Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

Intraoperative Methadone: A New Enhanced Recovery After Surgery Pathway for Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

Inadequate postoperative pain relief places patients at risk for increased morbidity, including surgical complications and chronic postoperative pain. Previous studies have shown that just one dose of methadone can achieve better analgesia than multiple doses of short-acting opioids. This study aims to evaluate the effectiveness of our Enhanced Recovery After Surgery (ERAS) protocol for deep inferior epigastric perforator flap breast reconstruction centered around a single weight-based intraoperative dose of methadone.

METHODS

The authors retrospectively reviewed patients from October 2020 to March 2021 to establish a historical control cohort (n = 29). The ERAS protocol was implemented in April 2021, and patients were prospectively enrolled in the ERAS cohort from April 2021 to January 2022 (n = 54). Primary outcomes compared between the ERAS and historical cohorts using univariate analysis were length of stay, postoperative opioid consumption, pain scores, heart rates, and incidence of tachycardia.

RESULTS

There was no difference in the length of stay between our ERAS and non-ERAS cohorts (P = 0.68). Patients in the ERAS pathway had significantly less opioid consumption at 12 hours postoperatively (P < 0.001), 24 hours postoperatively (P < 0.001), and throughout the entire admission (P = 0.002). Pain scores were significantly lower in the ERAS cohort at 24 hours postoperatively (P = 0.021) and throughout admission (P = 0.0051). The ERAS cohort had significantly lower heart rates at 12 hours postoperatively (P = 0.0014), 24 hours postoperatively (P < 0.001), and throughout admission (P < 0.001). The incidence of tachycardia was also significantly lower in the ERAS cohort (P = 0.029).

CONCLUSIONS

This preliminary data after newly instituting our ERAS protocol with a single dose of intraoperative methadone significantly reduced postoperative opioid analgesic usage, pain scores, heart rates, and incidence of tachycardia. This pilot study demonstrates that methadone has the potential to be used for patients undergoing plastic surgery procedures, both inpatient and ambulatory, to decrease postoperative pain, opioid use, and increase overall patient comfort and satisfaction.

Reduced length of stay and less systemic complications, implementation of the optimized DIEP recovery pathway

BACKGROUND AND AIMS

The present study aimed to compare patients who underwent deep inferior epigastric perforator (DIEP) flap reconstruction with and without the implementation of the new optimized surgical recovery pathway. The new protocol aims to standardize and optimize perioperative management, shorten hospital stays, and lower complication rates for patients undergoing major surgical procedures.

METHODS

Consecutive patients who underwent immediate or delayed DIEP flap breast reconstruction were included in this study. Data regarding patient demographics, timing, laterality of reconstruction, hospital length of stay (LOS), and drain management were collected and compared for the pre-protocol group and the post-protocol group.

RESULTS

The pre-protocol group consisted of 65 patients, while the post-protocol group consisted of 68 patients. The two groups had similar total complication rates (pre-protocol 43.1% versus post-protocol 32.4%, p = 0.20). Between the two groups, there was a significantly lower rate of major surgical complications in the post-protocol group (pre-protocol 32.3% versus post-protocol 14.7%, p = 0.016). There were no significant differences between the groups regarding minor surgical complications (pre-protocol 7.7% versus post-protocol 17.6%, p = 0.086). In the pre-protocol group, the mean LOS was 6.1 days (range = 4-10, median = 6); in the post-protocol group, the mean LOS was 3.6 days (range = 3-10, median = 3; p < 0.00001). Majority of the post-protocol patients were discharged on postoperative day 3 (n = 47, 69.1%).

CONCLUSION

Patients undergoing DIEP flap reconstruction can be discharged earlier without risking their safety by following the new protocol.

Long-Term Opioid Use After Free Flap Breast Reconstruction: Incidence and Associated Factors

Background: Opioid dependence can occur in 6% to 10% of patients undergoing breast reconstruction. With the expansion of interdisciplinary initiatives to decrease opioid use after surgery, an updated look at the incidence of and risk factors for prolonged opioid dependence after free flap breast reconstruction is essential. Methods: We retrospectively identified all cases of free flap breast reconstruction completed at our institution from 2017 to 2020. Patients undergoing additional surgery within 120 days of the free flap procedure were excluded. Postoperative opioid prescriptions were identified; prolonged opioid use was defined as the receipt of additional prescriptions 91 to 120 days after surgery. Demographic and perioperative variables were assessed for their relationship with prolonged opioid use by logistic regressions. Results: A total of 732 patients were included in the final analysis; of these, 15 patients (2%) received additional opioid prescriptions 91 to 120 days after surgery (ie, had prolonged opioid use). Univariable associations were identified between prolonged opioid use and intraoperative morphine milliequivalents (OR = 2.3 per 50 units [95% CI, 1.5-3.5]; P < .001), opioid prescriptions 31 to 60 days after surgery (OR = 16.1 [95% CI, 4.0-65.0]; P < .001) and 61 to 90 days after surgery (OR = 89.4 [95% CI, 13.7-584.5]; P < .001), and history of substance use disorder (OR = 8.3 [95% CI, 2.2-31.6]; P = .002), anxiety (OR = 3.8 [95% CI, 1.2-12.1]; P = .023), or mood disorder (OR = 12.7 [95% CI, 1.3-121.3]; P = .027). Conclusion: In our cohort, 2% of patients who underwent autologous breast reconstruction (15/732) had prolonged opioid use. The currently used perioperative opioid minimization initiatives may benefit patients undergoing autologous breast reconstruction.

