgery?

Antidepressant use has increased in recent years, with one study reporting that 1 out of 10 US adults and adolescents use these medications. Rates of antidepressant use may be even higher among patients undergoing cosmetic plastic surgery, or patients with breast cancer undergoing breast reconstruction.

While plastic surgeons are alert for use of medications that might increase complications, such as blood thinners, they are typically not concerned about antidepressants. Dr. Teo and Mr. Song performed an in-depth review of research data on the risks of antidepressant treatment in plastic surgery. They analyzed 26 studies assessing the effects of antidepressants on various plastic surgery risks, including:

Bleeding. Six studies assessed the impact of antidepressants and bleeding risk in more than 34,000 patients undergoing breast cancer surgery and 2,500 undergoing cosmetic plastic surgery. The results were inconsistent: while some studies found increased bleeding rates in patients taking antidepressants, others found no such risk.

So while the evidence doesn't rule out an increase in bleeding risk, stopping antidepressants before surgery—especially the widely used selective serotonin reuptake inhibitors (SSRIs)—might worsen depression symptoms or lead to a potentially disastrous "discontinuation syndrome." The authors conclude, "Therefore, routine discontinuation of antidepressants before surgery in the absence of a careful evaluation should be avoided."

Breast cancer risk. Six reports—mainly large meta-analyses of previous data—examined the risk of breast cancer among patients taking antidepressants. Again, the results were conflicting: some reviews found a "modest" increase of breast and ovarian cancer among antidepressant users while others found no relationship.

Breast cancer outcomes. Six studies including more than 11,000 patients examined whether antidepressants might interfere with tamoxifen—a drug used to lower the risk of recurrent breast cancer. Most studies found no evidence that this drug combination increased the risk of recurrent breast cancer. However, there was a possible interaction between tamoxifen and one specific antidepressant—the potent SSRI paroxetine.

Breast enlargement. One study of 59 patients suggested a possible increase in the risk of breast enlargement and pain among women taking SSRIs. However, most patients with breast enlargement also had weight gain—a known side effect of SSRI use.

A handful of studies looked at various other complications. One reported an increased risk of seromas (fluid collections) after plastic surgery in patients taking SSRIs. Another reported a possible interaction between SSRIs and methylene blue dye used for lymph node mapping in patients with breast cancer.

While acknowledging the limitations of the available data, Dr. Teo and Mr. Song note their review finds no consistent evidence of increased complications related to antidepressants. The risks of stopping prescribed antidepressant therapy in "psychologically vulnerable" patients likely outweigh any increase in complications.

However, plastic surgeons should consider the impact of the underlying depressive symptoms in patients taking these medications, the authors believe. They conclude, "The use of antidepressants for mental disorders may also implicate key patient risk factors for surgical complications and sufficient exploration into the patient's indications for the prescription is crucial."

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.