Perioperative Venous Thromboembolism Chemoprophylaxis Does Not Increase Risk of Complications in Free Flap Breast Reconstruction

BACKGROUND

Patients undergoing abdominal-based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation.

METHODS

A retrospective review was conducted on patients who underwent abdominal-based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010-2015 patients were pre-ERAS and 2015-2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation.

RESULTS

2317 patients were included: 679 were pre-ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre-ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre-ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre-ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05).

CONCLUSIONS

A standardized perioperative anticoagulation protocol for abdominal-based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.

ERAS-Based Anesthetic Management of Patients Undergoing Abdominal-Based Free Flap Breast Reconstruction: A Narrative Review

Microsurgical breast reconstruction after mastectomy is emerging as the standard of care for patients with breast cancer. The enhanced recovery after surgery (ERAS) pathway in abdominal-based free flap breast reconstruction is in its early stage of development and lacks established consensus or guidelines. In the multidisciplinary ERAS team, the anesthesia sub-team is responsible for the provision of several core elements in the ERAS pathway including anesthetic protocol optimization, perioperative fluid management and homeostasis regulation, normothermia maintenance, perioperative analgesia, and postoperative nausea and vomiting prophylaxis. Here, we summarized the state-of-the-art in anesthetic practice for the patients undergoing abdominal-based free flap breast reconstruction within an ERAS framework, and also introduced the perioperative strategy for this surgical population based on the ERAS pathway in our center, aiming to improve free flap outcome and patient satisfaction, and accelerating their recovery following surgery.

Transforming care: Optimizing ERAS pathway in breast cancer surgery with latissimus dorsi flap

INTRODUCTION

This study aims to establish, execute, and assess the effectiveness of a perioperative enhanced recovery after surgery (ERAS) clinical care pathway in breast reconstruction patients with LD flap breast cancer treatment. The goal is to improve early recovery outcomes, reduce hospitalization time, and enhance patient satisfaction by implementing a standardized approach to postoperative care.

METHODS

This study was conducted at the University of Malaya Medical Center. The outcomes of 21 breast cancer patients who underwent autologous reconstructive breast surgery with the latissimus dorsi (LD) flap within six months before the implementation of the ERAS pathway (pre-ERAS) were compared with 26 patients who underwent the same surgery with the ultrasound-guided erector spinae plane (ESP) block for the (ERAS protocol implementation) cohort. The study was conducted from November 2019 to October 2020. The length of hospital stay, amount of analgesic usage, and incidence of postoperative nausea vomiting (PONV) were recorded.

RESULTS

The implementation of the ERAS clinical care pathway resulted in shorter hospital stays compared with the preceding care. On average, ERAS patients were mostly discharged on Day 2 post-surgery, whereas pre-ERAS patients were mostly discharged on Day 7. ERAS patients had a lower incidence of PONV from Days 1 to 5, starting with 88.5% not experiencing the condition on Days 1 and 2 and increasing to 100% on Day 5. All pre-ERAS patients experienced PONV in the first 5 days post-surgery. Fewer ERAS patients required antiemetics post-surgery (88.5%) compared with pre-ERAS patients (42.9%).

CONCLUSION

The implementation of the ERAS protocol as part of clinical care in autologous reconstructive breast surgery with the LD flap can improve recovery by shortening hospital stay, decreasing the use of analgesia, and alleviating PONV.

Enhanced Recovery Protocol Decreases Postoperative Opioid Use after Penile Inversion Vaginoplasty

Background

Penile inversion vaginoplasty (PIV) entails considerable soft-tissue dissection to the perineal region and involves complex tissue rearrangement. This study examines the role of an enhanced recovery after surgery (ERAS) pathway after PIV in reducing opioid use and controlling postoperative pain.

Methods

A retrospective study of 50 transfemale patients who underwent PIV at a single institution from June 2021 to January 2023 was completed. The study compared 2 groups of patients who were given different postoperative pain management regimens: group A received standard postoperative analgesics and group B received ERAS. Variables such as postoperative pain scores on the numeric pain rating scale (0-10), use of opioid medication, length of hospital stay, and patient comorbidities were recorded and compared across the 2 groups.

Results

The average hospital stay length was 4.92 (±0.85) days. Group A had a slightly longer average stay compared with group B. The average pain level in both groups was 4.25 (SD ±1.51). Group A exhibited a slightly higher average pain level of 4.31 (±1.53), whereas group B exhibited 4.16 (SD±1.51) (P = 0.77). Although pain levels did not significantly vary between the 2 groups, there was a statistically significant decrease in the amount of opioid medication used in group B with a P value of 0.009.

Conclusions

ERAS protocol is effective in decreasing opioid usage in the immediate postoperative setting after PIV.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

BACKGROUND

Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction.

METHODS

The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills.

RESULTS

A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic characteristics, comorbidities, breast pathologic variables, surgery laterality, and immediate versus delayed reconstruction status were equivalent between groups. The control group had significantly higher average pain scores postoperatively (4.3 versus 3.6; P = 0.004). However, there were no significant differences in mean narcotic use (66.9 morphine milligram equivalents versus 60.2 morphine milligram equivalents; P = 0.47). Both length of stay and postoperative narcotic prescription refills were equivalent between groups (2.1 days versus 2.2 days, P = 0.55; 22% versus 17.2%, P = 0.52).

CONCLUSIONS

The addition of liposomal bupivacaine to the standard bupivacaine TAP block mixture in a standardized enhanced recovery after surgery protocol did not demonstrate a significant reduction in postoperative narcotic requirements after deep inferior epigastric perforator flap breast reconstruction compared with standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction

Introduction

Enhanced recovery after surgery (ERAS) protocols have been implemented to decrease opioid use and decrease patient hospital length of stay (LOS, days). Serratus anterior plane (SAP) blocks anesthetize the T2 through T9 dermatomes of the breast and can be applied intraoperatively. The purpose of this study was to compare postoperative opioid (OME) consumption and LOS between a control group, an ERAS group, and an ERAS/local anesthetic cocktail group in patients who underwent implant-based breast reconstruction.

Methods

In this study, 142 women who underwent implant-based breast reconstruction between 2004 and 2020 were divided into Group A (46 patients), a historical cohort; Group B (73 patients), an ERAS/no-block control group; and Group C (23 patients), an ERAS/anesthetic cocktail study group. Primary outcomes of interest were postanesthesia care unit (PACU), inpatient and total hospital OME consumption, and PACU LOS.

Results

A significant decrease was observed from Group A to C in PACU LOS (103.3 vs. 80.2 vs. 70.5; p = 0.011), OME use (25.1 vs. 11.4 vs. 5.7; p < 0.0001), and total hospital OME (120.3 vs. 95.2 vs. 35.9; p < 0.05). No difference was observed in inpatient OMEs between the three groups (95.2 vs. 83.8 vs. 30.8; p = 0.212). Despite not reaching statistical significance, Group C consumed an average of 50-60 % less opioids per patient than did Group B in PACU, inpatient, and total hospital OMEs.

Conclusion

Local anesthetic blocks are important components of ERAS protocols. Our results demonstrate that a combination regional block with a local anesthetic cocktail in an ERAS protocol can decrease opioid consumption in implant-based breast reconstruction.

Microsurgical breast reconstruction in the United States: a narrative review of the current state

Background and Objective

Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons.

Methods

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers.

Key Content and Findings

In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications.

Conclusions

While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

Evaluation of the clinical effect of a multimodal pre-rehabilitation program guided by the behaviour change wheel in elderly women with breast cancer

BACKGROUND

This study aims to explore the nursing effect of a multimodal pre-rehabilitation programme guided by BCW theory on elderly women patients with breast cancer.

METHODS

The participants were divided into two groups. The study group was administered with the pre-rehabilitation model guided by BCW theory; the control group was administered with conventional methods. The rehabilitation effects of the two groups were compared..

RESULTS

The scores of RISC, PTGI and FACT-B were higher in the study group(P < 0.05). The SUPPH score and ROM compliance rate were higher in the study group (P < 0.05) (96% vs 72%). The avoidance score and yield score were lower in the study group(P < 0.05).

CONCLUSION

A multimodal pre-rehabilitation program guided by BCW theory can significantly improve the quality of life and functional status of elderly women patients with breast cancer, and its popularisation and application are recommended.

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

Background

Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods

This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed.

Results

Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; P < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; P < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different.

Conclusions

LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.

The Cost-effectiveness of Enhanced Recovery after Surgery Protocols in Abdominally Based Autologous Breast Reconstruction

Background

The purpose of this study was to conduct a systematic review on the cost-effectiveness of enhanced recovery after surgery (ERAS) protocols in abdominally based autologous breast reconstruction. Further, we reviewed the use of liposomal bupivacaine transversus abdominis plane (TAP) blocks in abdominal autologous reconstruction.

Methods

PubMed, Embase, Cochrane, and Scopus were used for literature review, and PRISMA guidelines were followed. Included articles had full-text available, included cost data, and involved use of TAP block. Reviews, case reports, or comparisons between immediate and delayed breast reconstruction were excluded. Included articles were reviewed for data highlighting treatment cost and associated length of stay (LOS). Cost and LOS were further stratified by treatment group (ERAS versus non-ERAS) and method of postoperative pain control (TAP versus non-TAP). Incremental cost-effectiveness ratio (ICER) was used to compare the impact of the above treatments on cost and LOS.

Results

Of the 381 initial articles, 11 were included. These contained 919 patients, of whom 421 participated in an ERAS pathway. The average ICER for ERAS pathways was $1664.45 per day (range, $952.70-$2860). Average LOS of ERAS pathways was 3.12 days versus 4.57 days for non-ERAS pathways. The average ICER of TAP blocks was $909.19 (range, $89.64-$1728.73) with an average LOS of 3.70 days for TAP blocks versus 4.09 days in controls.

Conclusions

The use of ERAS pathways and postoperative pain control with liposomal bupivacaine TAP block during breast reconstruction is cost-effective. These interventions should be included in comprehensive perioperative plans aimed at positive outcomes with reduced costs.

Enhanced Recovery After Surgery in Immediate DIEP Flap Breast Reconstruction: Reducing Length of Stay and Opioid Use

Background: To improve patient outcomes amid reduced healthcare resources during the COVID-19 pandemic, a single Canadian cancer center implemented an Enhanced Recovery After Surgery (ERAS) protocol for autologous DIEP flap breast reconstruction. Methods: This retrospective cohort study included 100 consecutive patients undergoing microsurgical breast reconstruction with DIEP flaps using the ERAS protocol and 100 patients using a standard protocol. Primary outcomes were the hospital length of stay and opioid use. Secondary outcomes included postoperative complications, laxative and antiemetic consumption. Results: In this study, 80% of the patients had immediate reconstruction, while the remaining patients received either delayed immediate or delayed reconstruction. Patients in the ERAS group had shorter hospital stays (2.8 vs 4.5 days; P < 0.001) and lower total opioid use (50.2 vs 136.3 mg; P < 0.001). This reduction was also observed when breaking down opiates per day of hospitalization (30.2 vs 18.2 mg; P < 0.001), and in the first 24 postoperatively hours (35.7 vs 67.6 mg; P < 0.001). The control group had a higher incidence of postoperative complications, including seroma, partial and total flap necrosis, compared to the ERAS group. However, readmission rates were similar between the two groups. Conclusion: Implementing the ERAS protocol for DIEP flap breast reconstruction can significantly reduce hospital length of stay and postoperative opioid requirements without increasing the risk of adverse events. This pattern holds true for immediate reconstructions with DIEP flaps.

Enhanced recovery pathways for head and neck surgery with free tissue transfer reconstruction

The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial.

Enhanced recovery for acute open lower limb fracture 'fix and flap'

INTRODUCTION

Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates.

METHODS

An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases.

RESULTS

161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %.

CONCLUSION

In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction

Background and Objective

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway.

Methods

All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed.

Key Content and Findings

Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions.

Conclusions

Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach.

METHODS

Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4).

RESULTS

A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant.

CONCLUSIONS

The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.

Faster Return to Daily Activities and Better Pain Control: A Prospective Study of Enhanced Recovery After Surgery Protocol in Breast Augmentation

BACKGROUND

Enhanced recovery after surgery (ERAS) has been proven to decrease the amount of opioid use and reduce postoperative pain for a variety of surgeries, including breast reconstruction. However, data on ERAS in breast augmentation is lacking.

OBJECTIVES

This study aims to investigate the effectiveness and safety of ERAS for breast augmentation.

METHODS

A standardized ERAS protocol was established with full consideration of all aspects of perioperative care. Patients undergoing implant-based breast augmentation were prospectively recruited between December 2020 and January 2023, and assigned to either the ERAS or non-ERAS group randomly. The primary outcome was the activity of daily living after surgery. The secondary was postoperative pain and other outcomes included time to freely elevation, vomiting frequency, the use of analgesics, and complications.

RESULTS

A total of 122 patients were included, with 70 in the ERAS group and 52 in the non-ERAS group. Compared to non-ERAS patients, ERAS patients had a shorter time to freely elevation of upper limbs (2.3 d vs. 5.5 d, P < 0.001). For ERAS patients, the pain scores were significantly lower on postoperative days 1 to 3, the activity of daily living index was significantly higher on postoperative days 1 to 3 and the opioids consumption was decreased (7.1 mg vs. 46.2 mg, P = 0.018). No difference was observed in complication and hospital costs between the two groups.

CONCLUSION

The ERAS protocol significantly reduced postoperative pain and the use of opioids and promoted a return to daily activities without increasing complications in breast augmentation.

LEVEL OF EVIDENCE IV

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 .

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center.

Methods

The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls.

Results

The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant.

Conclusion

Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Drain-free donor site in Deep Inferior Epigastric Perforator free flap: A single-surgeon experience

Donor-site seroma and wound dehiscence in Deep Inferior Epigastric Perforator (DIEP) free flaps can be problematic. The value of donor-site drains is debated, with alternative closure techniques demonstrating good outcomes. However, no literature exists on patient outcomes in which no drain or dead space reduction technique is used. The senior author of this paper has opted for a drain-free, simple layered closure without adjuncts since 2016. We evaluate the outcomes of this technique against the literature. A single-center, single-surgeon, prospective study of all DIEP flap breast reconstruction between January 2016 and March 2020, whereby the donor site was closed without drains or alternative dead space reduction measures. One hundred and thirty-eight patients with a mean age of 50.72±9.16 (range 26-73) underwent DIEP breast reconstruction (78% unilateral (n = 107), 22% bilateral (n = 31). The incidence of drain-free specific donor-site complications was 9.4%, with wound breakdown being the most common (9/138, 6.5%). However, only one patient required secondary closure. The average length of hospital stay was 4.2±1 days (range 2-9). Abdominal drains may serve as a psychological barrier for patients in expediting discharge and can be painful and cumbersome. This translates into significant cost implications. Evidence suggests that superior outcomes are achieved when dead space-reducing adjuncts rather than drains are used. However, our data suggest that DIEP donor sites can also be safely closed without these adjuncts, which may unnecessarily lengthen procedure time, consume more resources, and increase localized foreign body tissue reactions, without good indication.

Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol

BACKGROUND

Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature.

METHODS

This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes.

RESULTS

One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature.

CONCLUSIONS

The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.

Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

With high success rates of autologous breast reconstruction, the focus has shifted from flap survival to improved patient outcomes. Historically, a criticism of autologous breast reconstruction has been the length of hospital stay. Our institution has progressively shortened the length of stay after deep inferior epigastric artery perforator (DIEP) flap reconstruction and began discharging select patients on postoperative day 1 (POD1). The purpose of this study was to document our experience with POD1 discharges and to identify preoperative and intraoperative factors that may identify patients as candidates for earlier discharge.

Methods

An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected.

Results

Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1.

Conclusions

POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.

Pushing the DIEP Envelope with ERAS: 24 Hour Discharge is Safe in Appropriately Selected Patients

Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours.

Methods

Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss.

Results

In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m² (SD 4.8 kg/m²). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%.

Conclusion

Hospital discharge in 24-48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction

INTRODUCTION

Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction.

METHODS

In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis.

RESULTS

The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol.

CONCLUSION

The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

BACKGROUND

There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives.

METHODS

English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team.

RESULTS

We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria.

CONCLUSIONS

Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

EFFECTS OF DIEP FLAP-BASED BREAST RECONSTRUCTION ON RESPIRATORY FUNCTION

BACKGROUND

Breast reconstruction (BR) is an essential part of breast cancer treatment, and the DIEP flap is considered the gold standard reconstruction technique, which uses a free abdominal flap. Concerns have been raised regarding the effects of abdominoplasty on respiratory functions. This topic has not been addressed regarding donor-site closure of DIEP flaps. Our aim is to prospectively compare preoperative and postoperative spirometry in patients undergoing DIEP flap-based BR, investigating its impact on respiratory function.

MATERIALS AND METHODS

We enrolled 21 patients who received BR with DIEP flap in our institution, who underwent pulmonary function assessment by spirometry 1 month preoperatively and 1 year postoperatively. We assessed Forced Expiratory Volume in the first second (FEV1), Forced Vital Capacity (FVC), FEV1/FVC ratio, and Peak Expiratory Flow (PEF). Statistical analysis was performed using the paired samples test.

RESULTS

An improvement in the mean values of all 4 variables was found at 1 year from surgery. Namely, FEV1 improved by 0.1 L with a standard deviation (SD) of 0.39 L, FVC by 0.04 L with SD of 0.627, FEV1/FVC by 2.11 L with SD of 7.85 L, and PEF by 1.2 L with SD of 1.45 L. Only PEF was statistically significant [P = 0.001].

CONCLUSION

Our results suggest that DIEP flap BR does not negatively impact respiratory function. Although further knowledge is required, we confirm the possibility of considering the indication for abdominoplasty and DIEP flap reconstruction in patients with altered and reduced pulmonary function.

Impact of rapid rehabilitation surgery on perioperative nursing in patients undergoing cardiac surgery: A meta-analysis

OBJECTIVE

To systematically evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative nursing of patients undergoing cardiac surgery.

METHODS

A systematic literature search was performed in PubMed, Embase, Web of science, Cochrane, CNKI, Wanfang, and VIP using predefined search strings from inception of database to May 2021. Randomized control trials (RCTs) with sample size >40 on cardiac surgery with either ERAS nursing or routine nursing reporting extubation (trachea) time, length of stay, out of bed activity time, and nursing satisfaction were included in the analysis. Stata SE 12.0 software was used for statistical analysis.

RESULTS

A total of 27 RCTs were included. All the included studies were Chinese due to lack of studies in English. The results of meta-analysis showed that the extubation time standardized mean difference ([SMD] = -3.11; 95% confidence interval [CI]: -3.77, -2.45; p < .001), out of bed activity time (SMD = -2.89; 95% CI: -3.34, -2.44; p < .001), and hospitalization time (SMD = -2.08; 95% CI: -2.37, -1.79; p < .001) of cardiac surgery patients with ERAS nursing was significantly shorter than those with routine nursing. The patient's satisfaction after surgery with ERAS was higher than that of routine nursing relative risk ([RR] = 1.24; 95% CI: 1.18, 1.30; p < .001).

CONCLUSION

ERAS nursing can accelerate perioperative rehabilitation of patients undergoing cardiac surgery and highly accepted by patients.

Can Anti-inflammatory Drugs used in Plastic Surgery Procedures Increase the Risk of Hematoma?

BACKGROUND

Anti-inflammatory drugs are commonly used to lower inflammation which is linked to a variety of disorders. It acts by inhibiting cyclooxygenase-mediated prostaglandin synthesis at the molecular level. Hematoma is related with the use of anti-inflammatory medications. However, the specific link is still unknown. Thus, the main objective of the study is to find out the association of hematoma with ant-inflammatory drugs.

MATERIAL AND METHODS

The relevant studies were searched in PubMed and screened based on inclusion and exclusion criteria. The quality of full-text studies was assessed using suitable Newcastle-Ottawa Scale. The overall estimate was calculated in terms of odds ratio with 95% confidence interval. The random effect model was used. The qualitative analysis of publication bias was done through funnel plot.

RESULTS

The overall estimate measures [OR 1.01 (0.50, 2.06)] have shown non-significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery as compared to non-anti-inflammatory drugs. The heterogeneity among studies was found to be 34%. The subgroup analysis of individual drugs was not done due to availability of a smaller number of studies.

CONCLUSION

Based on available data, there is no significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery.

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 .

Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience

BACKGROUND

This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization.

METHODS

A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol.

RESULTS

Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001).

CONCLUSIONS

ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane-Blocks in Abdominally-Based Microvascular Breast Reconstruction

BACKGROUND

Transversus Abdominis Plane (TAP) blocks can improve pain control and decrease opioid usage within an ERAS protocol, in patients undergoing abdominally-based autologous breast reconstruction. The author has transitioned to using a local analgesic cocktail in place of liposomal bupivacaine for TAP blocks. The purpose of this study is to compare post-operative opioid use in patients who received the different TAP blocks.

METHODS

A retrospective review of patients undergoing abdominally-based autologous breast reconstruction between November 2015 and December 2019 was performed. The study group received Bupivacaine, Ketorolac, Dexmedetomidine, and Dexamethasone, and the control group received Liposomal Bupivacaine +/- Bupivacaine, Ketorolac, or Dexmedetomidine, as a TAP block. The primary outcome of interest was post-operative opioid use and pain scores.

RESULTS

A total of 104 women met inclusion criteria: 36 in Group A (pre-ERAS, pre-TAP), 38 in Group B (ERAS, TAP with liposomal bupivacaine), and 30 in Group C (ERAS, TAP with local anesthetic cocktail). Total and average daily OME consumption were significantly less for Group C in the inpatient phase (Group A: 633, B: 240, C: 135; p<0.0001) (Group A: 137, B: 56, C: 29; p<0.0001). Patients in Group C were prescribed significantly less outpatient OMEs (Group A: 79, B: 74, C: 52; p=0.01).

CONCLUSION

TAP blocks are a significant component of an ERAS protocol for abdominally-based breast reconstruction. Liposomal bupivacaine is a popular option for TAP blocks. Our results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease post-operative opioid use.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety

INTRODUCTION

 Enhanced Recovery After Surgery (ERAS) protocols have decreased postoperative opioid consumption and hospital length of stay in deep inferior epigastric perforator (DIEP) flap breast reconstruction. We aim to evaluate whether there needs to be further adjustments to best improve outcomes specifically in patients with a preexisting psychiatric condition.

METHODS

 A retrospective review was performed of all patients that underwent DIEP flap breast reconstruction between October 2018 and September 2020. This includes all patients with the most recent ERAS protocol implementation of intraoperative transverse abdominal plane blocks with liposomal bupivacaine. We looked at patients with a psychiatric diagnosis at the time of surgery. Specifically, forms of depression and anxiety were the psychiatric diagnoses for these patients. We divided these patients into three groups: those with no diagnoses, those with a single diagnosis, and those with both diagnoses. Primary outcomes observed were postoperative opioid consumption and length of stay. A one-way analysis of variance determined whether there was a difference between the three groups and a Tukey post hoc analysis made pairwise comparisons. A p-value of < 0.05 was significant.

RESULTS

 A total of 176 patients were analyzed in this study: 59 (33.5%) of our study population had a diagnosis of either depression, anxiety, or both. Postoperative opioid consumption was higher in patients with a psychiatric diagnosis compared with those without (123.8 to 91.5; p < 0.0005). A multiple regression model consisting of operating time, hospital length of stay, whether the patient has a psychiatric diagnosis, and history of chemotherapy statistically significantly predicted opioid consumption (p < 0.0005).

CONCLUSION

 With similar hospital length of stay postoperatively, it is notable that patients with a psychiatric diagnosis had significantly higher amounts of postoperative opioid consumption. This study highlights the need to further improve multidisciplinary integrated care for patients with psychiatric comorbidities to improve pain management postoperatively.

Gender-affirming Phalloplasty: A Postoperative Protocol for Success

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution’s experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.

The Use of Closed Incision Negative Pressure Therapy on the Medial Thigh Donor Site in Transverse Musculocutaneous Gracilis Flap Breast Reconstruction

The objective of this study was to examine the impact of closed incision negative pressure therapy (CINPT) on donor site complications and patient perceptions in transverse musculocutaneous gracilis (TMG) flap breast reconstruction. Our institution conducted a retrospective cohort study, including all patients with TMG flap breast reconstruction from 1 January 2010 to 31 December 2021. Patients were grouped according to conventional wound management or CINPT. Outcomes were surgical site complications, fluid drainage, time to drain removal, and in-hospital stay length. A patient survey was created. A total of 56 patients with 83 TMG flaps were included (control group: 35 patients with 53 TMG flaps; CINPT group: 21 patients with 30 TMG flaps). Patient characteristics were similar in both groups. The flap width was significantly larger in the CINPT group (8.0 cm vs. 7.0 cm, p = 0.013). Surgical site complications were reduced in the CINPT group without statistical difference (30.0% vs. 50.9%, p = 0.064). Fluid drainage and time to drain removal were similar in both groups. The average in-hospital stay was significantly shortened in the CINPT group (10.0 days vs. 13.0 days, p = 0.030). The survey excluded pain, skin irritations, and discomfort during sleep and movement in the CINPT group and showed that the patients felt well protected. This study fails to provide compelling evidence for CINPT to enhance incision healing on the donor site in TMG flap breast reconstruction. There was a trend toward reduced surgical site complications on the donor thigh and the in-hospital stay was shortened. Prophylactic CINPT increases patient comfort and provides a feeling of additional wound protection.

Standardized Perioperative Protocol and Routine Ketorolac Use for Head and Neck Free Flap Reconstruction

No consensus exists on ideal perioperative management or anticoagulation regimen for free flap reconstruction of the head and neck. Perceived benefits from antiplatelet therapy need to be balanced against potential complications. Ketorolac, a platelet aggregation inhibitor and a parenteral analgesic, was introduced as part of a standardized perioperative protocol at our institution. In this study, we aimed to examine the impact of implementation of this protocol as well as complications associated with the routine use of perioperative ketorolac in a diverse group of patients who underwent head and neck free flap reconstruction.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway.

METHODS

Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications.

RESULTS

The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction.

CONCLUSION

The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19

BACKGROUND

Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity.

METHODS

A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services.

RESULTS

Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services.

CONCLUSIONS

A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates.

METHODS

The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates.

RESULTS

A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02).

CONCLUSIONS

Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction

INTRODUCTION

 Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution.

METHODS

 This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant.

RESULTS

 A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group.

CONCLUSION

 Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.

Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap

BACKGROUND

In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery¹, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps². We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions.

MATERIALS AND METHODS

In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively.

RESULTS

Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission.

CONCLUSION

Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.

Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction

BACKGROUND

Enhanced recovery after surgery (ERAS) includes multiple interventions that have yielded positive outcomes in a number of surgical fields. The authors evaluated whether an ERAS protocol and the subsequent addition of liposomal bupivacaine affect patient outcomes specifically in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

All patients treated with DIEP flaps from January of 2016 to December of 2019 were reviewed retrospectively. The ERAS protocol was implemented midway through 2017; halfway through 2018, intraoperative transversus abdominis plane blocks with liposomal bupivacaine were added to the protocol. Such interventions allowed for comparison of three patient groups: before ERAS, during ERAS, and after ERAS plus liposomal bupivacaine. Primary outcomes observed were postoperative opioid consumption and length of stay. The p values were obtained using the Wilcoxon test for pairwise comparisons.

RESULTS

After adjusting for ERAS group compliance, 216 patients were analyzed. The pre-ERAS group was composed of 67 patients, the ERAS group was composed of 69 patients, and the ERAS plus liposomal bupivacaine group was composed of 80 patients. Postoperative opioid consumption was reduced when comparing the pre-ERAS and ERAS groups (from 275.7 oral morphine equivalents to 146.7 oral morphine equivalents; p < 0.0001), and also reduced with the addition of liposomal bupivacaine (115.3 oral morphine equivalents; p = 0.016). Furthermore, hospital length of stay was decreased from 3.6 days in the pre-ERAS group to 3.2 days (p = 0.0029) in the ERAS group, and to 2.6 days (p < 0.0001) in the ERAS group plus liposomal bupivacaine groups.

CONCLUSIONS

Enhanced recovery after surgery protocols decrease postoperative opioid consumption and hospital length of stay in DIEP flap breast reconstruction. The addition of liposomal bupivacaine further strengthens the impact of the protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery.

OBJECTIVES

To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction.

DATA SOURCES

Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies.

INCLUSION CRITERIA

All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language.

OUTCOME MEASURES

The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications.

RESULTS

Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported.

CONCLUSION

ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction.

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 .

Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction?

BACKGROUND

 Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction.

METHODS

 Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected.

RESULTS

 A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption.

CONCLUSION

 Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

BACKGROUND

Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.

MATERIALS EN METHODS

The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.

RESULTS

152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).

CONCLUSION

An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

Cost-effectiveness of Multidisciplinary Care in Plastic Surgery: A Systematic Review

BACKGROUND

Multidisciplinary care has been previously shown to improve outcomes for patients and providers alike, fostering interprofessional collaboration and communication. Many studies have demonstrated the beneficial health care outcomes of interdisciplinary care. However, there has been minimal focus on the cost-effectiveness of such care, particularly in the realm of plastic surgery. This is the first systematic review to examine cost savings attributable to plastic surgery involvement in multidisciplinary care.

METHODS

A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary teams including a plastic surgeon was performed. Included articles reported on cost outcomes directly or indirectly attributable to a collaborative intervention. Explicitly reported cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described.

RESULTS

A total of 604 articles were identified in the initial query, of which 8 met the inclusion criteria. Three studies reported explicit cost savings from multidisciplinary care, with cost savings ranging from $707 to $26,098 per patient, and 5 studies reported changes in secondary factors such as complication rates and length of stay. All studies ultimately recommended multidisciplinary care, regardless of whether cost savings were achieved.

CONCLUSIONS

This systematic review of the cost-effectiveness of multidisciplinary plastic surgery care examined both primary cost savings and associated quality outcomes, such as length of stay, complication rate, and resource consumption. Our findings indicate that the inclusion of plastic surgery in team-based care provides both direct and indirect cost savings to all involved parties.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm

Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption

BACKGROUND

Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain.

OBJECTIVES

The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks.

METHODS

A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks.

RESULTS

There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily.

CONCLUSIONS

Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy.

LEVEL OF EVIDENCE: 4

The impact of closed incisional negative pressure therapy on anterior lateral thigh flap donor site healing and scarring: A retrospective case-control study

BACKGROUND

The objective of this study was to investigate whether closed incisional negative pressure therapy (cINPT) is suitable to improve anterior lateral thigh (ALT) flap donor site healing and scarring.

METHODS

We identified 271 ALT free flaps of widths between 7 and 9 cm and primary donor site closure performed between January 2012 to December 2019. Patients were divided into cases of cINPT versus controls without cINPT as part of this retrospective case-control review. We compared the incidences of postoperative donor site complications (wound dehiscence, infection, seroma, hematoma) and the degree of scarring severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS).

RESULTS

A total of 106 ALT donor sites received cINPT (39%), whereas the remaining 165 donor sites received conventional dressings (61%). The distribution of gender, age, body mass index, comorbidities, and mean flap sizes were comparable between both groups. The occurrence of surgical wound dehiscence was significantly lower in the cINPT group (2.8%), when compared to controls (9.0%) (p = 0.04). Furthermore, the mean length of postoperative hospital stay was significantly shorter in the cINPT group (19 ± 8 days versus 21 ± 11 days; p = 0.03). CINPT was associated with a more favorable donor site scar quality when assessed by VSS (p = 0.03) and POSAS (p = 0.002).

CONCLUSION

The use of cINPT was associated with significantly less ALT donor site complications and superior scar quality accelerating patients' postoperative recovery.

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes

BACKGROUND

The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction.

METHODS

We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q.

RESULTS

Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores.

CONCLUSION

System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.